Microplastics and plastisphere at surface waters in the Southwestern Caribbean sea.

Pollution generated by plastic waste has brought an environmental problem characterized by the omnipresence of smaller pieces of this material known as microplastics (MP). This issue was addresses by collecting samples with 250 µm pore size nets in two marine-coastal sectors of Southwestern Caribbean Sea during two contrasting seasons. Higher concentrations were found in rainy season than in dry season, reaching respectively 1.72 MP/m3 and 0.22 MP/m3. Within each sector, there were differences caused firstly by localities of higher concentrations of semi-closed water bodies localities during rainy season (Ciénaga Grande de Santa Marta and La Caimanera marsh), and secondly by lower concentrations of localities with less influenced of flow rates during dry season (Salamanca and Isla Fuerte). Moreover, the lowest concentration in dry season corresponding to La Caimanera marsh reflects how the community environmental management might decrease MP pollution. In both sectors and seasons, the particles of 0.3 mm (0.3-1.4 mm) size class dominated over those of 1.4 mm (1.4-5.0 mm) (reaching each respectively 1.33 MP/m3 and 0.39 MP/m3), with a dominance of fibers, except in the rainy season in Magdalena, where they were films. Using the FTIR technique, polypropylene was identified as the most abundant polymer in both sectors. The composition of the assemblage of microorganisms attached to microplastics presented higher richness and differed from that of free-living planktonic microbes. The most abundant members of the plastisphere were proteobacteria whose major representation was the pathogenic genus Vibrio, while the cyanobacteria dominated in seawater samples.

Cohesive framework for non-line-of-sight imaging based on Dirac notation.

The non-line-of-sight (NLOS) imaging field encompasses both experimental and computational frameworks that focus on imaging elements that are out of the direct line-of-sight, for example, imaging elements that are around a corner. Current NLOS imaging methods offer a compromise between accuracy and reconstruction time as experimental setups have become more reliable, faster, and more accurate. However, all these imaging methods implement different assumptions and light transport models that are only valid under particular circumstances. This paper lays down the foundation for a cohesive theoretical framework which provides insights about the limitations and virtues of existing approaches in a rigorous mathematical manner. In particular, we adopt Dirac notation and concepts borrowed from quantum mechanics to define a set of simple equations that enable: i) the derivation of other NLOS imaging methods from such single equation (we provide examples of the three most used frameworks in NLOS imaging: back-propagation, phasor fields, and f-k migration); ii) the demonstration that the Rayleigh-Sommerfeld diffraction operator is the propagation operator for wave-based imaging methods; and iii) the demonstration that back-propagation and wave-based imaging formulations are equivalent since, as we show, propagation operators are unitary. We expect that our proposed framework will deepen our understanding of the NLOS field and expand its utility in practical cases by providing a cohesive intuition on how to image complex NLOS scenes independently of the underlying reconstruction method.

Assessing the Predictive Factors for Bleeding in Esophageal Variceal Disease: A Systematic Review.

Esophageal varices, dilated submucosal distal esophageal veins, are a common source of upper gastrointestinal bleeding in patients with portal hypertension. This review aims to comprehensively assess predictive factors for both the first occurrence and subsequent risk of esophageal variceal bleeding. A systematic search was conducted in PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online) and Cochrane databases. A total of 33 studies were selected using rigorous inclusion and exclusion criteria. The risk of bias was assessed using the Newcastle-Ottawa Scale. Several predictive factors were identified for esophageal variceal bleeding, including the Child-Pugh score, Fibrosis Index, specific endoscopic findings, ultrasound parameters, portal vein diameter, presence and size of collaterals, CT scan findings, ascites, platelet counts, coagulation parameters, albumin levels, Von Willebrand Factor, bilirubin levels, diabetes mellitus, and the use of b-blocking agents in primary prophylaxis. The findings of this systematic review shed light on multiple potential predictive factors for esophageal variceal bleeding. Endoscopic findings were found to be reliable predictors. Additionally, ultrasound parameters showed associations with bleeding risk. This systematic review identifies multiple potential predictive factors for esophageal variceal bleeding in patients with portal hypertension. While certain factors exhibit strong predictive capabilities, further research is needed to refine and validate these findings, considering potential limitations and biases. This study serves as a critical resource for bridging knowledge gaps in this field.

Structure-aware parametric representations for time-resolved light transport.

