Protocol for the PINCER trial: a cluster randomised trial comparing the 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 are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods: Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

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.

Promoting sustainability: Efficacy and adoption of tobacco-based insecticides in Nigeria

The promotion of technologies seen to be aiding in the attainment of agricultural sustainability has been Popular amongst Northern-based development donors for many years. One of these, botanical insecticides (e.g., those based on neem, Pyrethrum and tobacco) have been a particular favorite as they are equated with being 'natural' and hence less damaging to human health and the environment. This paper describes the outcome of interactions between one non-government organisation (NGO), the Diocesan Development Services (DDS), based in Kogi State, Nigeria, and a major development donor based in Europe that led to the establishment of a programme designed to promote the Virtues of a tobacco-based insecticide to small-scale farmers. The Tobacco Insecticide Programme (TIP) began in the late 1980s and ended in 200 1, absorbing significant quantities of resource in the process. TIP began with exploratory investigations of efficacy on the DDS seed multiplication farm followed by stages of researcher-managed and farmer-managed on-farm trials. A survey in 2002 assessed adoption of the technology by farmers. While yield benefits from using the insecticide were nearly always positive and statistically significant relative to an untreated control, they were not as good as commercial insecticides. However, adoption of the tobacco insecticide by local farmers was poor. The paper discusses the reasons for poor adoption, including relative benefits in gross margin, and uses the TIP example to explore the differing power relationships that exist between donors, their field partners and farmers. (C) 2004 by The Haworth Press, Inc. All rights reserved.

Intake, growth and meat quality of steers given diets based on varying proportions of maize silage and grass silage

Simmental × Holstein-Friesian steers were offered four forage diets. These comprised grass silage (G); proportionately 0·67 grass silage, proportionately 0·33 maize silage (GGM); 0·33 grass silage, 0·67 maize silage ( MMG); maize silage ( M) from 424 (s.d. = 11·5) kg to slaughter at a minimum weight of 560 kg. Forages were mixed and offered ad libitum. Steers were offered 2 kg of a concentrate daily, the concentrate being formulated such that all steers had similar crude protein intakes across dietary treatments. A sample of steers was slaughtered at the beginning of the experimental period to allow the calculation of the rate of gain of the carcass and its components. Carcass dissection of a sample of steers allowed the development of a prediction equation of carcass composition based on thoracic limb dissection of all carcasses. Forage dry matter intake and live-weight gain increased linearly as maize silage replaced grass silage in the forage mixture, resulting in improvements in food conversion ratio (all P = 0·001). Killing-out proportion increased with maize silage inclusion ( P < 0·001) but fat and conformation scores did not differ significantly between diets. However, increasing maize inclusion in the diet resulted in a greater weight ( P = 0·05) and proportion ( P = 0·008) of fat in the carcass, and significant increases in internal fat deposition. The inclusion of maize led to a progressive increase in the daily gains of carcass ( P < 0·001), and significant increases in the daily gains of both fat ( P < 0·001) and lean tissue ( P < 0·001). Fat colour was more yellow in cattle given diets G and GGM than diets MMG and M ( P < 0·001) and colour intensity was lower on diet M than the other three diets ( P < 0·001). There were no significant differences in any aspects of eating quality between diets. Therefore, maize silage has the potential to reduce the time taken for finishing beef animals to achieve slaughter weight with no apparent detrimental effects on subsequent meat quality.

Dietary-based gut flora modulation against Clostridium difficile onset

Clostridium difficile infection is a frequent complication of antibiotic therapy in hospitalised patients, which today is attracting more attention than ever and has led to its classification as a 'superbug'. Disruption of the composition of the intestinal microflora following antibiotic treatment is an important prerequisite for overgrowth of C. difficile and the subsequent development of an infection. Treatment options for antibiotic-associated diarrhoea and C. difficile-induced colitis include administration of specific antibiotics (e.g. vancomycin), which often leads to high relapse rates. More importantly, both the rate and severity of C. difficile-associated diseases are increasing, with new epidemic strains of C. difficile often implicated. For the prevention and treatment of antibiotic-associated diarrhoea and C. difficile infection, several probiotic bacteria such as selected strains of lactobacilli (especially Lactobacillus rhamnosus GG), Bifidobacterium longum, and Enterococcus faecium and the non-pathogenic yeast Saccharomyces boulardii have been used. Controlled trials indicate a benefit of S. boulardii and L. rhamnosus GG as therapeutic agents when used as adjuncts to antibiotics. However, the need for more well designed controlled trials with probiotics is explicit.

Temperature-responsive water-soluble copolymers based on 2-hydroxyethyl acrylate and butyl acrylate

Amphiphilic copolymers have been synthesised by free radical copolymerisation of 2-hydroxyethyl acrylate with butyl acrylate, the reactivity ratios of which indicate practically equal reactivity. The copolymers containing less than 30 mol-% of BA were soluble in water and exhibited a LCST in aqueous solutions. It was found that the interaction between these copolymers and poly(acrylic acid) in aqueous solutions resulted in the formation of interpolymer complexes stabilised by hydrogen bonds and hydrophobic interactions. This interaction was significantly affected by solution I pH and led to modification of the temperature-responsive behaviour of the copolymers.

