The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study

Objectives: To assess the impact of a closed-loop electronic prescribing, automated dispensing, barcode patient identification and electronic medication administration record (EMAR) system on prescribing and administration errors, confirmation of patient identity before administration, and staff time. Design, setting and participants: Before-and-after study in a surgical ward of a teaching hospital, involving patients and staff of that ward. Intervention: Closed-loop electronic prescribing, automated dispensing, barcode patient identification and EMAR system. Main outcome measures: Percentage of new medication orders with a prescribing error, percentage of doses with medication administration errors (MAEs) and percentage given without checking patient identity. Time spent prescribing and providing a ward pharmacy service. Nursing time on medication tasks. Results: Prescribing errors were identified in 3.8% of 2450 medication orders pre-intervention and 2.0% of 2353 orders afterwards (p<0.001; χ2 test). MAEs occurred in 7.0% of 1473 non-intravenous doses pre-intervention and 4.3% of 1139 afterwards (p = 0.005; χ2 test). Patient identity was not checked for 82.6% of 1344 doses pre-intervention and 18.9% of 1291 afterwards (p<0.001; χ2 test). Medical staff required 15 s to prescribe a regular inpatient drug pre-intervention and 39 s afterwards (p = 0.03; t test). Time spent providing a ward pharmacy service increased from 68 min to 98 min each weekday (p = 0.001; t test); 22% of drug charts were unavailable pre-intervention. Time per drug administration round decreased from 50 min to 40 min (p = 0.006; t test); nursing time on medication tasks outside of drug rounds increased from 21.1% to 28.7% (p = 0.006; χ2 test). Conclusions: A closed-loop electronic prescribing, dispensing and barcode patient identification system reduced prescribing errors and MAEs, and increased confirmation of patient identity before administration. Time spent on medication-related tasks increased.

‘We are managing our own lives...’: life transitions and care in sibling-headed households affected by AIDS in Tanzania and Uganda

This paper explores the ways that young people express their agency and negotiate complex lifecourse transitions according to gender, age and inter- and intra-generational norms in sibling-headed households affected by AIDS in East Africa. Based on findings from a qualitative and participatory pilot study in Tanzania and Uganda, I examine young people's socio-spatial and temporal experiences of heading the household and caring for their siblings following their parent's/relative's death. Key dimensions of young people's caring pathways and life transitions are discussed: transitions into sibling care; the ways young people manage changing roles within the family; and the ways that young people are positioned and seek to position themselves within the community. The research reveals the relational and embodied nature of young people's life transitions over time and space. By living together independently, young people constantly reproduce and reconfigure gendered, inter- and intra-generational norms of ‘the family’, transgressing the boundaries of ‘childhood’, ‘youth’ and ‘adulthood’. Although young people take on ‘adult’ responsibilities and demonstrate their competencies in ‘managing their own lives’, this does not necessarily translate into more equal power relations with adults in the community. The research reveals the marginal ‘in-between’ place that young people occupy between local and global discourses of ‘childhood’ and ‘youth’ that construct them as ‘deviant’. Although young people adopt a range of strategies to resist marginalisation and harassment, I argue that constraints of poverty, unequal gender and generational power relations and the emotional impacts of sibling care, stigmatisation and exclusion can undermine their ability to exert agency and control over their sexual relationships, schooling, livelihood strategies and future lifecourse transitions.

Differences between naïve and expert observers’ vergence and accommodative responses to a range of targets

