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.

Intensive case management for severe psychotic illness: is there a general benefit for patients with complex needs? A secondary analysis of the UK700 trial data

The UK700 trial failed to demonstrate an overall benefit of intensive case management (ICM) in patients with severe psychotic illness. This does not discount a benefit for particular subgroups, and evidence of a benefit of ICM for patients of borderline intelligence has been presented. The aim of this study is to investigate whether this effect is part of a general benefit for patients with severe psychosis complicated by additional needs. In the UK700 trial patients with severe psychosis were randomly allocated to ICM or standard case management. For each patient group with complex needs the effect of ICM is compared with that in the rest of the study cohort. Outcome measures are days spent in psychiatric hospital and the admission and discharge rates. ICM may be of benefit to patients with severe psychosis complicated by borderline intelligence or depression, but may cause patients using illicit drugs to spend more time in hospital. There was no convincing evidence of an effect of ICM in a further seven patient groups. ICM is not of general benefit to patients with severe psychosis complicated by additional needs. The benefit of ICM for patients with borderline intelligence is an isolated effect which should be interpreted cautiously until further data are available.

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.

Survey of the nutritional recommendations and management practices adopted by feedlot cattle nutritionists in Brazil

Thirty-three feedlot cattle nutritionists were surveyed to evaluate the management practices and nutritional recommendations adopted by feedlots in Brazil. The web-based survey consisted of 81 questions that included: general information (n = 10); general commodity information (n = 15); use of coproducts (n = 5), roughage source and level (n = 5); adaptation methods (n = 7); feed mixers (n = 6); feeding management (n = 6); cattle management and type of cattle fed (n = 13); formulation practices (n = 9); information resources used for nutritional recommendations (n = 2); and additional questions (n = 3). In total, the 33 nutritionists were responsible for approximately 2,658,000 animals, and moreover, 65.5% of those participants had clients that feed less than 5000 animals yearly. Corn was the primary source of grain used in feedlot diets (87.9%) and cracking was the primary processing method recommended by nutritionists (57.6%). The average concentrate and roughage inclusion in finishing diets was 79.0% and 21.0%, respectively. The main challenges faced by nutritionists are the lack of available and precise equipment and lack of trained employees with respiratory diseases as the main health problem. This survey of nutrition and management practices should aid in the development of research for the feedlot industry in Brazil and similar tropical climates, as well as provide data to facilitate the broader application of future NRC models. (C) 2014 Elsevier B.V. All rights reserved.

A survey of the management of patients with temporomandibular disorders by general dental practitioners in southern Brazil

Purpose: Temporomandibular disorders (TMD) are recognized as one of the mostcontroversial topics in dentistry, despite the fact that both basic science and clinicalresearchers have currently reached some degree of consensus. This study aimed toconduct a questionnaire-based survey about the management of TMD patients bygeneral dental practitioners (GDPs).Materials and Methods: One hundred fifty-one GDPs with a private practice in a cityof southern Brazil were included, independent of school of origin, gender, graduationyear, and curriculum content. All participants were administered a questionnaire aboutthe management of patients with TMD, and the responses were analyzed by binomialand chi-square tests (α = 0.05).Results: Of the GDPs, 88.7% received TMD patients, who were primarily diagnosedon the basis of medical history (36.6%) or physical examination (30.4%). Of these,65.4% referred the patients elsewhere, primarily to specialists in occlusion (36.1%) ororthodontics (29.7%). Occlusal splinting was the most commonly used managementmodality (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy(16.6%). Splints were fabricated in maximum habitual intercuspation or centric re-lation depending on individual patient (54.8%). The hard stabilization form was themost common type of appliance used (35.0%). Moreover, 73.8% of the GDPs didnot employ semi-adjustable articulators, and 69.5% adjusted the appliances at thetime of fixing. The duration of splint use and the frequency of follow-up were con-sidered patient dependent by 62.1% and 72.8%, respectively. GDPs considered thetwo major TMD etiologic categories as multifactorial (20.8%) and occlusion (19.9%).Multidisciplinary medical and dental treatment was considered necessary by 97.9%.Conclusions: The evaluated general dental practitioners manage TMD patients ac-cording to international guidelines.

