Patients' attitudes towards, and information needs in relation to, nurse prescribing in rheumatology

Aims and objectives: To assess the level of confidence that rheumatology patients would have in nurse prescribing, the effects on likely adherence and particular concerns that these patients have. In addition, given that information provision has been cited as a potential benefit of nurse prescribing, the present study assessed the extent to which these patients would want an explanation for the selected medicine, as well as which types of information should be included in such an explanation. Background: Nurse prescribing has been successfully implemented in the UK in several healthcare settings. Existing research has not addressed the effects on patients' confidence and likely adherence, nor have patients' information needs been established. However, we know that inadequate medicines information provision by health professionals is one of the largest causes of patient dissatisfaction. Methods: Fifty-four patients taking disease-modifying drugs for inflammatory joint disease attending a specialist rheumatology clinic self-completed a written questionnaire. Results: Patients indicated a relatively high level of confidence in nurse prescribing and stated that they would be very likely to take the selected medication. The level of concern was relatively low and the majority of concerns raised did not relate to the nurse's status. Strong support was expressed for the nurse providing an explanation for medicine choice. Conclusion: This research provides support for the prescription of medicines by nurses working in the area of rheumatology, the importance of nurses providing a full explanation about the selected medicines they prescribe for these patients and some indication as to which categories of information should be included. Relevance to clinical practice: Rheumatology patients who have not yet experienced nurse prescribing are, in general, positive about nurses adopting this role. It is important that nurses provide appropriate information about the prescribed medicines, in a form that can be understood.

Predicting outcomes following cognitive behavior therapy in child anxiety disorders: the influence of genetic, demographic and clinical information

Background. Within a therapeutic gene by environment (GxE) framework, we recently demonstrated that variation in the Serotonin Transporter Promoter Polymorphism; 5HTTLPR and marker rs6330 in Nerve Growth Factor gene; NGF is associated with poorer outcomes following cognitive behaviour therapy (CBT) for child anxiety disorders. The aim of this study was to explore one potential means of extending the translational reach of G×E data in a way that may be clinically informative. We describe a ‘risk-index’ approach combining genetic, demographic and clinical data and test its ability to predict diagnostic outcome following CBT in anxious children. Method. DNA and clinical data were collected from 384 children with a primary anxiety disorder undergoing CBT. We tested our risk model in five cross-validation training sets. Results. In predicting treatment outcome, six variables had a minimum mean beta value of 0.5: 5HTTLPR, NGF rs6330, gender, primary anxiety severity, comorbid mood disorder and comorbid externalising disorder. A risk index (range 0-8) constructed from these variables had moderate predictive ability (AUC = .62-.69) in this study. Children scoring high on this index (5-8) were approximately three times as likely to retain their primary anxiety disorder at follow-up as compared to those children scoring 2 or less. Conclusion. Significant genetic, demographic and clinical predictors of outcome following CBT for anxiety-disordered children were identified. Combining these predictors within a risk-index could be used to identify which children are less likely to be diagnosis free following CBT alone or thus require longer or enhanced treatment. The ‘risk-index’ approach represents one means of harnessing the translational potential of G×E data.

Support and information needs of older and disabled older people in the UK

The aim of this study was to determine the support and information needs of older and disabled older people in the UK. Following an initial literature survey, an examination of data on enquiries made by older people to information providers, and a series of focus groups, a questionnaire was developed for a nationwide survey. Over 1630 questionnaires were completed by disabled older clients of Day Care Centres and less frail older members of social clubs. Findings showed that there is a serious shortfall in the number of older people getting the practical support that they need, and the information that enables access to this support, compared to the number that actually need help. Substantial percentages of the survey respondents experienced difficulty with everyday tasks and with accessing the information they needed. Implications for formal sources of support and information are discussed.

Bayesian design and conduct of phase II single-arm clinical trials with binary outcomes: a tutorial

The aim of phase II single-arm clinical trials of a new drug is to determine whether it has sufficient promising activity to warrant its further development. For the last several years Bayesian statistical methods have been proposed and used. Bayesian approaches are ideal for earlier phase trials as they take into account information that accrues during a trial. Predictive probabilities are then updated and so become more accurate as the trial progresses. Suitable priors can act as pseudo samples, which make small sample clinical trials more informative. Thus patients have better chances to receive better treatments. The goal of this paper is to provide a tutorial for statisticians who use Bayesian methods for the first time or investigators who have some statistical background. In addition, real data from three clinical trials are presented as examples to illustrate how to conduct a Bayesian approach for phase II single-arm clinical trials with binary outcomes.