Purpose: Vergence and accommodation studies often use adult participants with experience of vision science. Reports of infant and clinical responses are generally more variable and of lower gain, with the implication that differences lie in immaturity or sub-optimal clinical characteristics but expert/naïve differences are rarely considered or quantified. Methods: Sixteen undergraduates, naïve to vision science, were individually matched by age, visual acuity, refractive error, heterophoria, stereoacuity and near point of accommodation to second- and third-year orthoptics and optometry undergraduates (‘experts’). Accommodation and vergence responses were assessed to targets moving between 33 cm, 50 cm, 1 m and 2 m using a haploscopic device incorporating a PlusoptiX SO4 autorefractor. Disparity, blur and looming cues were separately available or minimised in all combinations. Instruction set was minimal. Results: In all cases, vergence and accommodation response slopes (gain) were steeper and closer to 1.0 in the expert group (p = 0.001), with the largest expert/naïve differences for both vergence and accommodation being for near targets (p = 0.012). For vergence, the differences between expert and naïve response slopes increased with increasingly open-loop targets (linear trend p = 0.025). Although we predicted that proximal cues would drive additional response in the experts, the proximity-only cue was the only condition that showed no statistical effect of experience. Conclusions: Expert observers provide more accurate responses to near target demand than closely matched naïve observers. We suggest that attention, practice, voluntary and proprioceptive effects may enhance responses in experienced participants when compared to a more typical general population. Differences between adult reports and the developmental and clinical literature may partially reflect expert/naïve effects, as well as developmental change. If developmental and clinical studies are to be compared to adult normative data, uninstructed naïve adult data should be used.

The visibility of agricultural subsidies and market illusions in the Common Agricultural Policy: Some evidence from farmers' views in Germany, Portugal and the United Kingdom

This article demonstrates that the design and nature of agricultural support schemes has an influence on farmers' perception of their level of dependence on agricultural support. While direct aid payments inform farmers about the extent to which they are subsidised, indirect support mechanisms veil the level of subsidisation, and therefore they are not fully aware of the extent to which they are supported. To test this hypothesis, we applied data from a survey of 4,500 farmers in three countries: the United Kingdom, Germany and Portugal. It is demonstrated that indirect support, such as that provided through artificially high consumer prices, gives an illusion of free and competitive markets among farmers. This 'visibility' hypothesis is evaluated against an alternative hypothesis that assumes farmers have complete, or at least a fairly comprehensive level of, information on agricultural support schemes. Our findings show that this alternative hypothesis can be ruled out.

Gold mining in Ghana's forest reserves: a report on the current debate

This paper examines the debate surrounding a recent decision made by the Ghanaian government to permit gold exploration - and potentially, mining - in 'protected' forest reserves. In 2001, four mining companies were awarded mineral exploration concessions in forested regions of the country, and have since put forward applications to mine for gold. Notwithstanding the sharp divide in opinion on the issue, the continued uncertainty surrounding the implications of the proposed activities makes further research on the ground imperative in the short term. Work aiming to elicit indigenous perspectives on the projects, as well as research that facilitates dialogue between and/or among stakeholder parties, should be prioritized.

No impact of malaria infection or immunisation on the expression of the immune GTPase GIMAP1 at the protein or mRNA levels (Article no. 53)

GIMAP (GTPase of the immunity-associated protein family) proteins are a family of putative GTPases believed to be regulators of cell death in lymphomyeloid cells. GIMAP1 was the first reported member of this gene family, identified as a gene up-regulated at the RNA level in the spleens of mice infected with the malarial parasite, Plasmodium chabaudi. Methods A monoclonal antibody against mouse GIMAP1 was developed and was used to analyse the expression of the endogenous protein in tissues of normal mice and in defined sub-populations of cells prepared from lymphoid tissues using flow cytometry. It was also used to assess the expression of GIMAP1 protein after infection and/or immunization of mice with P. chabaudi. Real-time PCR analysis was employed to measure the expression of GIMAP1 for comparison with the protein level analysis. Results GIMAP1 protein expression was detected in all lineages of lymphocytes (T, B, NK), in F4/80+ splenic macrophages and in some lymphoid cell lines. Additional evidence is presented suggesting that the strong expression by mature B cells of GIMAP1 and other GIMAP genes and proteins seen in mice may be a species-dependent characteristic. Unexpectedly, no increase was found in the expression of GIMAP1 in P. chabaudi infected mice at either the mRNA or protein level, and this remained so despite applying a number of variations to the protocol. Conclusion The model of up-regulation of GIMAP1 in response to infection/immunization with P. chabaudi is not a robustly reproducible experimental system. The GIMAP1 protein is widely expressed in lymphoid cells, with an interesting increase in expression in the later stages of B cell development. Alternative approaches will be required to define the functional role of this GTPase in immune cells.

