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.

Tree species diversity interacts with elevated CO2 to induce a greater root system response

As a consequence of land use change and the burning of fossil fuels, atmospheric concentrations of CO2 are increasing and altering the dynamics of the carbon cycle in forest ecosystems. In a number of studies using single tree species, fine root biomass has been shown to be strongly increased by elevated CO2. However, natural forests are often intimate mixtures of a number of co-occurring species. To investigate the interaction between tree mixture and elevated CO2, Alnus glutinosa, Betula pendula and Fagus sylvatica were planted in areas of single species and a three species polyculture in a free-air CO2 enrichment study (BangorFACE). The trees were exposed to ambient or elevated CO2 (580 µmol mol-1) for four years. Fine and coarse root biomass, together with fine root turnover and fine root morphological characteristics were measured. Fine root biomass, and morphology responded differentially to elevated CO2 at different soil depths in the three species when grown in monocultures. In polyculture, a greater response to elevated CO2 was observed in coarse roots to a depth of 20 cm, and fine root area index to a depth of 30 cm. Total fine root biomass was positively affected by elevated CO2 at the end of the experiment, but not by species diversity. Our data suggest that existing biogeochemical cycling models parameterised with data from species grown in monoculture may be underestimating the belowground response to global change.

The benefits of a compute cluster approach to high spatial resolution biodiversity richness modelling: projecting the impact of climate change on Mediterranean flora

High spatial resolution environmental data gives us a better understanding of the environmental factors affecting plant distributions at fine spatial scales. However, large environmental datasets dramatically increase compute times and output species model size stimulating the need for an alternative computing solution. Cluster computing offers such a solution, by allowing both multiple plant species Environmental Niche Models (ENMs) and individual tiles of high spatial resolution models to be computed concurrently on the same compute cluster. We apply our methodology to a case study of 4,209 species of Mediterranean flora (around 17% of species believed present in the biome). We demonstrate a 16 times speed-up of ENM computation time when 16 CPUs were used on the compute cluster. Our custom Java ‘Merge’ and ‘Downsize’ programs reduce ENM output files sizes by 94%. The median 0.98 test AUC score of species ENMs is aided by various species occurrence data filtering techniques. Finally, by calculating the percentage change of individual grid cell values, we map the projected percentages of plant species vulnerable to climate change in the Mediterranean region between 1950–2000 and 2020.

The influence of biostimulants on growth and vitality of three urban tree species following transplanting

Four commercially available, biostimulants sold under the trade names ‘Generate’, ‘Crop Set’, ‘Fulcrum’ and ‘Redicrop 2000’ were applied either as a root drench or foliar spray to three transplant-sensitive tree species, red oak(Quercus rubra), birch(Betula pendula) and beech (Fagus sylvatica) post transplanting. The short and long-term efficacy of the biostimulants on growth was quantified by recording root and shoot vigour at week 8 and 20. In addition, improvements in tree vitality were assessed by measurement of a chlorophyll a performance index based on leaf chlorophyll fluorescence emissions. Irrespective of species, no significant effect of mode of application (foliar spray versus root drench) was recorded on growth and vitality. The biostimulants Generate and Fulcrum increased growth of all three tree species. No significant effects on growth and chlorophyll fluorescence of birch and beech were recorded following applications of the biostimulants Crop Set and Redicrop 2000, however, significant increase in growth of red oak was recorded. Only the biostimulant Generate increased chlorophyll fluorescence values of all test species. Results show use of biostimulants can improve root and shoot vigour following transplanting. However, selection of an appropriate biostimulant is critical as effects on growth and vitality can vary widely between tree species possibly as a result of the differing active ingredient used in the formulation of the product.