Achieving whole-life value: The challenges of service-led construction

Major construction clients are increasingly looking to procure built facilities on the basis of added value, rather than capital cost. Recent advances in the procurement of construction projects have emphasised a whole-life value approach to meeting the client’s objectives, with strategies put in place to encourage long-term commitment and through-life service provision. Construction firms are therefore increasingly required to take on responsibility for the operation and maintenance of the construction project on the client’s behalf - with the emphasis on value and service. This inevitably throws up a host of challenges, not the least of which is the need for construction firms to manage and accommodate the new emphasis on service. Indeed, these ‘service-led’ projects represent a new realm of construction projects where the rationale for the project is driven by client’s objectives with some aspect of service provision. This vision of downstream service delivery increases the number of stakeholders, adds to project complexity and challenges deeply-ingrained working practices. Ultimately it presents a major challenge for the construction sector. This paper sets out to unravel some of the many implications that this change brings with it. It draws upon ongoing research investigating how construction firms can adapt to a more service-orientated built environment and add value in project-based environments. The conclusions lay bare the challenges that firms face when trying to compete on the basis of added-value and service delivery. In particular, how it affects deeply-ingrained working practices and established relationships in the sector.

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.

Synthesis, characterization, crystal structure, and DNA-binding of ruthenium(II) complexes of heterocyclic nitrogen ligands resulting from a benzimidazole-based quinazoline derivative

The reaction of cis-[RuCl2(dmso)(4)] with [6-(2-pyridinyl)-5,6-dihydrobenzimidazo[1,2-c] quinazoline] (L) afforded in pure form a blue ruthenium(II) complex, [Ru(L-1)(2)] (1), where the original L changed to [2-(1H-benzoimidazol-2-yl)-phenyl]-pyridin-2-ylmethylene-amine (HL1). Treatment of RuCl3 center dot 3H(2)O with L in dry tetrahydrofuran in inert atmosphere led to a green ruthenium(II) complex, trans-[RuCl2(L-2)(2)] (2), where L was oxidized in situ to the neutral species 6-pyridin-yl-benzo[4,5]imidazo[1,2-c] quinazoline (L-2). Complex 2 was also obtained from the reaction of RuCl3 center dot 3H(2)O with L-2 in dry ethanol. Complexes 1 and 2 have been characterized by physico-chemical and spectroscopic tools, and 1 has been structurally characterized by single-crystal X-ray crystallography. The electrochemical behavior of the complexes shows the Ru(III)/Ru(II) couple at different potentials with quasi-reversible voltammograms. The interaction of these complexes with calf thymus DNA by using absorption and emission spectral studies allowed determination of the binding constant K-b and the linear Stern-Volmer quenching constant K-SV

Unified framework for construction of rule based classification systems

Automatic generation of classification rules has been an increasingly popular technique in commercial applications such as Big Data analytics, rule based expert systems and decision making systems. However, a principal problem that arises with most methods for generation of classification rules is the overfit-ting of training data. When Big Data is dealt with, this may result in the generation of a large number of complex rules. This may not only increase computational cost but also lower the accuracy in predicting further unseen instances. This has led to the necessity of developing pruning methods for the simplification of rules. In addition, classification rules are used further to make predictions after the completion of their generation. As efficiency is concerned, it is expected to find the first rule that fires as soon as possible by searching through a rule set. Thus a suit-able structure is required to represent the rule set effectively. In this chapter, the authors introduce a unified framework for construction of rule based classification systems consisting of three operations on Big Data: rule generation, rule simplification and rule representation. The authors also review some existing methods and techniques used for each of the three operations and highlight their limitations. They introduce some novel methods and techniques developed by them recently. These methods and techniques are also discussed in comparison to existing ones with respect to efficient processing of Big Data.

Bizzy Break! The effect of a classroom-based activity break on in-school physical activity levels of primary school children

The school has been identified as a key setting to promote physical activity. The purpose of this study was to evaluate the effect of a classroom-based activity break on in-school step counts of primary school children. Data for 90 children (49 boys, 41 girls, 9.3 ± 1.4 years) from three Irish primary schools is presented. In each school one class was randomly assigned as the intervention group and another as controls. Children's step counts were measured for five consecutive days during school hours at baseline and follow-up. Teachers of the intervention classes led a 10 min activity break in the classroom each day (Bizzy Break!). Mean daily in-school steps for the intervention at baseline and follow-up were 5351 and 5054. Corresponding values for the control group were 5469 and 4246. There was a significant difference in the change in daily steps from baseline to follow-up between groups (p < .05). There was no evidence that girls and boys responded differently to the intervention (p > .05). Children participating in a daily 10 min classroom-based activity break undertake more physical activity during school hours than controls.