Fungicide resistance: the dose rate debate

It makes economic sense to use as little fungicide as possible on a crop. In many settings, it is common to apply less than the manufacturer's recommended dose. If sources of disease are scarce, or conditions are unsuitable for it to increase, the reduced control from a low dose may be adequate. In other cases, a big reduction in dose may cause little reduction in control, again permitting savings - especially for growers prepared to run a little risk. But the label recommendations for most fungicides state that to avoid resistance, a full dose must always be used. Are individual cost-savings therefore endangering everyone's access to an exceptionally useful tool? The emergence of fungicide resistance is evolution in action. In all cases, it involves the genetic replacement of the original susceptible population of the pathogen by a new population with genetically distinct biochemistry, which confers resistance. The resistant biochemistry originates in rare genetic mutations, so rare that initially the population is hardly altered. Replacement of susceptible forms by resistant ones happens because, with fungicide present, the resistant form multiplies more rapidly than the susceptible form. The key point to notice is that only the relative rates of multiplication of the resistant and susceptible types are involved in the evolution of resistance. The absolute rates are irrelevant.

The severity of malarial anaemia in Plasmodium chabaudi infections of BALB/c mice is determined independently of the number of circulating parasites

Background: Severe malarial anaemia is a major complication of malaria infection and is multifactorial resulting from loss of circulating red blood cells (RBCs) from parasite replication, as well as immune-mediated mechanisms. An understanding of the causes of severe malarial anaemia is necessary to develop and implement new therapeutic strategies to tackle this syndrome of malaria infection. Methods: Using analysis of variance, this work investigated whether parasite-destruction of RBCs always accounts for the severity of malarial anaemia during infections of the rodent malaria model Plasmodium chabaudi in mice of a BALB/c background. Differences in anaemia between two different clones of P. chabaudi were also examined. Results: Circulating parasite numbers were not correlated with the severity of anaemia in either BALB/c mice or under more severe conditions of anaemia in BALB/c RAG2 deficient mice (lacking T and B cells). Mice infected with P. chabaudi clone CB suffered more severe anaemia than mice infected with clone AS, but this was not correlated with the number of parasites in the circulation. Instead, the peak percentage of parasitized RBCs was higher in CB-infected animals than in AS-infected animals, and was correlated with the severity of anaemia, suggesting that the availability of uninfected RBCs was impaired in CB-infected animals. Conclusion: This work shows that parasite numbers are a more relevant measure of parasite levels in P. chabaudi infection than % parasitaemia, a measure that does not take anaemia into account. The lack of correlation between parasite numbers and the drop in circulating RBCs in this experimental model of malaria support a role for the host response in the impairment or destruction of uninfected RBC in P. chabaudi infections, and thus development of acute anaemia in this malaria model.

Soil disturbed using a strip tillage implement on a range of soil types and the effects on sugar beet establishment

The area of soil disturbed using a single tine is well documented. However, modern strip tillage implements using a tine and disc design have not been assessed in the UK or in mainland Europe. Using a strip tillage implement has potential benefits for European agriculture where economic returns and sustainability are key issues. Using a strip tillage system a narrow zone is cultivated leaving most of the straw residue on the soil surface. Small field plot experiments were undertaken on three soil types and the operating parameters of forward speed, tine depth and tine design were investigated together with measurements of seedbed tilth and crop emergence. The type of tine used was found to be the primary factor in achieving the required volume of disturbance within a narrow zone whilst maintaining an area of undisturbed soil with straw residue on the surface. The winged tine produced greater disturbance at a given depth compared with the knife tine. Increasing forward speed did not consistently increase the volume of disturbance. In a sandy clay loam the tilth created and emergence of sugar beet by strip tillage and ploughing were similar but on a sandy loam the strip tillage treatments generally gave a finer tilth but poorer emergence particularly at greater working depth.

