Effect of a pharmacist-led multicomponent intervention focussing on the medication monitoring phase to prevent potential adverse drug events in nursing homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

DESIGN: Randomized cluster trial.

SETTING: Twenty-five nursing homes serviced by two long-term care pharmacies.

PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care).

INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review.

MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity.

CONCLUSION: Using health information technology in long-term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use.

Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial

Objective: To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention.

Design: Randomised controlled trial with blinded outcome assessor.

Setting: Accident and emergency department and university based sports injury clinic.

Participants: 101 patients with an acute grade 1 or 2 ankle sprain.

Interventions: Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group).

Main outcome measures: The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks.

Results: An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity (53 minutes, 95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group).

Conclusion: An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.

Effect of preventive primary care outreach on health related quality of life among older adults at risk of functional decline: Randomised controlled trial

Objective: To evaluate the impact of a provider initiated primary care outreach intervention compared with usual care among older adults at risk of functional decline. Design: Randomised controlled trial. Setting: Patients enrolled with 35 family physicians in five primary care networks in Hamilton, Ontario, Canada. Participants Patients: were eligible if they were 75 years of age or older and were not receiving home care services. Of 3166 potentially eligible patients, 2662 (84%) completed the validated postal questionnaire used to determine risk of functional decline. Of 1724 patients who met the risk criteria, 769 (45%) agreed to participate and 719 were randomised. Intervention: The 12 month intervention, provided by experienced home care nurses in 2004-6, consisted of a comprehensive initial assessment using the resident assessment instrument for home care; collaborative care planning with patients, their families, and family physicians; health promotion; and referral to community health and social support services. Main outcome measures: Quality adjusted life years (QALYs), use and costs of health and social services, functional status, self rated health, and mortality. Results: The mean difference in QALYs between intervention and control patients during the study period was not statistically significant (0.017, 95% confidence interval -0.022 to 0.056; P=0.388). The mean difference in overall cost of prescription drugs and services between the intervention and control groups was not statistically significant, (-$C165 (£107; €118; $162), 95% confidence interval -$C16 545 to $C16 214; P=0.984). Changes over 12 months in functional status and self rated health were not significantly different between the intervention and control groups. Ten patients died in each group. Conclusions: The results of this study do not support adoption of this preventive primary care intervention for this target population of high risk older adults. Trial registration: Clinical trials NCT00134836.

Effect of sublingual application of cannabinoids on intraocular pressure:A pilot study

PURPOSE: The purpose of this study was to assess the effect on intraocular pressure (IOP) and the safety and tolerability of oromucosal administration of a low dose of delta-9-tetrahydrocannabinol (?-9-THC) and cannabidiol (CBD). PATIENTS AND METHODS: A randomized, double-masked, placebo-controlled, 4 way crossover study was conducted at a single center, using cannabis-based medicinal extract of ?-9-THC and CBD. Six patients with ocular hypertension or early primary open angle glaucoma received a single sublingual dose at 8 AM of 5 mg ?-9-THC, 20 mg CBD, 40 mg CBD, or placebo. Main outcome measure was IOP. Secondary outcomes included visual acuity, vital signs, and psychotropic effects. RESULTS: Two hours after sublingual administration of 5 mg ?-9-THC, the IOP was significantly lower than after placebo (23.5 mm Hg vs. 27.3 mm Hg, P=0.026). The IOP returned to baseline level after the 4-hour IOP measurement. CBD administration did not reduce the IOP at any time. However, the higher dose of CBD (40 mg) produced a transient elevation of IOP at 4 hours after administration, from 23.2 to 25.9 mm Hg (P=0.028). Vital signs and visual acuity were not significantly changed. One patient experienced a transient and mild paniclike reaction after ?-9-THC administration. CONCLUSIONS: A single 5 mg sublingual dose of ?-9-THC reduced the IOP temporarily and was well tolerated by most patients. Sublingual administration of 20 mg CBD did not reduce IOP, whereas 40 mg CBD produced a transient increase IOP rise. Copyright © 2006 by Lippincott Williams & Wilkins.

Hospital antibiotic use and its relationship to age-adjusted comorbidity and alcohol-based hand rub consumption

SUMMARY The objective of this study was to evaluate the effect of age-adjusted comorbidity and alcohol-based hand rub on monthly hospital antibiotic usage, retrospectively. A multivariate autoregressive integrated moving average (ARIMA) model was built to relate the monthly use of all antibiotics grouped together with age-adjusted comorbidity and alcohol-based hand rub over a 5-year period (April 2005-March 2010). The results showed that monthly antibiotic use was positively related to the age-adjusted comorbidity index (concomitant effect, coefficient 1·103, P = 0·0002), and negatively related to the use of alcohol-based hand rub (2-month delay, coefficient -0·069, P = 0·0533). Alcohol-based hand rub is considered a modifiable factor and as such can be identified as a target for quality improvement programmes. Time-series analysis may provide a suitable methodology for identifying possible predictive variables that explain antibiotic use in healthcare settings. Future research should examine the relationship between infection control practices and antibiotic use, identify other infection control predictive factors for hospital antibiotic use, and evaluate the impact of enhancing different infection control practices on antibiotic use in a healthcare setting.

