GP guide to drugs used in palliative care: psychostimulants

This is the third in a short series of articles that focus on what GPs should consider when monitoring and prescribing specialist‐initiated palliative‐care drugs. Here, the authors summarise the key issues around the shortterm use of psychostimulants in palliative care.

Mutual binding of polymer end-groups by complementary π–π-stacking: a molecular “Roman Handshake”

Self-complementary tweezer-molecules based on a naphthalenediimide core self-assemble into supramolecular dimers through mutual π–π-stacking and hydrogen bonding. The resulting motif is extremely stable in solution (Ka = 105 M−1), and its attachment to one terminal position of a poly(ethylene glycol) chain leads to a doubling of the polymer's apparent molecular weight.

Playing with history: negotiating subjectivity in contemporary lens based work

Contemporary artists exploring Jewish identity in the UK are caught between two exclusions, broadly speaking: an art community that that sees itself as ‘post –identity’ and a ‘black’ art scene that revolves around the organizations that emerged out of the Identity debates of the 1980s and 1990s, namely Iniva, Third Text, Autograph. These organizations and those debates, don’t usually include Jewish identity within their remit as Jewish artists are considered to be well represented in the British art scene and, in any case, white. Out of these assumptions, questions arise in relation to the position of Jews in Britain and what is at stake for an artist in exploring Jewish Identity in their work. There is considerable scholarship, relatively speaking on art and Jewish Identity in the US (such as Lisa Bloom; Norman Kleeblatt; Catherine Sousslouf), which inform the debates on visual culture and Jews. In this chapter, I will be drawing out some of the distinctions between the US and the UK debates within my analysis, building on my own writing over the last ten years as well as the work of Juliet Steyn, Jon Stratton and Griselda Pollock. In short, this chapter aims to explore the problematic of what Jewish Identity can offer the viewer as art; what place such art inhabits within a wider artistic context and how, if at all, it is received. There is a predominance of lens based work that explores Identity arising out of the provenance of feminist practices and the politics of documentary that will be important in the framing of the work. I do not aim to consider what constitutes a Jewish artist, that has been done elsewhere and is an inadequate and somewhat spurious conversation . I will also not be focusing on artists whose intention is to celebrate an unproblematised Jewishness (however that is constituted in any given work). Recent artworks and scholarship has in any case rendered the trumpeting of attachment to any singular identity anachronistic at best. I will focus on artists working in the UK who incorporate questions of Jewishness into a larger visual enquiry that build on Judith Butler’s notion of identity as process or performative as well as the more recent debates and artwork that consider the intersectionality of identifications that co-constitute provisional identities (Jones, Modood, Sara Ahmed, Braidotti/Nikki S Lee, Glenn Ligon). The case studies to think through these questions of identity, will be artworks by Susan Hiller, Doug Fishbone and Suzanne Triester. In thinking through works by these artists, I will also serve to contextualise them, situating them briefly within the history of the landmark exhibition in the UK, Rubies and Rebels and the work of Ruth Novaczek, Lily Markewitz, Oreet Ashery and myself.

An investigation of thermal comfort adaptation behaviour in office buildings in the UK

Around 40% of total energy consumption in the UK is consumed by creating comfortable indoor environment for occupants. Occupants’ behaviour in terms of achieving thermal comfort could have a significant impact on a building’s energy consumption. Therefore, understanding the interactions of occupants with their buildings would be essential to provide a thermal comfort environment that is less reliance on energy-intensive heating, ventilation and air-conditioning systems, to meet energysaving and carbon emission targets. This paper presents the findings of a year-long field study conducted in non-air-conditioned office buildings in the UK. Occupants’ adaptive responses in terms of technological and personal dimensions are dynamic processes which could vary with both indoor and outdoor thermal conditions. The adaptive behaviours of occupants in the surveyed building show substantial seasonal and daily variations. Our study shows that non-physical factors such as habit could influence the adaptive responses of occupants. However, occupants sometimes displayed inappropriate adaptive behaviour, which could lead to a misuse of energy. This paper attempts to illustrate how occupants would adapt and interact with their built environment and consequently contribute to development of a guide for future design/refurbishment of buildings and to develop energy management systems for a comfortable built environment.

What GPs need to know about palliative-care drugs : methadone

This is the second in a short series of articles that focus on what GPs should consider when monitoring and prescribing specialist‐initiated palliative‐care drugs. Here, the authors summarise the key issues around the use of methadone for pain management.

Training pharmacists to deliver a complex information technology intervention (PINCER) using the principles of educational outreach and root cause analysis

Objective: To describe the training undertaken by pharmacists employed in a pharmacist-led information technology-based intervention study to reduce medication errors in primary care (PINCER Trial), evaluate pharmacists’ assessment of the training, and the time implications of undertaking the training. Methods: Six pharmacists received training, which included training on root cause analysis and educational outreach, to enable them to deliver the PINCER Trial intervention. This was evaluated using self-report questionnaires at the end of each training session. The time taken to complete each session was recorded. Data from the evaluation forms were entered onto a Microsoft Excel spreadsheet, independently checked and the summary of results further verified. Frequencies were calculated for responses to the three-point Likert scale questions. Free-text comments from the evaluation forms and pharmacists’ diaries were analysed thematically. Key findings: All six pharmacists received 22 hours of training over five sessions. In four out of the five sessions, the pharmacists who completed an evaluation form (27 out of 30 were completed) stated they were satisfied or very satisfied with the various elements of the training package. Analysis of free-text comments and the pharmacists’ diaries showed that the principles of root cause analysis and educational outreach were viewed as useful tools to help pharmacists conduct pharmaceutical interventions in both the study and other pharmacy roles that they undertook. The opportunity to undertake role play was a valuable part of the training received. Conclusions: Findings presented in this paper suggest that providing the PINCER pharmacists with training in root cause analysis and educational outreach contributed to the successful delivery of PINCER interventions and could potentially be utilised by other pharmacists based in general practice to deliver pharmaceutical interventions to improve patient safety.

