The causes of prescribing errors in English general practices: a qualitative study

Aim: To examine the causes of prescribing and monitoring errors in English general practices and provide recommendations for how they may be overcome. Design: Qualitative interview and focus group study with purposive sampling and thematic analysis informed by Reason’s accident causation model. Participants: General practice staff participated in a combination of semi-structured interviews (n=34) and six focus groups (n=46). Setting: Fifteen general practices across three primary care trusts in England. Results: We identified seven categories of high-level error-producing conditions: the prescriber, the patient, the team, the task, the working environment, the computer system, and the primary-secondary care interface. Each of these was further broken down to reveal various error-producing conditions. The prescriber’s therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health, were all identified as possible causes. The patient’s characteristics and the complexity of the individual clinical case were also found to have contributed to prescribing errors. The importance of feeling comfortable within the practice team was highlighted, as well as the safety of general practitioners (GPs) in signing prescriptions generated by nurses when they had not seen the patient for themselves. The working environment with its high workload, time pressures, and interruptions, and computer related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts, were all highlighted as possible causes of prescribing errors and often interconnected. Conclusion: This study has highlighted the complex underlying causes of prescribing and monitoring errors in general practices, several of which are amenable to intervention.

RNA interference suppression of genes in glycosyl transferase families 43 and 47 in wheat starchy endosperm causes large decreases in arabinoxylan content

The cell walls of wheat (Triticum aestivum) starchy endosperm are dominated by arabinoxylan (AX), accounting for 65% to 70% of the polysaccharide content. Genes within two glycosyl transferase (GT) families, GT43 (IRREGULAR XYLEM9 [IRX9] and IRX14) and GT47 (IRX10), have previously been shown to be involved in the synthesis of the xylan backbone in Arabidopsis, and close homologs of these have been implicated in the synthesis of xylan in other species. Here, homologs of IRX10 TaGT47_2 and IRX9 TaGT43_2, which are highly expressed in wheat starchy endosperm cells, were suppressed by RNA interference (RNAi) constructs driven by a starchy endosperm-specific promoter. The total amount of AX was decreased by 40% to 50% and the degree of arabinosylation was increased by 25% to 30% in transgenic lines carrying either of the transgenes. The cell walls of starchy endosperm in sections of grain from TaGT43_2 and TaGT47_2 RNAi transgenics showed decreased immunolabeling for xylan and arabinoxylan epitopes and approximately 50% decreased cell wall thickness compared with controls. The proportion of AX that was water soluble was not significantly affected, but average AX polymer chain length was decreased in both TaGT43_2 and TaGT47_2 RNAi transgenics. However, the long AX chains seen in controls were absent in TaGT43_2 RNAi transgenics but still present in TaGT47_2 RNAi transgenics. The results support an emerging picture of IRX9-like and IRX10-like proteins acting as key components in the xylan synthesis machinery in both dicots and grasses. Since AX is the main component of dietary fiber in wheat foods, the TaGT43_2 and TaGT47_2 genes are of major importance to human nutrition.

Simulation of late-twenty-first-century changes in wintertime atmospheric circulation over Europe due to anthropogenic causes

Evidence is presented, based on an ensemble of climate change scenarios performed with a global general circulation model of the atmosphere with high horizontal resolution over Europe, to suggest that the end-of-century anthropogenic climate change over the North Atlantic--European region strongly projects onto the positive phase of the North Atlantic Oscillation during wintertime. It is reflected in a doubling of the residence frequency of the climate system in the associated circulation regime, in agreement with the nonlinear climate perspective. The strong increase in the amplitude of the response, compared to coarse-resolution coupled model studies, suggests that improved model representation of regional climate is needed to achieve more reliable projections of anthropogenic climate change on European climate.

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

NK1 receptor stimulation causes contraction and inositol phosphate increase in medium-size human isolated bronchi

Although contraction of human isolated bronchi is mediated mainly by tachykinin NK2 receptors, NK1 receptors, via prostanoid release, contract small-size (approximately 1 mm in diameter) bronchi. Here, we have investigated the presence and biological responses of NK1 receptors in medium-size (2-5 mm in diameter) human isolated bronchi. Specific staining was seen in bronchial sections with an antibody directed against the human NK1 receptor. The selective NK1 receptor agonist, [Sar(9), Met(O2)(11)]SP, contracted about 60% of human isolated bronchial rings. This effect was reduced by two different NK1 receptor antagonists, CP-99,994 and SR 140333. Contraction induced by [Sar(9), Met(O2)(11)]SP was independent of acetylcholine and histamine release and epithelium removal, and was not affected by nitric oxide synthase and cyclooxygenase (COX) inhibition. [Sar(9), Met(O2)(11)]SP increased inositol phosphate (IP) levels, and SR 140333 blocked this increase, in segments of medium- and small-size (approximately 1 mm in diameter) human bronchi. COX inhibition blocked the IP increase induced by [Sar(9), Met(O2)(11)]SP in small-size, but not in medium-size, bronchi. NK1 receptors mediated bronchoconstriction in a large proportion of medium-size human bronchi. Unlike small-size bronchi this effect is independent of prostanoid release, and the results are suggestive of a direct activation of smooth muscle receptors and IP release.

