Effectiveness of medicines review with web-based pharmaceutical treatment algorithms in reducing potentially inappropriate prescribing in older people in primary care:a cluster randomized trial (OPTI-SCRIPT study protocol)

Potentially inappropriate prescribing in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. In Ireland, 36% of those aged 70 years or over received at least one potentially inappropriate medication, with an associated expenditure of over €45 million.The main objective of this study is to determine the effectiveness and acceptability of a complex, multifaceted intervention in reducing the level of potentially inappropriate prescribing in primary care.

Addressing potentially inappropriate prescribing in older patients: development and pilot study of an intervention in primary care (the OPTI-SCRIPT study)

Background: Potentially inappropriate prescribing (PIP) in older people is common in primary care and can result in increased morbidity, adverse drug events, hospitalizations and mortality. The prevalence of PIP in Ireland is estimated at 36% with an associated expenditure of over [euro sign]45 million in 2007. The aim of this paper is to describe the application of the Medical Research Council (MRC) framework to the development of an intervention to decrease PIP in Irish primary care.

Methods: The MRC framework for the design and evaluation of complex interventions guided the development of the study intervention. In the development stage, literature was reviewed and combined with information obtained from experts in the field using a consensus based methodology and patient cases to define the main components of the intervention. In the pilot stage, five GPs tested the proposed intervention. Qualitative interviews were conducted with the GPs to inform the development and implementation of the intervention for the main randomised controlled trial.

Results: The literature review identified PIP criteria for inclusion in the study and two initial intervention components - academic detailing and medicines review supported by therapeutic treatment algorithms. Through patient case studies and a focus group with a group of 8 GPs, these components were refined and a third component of the intervention identified - patient information leaflets. The intervention was tested in a pilot study. In total, eight medicine reviews were conducted across five GP practices. These reviews addressed ten instances of PIP, nine of which were addressed in the form of either a dose reduction or a discontinuation of a targeted medication. Qualitative interviews highlighted that GPs were receptive to the intervention but patient preference and time needed both to prepare for and conduct the medicines review, emerged as potential barriers. Findings from the pilot study allowed further refinement to produce the finalised intervention of academic detailing with a pharmacist, medicines review with web-based therapeutic treatment algorithms and tailored patient information leaflets.

Conclusions: The MRC framework was used in the development of the OPTI-SCRIPT intervention to decrease the level of PIP in primary care in Ireland. Its application ensured that the intervention was developed using the best available evidence, was acceptable to GPs and feasible to deliver in the clinical setting. The effectiveness of this intervention is currently being tested in a pragmatic cluster randomised controlled trial.

Trial registration: Current controlled trials ISRCTN41694007.© 2013 Clyne et al.; licensee BioMed Central Ltd.

Effectiveness of a Multifaceted Intervention for Potentially Inappropriate Prescribing in Older Patients in Primary Care: A Cluster-Randomized Controlled Trial (OPTI-SCRIPT Study)

PURPOSE Potentially inappropriate prescribing (PIP) is common in older people and can result in increased morbidity, adverse drug events, and hospitalizations. The OPTI-SCRIPT study (Optimizing Prescribing for Older People in Primary Care, a cluster-randomized controlled trial) tested the effectiveness of a multifaceted intervention for reducing PIP in primary care.

METHODS We conducted a cluster-randomized controlled trial among 21 general practitioner practices and 196 patients with PIP. Intervention participants received a complex, multifaceted intervention incorporating academic detailing; review of medicines with web-based pharmaceutical treatment algorithms that provide recommended alternative-treatment options; and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions. We performed intention-to-treat analysis using random-effects regression.

RESULTS All 21 practices and 190 patients were followed. At intervention completion, patients in the intervention group had significantly lower odds of having PIP than patients in the control group (adjusted odds ratio = 0.32; 95% CI, 0.15–0.70; P = .02). The mean number of PIP drugs in the intervention group was 0.70, compared with 1.18 in the control group (P = .02). The intervention group was almost one-third less likely than the control group to have PIP drugs at intervention completion, but this difference was not significant (incidence rate ratio = 0.71; 95% CI, 0.50–1.02; P = .49). The intervention was effective in reducing proton pump inhibitor prescribing (adjusted odds ratio = 0.30; 95% CI, 0.14–0.68; P = .04).

CONCLUSIONS The OPTI-SCRIPT intervention incorporating academic detailing with a pharmacist, and a review of medicines with web-based pharmaceutical treatment algorithms, was effective in reducing PIP, particularly in modifying prescribing of proton pump inhibitors, the most commonly occurring PIP drugs nationally.

