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.

Making the most of PAS data: Macro- and micro-level studies of Romano-British settlement

The Portable Antiquities Scheme (PAS) database includes records of over 225,000 artefacts of Roman date, with a wide geographical coverage and the potential to contribute to our understanding of Romano-British landscapes and settlement at several scales of analysis. This paper draws upon the author’s doctoral research to describe regional case studies from six counties (Wiltshire, Worcestershire, Warwickshire, Northamptonshire, North Lincolnshire and Cumbria) on the use of PAS data. The data have value nationally and regionally as general guides to ancient settlement patterns, but it is arguably at the micro-scale that they have the most potential. With reference to detailed landscape studies from parts of Warwickshire and Wiltshire, the paper argues that sites represented by PAS data are often rural settlements that show evidence for continued activity throughout the Roman period. The paper demonstrates that with an appropriate methodology PAS data can be an immensely valuable archaeological resource, particularly when interpreted at multiple scales, and can be considerably more than a guide to broad distributions of Roman finds.

The AVOID programme’s new simulations of the global benefits of stringent climate change mitigation

Quantitative simulations of the global-scale benefits of climate change mitigation are presented, using a harmonised, self-consistent approach based on a single set of climate change scenarios. The approach draws on a synthesis of output from both physically-based and economics-based models, and incorporates uncertainty analyses. Previous studies have projected global and regional climate change and its impacts over the 21st century but have generally focused on analysis of business-as-usual scenarios, with no explicit mitigation policy included. This study finds that both the economics-based and physically-based models indicate that early, stringent mitigation would avoid a large proportion of the impacts of climate change projected for the 2080s. However, it also shows that not all the impacts can now be avoided, so that adaptation would also therefore be needed to avoid some of the potential damage. Delay in mitigation substantially reduces the percentage of impacts that can be avoided, providing strong new quantitative evidence for the need for stringent and prompt global mitigation action on greenhouse gas emissions, combined with effective adaptation, if large, widespread climate change impacts are to be avoided. Energy technology models suggest that such stringent and prompt mitigation action is technologically feasible, although the estimated costs vary depending on the specific modelling approach and assumptions.

Introduction to politics of climate change: discourses of policy and practice in developing countries

This Themed Section aims to increase understanding of how the idea of climate change, and the policies and actions that spring from it, travel beyond their origins in natural sciences to meet different political arenas in the developing world. It takes a discursive approach whereby climate change is not just a set of physical processes but also a series of messages, narratives and policy prescriptions. The articles are mostly case study-based and focus on sub-Saharan Africa and Small Island Developing States (SIDS). They are organised around three interlinked themes. The first theme concerns the processes of rapid technicalisation and professionalisation of the climate change ‘industry’, which have sustantially narrowed the boundaries of what can be viewed as a legitimate social response to the problem of global warming. The second theme deals with the ideological effects of the climate change industry, which is ‘depoliticisation’, in this case the deflection of attention away from underlying political conditions of vulnerability and exploitation towards the nature of the physical hazard itself. The third theme concerns the institutional effects of an insufficiently socialised idea of climate change, which is the maintenance of existing relations of power or their reconfiguration in favour of the already powerful. Overall, the articles suggest that greater scrutiny of the discursive and political dimensions of mitigation and adaptation activities is required. In particular, greater attention should be directed towards the policy consequences that governments and donors construct as a result of their framing and rendition of climate change issues.

Exploring socioeconomic impacts of forest based mitigation projects: Lessons from Brazil and Bolivia

This paper aims to contribute new insights globally and regionally on how carbon forest mitigation contributes to sustainable development in South America. Carbon finance has emerged as a potential policy option to tackling global climate change, degradation of forests, and social development in poor countries. This paper focuses on evaluating the socioeconomic impacts of a set of forest based mitigation pilot projects that emerged under the United Nations Framework Convention on Climate Change. The paper reviews research conducted in 2001–2002, drawing from empirical data from four pilot projects, derived from qualitative stakeholder interviews, and complemented by policy documents and literature. Of the four projects studied three are located in frontier areas, where there are considerable pressures for conversion of standing forest to agriculture. In this sense, forest mitigation projects have a substantial role to play in the region. Findings suggest however, that all four projects have experienced cumbersome implementation processes specifically, due to weak social objectives, poor communication, as well as time constraints. In three out of four cases, stakeholders highlighted limited local acceptance at the implementation stages. In the light of these findings, we discuss opportunities for implementation of future forest based mitigation projects in the land use sector.

