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.

Changing standards revisited: children’s awareness and knowledge of features of written standard English at ages 10-11

This paper reports the findings of a small-scale research project which investigated the levels of awareness and knowledge of written standard English of 10 and 11 year old children in two English primary schools. The project involved repeating in 2010 a written questionnaire previously used with children in the same schools in three separate surveys in 1999, 2002 and 2005. Data from the latest survey are compared to those from the previous three. The analysis seeks to identify any changes over time in children’s ability to recognise non-standard forms and supply standard English alternatives, as well as their ability to use technical terms related to language variation. Differences between the performance of boys and girls and that of the two schools are also analysed. The paper concludes that the socio-economic context of the schools may be a more important factor than gender in variations over time identified in the data.

Production and processing asymmetries in the acquisition of tense morphology by sequential bilingual children

This study investigates the production and on-line processing of English tense morphemes by sequential bilingual (L2) Turkish-speaking children with more than three years of exposure to English. Thirty nine 6-9-year-old L2 children and 28 typically developing age-matched monolingual (L1) children were administered the production component for third person –s and past tense of the Test for Early Grammatical Impairment (Rice & Wexler, 1996) and participated in an on-line word-monitoring task involving grammatical and ungrammatical sentences with presence/omission of tense (third person –s, past tense -ed) and non-tense (progressive –ing, possessive ‘s) morphemes. The L2 children’s performance on the on-line task was compared to that of children with Specific Language Impairment (SLI) in Montgomery & Leonard (1998, 2006) to ascertain similarities and differences between the two populations. Results showed that the L2 children were sensitive to the ungrammaticality induced by the omission of tense morphemes, despite variable production. This reinforces the claim about intact underlying syntactic representations in child L2 acquisition despite non target-like production (Haznedar & Schwartz, 1997).

Speech-like and non-speech lip kinematics and coordination in aphasia

Background and aims: In addition to the well-known linguistic processing impairments in aphasia, oro-motor skills and articulatory implementation of speech segments are reported to be compromised to some degree in most types of aphasia. This study aimed to identify differences in the characteristics and coordination of lip movements in the production of a bilabial closure gesture between speech-like and nonspeech tasks in individuals with aphasia and healthy control subjects. Method and procedure: Upper and lower lip movement data were collected for a speech-like and a nonspeech task using an AG 100 EMMA system from five individuals with aphasia and five age and gender matched control subjects. Each task was produced at two rate conditions (normal and fast), and in a familiar and a less-familiar manner. Single articulator kinematic parameters (peak velocity, amplitude, duration, and cyclic spatio-temporal index) and multi-articulator coordination indices (average relative phase and variability of relative phase) were measured to characterize lip movements. Outcome and results: The results showed that when the two lips had similar task goals (bilabial closure) in speech-like versus nonspeech task, kinematic and coordination characteristics were not found to be different. However, when changes in rate were imposed on the bilabial gesture, only speech-like task showed functional adaptations, indicated by a greater decrease in amplitude and duration at fast rates. In terms of group differences, individuals with aphasia showed smaller amplitudes and longer movement durations for upper lip, higher spatio-temporal variability for both lips, and higher variability in lip coordination than the control speakers. Rate was an important factor in distinguishing the two groups, and individuals with aphasia were limited in implementing the rate changes. Conclusion and implications: The findings support the notion of subtle but robust differences in motor control characteristics between individuals with aphasia and the control participants, even in the context of producing bilabial closing gestures for a relatively simple speech-like task. The findings also highlight the functional differences between speech-like and nonspeech tasks, despite a common movement coordination goal for bilabial closure.

