Any versus long-term prescribing of high risk medications in older people using 2012 Beers Criteria: results from three cross-sectional samples of primary care records for 2003/4, 2007/8 and 2011/12

Background: High risk medications are commonly prescribed to older US patients. Currently, less is known about high risk medication prescribing in other Western Countries, including the UK. We measured trends and correlates of high risk medication prescribing in a subset of the older UK population (community/institutionalized) to inform harm minimization efforts. Methods: Three cross-sectional samples from primary care electronic clinical records (UK Clinical Practice Research Datalink, CPRD) in fiscal years 2003/04, 2007/08 and 2011/12 were taken. This yielded a sample of 13,900 people aged 65 years or over from 504 UK general practices. High risk medications were defined by 2012 Beers Criteria adapted for the UK. Using descriptive statistical methods and regression modelling, prevalence of ‘any’ (drugs prescribed at least once per year) and ‘long-term’ (drugs prescribed all quarters of year) high risk medication prescribing and correlates were determined. Results: While polypharmacy rates have risen sharply, high risk medication prevalence has remained stable across a decade. A third of older (65+) people are exposed to high risk medications, but only half of the total prevalence was long-term (any = 38.4 % [95 % CI: 36.3, 40.5]; long-term = 17.4 % [15.9, 19.9] in 2011/12). Long-term but not any high risk medication exposure was associated with older ages (85 years or over). Women and people with higher polypharmacy burden were at greater risk of exposure; lower socio-economic status was not associated. Ten drugs/drug classes accounted for most of high risk medication prescribing in 2011/12. Conclusions: High risk medication prescribing has not increased over time against a background of increasing polypharmacy in the UK. Half of patients receiving high risk medications do so for less than a year. Reducing or optimising the use of a limited number of drugs could dramatically reduce high risk medications in older people. Further research is needed to investigate why the oldest old and women are at greater risk. Interventions to reduce high risk medications may need to target shorter and long-term use separately.

Potentially inappropriate prescribing in two populations with differing socio-economic profiles: a cross-sectional database study using the PROMPT criteria

PURPOSE: The purpose of this study is to establish the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (45-64 years) in two populations with differing socio-economic profiles, and to investigate factors associated with PIP, using the PROMPT (PRescribing Optimally in Middle-aged People's Treatments) criteria.METHODS: A retrospective cross-sectional study was conducted using 2012 data from the Enhanced Prescribing Database (EPD), covering the full population in Northern Ireland and the Health Services Executive Primary Care Reimbursement Service (HSE-PCRS) database, covering the most socio-economically deprived third of the population in this age group in the Republic of Ireland. The prevalence for each PROMPT criterion and overall prevalence of PIP were calculated. Logistic regression was used to investigate the association between PIP and gender, age group and polypharmacy.RESULTS: This study included 441,925 patients from the EPD and 309,748 patients from the HSE-PCRS database. Polypharmacy was common in both datasets (46.7 % in the HSE-PCRS and 20.3 % in the EPD). The prevalence of PIP was 42.9 % (95%CI 42.7, 43.1) in the HSE-PCRS and 21.1 % (95%CI 21.0, 21.2) in the EPD. Age group, female gender and polypharmacy were significantly associated with PIP in both populations (p < 0.05) and polypharmacy had the strongest association.CONCLUSIONS: PIP is common amongst middle-aged people with the risk of PIP increasing with polypharmacy. Differences in the prevalence of polypharmacy and PIP between the two populations may relate to heterogeneity in healthcare services and different socio-economic profiles, with higher rates of multimorbidity and associated polypharmacy in more deprived groups.

