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BackgroundA national clinical registry was established in the Netherlands containing data directly sampled from electronic health record systems of physical therapists (PTs). This registry aims to evaluate the potential of patient reported outcome measures (PROMs) to develop quality indicators (QIs) in physical therapy care.PurposeTo test to what extent the collected PROM data are reliable, valid and discriminatory between practices in measuring outcomes of patients with non-specific low back pain (NSLBP).MethodsIn this retrospective cohort study 865 PT practices with 6,560 PTs voluntarily collected PROM data of patients with NSLBP, using the Quebec Back Pain Disability Scale (QBPDS), the Numeric Pain Rating Scale (NPRS) and the Patient Specific Functioning Scale (PSFS). Reliability was determined by analysing the completeness of the dataset, the comparability by using national reference data, and through checking selection bias in the included patients. Validity was tested using the known-groups contrast between patients with (sub)acute vs. chronic NSLBP. To determine discriminative ability of outcomes between PT practices, case-mix corrected hierarchical multilevel analyses were performed.ResultsReliability was sufficient by confirming fifteen of the sixteen hypotheses: 59% of all patients opted in for data analysis, 42% of these included patients showed repeated measurement, comparing with reference data and potential selection bias showed < 5% between group differences, while differences between (sub)acute and chronic NSLB-groups were significantly larger than 5% (less treatment sessions, lager differences in outcomes in (sub)acute NSLB patients). In addition, all nine adjusted hierarchical multilevel models confirm that the collected dataset on outcomes in PT care is able to discriminate between practices using PROM results of patients with NSLBP (ICC-scores range 0.11-0.21).LimitationsAlthough we have shown the reliability, validity and discriminative ability of the dataset in the quest to develop QIs, we are aware that reducing missing values in patient records and the selective participation of PTs that belong to the innovators needs attention in the next stages of implementation to avoid bias in the results.ConclusionPROMs of patients with NSLBP collected in the national clinical registry of KNGF are reliable, valid and able to discriminate between primary care PT practices.

PURPOSE:To assess and improve the effectiveness of ICU care, in-hospital mortality rates are often used as principal quality indicator for benchmarking purposes. Two other often used, easily quantifiable, quality indicators to assess the efficiency of ICU care are based on readmission to the ICU and ICU length of stay. Our aim was to examine whether there is an association between case-mix adjusted outcome-based quality indicators in the general ICU population as well as within specific subgroups. MATERIALS AND METHODS:We included patients admitted in 2015 of all Dutch ICUs. We derived the standardized in-hospital mortality ratio (SMR); the standardized readmission ratio (SRR); and the standardized length of stay ratio (SLOSR). We expressed association through Pearson's correlation coefficients. RESULTS:The SMR ranged from 0.6 to 1.5; the SRR ranged from 0.7 to 2.1; and the SLOSR ranged from 0.7 to 1.3. For the total ICU population we found no significant associations. We found a positive, non-significant, association between SMR and SLOSR for admissions with low-mortality risk, (r = 0.25; p = 0.024), and a negative association between these indicators for admissions with high-mortality risk (r = -0.49; p

Depression research has resulted in knowledge about neurobiology, pharmacological strategies and short-term cost-effective treatments. However, more than two-thirds of all depressed patients experience insufficient improvement. Therefore, a better understanding of what patients, carers and professionals perceive as most helpful in the treatment of depression is needed.Concept mapping, a mixed-method design, was used to identify the patients (n = 33), carers (n = 22) and professionals (n = 50) perspectives. In six brainstorm sessions, the patients, carers and professionals generated 795 ideas, which were condensed into 55 unique statements. Subsequently, 100 participants prioritized and sorted these statements, which were analysed by multidimensional scaling and cluster analysis and visualized as a two-dimensional map.The 55 statements were clustered in 10 factors and further grouped into four main-factors (meta-clusters): 'Professional therapist', 'Treatment content', 'Structured treatment process' and 'Treatment organisation'. Patients and carers prioritized 'Treatment organisation' higher than professionals, but overall there was considerable agreement about the factors of treatment the participants perceived as most helpful including factors related to the therapeutic relationship and the 'creation of hope'.Our study identified factors of depression treatment perceived as helpful according to patients, carers and professionals. Findings suggest that in a scientific era with emphasis on biological psychiatry, not only patients and carers, but also professionals consider aspecific factors the most helpful. Further studies might show that factors we found to be helpful in the treatment for depression, can be generalized to mental health treatment in general.

