[Ethics of (big) data applications in psychiatric practice]. / Ethiek van (big)datatoepassingen in de psychiatrische praktijk.

BACKGROUND: Due to rapid digitalization, an increasing amount of data is available in healthcare settings; big data and artificial intelligence (AI) have also made their appearance. AIM: To provide insight into various ethical dilemmas that need to be considered when applying big data in clinical practice. METHOD: Description and analyses of the ethical aspects associated with the use of clinical data in the context of psychiatric care. RESULTS: Various ethical aspects play a role in four phases; data collection, analysis, dissemination and application of results. In order to use clinical data and AI in a responsible manner, these aspects must be taken into account. CONCLUSION: The use of big data and AI in healthcare should aim to stimulate learning and improving care together with patients and professionals. Big data and AI should not be seen as the holy grail, but as a supporting tool in healthcare - a field in which many of the aspects that play a role in clinical care cannot be converted into measurable data.

Narrative medicine as a medical education tool: A systematic review.

Aim: Narrative medicine has been promoted as an innovative and effective means of stimulating medical students' professional development by teaching them to approach their patients' experiences of illness with more understanding and compassion. This systematic literature review aims to answer the following question: what evidence of effect is available in the literature about models for teaching narrative medicine? Methods: We conducted a narrative review of 36 articles and used the Best Evidence in Medical Education (BEME) Global Scale and Kirkpatrick Scale for strength and importance of evidence to categorize reported assessment strategies and to evaluate the effectiveness of their narrative medicine programs. Results: We found evidence that narrative medicine is an effective pedagogic tool with a clear and replicable structure and methodology. We also determined that a positive impact could be measured when pertaining to participation and modification of attitudes, knowledge, and skills. However, unequivocal evidence of the effect of narrative medicine on students' behavior or ongoing interaction with colleagues and patients is still lacking. Conclusion: While many recent publications describe the goals and virtues of a narrative-based approach, more research is needed to determine whether or not there is an ideological consensus undergirding this approach. In addition, it is still unclear whether the long-term impact of narrative medicine classroom interventions are felt by patients, or whether such interventions positively impact patient care.

Responsible data sharing in a big data-driven translational research platform: lessons learned.

BACKGROUND: To foster responsible data sharing in health research, ethical governance complementary to the EU General Data Protection Regulation is necessary. A governance framework for Big Data-driven research platforms will at least need to consider the conditions as specified a priori for individual datasets. We aim to identify and analyze these conditions for the Innovative Medicines Initiative's (IMI) BigData@Heart platform. METHODS: We performed a unique descriptive case study into the conditions for data sharing as specified for datasets participating in BigData@Heart. Principle investigators of 56 participating databases were contacted via e-mail with the request to send any kind of documentation that possibly specified the conditions for data sharing. Documents were qualitatively reviewed for conditions pertaining to data sharing and data access. RESULTS: Qualitative content analysis of 55 relevant documents revealed overlap on the conditions: (1) only to share health data for scientific research, (2) in anonymized/coded form, (3) after approval from a designated review committee, and while (4) observing all appropriate measures for data security and in compliance with the applicable laws and regulations. CONCLUSIONS: Despite considerable overlap, prespecified conditions give rise to challenges for data sharing. At the same time, these challenges inform our thinking about the design of an ethical governance framework for data sharing platforms. We urge current data sharing initiatives to concentrate on: (1) the scope of the research questions that may be addressed, (2) how to deal with varying levels of de-identification, (3) determining when and how review committees should come into play, (4) align what policies and regulations mean by "data sharing" and (5) how to deal with datasets that have no system in place for data sharing.

Ethics in clinical trial regulation: ethically relevant issues from EMA inspection reports.