Understanding and modelling hydrological and soil erosion processes in burnt forest catchments

Forest fires implications in overland flow and soil erosion have been researched for several years. Therefore, is widely known that fires enhance hydrological and geomorphological activity worldwide as also in Mediterranean areas. Soil burn severity has been widely used to describe the impacts of fire on soils, and has being recognized as a decisive factor controlling post-fire erosion rates. However, there is no unique definition of the term and the relationship between soil burn severity and post-fire hydrological and erosion response has not yet been fully established. Few studies have assessed post-fire erosion over multiple years, and the authors are aware of none which assess runoff. Small amount of studies concerning pre-fire management practices were also found. In the case of soil erosion models, the Revised Universal Soil Loss Equation (RUSLE) and the revised Morgan–Morgan–Finney (MMF) are well-known models, but not much information is available as regards their suitability in predicting post-fire soil erosion in forest soils. The lack of information is even more pronounced as regards post-fire rehabilitation treatments. The aim of the thesis was to perform an extensive research under the post fire hydrologic and erosive response subject. By understanding the effect of burn severity in ecosystems and its implications regarding post fire hydrological and erosive responses worldwide. Test the effect of different pre-fire land management practices (unplowed, downslope plowed and contour plowed) and time-since-fire, in the post fire hydrological and erosive response, between the two most common land uses in Portugal (pine and eucalypt). Assess the performance of two widely-known erosion models (RUSLE and Revised MMF), to predict soil erosion rates during first year following two wildfires of distinctive burn severity. Furthermore, to apply these two models considering different post-fire rehabilitation treatments in an area severely affected by fire. Improve model estimations of post-fire runoff and erosion rates in two different land uses (pine and eucalypt) using the revised MMF. To assess these improvements by comparing estimations and measurements of runoff and erosion, in two recently burned sites, as also with their post fire rehabilitation treatments. Model modifications involved: (1) focusing on intra-annual changes in parameters to incorporate seasonal differences in runoff and erosion; and (2) inclusion of soil water repellency in runoff predictions. Additionally, validate these improvements with the application of the model to other pine and eucalypt sites in Central Portugal. The review and meta-analysis showed that fire occurrence had a significant effect on the hydrological and erosive response. However, this effect was only significantly higher with increasing soil burn severity for inter-rill erosion, and not for runoff. This study furthermore highlighted the incoherencies between existing burn severity classifications, and proposed an unambiguous classification. In the case of the erosion plots with natural rainfall, land use factor affected annual runoff while land management affected both annual runoff and erosion amounts significantly. Time-since-fire had an important effect in erosion amounts among unplowed sites, while for eucalypt sites time affected both annual runoff and erosion amounts. At all studied sites runoff coefficients increase over the four years of monitoring. In the other hand, sediment concentration in the runoff, recorded a decrease during the same period. Reasons for divergence from the classic post-fire recovery model were also explored. Short fire recurrence intervals and forest management practices are viewed as the main reasons for the observed severe and continuing soil degradation. The revised MMF model presented reasonable accuracy in the predictions while the RUSLE clearly overestimated the observed erosion rates. After improvements: the revised model was able to predict first-year post-fire plot-scale runoff and erosion rates for both forest types, these predictions were improved both by the seasonal changes in the model parameters; and by considering the effect of soil water repellency on the runoff, individual seasonal predictions were considered accurate, and the inclusion of the soil water repellency in the model also improved the model at this base. The revised MMF model proved capable of providing a simple set of criteria for management decisions about runoff and erosion mitigation measures in burned areas. The erosion predictions at the validation sites attested both to the robustness of the model and of the calibration parameters, suggesting a potential wider application.

Eliciting Security Requirements and Tracing them to Design: An Integration of Common Criteria, Heuristics, and UMLsec

Building secure systems is difficult for many reasons. This paper deals with two of the main challenges: (i) the lack of security expertise in development teams, and (ii) the inadequacy of existing methodologies to support developers who are not security experts. The security standard ISO 14508 (Common Criteria) together with secure design techniques such as UMLsec can provide the security expertise, knowledge, and guidelines that are needed. However, security expertise and guidelines are not stated explicitly in the Common Criteria. They are rather phrased in security domain terminology and difficult to understand for developers. This means that some general security and secure design expertise are required to fully take advantage of the Common Criteria and UMLsec. In addition, there is the problem of tracing security requirements and objectives into solution design,which is needed for proof of requirements fulfilment. This paper describes a security requirements engineering methodology called SecReq. SecReq combines three techniques: the Common Criteria, the heuristic requirements editorHeRA, andUMLsec. SecReqmakes systematic use of the security engineering knowledge contained in the Common Criteria and UMLsec, as well as security-related heuristics in the HeRA tool. The integrated SecReq method supports early detection of security-related issues (HeRA), their systematic refinement guided by the Common Criteria, and the ability to trace security requirements into UML design models. A feedback loop helps reusing experiencewithin SecReq and turns the approach into an iterative process for the secure system life-cycle, also in the presence of system evolution.