Thinking for speaking and linguistic relativity among bilinguals: towards a new research agenda

This article evaluates how the different papers in this special issue fill a gap in our understanding of cognitive processes that are being activated when second language learners or bilinguals prepare to speak. All papers are framed in Slobin’s (1987) Thinking for Speaking theory, and aim to test whether the conceptualisation patterns that were learned in early childhood can be relearned or restructured in L2 acquisition. In many papers the focus is on identifying constraints on this restructuring process. Among these constraints, the role of typological differences between languages is investigated in great depth. The studies involve different types of learners, language combinations and tasks. As all informants were given verbal rather than non-verbal tasks, the focus is here on the effects of conceptual transfer from one language on another, and not on the effects of language on non-linguistic cognition. The paper also sketches different avenues for further research in this field and proposes that researchers working in this field might want to take up the challenge of investigating whether speakers of different languages perceive motion outside explicitly verbal contexts differently, as this will enable us to gain an understanding of linguistic relativity effects in this domain. Studying which teaching methods can help learners to restructure their conceptualisation patterns may also shed new light on the aspects of discourse organization and motion event construal that are most difficult for learners.

Apartment ownership: the English version needs reforming

In this contribution, the English commonhold system, which enables the development of freehold units in a multi-unit development, is critically re-visited. Provision is made for the development of freehold apartments on land with a registered commonhold title. At the date of registration, a management body for the scheme, the commonhold association, must be in place. Each purchaser of a unit in the relevant building obtains freehold property on purchase. The property and management of the building housing the units and of the common areas of the scheme are, by contrast, withheld from unit holders and vested in the commonhold association, which is a special kind of body corporate. Since the coming into force of the English legislation, a set of defects have been detected. This contribution re-assesses the main problem areas and makes a number of reform suggestions drawing on material from a number of jurisdictions, notably South Africa, France and Germany. Avoidable problems are likely to arise with any conversions to commonhold from the predominant English long lease system, owing to the narrowness of the conversion rules. The manner in which ownership of units and the common parts are regulated, a key aspect in any such system, merits re-assessment. It seems that here the English rules survive comparison. The rules pertaining to constitution of the commonhold association fail to provide sufficient safeguards for unpaid scheme creditors. The rules relating leasing of commonhold units seem inadequately thought out. There is a conspicuous absence of real remedies for non-payment of assessments by unit holders. The effect of these and other aspects may help to explain why commonhold has had a limited numerical impact. The time for a second generation reforming statute may have come.

The relationship between rapid naming and word spelling in English

A study of the concurrent relationships between naming speed, phonological awareness and spelling ability in 146 children in Year 3 and 4 of state funded school in SE England (equivalent to US Grades 2 and 3) is reported. Seventy-two children identified as having normal phonological awareness but reduced rapid automatized naming (RAN) performance (1 standard deviation below the mean) participated in the study. A group of 74 children were further identified. These children were matched on phonological awareness, verbal and non verbal IQ, and visual acuity but all members of this group showed normal rapid automatized naming performance. Rapid automatized naming made a significant unique contribution to spelling performance. Further analyses showed that the participants with low naming performance were significantly poorer spellers overall and had a specific difficulty in spelling irregular words. The findings support the view that rapid automatized naming may be indexing processes that are implicated in the establishment of fully specified orthographic representations.

Dynamical control of the mesosphere by orographic and non-orographic gravity wave drag during the extended northern winters of 2006 and 2009

A version of the Canadian Middle Atmosphere Model (CMAM) that is nudged toward reanalysis data up to 1 hPa is used to examine the impacts of parameterized orographic and non-orographic gravity wave drag (OGWD and NGWD) on the zonal-mean circulation of the mesosphere during the extended northern winters of 2006 and 2009 when there were two large stratospheric sudden warmings. The simulations are compared to Aura Microwave Limb Sounder (MLS) observations of mesospheric temperature, carbon monoxide (CO) and derived zonal winds. The control simulation, which uses both OGWD and NGWD, is shown to be in good agreement with MLS. The impacts of OGWD and NGWD are assessed using simulations in which those sources of wave drag are removed. In the absence of OGWD the mesospheric zonal winds in the months preceding the warmings are too strong, causing increased mesospheric NGWD, which drives excessive downwelling, resulting in overly large lower mesospheric values of CO prior to the warming. NGWD is found to be most important following the warmings when the underlying westerlies are too weak to allow much vertical propagation of the orographic gravity waves to the mesosphere. NGWD is primarily responsible for driving the circulation that results in the descent of CO from the thermosphere following the warmings. Zonal mean mesospheric winds and temperatures in all simulations are shown to be strongly constrained by (i.e. slaved to) the stratosphere. Finally, it is demonstrated that the responses to OGWD and NGWD are non-additive due to their dependence and influence on the background winds and temperatures.