BACKGROUND: Within the EU, regulators are obliged to take ethical issues into consideration during marketing authorization deliberation. The goal of this manuscript is to identify what kinds of ethical issues regulators encounter during marketing authorization application deliberations, and the incidence of these ethical issues. METHODS: This study used an EMA-provided Excel file that contains all the GCP non-compliance findings from all inspection reports from 2008-2012. There were 112 medicinal products and a total of 288 clinical trial sites. There were a total of 4014 GCP non-compliance findings. The findings that were ethically relevant were extracted using NVivo 10.0 and categories for the ethically relevant findings (ERFs) were created. Note was taken of the incidence of ERFs for each category and the inspectors' gradings of these findings were extracted. This study also looked at the mean and the maximum number of ERFs per grading per medicinal product application, as well as the number of medicinal products with at least one ERF and those with at least major ERFs. RESULTS: With multiple coding, there were 1685 ERFs. ERFs were present in almost all of the medicinal products (97.3%). The majority of ERFs were graded as major. At least major ERFs were present in almost all medicinal products with ERFs. The categories with the highest number of ERFs were protocol issues, patient safety, and professionalism issues. In terms of the density of combined critical and major findings, monitoring and oversight, protocol issues, and respect for persons top the list. This study also showed that, on average, there were 7.54 major and 2.95 critical ERFs per medicinal product application, although ERFs can increase to 30 major and 12 critical. CONCLUSION: Regulators regularly encounter ERFs that at least "might adversely affect the rights, safety or well-being of the subjects". It remains to be explored how regulators respond to these ethical issues.

Site-specific ion occupation in the selectivity filter causes voltage-dependent gating in a viral K+ channel.

Many potassium channels show voltage-dependent gating without a dedicated voltage sensor domain. This is not fully understood yet, but often explained by voltage-induced changes of ion occupation in the five distinct K+ binding sites in the selectivity filter. To better understand this mechanism of filter gating we measured the single-channel current and the rate constant of sub-millisecond channel closure of the viral K+ channel KcvNTS for a wide range of voltages and symmetric and asymmetric K+ concentrations in planar lipid membranes. A model-based analysis employed a global fit of all experimental data, i.e., using a common set of parameters for current and channel closure under all conditions. Three different established models of ion permeation and various relationships between ion occupation and gating were tested. Only one of the models described the data adequately. It revealed that the most extracellular binding site (S0) in the selectivity filter functions as the voltage sensor for the rate constant of channel closure. The ion occupation outside of S0 modulates its dependence on K+ concentration. The analysis uncovers an important role of changes in protein flexibility in mediating the effect from the sensor to the gate.

Directional K+ channel insertion in a single phospholipid bilayer: Neutron reflectometry and electrophysiology in the joint exploration of a model membrane functional platform.

We investigated the insertion of small potassium (K+) channel proteins (KcvMA-1D and KcvNTS) into model membranes and the lipid-protein structural interference, combining neutron reflectometry and electrophysiology. Neutron reflectometry experiments showed how the transverse structure and mechanical properties of the bilayer were modified, upon insertion of the proteins in single model-membranes, either supported on solid substrate or floating. Parallel electrophysiology experiments were performed on the same channels reconstituted in free-standing planar lipid bilayers, of both typical composition and matched to the neutron reflectometry experiment, assessing their electrical features. Functional and structural results converge in detecting that the proteins, conical in shape, insert with a directionality, cytosolic side first. Our work addresses the powerful combination of the two experimental approaches. We show here that membrane structure spectroscopy and ion channel electrophysiology can become synergistic tools in the analysis of structural-functional properties of biomimetic complex environment.

Phospholamban spontaneously reconstitutes into giant unilamellar vesicles where it generates a cation selective channel.

Phospholamban (PLN) is a small integral membrane protein, which modulates the activity of the Sarcoplasmic Reticulum Ca(2+)-ATPase (SERCA) of cardiac myocytes. PLN, as a monomer, can directly interact and tune SERCA activity, but the physiological function of the pentameric form is not yet fully understood and still debated. In this work, we reconstituted PLN in Giant Unilamellar Vesicles (GUVs), a simple and reliable experimental model system to monitor the activity of proteins in membranes. By Laser Scanning Confocal Microscopy (LSCM) and Fluorescence Correlation Spectroscopy (FCS) we verified a spontaneous reconstitution of PLN into the phospholipid bilayer. In parallel experiments, we measured with the patch clamp technique canonical ion channel fluctuations, which highlight a preference for Cs(+) over K(+) and do not conduct Ca(2+). The results prove that PLN forms, presumably in its pentameric form, a cation selective ion channel.