Sexual inequality starts in utero. The contribution of biological sex to the developmental origins of health and disease is increasingly recognized. The aim of this study was to assess and interpret sexual dimorphisms for three major adverse pregnancy outcomes which affect the health of the neonate, child and potentially adult.Retrospective population-based study of 574,358 South Australian singleton live births during 1981-2011. The incidence of three major adverse pregnancy outcomes [preterm birth (PTB), pregnancy induced hypertensive disorders (PIHD) and gestational diabetes mellitus (GDM)] in relation to fetal sex was compared according to traditional and fetus-at-risk (FAR) approaches.The traditional approach showed male predominance for PTB [20-24 weeks: Relative Risk (RR) M/F 1.351, 95%-CI 1.274-1.445], spontaneous PTB [25-29 weeks: RR M/F 1.118, 95%-CI 1.044-1.197%], GDM [RR M/F 1.042, 95%-CI 1.011-1.074], overall PIHD [RR M/F 1.053, 95%-CI 1.034-1.072] and PIHD with term birth [RR M/F 1.074, 95%-CI 1.044-1.105]. The FAR approach showed that males were at increased risk for PTB [20-24 weeks: RR M/F 1.273, 95%-CI 1.087-1.490], for spontaneous PTB [25-29 weeks: RR M/F 1.269, 95%-CI 1.143-1.410] and PIHD with term birth [RR M/F 1.074, 95%-CI 1.044-1.105%]. The traditional approach demonstrated female predominance for iatrogenic PTB [25-29 weeks: RR M/F 0.857, 95%-CI 0.780-0.941] and PIHD associated with PTB [25-29 weeks: RR M/F 0.686, 95%-CI 0.581-0.811]. The FAR approach showed that females were at increased risk for PIHD with PTB [25-29 weeks: RR M/F 0.779, 95%-CI 0.648-0.937].This study confirms the presence of sexual dimorphisms and presents a coherent framework based on two analytical approaches to assess and interpret the sexual dimorphisms for major adverse pregnancy outcomes. The mechanisms by which these occur remain elusive, but sex differences in placental gene expression and function are likely to play a key role. Further research on sex differences in placental function and maternal adaptation to pregnancy is required to delineate the causal molecular mechanisms in sex-specific pregnancy outcome. Identifying these mechanisms may inform fetal sex specific tailored antenatal and neonatal care.

In spite of the high importance of forests, global forest loss has remained alarmingly high during the last decades. Forest loss at a global scale has been unveiled with increasingly finer spatial resolution, but the forest extent and loss in protected areas (PAs) and in large intact forest landscapes (IFLs) have not so far been systematically assessed. Moreover, the impact of protection on preserving the IFLs is not well understood. In this study we conducted a consistent assessment of the global forest loss in PAs and IFLs over the period 2000-2012. We used recently published global remote sensing based spatial forest cover change data, being a uniform and consistent dataset over space and time, together with global datasets on PAs' and IFLs' locations. Our analyses revealed that on a global scale 3% of the protected forest, 2.5% of the intact forest, and 1.5% of the protected intact forest were lost during the study period. These forest loss rates are relatively high compared to global total forest loss of 5% for the same time period. The variation in forest losses and in protection effect was large among geographical regions and countries. In some regions the loss in protected forests exceeded 5% (e.g. in Australia and Oceania, and North America) and the relative forest loss was higher inside protected areas than outside those areas (e.g. in Mongolia and parts of Africa, Central Asia, and Europe). At the same time, protection was found to prevent forest loss in several countries (e.g. in South America and Southeast Asia). Globally, high area-weighted forest loss rates of protected and intact forests were associated with high gross domestic product and in the case of protected forests also with high proportions of agricultural land. Our findings reinforce the need for improved understanding of the reasons for the high forest losses in PAs and IFLs and strategies to prevent further losses.

The globalisation of trade affects land use, food production and environments around the world. In principle, globalisation can maximise productivity and efficiency if competition prompts specialisation on the basis of productive capacity. In reality, however, such specialisation is often constrained by practical or political barriers, including those intended to ensure national or regional food security. These are likely to produce globally sub-optimal distributions of land uses. Both outcomes are subject to the responses of individual land managers to economic and environmental stimuli, and these responses are known to be variable and often (economically) irrational. We investigate the consequences of stylised food security policies and globalisation of agricultural markets on land use patterns under a variety of modelled forms of land manager behaviour, including variation in production levels, tenacity, land use intensity and multi-functionality. We find that a system entirely dedicated to regional food security is inferior to an entirely globalised system in terms of overall production levels, but that several forms of behaviour limit the difference between the two, and that variations in land use intensity and functionality can substantially increase the provision of food and other ecosystem services in both cases. We also find emergent behaviour that results in the abandonment of productive land, the slowing of rates of land use change and the fragmentation or, conversely, concentration of land uses following changes in demand levels.

