Uptake of a free coronary heart disease risk screening programme in community pharmacy: the Healthy Heart Assessment service

Introduction Health promotion (HP) aims to enhance good health while preventing ill-health at three levels of activity; primary (preventative), secondary (diagnostic) and tertiary (management).1 It can range from simple provision of health education to ongoing support, but the effectiveness of HP is ultimately dependent on its ability to influence change. HP as part of the Community Pharmacy Contract (CPC) aims to increase public knowledge and target ‘hard-to-reach’ individuals by focusing mainly on primary and tertiary HP. The CPC does not include screening programmes (secondary HP) as a service. Coronary heart disease (CHD) is a significant cause of morbidity and mortality in the UK. While there is evidence to support the effectiveness of some community pharmacy HP strategies in CHD, there is paucity of research in relation to screening services.2 Against this background, Alliance Pharmacy introduced a free CHD risk screening programme to provide tailored HP advice as part of a participant–pharmacist consultation. The aim of this study is to report on the CHD risk levels of participants and to provide a qualitative indication of consultation outcomes. Methods Case records for 12 733 people who accessed a free CHD risk screening service between August 2004 and April 2006 offered at 217 community pharmacies were obtained. The service involved initial self-completion of the Healthy Heart Assessment (HHA) form and measurement of height, weight, body mass index, blood pressure, total cholesterol and highdensity lipoprotein levels by pharmacists to calculate CHD risk.3 Action taken by pharmacists (lifestyle advice, statin recommendation or general practitioner (GP) referral) and qualitative statements of advice were recorded, and a copy provided to the participants. The service did not include follow-up of participants. All participants consented to taking part in evaluations of the service. Ethical committee scrutiny was not required for this service development evaluation. Results Case records for 10 035 participants (3658 male) were evaluable; 5730 (57%) were at low CHD risk (<15%); 3636 (36%) at moderate-to-high CHD risk (≥15%); and 669 (7%) had existing heart disease. A significantly higher proportion of male (48% versus 30% female) participants were at moderate- to-high risk of CHD (chi-square test; P < 0.005). A range of outcomes resulted from consultations. Lifestyle advice was provided irrespective of participants’ CHD risk or existing disease. In the moderate-to-high-risk group, of which 52% received prescribed medication, lifestyle advice was recorded for 62%, 16% were referred and 34% were advised to have a re-assessment. Statin recommendations were made in 1% of all cases. There was evidence of supportive and motivational statements in the advice recorded. Discussion Pharmacists were able to identify individuals’ level of CHD risk and provide them with bespoke advice. Identification of at-risk participants did not automatically result in referrals or statin recommendation. One-third of those accessing the screening service had moderate-to-high risk of CHD, a significantly higher proportion of whom were men. It is not known whether these individuals had been previously exposed to HP but presumably by accessing this service they may have contemplated change. As effectiveness of HP advice will depend among other factors on ability to influence change, future consultations may need to explore patients’ attitude towards change in relation to the Trans Theoretical Model4 to better tailor HP advice. The high uptake of the service by those at moderate-to-high CHD risk indicates a need for this type of screening programme in community pharmacy, perhaps specifically to reach men who access medical services less.

Investigating age related changes in taste and affects on sensory perceptions of oral nutritional supplements

Background: sip feeds are oral nutritional supplements (ONSs) that are commonly prescribed to malnourished patients to improve their nutritional and clinical status. However, ONSs are poorly consumed and frequently wasted, with sweetness being identified as one of the factors leading to patients’ dislike of ONSs. Objectives: to investigate if age affects sweetness thresholds and if this impacts upon perceived sweetness intensity, hedonic (sweetness and overall) and ranked preference of ONS products. Design: prospective, observational. Subjects: thirty-six young adults (18–33 years) and 48 healthy older adults (63–85 years). Setting: Department of Food and Nutritional Sciences and the Clinical Health Sciences at the University of Reading. Methods: detection and recognition threshold levels, basic taste identification and ‘just about right’ level of sweetness were examined. Three ONSs (chocolate, vanilla, strawberry) and sucrose solutions were evaluated for hedonic sweetness, overall hedonic liking, sweetness intensity and rank preference. Results: significant differences were found in both sweetness detection and recognition thresholds (P = 0.0001) between young and older adults, with older adults more likely to incorrectly identify the taste (P = 0.0001). Despite the deterioration in sweetness sensitivity among the older adults, there were no significant differences found in sweetness intensity perceived for the ONS products presented (P > 0.05) when compared with the young adults. However, across both groups sweetness intensity was found to be correlated with overall product dislike across all flavour variants tested (R = 0.398, P = 0.0001). Conclusions: sweetness appears to be one of many factors contributing to the dislike of ONSs. Manufacturers are encouraged to reconsider the formulations of these products so that beneficial effects of ONSs can be delivered in a more palatable and acceptable form and wastage reduced.