Can the Revised UK Code Direct Practice?

The Nursing and Midwifery Council, the United Kingdom regulator of nursing and midwifery has recently revised its professional code of practice. This paper begins by arguing that a professional code must be capable of sustaining close reading and of action guidance. Using four exemplar clauses it is argued that the new revised code does not met this purpose. First, I show that in setting out requirements for consent and documentation, the meaning of the relevant clause has changed significantly during the editing process so that a literal reading of the final document bears little relation to established professional practice. Second, I argue that the clause concerning the nature of professional relationships has also been altered during the editing process so that it is inconsistent with other professional groups and established accounts of the professional nurse-patient relationship. Third, I argue that the clause concerning disclosure of confidential information, which survived revision and editing with its meaning intact is nevertheless factually incorrect and inconsistent with UK law and authoritative guidance. Finally, fourth, I argue that use of the word ‘inappropriate’ is inappropriate as it amounts to meaningless circularity, discussed in relation to a clause on expressing personal beliefs. Taken together, these examples demonstrate that the Code is seriously flawed and does not fulfil its purpose. One way that simple prescriptive clauses in the Code can be usefully understood is through the provision of detailed guidance. I argue that the NMC has changed its position on its view of the value of guidance and has significantly reduced the amount of written guidance and advice is provides. The paper concludes by arguing that in order to meet its action directing function, further clarifying revision and the provision of detailed guidance is required.

Risk criteria in occupational environments: critical overview and discussion

The current work can be seen as a starting point for the discussion of the problematic on risk acceptance criteria in occupational environments. Some obstacles to the quantitative acceptance criteria formulation and use were analyzed. A look to the long tradition of major hazards accidents was also performed. This work shows that organizations can have several difficulties in acceptance criteria formulation and that the use of pre-defined acceptance criteria in risk assessment methodologies can be inadequate in some cases. It is urgent to define guidelines that can help organizations in the formulation of risk acceptance criteria for occupational environments.

Defining risk acceptance criteria in occupational settings: A case study in the furniture industrial sector

The use of appropriate acceptance criteria in the risk assessment process for occupational accidents is an important issue but often overlooked in the literature, particularly when new risk assessment methods are proposed and discussed. In most cases, there is no information on how or by whom they were defined, or even how companies can adapt them to their own circumstances. Bearing this in mind, this study analysed the problem of the definition of risk acceptance criteria for occupational settings, defining the quantitative acceptance criteria for the specific case study of the Portuguese furniture industrial sector. The key steps to be considered in formulating acceptance criteria were analysed in the literature review. By applying the identified steps, the acceptance criteria for the furniture industrial sector were then defined. The Cumulative Distribution Function (CDF) for the injury statistics of the industrial sector was identified as the maximum tolerable risk level. The acceptable threshold was defined by adjusting the CDF to the Occupational, Safety & Health (OSH) practitioners’ risk acceptance judgement. Adjustments of acceptance criteria to the companies’ safety cultures were exemplified by adjusting the Burr distribution parameters. An example of a risk matrix was also used to demonstrate the integration of the defined acceptance criteria into a risk metric. This work has provided substantial contributions to the issue of acceptance criteria for occupational accidents, which may be useful in overcoming the practical difficulties faced by authorities, companies and experts.