Safeguarding the benefits that ecosystems provide to society is increasingly included as a target in international policies. To support such policies, ecosystem service maps are made. However, there is little attention for the accuracy of these maps. We made a systematic review and quantitative comparison of ecosystem service maps on the European scale to generate insights in the uncertainty of ecosystem service maps and discuss the possibilities for quantitative validation. Maps of climate regulation and recreation were reasonably similar while large uncertainties among maps of erosion protection and flood regulation were observed. Pollination maps had a moderate similarity. Differences among the maps were caused by differences in indicator definition, level of process understanding, mapping aim, data sources and methodology. Absence of suitable observed data on ecosystem services provisioning hampers independent validation of the maps. Consequently, there are, so far, no accurate measures for ecosystem service map quality. Policy makers and other users need to be cautious when applying ecosystem service maps for decision-making. The results illustrate the need for better process understanding and data acquisition to advance ecosystem service mapping, modelling and validation.

Intensive care units (ICUs) are increasingly interested in assessing and improving their performance. ICU Length of Stay (LoS) could be seen as an indicator for efficiency of care. However, little consensus exists on which prognostic method should be used to adjust ICU LoS for case-mix factors. This study compared the performance of different regression models when predicting ICU LoS. We included data from 32,667 unplanned ICU admissions to ICUs participating in the Dutch National Intensive Care Evaluation (NICE) in the year 2011. We predicted ICU LoS using eight regression models: ordinary least squares regression on untransformed ICU LoS,LoS truncated at 30 days and log-transformed LoS; a generalized linear model with a Gaussian distribution and a logarithmic link function; Poisson regression; negative binomial regression; Gamma regression with a logarithmic link function; and the original and recalibrated APACHE IV model, for all patients together and for survivors and non-survivors separately. We assessed the predictive performance of the models using bootstrapping and the squared Pearson correlation coefficient (R2), root mean squared prediction error (RMSPE), mean absolute prediction error (MAPE) and bias. The distribution of ICU LoS was skewed to the right with a median of 1.7 days (interquartile range 0.8 to 4.0) and a mean of 4.2 days (standard deviation 7.9). The predictive performance of the models was between 0.09 and 0.20 for R2, between 7.28 and 8.74 days for RMSPE, between 3.00 and 4.42 days for MAPE and between -2.99 and 1.64 days for bias. The predictive performance was slightly better for survivors than for non-survivors. We were disappointed in the predictive performance of the regression models and conclude that it is difficult to predict LoS of unplanned ICU admissions using patient characteristics at admission time only.

Meta-analysis of case studies has become an important tool for synthesizing case study findings in land change. Meta-analyses of deforestation, urbanization, desertification and change in shifting cultivation systems have been published. This present study adds to this literature, with an analysis of the proximate causes and underlying forces of wetland conversion at a global scale using two complementary approaches of systematic review. Firstly, a meta-analysis of 105 case-study papers describing wetland conversion was performed, showing that different combinations of multiple-factor proximate causes, and underlying forces, drive wetland conversion. Agricultural development has been the main proximate cause of wetland conversion, and economic growth and population density are the most frequently identified underlying forces. Secondly, to add a more quantitative component to the study, a logistic meta-regression analysis was performed to estimate the likelihood of wetland conversion worldwide, using globally-consistent biophysical and socioeconomic location factor maps. Significant factors explaining wetland conversion, in order of importance, are market influence, total wetland area (lower conversion probability), mean annual temperature and cropland or built-up area. The regression analyses results support the outcomes of the meta-analysis of the processes of conversion mentioned in the individual case studies. In other meta-analyses of land change, similar factors (e.g., agricultural development, population growth, market/economic factors) are also identified as important causes of various types of land change (e.g., deforestation, desertification). Meta-analysis helps to identify commonalities across the various local case studies and identify which variables may lead to individual cases to behave differently. The meta-regression provides maps indicating the likelihood of wetland conversion worldwide based on the location factors that have determined historic conversions.

