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.

Stratosphere‐troposphere coupling and annular mode variability in chemistry‐climate models

The internal variability and coupling between the stratosphere and troposphere in CCMVal‐2 chemistry‐climate models are evaluated through analysis of the annular mode patterns of variability. Computation of the annular modes in long data sets with secular trends requires refinement of the standard definition of the annular mode, and a more robust procedure that allows for slowly varying trends is established and verified. The spatial and temporal structure of the models’ annular modes is then compared with that of reanalyses. As a whole, the models capture the key features of observed intraseasonal variability, including the sharp vertical gradients in structure between stratosphere and troposphere, the asymmetries in the seasonal cycle between the Northern and Southern hemispheres, and the coupling between the polar stratospheric vortices and tropospheric midlatitude jets. It is also found that the annular mode variability changes little in time throughout simulations of the 21st century. There are, however, both common biases and significant differences in performance in the models. In the troposphere, the annular mode in models is generally too persistent, particularly in the Southern Hemisphere summer, a bias similar to that found in CMIP3 coupled climate models. In the stratosphere, the periods of peak variance and coupling with the troposphere are delayed by about a month in both hemispheres. The relationship between increased variability of the stratosphere and increased persistence in the troposphere suggests that some tropospheric biases may be related to stratospheric biases and that a well‐simulated stratosphere can improve simulation of tropospheric intraseasonal variability.

Nodal variations and long-term changes in the main tides on the coasts of China

The long-term changes in the main tidal constituents (O1, K1, M2, N2, and S2) along the coasts of China and in adjacent seas are investigated based on 17 tide-gauge records covering the period 1954–2012. The observed 18.61 year nodal modulations of the diurnal constituents O1 and K1 are in agreement with the equilibrium tidal theory, except in the South China Sea. The observed modulations of the M2 and N2 amplitudes are smaller than theoretically predicted at the northern stations and larger at the southern stations. The discrepancies between the theoretically predicted nodal variations and the observations are discussed. The 8.85 year perigean cycle is identifiable in the N2 parameters at most stations, except those in the South China Sea. The radiational component of S2 contributes on average 16% of the observed S2 except in the Gulf of Tonkin, on the south coast, where it accounts for up to 65%. We confirmed the existence of nodal modulation in S2, which is stronger on the north coast. The semidiurnal tidal parameters show significant secular trends in the Bohai and Yellow Seas, on the north coast, and in the Taiwan Strait. The largest increase is found for M2 for which the amplitude increases by 4–7 mm/yr in the Yellow Sea. The potential causes for the linear trends in tidal constants are discussed.

Morphometrical, biochemical and molecular tools for assessing biodiversity. An example in Plebeia remota (Holmberg, 1903) (Apidae, Meliponini)

We see today many efforts to quantify biodiversity in different biomes. It is very important then to develop and to apply other methodologies that allow us to assess biodiversity. Here we present an example of application of three tools with this goal. We analyzed two populations of Plebeia remota from two distinct biomes that already showed several differences in morphology and behavior. Based on these differences, it has been suggested that the populations of Cunha and Prudentopolis do not represent a single species. In order to verify the existence or absence of gene flow between these two groups, we characterized the patterns of mtDNA through RFLP, the patterns of wing venation through geometric morphometry, and the cuticular hydrocarbons through gas chromatography-mass spectrometry. We used bees collected in these two locations and also from colonies which have being kept for around 9 years at Sao Paulo University. We found six different haplotypes in these specimens, of which three of them occurred exclusively in the population of Cunha and three only in the Prudentopolis population. The fact that the populations do not share haplotypes suggests no maternal gene flow between them. The two populations were differentiated by the pattern of the wing veins. They also had different mixtures of cuticle hydrocarbons. Furthermore it was shown that the colonies kept at the university did not hybridize. These two groups may constitute different species. We also show here the importance of using other methodologies than traditional taxonomy to assess and understand biodiversity, especially in bees.