Sustained effectiveness of a multifaceted intervention to reduce potentially inappropriate prescribing in older patients in primary care (OPTI-SCRIPT study)

Background: Potentially inappropriate prescribing (PIP) is common in older people in primary care and can result in increased morbidity, adverse drug events and hospitalisations. We previously demonstrated the success of a multifaceted intervention in decreasing PIP in primary care in a cluster randomised controlled trial (RCT).
Objective: We sought to determine whether the improvement in PIP in the short term was sustained at 1-year follow-up.
Methods: A cluster RCT was conducted with 21 GP practices and 196 patients (aged ≥70) with PIP in Irish primary care. Intervention participants received a complex multifaceted intervention incorporating academic detailing, medicine review with web-based pharmaceutical treatment algorithms that provide recommended alternative treatment options, and tailored patient information leaflets. Control practices delivered usual care and received simple, patient-level PIP feedback. Primary outcomes were the proportion of patients with PIP and the mean number of potentially inappropriate prescriptions at 1-year follow-up. Intention-to-treat analysis using random effects regression was used.
Results: All 21 GP practices and 186 (95 %) patients were followed up. We found that at 1-year follow-up, the significant reduction in the odds of PIP exposure achieved during the intervention was sustained after its discontinuation (adjusted OR 0.28, 95 % CI 0.11 to 0.76, P = 0.01). Intervention participants had significantly lower odds of having a potentially inappropriate proton pump inhibitor compared to controls (adjusted OR 0.40, 95 % CI 0.17 to 0.94, P = 0.04).
Conclusion: The significant reduction in the odds of PIP achieved during the intervention was sustained after its discontinuation. These results indicate that improvements in prescribing quality can be maintained over time.

A process evaluation of a cluster randomised trial to reduce potentially inappropriate prescribing in older people in primary care (OPTI-SCRIPT study)

Background
The OPTI-SCRIPT cluster randomised controlled trial (RCT) found that a three-phase multifaceted intervention including academic detailing with a pharmacist, GP-led medicines reviews, supported by web-based pharmaceutical treatment algorithms, and tailored patient information leaflets, was effective in reducing potentially inappropriate prescribing (PIP) in Irish primary care. We report a process evaluation exploring the implementation of the intervention, the experiences of those participating in the study and lessons for future implementation.

Methods
The OPTI-SCRIPT trial included 21 GP practices and 196 patients. The process evaluation used mixed methods. Quantitative data were collected from all GP practices and semi-structured interviews were conducted with GPs from intervention and control groups, and a purposive sample of patients from the intervention group. All interviews were transcribed verbatim and analysed using a thematic analysis.

Results
Despite receiving a standardised academic detailing session, intervention delivery varied among GP practices. Just over 70 % of practices completed medicines review as recommended with the patient present. Only single-handed practices conducted reviews without patients present, highlighting the influence of practice characteristics and resources on variation. Medications were more likely to be completely stopped or switched to another more appropriate medication when reviews were conducted with patients present. The patient information leaflets were not used by any of the intervention practices. Both GP (32 %) and patient (40 %) recruitment rates were modest. For those who did participate, overall, the experience was positively viewed, with GPs and patients referring to the value of medication reviews to improve prescribing and reduce unnecessary medications. Lack of time in busy GP practices and remuneration were identified as organisational barriers to future implementation.

Conclusions
The OPTI-SCRIPT intervention was positively viewed by both GPs and patients, both of whom valued the study’s objectives. Patient information leaflets were not a successful component of the intervention. Academic detailing and medication reviews are important components in changing PIP, and having patients present during the review process seems to be a more effective approach for decreasing PIP.

Form Follows Media::What is The Matrix as Film, Animation, Game and Comics?

In the digital age, the hyperspace of virtual reality systems stands out as a new spatial notion creating a parallel world to the space we live in. In this alternative realm, the body transforms into a hyperbody, and begins to follow the white rabbit. Not only in real world but also in the Matrix world. The Matrix project of Andy and Larry Wachowski started with a feature film released in 1999. However, The Matrix is not only a film (trilogy). It is a concept, a universe that brings real space and hyperspace together. It is a world represented not only in science fiction films but also in The Animatrix that includes nine animated Matrix films directed by Peter Chung, Andy Jones, Yoshiaki Kawajiri and others, four of which are written by the Wachowskis. The same universe is used in Enter the Matrix, a digital game whose script was written and directed by the brothers and a comic book, The Matrix Comics, which includes twelve different stories by artists like Neil Gaiman and Goef Darrow. The Wachowskis played an active role in the creation and realization of all these “products” of different media. The comic book came last (November 2003), however it is possible to argue that everything came out of comics – the storyboards of the original film. After all the Wachowskis have a background in comics.

In this study, I will focus on the formal analysis of the science fiction world of The Matrix - as a representation of hyperspace - in different media, feature film, animated film, digital game and comic book, focusing on diverse forms of space that come into being as a result of medium differences. To unfold the different formal characters of film, animation, game and comics, concepts and features including framing, flattening, continuity, movement, montage, sound/text, light and color will be discussed. An analysis of these products will help to open up a discussion on the relation of form, media and representation.