Time-resolved illumination provides rich spatiotemporal information for applications such as accurate depth sensing or hidden geometry reconstruction, becoming a useful asset for prototyping and as input for data-driven approaches. However, time-resolved illumination measurements are high-dimensional and have a low signal-to-noise ratio, hampering their applicability in real scenarios. We propose a novel method to compactly represent time-resolved illumination using mixtures of exponentially modified Gaussians that are robust to noise and preserve structural information. Our method yields representations two orders of magnitude smaller than discretized data, providing consistent results in such applications as hidden-scene reconstruction and depth estimation, and quantitative improvements over previous approaches.

Predator control of marine communities increases with temperature across 115 degrees of latitude.

Early naturalists suggested that predation intensity increases toward the tropics, affecting fundamental ecological and evolutionary processes by latitude, but empirical support is still limited. Several studies have measured consumption rates across latitude at large scales, with variable results. Moreover, how predation affects prey community composition at such geographic scales remains unknown. Using standardized experiments that spanned 115° of latitude, at 36 nearshore sites along both coasts of the Americas, we found that marine predators have both higher consumption rates and consistently stronger impacts on biomass and species composition of marine invertebrate communities in warmer tropical waters, likely owing to fish predators. Our results provide robust support for a temperature-dependent gradient in interaction strength and have potential implications for how marine ecosystems will respond to ocean warming.

Use of Generic Antiretroviral Drugs and Single-Tablet Regimen De-Simplification for the Treatment of HIV Infection in Spain.

The present study sought to describe the use of generic drugs and single-tablet regimen (STR) de-simplification for the treatment of human immunodeficiency virus (HIV) infection among 41 hospitals from the cohort of the Spanish HIV/AIDS Research Network (CoRIS). In June 2018, we collected information on when generic antiretroviral drugs (ARVs) were introduced in the different hospitals, how the decisions to use them were made, and how the information was provided to the patients. Most of the nine available generic ARVs in Spain by June 2018 had been introduced in at least 85% of the participating hospitals, except for zidovudine (AZT)/lamivudine (3TC) and AZT. The time difference between the effective marketing date of each generic ARV and its first dispensing date in the hospitals was much shorter for the more recently approved generic ARV since the year 2017. However, only up to 20% of the hospitals de-simplified efavirenz (EFV)/tenofovir disoproxil (TDF)/emtricitabine (FTC), dolutegravir (DTG)/abacavir (ABC)/3TC, and rilpivirine (RPV)/TDF/FTC (to generic EFV+TDF/FTC, DTG+generic ABC/3TC, and RPV+generic TDF/FTC, respectively), whereas the generic STR EFV/TDF/FTC was introduced in 87.8% of the centers. The median times between the date of effective marketing of generic TDF/FTC and the date of de-simplification of EFV/TDF/FTC and RPV/TDF/FTC were 723 [interquartile range (IQR): 369-1,119] and 234 (IQR: 142-264) days, respectively; this time was 155 (IQR: 28-287) days for de-simplification of DTG/ABC/3TC. In conclusion, despite the widespread use of generic ARVs, STRs de-simplification was only undertaken in <20% of the hospitals. There was wide variability in the timing of the introduction of each generic ARV after they were available in the market.

How patients with COVID-19 managed the disease at home during the first wave in Spain: a cross-sectional study.

OBJECTIVE: Most patients with mild COVID-19 had to stay at home trying to implement an optimal quarantine. The aim of this study was to describe the COVID-19 cases during the first wave of the pandemic in Spain, how they managed the disease at home, focusing on differences by age, as well as differences in knowledge, attitudes and preventive practices, compared with the uninfected population. DESIGN: An online survey was used to conduct a cross-sectional study of individuals who were 14 years or older living in Spain during the COVID-19 lockdown. The main variable was a COVID-19 case. Logistic regression models for COVID-19 cases were obtained using a backward stepwise procedure to assess the association between social variables, disease knowledge, attitudes, prevention practices and emotional impact. RESULTS: 3398 people completed the survey. Participants' mean age was 49.6 (SD=14.3). COVID-19 was significantly more prevalent among married people (5.3%) and those currently doing an on-site work (8.7%). Most of the COVID-19 cases stayed at home (84.0%) during the episode. There were significant age-based differences with regard to self-isolation conditions at home during the disease. COVID-19 cases showed better attitudes, practices and knowledge about disease symptoms and transmission than the uninfected population. COVID-19 cases also felt more depressed (adjusted OR: 3.46, 95% CI 1.45 to 8.26) and had better preventive behaviour than the uninfected population, such as always wearing a mask outside the home (adjusted OR 1.58, 95% CI 1.06 to 2.30). CONCLUSION: COVID-19 cases found it difficult to comply with recommended home self-isolation conditions, with differences by age group. COVID-19 had an important impact on care dependency in non-hospitalised patients, who were mostly dependent on their families for care. It is necessary to reinforce social and health services and to be ready to meet the care needs of populations during the different waves or in future epidemics.