(PDF, 406 KB) On L3 acquisition and phonological permeability: a new test case for debates on the mental representation of non-native phonological systems

The goal of this article is to make an epistemological and theoretical contribution to the nascent field of third language (L3) acquisition and show how examining L3 development can offer a unique view into longstanding debates within L2 acquisition theory. We offer the Phonological Permeability Hypothesis (PPH), which maintains that examining the development of an L3/Ln phonological system and its effects on a previously acquired L2 phonological system can inform contemporary debates regarding the mental constitution of postcritical period adult phonological acquisition. We discuss the predictions and functional significance of the PPH for adult SLA and multilingualism studies, detailing a methodology that examines the effects of acquiring Brazilian Portuguese on the Spanish phonological systems learned before and after the so-called critical period (i.e., comparing simultaneous versus successive adult English-Spanish bilinguals learning Brazilian Portuguese as an L3).

Knowledge of A/A'-dependencies on subject extraction with two types of infinitives in non-native Portuguese adult bilingualism

Within generative L2 acquisition research there is a longstanding debate as to what underlies observable differences in L1/L2 knowledge/ performance. On the one hand, Full Accessibility approaches maintain that target L2 syntactic representations (new functional categories and features) are acquirable (e.g., Schwartz & Sprouse, 1996). Conversely, Partial Accessibility approaches claim that L2 variability and/or optionality, even at advanced levels, obtains as a result of inevitable deficits in L2 narrow syntax and is conditioned upon a maturational failure in adulthood to acquire (some) new functional features (e.g., Beck, 1998; Hawkins & Chan, 1997; Hawkins & Hattori, 2006; Tsimpli & Dimitrakopoulou, 2007). The present study tests the predictions of these two sets of approaches with advanced English learners of L2 Brazilian Portuguese (n = 21) in the domain of inflected infinitives. These advanced L2 learners reliably differentiate syntactically between finite verbs, uninflected and inflected infinitives, which, as argued, only supports Full Accessibility approaches. Moreover, we will discuss how testing the domain of inflected infinitives is especially interesting in light of recent proposals that Brazilian Portuguese colloquial dialects no longer actively instantiate them (Lightfoot, 1991; Pires, 2002, 2006; Pires & Rothman, 2009; Rothman, 2007).

The impact of overseas training on curriculum innovation and change in English language education in Western China

This article assesses the impact of a UK-based professional development programme on curriculum innovation and change in English Language Education (ELE) in Western China. Based on interviews, focus group discussions and observation of a total of 48 English teachers who had participated in an overseas professional development programme influenced by modern approaches to education and ELE, and 9 of their colleagues who had not taken part, it assesses the uptake of new approaches on teachers’ return to China. Interviews with 10 senior managers provided supplementary data. Using Diffusion of Innovations Theory as the conceptual framework, we examine those aspects of the Chinese situation that are supportive of change and those that constrain innovation. We offer evidence of innovation in classroom practice on the part of returnees and ‘reinvention’ of the innovation to ensure a better fit with local needs. The key role of course participants as opinion leaders in the diffusion of new ideas is also explored. We conclude that the selective uptake of this innovation is under way and likely to be sustained against a background of continued curriculum reform in China.

The ‘thinking’ in thinking-for-speaking: where is it?

