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.

Prediction of the thermal performance of horizontal-coupled ground source heat exchangers

The thermal performance of a horizontal-coupled ground-source heat pump system has been assessed both experimentally and numerically in a UK climate. A numerical simulation of thermal behaviour of the horizontal-coupled heat exchanger for combinations of different ambient air temperatures, wind speeds, refrigerant temperature and soil thermal properties was studied using a validated 2D transient model. The specific heat extraction by the heat exchanger increased with ambient temperature and soil thermal conductivity, however it decreased with increasing refrigerant temperature. The effect of wind speed was negligible.

The occipital lateral plate mesoderm is a novel source for vertebrate neck musculature

In vertebrates, body musculature originates from somites, whereas head muscles originate from the cranial mesoderm. Neck muscles are located in the transition between these regions. We show that the chick occipital lateral plate mesoderm has myogenic capacity and gives rise to large muscles located in the neck and thorax. We present molecular and genetic evidence to show that these muscles not only have a unique origin, but additionally display a distinct temporal development, forming later than any other muscle group described to date. We further report that these muscles, found in the body of the animal, develop like head musculature rather than deploying the programme used by the trunk muscles. Using mouse genetics we reveal that these muscles are formed in trunk muscle mutants but are absent in head muscle mutants. In concordance with this conclusion, their connective tissue is neural crest in origin. Finally, we provide evidence that the mechanism by which these neck muscles develop is conserved in vertebrates.

Exploitation of a pulsed neutron source for the structural study of anisotropic polymer films

A novel but simple time-of-flight neutron scattering geometry which allows structural anisotropy to be probed directly, simultaneously and thus unambiguously in polymeric and other materials is described. A particular advantage of the simultaneous data collection when coupled to the large area of the beam is that it enables thin films (< 10 μm < 10 mg) to be studied with relative ease. The utility of the technique is illustrated by studies on both deformed poly(styrene) glasses and on thin films of electrical conducting polymers. In the latter case, the power of isotopic substitution is illustrated to great effect. The development of these procedures for use in other areas of materials science is briefly discussed.

Dispersion of a point-source release of a passive scalar through an urban-like array for different wind directions

The dispersion of a point-source release of a passive scalar in a regular array of cubical, urban-like, obstacles is investigated by means of direct numerical simulations. The simulations are conducted under conditions of neutral stability and fully rough turbulent flow, at a roughness Reynolds number of Reτ = 500. The Navier–Stokes and scalar equations are integrated assuming a constant rate release from a point source close to the ground within the array. We focus on short-range dispersion, when most of the material is still within the building canopy. Mean and fluctuating concentrations are computed for three different pressure gradient directions (0◦ , 30◦ , 45◦). The results agree well with available experimental data measured in a water channel for a flow angle of 0◦ . Profiles of mean concentration and the three-dimensional structure of the dispersion pattern are compared for the different forcing angles. A number of processes affecting the plume structure are identified and discussed, including: (i) advection or channelling of scalar down ‘streets’, (ii) lateral dispersion by turbulent fluctuations and topological dispersion induced by dividing streamlines around buildings, (iii) skewing of the plume due to flow turning with height, (iv) detrainment by turbulent dispersion or mean recirculation, (v) entrainment and release of scalar in building wakes, giving rise to ‘secondary sources’, (vi) plume meandering due to unsteady turbulent fluctuations. Finally, results on relative concentration fluctuations are presented and compared with the literature for point source dispersion over flat terrain and urban arrays. Keywords Direct numerical simulation · Dispersion modelling · Urban array

An inverse method for determining source characteristics for emergency response applications

Following a malicious or accidental atmospheric release in an outdoor environment it is essential for first responders to ensure safety by identifying areas where human life may be in danger. For this to happen quickly, reliable information is needed on the source strength and location, and the type of chemical agent released. We present here an inverse modelling technique that estimates the source strength and location of such a release, together with the uncertainty in those estimates, using a limited number of measurements of concentration from a network of chemical sensors considering a single, steady, ground-level source. The technique is evaluated using data from a set of dispersion experiments conducted in a meteorological wind tunnel, where simultaneous measurements of concentration time series were obtained in the plume from a ground-level point-source emission of a passive tracer. In particular, we analyze the response to the number of sensors deployed and their arrangement, and to sampling and model errors. We find that the inverse algorithm can generate acceptable estimates of the source characteristics with as few as four sensors, providing these are well-placed and that the sampling error is controlled. Configurations with at least three sensors in a profile across the plume were found to be superior to other arrangements examined. Analysis of the influence of sampling error due to the use of short averaging times showed that the uncertainty in the source estimates grew as the sampling time decreased. This demonstrated that averaging times greater than about 5min (full scale time) lead to acceptable accuracy.