Frequent induction of chromosomal aberrations in in vivo skin fibroblasts after allogeneic stem cell transplantation: hints to chromosomal instability after irradiation.

BACKGROUND: Total body irradiation (TBI) has been part of standard conditioning regimens before allogeneic stem cell transplantation for many years. Its effect on normal tissue in these patients has not been studied extensively. METHOD: We studied the in vivo cytogenetic effects of TBI and high-dose chemotherapy on skin fibroblasts from 35 allogeneic stem cell transplantation (SCT) patients. Biopsies were obtained prospectively (n = 18 patients) before, 3 and 12 months after allogeneic SCT and retrospectively (n = 17 patients) 23-65 months after SCT for G-banded chromosome analysis. RESULTS: Chromosomal aberrations were detected in 2/18 patients (11 %) before allogeneic SCT, in 12/13 patients (92 %) after 3 months, in all patients after 12 months and in all patients in the retrospective group after allogeneic SCT. The percentage of aberrant cells was significantly higher at all times after allogeneic SCT compared to baseline analysis. Reciprocal translocations were the most common aberrations, but all other types of stable, structural chromosomal aberrations were also observed. Clonal aberrations were observed, but only in three cases they were detected in independently cultured flasks. A tendency to non-random clustering throughout the genome was observed. The percentage of aberrant cells was not different between patients with and without secondary malignancies in this study group. CONCLUSION: High-dose chemotherapy and TBI leads to severe chromosomal damage in skin fibroblasts of patients after SCT. Our long-term data suggest that this damage increases with time, possibly due to in vivo radiation-induced chromosomal instability.

Tectonics of a K⁺ channel: The importance of the N-terminus for channel gating.

The small K⁺ channel Kcv represents the pore module of complex potassium channels. It was found that its gating can be modified by sensor domains, which are N-terminally coupled to the pore. This implies that the short N-terminus of the channel can transmit conformational changes from upstream sensors to the channel gates. To understand the functional role of the N-terminus in the context of the entire channel protein, we apply combinatorial screening of the mechanical coupling and long-range interactions in the Kcv potassium channel by reduced molecular models. The dynamics and mechanical connections in the channel complex show that the N-terminus is indeed mechanically connected to the pore domain. This includes a long rang coupling to the pore and the inner and outer transmembrane domains. Since the latter domains host the two gates of the channel, the data support the hypothesis that mechanical perturbation of the N-terminus can be transmitted to the channel gates. This effect is solely determined by the topology of the channel; sequence details only have an implicit effect on the coarse-grained dynamics via the fold and not through biochemical details at a smaller scale. This observation has important implications for engineering of synthetic channels on the basis of a K⁺ channel pore.

Factors affecting hearing improvement following successful repair of the tympanic membrane.

BACKGROUND: The main aim of tympanic membrane repair is the elimination of chronic or intermittent aural discharge. Hearing improvement may or may not occur following a technically successful operation. METHOD: This study entailed a retrospective analysis of prospectively collected data from 203 operations that resulted in an intact tympanic membrane 6 months after surgery. RESULTS: Complete hearing data were available for 169 operations on 160 patients. Of these, 53 per cent resulted in closure of the air-bone gap to within 10 dB, and 54 per cent of cases had post-operative hearing thresholds of at least 30 dB. The mean hearing change after surgery was +8.3 dB. Multiple regression analysis indicated that hearing improvement was more likely in large compared with small perforations. Smaller hearing gains occurred in ears with erosion of the stapes arch and/or fixation of the stapes, as well as in those with active discharge at the time of surgery and in revision cases. CONCLUSION: Greater hearing improvement can be expected following successful repair of perforations involving more than 50 per cent of the drum area. Poorer results are likely to occur in ears with additional middle-ear pathology and in revision cases.

Arsenite-induced apoptosis of human neuroblastoma cells requires p53 but occurs independently of c-Jun.