According to the thinking-for-speaking (TFS) hypothesis, speakers of different languages think differently while in the process of mentally preparing content for speech. The aim of the present paper is to critically discuss the research carried out within the TFS paradigm, against the background of the basic tenets laid out by the proponents of this framework. We will show that despite substantial progress in the investigation of crosslinguistic differences in the organisation of information in discourse, the studies that actually examine the cognitive aspects of speech production are, to date, vanishingly few. This state of affairs creates a gap in our knowledge about the thought processes that co-occur with speech production during language use and acquisition. We will argue that in order to reach a more comprehensive picture of the cognitive processes and outcomes of speech production, methodologies additional to the analysis of information organisation must be used.

Guided growth of neurons and glia using microfabricated patterns of parylene-C on a SiO2 background

This paper describes a simple technique for the patterning of glia and neurons. The integration of neuronal patterning to Multi-Electrode Arrays (MEAs), planar patch clamp and silicon based ‘lab on a chip’ technologies necessitates the development of a microfabrication-compatible method, which will be reliable and easy to implement. In this study a highly consistent, straightforward and cost effective cell patterning scheme has been developed. It is based on two common ingredients: the polymer parylene-C and horse serum. Parylene-C is deposited and photo-lithographically patterned on silicon oxide (SiO2) surfaces. Subsequently, the patterns are activated via immersion in horse serum. Compared to non-activated controls, cells on the treated samples exhibited a significantly higher conformity to underlying parylene stripes. The immersion time of the patterns was reduced from 24 to 3 h without compromising the technique. X-ray photoelectron spectroscopy (XPS) analysis of parylene and SiO2 surfaces before and after immersion in horse serum and gel based eluant analysis suggests that the quantity and conformation of proteins on the parylene and SiO2 substrates might be responsible for inducing glial and neuronal patterning.

Morphological decomposition in Broca's aphasia

Background: Few studies have investigated how individuals diagnosed with post-stroke Broca’s aphasia decompose words into their constituent morphemes in real-time processing. Previous research has focused on morphologically complex words in non-time-constrained settings or in syntactic frames, but not in the lexicon. Aims: We examined real-time processing of morphologically complex words in a group of five Greek-speaking individuals with Broca’s aphasia to determine: (1) whether their morphological decomposition mechanisms are sensitive to lexical (orthography and frequency) vs. morphological (stem-suffix combinatory features) factors during visual word recognition, (2) whether these mechanisms are different in inflected vs. derived forms during lexical access, and (3) whether there is a preferred unit of lexical access (syllables vs. morphemes) for inflected vs. derived forms. Methods & Procedures: The study included two real-time experiments. The first was a semantic judgment task necessitating participants’ categorical judgments for high- and low-frequency inflected real words and pseudohomophones of the real words created by either an orthographic error at the stem or a homophonous (but incorrect) inflectional suffix. The second experiment was a letter-priming task at the syllabic or morphemic boundary of morphologically transparent inflected and derived words whose stems and suffixes were matched for length, lemma and surface frequency. Outcomes & Results: The majority of the individuals with Broca’s aphasia were sensitive to lexical frequency and stem orthography, while ignoring the morphological combinatory information encoded in the inflectional suffix that control participants were sensitive to. The letter-priming task, on the other hand, showed that individuals with aphasia—in contrast to controls—showed preferences with regard to the unit of lexical access, i.e., they were overall faster on syllabically than morphemically parsed words and their morphological decomposition mechanisms for inflected and derived forms were modulated by the unit of lexical access. Conclusions: Our results show that in morphological processing, Greek-speaking persons with aphasia rely mainly on stem access and thus are only sensitive to orthographic violations of the stem morphemes, but not to illegal morphological combinations of stems and suffixes. This possibly indicates an intact orthographic lexicon but deficient morphological decomposition mechanisms, possibly stemming from an underspecification of inflectional suffixes in the participants’ grammar. Syllabic information, however, appears to facilitate lexical access and elicits repair mechanisms that compensate for deviant morphological parsing procedures.