A method for incorporating climate variability in climate change impact assessments: sensitivity of river flows in the Eden catchment to precipitation scenarios

Interest in the impacts of climate change is ever increasing. This is particularly true of the water sector where understanding potential changes in the occurrence of both floods and droughts is important for strategic planning. Climate variability has been shown to have a significant impact on UK climate and accounting for this in future climate cahgne projections is essential to fully anticipate potential future impacts. In this paper a new resampling methodology is developed which includes the variability of both baseline and future precipitation. The resampling methodology is applied to 13 CMIP3 climate models for the 2080s, resulting in an ensemble of monthly precipitation change factors. The change factors are applied to the Eden catchment in eastern Scotland with analysis undertaken for the sensitivity of future river flows to the changes in precipitation. Climate variability is shown to influence the magnitude and direction of change of both precipitation and in turn river flow, which are not apparent without the use of the resampling methodology. The transformation of precipitation changes to river flow changes display a degree of non-linearity due to the catchment's role in buffering the response. The resampling methodology developed in this paper provides a new technique for creating climate change scenarios which incorporate the important issue of climate variability.

'Eden Cinema' by Marguerite Duras

Duras’s theatre work has been profoundly neglected by UK theatre academics and practitioners, and Eden Cinema has almost no performance history in Britain. My project asked three interconnected research questions: how developing the performance contributes to understanding Duras’s theatre and specifically Eden Cinema’s problems of performability; how multimedia performance emphasising mediated sound and the live body reconfigures memory, autobiography, storytelling, gender and racial identity; how to locate a performance style appropriate for Durasian narratives of displacement and death which reflect the discontinuous and mutable form of Duras’s ‘texte/film/théâtre’. Drawing on my research interests in gender, post-colonial hybridity and performed deconstruction, I focused my staging decisions on the discontinuities and ambivalences of the text. I addressed performability by avoiding the temptation to resolve the strange ellipses in the text and instead evoked the text’s imperfect and fragmented memories, and its uncertain spatial and temporal locations, by means of a fluid theatrical form. The mise-en-scène represented imagined and remembered spaces simultaneously, and co-existing historical moments. The performance style counterpointed live and mediated action and audio-visual forms. A complex through-composed soundscape, comprising voice-over, sound and music, became a key means for evoking overlapping temporalities, interconnected narratives and fragmented memories that were dispersed across the performance. The disempowerment of the mother figure and the silent indigenous servant in the text was demonstrated through their spatial centrality but physical stillness. The servant’s colonial subaltern identity was paralleled and linked with the mother’s disenfranchisement through their proxemic relationships. I elicited a performance style which evoked ‘characters’, whose being was deferred across different regimes of reality and who ‘haunted’ the stage rather than inhabited it. I developed the project further in the additional written outcomes and presentations, and the subsequent performance of Savannah Bay where problems of performability intensify until embodiment is almost erased except via voice.

LiDAR mapping of tidal marshes for ecogeomorphological modelling in the TIDE project

The European research project TIDE (Tidal Inlets Dynamics and Environment) is developing and validating coupled models describing the morphological, biological and ecological evolution of tidal environments. The interactions between the physical and biological processes occurring in these regions requires that the system be studied as a whole rather than as separate parts. Extensive use of remote sensing including LiDAR is being made to provide validation data for the modelling. This paper describes the different uses of LiDAR within the project and their relevance to the TIDE science objectives. LiDAR data have been acquired from three different environments, the Venice Lagoon in Italy, Morecambe Bay in England, and the Eden estuary in Scotland. LiDAR accuracy at each site has been evaluated using ground reference data acquired with differential GPS. A semi-automatic technique has been developed to extract tidal channel networks from LiDAR data either used alone or fused with aerial photography. While the resulting networks may require some correction, the procedure does allow network extraction over large areas using objective criteria and reduces fieldwork requirements. The networks extracted may subsequently be used in geomorphological analyses, for example to describe the drainage patterns induced by networks and to examine the rate of change of networks. Estimation of the heights of the low and sparse vegetation on marshes is being investigated by analysis of the statistical distribution of the measured LiDAR heights. Species having different mean heights may be separated using the first-order moments of the height distribution.