Late presentation for HIV impairs immunological but not virological response to antiretroviral treatment.

OBJECTIVES: The aim of this study was to examine the impact of late presentation (CD4+ cell count <350 cells/µl or an AIDS-defining event) on effectiveness and safety of initial antiretroviral therapy (ART) and to evaluate whether treatment response depends on first-line ART regimen in late presenters. DESIGN: ART-naive adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) starting triple ART between 2010 and 2018. METHODS: We used multivariable models to assess differences in viral suppression (viral load <50 copies/ml), immunological response (change in CD4+ cell count, CD4% (>29%) and CD4/CD8 normalization (>0.4 and >1) multiple T-cell marker recovery (MTMR): CD4+ cell count more than 500 cells/µl and CD4% >29% and CD4/CD8 >1), and treatment discontinuation due to adverse events (TDAE) at 48 weeks from ART initiation. RESULTS: Out of 8002 participants, 48.7% were late presenters. Of them, 45.8% initiated ART with a NNRTI- (mostly TDF/FTC/EFV), 33.9% with a protease inhibitor (mostly TDF/FTC+boosted DRV) and 20.3% with an INI-based regimen (mostly ABC/3TC/DTG). At 48 weeks, late presenters had similar viral suppression, but worse immunological response, than non-late presenters with no difference on TDAE. Late presenters initiating with NNRTI-based regimens were more likely to achieve viral suppression than those starting with INI-based, due to the higher chance of achieving viral suppression observed with TDF/FTC/RPV compared to ABC/3TC/DTG. Initial treatment with NNRTI or protease inhibitor based showed similar immunological response than the INI-based regimens, which showed lower rates of TDAE than NNRTI- and protease inhibitor based regimens. CONCLUSION: Despite safety and effectiveness of initial ART in terms of viral suppression, late presenters may not experience complete immunological response. In late presenters, effectiveness and safety depends on both the class and the specific first-line ART regimen.

Defining a Standardized Information Model for Multi-Source Representation of Breast Cancer Data.

This work aims to define a standardized information model for representation of multiple data sources in breast cancer. A set of data elements has been identified using ICHOM Breast Cancer as the minimum data set and adapting it to the needs of Hospital Universitario 12 de Octubre. With this, an information model has been defined according to ISO 13606 and SNOMED CT standards.

Compression and denoising of time-resolved light transport.

Exploiting temporal information of light propagation captured at ultra-fast frame rates has enabled applications such as reconstruction of complex hidden geometry and vision through scattering media. However, these applications require high-dimensional and high-resolution transport data, which introduces significant performance and storage constraints. Additionally, due to different sources of noise in both captured and synthesized data, the signal becomes significantly degraded over time, compromising the quality of the results. In this work, we tackle these issues by proposing a method that extracts meaningful sets of features to accurately represent time-resolved light transport data. Our method reduces the size of time-resolved transport data up to a factor of 32, while significantly mitigating variance in both temporal and spatial dimensions.

Executing Complexity-Increasing Queries in Relational (MySQL) and NoSQL (MongoDB and EXist) Size-Growing ISO/EN 13606 Standardized EHR Databases.

This research shows a protocol to assess the computational complexity of querying relational and non-relational (NoSQL (not only Structured Query Language)) standardized electronic health record (EHR) medical information database systems (DBMS). It uses a set of three doubling-sized databases, i.e. databases storing 5000, 10,000 and 20,000 realistic standardized EHR extracts, in three different database management systems (DBMS): relational MySQL object-relational mapping (ORM), document-based NoSQL MongoDB, and native extensible markup language (XML) NoSQL eXist. The average response times to six complexity-increasing queries were computed, and the results showed a linear behavior in the NoSQL cases. In the NoSQL field, MongoDB presents a much flatter linear slope than eXist. NoSQL systems may also be more appropriate to maintain standardized medical information systems due to the special nature of the updating policies of medical information, which should not affect the consistency and efficiency of the data stored in NoSQL databases. One limitation of this protocol is the lack of direct results of improved relational systems such as archetype relational mapping (ARM) with the same data. However, the interpolation of doubling-size database results to those presented in the literature and other published results suggests that NoSQL systems might be more appropriate in many specific scenarios and problems to be solved. For example, NoSQL may be appropriate for document-based tasks such as EHR extracts used in clinical practice, or edition and visualization, or situations where the aim is not only to query medical information, but also to restore the EHR in exactly its original form.

