Minimum recovery time between reactive hyperemia stimulus in the repeated measurement of brachial flow-mediated dilatation.

The ability to undertake repeat measurements of flow-mediated dilatation (FMD) within a short time of a previous measurement would be useful to improve accuracy or to repeat a failed initial procedure. Although standard methods report that a minimum of 10 min is required between measurements, there is no published data to support this. Thirty healthy volunteers had five FMD measurements performed within a 2-h period, separated by various time intervals (5, 15 and 30 min). In 19 volunteers, FMD was also performed as soon as the vessel had returned to its baseline diameter. There was no significant difference between any of the FMD measurements or parameters across the visits indicating that repeat measurements may be taken after a minimum of 5 min or as soon as the vessel has returned to its baseline diameter, which in some subjects may be less than 5 min.

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.

Cloud statistics and cloud radiative effect for a low-mountain site

In 2007, the Atmospheric Radiation Measurement (ARM) Mobile Facility (AMF) was operated for a nine-month period in the Murg Valley, Black Forest, Germany, in support of the Convective and Orographically-induced Precipitation Study (COPS). The synergy of AMF and COPS partner instrumentation was exploited to derive a set of high-quality thermodynamic and cloud property profiles with 30 s resolution. In total, clouds were present 72% of the time, with multi-layer mixed phase (28.4%) and single-layer water clouds (11.3%) occurring most frequently. A comparison with the Cloudnet sites Chilbolton and Lindenberg for the same time period revealed that the Murg Valley exhibits lower liquid water paths (LWPs; median = 37.5 g m−2) compared to the two sites located in flat terrain. In order to evaluate the derived thermodynamic and cloud property profiles, a radiative closure study was performed with independent surface radiation measurements. In clear sky, average differences between calculated and observed surface fluxes are less than 2% and 4% for the short wave and long wave part, respectively. In cloudy situations, differences between simulated and observed fluxes, particularly in the short wave part, are much larger, but most of these can be related to broken cloud situations. The daytime cloud radiative effect (CRE), i.e. the difference of cloudy and clear-sky net fluxes, has been analysed for the whole nine-month period. For overcast, single-layer water clouds, sensitivity studies revealed that the CRE uncertainty is likewise determined by uncertainties in liquid water content and effective radius. For low LWP clouds, CRE uncertainty is dominated by LWP uncertainty; therefore refined retrievals, such as using infrared and/or higher microwave frequencies, are needed.

Provider diversity in the English NHS: a study of recent developments in four local health economies

Objectives: The overall objective of the research was to assess the impact of provider diversity on quality and innovation in the English NHS. The aims were to map the extent of diverse provider activity, identify the differences in performance between Third Sector Organisations (TSOs), for-profit private enterprises, and incumbent organisations within the NHS, and the factors that affect the entry and growth of new private and TSOs. Methods: Case studies of four Local Health Economies (LHEs). Data included: semi-structured interviews with 48 managerial and clinical staff from NHS organizations and providers from the private and Third Sector; some documentary evidence; a focus group with service users; and routine data from the Care Quality Commission and Companies House. Data collection was mainly between November 2008 and November 2009. Results: Involvement of diverse providers in the NHS is limited. Commissioners’ local strategies influence degrees of diversity. Barriers to the entry for TSOs include lack of economies of scale in the bidding process. Private providers have greater concern to improve patient pathways and patient experience, whereas TSOs deliver quality improvements by using a more holistic approach and a greater degree of community involvement. Entry of new providers drives NHS Trusts to respond by making improvements. Information sharing diminishes as competition intensifies. Conclusions: There is scope to increase the participation of diverse providers in the NHS, but care must be taken not to damage public accountability, overall productivity, equity and NHS providers (especially acute hospitals, which are likely to remain in the NHS) in the process.

