The potential for pharmacists to manage children attending emergency departments

AIM: There have been concerns about maintaining appropriate clinical staff levels in Emergency Departments in England.1 The aim of this study was to determine if Emergency Department attendees aged from 0-16 years could be managed by community pharmacists or hospital independent prescriber pharmacists with or without further advanced clinical practice training. METHOD: A prospective, 48 site, cross-sectional, observational study of patients attending Emergency Departments (ED) in England, UK was conducted. Pharmacists at each site collected up to 400 admissions and paediatric patients were included in the data collection. The pharmacist independent prescribers (one for each site) were asked to identify patient attendance at their Emergency Department, record anonymised details of the cases-age, weight, presenting complaint, clinical grouping (e.g. medicine, orthopaedics), and categorise each presentation into one of four possible categories: CP, Community Pharmacist, cases which could be managed by a community pharmacist outside an ED setting; IP-cases that could be managed at ED by a hospital pharmacist with independent prescriber status; IPT, Independent Prescriber Pharmacist with additional training-cases which could be managed at ED by a hospital pharmacist independent prescriber with additional clinical training; and MT, Medical Team only-cases that were unsuitable for the pharmacist to manage. An Impact Index was calculated for the two most frequent clinical groupings using the formula: Impact index=percentage of the total workload of the clinical grouping multiplied by the percentage ability of pharmacists to manage that clinical group. RESULTS: 1623 out of 18,229 (9%) attendees, from 45 of the 48 sites, were children aged from 0 to 16 years of age (median 8 yrs, range 0-16), 749 were female and 874 were male. Of the 1623 admissions, 9% of the cases were judged to be suitable for clinical management by a community pharmacist (CP), 4% suitable for a hospital pharmacist independent prescriber (IP), 32% suitable for a hospital independent pharmacist prescriber with additional training (IPT); and the remaining 55% were only suitable for the Medical Team (MT). The most frequent clinical groups and impact index for the attendees were General Medicine=10.78 and orthopaedics=10.60. CONCLUSION: Paediatric patients attending Emergency Departments were judged by pharmacists to be suitable for management outside a hospital setting in approximately 1 in 11 cases, and by hospital independent prescriber pharmacists in 4 in 10 cases. With further training, it was found that the total proportion of cases that could be managed by a pharmacist was 45%. The greatest impact for pharmacist management occurs in general medicine and orthopaedics.

Efficient use of training data in the n-tuple recognition method

A simple technique is presented for improving the robustness of the n-tuple recognition method against inauspicious choices of architectural parameters, guarding against the saturation problem, and improving the utilisation of small data sets. Experiments are reported which confirm that the method significantly improves performance and reduces saturation in character recognition problems.

The 'moving targets' training algorithm

A simple method for training the dynamical behavior of a neural network is derived. It is applicable to any training problem in discrete-time networks with arbitrary feedback. The algorithm resembles back-propagation in that an error function is minimized using a gradient-based method, but the optimization is carried out in the hidden part of state space either instead of, or in addition to weight space. Computational results are presented for some simple dynamical training problems, one of which requires response to a signal 100 time steps in the past.

The 'moving targets' training algorithm

A simple method for training the dynamical behavior of a neural network is derived. It is applicable to any training problem in discrete-time networks with arbitrary feedback. The method resembles back-propagation in that it is a least-squares, gradient-based optimization method, but the optimization is carried out in the hidden part of state space instead of weight space. A straightforward adaptation of this method to feedforward networks offers an alternative to training by conventional back-propagation. Computational results are presented for simple dynamical training problems, with varied success. The failures appear to arise when the method converges to a chaotic attractor. A patch-up for this problem is proposed. The patch-up involves a technique for implementing inequality constraints which may be of interest in its own right.

Bayesian training of mixture density networks

Mixture Density Networks (MDNs) are a well-established method for modelling the conditional probability density which is useful for complex multi-valued functions where regression methods (such as MLPs) fail. In this paper we extend earlier research of a regularisation method for a special case of MDNs to the general case using evidence based regularisation and we show how the Hessian of the MDN error function can be evaluated using R-propagation. The method is tested on two data sets and compared with early stopping.

Mixture density network training by computation in parameter space

Training Mixture Density Network (MDN) configurations within the NETLAB framework takes time due to the nature of the computation of the error function and the gradient of the error function. By optimising the computation of these functions, so that gradient information is computed in parameter space, training time is decreased by at least a factor of sixty for the example given. Decreased training time increases the spectrum of problems to which MDNs can be practically applied making the MDN framework an attractive method to the applied problem solver.