Examining database persistence of ISO/EN 13606 standardized electronic health record extracts: relational vs. NoSQL approaches.

BACKGROUND: The objective of this research is to compare the relational and non-relational (NoSQL) database systems approaches in order to store, recover, query and persist standardized medical information in the form of ISO/EN 13606 normalized Electronic Health Record XML extracts, both in isolation and concurrently. NoSQL database systems have recently attracted much attention, but few studies in the literature address their direct comparison with relational databases when applied to build the persistence layer of a standardized medical information system. METHODS: One relational and two NoSQL databases (one document-based and one native XML database) of three different sizes have been created in order to evaluate and compare the response times (algorithmic complexity) of six different complexity growing queries, which have been performed on them. Similar appropriate results available in the literature have also been considered. RESULTS: Relational and non-relational NoSQL database systems show almost linear algorithmic complexity query execution. However, they show very different linear slopes, the former being much steeper than the two latter. Document-based NoSQL databases perform better in concurrency than in isolation, and also better than relational databases in concurrency. CONCLUSION: Non-relational NoSQL databases seem to be more appropriate than standard relational SQL databases when database size is extremely high (secondary use, research applications). Document-based NoSQL databases perform in general better than native XML NoSQL databases. EHR extracts visualization and edition are also document-based tasks more appropriate to NoSQL database systems. However, the appropriate database solution much depends on each particular situation and specific problem.

Normalized medical information visualization.

A new mark-up programming language is introduced in order to facilitate and improve the visualization of ISO/EN 13606 dual model-based normalized medical information. This is the first time that visualization of normalized medical information is addressed and the programming language is intended to be used by medical non-IT professionals.

Service for the Pseudonymization of Electronic Healthcare Records Based on ISO/EN 13606 for the Secondary Use of Information.

The availability of electronic health data favors scientific advance through the creation of repositories for secondary use. Data anonymization is a mandatory step to comply with current legislation. A service for the pseudonymization of electronic healthcare record (EHR) extracts aimed at facilitating the exchange of clinical information for secondary use in compliance with legislation on data protection is presented. According to ISO/TS 25237, pseudonymization is a particular type of anonymization. This tool performs the anonymizations by maintaining three quasi-identifiers (gender, date of birth, and place of residence) with a degree of specification selected by the user. The developed system is based on the ISO/EN 13606 norm using its characteristics specifically favorable for anonymization. The service is made up of two independent modules: the demographic server and the pseudonymizing module. The demographic server supports the permanent storage of the demographic entities and the management of the identifiers. The pseudonymizing module anonymizes the ISO/EN 13606 extracts. The pseudonymizing process consists of four phases: the storage of the demographic information included in the extract, the substitution of the identifiers, the elimination of the demographic information of the extract, and the elimination of key data in free-text fields. The described pseudonymizing system was used in three telemedicine research projects with satisfactory results. A problem was detected with the type of data in a demographic data field and a proposal for modification was prepared for the group in charge of the drawing up and revision of the ISO/EN 13606 norm.

La relación entre peltigera sp. y rhizophora magle en arroyo de plata (Bolívar), caribe Colombiano / The relationhip between peltigera sp. and rhizophora manglein arroyo de pllata (bolivar), Colombian caribbean region

Objetivo: determinar la distribución y el estado de los rodales de manglar en Arroyo de Plata (Departamento de Bolívar). Metodología: se realizaron labores de campo a través del arbolado, mediante el muestreo biológico de la flora y de los parámetros físicos y químicos del agua y de los suelos a lo largo de transectos dentro del bosque. Resultados: la composición del rodal incluye cinco especies, Rhizophora mangle (mangle rojo, colorao o colorado), Avicennia germinans (mangle salado, prieto, negro o iguanero), Laguncularia racemosa (mangle blanco, amarillo o bobo), Conocarpus erecta (mangle zaragoza) y Pelliciera rhizophorae (mangle piñuelo). Asociado a la especie pionera (R. mangle) se encontró el líquen (Peltigera sp.), cuya relación se lleva a cabo solo cuando el mangle está en estado de degradación y los parámetros fisicoquímicos de las aguas y los suelos, son extremos. Conclusión: Los manglares mostraron características mixtas, tipo maduro ribereño y de cuenca, donde la especie invasora P. rhizophorae presenta el mayor IVI, debido a su alta densidad. El registro de los líquenes Peltigera sp. y su presencia en los manglares del Caribe colombiano no solo es el primero para esta Región, su distribución puede estar restringida a la zona costera, es incidental, y demuestra su gran capacidad de adaptación a los cambios ambientales, y puede ser considerada entre los en bio-indicadores de las características ambientales, especialmente de las alteraciones actuales de los suelos y las aguas.