Technical note: A proposed method to determine the extent of degradation of a feed in the rumen from the degradation profile obtained with the in vitro gas production technique using feces as the inoculum

A method is proposed to determine the extent of degradation in the rumen involving a two-stage mathematical modeling process. In the first stage, a statistical model shifts (or maps) the gas accumulation profile obtained using a fecal inoculum to a ruminal gas profile. Then, a kinetic model determines the extent of degradation in the rumen from the shifted profile. The kinetic model is presented as a generalized mathematical function, allowing any one of a number of alternative equation forms to be selected. This method might allow the gas production technique to become an approach for determining extent of degradation in the rumen, decreasing the need for surgically modified animals while still maintaining the link with the animal. Further research is needed before the proposed methodology can be used as a standard method across a range of feeds.

Effects of straw and silicon soil amendments on some foliar and stem-base diseases in pot-grown winter wheat

Four foliar and two stem-base pathogens were inoculated onto wheat plants grown in different substrates in pot experiments. Soils from four different UK locations were each treated in three ways: (i) straw incorporated in the field at 10 t ha−1 several months previously; (ii) silicon fertilization at 100 mg L−1 during the experiment; and (iii) no amendments. A sand and vermiculite mix was used with and without silicon amendment. The silicon treatment increased plant silica concentrations in all experiments, but incorporating straw was not associated with raised plant silica concentrations. Blumeria graminis and Puccinia recondita were inoculated by shaking infected plants over the test plants, followed by suitable humid periods. The silicon treatment reduced powdery mildew (B. graminis) substantially in sand and vermiculite and in two of the soils, but there were no effects on the slight infection by brown rust (P. recondita). Phaeosphaeria nodorum and Mycosphaerella graminicola were inoculated as conidial suspensions. Leaf spot caused by P. nodorum was reduced in silicon-amended sand and vermiculite; soil was not tested. Symptoms of septoria leaf blotch caused by M. graminicola were reduced by silicon amendment in a severely infected sand and vermiculite experiment but not in soil or a slightly infected sand and vermiculite experiment. Oculimacula yallundae (eyespot) and Fusarium culmorum (brown foot rot) were inoculated as agar plugs on the stem base. Severity of O. yallundae was reduced by silicon amendment of two of the soils but not sand and vermiculite; brown foot rot symptoms caused by F. culmorum were unaffected by silicon amendment. The straw treatment reduced severity of powdery mildew but did not detectably affect the other pathogens. Both straw and silicon treatments appeared to increase plant resistance to all diseases only under high disease pressure.

Mechanisms underlying agonist efficacy

Agonist efficacy is a measure of how well an agonist can stimulate a response system linked to a receptor. Efficacy can be assessed in functional assays and various parameters (E-max, K-A/EC50, E-max center dot K-A/EC50) determined. The E-max center dot K-A/EC50 parameter provides a good estimate of efficacy across the full range of efficacy. A convenient assay for the efficacy of agonists for some receptors is provided by the [S-35]GTP[S] (guanosine 5'-[gamma-[S-35]thio]triphosphate)-binding assay. in this assay, the normal GTP-binding event in GPCR (G-protein-coupled receptor) activation is replaced by the binding of the non-hydrolysable analogue [S-35]GTP[S]. This assay may be used to profile ligands for their efficacy, and an example here is the D-2 dopamine receptor where an efficacy scale has been set up using this assay. The mechanisms underlying the assay have been probed. The time course of [S-35]GTP[S] binding follows a pseudo-first-order reaction with [S-35]GTP[S] binding reaching equilibrium after approx. 3 h. The [S-35]GTP[S]-binding event is the rate-deter mining step in the assay. Agonists regulate the maximal level of [S-35]GTP[S] bound, rather than the rate constant for binding. The [S-35]GTP[S]-binding assay therefore determines agonist efficacy on the basis of the amount of [S-35]GTP[S] bound rather than the rate of binding.

Experimental design and model construction algorithms for radial basis function networks

New construction algorithms for radial basis function (RBF) network modelling are introduced based on the A-optimality and D-optimality experimental design criteria respectively. We utilize new cost functions, based on experimental design criteria, for model selection that simultaneously optimizes model approximation, parameter variance (A-optimality) or model robustness (D-optimality). The proposed approaches are based on the forward orthogonal least-squares (OLS) algorithm, such that the new A-optimality- and D-optimality-based cost functions are constructed on the basis of an orthogonalization process that gains computational advantages and hence maintains the inherent computational efficiency associated with the conventional forward OLS approach. The proposed approach enhances the very popular forward OLS-algorithm-based RBF model construction method since the resultant RBF models are constructed in a manner that the system dynamics approximation capability, model adequacy and robustness are optimized simultaneously. The numerical examples provided show significant improvement based on the D-optimality design criterion, demonstrating that there is significant room for improvement in modelling via the popular RBF neural network.