Forest management: different criteria – equal sustainability

From the forest management perspective, many definitions have been proposed for the concept of forest sustainability. Despite this apparent diversity, most of them converge on the same aspects. In this work we developed a comparative approach of two distinct forest management methodologies used in Europe, more precisely in Slovenia and in Portugal. Although in each case study differences in vegetation, climate and pedological characteristics are evident, we were able to show some peculiar aspects of both the Slovenian and the Portuguese examples. This study also dealt with the evolution of the term sustainability in the last decades and how it played an important role for forest management options.

A Multiple Criteria Utility-based Approa h for the Unit Commitment with Wind Power and Pumped Storage Hydro

The integration of wind power in eletricity generation brings new challenges to unit commitment due to the random nature of wind speed. For this particular optimisation problem, wind uncertainty has been handled in practice by means of conservative stochastic scenario-based optimisation models, or through additional operating reserve settings. However, generation companies may have different attitudes towards operating costs, load curtailment, or waste of wind energy, when considering the risk caused by wind power variability. Therefore, alternative and possibly more adequate approaches should be explored. This work is divided in two main parts. Firstly we survey the main formulations presented in the literature for the integration of wind power in the unit commitment problem (UCP) and present an alternative model for the wind-thermal unit commitment. We make use of the utility theory concepts to develop a multi-criteria stochastic model. The objectives considered are the minimisation of costs, load curtailment and waste of wind energy. Those are represented by individual utility functions and aggregated in a single additive utility function. This last function is adequately linearised leading to a mixed-integer linear program (MILP) model that can be tackled by general-purpose solvers in order to find the most preferred solution. In the second part we discuss the integration of pumped-storage hydro (PSH) units in the UCP with large wind penetration. Those units can provide extra flexibility by using wind energy to pump and store water in the form of potential energy that can be generated after during peak load periods. PSH units are added to the first model, yielding a MILP model with wind-hydro-thermal coordination. Results showed that the proposed methodology is able to reflect the risk profiles of decision makers for both models. By including PSH units, the results are significantly improved.

Qualidade de vida relacionada com a saúde em doentes com lúpus eritematoso sistémico neuropsiquiátrico em Portugal

RESUMO - Este estudo tem como objetivo principal analisar o impacto do lúpus eritematoso sistémico (LES) na qualidade de vida relacionada com a saúde num grupo de doentes portugueses, através de instrumentos genéricos. Trata-se de um estudo transversal, onde os instrumentos de colheita de dados foram o EQ-5D-3L e o SF-36 v.2, aplicados no decorrer de 2012, sendo a população constituída por 116 doentes com LES-NP, inscritos na Unidade de Doenças Autoimunes do Hospital Curry Cabral, Lisboa. Todos os doentes preencheram os critérios revistos ACR de 97 para a classificação de LES. Dos 116 doentes, 104 eram mulheres (89,7%) e 12 homens (10,3%). A idade média da amostra é de 46 anos. Os indivíduos apresentam um critério ACR médio de 5,0, um índice SLICC/ACR (SDI) médio de 0,6 (± 1,1) e uma duração média de doença de 13 anos, onde 50% dos participantes indica ser portador de LES pelo menos há 11 anos. Os resultados obtidos evidenciaram que a qualidade de vida relacionada com a saúde no LES varia em função de determinadas características demográficas dos doentes como são o caso da idade e o sexo, relacionando-se também com a duração da doença e o índice de irreversibilidade de lesão, nalgumas dimensões do EQ-5D-3L e SF-36. Estes dois instrumentos genéricos apresentam forte associação em todas as suas dimensões. Um achado relevante, prende-se com o facto de o LES apresentar uma pior qualidade de vida relacionada com a saúde em relação a outras doenças crónicas comparáveis.

Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica.