Description and process evaluation of pharmacists’ interventions in a pharmacist-led information technology-enabled multicentre cluster randomised controlled trial for reducing medication errors in general practice (PINCER trial)

Objective To undertake a process evaluation of pharmacists' recommendations arising in the context of a complex IT-enabled pharmacist-delivered randomised controlled trial (PINCER trial) to reduce the risk of hazardous medicines management in general practices. Methods PINCER pharmacists manually recorded patients’ demographics, details of interventions recommended, actions undertaken by practice staff and time taken to manage individual cases of hazardous medicines management. Data were coded and double entered into SPSS v15, and then summarised using percentages for categorical data (with 95% CI) and, as appropriate, means (SD) or medians (IQR) for continuous data. Key findings Pharmacists spent a median of 20 minutes (IQR 10, 30) reviewing medical records, recommending interventions and completing actions in each case of hazardous medicines management. Pharmacists judged 72% (95%CI 70, 74) (1463/2026) of cases of hazardous medicines management to be clinically relevant. Pharmacists recommended 2105 interventions in 74% (95%CI 73, 76) (1516/2038) of cases and 1685 actions were taken in 61% (95%CI 59, 63) (1246/2038) of cases; 66% (95%CI 64, 68) (1383/2105) of interventions recommended by pharmacists were completed and 5% (95%CI 4, 6) (104/2105) of recommendations were accepted by general practitioners (GPs), but not completed at the end of the pharmacists’ placement; the remaining recommendations were rejected or considered not relevant by GPs. Conclusions The outcome measures were used to target pharmacist activity in general practice towards patients at risk from hazardous medicines management. Recommendations from trained PINCER pharmacists were found to be broadly acceptable to GPs and led to ameliorative action in the majority of cases. It seems likely that the approach used by the PINCER pharmacists could be employed by other practice pharmacists following appropriate training.

Extreme wind storms over Europe in present and future climate: a cluster analysis approach

Boreal winter wind storm situations over Central Europe are investigated by means of an objective cluster analysis. Surface data from the NCEP-Reanalysis and ECHAM4/OPYC3-climate change GHG simulation (IS92a) are considered. To achieve an optimum separation of clusters of extreme storm conditions, 55 clusters of weather patterns are differentiated. To reduce the computational effort, a PCA is initially performed, leading to a data reduction of about 98 %. The clustering itself was computed on 3-day periods constructed with the first six PCs using "k-means" clustering algorithm. The applied method enables an evaluation of the time evolution of the synoptic developments. The climate change signal is constructed by a projection of the GCM simulation on the EOFs attained from the NCEP-Reanalysis. Consequently, the same clusters are obtained and frequency distributions can be compared. For Central Europe, four primary storm clusters are identified. These clusters feature almost 72 % of the historical extreme storms events and add only to 5 % of the total relative frequency. Moreover, they show a statistically significant signature in the associated wind fields over Europe. An increased frequency of Central European storm clusters is detected with enhanced GHG conditions, associated with an enhancement of the pressure gradient over Central Europe. Consequently, more intense wind events over Central Europe are expected. The presented algorithm will be highly valuable for the analysis of huge data amounts as is required for e.g. multi-model ensemble analysis, particularly because of the enormous data reduction.

Building the niche through time: using 13,000 years of data to predict the effects of climate change on three tree species in Europe

Aim  Species distribution models (SDMs) based on current species ranges underestimate the potential distribution when projected in time and/or space. A multi-temporal model calibration approach has been suggested as an alternative, and we evaluate this using 13,000 years of data. Location  Europe. Methods  We used fossil-based records of presence for Picea abies, Abies alba and Fagus sylvatica and six climatic variables for the period 13,000 to 1000 yr bp. To measure the contribution of each 1000-year time step to the total niche of each species (the niche measured by pooling all the data), we employed a principal components analysis (PCA) calibrated with data over the entire range of possible climates. Then we projected both the total niche and the partial niches from single time frames into the PCA space, and tested if the partial niches were more similar to the total niche than random. Using an ensemble forecasting approach, we calibrated SDMs for each time frame and for the pooled database. We projected each model to current climate and evaluated the results against current pollen data. We also projected all models into the future. Results  Niche similarity between the partial and the total-SDMs was almost always statistically significant and increased through time. SDMs calibrated from single time frames gave different results when projected to current climate, providing evidence of a change in the species realized niches through time. Moreover, they predicted limited climate suitability when compared with the total-SDMs. The same results were obtained when projected to future climates. Main conclusions  The realized climatic niche of species differed for current and future climates when SDMs were calibrated considering different past climates. Building the niche as an ensemble through time represents a way forward to a better understanding of a species' range and its ecology in a changing climate.

