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.

Priority setting in healthcare: from arbitrariness to societal values

This paper develops an account of the normative basis of priority setting in health care as combining the values which a given society holds for the common good of its members, with the universal provided by a principle of common humanity. We discuss national differences in health basket in Europe and argue that health care decision-making in complex social and moral frameworks is best thought of as anchored in such a principle by drawing on the philosophy of need. We show that health care needs are ethically ‘thick’ needs whose psychological and social construction can best be understood in terms of David Wiggins's notion of vital need: a person's need is vital when failure to meet it leads to their harm and suffering. The moral dimension of priority setting which operates across different societies’ health care systems is located in the demands both of and on any society to avoid harm to its members.

A copyright exception for private copying in the United Kingdom

This paper discusses the proposed copyright exception for private copying in the UK in the aftermath of the Hargreaves Review. It explores the options by which the exception shall retain a realistic scope without significantly impacting on the interests of the rightholders and addresses the concept of possible harm that may arise due to private copying. It concludes that an exception for copying of content legally owned by an individual to another medium or device for private use corresponds to consumers’ reasonable expectations without causing more than minimal harm to the rightholders’ interests and without requiring an accompanying introduction of a fair compensation scheme.

Backtracks: a devised performance

Backtracks aimed to investigate critical relationships between audio-visual technologies and live performance, emphasising technologies producing sound, contrasted with non-amplified bodily sound. Drawing on methodologies for studying avant garde theatre, live performance and the performing body, it was informed by work in critical and cultural theory by, for example, Steven Connor and Jonathan Rée, on the body's experience and interpretation of sound. The performance explored how shifting national boundaries, mobile workforces, complex family relationships, cultural pluralities and possibilities for bodily transformation have compelled a re-evaluation of what it means to feel 'at home' in modernity. Using montages of live and mediated images, disrupted narratives and sound, it evoked destablised identities which characterise contemporary lived experience, and enacted the displacement of certainties provided by family and nation, community and locality, body and selfhood. Homer's Odyssey framed the performance: elements could be traced in the mise-en-scène; in the physical presence of Athene, the narrator and Penelope weaving mementoes from the past into her loom; and in voice-overs from Homer's work. The performance drew on personal experiences and improvisations, structured around notions of journey. It presented incomplete narratives, memories, repressed anxieties and dreams through different combinations of sounds, music, mediated images, movement, voice and bodily sound. The theme of travel was intensified by performers carrying suitcases and umbrellas, by soundtracks incorporating travel effects, and by the distorted video images of forms of transport playing across 'screens' which proliferated across the space (sails, umbrellas, the loom, actors' bodies). The performance experimented with giving sound and silence performative dimensions, including presenting sound in visual and imagistic ways, for example by using signs from deaf sign language. Through-composed soundtracks of live and recorded song, music, voice-over, and noise exploited the viscerality of sound and disrupted cognitive interpretation by phenomenological, somatic experience, thereby displacing the impulse for closure/destination/home.

Acts of estrangement: reading the psoriatic-skin

I am continually surprised by the acts of estrangement in which my body engages. All bodies do this to some extent – lungs breathe, hearts beat and so on, but with psoriasis, which my article is concerned with, these processes are highly visible. As a condition of the skin, it is a pathology which is enacted both within and without, visible to the social world as well emerging from some little understood inflammatory source within the body. This article will undertake a phenomenological exploration of my own skin and how my experience of my body is affected by its lack of compliance with medicine, cosmetics etc. By some unknown causation it flakes, breaks, itches constantly drawing attention to bodily limits and the limits of medical knowledge. I want to think through the meanings we ascribe to such inflammatory conditions in Western society, how my skin materialises at the nexus of industrialisation, medicine, class and capital. This investigation will emerge at the limit point, the thin skin between the subjective and objective, observing and theorising my skin in ways which dissolve disciplinary boundaries, to comprehend the cultural, biological and environmental forces that work upon my body, estranging it from me.

Assessment and management of anxiety disorders in children and adolescents

Anxiety disorders in childhood and adolescence are extremely common and are often associated with lifelong psychiatric disturbance. Consistent with DSM-5 and the extant literature, this review concerns the assessment and treatment of specific phobias, separation anxiety disorder, generalised anxiety disorder, social anxiety disorder, panic disorder and agoraphobia. Evidence-based psychological treatments (cognitive behaviour therapy; CBT) for these disorders have been developed and investigated, and in recent years promising low-intensity versions of CBT interventions have been proposed that offer a means to increase access to evidence-based treatments. There is some evidence of effectiveness of pharmacological treatments for anxiety disorders in children and young people, however, routine prescription is not recommended due to concerns about potential harm.