Colloidal gas aphrons based separation process for the purification and fractionation of natural phenolic extracts

Following previous studies, the aim of this work is to further investigate the application of colloidal gas aphrons (CGA) to the recovery of polyphenols from a grape marc ethanolic extract with particular focus on exploring the use of a non-ionic food grade surfactant (Tween 20) as an alternative to the more toxic cationic surfactant CTAB. Different batch separation trials in a flotation column were carried out to evaluate the influence of surfactant type and concentration and processing parameters (such as pH, drainage time, CGA/extract volumetric and molar ratio) on the recovery of total and specific phenolic compounds. The possibility of achieving selective separation and concentration of different classes of phenolic compounds and non-phenolic compounds was also assessed, together with the influence of the process on the antioxidant capacity of the recovered compounds. The process led to good recovery, limited loss of antioxidant capacity, but low selectivity under the tested conditions. Results showed the possibility of using Tween 20 with a separation mechanism mainly driven by hydrophobic interactions. Volumetric ratio rather than the molar ratio was the key operating parameter in the recovery of polyphenols by CGA.

Rhodosporidium toruloides cultivated in NaCl-enriched glucose-based media: adaptation dynamics and lipid production

In the present report and for the first time in the international literature, the impact of the addition of NaCl upon growth and lipid production on the oleaginous yeast Rhodosporidium toruloides was studied. Moreover, equally for first time, lipid production by R. toruloides was performed under non-aseptic conditions. Therefore, the potentiality of R. toruloides DSM 4444 to produce lipid in media containing several initial concentrations of NaCl with glucose employed as carbon source was studied. Preliminary batch-flask trials with increasing amounts of NaCl revealed the tolerance of the strain against NaCl content up to 6.0% (w/v). However, 4.0% (w/v) of NaCl stimulated lipid accumulation for this strain, by enhancing lipid production up to 71.3% (w/w) per dry cell weight. The same amount of NaCl was employed in pasteurized batch-flask cultures in order to investigate the role of the salt as bacterial inhibiting agent. The combination of NaCl and high glucose concentrations was found to satisfactorily suppress bacterial contamination of R. toruloides cultures under these conditions. Batch-bioreactor trials of the yeast in the same media with high glucose content (up to 150 g/L) resulted in satisfactory substrate assimilation, with almost linear kinetic profile for lipid production, regardless of the initial glucose concentration imposed. Finally, fed-batch bioreactor cultures led to the production of 37.2 g/L of biomass, accompanied by 64.5% (w/w) of lipid yield. Lipid yield per unit of glucose consumed received the very satisfactory value of 0.21 g/g, a value amongst the highest ones in the literature. The yeast lipid produced contained mainly oleic acid and to lesser extent palmitic and stearic acids, thus constituting a perfect starting material for “second generation” biodiesel

Accrual-based and real earnings management before and after IFRS adoption: the case of Greece

Purpose – The purpose of this study is to examine the use of accrual-based vs real earnings management (EM) by Greek firms, before and after the mandatory adoption of International Financial Reporting Standards (IFRS). The research is motivated by the fact that past studies have indicated the existence of significant levels of EM for Greece in particular before IFRS. Design/methodology/approach – Accrual-based earnings management (AEM) is examined by assessing performance-adjusted discretionary accruals, while real earnings management (REM) is defined in terms of abnormal levels of production costs, discretionary expenses, and cash flows from operations, for a three-year period before and after the adoption of IFRS in 2005. Findings – The authors find evidence on a statistically significant shift from AEM to REM after the adoption of IFRS, indicating the replacement of one form of EM with the other. Research limitations/implications – The validity of the results depends on the ability of the empirical models used to efficiently capture the existence of AEM and REM. Practical implications – IFRS adoption aims to improve accounting quality, especially in countries with high need for such an improvement; however, the tendency to substitute one form of EM with another highlights unintended consequences of IFRS adoption, which do not improve the informational content of financial statements if EM continues under different forms. Originality/value – Under the expectation that IFRS adoption should lead to improvements in accounting quality, this study examines whether IFRS actually led to a reduction of EM practices for a country with exceptionally high levels of EM before IFRS, by accounting for all possible forms of EM.

Using NMR-based metabolomics to evaluate postprandial urinary responses following consumption of minimally processed wheat bran or wheat aleurone by men and women

Wheat bran, and especially wheat aleurone fraction, are concentrated sources of a wide range of components which may contribute to the health benefits associated with higher consumption of whole-grain foods. This study used NMR metabolomics to evaluate urine samples from baseline at one and two hours postprandially, following the consumption of minimally processed bran, aleurone or control by 14 participants (7 Females; 7 Males) in a randomized crossover trial. The methodology discriminated between the urinary responses of control, and bran and aleurone, but not between the two fractions. Compared to control, consumption of aleurone or bran led to significantly and substantially higher urinary concentrations of lactate, alanine, N-acetylaspartate acid and N-acetylaspartylglutamate and significantly and substantially lower urinary betaine concentrations at one and two hours postprandially. There were sex related differences in urinary metabolite profiles with generally higher hippurate and citrate and lower betaine in females compared to males. Overall, this postprandial study suggests that acute consumption of bran or aleurone is associated with a number of physiological effects that may impact on energy metabolism and which are consistent with longer term human and animal metabolomic studies that used whole-grain wheat diets or wheat fractions.