Effect of geosynthetic reinforcement creep on the long term performance of an embankment

Geo-synthetic reinforcements are often used to enhance the stability of geotechnical structures such as embankments. These geosynthetic polymers often show significant creep deformational behaviour. In the short-term performance of a geotechnical structure, it may not play a significant role. However, while dealing with the long term behaviour, it is necessary to investigate its effect. In this paper two plane strain fully coupled finite element analysis have been conducted; one with and the other without taking into account of the creep behaviour of geosynthetics. A well documented field case of Leneghans embankment (Geogrid improved wide embankment constructed near Sydney, Australia in 1990s) have been used for this purpose. It is evident from the analyses that though the geosynthetic reinforcements may play a vital role in the performance/stability of an embankment in the early days (during and after construction), its contribution may become insignificant with time and the creep of geo-synthetic may not play a significant role in the long term stability. © 2012 American Society of Civil Engineers.

Investigating the promotional effect of methanol on the low temperature SCR reaction on Ag/Al2O3

Methanol has been shown to promote the hydrocarbon selective catalytic reduction of NO with octane and toluene over 2wt% Ag/AlO catalyst for the first time. In order to understand its role in the reaction fast transient kinetic methods and in situ DRIFTS analysis have been used. The catalytic activity tests showed that the addition of methanol to the HC-SCR reaction results in a significant improvement in the low temperature activity of a Ag/AlO catalyst, despite the fact that methanol on its own is not reactive for the HC-SCR reaction. This promotional effect of methanol is dependent on the concentration of added methanol and is not necessarily associated with a higher concentration of reductant in the SCR feed. The fast transient kinetic analysis has shown that at each temperature the addition of methanol enhances the conversions of both NO and octane and the production of N with high selectivity in comparison with those observed with n-octane or toluene alone. This phenomenon is similar to the effect of H which may be associated with the release of hydrogen and ammonia during the transient switches at 250 and 300°C. Together with the fast transient experiments, the DRIFTS results showed that NCO species are formed when introducing methanol to the n-octane-SCR feed while CN species are removed/consumed from the surfaces of the Ag catalyst. These NCO species formed by adding methanol may play a vital role in promoting the catalytic activity of NO reduction and methanol itself can be an in situ source for hydrogen formation, which subsequently enhances the SCR reaction. © 2014 Elsevier B.V.

The effect of warfarin therapy on breast, colorectal, lung, and prostate cancer survival: a population-based cohort study using the Clinical Practice Research Datalink

PURPOSE: Pre-clinical studies suggest that oral anticoagulant agents, such as warfarin, may inhibit metastases and potentially prolong survival in cancer patients. However, few population-based studies have examined the association between warfarin use and cancer-specific mortality.

METHODS: Using prescribing, cause of death, and cancer registration data from the UK Clinical Practice Research Datalink, four population-based cohorts were constructed, comprising breast, colorectal, lung, and prostate cancer patients diagnosed between 1 January 1998, and the 31 December 2010. Comparing pre-diagnostic warfarin users to non-users, multivariable Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95 % confidence intervals (CIs) for cancer-specific mortality.

RESULTS: Overall, 16,525 breast, 12,902 colorectal, 12,296 lung, and 12,772 prostate cancers were included. Pre-diagnostic warfarin use ranged from 2.4 to 4.7 %. There was little evidence of any strong association between warfarin use pre-diagnosis and cancer-specific mortality in prostate (adjusted HR 1.03, 95 % CI 0.84-1.26), lung (adjusted HR 1.06, 95 % CI 0.96-1.16), breast (adjusted HR 0.81, 95 % CI 0.62-1.07), or colorectal (adjusted HR 0.88, 95 % CI 0.77-1.01) cancer patients. Dose-response analyses did not reveal consistent evidence of reductions in users of warfarin defined by the number of prescriptions used and daily defined doses.

CONCLUSIONS: There was little evidence of associations between pre-diagnostic use of warfarin and cancer-specific mortality in lung, prostate, breast, or colorectal cancer patients.