Effective LAI and CHP of a single tree from small-footprint full-waveform LiDAR

This letter has tested the canopy height profile (CHP) methodology as a way of effective leaf area index (LAIe) and vertical vegetation profile retrieval at a single-tree level. Waveform and discrete airborne LiDAR data from six swaths, as well as from the combined data of six swaths, were used to extract the LAIe of a single live Callitris glaucophylla tree. LAIe was extracted from raw waveform as an intermediate step in the CHP methodology, with two different vegetation-ground reflectance ratios. Discrete point LAIe estimates were derived from the gap probability using the following: 1) single ground returns and 2) all ground returns. LiDAR LAIe retrievals were subsequently compared to hemispherical photography estimates, yielding mean values within ±7% of the latter, depending on the method used. The CHP of a single dead Callitris glaucophylla tree, representing the distribution of vegetation material, was verified with a field profile manually reconstructed from convergent photographs taken with a fixed-focal-length camera. A binwise comparison of the two profiles showed very high correlation between the data reaching R2 of 0.86 for the CHP from combined swaths. Using a study-area-adjusted reflectance ratio improved the correlation between the profiles, but only marginally in comparison to using an arbitrary ratio of 0.5 for the laser wavelength of 1550 nm.

Classification of seed storage behaviour of 67 Amazonian tree species

Information was collated on the seed storage behaviour of 67 tree species native to the Amazon rainforest of Brazil; 38 appeared to show orthodox, 23 recalcitrant and six intermediate seed storage behaviour. A double-criteria key based on thousand-seed weight and seed moisture content at shedding to estimate likely seed storage behaviour, developed previously, showed good agreement with the above classifications. The key can aid seed storage behaviour identification considerably.

The anti-proliferative Effects of enterolactone in prostate cancer cells: evidence for the role of DNA licencing genes, mi-R106b cluster expression, and PTEN dosage

The mammalian lignan, enterolactone, has been shown to reduce the proliferation of the earlier stages of prostate cancer at physiological concentrations in vitro. However, efficacy in the later stages of the disease occurs at concentrations difficult to achieve through dietary modification. We have therefore investigated what concentration(s) of enterolactone can restrict proliferation in multiple stages of prostate cancer using an in vitro model system of prostate disease. We determined that enterolactone at 20 μM significantly restricted the proliferation of mid and late stage models of prostate disease. These effects were strongly associated with changes in the expression of the DNA licencing genes (GMNN, CDT1, MCM2 and 7), in reduced expression of the miR-106b cluster (miR-106b, miR-93, and miR-25), and in increased expression of the PTEN tumour suppressor gene. We have shown anti-proliferative effects of enterolactone in earlier stages of prostate disease than previously reported and that these effects are mediated, in part, by microRNA-mediated regulation.

Word position and stress effects in consonant cluster perception and production

The aim of the present study was to investigate whether the saliency effect for word beginnings reported in children with Dyslexia (Marshall & van der Lely, 2009) can be found also in TD children. Thirty-four TD Italian children aged 8-10 completed two specifically designed tasks: a production task and a perception task. Both tasks used nonwords containing clusters consisting of plosive plus liquid (eg. pl). Clusters could be either in a stressed or in an unstressed syllable, and could be either in initial position (first syllable) or in medial position (second syllable). In the production task children were asked to repeat the non-words. In the perception task, the children were asked to discriminate between two nonwords differing in one phoneme belonging to a cluster by reporting whether two repetitions were the same or different. Results from the production task showed that children are more accurate in repeating stressed than unstressed syllables, but there was no difference with respect to position of the cluster. Results from the perception task showed that children performed more accurately when discriminating word initial contrasts than when discriminating word medial contrasts, especially if the cluster was unstressed. Implications of this finding for clinical assessments are discussed.