The long-term safety and efficacy of bilateral transplantation of human fetal striatal tissue in patients with mild to moderate Huntington's disease.

Huntington's disease (HD) is a fatal autosomal dominant neurodegenerative disease involving progressive motor, cognitive and behavioural decline, leading to death approximately 20 years after motor onset. The disease is characterised pathologically by an early and progressive striatal neuronal cell loss and atrophy, which has provided the rationale for first clinical trials of neural repair using fetal striatal cell transplantation. Between 2000 and 2003, the 'NEST-UK' consortium carried out bilateral striatal transplants of human fetal striatal tissue in five HD patients. This paper describes the long-term follow up over a 3-10-year postoperative period of the patients, grafted and non-grafted, recruited to this cohort using the 'Core assessment program for intracerebral transplantations-HD' assessment protocol. No significant differences were found over time between the patients, grafted and non-grafted, on any subscore of the Unified Huntington's Disease Rating Scale, nor on the Mini Mental State Examination. There was a trend towards a slowing of progression on some timed motor tasks in four of the five patients with transplants, but overall, the trial showed no significant benefit of striatal allografts in comparison with a reference cohort of patients without grafts. Importantly, no significant adverse or placebo effects were seen. Notably, the raclopride positron emission tomography (PET) signal in individuals with transplants, indicated that there was no obvious surviving striatal graft tissue. This study concludes that fetal striatal allografting in HD is safe. While no sustained functional benefit was seen, we conclude that this may relate to the small amount of tissue that was grafted in this safety study compared with other reports of more successful transplants in patients with HD.

Description and process evaluation of pharmacists’ interventions in a pharmacist-led information technology-enabled multicentre cluster randomised controlled trial for reducing medication errors in general practice (PINCER trial)

Objective To undertake a process evaluation of pharmacists' recommendations arising in the context of a complex IT-enabled pharmacist-delivered randomised controlled trial (PINCER trial) to reduce the risk of hazardous medicines management in general practices. Methods PINCER pharmacists manually recorded patients’ demographics, details of interventions recommended, actions undertaken by practice staff and time taken to manage individual cases of hazardous medicines management. Data were coded and double entered into SPSS v15, and then summarised using percentages for categorical data (with 95% CI) and, as appropriate, means (SD) or medians (IQR) for continuous data. Key findings Pharmacists spent a median of 20 minutes (IQR 10, 30) reviewing medical records, recommending interventions and completing actions in each case of hazardous medicines management. Pharmacists judged 72% (95%CI 70, 74) (1463/2026) of cases of hazardous medicines management to be clinically relevant. Pharmacists recommended 2105 interventions in 74% (95%CI 73, 76) (1516/2038) of cases and 1685 actions were taken in 61% (95%CI 59, 63) (1246/2038) of cases; 66% (95%CI 64, 68) (1383/2105) of interventions recommended by pharmacists were completed and 5% (95%CI 4, 6) (104/2105) of recommendations were accepted by general practitioners (GPs), but not completed at the end of the pharmacists’ placement; the remaining recommendations were rejected or considered not relevant by GPs. Conclusions The outcome measures were used to target pharmacist activity in general practice towards patients at risk from hazardous medicines management. Recommendations from trained PINCER pharmacists were found to be broadly acceptable to GPs and led to ameliorative action in the majority of cases. It seems likely that the approach used by the PINCER pharmacists could be employed by other practice pharmacists following appropriate training.

The prevalence and nature of prescribing and monitoring errors in English general practice – a retrospective case note review

Objective To determine the prevalence and nature of prescribing and monitoring errors in general practices in England. Design Retrospective case note review of unique medication items prescribed over a 12 month period to a 2% random sample of patients. Mixed effects logistic regression was used to analyse the data. Setting Fifteen general practices across three primary care trusts in England. Data sources Examination of 6048 unique prescription items prescribed over the previous 12 months for 1777 patients. Main outcome measures Prevalence of prescribing and monitoring errors, and severity of errors, using validated definitions. Results Prescribing and/or monitoring errors were detected in 4.9% (296/6048) of all prescription items (95% confidence interval 4.4 - 5.5%). The vast majority of errors were of mild to moderate severity, with 0.2% (11/6048) of items having a severe error. After adjusting for covariates, patient-related factors associated with an increased risk of prescribing and/or monitoring errors were: age less than 15 (Odds Ratio (OR) 1.87, 1.19 to 2.94, p=0.006) or greater than 64 years (OR 1.68, 1.04 to 2.73, p=0.035), and higher numbers of unique medication items prescribed (OR 1.16, 1.12 to 1.19, p<0.001). Conclusion Prescribing and monitoring errors are common in English general practice, although severe errors are unusual. Many factors increase the risk of error. Having identified the most common and important errors, and the factors associated with these, strategies to prevent future errors should be developed based on the study findings.