The timing and causes of the Neolithic elm decline: new evidence from the Lower Thames Valley (London, UK)

Two new multi-proxy records of environmental change are provided from Horton Kirby Paper Mill and Old Seager Distillery in the Lower Thames Valley. Each site has evidence for a decline in elm woodland, which at Horton Kirby Paper Mill is recorded earlier than any other published record from the British Isles: sometime between 7320 and 7240 cal BP. Scolytus scolytus/S. multistriatus (the vectors for Dutch elm disease) are recorded after the decline in both sequences, adding to the number of sites with such evidence in the British Isles. Evidence of paludification and human activity are also recorded at the time of the elm decline reinforcing the multi-causal hypothesis. Integration of these results with 21 palaeoenvironmental records has produced a large number of well-dated, multiproxy records of the elm decline in this part of the UK. On the basis of this dataset, a classification system for categorising the relationships between the causal factors of the elm decline is proposed and recommended for future studies.

Solar causes of the long-term increase in geomagnetic activity

We analyze the causes of the century-long increase in geomagnetic activity, quantified by annual means of the aa index, using observations of interplanetary space, galactic cosmic rays, the ionosphere, and the auroral electrojet, made during the last three solar cycles. The effects of changes in ionospheric conductivity, the Earth's dipole tilt, and magnetic moment are shown to be small; only changes in near-Earth interplanetary space make a significant contribution to the long-term increase in activity. We study the effects of the interplanetary medium by applying dimensional analysis to generate the optimum solar wind-magnetosphere energy coupling function, having an unprecedentedly high correlation coefficient of 0.97. Analysis of the terms of the coupling function shows that the largest contributions to the drift in activity over solar cycles 20-22 originate from rises in the average interplanetary magnetic field (IMF) strength, solar wind concentration, and speed; average IMF orientation has grown somewhat less propitious for causing geomagnetic activity. The combination of these factors explains almost all of the 39% rise in aa observed over the last three solar cycles. Whereas the IMF strength varies approximately in phase with sunspot numbers, neither its orientation nor the solar wind density shows any coherent solar cycle variation. The solar wind speed peaks strongly in the declining phase of even-numbered cycles and can be identified as the chief cause of the phase shift between the sunspot numbers and the aa index. The rise in the IMF magnitude, the largest single contributor to the drift in geomagnetic activity, is shown to be caused by a rise in the solar coronal magnetic field, consistent with a rise in the coronal source field, modeled from photospheric observations, and an observed decay in cosmic ray fluxes.

Causes of plasma flow bursts and dayside auroral transients: An evaluation of two models Invoking reconnection pulses and changes in the Y component of the magnetosheath field

Longitudinal flow bursts observed by the European Incoherent Scatter (EISCAT) radar, in association with dayside auroral transients observed from Svalbard, have been interpreted as resulting from pulses of enhanced reconnection at the dayside magnetopause. However, an alternative model has recently been proposed for a steady rate of magnetopause reconnection, in which the bursts of longitudinal flow are due to increases in the field line curvature force, associated with the By component of the magnetosheath field. We here evaluate these two models, using observations on January 20, 1990, by EISCAT and a 630-nm all-sky camera at Ny Ålesund. For both models, we predict the behavior of both the dayside flows and the 630-nm emissions on newly opened field lines. It is shown that the signatures of steady reconnection and magnetosheath By changes could possibly resemble the observed 630-nm auroral events, but only for certain locations of the observing site, relative to the ionospheric projection of the reconnection X line: however, in such cases, the flow bursts would be seen between the 630-nm transients and not within them. On the other hand, the model of reconnection rate pulses predicts that the flows will be enhanced within each 630-nm transient auroral event. The observations on January 20, 1990, are shown to be consistent with the model of enhanced reconnection rate pulses over a background level and inconsistent with the effects of periodic enhancements of the magnitude of the magnetosheath By component. We estimate that the reconnection rate within the pulses would have to be at least an order of magnitude larger than the background level between the pulses.