Antithrombotic actions of statins involve PECAM-1 signalling

Statins are widely prescribed cholesterol-lowering drugs that are a first-line treatment for coronary artery disease and atherosclerosis, reducing the incidence of thrombotic events such as myocardial infarction and stroke. Statins have been shown to reduce platelet activation, although the mechanism(s) through which this occurs is unclear. Since several of the characteristic effects of statins on platelets are shared with those elicited by the inhibitory platelet adhesion receptor PECAM-1, we investigated a potential connection between the influence of statins on platelet function and PECAM-1 signalling. Statins were found to inhibit a range of platelet functional responses and thrombus formation in vitro and in vivo. Notably, these effects of statins on platelet function in vitro and in vivo were diminished in PECAM-1-/- platelets. Activation of PECAM-1 signalling results in its tyrosine phosphorylation, the recruitment and activation of tyrosine phosphatase SHP-2, the subsequent binding of phosphoinositol 3-kinase (PI3-K) and diminished PI3-K signalling. Statins resulted in the stimulation of these events, leading to the inhibition of Akt activation. Together, these data provides evidence for a fundamental role of PECAM-1 in the inhibitory effects of statins on platelet activation, which may explain some of the pleiotropic actions of these drugs.

Regional climate change mitigation with crops: context and assessment

The intention of this review is to place crop albedo biogeoengineering in the wider picture of climate manipulation. Crop biogeoengineering is considered within the context of the long-term modification of the land surface for agriculture over several thousand years. Biogeoengineering is also critiqued in relation to other geoengineering schemes in terms of mitigation power and adherence to social principles for geoengineering. Although its impact is small and regional, crop biogeoengineering could be a useful and inexpensive component of an ensemble of geoengineering schemes to provide temperature mitigation. The method should not detrimentally affect food security and there may even be positive impacts on crop productivity, although more laboratory and field research is required in this area to understand the underlying mechanisms.

Participatory scenarios as a tool to link science and policy on food security under climate change in East Africa

How effective are multi-stakeholder scenarios building processes to bring diverse actors together and create a policy-making tool to support sustainable development and promote food security in the developing world under climate change? The effectiveness of a participatory scenario development process highlights the importance of ‘boundary work’ that links actors and organizations involved in generating knowledge on the one hand, and practitioners and policymakers who take actions based on that knowledge on the other. This study reports on the application of criteria for effective boundary work to a multi-stakeholder scenarios process in East Africa that brought together a range of regional agriculture and food systems actors. This analysis has enabled us to evaluate the extent to which these scenarios were seen by the different actors as credible, legitimate and salient, and thus more likely to be useful. The analysis has shown gaps and opportunities for improvement on these criteria, such as the quantification of scenarios, attention to translating and communicating the results through various channels and new approaches to enable a more inclusive and diverse group of participants. We conclude that applying boundary work criteria to multi-stakeholder scenarios processes can do much to increase the likelihood of developing sustainable development and food security policies that are more appropriate.

Options for support to agriculture and food security under climate change

Agriculture and food security are key sectors for intervention under climate change. Agricultural production is highly vulnerable even to 2C (low-end) predictions for global mean temperatures in 2100, with major implications for rural poverty and for both rural and urban food security. Agriculture also presents untapped opportunities for mitigation, given the large land area under crops and rangeland, and the additional mitigation potential of aquaculture. This paper presents a summary of current knowledge on options to support farmers, particularly smallholder farmers, in achieving food security through agriculture under climate change. Actions towards adaptation fall into two broad overlapping areas: (1) accelerated adaptation to progressive climate change over decadal time scales, for example integrated packages of technology, agronomy and policy options for farmers and food systems, and (2) better management of agricultural risks associated with increasing climate variability and extreme events, for example improved climate information services and safety nets. Maximization of agriculture’s mitigation potential will require investments in technological innovation and agricultural intensification linked to increased efficiency of inputs, and creation of incentives and monitoring systems that are inclusive of smallholder farmers. Food systems faced with climate change need urgent, broad-based action in spite of uncertainties.

Aluminium and breast cancer: sources of exposure, tissue measurements and mechanisms of toxicological actions on breast biology

This review examines recent evidence linking exposure to aluminium with the aetiology of breast cancer. The human population is exposed to aluminium throughout daily life including through diet, application of antiperspirants, use of antacids and vaccination. Aluminium has now been measured in a range of human breast structures at higher levels than in blood serum and experimental evidence suggests that the tissue concentrations measured have the potential to adversely influence breast epithelial cells including generation of genomic instability, induction of anchorage-independent proliferation and interference in oestrogen action. The presence of aluminium in the human breast may also alter the breast microenvironment causing disruption to iron metabolism, oxidative damage to cellular components, inflammatory responses and alterations to the motility of cells. The main research need is now to investigate whether the concentrations of aluminium measured in the human breast can lead in vivo to any of the effects observed in cells in vitro and this would be aided by the identification of biomarkers specific for aluminium action.