Comparative Cluster/Double Star observations of the high and low latitude dayside magnetopause

The launch of the Double Star mission has provided the opportunity to monitor events at distinct locations on the dayside magnetopause, in coordination with the quartet of Cluster spacecraft. We present results of two such coordinated studies. In the first, 6 April 2004, both Cluster and the Double Star TC-1 spacecraft were on outbound transits through the dawn-side magnetosphere. Cluster observed northward moving FTEs with +/- polarity, whereas TC-1 saw -/+ polarity FTEs. The strength, motion and occurrence of the FTE signatures changes somewhat according to changes in IMF clock angle. These observations are consistent with ongoing reconnection on the dayside magnetopause, resulting in a series of flux transfer events (FTEs) seen both at Cluster and TC-1. The observed polarity and motion of each FTE signature advocates the existence of an active reconnection region consistently located between the positions of Cluster and TC-1, lying north and south of the reconnection line, respectively. This scenario is supported by the application of a model, designed to track flux tube motion, to conditions appropriate for the prevailing interplanetary conditions. The results from the model confirm the observational evidence that the low-latitude FTE dynamics is sensitive to changes in convected upstream conditions. In particular, changing the interplanetary magnetic field (IMF) clock angle in the model predicts that TC-1 should miss the resulting FTEs more often than Cluster, as is observed. For the second conjunction, on the 4 Jan 2005, the Cluster and TC-1 spacecraft all exited the dusk-side magnetosphere almost simultaneously, with TC-1 lying almost equatorial and Cluster at northern latitudes at about 4 RE from TC-1. The spacecraft traverse the magnetopause during a strong reversal in the IMF from northward to southward and a number of magnetosheath FTE signatures are subsequently observed. One coordinated FTE, studied in detail by Pu et al, [this issue], carries and inflowing energetic electron population and shows a motion and orientation which is similar at all spacecraft and consistent with the predictions of the model for the flux tube dynamics, given a near sub-solar reconnection line. This event can be interpreted either as the passage of two parallel flux tubes arising from adjacent x-line positions, or as a crossing of a single flux tube at different positions.

Coordinated Cluster/Double Star observations of dayside reconnection signatures

The recent launch of the equatorial spacecraft of the Double Star mission, TC-1, has provided an unprecedented opportunity to monitor the southern hemisphere dayside magnetopause boundary layer in conjunction with northern hemisphere observations by the quartet of Cluster spacecraft. We present first results of one such situation where, on 6 April 2004, both Cluster and the Double Star TC-1 spacecraft were on outbound transits through the dawnside magnetosphere. The observations are consistent with ongoing reconnection on the dayside magnetopause, resulting in a series of flux transfer events (FTEs) seen both at Cluster and TC-1, which appear to lie north and south of the reconnection line, respectively. In fact, the observed polarity and motion of each FTE signature advocates the existence of an active reconnection region consistently located between the positions of Cluster and TC-1, with Cluster observing northward moving FTEs with +/− polarity, whereas TC-1 sees −/+ polarity FTEs. This assertion is further supported by the application of a model designed to track flux tube motion for the prevailing interplanetary conditions. The results from this model show, in addition, that the low-latitude FTE dynamics are sensitive to changes in convected upstream conditions. In particular, changing the interplanetary magnetic field (IMF) clock angle in the model suggests that TC-1 should miss the resulting FTEs more often than Cluster and this is borne out by the observations.