Bacterial motility confers fitness advantage in the presence of phages

Dispersal provides the opportunity to escape harm and colonize new patches, enabling populations to expand and persist. However, the benefits of dispersal associated with escaping harm will be dependent on the structure of the environment and the likelihood of escape. Here, we empirically investigate how the spatial distribution of a parasite influences the evolution of host dispersal. Bacteriophages are a strong and common threat for bacteria in natural environments and offer a good system with which to explore parasite-mediated selection on host dispersal. We used two transposon mutants of the opportunistic bacteria, Pseudomonas aeruginosa, which varied in their motility (a disperser and a nondisperser), and the lytic bacteriophage ФKZ. The phage was distributed either in the central point of colony inoculation only, thus offering an escape route for the dispersing bacteria; or, present throughout the agar, where benefits of dispersal might be lost. Surprisingly, we found dispersal to be equally advantageous under both phage conditions relative to when phages were absent. A general explanation is that dispersal decreased the spatial structuring of host population, reducing opportunities for parasite transmission, but other more idiosyncratic mechanisms may also have contributed. This study highlights the crucial role the parasites can play on the evolution of dispersal and, more specifically, that bacteriophages, which are ubiquitous, are likely to select for bacterial motility.

Traditional medicine use by cancer patients in Thailand

Ethnobotanical relevance Cancer patients commonly use traditional medicines (TM) and in Thailand these are popular for both self-medication and as prescribed by TM practitioners, and are rarely monitored. A study was conducted at Wat Khampramong, a Thai Buddhist temple herbal medicine hospice, to document some of these practices as well as the hospice regime. Materials and methods Cancer patients (n=286) were surveyed shortly after admission as to which TMs they had previously taken and perceptions of effects experienced. They were also asked to describe their current symptoms. Treatment at the hospice is built upon an 11-herb anti-cancer formula, yod-ya-mareng, prescribed for all patients, and ideally, its effects would have been evaluated. However other herbal medicines and holistic practices are integral to the regime, so instead we attempted to assess the value of the patients׳ stay at the hospice by measuring any change in symptom burden, as they perceived it. Surviving patients (n=270) were therefore asked to describe their symptoms again just before leaving. Results 42% of patients (120/286; 95% CI 36.4%, 47.8%) had used herbal medicines before their arrival, with 31.7% (38/120; 95% CI 24%, 40.4%) using several at once. Mixed effects were reported for these products. After taking the herbal regime at Khampramong, 77% (208/270 95% CI; 71.7%, 81.7%) reported benefit, and a comparison of the incidence of the most common (pain, dyspepsia, abdominal or visceral pain, insomnia, fatigue) showed statistical significance (χ2 57.1, df 7, p<0.001). Conclusions A wide range of TMs is taken by cancer patients in Thailand and considered to provide more benefit than harm, and this perception extends to the temple regime. Patients reported a significant reduction in symptoms after staying at Khampramong, indicating an improvement in quality of life, the aim of hospices everywhere. Based on this evidence, it is not possible to justify the use of TM for cancer in general, but this study suggests that further research is warranted. The uncontrolled use of TMs, many of which are uncharacterised, raises concerns, and this work also highlights the fact that validated, robust methods of assessing holistic medical regimes are urgently needed.

Saplings or caterpillars? Trying to understand children's wellbeing

Is childhood valuable? And is childhood as, less, or more, valuable than adulthood? In this essay I first delineate several different questions that we might be asking when we think about the ‘value of childhood’, and I explore some difficulties of doing so. I then focus on the question of whether childhood is good for the person who experiences it. I argue for two key claims. First, if childhood wellbeing is measured by the same standards as adulthood, then children are worse off than adults. Second, if childhood and adulthood wellbeing are measured by different standards, then we cannot compare them, and children are neither better off nor worse off than adults. This has some counter-intuitive implications, such as we do not harm persons by depriving them of a childhood, nor by keeping them as children for elongated periods.

Contribution to collective harms and responsibility

In the present contribution, I discuss the claim, endorsed by a number of authors, that contributing to a collective harm is the ground for special responsibilities to the victims of that harm. Contributors should, between them, cover the costs of the harms they have inflicted, at least if those harms would otherwise be rights-violating. I raise some doubts about the generality of this principle before moving on to sketch a framework for thinking about liability for the costs of harms in general. This framework uses a contractualist framework to build an account of how to think about liability for costs on the basis of the presumably attractive thought that individual agents should have as much control over their liabilities as is compatible with others having like control. I then use that framework to suggest that liability on the basis of contribution should be restricted to cases in which the contributors could have avoided their contribution relatively costlessly, in which meeting the liability is not crippling for them, and in which such a liability would not have chilling effects, either on them or on third parties. This account of the grounds for contributory liability also has the advantage of avoiding a number of awkward questions about what counts as a contribution by shifting the issue away from often unanswerable questions about the precise causal genesis of some harm or other. Instead, control over conduct, which plausibly has some relation to the harm, becomes crucial. On the basis of this account, I then investigate whether a number of uses of the contributory principle are entirely appropriate. I argue that contributory liability is not appropriate for cases of collective harms committed by coordinated groups in the way that, for example, Iris Marion Young and Thomas Pogge have suggested and that further investigation of how members of such groups may be liable will be needed.