Green tea (Camellia sinensis) catechins and vascular function

The health benefits of green tea (Camellia sinensis) catechins are becoming increasingly recognised. Amongst the proposed benefits are the maintenance of endothelial function and vascular homeostasis and an associated reduction in atherogenesis and CVD risk. The mounting evidence for the influential effect of green tea catechins on vascular function from epidemiological, human intervention and animal studies is subject to review together with exploration of the potential mechanistic pathways involved. Epigallocatechin-3-gallate, one of the most abundant and widely studied catechin found in green tea, will be prominent in the present review. Since there is a substantial inconsistency in the published data with regards to the impact of green tea catechins on vascular function, evaluation and interpretation of the inter- and intra-study variability is included. In conclusion, a positive effect of green tea catechins on vascular function is becoming apparent. Further studies in animal and cell models using physiological concentrations of catechins and their metabolites are warranted in order to gain some insight into the physiology and molecular basis of the observed beneficial effects.

Absorption, tissue distribution and excretion of pelargonidin and its metabolites following oral administration to rats

Recent reports have demonstrated various cardiovascular and neurological benefits associated with the consumption of foods rich in anthocyanidins. However, information regarding absorption, metabolism, and especially, tissue distribution are only beginning to accumulate. In the present study, we investigated the occurrence and the kinetics of various circulating pelargonidin metabolites, and we aimed at providing initial information with regard to tissue distribution. Based on HPLC and LC-MS analyses we demonstrate that pelargonidin is absorbed and present in plasma following oral gavage to rats. In addition, the main structurally related pelargonidin metabolite identified in plasma and urine was pelargonidin glucuronide. Furthermore, p-hydroxybenzoic acid, a ring fission product of pelargonidin, was detected in plasma and urine samples obtained at 2 and 18 h after ingestion. At 2 h post-gavage, pelargonidin glucuronide was the major metabolite detected in kidney and liver, with levels reaching 0.5 and 0.15 nmol pelargonidin equivalents/g tissue, respectively. Brain and lung tissues contained detectable levels of the aglycone, with the glucuronide also present in the lungs. Other tissues, including spleen and heart, did not contain detectable levels of pelargonidin or ensuing metabolites. At 18 h post-gavage, tissue analyses did not reveal detectable levels of the aglycone nor of pelargonidin glucuronides. Taken together, our results demonstrate that the overall uptake of the administered pelargonidin was 18 % after 2 h, with the majority of the detected levels located in the stomach. However, the amounts recovered dropped to 1.2 % only 18 h post-gavage, with the urine and faecal content constituting almost 90 % of the total recovered pelargonidin.

Large-scale functional expression of WT and truncated human adenosine A(2A) receptor in Pichia pastoris bioreactor cultures

Background: The large-scale production of G-protein coupled receptors (GPCRs) for functional and structural studies remains a challenge. Recent successes have been made in the expression of a range of GPCRs using Pichia pastoris as an expression host. P. pastoris has a number of advantages over other expression systems including ability to post-translationally modify expressed proteins, relative low cost for production and ability to grow to very high cell densities. Several previous studies have described the expression of GPCRs in P. pastoris using shaker flasks, which allow culturing of small volumes (500 ml) with moderate cell densities (OD600 similar to 15). The use of bioreactors, which allow straightforward culturing of large volumes, together with optimal control of growth parameters including pH and dissolved oxygen to maximise cell densities and expression of the target receptors, are an attractive alternative. The aim of this study was to compare the levels of expression of the human Adenosine 2A receptor (A(2A)R) in P. pastoris under control of a methanol-inducible promoter in both flask and bioreactor cultures. Results: Bioreactor cultures yielded an approximately five times increase in cell density (OD600 similar to 75) compared to flask cultures prior to induction and a doubling in functional expression level per mg of membrane protein, representing a significant optimisation. Furthermore, analysis of a C-terminally truncated A2AR, terminating at residue V334 yielded the highest levels (200 pmol/mg) so far reported for expression of this receptor in P. pastoris. This truncated form of the receptor was also revealed to be resistant to C-terminal degradation in contrast to the WT A(2A)R, and therefore more suitable for further functional and structural studies. Conclusion: Large-scale expression of the A(2A)R in P. pastoris bioreactor cultures results in significant increases in functional expression compared to traditional flask cultures.