Desenvolvimento de dobras e falhas em ambiente distensional: Aplicação da modelagem física

The geological modeling allows, at laboratory scaling, the simulation of the geometric and kinematic evolution of geological structures. The importance of the knowledge of these structures grows when we consider their role in the creation of traps or conduits to oil and water. In the present work we simulated the formation of folds and faults in extensional environment, through physical and numerical modeling, using a sandbox apparatus and MOVE2010 software. The physical modeling of structures developed in the hangingwall of a listric fault, showed the formation of active and inactive axial zones. In consonance with the literature, we verified the formation of a rollover between these two axial zones. The crestal collapse of the anticline formed grabens, limited by secondary faults, perpendicular to the extension, with a curvilinear aspect. Adjacent to these faults we registered the formation of transversal folds, parallel to the extension, characterized by a syncline in the fault hangingwall. We also observed drag folds near the faults surfaces, these faults are parallel to the fault surface and presented an anticline in the footwall and a syncline hangingwall. To observe the influence of geometrical variations (dip and width) in the flat of a flat-ramp fault, we made two experimental series, being the first with the flat varying in dip and width and the second maintaining the flat variation in width but horizontal. These experiments developed secondary faults, perpendicular to the extension, that were grouped in three sets: i) antithetic faults with a curvilinear geometry and synthetic faults, with a more rectilinear geometry, both nucleated in the base of sedimentary pile. The normal antithetic faults can rotate, during the extension, presenting a pseudo-inverse kinematics. ii) Faults nucleated at the top of the sedimentary pile. The propagation of these faults is made through coalescence of segments, originating, sometimes, the formation of relay ramps. iii) Reverse faults, are nucleated in the flat-ramp interface. Comparing the two models we verified that the dip of the flat favors a differentiated nucleation of the faults at the two extremities of the mater fault. V These two flat-ramp models also generated an anticline-syncline pair, drag and transversal folds. The anticline was formed above the flat being sub-parallel to the master fault plane, while the syncline was formed in more distal areas of the fault. Due the geometrical variation of these two folds we can define three structural domains. Using the physical experiments as a template, we also made numerical modeling experiments, with flat-ramp faults presenting variation in the flat. Secondary antithetic, synthetic and reverse faults were generated in both models. The numerical modeling formed two folds, and anticline above the flat and a syncline further away of the master fault. The geometric variation of these two folds allowed the definition of three structural domains parallel to the extension. These data reinforce the physical models. The comparisons between natural data of a flat-ramp fault in the Potiguar basin with the data of physical and numerical simulations, showed that, in both cases, the variation of the geometry of the flat produces, variation in the hangingwall geometry

Variação morfológica de Imantodes cenchoa (Linnaeus, 1758) (Serpentes, Dipsadidae) na América do Sul, com a descrição de duas novas espécies

Imantodes compreende um grupo de serpentes primariamente arborícolas, com ampla distribuição Neotropical, agrupando sete espécies atualmente reconhecidas com grande variação cromática, sendo I. cenchoa a que apresenta a maior distribuição (sul do México ao norte da Argentina). A necessidade de estudos abordando a variação morfológica de I. cenchoa na América do Sul foi apontada por alguns autores, que sugeriram a provável existência de mais de um táxon distinguível. Estudos com base em dados moleculares apresentaram resultados divergentes quanto à diversidade genética de I. cenchoa. Assumindo que a diferenciação genética pode refletir a variação morfológica, a proposição de barreiras impedindo o fluxo gênico de I. cenchoa pode ser testada mediante um estudo criterioso de variação morfológica das populações sul-americanas, abordando e verificando os padrões populacionais e a estruturação destes padrões. Para isto, este trabalho foi organizado em três seções: Introdução Geral, capítulos 1 e 2. Na Introdução Geral apresentamos informação sobre polimorfismo cromático em Imantodini e um breve histórico taxonômico de Imantodes cenchoa. No capítulo 1 abordamos a variação morfológica externa e interna das populações de I. cenchoa (folidose, morfometria linear e geométrica, coloração e padrão de manchas e hemipênis), dentro e entre as diferentes fitofisionomias do Brasil, comparando-a às demais populações da América do Sul, e descrevemos uma nova espécie para a Mata Atlântica. No capítulo 2, a partir da análise comparativa do material de Imantodes da América do Sul cis e trans-Andina, descrevemos uma nova espécie de Imantodes para a Cordilheira Oriental da Colômbia.