Objective: To determine the distribution and status of mangrove stands in Arroyo de Plata (Department of Bolívar). Methodology: Field work was conducted through woodland, using biological sampling of the flora and the physical and chemical parameters of water and soil along transects within the forest. Results: The composition of the stand includes five species, Rhizophoramangle (red, colorao or colorado mangrove), Avicenniagerminans (salty, dark color, black or iguanero mangle) Laguncularia racemosa (white, yellow or bobo mangrove), Conocarpus erecta (zaragoza mangle) and Pelliciera rhizophorae (tea mangrove). The lichen (Peltigera sp), was found associated with the pioneer species (R. mangrove) whose relationship is carried out only when the mangrove is in a state of degradation and the physical-chemical parameters of water and soil, are extreme. Conclusion: Mangroves showed mature coastal basin type mixed characteristics, where the invasive species P. rhizophorae has the highest IVI due to its high density. Registration of Peltigera sp lichens and its presence of the Colombian Caribbean mangrove is not only the first for this region, its distribution may be restricted to the coastal zone, it is incidental and demonstrates its ability to adapt to environmental changes, and can be considered between the bio-indicators of environmental characteristics, especially of the the current alterations of soil and water.

Compliance with antibiotic prophylaxis in spinal fusion surgery and surgical wound infection.

BACKGROUND: Surgical wound infection is an important complication of spinal surgery. Antibiotic prophylaxis has served to decrease its rates significantly, with the ensuing reduction in hospital stay, costs, and morbidity and mortality. To date, a large assessment of the degree of compliance with antibiotic prophylaxis in spinal fusion surgery has not been undertaken in Spain with large prospective studies. We sought to assess the degree of compliance with our antibiotic prophylaxis protocol among patients who underwent spinal fusion surgery and its effect on surgical wound infection. MATERIAL AND METHODS: A prospective cohort study was carried out. Six hundred and forty patients with at least 1-year clinical followup who underwent spinal fusion surgery were included. Percentage of administration and degree of compliance with protocol was studied. Both overall and the different aspects of prophylaxis received by patients to those stipulated in the protocol in force at our hospital were compared. Percentages of compliance were assessed and the effect of prophylaxis compliance on the incidence of infection was estimated using the Relative Risk. RESULTS: The study covered 640 patients. Overall compliance with the protocol was 71.5% (95% CI = 67.9- 75.1). The most frequent cause of non-compliance with the protocol was the duration of recommended antibiotic prophylaxis (77.8%). Incidence of surgical wound infection was 4.1% (95% CI: 2.5-5.5). No relationship was found between surgical wound infection and antibiotic prophylaxis non-compliance (RR 0.92, 95% CI = 0.38-2.22). CONCLUSIONS: Compliance and administration of antibiotic prophylaxis were high. Surgical wound infection rate was similar to those found in the literature although there is always room for improvement.

The usefulness of activity trackers in elderly with reduced mobility: a case study.

UNLABELLED: This study was conducted to determine the accuracy and usefulness of two current commercially available activity trackers in rollator dependent elderly with reduced mobility (RME), compared with elderly with normal mobility (NME) and healthy adults (HA). METHODS: Accuracy of pedometers placed at hip (Fitbit Ultra and Samsung GT-I9300 mobile phone) and wrist (Fitbit Ultra) were evaluated against actual steps (video) in RME (n=5), NME (n=7) and HA (n=6). Walk speed, Tinetti gait score and device percent error was calculated and analyzed in SPSS using Kruskal-Wallis, Mann-Whitney U and correlation tests. RESULTS: NME and HA walked significantly faster (p = 0.001) than RME, had significantly higher gait score (p < 0.05). Gait scores were correlated with walking speed and negatively with pedometer percent error (p < 0.01). Estimation error in RME were >60% at all device locations CONCLUSIONS: Slow walking speed and gait disorders hamper the utility of pedometers for physical activity measurement in rollator dependent elderly, with estimation errors >60%. The tested devices are better suited for use by ostensibly healthy elderly or adult populations.

