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.

Pollination services in the UK: how important are honeybees?

Pollination services are known to provide substantial benefits to human populations and agriculture in particular. Although many species are known to provide pollination services, honeybees (Apis mellifera) are often assumed to provide the majority of these services to agriculture. Using data from a range of secondary sources, this study assesses the importance of insect pollinated crops at regional and national scales and investigates the capacity of honeybees to provide optimal pollination services to UK agriculture. The findings indicate that insect pollinated crops have become increasingly important in UK crop agriculture and, as of 2007, accounted for 20% of UK cropland and 19% of total farmgate crop value. Analysis of honeybee hive numbers indicates that current UK populations are only capable of supplying 34% of pollination service demands even under favourable assumptions, falling from 70% in 1984. In spite of this decline, insect pollinated crop yields have risen by an average of 54% since 1984, casting doubt on long held beliefs that honeybees provide the majority of pollination services. Future land use and crop production patterns may further increase the role of pollination services to UK agriculture, highlighting the importance of measures aimed at maintaining both wild and managed species.

Climate change and the risks associated with delayed breeding in a tropical wild bird population

There is growing evidence of changes in the timing of important ecological events, such as flowering in plants and reproduction in animals, in response to climate change, with implications for population decline and biodiversity loss. Recent work has shown that the timing of breeding in wild birds is changing in response to climate change partly because individuals are remarkably flexible in their timing of breeding. Despite this work, our understanding of these processes in wild populations remains very limited and biased towards species from temperate regions. Here, we report the response to changing climate in a tropical wild bird population using a long-term dataset on a formerly critically endangered island endemic, the Mauritius kestrel. We show that the frequency of spring rainfall affects the timing of breeding, with birds breeding later in wetter springs. Delays in breeding have consequences in terms of reduced reproductive success as birds get exposed to risks associated with adverse climatic conditions later on in the breeding season, which reduce nesting success. These results, combined with the fact that frequency of spring rainfall has increased by about 60 per cent in our study area since 1962, imply that climate change is exposing birds to the stochastic risks of late reproduction by causing them to start breeding relatively late in the season.

Population estimates and habitat use by the critically endangered Taita Apalis Apalis fuscigularis in south-eastern Kenya

The Taita Apalis Apalis fuscigularis (IUCN category: Critically Endangered) is a species endemic to south-eastern Kenya. We assessed population size and habitat use in the three forest sites in which it is known to occur (Ngangao, Chawia and Vuria, totalling 257 ha). The estimate of total population size, derived from distance sampling at 412 sample points, ranged from 310 to 654 individuals, with the northern section of Ngangao fragment having 10-fold higher densities than Chawia (2.47-4.93 versus 0.22-0.41 birds ha(-1)). Ngangao north alone hosted 50% of the global population of the species. The highly degraded Vuria fragment also had moderately high densities (1.63-3.72 birds ha(-1)) suggesting that the species tolerates some human disturbance. Taita Apalis prefers vegetation with abundant climbers, but the predictive power of habitat use models was low, suggesting that habitat structure is not a primary cause for the low density of the species in Chawia. Protecting the subpopulation in the northern section of Ngangao is a priority, as is identifying factors responsible of the low abundance in Chawia, because ameliorating conditions in this large fragment could substantially increase the population of Taita Apalis.

BbgIV is an important Bifidobacterium β-galactosidase for the synthesis of prebiotic galactooligosaccharides at high temperatures

The individual contribution of four β-galactosidases present in Bifidobacterium bifidum NCIMB 41171 towards galactooligosaccharides (GOS) synthesis was investigated. Although the β-galactosidase activity of the whole cells significantly decreased as a function of temperature (40 to 75 °C), GOS yield was at its maximum at 65 °C. Native-PAGE electrophoresis of the whole cells showed that the contribution of BbgIII and BbgIV towards GOS synthesis increased as the temperature increased. Moreover, BbgIII and BbgIV were found to be more temperature stable and to produce a higher GOS yield than BbgI and BbgII, when used in their free form. The GOS yield using BbgIV was 54.8 % (% of total carbohydrates) and 63.9 % (% lactose converted to GOS) at 65 °C from 43 % w/w lactose. It was shown that BbgIV is the most important β-galactosidase in B. bifidum NCIMB 41171 and can be used for GOS synthesis at elevated temperatures.