Ecomorfologia de três espécies de Dipsas Laurenti, 1768 e Sibynomorphus Fitzinger, 1843 (Dipsadidae: Dipsadinae)

Fatores ecológicos como a utilização do ambiente e a alimentação, podem influenciar na morfologia corporal e cefálica de um organismo, porém, esta também pode ser o reflexo da linhagem filogenética a que ele pertence. A subfamília Dipsadinae inclui serpentes sul-americanas formadas por dois clados, um incluindo Geophis e Atractus e outro incluindo Dipsas, Ninia, Sibon e Sibynomorphus, que formam a tribo Dipsadini. As serpentes desta tribo apresentam um alto grau de modificações na morfologia corporal e cefálica relacionadas ao ambiente e a alimentação malacófaga. As espécies de Dipsas e Sibon possuem especializações relacionadas à utilização do ambiente arborícola, conferindo um melhor desempenho na locomoção pela vegetação, enquanto que as espécies de Sibynomorphus, em sua grande maioria, são adaptadas ao ambiente terrestre. Quanto à alimentação todas elas apresentam, em diferentes graus, uma série de modificações cranianas relacionadas à manipulação e ingestão de gastrópodes, lesmas e caramujos. Considerando que existe uma relação direta entre a forma da cabeça e a dieta, este trabalho tem como objetivo analisar as divergências da morfologia cefálica relacionadas à dieta entre espécies de Dipsas e Sibynomorphus, assim como analisar possíveis convergências entre espécies destes gêneros e Tomodon dorsatus, espécie da tribo Tachymenini, reconhecidamente especialista em lesmas. Para isto este trabalho está estruturado em duas partes: a primeira refere-se à Introdução geral, onde é apresentada uma ampla abordagem sobre as adaptações morfológicas relacionadas à alimentação dos Dipsadini, assim como as vantagens da utilização da técnica de morfometria geométrica em estudos morfológicos; e a segunda parte refere-se ao trabalho propriamente dito, intitulado “Ecomorfologia de três espécies de Dipsas Laurenti, 1768 e Sibynomorphus Fitzinger, 1843 (Dipsadidae: Dipsadinae)”.

Efeitos dentoesqueléticos do tratamento da classe II utilizando o aparelho de Herbst associados à mecânica Straight-wire

This study compared the effect of the treatment protocol for correcting Class Il malocclusion using the Herbst appliance followed by full fixed Straigh-wire mechanics, in two populations, one Brazilian and one of North American origin As a untreated control sample the data from the University of Michigan Elementary and Secondary School Growth Study (UMGS) was used. Our sample was composed of 12 males and 12 females, with initial mean age of 12 years 7 months and final mean ages of 15 years and 3 months. The Michigan patients comprised 21 females and 7 males, with an initial mean age of 11 years and 9 months and final mean age of 14 years and 4 months. The control sample was paired in number, sex and age to the treated Michigan sample. ln both treated groups, lateral cephalometric radiographs were obtained before the Herbst appliance was cemented and at the end of the fixed appliance phase, The first comparison involved the Brazil group and the untreated controls, which demonstrated that the association of the Herbst appliance followed by fixed Straight-wire appliances provoked positive effects on the dentofacial complex, improving pre-existing maxillo-mandibular relationships, besides increasing dentoalveolar compensations which contributed to correct the malocclusion. The second comparison, involved the Brazl1ian and North-American patients treated with the same protocol. Although the pre-treatment comparison showed that the two groups were not similar in all aspects, they presented almost identical therapeutic modifications, which indicate that the effect of' treatment was very similar. These results point out that, in Class ll treatment, the combination of Herbst/Straight-wire mechanics produce consistent and systematic effects, correcting or minimizing possible skeletal imbalances

