Appropriate Polypharmacy and Medicine Safety: When Many is not Too Many

The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of ‘many’ drugs and ‘too many’ drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients’ clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients’ safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving ‘many’ medicines. It is now recognised that the prescribing of ‘many’ medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients’ clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term ‘appropriate polypharmacy’ in differentiating between the prescribing of ‘many’ drugs and ‘too many’ drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research.

Footbridge system identification using wireless inertial measurement units for force and response measurements

With the main focus on safety, design of structures for vibration serviceability is often overlooked or mismanaged, resulting in some high profile structures failing publicly to perform adequately under human dynamic loading due to walking, running or jumping. A standard tool to inform better design, prove fitness for purpose before entering service and design retrofits is modal testing, a procedure that typically involves acceleration measurements using an array of wired sensors and force generation using a mechanical shaker. A critical but often overlooked aspect is using input (force) to output (response) relationships to enable estimation of modal mass, which is a key parameter directly controlling vibration levels in service.

This paper describes the use of wireless inertial measurement units (IMUs), designed for biomechanics motion capture applications, for the modal testing of a 109 m footbridge. IMUs were first used for an output-only vibration survey to identify mode frequencies, shapes and damping ratios, then for simultaneous measurement of body accelerations of a human subject jumping to excite specific vibrations modes and build up bridge deck accelerations at the jumping location. Using the mode shapes and the vertical acceleration data from a suitable body landmark scaled by body mass, thus providing jumping force data, it was possible to create frequency response functions and estimate modal masses.

The modal mass estimates for this bridge were checked against estimates obtained using an instrumented hammer and known mass distributions, showing consistency among the experimental estimates. Finally, the method was used in an applied research application on a short span footbridge where the benefits of logistical and operational simplicity afforded by the highly portable and easy to use IMUs proved extremely useful for an efficient evaluation of vibration serviceability, including estimation of modal masses.

Combustion Noise

Combustion noise is becoming increasingly important as a major noise source in aeroengines and ground based gas turbines. This is partially because advances in design have reduced the other noise sources, and partially because next generation combustion modes burn more unsteadily, resulting in increased external noise from the combustion. This review reports recent progress made in understanding combustion noise by theoretical, numerical and experimental investigations. We first discuss the fundamentals of the sound emission from a combustion region. Then the noise of open turbulent flames is summarized. We subsequently address the effects of confinement on combustion noise. In this case not only is the sound generated by the combustion influenced by its transmission through the boundaries of the combustion chamber, there is also the possibility of a significant additional source, the so-called ‘indirect’ combustion noise. This involves hot spots (entropy fluctuations) or vorticity perturbations produced by temporal variations in combustion, which generate pressure waves (sound) as they accelerate through any restriction at the exit of the combustor. We describe the general characteristics of direct and indirect noise. To gain further insight into the physical phenomena of direct and indirect sound, we investigate a simple configuration consisting of a cylindrical or annular combustor with a low Mach number flow in which a flame zone burns unsteadily. Using a low Mach number approximation, algebraic exact solutions are developed so that the parameters controlling the generation of acoustic, entropic and vortical waves can be investigated. The validity of the low Mach number approximation is then verified by solving the linearized Euler equations numerically for a wide range of inlet Mach numbers, stagnation temperature ratios, frequency and mode number of heat release fluctuations. The effects of these parameters on the magnitude of the waves produced by the unsteady combustion are investigated. In particular the magnitude of the indirect and direct noise generated in a model combustor with a choked outlet is analyzed for a wide range of frequencies, inlet Mach numbers and stagnation temperature ratios. Finally, we summarize some of the unsolved questions that need to be the focus of future research