Cost733cat: a database of weather and circulation type classifications

A new database of weather and circulation type catalogs is presented comprising 17 automated classification methods and five subjective classifications. It was compiled within COST Action 733 "Harmonisation and Applications of Weather Type Classifications for European regions" in order to evaluate different methods for weather and circulation type classification. This paper gives a technical description of the included methods using a new conceptual categorization for classification methods reflecting the strategy for the definition of types. Methods using predefined types include manual and threshold based classifications while methods producing types derived from the input data include those based on eigenvector techniques, leader algorithms and optimization algorithms. In order to allow direct comparisons between the methods, the circulation input data and the methods' configuration were harmonized for producing a subset of standard catalogs of the automated methods. The harmonization includes the data source, the climatic parameters used, the classification period as well as the spatial domain and the number of types. Frequency based characteristics of the resulting catalogs are presented, including variation of class sizes, persistence, seasonal and inter-annual variability as well as trends of the annual frequency time series. The methodological concept of the classifications is partly reflected by these properties of the resulting catalogs. It is shown that the types of subjective classifications compared to automated methods show higher persistence, inter-annual variation and long-term trends. Among the automated classifications optimization methods show a tendency for longer persistence and higher seasonal variation. However, it is also concluded that the distance metric used and the data preprocessing play at least an equally important role for the properties of the resulting classification compared to the algorithm used for type definition and assignment.

How to quantify the resolution of surface climate by circulation types: an example for Alpine precipitation

A novel approach is presented for the evaluation of circulation type classifications (CTCs) in terms of their capability to predict surface climate variations. The approach is analogous to that for probabilistic meteorological forecasts and is based on the Brier skill score. This score is shown to take a particularly simple form in the context of CTCs and to quantify the resolution of a climate variable by the classifications. The sampling uncertainty of the skill can be estimated by means of nonparametric bootstrap resampling. The evaluation approach is applied for a systematic intercomparison of 71 CTCs (objective and manual, from COST Action 733) with respect to their ability to resolve daily precipitation in the Alpine region. For essentially all CTCs, the Brier skill score is found to be higher for weak and moderate compared to intense precipitation, for winter compared to summer, and over the north and west of the Alps compared to the south and east. Moreover, CTCs with a higher number of types exhibit better skill than CTCs with few types. Among CTCs with comparable type number, the best automatic classifications are found to outperform the best manual classifications. It is not possible to single out one ‘best’ classification for Alpine precipitation, but there is a small group showing particularly high skill.

‘God’s Truth’: Kant, Mill and moral epistemology in Oliver Twist

This essay aims to demonstrate how Dickens’s search for ‘truth’ (and his understanding of what that abstraction consists of) entered into and emerged from one of the key philosophical discussions of the early nineteenth century: namely whether moral knowledge is the sum of one’s experiences or whether there are such things as a priori or ‘natural’ principles of ethics that transcend human practice.

Protease-activated receptor 2 sensitizes the transient receptor potential vanilloid 4 ion channel to cause mechanical hyperalgesia in mice

Exacerbated sensitivity to mechanical stimuli that are normally innocuous or mildly painful (mechanical allodynia and hyperalgesia) occurs during inflammation and underlies painful diseases. Proteases that are generated during inflammation and disease cleave protease-activated receptor 2 (PAR2) on afferent nerves to cause mechanical hyperalgesia in the skin and intestine by unknown mechanisms. We hypothesized that PAR2-mediated mechanical hyperalgesia requires sensitization of the ion channel transient receptor potential vanilloid 4 (TRPV4). Immunoreactive TRPV4 was coexpressed by rat dorsal root ganglia (DRG) neurons with PAR2, substance P (SP) and calcitonin gene-related peptide (CGRP), mediators of pain transmission. In PAR2-expressing cell lines that either naturally expressed TRPV4 (bronchial epithelial cells) or that were transfected to express TRPV4 (HEK cells), pretreatment with a PAR2 agonist enhanced Ca2+ and current responses to the TRPV4 agonists phorbol ester 4alpha-phorbol 12,13-didecanoate (4alphaPDD) and hypotonic solutions. PAR2-agonist similarly sensitized TRPV4 Ca2+ signals and currents in DRG neurons. Antagonists of phospholipase Cbeta and protein kinases A, C and D inhibited PAR2-induced sensitization of TRPV4 Ca2+ signals and currents. 4alphaPDD and hypotonic solutions stimulated SP and CGRP release from dorsal horn of rat spinal cord, and pretreatment with PAR2 agonist sensitized TRPV4-dependent peptide release. Intraplantar injection of PAR2 agonist caused mechanical hyperalgesia in mice and sensitized pain responses to the TRPV4 agonists 4alphaPDD and hypotonic solutions. Deletion of TRPV4 prevented PAR2 agonist-induced mechanical hyperalgesia and sensitization. This novel mechanism, by which PAR2 activates a second messenger to sensitize TRPV4-dependent release of nociceptive peptides and induce mechanical hyperalgesia, may underlie inflammatory hyperalgesia in diseases where proteases are activated and released.