Vocabulary is important for some, but not all reading skills

Although there is evidence for a close link between the development of oral vocabulary and reading comprehension, less clear is whether oral vocabulary skills relate to the development of word-level reading skills. This study investigated vocabulary and literacy in 81 children aged 8 to 10 years. In regression analyses, vocabulary accounted for unique variance in exception word reading and reading comprehension, but not text reading accuracy, decoding, or regular word reading. Consistent with these data, children with poor reading comprehension exhibited oral vocabulary weaknesses and read fewer exception words correctly. These findings demonstrate that oral vocabulary is associated with some, but not all, reading skills. Results are discussed in terms of current models of reading development.

Escherichia coli O157:H7 colonization in small domestic ruminants

Enterohaemorrhagic Escherichia coli O157:H7 was first implicated in human disease in the early 1980s, with ruminants cited as the primary reservoirs. Preliminary studies indicated cattle to be the sole source of E. coli O157:H7 outbreaks in humans; however, further epidemiological studies soon demonstrated that E. coli O157:H7 was widespread in other food sources and that a number of transmission routes existed. More recently, small domestic ruminants (sheep and goats) have emerged as important sources of E. coli O157:H7 human infection, particularly with the widespread popularity of petting farms and the increased use of sheep and goat food products, including unpasteurized cheeses. Although the colonization and persistence characteristics of E. coli O157:H7 in the bovine host have been studied intensively, this is not the case for small ruminants. Despite many similarities to the bovine host, the pathobiology of E. coli O157:H7 in small domestic ruminants does appear to differ significantly from that described in cattle. This review aims to critically review the current knowledge regarding colonization and persistence of E. coli O157:H7 in small domestic ruminants, including comparisons with the bovine host where appropriate.

Flagella and curli fimbriae are important for the growth of Salmonella enterica serovars in hen eggs

Salmonella enterica serovar Enteritidis is unable to multiply in the albumen of fresh eggs and must gain access to the yolk contents in order to multiply to a high level (> 10(6) c.f.u. per ml egg contents). As human Salmonella infections resulting from the consumption of infected eggs more frequently involve serovar Enteritidis phage type (PT) 4 than other serovars or PTs, a number of isolates of various S. enterica serovars were examined for their ability to multiply to a high level in eggs over a period of 8 days storage at 20 degreesC. Their behaviour was compared to that of a range of defined fimbrial and flagella mutants of S. Enteritidis. Strains that did not express flagella were unable to multiply in eggs, and those deficient for curli fimbriae, including strains of S. Enteritidis PT6, displayed high-level growth in significantly fewer eggs than those able to express curli. Most S. Enteritidis strains multiplied to a high level in between 5 and 10 % of eggs during 8 days storage. One PT4 strain, though, showed high levels of growth in more than 25 % of eggs over this period, significantly higher than the other PTs or the two other isolates of PT4 tested. This ability may be important for the association of PT4 infection with the consumption of eggs.

The impact of information and communications technology on commercial real estate in the new economy

Purpose – This paper seeks to critically review the conceptual frameworks that have been developed for assessing the impact of information and communications technology (ICT) on real estate. Design/methodology/approach – The research is based on a critical review of existing literature and draws from examples of previous empirical research in the field. Findings – The paper suggests that a “socio-technical framework” is more appropriate to examine ICT impact in real estate than other “deterministic” frameworks. Therefore, ICT is an important part of the new economy, but must be seen in the context of a number of other social and economic factors. Research limitations/implications – The research is based on a qualitative assessment of existing frameworks, and by using examples from commercial real estate, assesses the extent to which a “socio-technical” framework can aid understanding of ICT impact. Practical implications – The paper is important in highlighting a number of the main issues in conceptualising ICT impact in real estate and also critically examines the emergence of a new economy in the information society within the general context of real estate. The paper also highlights research gaps in the field. Originality/value – The paper deconstructs the myths of the “death of real estate” and “productivity increase means jobs loss”, in relation to office real estate. Finally, it examines some of the ways in which ICT is impacting on real estate and suggests the most important components for a future research agenda in the field of ICT and real estate impact, and will be of value to property investors, facilities managers, developers, financiers, and others.