Changing climate and the Irish landscape

The impacts of current and future changes in climate have been investigated for Irish vegetation. Warming has been observed over the last two decades, with impacts that are also strongly influenced by natural oscillations of the surrounding ocean, seen as fluctuations in the North Atlantic Oscillation and the Atlantic Multidecadal Oscillation. Satellite observations show that vegetation greenness increases in warmer years, a feature mirrored by increases in net ecosystem production observed for a grassland and a plantation forest. An ensemble of general circulation model simulations of future climates indicate temperature rises over the twenty-first century ranging from 1°C to 7°C, depending on future scenarios of greenhouse gas emissions. Net primary production is simulated to increase under all scenarios, due to the positive impacts of rising temperature, a modest rise of precipitation and rising carbon dioxide concentrations. In an optimistic scenario of reducing future emissions, CO2 concentration is simulated to flatten from about 2070, although temperatures continue to increase. Under this scenario Ireland could become a source of carbon, whereas under all other emission scenarios Ireland is a sink for carbon that may increase by up to three-fold over the twenty-first century. A likely and unavoidable impact of changing climate is the arrival of alien plant species, which may disrupt ecosystems and exert negative impacts on native biodiversity. Alien species arrive continually, with about 250 dated arrivals in the twentieth century. A simulation model indicates that this rate of alien arrival may increase by anything between two and ten times, dependent on the future climatic scenario, by 2050. Which alien species may become severely disruptive is, however, not known.

Hypothesis management in situation assessment

A situation assessment uses reports from sensors to produce hypotheses about a situation at a level of aggregation that is of direct interest to a military commander. A low level of aggregation could mean forming tracks from reports, which is well documented in the tracking literature as track initiation and data association. In this paper there is also discussion on higher level aggregation; assessing the membership of tracks to larger groups. Ideas used in joint tracking and identification are extended, using multi-entity Bayesian networks to model a number of static variables, of which the identity of a target is one. For higher level aggregation a scheme for hypothesis management is required. It is shown how an offline clustering of vehicles can be reduced to an assignment problem.

Simulation of a domestic ground source heat pump system using a three-dimensional numerical borehole heat exchanger model

Common approaches to the simulation of borehole heat exchangers (BHEs) assume heat transfer in circulating fluid and grout to be in a quasi-steady state and ignore fluctuations in fluid temperature due to transport of the fluid around the loop. However, in domestic ground source heat pump (GSHP) systems, the heat pump and circulating pumps switch on and off during a given hour; therefore, the effect of the thermal mass of the circulating fluid and the dynamics of fluid transport through the loop has important implications for system design. This may also be important in commercial systems that are used intermittently. This article presents transient simulation of a domestic GSHP system with a single BHE using a dynamic three-dimensional (3D) numerical BHE model. The results show that delayed response associated with the transit of fluid along the pipe loop is of some significance in moderating swings in temperature during heat pump operation. In addition, when 3D effects are considered, a lower heat transfer rate is predicted during steady operations. These effects could be important when considering heat exchanger design and system control. The results will be used to develop refined two-dimensional models.

Source splitting via the point source method

We introduce a new algorithm for source identification and field splitting based on the point source method (Potthast 1998 A point-source method for inverse acoustic and electromagnetic obstacle scattering problems IMA J. Appl. Math. 61 119–40, Potthast R 1996 A fast new method to solve inverse scattering problems Inverse Problems 12 731–42). The task is to separate the sound fields uj, j = 1, ..., n of sound sources supported in different bounded domains G1, ..., Gn in from measurements of the field on some microphone array—mathematically speaking from the knowledge of the sum of the fields u = u1 + + un on some open subset Λ of a plane. The main idea of the scheme is to calculate filter functions , to construct uℓ for ℓ = 1, ..., n from u|Λ in the form We will provide the complete mathematical theory for the field splitting via the point source method. In particular, we describe uniqueness, solvability of the problem and convergence and stability of the algorithm. In the second part we describe the practical realization of the splitting for real data measurements carried out at the Institute for Sound and Vibration Research at Southampton, UK. A practical demonstration of the original recording and the splitting results for real data is available online.

The prediction of nutrients into estuaries and their subsequent behaviour: application to the Tamar and comparison with the Tweed, U.K.

Some of the techniques used to model nitrogen (N) and phosphorus (P) discharges from a terrestrial catchment to an estuary are discussed and applied to the River Tamar and Tamar Estuary system in Southwest England, U.K. Data are presented for dissolved inorganic nutrient concentrations in the Tamar Estuary and compared with those from the contrasting, low turbidity and rapidly flushed Tweed Estuary in Northeast England. In the Tamar catchment, simulations showed that effluent nitrate loads for typical freshwater flows contributed less than 1% of the total N load. The effect of effluent inputs on ammonium loads was more significant (∼10%). Cattle, sheep and permanent grassland dominated the N catchment export, with diffuse-source N export greatly dominating that due to point sources. Cattle, sheep, permanent grassland and cereal crops generated the greatest rates of diffuse-source P export. This reflected the higher rates of P fertiliser applications to arable land and the susceptibility of bare, arable land to P export in wetter winter months. N and P export to the Tamar Estuary from human sewage was insignificant. Non-conservative behaviour of phosphate was particularly marked in the Tamar Estuary. Silicate concentrations were slightly less than conservative levels, whereas nitrate was essentially conservative. The coastal sea acted as a sink for these terrestrially derived nutrients. A pronounced sag in dissolved oxygen that was associated with strong nitrite and ammonium peaks occurred in the turbidity maximum region of the Tamar Estuary. Nutrient behaviour within the Tweed was very different. The low turbidity and rapid flushing ensured that nutrients there were essentially conservative, so that flushing of nutrients to the coastal zone from the river occurred with little estuarine modification.