Generating recipient-centred explanations about drug prescription

In this paper we describe how we generated written explanations to ‘indirect users’ of a knowledge-based system in the domain of drug prescription. We call ‘indirect users’ the intended recipients of explanations, to distinguish them from the prescriber (the ‘direct’ user) who interacts with the system. The Explanation Generator was designed after several studies about indirect users' information needs and physicians' explanatory attitudes in this domain. It integrates text planning techniques with ATN-based surface generation. A double modeling component enables adapting the information content, order and style to the indirect user to whom explanation is addressed. Several examples of computer-generated texts are provided, and they are contrasted with the physicians' explanations to discuss advantages and limits of the approach adopted.

Modelling for planning building design - a critique of available approaches

This paper reviews four approaches used to create rational tools to aid the planning and the management of the building design process and then proposes a fifth approach. The new approach that has been developed is based on the mechanical aspects of technology rather than subjective design issues. The knowledge base contains, for each construction technology, a generic model of the detailed design process. Each activity in the process is specified by its input and output information needs. By connecting the input demands of one technology with the output supply from another technology a map or network of design activity is formed. Thus, it is possible to structure a specific model from the generic knowledge base within a KBE system.

A qualitative exploration of the underlying causes of preventable drug-related morbidity in primary care, resulting in hospitalisation

This study has explored the underlying causes of preventable drug-related admissions to hospital, from primary care through semi-structured interviews and review of patients’ medical records. Analysis of the data has revealed that communication failures between different groups of healthcare professionals and between healthcare professionals and patients contribute to preventable drug-related admissions, as do knowledge gaps about medication in both healthcare professionals and patients. In addition, working conditions for community pharmacists severely limit their ability to effectively act as a safety barrier to patients receiving inappropriate medication. Limitations include heavy workloads, lack of access to patients’ clinical information, poor relationships with general practitioners and time restrictions. The results of this study represent an important addition to our understanding of the contribution of human error as an underlying cause of preventable drug-related morbidity, and the factors which contribute to errors occurring in the primary healthcare setting.

Neural competition for conscious representation across time: An fMRI study

Background The information processing capacity of the human mind is limited, as is evidenced by the attentional blink (AB) - a deficit in identifying the second of two temporally-close targets (T1 and T2) embedded in a rapid stream of distracters. Theories of the AB generally agree that it results from competition between stimuli for conscious representation. However, they disagree in the specific mechanisms, in particular about how attentional processing of T1 determines the AB to T2. Methodology/Principal Findings The present study used the high spatial resolution of functional magnetic resonance imaging (fMRI) to examine the neural mechanisms underlying the AB. Our research approach was to design T1 and T2 stimuli that activate distinguishable brain areas involved in visual categorization and representation. ROI and functional connectivity analyses were then used to examine how attentional processing of T1, as indexed by activity in the T1 representation area, affected T2 processing. Our main finding was that attentional processing of T1 at the level of the visual cortex predicted T2 detection rates Those individuals who activated the T1 encoding area more strongly in blink versus no-blink trials generally detected T2 on a lower percentage of trials. The coupling of activity between T1 and T2 representation areas did not vary as a function of conscious T2 perception. Conclusions/Significance These data are consistent with the notion that the AB is related to attentional demands of T1 for selection, and indicate that these demands are reflected at the level of visual cortex. They also highlight the importance of individual differences in attentional settings in explaining AB task performance.