An Investigation Into Improving Off-Design Performance in a Turbocharger Turbine Utilizing Non-Radial Blading

Off-design performance now plays a vital role in the design decisions made for automotive turbocharger turbines. Of particular interest is extracting more energy at high pressure ratios and lower rotational speeds. In this region of operation the U/C value will be low and the rotor will experience high values of positive incidence at the inlet. The positive incidence causes flow to separate on the suction surface and produces high blade loading at inlet, which drives tip leakage. A CFD analysis has been carried out on a number of automotive turbines utilizing non-radial fibred blading. To help improve secondary flows yet meet stress requirements a number of designs have been investigated. The inlet blade angle has been modified in a number of ways. Firstly, the blading has been adjusted as to provide a constant back swept angle in the span wise direction. Using the results of the constant back swept blading studies, the back swept blade angle was then varied in the span wise direction. In addition to this, in an attempt to avoid an increase in stress, the effect of varying the leading edge profile of the blade was investigated. It has been seen that off-design performance is improved by implementing back swept blading at the inlet. Varying the inlet angle in the span wise direction provided more freedom for meeting stress requirements and reduces the negative impact on blade performance at the design point. The blade leading edge profile was seen to offer small improvements during off-design operation with minimal effects on stress within the rotor. However, due to the more pointed nature of the leading edge, the rotor was less tolerant to flow misalignment at the design point.

Integration of design of experiment, surface response methodology and multi-layer validation to predict the effect of blanching on colour of tomato juice

Response surface methodology was used to develop models to predict the effect of tomato cultivar, juice pH, blanching temperature and time on colour change of tomato juice after blanching. The juice from three tomato cultivars with adjusted pH levels ranging from 3.9 to 4.6 were blanched at temperatures from 60-100 °C for 1-5 min using the central composite design (CCD). The colour change was assessed by calculating the redness (a/b) and total colour change (∆E) after measuring the Hunter L, a and b values. Developed models for both redness and ∆E were significant (p<0.0001) with satisfactory coefficient of determination (R2 = 0.99 and 0.97) and low coefficient of variation (CV% = 1.89 and 7.23), respectively. Multilevel validation that was implemented revealed that the variation between the predicted and experimental values obtained for redness and ∆E were within the acceptable error range of 7.3 and 22.4%, respectively

Effect of providing free glasses on children's educational outcomes in China: cluster randomized controlled trial

Objective: To assess the effect of provision of free glasses on academic performance in rural Chinese children with myopia. Design: Cluster randomized, investigator masked, controlled trial.Setting 252 primary schools in two prefectures in western China, 2012-13. Participants: 3177 of 19 934 children in fourth and fifth grades (mean age 10.5 years) with visual acuity <6/12 in either eye without glasses correctable to >6/12 with glasses. 3052 (96.0%) completed the study.Interventions Children were randomized by school (84 schools per arm) to one of three interventions at the beginning of the school year: prescription for glasses only (control group), vouchers for free glasses at a local facility, or free glasses provided in class. Main outcome measures: Spectacle wear at endline examination and end of year score on a specially designed mathematics test, adjusted for baseline score and expressed in standard deviations. Results: Among 3177 eligible children, 1036 (32.6%) were randomized to control, 988 (31.1%) to vouchers, and 1153 (36.3%) to free glasses in class. All eligible children would benefit from glasses, but only 15% wore them at baseline. At closeout glasses wear was 41% (observed) and 68% (self reported) in the free glasses group, and 26% (observed) and 37% (self reported) in the controls. Effect on test score was 0.11 SD (95% confidence interval 0.01 to 0.21) when the free glasses group was compared with the control group. The adjusted effect of providing free glasses (0.10, 0.002 to 0.19) was greater than parental education (0.03, −0.04 to 0.09) or family wealth (0.01, −0.06 to 0.08). This difference between groups was significant, but was smaller than the prespecified 0.20 SD difference that the study was powered to detect. Conclusions: The provision of free glasses to Chinese children with myopia improves children’s performance on mathematics testing to a statistically significant degree, despite imperfect compliance, although the observed difference between groups was smaller than the study was originally designed to detect. Myopia is common and rarely corrected in this setting. Trial Registration: Current Controlled Trials ISRCTN03252665.

Effect of accelerated rehabilitation on function after ankle sprain:randomised controlled trial

OBJECTIVE: To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention.

DESIGN: Randomised controlled trial with blinded outcome assessor.

SETTING: Accident and emergency department and university based sports injury clinic.

PARTICIPANTS: 101 patients with an acute grade 1 or 2 ankle sprain.

INTERVENTIONS: Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group).

MAIN OUTCOME MEASURES: The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks.

RESULTS: An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity (53 minutes, 95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group).

CONCLUSION: An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.

TRIAL REGISTRATION: Current Controlled Trials ISRCTN13903946.