Arsenite treatment of human SH-SY5Y neuroblastoma cells leads to an upregulation of caspase-3/7 activity and to the fragmentation of chromatin that is accompanied by elevated p53 and c-Jun levels. Expression of a truncated mutant of p53, p53DD, which interfered with the oligomerization of p53, suppressed the arsenite-induced upregulation of caspase-3/7 activity and the fragmentation of chromatin, indicating that p53 is required for arsenite-induced cell death. These data were corroborated by knockdown experiments of p53 following expression of a p53-specific short hairpin RNA. Likewise, expression of either p53DD or knockdown of p53 prevented caspase-3/7 activation and chromatin fragmentation induced by nutlin-3, a compound that prevents the interaction between p53 and the E3 ubiquitin ligase MDM2. Transcriptional upregulation of a chromatin-embedded p53-responsive reporter gene in either arsenite or nutlin-3 stimulated neuroblastoma cells revealed that the transcriptional activity of p53 was increased under these conditions. Expression of a c-Jun-specific short hairpin RNA failed to impair arsenite-induced caspase-3/7 activation and fragmentation of chromatin. Likewise, inhibition of c-Jun target gene expression by expression of a dominant-negative mutant of c-Jun did not interfere with arsenite-induced caspase-3/7 activation and chromatin fragmentation. However, this approach successfully reduced caspase-3/7 activity induced as a result of forced expression of a constitutively active mutant of mitogen-activated protein kinase/extracellular signal-regulated kinase kinase kinase (MEKK)-1. Together, these data show that the upregulation of p53 is causally linked with arsenite-induced cell death in neuroblastoma cells, whereas the upregulation of c-Jun is not part of this apoptotic signaling cascade.

Thymic-thoracic ratio in fetuses with trisomy 21, 18 or 13.

OBJECTIVES: To assess thymic size expressed as the thymic-thoracic ratio (TT-ratio) in fetuses with trisomy 21, 18 or 13. METHODS: The TT-ratio, the quotient of the anteroposterior thymic and the intrathoracic mediastinal diameter, was measured in 65 trisomic fetuses between 15 and 36 weeks' gestation, including 30 cases with trisomy 21, 19 with trisomy 18 and 16 with trisomy 13. In addition these 65 fetuses were divided into two groups, according to whether they showed growth that was appropriate-for-gestational age (AGA) (n = 39) or intrauterine growth restriction (IUGR) (n = 26). Measurements were compared with reference ranges from 302 normal fetuses. RESULTS: The TT-ratio was low in 27.7% (n = 18) of the 65 fetuses with aneuploidy. In comparison to normal fetuses (mean TT-ratio, 0.44), those with trisomy 18 or 21 had a significantly smaller TT-ratio (mean, 0.38 (P < 0.001) and 0.40 (P < 0.05), respectively), while those with trisomy 13 did not (mean, 0.43). These values were not as low as those observed previously in fetuses with del.22q11, suggesting a mechanism involving accelerated thymic involution rather than primary thymic hypoplasia. Furthermore, the TT-ratio was significantly lower than normal in both AGA (P < 0.05) and IUGR (P < 0.001) fetuses. CONCLUSION: Fetuses with trisomy 18 or 21, but not trisomy 13, have a small thymus, suggesting accelerated thymic involution in utero. IUGR may contribute to the reduced thymic size in trisomy 18 fetuses. Trisomy 21 fetuses seem to have additional factors leading to a small thymus which could be a possible confirmation of the reduced immune response observed in fetuses and neonates with Down syndrome.

Wegener's granulomatosis presenting as meningitis.

BACKGROUND: Wegener's granulomatosis is a rare but well recognised autoimmune necrotising vasculitis. Presentation of disease in the head and neck is common and mostly consists of nasal crusting, blockage and bloody discharge. Neurological presentation is very uncommon. METHODS: We report a patient who presented to the medical emergency services with signs and symptoms of meningitis, but who was eventually diagnosed with Wegener's granulomatosis. A literature search on this topic was carried out using Medline and Embase (1996 to 2011), searching for 'Wegener's granulomatosis' and 'meningitis'. RESULTS: After thorough neurological and medical investigation, a combination of brain computed tomography, lumbar puncture, nasal biopsy and laboratory results refuted the diagnosis of meningitis and confirmed the diagnosis of Wegener's granulomatosis. CONCLUSION: To the best of our knowledge, this is the first English-language case report of a patient with Wegener's granulomatosis presenting with symptoms of meningitis unconfirmed on computed tomography and lumbar puncture.