Provider diversity in the NHS: impact on quality and innovation

The overall objective of the research project has been to assess the impact of provider diversity on quality and innovation in the NHS. The specific research aims were to identify the differences in performance between non-profit Third Sector organisations, for-profit private enterprises, and incumbent public sector institutions within the NHS as providers of health care services, as well as the factors that affect the entry and growth of new private and Third Sector providers. The study used both qualitative and quantitative methods based on case studies of four Local Health Economies (LHEs). Qualitative methods included documentary analysis and interviews with key informants and managers of both commissioning and provider organisations. To provide a focus to the study, two tracer conditions were followed: orthopaedic surgery and home health care for frail older people. In the case of hospital inpatient care, data on patient characteristics were also collected from the HES database. The analysis of this data provided preliminary estimates of the effects of provider type on quality, controlling for client characteristics and case mix. In addition, a survey of patient experience in diverse provider organisations was analysed to compare the different dimensions of quality of provision of acute services between incumbent NHS organisations and new independent sector treatment centres. The research has shown that, in respect of inpatient hospital services, diverse providers supply health services of at least as good quality as traditional NHS providers, and that there is ample opportunity to expand their scale and scope as providers of services commissioned by the NHS. The research used patient experience survey data to investigate whether hospital ownership affects the quality of services reported by NHS patients in areas other than clinical quality. The raw survey data appear to show that private hospitals provide higher quality services than the public hospitals. However, further empirical analysis leads to a more nuanced understanding of the performance differences. Firstly, the analysis shows that each sector offers greater quality in certain specialties. Secondly, the analysis shows that differences in the quality of patients’ reported experience are mainly attributable to patient characteristics, the selection of patients into each type of hospital, and the characteristics of individual hospitals, rather than to hospital ownership as such. Controlling for such differences, NHS patients are on average likely to experience a similar quality of care in a public or privately-run hospital. Nevertheless, for specific groups of patients and for specific types of treatments, especially the more straightforward ones, the private sector provides an improved patient experience compared to the public sector. Elsewhere, the NHS continues to provide a high quality service and outperforms the private sector in a range of services and for a range of clients.

The effect of Arabian Sea optical properties on SST biases and the South Asian summer monsoon in a coupled GCM

This study examines the effect of seasonally varying chlorophyll on the climate of the Arabian Sea and South Asian monsoon. The effect of such seasonality on the radiative properties of the upper ocean is often a missing process in coupled general circulation models and its large amplitude in the region makes it a pertinent choice for study to determine any impact on systematic biases in the mean and seasonality of the Arabian Sea. In this study we examine the effects of incorporating a seasonal cycle in chlorophyll due to phytoplankton blooms in the UK Met Office coupled atmosphere-ocean GCM HadCM3. This is achieved by performing experiments in which the optical properties of water in the Arabian Sea - a key signal of the semi-annual cycle of phytoplankton blooms in the region - are calculated from a chlorophyll climatology derived from Sea-viewing Wide Field-of-View Sensor (SeaWiFS) data. The SeaWiFS chlorophyll is prescribed in annual mean and seasonally-varying experiments. In response to the chlorophyll bloom in late spring, biases in mixed layer depth are reduced by up to 50% and the surface is warmed, leading to increases in monsoon rainfall during the onset period. However when the monsoons are fully established in boreal winter and summer and there are strong surface winds and a deep mixed layer, biases in the mixed layer depth are reduced but the surface undergoes cooling. The seasonality of the response of SST to chlorophyll is found to depend on the relative depth of the mixed layer to that of the anomalous penetration depth of solar fluxes. Thus the inclusion of the effects of chlorophyll on radiative properties of the upper ocean acts to reduce biases in mixed layer depth and increase seasonality in SST.