Temperature dependent high-resolution infrared photoabsorption cross-sections of trifluoromethyl sulphur pentafluoride

Absolute infrared photoabsorption cross-sections have been measured over the range 600-1500 cm(-1) for the powerful greenhouse gas SF5CF3 at high resolution (0.03 cm(-1)) and at temperatures between 203 and 298 K. Our data indicate that the integrated absorption intensity shows a weak negative dependence on temperature. It is concluded therefore that previous calculations of radiative forcings and global warming potentials based on room-temperature data are reasonable estimates for the atmosphere, but may be low by a few percent. (C) 2002 Elsevier Science B.V. All rights reserved.

PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis

Background: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. Methods: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to general practices, patients, pharmacists, researchers, and statisticians. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-eff ectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. Findings: 72 general practices with a combined list size of 480 942 patients were randomised. At 6 months’ follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0∙58, 95% CI 0∙38–0∙89); a β blocker if they had asthma (0∙73, 0∙58–0∙91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0∙51, 0∙34–0∙78). PINCER has a 95% probability of being cost eff ective if the decision-maker’s ceiling willingness to pay reaches £75 per error avoided at 6 months. Interpretation: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. Funding: Patient Safety Research Portfolio, Department of Health, England.

Reducing inconsistencies in point observations of maximum flood inundation level

Flood simulation models and hazard maps are only as good as the underlying data against which they are calibrated and tested. However, extreme flood events are by definition rare, so the observational data of flood inundation extent are limited in both quality and quantity. The relative importance of these observational uncertainties has increased now that computing power and accurate lidar scans make it possible to run high-resolution 2D models to simulate floods in urban areas. However, the value of these simulations is limited by the uncertainty in the true extent of the flood. This paper addresses that challenge by analyzing a point dataset of maximum water extent from a flood event on the River Eden at Carlisle, United Kingdom, in January 2005. The observation dataset is based on a collection of wrack and water marks from two postevent surveys. A smoothing algorithm for identifying, quantifying, and reducing localized inconsistencies in the dataset is proposed and evaluated showing positive results. The proposed smoothing algorithm can be applied in order to improve flood inundation modeling assessment and the determination of risk zones on the floodplain.

Parents' experiences of their children's presence in discussions with physicians about leukemia

OBJECTIVE: We aimed to examine parents' views regarding their preadolescent child's presence during discussions about serious illnesses. METHODS: In-depth qualitative interviews with parents of children receiving treatment for acute lymphoblastic leukemia were conducted. Parents were sampled from 6 UK treatment centers. Analysis was informed by the constant comparative method and content analysis. RESULTS: We report on interviews with 53 parents (33 mothers, 20 fathers). Parents acknowledged the benefits of communicating openly with children, but few thought that their child's presence in discussions was straightforwardly desirable. They described how their child's presence restricted their own communication with physicians, made concentrating difficult, and interfered with their efforts to care for their child emotionally. Children's presence was particularly difficult when significant issues were being discussed, including prognoses, adverse results, and certain medical procedures. Parents felt that such discussions posed a potential threat to their child, particularly when they had not first had an opportunity to discuss information with the physician separately from the child. In contrast, separate meetings enabled parents to absorb information and to convey it to their child at an appropriate time and in a reassuring way. Some parents experienced difficulties in accessing separate meetings with physicians. CONCLUSIONS: The difficulties parents described could potentially be addressed by extending, beyond the diagnosis period, the practice of sequencing significant information so that it is communicated to parents in separate meetings before being communicated to the child and by periodically exploring with parents what information would be in each child's interests.

Treatment non-adherence in teenage and young adult patients with cancer

Adhering to treatment can be a significant issue for many patients diagnosed with chronic health conditions and this has been reported to be greater during the adolescent years. However, little is known about treatment adherence in teenage and young adult (TYA) patients with cancer. To increase awareness of the adherence challenges faced by these patients, we have reviewed the published work. The available evidence suggests that a substantial proportion of TYA patients with cancer do have difficulties, with reports that up to 63% of patients do not adhere to their treatment regimens. However, with inconsistent findings across studies, the true extent of non-adherence for these young patients is still unclear. Furthermore, it is apparent that there are many components of the cancer treatment regimen that have yet to be assessed in relation to patient adherence. Factors that have been shown to affect treatment adherence in TYA patients include patient emotional functioning (depression and self-esteem), patient health beliefs (perceived illness severity and vulnerability), and family environment (parental support and parent–child concordance). Strategies that foster greater patient adherence are also identified. These strategies are multifactorial, targeting not only the patient, but the health professional, family, and treatment regimen. This review highlights the lack of interventional studies addressing treatment adherence in TYA patients with cancer, with only one such intervention being identified: a video game intervention focusing on behavioural issues related to cancer treatment and care. Methodological issues in measuring adherence are addressed and suggestions for improving the design of future adherence studies highlighted, of which there is a great need.