Publication trends in newspapers and scientific journals for SSRIs and suicidality: a systematic longitudinal study.

Background In the period 2003-2008, the regulatory authorities issued several warnings restricting the use of selective serotonin re-uptake inhibitors (SSRIs) in paediatrics, in reaction to safety concerns regarding the risk of suicidality. In this study, the SSRIs and suicidality controversy serves as a template to analyse the long-term publication trends regarding the benefit/risk profile of medications. The aim is to ascertain differences (in terms of numbers, categories and timing) between negative and positive newspaper and journal articles on SSRIs and suicidality and to ascertain correlations between changes in the reports and regulatory warnings. Methods A systematic review of scientific articles (Embase) and the Netherlands (NL) and the UK newspapers (LexisNexis) was performed between 2000 and 2010. Categorisation was done by 'effect' (related treatment effect), 'type of article' and 'age group'. The articles' positive-to-negative effect ratio was determined. Differences in distribution of effect categories were analysed across sources, type of article and age group using the Mann-Whitney (two subgroups) or Kruskal-Wallis test (three or more). Findings In total, 1141 articles were categorised: 352 scientific, 224 Dutch and 565 British newspaper articles. Scientific articles were predominantly on research and were positive, whereas newspaper articles were negative (ratios=3.50-scientific, 0.69-NL and 0.94-UK; p<0.001). Articles on paediatrics were less positive in scientific journals and more negative in newspapers (ratios=2.29-scientific, 0.26-NL and 0.20-UK; p<0.001), while articles on adults were positive overall (ratios=10.0-scientific, 1.06-NL and 1.70-UK; p<0.001). In addition, negative-effect reporting trends were exacerbated following regulatory warnings and were generally opinion articles, both in scientific journals and in newspapers (2003/2004 and after 2007). Interpretation The authors found a positive publication tendency inherent in journal research articles. This apparent positive publication bias present in scientific journals, however, does not seem to prevent the dissemination of 'bad' news about medications. The negative tendency present in Dutch and British newspapers was perceivable in the paediatrics group and during the warnings, indicating that national news media have informed the public about this international drug safety controversy on time.

The thymic-thoracic ratio in fetal heart defects: a simple way to identify fetuses at high risk for microdeletion 22q11.

OBJECTIVES: To establish reference ranges for the fetal thymic-thoracic ratio (TT-ratio) and to compare results with those from fetuses with congenital heart defects (CHD) with and without microdeletion 22q11 (del.22q11), a condition known to be associated with a hypoplastic thymus. METHODS: TT-ratio was defined as the quotient of the anteroposterior thymic to the intrathoracic mediastinal diameters measured in the three vessels and trachea view. This ratio was measured in a prospective cross-sectional study of 302 normal healthy fetuses between 15 and 39 weeks' gestation. The study group comprised two groups: one group (CHDn) consisted of 90 fetuses with CHD and a normal karyotype with no del.22q11 and the other group (CHD(22)) included 20 fetuses with CHD and a normal karyotype but with proven del.22q11. RESULTS: The TT-ratio of the normal fetuses did not show any statistically significant change during gestation, with a mean value of 0.44. The values of all 90 fetuses of the CHDn group were within the normal range and no different from normal fetuses. However, 19 of the 20 (95%) fetuses in the CHD(22) group had a significantly smaller TT-ratio (P < 0.001) compared with both the CHDn group and the normal fetuses, having a mean value of 0.25. CONCLUSIONS: The TT-ratio is reliable and easy to obtain during fetal echocardiography. Fetuses with CHD and a low TT-ratio can be considered at high risk of having microdeletion del.22q11.