Cities’ low carbon plans in an ‘age of austerity’: an analysis of UK local authority actions, attitudes and responses

Background: Cities play a significant role globally in creating carbon emissions but, as centers of major population, innovation and social practice, they also offer important opportunities to tackle climate change. The new challenges faced by cities in an ‘age of austerity’ and decentralist agendas present substantial challenges for coordinated multilevel governance. Results: Based on research carried out in 2011–2012, this paper examines the attitudes and responses of sustainability and climate change officers in UK cities that have prepared low carbon and climate change plans, in the context of these challenges. Using a conceptual framework that analyses ‘awareness’, ‘analysis’ and ‘actions’ (in the context of spending cuts and a new ‘decentralized’ policy agenda) this research suggests that progress on low-carbon futures for cities continues to be fragmented, with increased funding constraints, short-termism and lack of leadership acting as key barriers to progress. Conclusion: Recent UK national policies (including localism, austerity measures and new economic incentives) have not only created further uncertainties, but also scope for cities’ local innovation through policy leverage and self-governing actions.

Cost effectiveness of mitigation measures for water security and water quality in the River Thames catchment: impacts of changing climate, land use and water scarcity

The catchment of the River Thames, the principal river system in southern England, provides the main water supply for London but is highly vulnerable to changes in climate, land use and population. The river is eutrophic with significant algal blooms with phosphorus assumed to be the primary chemical indicator of ecosystem health. In the Thames Basin, phosphorus is available from point sources such as wastewater treatment plants and from diffuse sources such as agriculture. In order to predict vulnerability to future change, the integrated catchments model for phosphorus (INCA-P) has been applied to the river basin and used to assess the cost-effectiveness of a range of mitigation and adaptation strategies. It is shown that scenarios of future climate and land-use change will exacerbate the water quality problems, but a range of mitigation measures can improve the situation. A cost-effectiveness study has been undertaken to compare the economic benefits of each mitigation measure and to assess the phosphorus reductions achieved. The most effective strategy is to reduce fertilizer use by 20% together with the treatment of effluent to a high standard. Such measures will reduce the instream phosphorus concentrations to close to the EU Water Framework Directive target for the Thames.

Privatisation, empowerment and accountability: What are the policy implications for establishing effective farmer organisations?

Weak institutional development and information flows have constrained the extent to which the small-holder farming sector in developing countries can significantly drive growth and poverty reduction. Thisis despite widely implemented economic liberalisation policies focussing on market efficiency. Farmerorganisations are viewed as a potential means of addressing public and private institutional failure but thishas frequently been limited by inequalities in access to power and information. This article investigatestwo issues that have received little research attention to date: what role downward accountability plays inenabling farmer organisations to improve services and markets, and what influences the extent to whichdownward accountability is achieved. Kenya Tea Development Agency (KTDA), one of the largest farmerorganisations in the world (>400,000 farmers) is examined alongside wider literature. Mixed methodswere used including key informant interviews, and eight months of participant observation followedby a questionnaire survey. The article concludes that without effective downward accountability farmerorganisations can become characterised by institutions and mechanisms that favour elites, restrictedweak coordination and regulation, and manipulated information flows. This in turn reduces individuals’incentives to invest. If farmer organisations are to realise their potential as a means of enabling the small-holder sector to significantly contribute to economic growth and poverty reduction, policy and researchneeds to address key factors which influence accountability including: how to ensure initial processes information of farmer organisations establish appropriate structures and rules; strong state regulation toenhance corporate accountability; transparent information provision regarding actions of farmer organi-sation leaders; and the role independent non-government organisations can play. Consequently attentionneeds to focus on developing means of legitimising rights, building poor people’s capacity to challengeexclusion, and moving from rights to obligations regarding information provision.

From Rio to Copenhagen: multilateral agreements, disagreements and situated actions

Governing climate change is arguably one of the most complex problems, environmental or otherwise, that the global community has had to contend with. This chapter highlights the innovations in governance that have characterized the global climate change regime as it sought to respond to and manage these complexities, political imperatives and competing interests. We suggest that the key contestations and innovations within climate governance can be understood in terms of four themes/questions all of which relate to issues of justice and equity.