Noise, regularizers, and unrealizable scenarios in online learning from restricted training sets

We study the dynamics of on-line learning in multilayer neural networks where training examples are sampled with repetition and where the number of examples scales with the number of network weights. The analysis is carried out using the dynamical replica method aimed at obtaining a closed set of coupled equations for a set of macroscopic variables from which both training and generalization errors can be calculated. We focus on scenarios whereby training examples are corrupted by additive Gaussian output noise and regularizers are introduced to improve the network performance. The dependence of the dynamics on the noise level, with and without regularizers, is examined, as well as that of the asymptotic values obtained for both training and generalization errors. We also demonstrate the ability of the method to approximate the learning dynamics in structurally unrealizable scenarios. The theoretical results show good agreement with those obtained by computer simulations.

Delivering phonological and phonics training within whole-class teaching

Background: Early, intensive phonological awareness and phonics training is widely held to be beneficial for children with poor phonological awareness. However, most studies have delivered this training separately from children's normal whole-class reading lessons. Aims: We examined whether integrating this training into whole class, mixed-ability reading lessons could impact on children with poor phonological awareness, whilst also benefiting normally developing readers. Sample: Teachers delivered the training within a broad reading programme to whole classes of children from Reception to the end of Year 1 (N=251). A comparison group of children received standard teaching methods (N=213). Method: Children's literacy was assessed at the beginning of Reception, and then at the end of each year until 1 year post-intervention. Results: The strategy significantly impacted on reading performance for normally developing readers and those with poor phonological awareness, vastly reducing the incidence of reading difficulties from 20% in comparison schools to 5% in intervention schools. Conclusions: Phonological and phonics training is highly effective for children with poor phonological awareness, even when incorporated into whole-class teaching.

An evaluation of pharmacy education and pre-registration training

This thesis covers two major aspects of pharmacy education; undergraduate education and pre-registration training. A cohort of pharmacy graduates were surveyed over a period of four years, on issues related to undergraduate education, pre-registration training and continuing education. These graduates were the first-ever to sit the pre-registration examination. In addition, the opinions of pre-registration tutors were obtained on pre-registration training, during the year that competence-based assessment was introduced. It was concluded that although the undergraduate course provided a broad base of knowledge suitable for graduates in all branches of pharmacy, several issues were identified which would require attention in future developments of the course. These were: 1. the strong support for the expansion of clinical, social and practice-based teaching. 2. the strong support to retain the scientific content to the same extent as in the three-year course. 3. a greater use of problem-based learning methods. The graduates supported the provision of a pre-registration continuing education course to help prepare for the examination and in areas inadequately covered in the undergraduate course. There was also support for the introduction of some form of split branch training. There was no strong evidence to suggest that the training had been an application of undergraduate education. In general, competence-based training was well regarded by tutors as an appropriate and effective method of skill assessment. However, community tutors felt it was difficult to carry out effectively due to day-to-day time constraints. The assistant tutors in hospital pharmacy were found to have a very important role in provision of training, and should be adequately trained and supported. The study recommends the introduction of uniform training and a quality assurance mechanism for all tutors and assistants undertaking this role.

Identifying candidate subunit vaccines using an alignment-independent method based on principal amino acid properties

Subunit vaccine discovery is an accepted clinical priority. The empirical approach is time- and labor-consuming and can often end in failure. Rational information-driven approaches can overcome these limitations in a fast and efficient manner. However, informatics solutions require reliable algorithms for antigen identification. All known algorithms use sequence similarity to identify antigens. However, antigenicity may be encoded subtly in a sequence and may not be directly identifiable by sequence alignment. We propose a new alignment-independent method for antigen recognition based on the principal chemical properties of protein amino acid sequences. The method is tested by cross-validation on a training set of bacterial antigens and external validation on a test set of known antigens. The prediction accuracy is 83% for the cross-validation and 80% for the external test set. Our approach is accurate and robust, and provides a potent tool for the in silico discovery of medically relevant subunit vaccines.

Laser-induced breakdown spectroscopy quantitative analysis method via adaptive analytical line selection and relevance vector machine regression model

Abstract A new LIBS quantitative analysis method based on analytical line adaptive selection and Relevance Vector Machine (RVM) regression model is proposed. First, a scheme of adaptively selecting analytical line is put forward in order to overcome the drawback of high dependency on a priori knowledge. The candidate analytical lines are automatically selected based on the built-in characteristics of spectral lines, such as spectral intensity, wavelength and width at half height. The analytical lines which will be used as input variables of regression model are determined adaptively according to the samples for both training and testing. Second, an LIBS quantitative analysis method based on RVM is presented. The intensities of analytical lines and the elemental concentrations of certified standard samples are used to train the RVM regression model. The predicted elemental concentration analysis results will be given with a form of confidence interval of probabilistic distribution, which is helpful for evaluating the uncertainness contained in the measured spectra. Chromium concentration analysis experiments of 23 certified standard high-alloy steel samples have been carried out. The multiple correlation coefficient of the prediction was up to 98.85%, and the average relative error of the prediction was 4.01%. The experiment results showed that the proposed LIBS quantitative analysis method achieved better prediction accuracy and better modeling robustness compared with the methods based on partial least squares regression, artificial neural network and standard support vector machine.