From imagery to intention: A dual route model of imagined contact effects

Imagined intergroup contact (Crisp & R. Turner, 2009) is a new indirect contact strategy for promoting tolerance and more positive intergroup relations. In this chapter, we review existing research on imagined contact and propose two routes-cognitive and affective-through which it can exert a positive influence on contact-related attitudes and intentions. We first review research that has established the beneficial impacts of imagined contact on intergroup attitudes via reduced intergroup anxiety, supporting its efficacy as an intervention where there exists little or no opportunity for direct contact. We then review more recent research showing that imagined contact not only improves attitudes, but can also enhance intentions to engage in future contact. These studies suggest that contact imagery provides a behavioural script that forms the cognitive basis for subsequent judgements about future contact intentions. Collectively, the findings from this research programme support the idea that imagined contact can complement more direct forms of contact-providing a way of initially encouraging an interest in engaging positively with outgroups before introducing face-to-face encounters. We discuss the implications of these findings for future theory and research, and how they can inform prejudice-reduction interventions seeking to capitalise on the beneficial effects of mental imagery.

Beyond Sex, Bond and Star Wars : Exhibition Data from the Southampton Odeon 1972-1980

This article uses the personal ledgers of a cinema manager to explore programming and film exhibition at the Southampton Odeon in the 1970s. The detailed accounts provide a rare insight into cinema exhibition and challenge the notion that 1970s cinema was all about sex, violence, horror and exploitation, suggesting instead that audiences at this cinema, favoured very different fare.

The systematic development of an innovative DVD to raise awareness of preconception care

The purpose of this article is to describe the design, development and process evaluation of a preconception counselling resource (a DVD) for women with pre-gestational diabetes. DVD design and development centred on two key stakeholders ('DVD user group' and 'professional advisory group') working alongside a professional multimedia company. The DVD user group provided feedback on preferred DVD style, and informed modifications and improvements. The professional advisory group prepared the script, and ensured content and face validity. Evaluation of the DVD's acceptability and usefulness was assessed among women with diabetes via a postal questionnaire. Development phase: the resulting DVD is a 45-minute programme with three parts, featuring eight women with diabetes sharing their views and experiences, alongside an evidence-based commentary. The programme focuses on the importance of preventing an unplanned pregnancy (highlighting contraception) and on essential planning advice. Evaluation phase: 97 women (89 with type 1 and 8 with type 2 diabetes) evaluated the DVD using a rating scale of 0-10. Mean (SD) scores were: 9.1 (1.3) for quality; 9.0 (1.4) for content; 8.8 (1.5) for interest; 8.7 (1.8) for usefulness; 7.8 (2.2) for knowledge acquisition; and 8.0 (2.1) for knowledge confirmation. This combined user and multi-professional advisory group approach has produced an innovative and highly acceptable preconception counselling resource for women with diabetes. The development process and outcome evaluation are an important point of reference for future educational programmes. Future research will evaluate the impact of this preconception counselling resource on pregnancy planning indicators and pregnancy outcome.

Jump

A feature film. I worked as script doctor on the film and wrote the final draft, for which I am credited. The film tells the story of New Year's Eve in Derry/Londonderry and a young woman's thwarted attempts to throw herself off the Foyle Bridge.

K-Theory of Azumaya Algebras over Schemes

Let X be a connected, noetherian scheme and A{script} be a sheaf of Azumaya algebras on X, which is a locally free O{script}-module of rank a. We show that the kernel and cokernel of K(X) ? K(A{script}) are torsion groups with exponent a for some m and any i = 0, when X is regular or X is of dimension d with an ample sheaf (in this case m = d + 1). As a consequence, K(X, Z/m) ? K(A{script}, Z/m), for any m relatively prime to a. © 2013 Copyright Taylor and Francis Group, LLC.

Three Types of Temporal Perspective: Characterizing Developmental Changes in Temporal Thought

This paper provides an outline of the development of temporal thinking that is underpinned by the idea that temporal cognition shifts from being event dependent to event independent over the preschool period. I distinguish between three different ways in which it may be possible to have a perspective on time: (1) a perspective that is grounded in script-like representations of repeated events; (2) a more sophisticated perspective that brings in an fundamental categorical distinction between events that have already happened and events that are yet to come; and (3) a mature temporal perspective that involves orienting oneself in time using a linear temporal framework, with a grasp of the distinctions between past, present, and future. I propose that, with development, children possess each of these types of perspective in turn, and that only the last of these involves being able to represent time in an event-independent way.

Es teatro vuestra oración: Santa Teresa’s performed confession in Juan Mayorga’s La lengua en pedazos

Juan Mayorga’s La Lengua en Pedazos (2010) strikes at the heart of the compositional circumstances of St Teresa's Libro de la Vida– staging, and arguably heightening the origins of her rhetorical strategies, the sense of awareness of readership and potential censure we encounter within the Libro de la Vida. His inquisitor refuses to be complicit in the tacit agreement that the word spoken in the theatrical space can conjure new realities –insistent on underscoring the textual origin of the visions painfully and partially offered up for his and our scrutiny. I will suggest that the persistent undertow towards a meta-commentary on the unmaking and remaking of the autobiographical text creates an unresolved tension between Teresa’s eloquent ability to take the spectator to a place beyond language, and our awareness that we are in the presence of a consummate performer, the textual source for the script itself produced with a supreme awareness of audience scrutiny. The play reflects ongoing lines of inquiry in our evolving understanding of the cultural production of Teresa and other holy women of the Early Modern period.