Heart failure in primary care: co-morbidity and utilization of health care resources.

BACKGROUND: In order to ensure proper management of primary care (PC) services, the efficiency of the health professionals tasked with such services must be known. Patients with heart failure (HF) are characterized by advanced age, high co-morbidity and high resource utilization. OBJECTIVE: To ascertain PC resource utilization by HF patients and variability in the management of such patients by GPs. METHODS: Descriptive, cross-sectional study targeting a population attended by 129 GPs over the course of 1 year. All patients with diagnosis of HF in their clinical histories were included, classified using the Adjusted Clinical Group system and then grouped into six resource utilization bands (RUBs). Resource utilization and Efficiency Index were both calculated. RESULTS: One hundred per cent of patients with HF were ranked in RUBs 3, 4 and 5. The highest GP visit rate was 20 and the lowest in excess of 10 visits per year. Prescription drug costs for these patients ranged from €885 to €1422 per patient per year. Health professional efficiency varied notably, even after adjustment for co-morbidity (Efficiency Index Variation Ratio of 28.27 for visits and 404.29 for prescription drug cost). CONCLUSIONS: Patients with HF register a high utilization of resources, and there is great variability in the management of such patients by health professionals, which cannot be accounted for by the degree of case complexity.

Comorbidity in patients with chronic obstructive pulmonary disease in family practice: a cross sectional study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is frequent and often coexists with other diseases. The aim of this study was to quantify the prevalence of COPD and related chronic comorbidity among patients aged over 40 years visiting family practices in an area of Madrid. METHODS: An observational, descriptive, cross-sectional study was conducted in a health area of the Madrid Autonomous Region (Comunidad Autónoma de Madrid). The practice population totalled 198,670 persons attended by 129 Family Physicians (FPs), and the study population was made up of persons over the age of 40 years drawn from this practice population. Patients were deemed to have COPD if this diagnosis appeared on their clinical histories. Prevalence of COPD; prevalence of a further 25 chronic diseases in patients with COPD; and standardised prevalence ratios, were calculated. RESULTS: Prevalence of COPD in family medicine was 3.2% (95% CI 3.0-3.3) overall, 5.3% among men and 1.4% among women; 90% of patients presented with comorbidity, with a mean of 4 ± 2.04 chronic diseases per patient, with the most prevalent related diseases being arterial hypertension (52%), disorders of lipid metabolism (34%), obesity (25%), diabetes (20%) and arrhythmia (15%). After controlling for age and sex, the observed prevalence of the following ten chronic diseases was higher than expected: heart failure; chronic liver disease; asthma; generalised artherosclerosis; osteoporosis; ischaemic heart disease; thyroid disease; anxiety/depression; arrhythmia; and obesity. CONCLUSIONS: Patients with COPD, who are frequent in family practice, have a complex profile and pose a clinical and organisational challenge to FPs.

ccML, a new mark-up language to improve ISO/EN 13606-based electronic health record extracts practical edition.

OBJECTIVE: The objective of this paper is to introduce a new language called ccML, designed to provide convenient pragmatic information to applications using the ISO/EN13606 reference model (RM), such as electronic health record (EHR) extracts editors. EHR extracts are presently built using the syntactic and semantic information provided in the RM and constrained by archetypes. The ccML extra information enables the automation of the medico-legal context information edition, which is over 70% of the total in an extract, without modifying the RM information. MATERIALS AND METHODS: ccML is defined using a W3C XML schema file. Valid ccML files complement the RM with additional pragmatics information. The ccML language grammar is defined using formal language theory as a single-type tree grammar. The new language is tested using an EHR extracts editor application as proof-of-concept system. RESULTS: Seven ccML PVCodes (predefined value codes) are introduced in this grammar to cope with different realistic EHR edition situations. These seven PVCodes have different interpretation strategies, from direct look up in the ccML file itself, to more complex searches in archetypes or system precomputation. DISCUSSION: The possibility to declare generic types in ccML gives rise to ambiguity during interpretation. The criterion used to overcome ambiguity is that specificity should prevail over generality. The opposite would make the individual specific element declarations useless. CONCLUSION: A new mark-up language ccML is introduced that opens up the possibility of providing applications using the ISO/EN13606 RM with the necessary pragmatics information to be practical and realistic.