Speleoclimate dynamics in Santana Cave (PETAR, S(a)over-tildeo Paulo State, Brazil): general characterization and implications for tourist management

Show caves provide tourists with the opportunity to have close contact with natural underground spaces. However, visitation to these places also creates a need for management measures, mainly the definition of tourist carrying capacity. The present work describes the results of climate monitoring and atmospheric profiling performed in Santana Cave (Alto Ribeira State and Tourist Park - PETAR, Brazil) between 2008 and 2011. Based on the results, distinct preliminary zones with different levels of thermal variation were identified, which classify Santana Cave as a warm trap. Two critical points along the tourist route (Cristo and Encontro Halls) were identified where the temperature of the locality increased by 1.3 degrees C when tourists were present. Air flow from the inner cave to the outside occurs during the austral summer, and the opposite flow occurs when the outside environment is colder than the air inside the cave during the austral winter. The temperature was used to establish thresholds to the tourist carrying capacity by computing the recovery time of the atmospheric conditions after the changes caused by the presence of tourists. This method suggests a maximum limit of approximately 350 visits per day to Santana Cave. The conclusion of the study is that Santana Cave has an atmosphere that is highly connected with the outside; daily variations in temperature and, to a lesser extent, in the relative humidity occur throughout the entire studied area of the cave. Therefore, the tourist carrying capacity in Santana Cave can be flexible and can be implemented based on the climate seasonality, the tourism demand and other management strategies.

A Dynamic Approach to Stakeholder Theory: A Case Study of Labor - Management Relations at General Motors

The purpose of this thesis is to identify areas for improvement in the current stakeholder management literature. The current stakeholder management theories were analyzed to determine their benefits and detriments. To determine how these theories work in a corporation, General Motors was selected as a single-case study to determine the patterns of stakeholder management over time. These patterns demonstrated the need for dynamic stakeholder management over time, with an emphasis on collaboration and the necessity of recognizing the greater stakeholder network surrounding the corporation. Proper stakeholder management in the early years of General Motors would have prevented its failure, while the organizational culture as a path-dependent variable made it difficult for General Motors to alter long-standing stakeholder relationships.

Halitosis management by the general dental practitioner—results of an international consensus workshop.

Clinical investigations on patients suffering from halitosis clearly reveal that in the vast majority of cases the source for an offensive breath odor can be found within the oral cavity (90%). Based on these studies, the main sources for intra-oral halitosis where tongue coating, gingivitis/periodontitis or a combination of the two. Thus, it is perfectly logical that general dental practitioners (GDPs) should be able to manage intra-oral halitosis under the conditions found in a normal dental practice. However, GDPs who are interested in diagnosing and treating halitosis are challenged to incorporate scientifically based strategies for use in their clinics. Therefore, the present paper summarizes the results of a consensus workshop of international authorities held with the aim to reach a consensus on general guidelines on how to assess and diagnose patients' breath odor concerns and general guidelines on regimens for the treatment of halitosis.

The Role of Knowledge Modeling Techniques in Software Development: A General Approach Based on a Knowledge Management Tool

The aim of the paper is to discuss the use of knowledge models to formulate general applications. First, the paper presents the recent evolution of the software field where increasing attention is paid to conceptual modeling. Then, the current state of knowledge modeling techniques is described where increased reliability is available through the modern knowledge acquisition techniques and supporting tools. The KSM (Knowledge Structure Manager) tool is described next. First, the concept of knowledge area is introduced as a building block where methods to perform a collection of tasks are included together with the bodies of knowledge providing the basic methods to perform the basic tasks. Then, the CONCEL language to define vocabularies of domains and the LINK language for methods formulation are introduced. Finally, the object oriented implementation of a knowledge area is described and a general methodology for application design and maintenance supported by KSM is proposed. To illustrate the concepts and methods, an example of system for intelligent traffic management in a road network is described. This example is followed by a proposal of generalization for reuse of the resulting architecture. Finally, some concluding comments are proposed about the feasibility of using the knowledge modeling tools and methods for general application design.