We hypothesised that normal skeletal muscle stimulated intensely either in vitro or in situ would exhibit reactive oxygen species (ROS)-mediated contractile apparatus changes common to many pathophysiological conditions. Isolated soleus (SOL) and extensor digitorum longus (EDL) muscles of the rat were bubbled with 95% O(2) and stimulated in vitro at 31°C to give isometric tetani (50 Hz for 0.5 s every 2 s) until maximum force declined to ≤30%. Skinned superficial slow-twitch fibers from the SOL muscles displayed a large reduction (∼41%) in maximum Ca(2+)-activated specific force (F(max)), with Ca(2+)-sensitivity unchanged. Fibers from EDL muscles were less affected. The decrease in F(max) in SOL fibers was evidently due to oxidation effects on cysteine residues because it was reversed if the reducing agent DTT was applied prior to activating the fiber. The GSH:GSSG ratio was ∼3-fold lower in the cytoplasm of superficial fibers from stimulated muscle compared to control, confirming increased oxidant levels. The presence of Tempol and L-NAME during in vitro stimulation prevented reduction in F(max). Skinned fibers from SOL muscles stimulated in vivo at 37°C with intact blood supply also displayed reduction in F(max), though to a much smaller extent (∼12%). Thus, fibers from muscles stimulated even with putatively adequate O(2) supply display a reversible oxidation-induced decrease in F(max) without change in Ca(2+)-sensitivity, consistent with action of peroxynitrite (or possibly superoxide) on cysteine residues of the contractile apparatus. Significantly, the changes closely resemble the contractile deficits observed in a range of pathophysiological conditions. These findings highlight how readily muscle experiences ROS-related deficits, and also point to potential difficulties when defining muscle performance and fatigue.

BackgroundDuring the inflammatory process, chemokine CXCL8 plays a pivotal role in recruitment of human neutrophilic granulocytes. A diversity of sequences similar to CXCL8 was reported in fish, but their evolutionary relationships and functional homology with their human homolog remain unclear.Principal findingsWe screened fish genomes to seek for sequences related to CXCL8. A first lineage was retrieved in all teleosts, while a second CXCL8 lineage was found in zebrafish and carp only. An early inflammatory function for both lineages was indicated by several lines of evidence. The induction of carp CXCL8s, CXCb, and CXC receptor-1 and -2 was analyzed after in vitro stimulation of leukocyte subpopulations and in two in vivo inflammation models. Recombinant proteins of carp CXCL8 proteins were produced and showed significant chemotactic activity for carp leukocytes.ConclusionsWhile both carp CXCL8s appear to be functional homologs of mammalian CXCL8, their different induction requirements and kinetics evoke a gene-specific sub-functionalization.

BACKGROUND: In mammalian vertebrates, the cytokine interleukin (IL)-12 consists of a heterodimer between p35 and p40 subunits whereas interleukin-23 is formed by a heterodimer between p19 and p40 subunits. During an immune response, the balance between IL-12 and IL-23 can depend on the nature of the pathogen associated molecular pattern (PAMP) recognized by, for example TLR2, leading to a preferential production of IL-23. IL-23 production promotes a Th17-mediated immune response characterized by the production of IL-17A/F and several chemokines, important for neutrophil recruitment and activation. For the cold blooded vertebrate common carp, only the IL-12 subunits have been described so far. METHODOLOGY/PRINCIPAL FINDINGS: Common carp is the natural host of two protozoan parasites: Trypanoplasma borreli and Trypanosoma carassii. We found that these parasites negatively affect p35 and p40a gene expression in carp. Transfection studies of HEK293 and carp macrophages show that T. carassii-derived PAMPs are agonists of carp TLR2, promoting p19 and p40c gene expression. The two protozoan parasites induce different immune responses as assessed by gene expression and histological studies. During T. carassii infections, in particular, we observed a propensity to induce p19 and p40c gene expression, suggestive of the formation of IL-23. Infections with T. borreli and T. carassii lead to an increase of IFN-γ2 gene expression whereas IL-17A/F2 gene expression was only observed during T. carasssii infections. The moderate increase in the number of splenic macrophages during T. borreli infection contrasts the marked increase in the number of splenic neutrophilic granulocytes during T. carassii infection, along with an increased gene expression of metalloproteinase-9 and chemokines. CONCLUSION/SIGNIFICANCE: This is the first study that provides evidence for a Th17-like immune response in fish in response to infection with a protozoan parasite.