Fit for planning? An evaluation of the application of development viability appraisal models in the UK planning system

The aim of this paper is to critically examine the application of development appraisal to viability assessment in the planning system. This evaluation is of development appraisal models in general and also their use in particular applications associated with estimating planning obligation capacity. The paper is organised into four themes: · The context and conceptual basis for development viability appraisal · A review of development viability appraisal methods · A discussion of selected key inputs into a development viability appraisal · A discussion of the applications of development viability appraisals in the planning system It is assumed that readers are familiar with the basic models and information needs of development viability appraisal rather than at the cutting edge of practice and/or academe

The role of agronomic research in climate change and food security policy

Societal concern is growing about the consequences of climate change for food systems and, in a number of regions, for food security. There is also concern that meeting the rising demand for food is leading to environmental degradation thereby exacerbating factors in part responsible for climate change, and further undermining the food systems upon which food security is based. A major emphasis of climate change/food security research over recent years has addressed the agronomic aspects of climate change, and particularly crop yield. This has provided an excellent foundation for assessments of how climate change may affect crop productivity, but the connectivity between these results and the broader issues of food security at large are relatively poorly explored; too often discussions of food security policy appear to be based on a relatively narrow agronomic perspective. To overcome the limitation of current agronomic research outputs there are several scientific challenges where further agronomic effort is necessary, and where agronomic research results can effectively contribute to the broader issues underlying food security. First is the need to better understand how climate change will affect cropping systems including both direct effects on the crops themselves and indirect effects as a result of changed pest and weed dynamics and altered soil and water conditions. Second is the need to assess technical and policy options for either reducing the deleterious impacts or enhancing the benefits of climate change on cropping systems while minimising further environmental degradation. Third is the need to understand how best to address the information needs of policy makers and report and communicate agronomic research results in a manner that will assist the development of food systems adapted to climate change. There are, however, two important considerations regarding these agronomic research contributions to the food security/climate change debate. The first concerns scale. Agronomic research has traditionally been conducted at plot scale over a growing season or perhaps a few years, but many of the issues related to food security operate at larger spatial and temporal scales. Over the last decade, agronomists have begun to establish trials at landscape scale, but there are a number of methodological challenges to be overcome at such scales. The second concerns the position of crop production (which is a primary focus of agronomic research) in the broader context of food security. Production is clearly important, but food distribution and exchange also determine food availability while access to food and food utilisation are other important components of food security. Therefore, while agronomic research alone cannot address all food security/climate change issues (and hence the balance of investment in research and development for crop production vis à vis other aspects of food security needs to be assessed), it will nevertheless continue to have an important role to play: it both improves understanding of the impacts of climate change on crop production and helps to develop adaptation options; and also – and crucially – it improves understanding of the consequences of different adaptation options on further climate forcing. This role can further be strengthened if agronomists work alongside other scientists to develop adaptation options that are not only effective in terms of crop production, but are also environmentally and economically robust, at landscape and regional scales. Furthermore, such integrated approaches to adaptation research are much more likely to address the information need of policy makers. The potential for stronger linkages between the results of agronomic research in the context of climate change and the policy environment will thus be enhanced.

Memory as discrimination: what distraction reveals

Recalling information involves the process of discriminating between relevant and irrelevant information stored in memory. Not infrequently, the relevant information needs to be selected from amongst a series of related possibilities. This is likely to be particularly problematic when the irrelevant possibilities are not only temporally or contextually appropriate but also overlap semantically with the target or targets. Here, we investigate the extent to which purely perceptual features which discriminate between irrelevant and target material can be used to overcome the negative impact of contextual and semantic relatedness. Adopting a distraction paradigm, it is demonstrated that when distracters are interleaved with targets presented either visually (Experiment 1) or auditorily (Experiment 2), a within-modality semantic distraction effect occurs; semantically-related distracters impact upon recall more than unrelated distracters. In the semantically-related condition, the number of intrusions in recall is reduced whilst the number of correctly recalled targets is simultaneously increased by the presence of perceptual cues to relevance (color features in Experiment 1 or speaker’s gender in Experiment 2). However, as demonstrated in Experiment 3, even presenting semantically-related distracters in a language and a sensory modality (spoken Welsh) distinct from that of the targets (visual English) is insufficient to eliminate false recalls completely, or to restore correct recall to levels seen with unrelated distracters . Together, the study shows how semantic and non-semantic discriminability shape patterns of both erroneous and correct recall.