Elevated atmospheric CO2 changes phosphorus fractions in soils under a short rotation poplar plantation (EuroFACE)

Future high levels of atmospheric carbon dioxide (CO2) may increase biomass production of terrestrial plants and hence plant requirements for soil mineral nutrients to sustain a greater biomass production. Phosphorus (P), an element essential for plant growth, is found in soils both in inorganic and in organic forms. In this work, three genotypes of Populus were grown under ambient and elevated atmospheric CO2 concentrations (FACE) for 5 years. An N fertilisation treatment was added in years 4 and 5 after planting. Using a fractionation scheme, total P was sequentially extracted using H2O, NaOH, HCl and HNO3, and P determined as both molybdate (Mo) reactive and total P. Molybdate-reactive P is defined as mainly inorganic but also some labile organic P which is determined by Vanado-molybdophosphoric acid colorimetric methods. Organic P was also measured to assess all plant available and weatherable P pools. We tested the hypotheses that higher P demand due to increased growth is met by a depletion of easily weatherable soil P pools, and that increased biomass inputs increases the amount of organic P in the soil. The concentration of organic P increased under FACE, but was associated with a decrease in total soil organic matter. The greatest increase in the soil P due to elevated CO2 was found in the HCl-extractable P fraction in the non-fertilised treatment. In the NaOH-extractable fraction the Mo-reactive P increased under FACE, but total P did not differ between ambient and FACE. The increase in both the NaOH- and HCl-extractable fractions was smaller after N addition. The results showed that elevated atmospheric CO2 has a positive effect on soil P availability rather than leading to depletion.We suggest that the increase in the NaOH- and HCl-extractable fractions is biologically driven by organic matter mineralization, weathering and mycorrhizal hyphal turnover.

Will the South Asian monsoon overturning circulation stabilize any further?

Understanding the response of the South Asian monsoon (SAM) system to global climate change is an interesting scientific problem that has enormous implications from the societal viewpoint. While the CMIP3 projections of future changes in monsoon precipitation used in the IPCC AR4 show major uncertainties, there is a growing recognition that the rapid increase of moisture in a warming climate can potentially enhance the stability of the large-scale tropical circulations. In this work, the authors have examined the stability of the SAM circulation based on diagnostic analysis of climate datasets over the past half century; and addressed the issue of likely future changes in the SAM in response to global warming using simulations from an ultrahigh resolution (20 km) global climate model. Additional sensitivity experiments using a simplified atmospheric model have been presented to supplement the overall findings. The results here suggest that the intensity of the boreal summer monsoon overturning circulation and the associated southwesterly monsoon flow have significantly weakened during the past 50-years. The weakening trend of the monsoon circulation is further corroborated by a significant decrease in the frequency of moderate-to-heavy monsoon rainfall days and upward vertical velocities particularly over the narrow mountain ranges of the Western Ghats. Based on simulations from the 20-km ultra high-resolution model, it is argued that a stabilization (weakening) of the summer monsoon Hadley-type circulation in response to global warming can potentially lead to a weakened large-scale monsoon flow thereby resulting in weaker vertical velocities and reduced orographic precipitation over the narrow Western Ghat mountains by the end of the twenty-first century. Supplementary experiments using a simplified atmospheric model indicate a high sensitivity of the large-scale monsoon circulation to atmospheric stability in comparison with the effects of condensational heating.

Healthcare providers in the English National Health Service: public, private or hybrids?

In recent years it has been noted that boundaries between public and private providers of many types of welfare have become blurred. This paper uses three dimensions of publicness to analyse this blurring of boundaries in relation to providers of healthcare in England. The authors find that, although most care is still funded and provided by the state, there are significant additional factors in respect of ownership and social control which indicate that many English healthcare providers are better understood as hybrids. Furthermore, the authors raise concerns about the possible deleterious effects of diminishing aspects of publicness on English healthcare. The most important of these is a decrease in accountability

The Epipalaeolithic (Iberomaurusian) at Grotte des Pigeons (Taforalt), Morocco: a preliminary study of the land Mollusca