The role of retailing in urban regeneration

Recent ‘best practice’ research and guidance has emphasised the important role that can be played by retail-led urban regeneration projects, particularly in ‘under-served markets’ in the UK. This builds on ideas first formulated in the USA by Michael Porter through his close relationship with the Initiative for the Competitive Inner City (ICIC). This paper critically examines the role of retailing in urban regeneration nationally and locally in the UK, focusing on in-town shopping centres located in inner city areas of the UK. The paper is based on case study research in these centres, and was completed during 2003 for The Office of Science and Technology. The paper examines how employment impact in retail-led regeneration is commonly measured, and calls for more research to determine the real impact of retail in deprived communities using other, relevant measures.

Inside the black box: unravelling the development viability appraisal process

Over the last decade issues related to the financial viability of development have become increasingly important to the English planning system. As part of a wider shift towards the compartmentalisation of planning tasks, expert consultants are required to quantify, in an attempt to rationalise, planning decisions in terms of economic ‘viability’. Often with a particular focus on planning obligations, the results of development viability modelling have emerged as a key part of the evidence base used in site-specific negotiations and in planning policy formation. Focussing on the role of clients and other stakeholders, this paper investigates how development viability is tested in practice. It draws together literature on the role of calculative practices in policy formation, client feedback and influence in real estate appraisals and stakeholder engagement and consultation in the planning literature to critically evaluate the role of clients and other interest groups in influencing the production and use of development viability appraisal models. The paper draws upon semi-structured interviews with the main producers of development viability appraisals to conclude that, whilst appraisals have the potential to be biased by client and stakeholder interests, there are important controlling influences on potential opportunistic behaviour. One such control is local authorities’ weak understanding of development viability appraisal techniques which limits their capacity to question the outputs of appraisal models. However, this also is of concern given that viability is now a central feature of the town planning system.

Control of contagious bovine pleuropneumonia: knowledge, attitudes, perceptions and practices in Narok district of Kenya

CBPP is an important transboundary disease in sub-Saharan Africa whose control is urgent. Participatory data collection involving 52 focus group discussions in 37 village clusters and key informant interviews, a cross-sectional study involving 232 households and a post-vaccination follow up involving 203 households was carried out in 2006-2007 in Narok South district of Kenya. This was to investigate knowledge, attitudes, perceptions and practices (KAPP) associated with control of CBPP as well as the adverse post-vaccination reactions in animals in order to advice the control policy. The community perceived trans-boundary CBPP threat to their cattle. They had traditional disease coping mechanisms and were conversant with CBPP prevention and control with 49.8% (95%CI: 42.8-56.7%) giving priority to CBPP control. However, 12.9% (95%CI: 9.0-18.1%) of pastoralists had no knowledge of any prevention method and 10.0% (95%CI: 6.5-14.7%) would not know what to do or would do nothing in the event of an outbreak. Although 43.5% (95%CI: 37.1-50.2%) of pastoralists were treating CBPP cases with antimicrobials, 62.5% (95%CI: 52.1-71.7%) of them doubted the effectiveness of the treatments. Pastoralists perceived vaccination to be the solution to CBPP but vaccination was irregular due to unavailability of the vaccine. Vaccination was mainly to control outbreaks rather than preventive and exhibited adverse post-vaccination reactions among 70.4% (95%CI: 63.6-76.5%) of herds and 3.8% (95%CI: 3.5-4.2%) of animals. Consequently, nearly 25.2% (95%CI: 18.5-33.2%) of pastoralists may resist subsequent vaccinations against CBPP. Pastoralists preferred CBPP vaccination at certain times of the year and that it is combined with other vaccinations. In conclusion, pastoralists were not fully aware of the preventive measures and interventions and post-vaccination reactions may discourage subsequent CBPP vaccinations. Consequently there is need for monitoring and management of post vaccination reactions and awareness creation on CBPP prevention and interventions and their merits and demerits. CBPP vaccine was largely unavailable to the pastoralists and the preference of the pastoralists was for vaccination at specified times and vaccine combinations which makes it necessary to avail the vaccine in conformity with the pastoralists preferences. In addition, planning vaccinations should involve pastoralists and neighbouring countries. As the results cannot be generalized, further studies on CBPP control methods and their effectiveness are recommended.