Faith and protection: the construction of hope by parents of children with leukemia and their oncologists

Background. Oncologists are criticized for fostering unrealistic hope in patients and families, but criticisms reflect a perspective that is oversimplified and “expert” guidance that is ambiguous or impractical. Our aim was to understand how pediatric oncologists manage parents' hope in practice and to evaluate how they address parents' needs. Methods. Participants were 53 parents and 12 oncologists whom they consulted across six U.K. centers. We audio recorded consultations approximately 1–2, 6, and 12 months after diagnosis. Parents were interviewed after each consultation to elicit their perspectives on the consultation and clinical relationship. Transcripts of consultations and interviews were analyzed qualitatively. Results. Parents needed hope in order to function effectively in the face of despair, and all wanted the oncologists to help them be hopeful. Most parents focused hope on the short term. They therefore needed oncologists to be authoritative in taking responsibility for the child's long-term survival while cushioning parents from information about longer-term uncertainties and being positive in providing information about short-term progress. A few parents who could not fully trust their oncologist were unable to hope. Conclusion. Oncologists' pivotal role in sustaining hope was one that parents gave them. Most parents' “faith” in the oncologist allowed them to set aside, rather than deny, their fears about survival while investing their hopes in short-term milestones. Oncologists' behavior generally matched parents' needs, contradicting common criticisms of oncologists. Nevertheless, oncologists need to identify and address the difficulty that some parents have in fully trusting the oncologist and, consequently, being hopeful.

Is communication guidance mistaken? Qualitative study of parent-oncologist communication in childhood cancer

background: Guidance encourages oncologists to engage patients and relatives in discussing the emotions that accompany cancer diagnosis and treatment. We investigated the perspectives of parents of children with leukaemia on the role of paediatric oncologists in such discussion. methods: Qualitative study comprising 33 audio-recorded parent–oncologist consultations and semi-structured interviews with 67 parents during the year following diagnosis. results: Consultations soon after the diagnosis were largely devoid of overt discussion of parental emotion. Interviewed parents did not describe a need for such discussion. They spoke of being comforted by oncologists’ clinical focus, by the biomedical information they provided and by their calmness and constancy. When we explicitly asked parents 1 year later about the oncologists’ role in emotional support, they overwhelmingly told us that they did not want to discuss their feelings with oncologists. They wanted to preserve the oncologists’ focus on their child’s clinical care, deprecated anything that diverted from this and spoke of the value of boundaries in the parent–oncologist relationship. conclusion: Parents were usually comforted by oncologists, but this was not achieved in the way suggested by communication guidance. Communication guidance would benefit from an enhanced understanding of how emotional support is experienced by those who rely on it.

A global empirical system for probabilistic seasonal climate prediction

Preparing for episodes with risks of anomalous weather a month to a year ahead is an important challenge for governments, non-governmental organisations, and private companies and is dependent on the availability of reliable forecasts. The majority of operational seasonal forecasts are made using process-based dynamical models, which are complex, computationally challenging and prone to biases. Empirical forecast approaches built on statistical models to represent physical processes offer an alternative to dynamical systems and can provide either a benchmark for comparison or independent supplementary forecasts. Here, we present a simple empirical system based on multiple linear regression for producing probabilistic forecasts of seasonal surface air temperature and precipitation across the globe. The global CO2-equivalent concentration is taken as the primary predictor; subsequent predictors, including large-scale modes of variability in the climate system and local-scale information, are selected on the basis of their physical relationship with the predictand. The focus given to the climate change signal as a source of skill and the probabilistic nature of the forecasts produced constitute a novel approach to global empirical prediction. Hindcasts for the period 1961–2013 are validated against observations using deterministic (correlation of seasonal means) and probabilistic (continuous rank probability skill scores) metrics. Good skill is found in many regions, particularly for surface air temperature and most notably in much of Europe during the spring and summer seasons. For precipitation, skill is generally limited to regions with known El Niño–Southern Oscillation (ENSO) teleconnections. The system is used in a quasi-operational framework to generate empirical seasonal forecasts on a monthly basis.