Land snail middens occur widely throughout the circum-Mediterranean, particularly in the Maghreb and Libya, but are relatively understudied when compared with the better known coastal marine middens. The site of Taforalt (Grotte des Pigeons) in north east Morocco contains thick ashy deposits with considerable numbers of land snails, dating between 13,000 and 11,000 BP. The site has been excavated periodically since its discovery in 1908, but little attention has been paid to the land snail component. Recent excavations at the site as part of the Cemeteries and Sedentism Project has facilitated reinvestigation of the Iberomaurusian layers, including the upper ashy midden unit. This investigation addresses questions surrounding chronological variation in the lithic assemblage, subsistence strategies, population health and mortuary practices. Preliminary work on the land snails has identified a low species diversity in the grey series midden layers, characterised by the large edible species Alabastrina alabastrites, Helix cf aspersa, Dupotetia dupotetiana, Otala punctata and Cernuella sp, which appear to represent an abrupt intensification in the use of land snails as a food source. Significant quantities of associated plant material and animal bone suggest that land snails are part of a broader based diet which is adopted from around 13,000 BP.

Control of DNA conformation using 3'-S-phosphorothiolate-modified linkages

An in-depth study into the incorporation of multiple 3'-S-phosphorothiolate modifications into oligodeoxynucleotides (ODNs) and their subsequent effect on ODN/DNA and ODN/RNA duplex stability. 3'-S-Phosphorothiolate linkages increase the stability of ODN/RNA duplexes and decrease the stability of ODN/DNA duplexes.

RACORO extended-term, aircraft observations of boundary-layer clouds

A first-of-a-kind, extended-term cloud aircraft campaign was conducted to obtain an in-situ statistical characterization of continental boundary-layer clouds needed to investigate cloud processes and refine retrieval algorithms. Coordinated by the Atmospheric Radiation Measurement (ARM) Aerial Facility (AAF), the Routine AAF Clouds with Low Optical Water Depths (CLOWD) Optical Radiative Observations (RACORO) field campaign operated over the ARM Southern Great Plains (SGP) site from 22 January to 30 June 2009, collecting 260 h of data during 59 research flights. A comprehensive payload aboard the Center for Interdisciplinary Remotely-Piloted Aircraft Studies (CIRPAS) Twin Otter aircraft measured cloud microphysics, solar and thermal radiation, physical aerosol properties, and atmospheric state parameters. Proximity to the SGP's extensive complement of surface measurements provides ancillary data that supports modeling studies and facilitates evaluation of a variety of surface retrieval algorithms. The five-month duration enabled sampling a range of conditions associated with the seasonal transition from winter to summer. Although about two-thirds of the cloud flights occurred in May and June, boundary-layer cloud fields were sampled under a variety of environmental and aerosol conditions, with about 77% of the flights occurring in cumulus and stratocumulus. Preliminary analyses illustrate use of these data to analyze cloud-aerosol relationships, characterize the horizontal variability of cloud radiative impacts, and evaluate surface-based retrievals. We discuss how an extended-term campaign requires a simplified operating paradigm that is different from that used for typical, short-term, intensive aircraft field programs.

Toward understanding of differences in current cloud retrievals of ARM ground-based measurements

Accurate observations of cloud microphysical properties are needed for evaluating and improving the representation of cloud processes in climate models and better estimate of the Earth radiative budget. However, large differences are found in current cloud products retrieved from ground-based remote sensing measurements using various retrieval algorithms. Understanding the differences is an important step to address uncertainties in the cloud retrievals. In this study, an in-depth analysis of nine existing ground-based cloud retrievals using ARM remote sensing measurements is carried out. We place emphasis on boundary layer overcast clouds and high level ice clouds, which are the focus of many current retrieval development efforts due to their radiative importance and relatively simple structure. Large systematic discrepancies in cloud microphysical properties are found in these two types of clouds among the nine cloud retrieval products, particularly for the cloud liquid and ice particle effective radius. Note that the differences among some retrieval products are even larger than the prescribed uncertainties reported by the retrieval algorithm developers. It is shown that most of these large differences have their roots in the retrieval theoretical bases, assumptions, as well as input and constraint parameters. This study suggests the need to further validate current retrieval theories and assumptions and even the development of new retrieval algorithms with more observations under different cloud regimes.