STUDY DESIGN: Prospective, controlled, observational outcome study using clinical, radiographic, and patient/physician-based questionnaire data, with patient outcomes at 12 months follow-up. OBJECTIVE: To validate appropriateness criteria for low back surgery. SUMMARY OF BACKGROUND DATA: Most surgical treatment failures are attributed to poor patient selection, but no widely accepted consensus exists on detailed indications for appropriate surgery. METHODS: Appropriateness criteria for low back surgery have been developed by a multispecialty panel using the RAND appropriateness method. Based on panel criteria, a prospective study compared outcomes of patients appropriately and inappropriately treated at a single institution with 12 months follow-up assessment. Included were patients with low back pain and/or sciatica referred to the neurosurgical department. Information about symptoms, neurologic signs, the health-related quality of life (SF-36), disability status (Roland-Morris), and pain intensity (VAS) was assessed at baseline, at 6 months, and at 12 months follow-up. The appropriateness criteria were administered prospectively to each clinical situation and outside of the clinical setting, with the surgeon and patients blinded to the results of the panel decision. The patients were further stratified into 2 groups: appropriate treatment group (ATG) and inappropriate treatment group (ITG). RESULTS: Overall, 398 patients completed all forms at 12 months. Treatment was considered appropriate for 365 participants and inappropriate for 33 participants. The mean improvement in the SF-36 physical component score at 12 months was significantly higher in the ATG (mean: 12.3 points) than in the ITG (mean: 6.8 points) (P = 0.01), as well as the mean improvement in the SF-36 mental component score (ATG mean: 5.0 points; ITG mean: -0.5 points) (P = 0.02). Improvement was also significantly higher in the ATG for the mean VAS back pain (ATG mean: 2.3 points; ITG mean: 0.8 points; P = 0.02) and Roland-Morris disability score (ATG mean: 7.7 points; ITG mean: 4.2 points; P = 0.004). The ATG also had a higher improvement in mean VAS for sciatica (4.0 points) than the ITG (2.8 points), but the difference was not significant (P = 0.08). The SF-36 General Health score declined in both groups after 12 months, however, the decline was worse in the ITG (mean decline: 8.2 points) than in the ATG (mean decline: 1.2 points) (P = 0.04). Overall, in comparison to ITG patients, ATG patients had significantly higher improvement at 12 months, both statistically and clinically. CONCLUSION: In comparison to previously reported literature, our study is the first to assess the utility of appropriateness criteria for low back surgery at 1-year follow-up with multiple outcome dimensions. Our results confirm the hypothesis that application of appropriateness criteria can significantly improve patient outcomes.

Thyroid function and prevalent and incident metabolic syndrome in older adults: the Health, Ageing and Body Composition Study.

OBJECTIVE: Both subclinical hypothyroidism and the metabolic syndrome have been associated with increased risk of coronary heart disease events. It is unknown whether the prevalence and incidence of metabolic syndrome is higher as TSH levels increase, or in individuals with subclinical hypothyroidism. We sought to determine the association between thyroid function and the prevalence and incidence of the metabolic syndrome in a cohort of older adults. DESIGN: Data were analysed from the Health, Ageing and Body Composition Study, a prospective cohort of 3075 community-dwelling US adults. PARTICIPANTS: Two thousand one hundred and nineteen participants with measured TSH and data on metabolic syndrome components were included in the analysis. MEASUREMENTS: TSH was measured by immunoassay. Metabolic syndrome was defined per revised ATP III criteria. RESULTS: At baseline, 684 participants met criteria for metabolic syndrome. At 6-year follow-up, incident metabolic syndrome developed in 239 individuals. In fully adjusted models, each unit increase in TSH was associated with a 3% increase in the odds of prevalent metabolic syndrome (OR, 1.03; 95% CI, 1.01-1.06; P = 0.02), and the association was stronger for TSH within the normal range (OR, 1.16; 95% CI, 1.03-1.30; P = 0.02). Subclinical hypothyroidism with a TSH > 10 mIU/l was significantly associated with increased odds of prevalent metabolic syndrome (OR, 2.3; 95% CI, 1.0-5.0; P = 0.04); the odds of incident MetS was similar (OR 2.2), but the confidence interval was wide (0.6-7.5). CONCLUSIONS: Higher TSH levels and subclinical hypothyroidism with a TSH > 10 mIU/l are associated with increased odds of prevalent but not incident metabolic syndrome.