Mudanças dento-esquelétics naturais e decorrentes do tratamento ortopédico da má oclusão de Classe II

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Avaliação das alterações dentárias e esqueléticas induzidas pelo uso do aparelho de Herbst no tratamento da classe II na dentadura mista: Revisão sistemática

Objective: evaluate the immediate dental and skeletal changes induced by the Herbst appliance on early treatment of Angle´s Class II malocclusion. Material and Method: several electronic databases such as Scopus, Pub Med, Medline, Cochrane Library, Lilacs and Scielo were searched. The abstracts that fullfilled the selection criteria were selected and those that did not provide enough information about these criteria were selected but the final decision of including them or not on the research, was taken after the complete reading of the article. The selection criteria were: clinical studies with Class II individuals, both male and female, with initial age of 7 to 10 years, treated with the Herbst appliance that analysed the dental and/or skeletal changes evaluated on lateral cephalometric radiographs; researches where the treatment performed did not involve extractions or surgical interventions; studies that included patients without syndromes or health concerns and articles published in English or Portuguese. Results and Conclusions: five articles were selected. The articles showed that significant changes happened in the mandibular sagittal lenght, on facial convexity angle, on maxillo-mandibular relationship, on retroclination of the upper incisors and on distal movement of the upper molars, on proclination of the lower incisors and on extrusion of the lower molars. The appliance exerted a limited effect on the anterior relocation of the maxillary complex and on facial heights. However, more studies about the performance of the Herbst appliance on early treatment of Class II are needed.

Candida spp. isolated from inpatients, the environment, and health practitioners in the Pediatric Unit at the Universitary Hospital of the Jundiai Medical College, State of Sao Paulo, Brazil

Introduction: This study aimed to isolate and identify Candida spp. from the environment, health practitioners, and patients with the presumptive diagnosis of candidiasis in the Pediatric Unit at the Universitary Hospital of the Jundiai Medical College, to verify the production of enzymes regarded as virulence factors, and to determine how susceptible the isolated samples from patients with candidiasis are to antifungal agents. Methods: Between March and November of 2008 a total of 283 samples were taken randomly from the environment and from the hands of health staff, and samples of all the suspected cases of Candida spp. hospital-acquired infection were collected and selected by the Infection Control Committee. The material was processed and the yeast genus Candida was isolated and identified by physiological, microscopic, and macroscopic attributes. Results: The incidence of Candida spp. in the environment and employees was 19.2%. The most frequent species were C. parapsilosis and C. tropicalis among the workers, C. guilliermondii and C. tropicalis in the air, C. lusitanae on the contact surfaces, and C. tropicalis and C. guilliermondii in the climate control equipment. The college hospital had 320 admissions, of which 13 (4%) presented Candida spp. infections; three of them died, two being victims of a C. tropicalis infection and the remaining one of C. albicans. All the Candida spp. in the isolates evidenced sensitivity to amphotericin B, nystatin, and fluconazole. Conclusions: The increase in the rate of hospital-acquired infections caused by Candida spp. indicates the need to take larger measures regarding recurrent control of the environment.

Genetic and morphological variation and differentiation of Raja clavata populations in the European seas: marker development and preliminary data