A multi-model evaluation of aerosols over South Asia: common problems and possible causes

Atmospheric pollution over South Asia attracts special attention due to its effects on regional climate, water cycle and human health. These effects are potentially growing owing to rising trends of anthropogenic aerosol emissions. In this study, the spatio-temporal aerosol distributions over South Asia from seven global aerosol models are evaluated against aerosol retrievals from NASA satellite sensors and ground-based measurements for the period of 2000–2007. Overall, substantial underestimations of aerosol loading over South Asia are found systematically in most model simulations. Averaged over the entire South Asia, the annual mean aerosol optical depth (AOD) is underestimated by a range 15 to 44% across models compared to MISR (Multi-angle Imaging SpectroRadiometer), which is the lowest bound among various satellite AOD retrievals (from MISR, SeaWiFS (Sea-Viewing Wide Field-of-View Sensor), MODIS (Moderate Resolution Imaging Spectroradiometer) Aqua and Terra). In particular during the post-monsoon and wintertime periods (i.e., October–January), when agricultural waste burning and anthropogenic emissions dominate, models fail to capture AOD and aerosol absorption optical depth (AAOD) over the Indo–Gangetic Plain (IGP) compared to ground-based Aerosol Robotic Network (AERONET) sunphotometer measurements. The underestimations of aerosol loading in models generally occur in the lower troposphere (below 2 km) based on the comparisons of aerosol extinction profiles calculated by the models with those from Cloud–Aerosol Lidar with Orthogonal Polarization (CALIOP) data. Furthermore, surface concentrations of all aerosol components (sulfate, nitrate, organic aerosol (OA) and black carbon (BC)) from the models are found much lower than in situ measurements in winter. Several possible causes for these common problems of underestimating aerosols in models during the post-monsoon and wintertime periods are identified: the aerosol hygroscopic growth and formation of secondary inorganic aerosol are suppressed in the models because relative humidity (RH) is biased far too low in the boundary layer and thus foggy conditions are poorly represented in current models, the nitrate aerosol is either missing or inadequately accounted for, and emissions from agricultural waste burning and biofuel usage are too low in the emission inventories. These common problems and possible causes found in multiple models point out directions for future model improvements in this important region.

Focus on environmental risks and migration: causes and consequences

Environmental change poses risks to societies, including disrupting social and economic systems such as migration. At the same time, migration is an effective adaptation to environmental and other risks. We review novel science on interactions between migration, environmental risks and climate change. We highlight emergent findings, including how dominant flows of rural to urban migration mean that populations are exposed to new risks within destination areas and the requirement for urban sustainability. We highlight the issue of lack of mobility as a major issue limiting the effectiveness of migration as an adaptation strategy and leading to potentially trapped populations. The paper presents scenarios of future migration that show both displacement and trapped populations over the incoming decades. Papers in the special issue bring new insights from demography, human geography, political science and environmental science to this emerging field.

The solsticial pause on Mars: 2 modelling and investigation of causes

The martian solsticial pause, presented in a companion paper (Lewis et al., this issue), was investigated further through a series of model runs using the UK version of the LMD/UK Mars Global Climate Model. It was found that the pause could not be adequately reproduced if radiatively active water ice clouds were omitted from the model. When clouds were used, along with a realistic time-dependent dust opacity distribution, a substantial minimum in near-surface transient eddy activity formed around solstice in both hemispheres. The net effect of the clouds in the model is, by altering the thermal structure of the atmosphere, to decrease the vertical shear of the westerly jet near the surface around solstice, and thus reduce baroclinic growth rates. A similar effect was seen under conditions of large dust loading, implying that northern midlatitude eddy activity will tend to become suppressed after a period of intense flushing storm formation around the northern cap edge. Suppression of baroclinic eddy generation by the barotropic component of the flow and via diabatic eddy dissipation were also investigated as possible mechanisms leading to the formation of the solsticial pause but were found not to make major contributions. Zonal variations in topography were found to be important, as their presence results in weakened transient eddies around winter solstice in both hemispheres, through modification of the near-surface flow. The zonal topographic asymmetry appears to be the primary reason for the weakness of eddy activity in the southern hemisphere relative to the northern hemisphere, and the ultimate cause of the solsticial pause in both hemispheres. The meridional topographic gradient was found to exert a much weaker influence on near-surface transient eddies.

Loss of Dictyostelium HSPC300 causes a scar-like phenotype and loss of SCAR protein.

HSPC300 is essential for most SCAR complex functions. The phenotype of HSPC300 knockouts is most similar to mutants in scar, not the other members of the SCAR complex, suggesting that HSPC300 acts most directly on SCAR itself.