Verb retrieval in fluent aphasia: a clinical study

Background: Problems with lexical retrieval are common across all types of aphasia but certain word classes are thought to be more vulnerable in some aphasia types. Traditionally, verb retrieval problems have been considered characteristic of non-fluent aphasias but there is growing evidence that verb retrieval problems are also found in fluent aphasia. As verbs are retrieved from the mental lexicon with syntactic as well as phonological and semantic information, it is speculated that an improvement in verb retrieval should enhance communicative abilities in this population as in others. We report on an investigation into the effectiveness of verb treatment for three individuals with fluent aphasia. Methods & Procedures: Multiple pre-treatment baselines were established over 3 months in order to monitor language change before treatment. The three participants then received twice-weekly verb treatment over approximately 4 months. All pre-treatment assessments were administered immediately after treatment and 3 months post-treatment. Outcome & Results: Scores fluctuated in the pre-treatment period. Following treatment, there was a significant improvement in verb retrieval for two of the three participants on the treated items. The increase in scores for the third participant was statistically nonsignificant but post-treatment scores moved from below the normal range to within the normal range. All participants were significantly quicker in the verb retrieval task following treatment. There was an increase in well-formed sentences in the sentence construction test and in some samples of connected speech. Conclusions: Repeated systematic treatment can produce a significant improvement in verb retrieval of practised items and generalise to unpractised items for some participants. An increase in well-formed sentences is seen for some speakers. The theoretical and clinical implications of the results are discussed.

Prevalence of disorders of the autism spectrum in a population cohort of children in South Thames: the special needs and autism project (SNAP)

Background Recent reports have suggested that the prevalence of autism and related spectrum disorders (ASDs) is substantially higher than previously recognised. We sought to quantify prevalence of ASDs in children in South Thames, UK. Methods Within a total population cohort of 56946 children aged 9-10 years, we screened all those with a current clinical diagnosis of ASD (n=255) or those judged to be at risk for being an undetected case (n=1515). A stratified subsample (n=255) received a comprehensive diagnostic assessment, including standardised clinical observation, and parent interview assessments of autistic symptoms, language, and intelligence quotient (IQ). Clinical consensus diagnoses of childhood autism and other ASDs were derived. We used a sample weighting procedure to estimate prevalence. Findings The prevalence of childhood autism was 38.9 per 10000 (95% CI 29.9-47.8) and that of other ASDs was 77.2 per 10000 (52.1-102.3), making the total prevalence of all AS Ds 116.1 per 10000 (90.4-141.8). A narrower definition of childhood autism, which combined clinical consensus with instrument criteria for past and current presentation, provided a prevalence of 24.8 per 10 000 (17.6-32.0). The rate of previous local identification was lowest for children of less educated parents. Interpretation Prevalence of autism and related ASDs is substantially greater than previously recognised. Whether the increase is due to better ascertainment, broadening diagnostic criteria, or increased incidence is unclear. Services in health, education, and social care will need to recognise the needs of children with some form of ASD, who constitute 1% of the child population.

IQ in children with autism spectrum disorders: data from the Special Needs and Autism Project (SNAP)

Background Autism spectrum disorder (ASD) was once considered to be highly associated with intellectual disability and to show a characteristic IQ profile, with strengths in performance over verbal abilities and a distinctive pattern of ‘peaks’ and ‘troughs’ at the subtest level. However, there are few data from epidemiological studies. Method Comprehensive clinical assessments were conducted with 156 children aged 10–14 years [mean (s.d.)=11.7 (0.9)], seen as part of an epidemiological study (81 childhood autism, 75 other ASD). A sample weighting procedure enabled us to estimate characteristics of the total ASD population. Results Of the 75 children with ASD, 55% had an intellectual disability (IQ<70) but only 16% had moderate to severe intellectual disability (IQ<50); 28% had average intelligence (115>IQ>85) but only 3% were of above average intelligence (IQ>115). There was some evidence for a clinically significant Performance/Verbal IQ (PIQ/VIQ) discrepancy but discrepant verbal versus performance skills were not associated with a particular pattern of symptoms, as has been reported previously. There was mixed evidence of a characteristic subtest profile: whereas some previously reported patterns were supported (e.g. poor Comprehension), others were not (e.g. no ‘peak’ in Block Design). Adaptive skills were significantly lower than IQ and were associated with severity of early social impairment and also IQ. Conclusions In this epidemiological sample, ASD was less strongly associated with intellectual disability than traditionally held and there was only limited evidence of a distinctive IQ profile. Adaptive outcome was significantly impaired even for those children of average intelligence.

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.