Post-conflict recovery and peacebuilding

Civil wars are the most common type of large scale violent conflict. They are long, brutal and continue to harm societies long after the shooting stops. Post-conflict countries face extraordinary challenges with respect to development and security. In this paper we examine how countries can recover economically from these devastating conflicts and how international interventions can help to build lasting peace. We revisit the aid and growth debate and confirm that aid does not increase growth in general. However, we find that countries experience increased growth after the end of the war and that aid helps to make the most of this peace dividend. However, aid is only growth enhancing when the violence has stopped, in violent post-war societies aid has no growth enhancing effect. We also find that good governance is robustly correlated with growth, however we cannot confirm that aid increases growth conditional on good policies. We examine various aspects of aid and governance by disaggregating the aid and governance variables. Our analysis does not provide a clear picture of which types of aid and policy should be prioritized. We find little evidence for a growth enhancing effect of UN missions and suggest that case studies may provide better insight into the relationship between security guarantees and economic stabilization.

Rotational aesthetics: Michael Bay and contemporary cinema’s machine movement

Digital imaging technologies enable a mastery of the visual that in recent mainstream cinema frequently manifests as certain kinds of spatial reach, orientation and motion. In such a context Michael Bay’s Transformers franchise can be framed as a digital re-tooling of a familiar fantasy of vehicular propulsion, US car culture writ large in digitally crafted spectacles of diegetic speed, the vehicular chase film ‘2.0’. Movement is central to these films, calling up Scott Bukatman’s observation that in spectacular visual media ‘movement has become more than a tool of bodily knowledge; it has become an end in itself’ (2003: 125). Not all movements and not all instances of vehicular propulsion are the same however. How might we evaluate what is at stake in a film’s assertion of movement as an end in itself, and the form that assertion takes, its articulations of diegetic velocity, corporeality, and spatial penetration? Deploying an attentiveness towards the specificity of aesthetic detail and affective impact in Bay’s delineation of movement, this essay suggests that the franchise poses questions about the relationship of human movement to machine movement that exceed their narrative basis. Identifying a persistent rotational trope in the franchise that in its audio-visual articulation combines oddly anachronistic elements (evoking the mechanical rather than the digital), the article argues that the films prioritise certain fantasies of transformation and spatial penetration, and certain modes of corporeality, as one response to contemporary debates about digital technologisation, sustainable energy, and cinematic spectacle. In this way the franchise also represents a particular moment in a more widely discernible preoccupation in contemporary cinema with what we might call a ‘rotational aesthetics’ of action, a machine movement made possible by the digital, but which invokes earlier histories and fantasies of animation, propulsion, mechanization and mechanization to particular ends.

The role of text in televideo cybersex

Televideo cybersex provides a unique example of the ways meanings are instantiated, identities constructed, and relationships negotiated across different semiotic modes. This article explores the role of verbal messages in these multimodal exchanges, examining the specific interactional functions they perform. Text, it is argued, plays a rather unique role in this particular kind of interaction. Unlike ordinary face-to-face conversation, in which the body (posture, gestures, gaze) usually plays more of an ancillary role, in televideo cybersex, the bodily performance is primary, with verbal messages functioning to contextualize physical actions. Text is used to help increase the sense of ‘presence’ participants feel, to regulate the rhythm of the unfolding interaction, to help manage the orderly exchange of information, and to create narrative frames within which bodily displays can be interpreted and made coherent.

The metaphysics of self in Praśastapāda's differential naturalism

In A Compendium of the Characteristics of Categories (Padārthadharmasaṃgraha) the classical Vaiśeṣika philosopher Praśastapāda (6th c. CE) presents an innovative metaphysics of the self. This article examines the defining metaphysical and axiological features of this conception of self and the dualist categorial schema in which it is located. It shows how this idea of the self, as a reflexive and ethical being, grounds a multinaturalist view of natural order and offers a conception of agency that claims to account for all the reflexive features of human mental and bodily life. Finally, it discusses the ends of self’s reflexivity and of human life as a return to the true self. It argues that at the heart of Praśastapāda’s metaphysics of self is the idea that ethics is metaphysics, and that epistemic practice is ethical practice.