In this study the population structure and connectivity of the Mediterranean and Atlantic Raja clavata (L., 1758) were investigated by analyzing the genetic variation of six population samples (N = 144) at seven nuclear microsatellite loci. The genetic dataset was generated by selecting population samples available in the tissue databases of the GenoDREAM laboratory (University of Bologna) and of the Department of Life Sciences and Environment (University of Cagliari), all collected during past scientific surveys (MEDITS, GRUND) from different geographical locations in the Mediterranean basin and North-east Atlantic sea, as North Sea, Sardinian coasts, Tuscany coasts and Cyprus Island. This thesis deals with to estimate the genetic diversity and differentiation among 6 geographical samples, in particular, to assess the presence of any barrier (geographic, hydrogeological or biological) to gene flow evaluating both the genetic diversity (nucleotide diversity, observed and expected heterozygosity, Hardy- Weinberg equilibrium analysis) and population differentiation (Fst estimates, population structure analysis). In addition to molecular analysis, quantitative representation and statistical analysis of morphological individuals shape are performed using geometric morphometrics methods and statistical tests. Geometric coordinates call landmarks are fixed in 158 individuals belonging to two population samples of Raja clavata and in population samples of closely related species, Raja straeleni (cryptic sibling) and Raja asterias, to assess significant morphological differences at multiple taxonomic levels. The results obtained from the analysis of the microsatellite dataset suggested a geographic and genetic separation between populations from Central-Western and Eastern Mediterranean basins. Furthermore, the analysis also showed that there was no separation between geographic samples from North Atlantic Ocean and central-Western Mediterranean, grouping them to a panmictic population. The Landmark-based geometric morphometry method results showed significant differences of body shape able to discriminate taxa at tested levels (from species to populations).

Change in physical activity after smoking cessation: the Coronary Artery Risk Development in Young Adults (CARDIA) study

AIMS To estimate physical activity trajectories for people who quit smoking, and compare them to what would have been expected had smoking continued. DESIGN, SETTING AND PARTICIPANTS A total of 5115 participants in the Coronary Artery Risk Development in Young Adults Study (CARDIA) study, a population-based study of African American and European American people recruited at age 18-30 years in 1985/6 and followed over 25 years. MEASUREMENTS Physical activity was self-reported during clinical examinations at baseline (1985/6) and at years 2, 5, 7, 10, 15, 20 and 25 (2010/11); smoking status was reported each year (at examinations or by telephone, and imputed where missing). We used mixed linear models to estimate trajectories of physical activity under varying smoking conditions, with adjustment for participant characteristics and secular trends. FINDINGS We found significant interactions by race/sex (P = 0.02 for the interaction with cumulative years of smoking), hence we investigated the subgroups separately. Increasing years of smoking were associated with a decline in physical activity in black and white women and black men [e.g. coefficient for 10 years of smoking: -0.14; 95% confidence interval (CI) = -0.20 to -0.07, P < 0.001 for white women]. An increase in physical activity was associated with years since smoking cessation in white men (coefficient 0.06; 95% CI = 0 to 0.13, P = 0.05). The physical activity trajectory for people who quit diverged progressively towards higher physical activity from the expected trajectory had smoking continued. For example, physical activity was 34% higher (95% CI = 18 to 52%; P < 0.001) for white women 10 years after stopping compared with continuing smoking for those 10 years (P = 0.21 for race/sex differences). CONCLUSIONS Smokers who quit have progressively higher levels of physical activity in the years after quitting compared with continuing smokers.

Time variable Earth’s gravity field from SLR satellites

The time variable Earth’s gravity field contains information about the mass transport within the system Earth, i.e., the relationship between mass variations in the atmosphere, oceans, land hydrology, and ice sheets. For many years, satellite laser ranging (SLR) observations to geodetic satellites have provided valuable information of the low-degree coefficients of the Earth’s gravity field. Today, the Gravity Recovery and Climate Experiment (GRACE) mission is the major source of information for the time variable field of a high spatial resolution. We recover the low-degree coefficients of the time variable Earth’s gravity field using SLR observations up to nine geodetic satellites: LAGEOS-1, LAGEOS-2, Starlette, Stella, AJISAI, LARES, Larets, BLITS, and Beacon-C. We estimate monthly gravity field coefficients up to degree and order 10/10 for the time span 2003–2013 and we compare the results with the GRACE-derived gravity field coefficients. We show that not only degree-2 gravity field coefficients can be well determined from SLR, but also other coefficients up to degree 10 using the combination of short 1-day arcs for low orbiting satellites and 10-day arcs for LAGEOS-1/2. In this way, LAGEOS-1/2 allow recovering zonal terms, which are associated with long-term satellite orbit perturbations, whereas the tesseral and sectorial terms benefit most from low orbiting satellites, whose orbit modeling deficiencies are minimized due to short 1-day arcs. The amplitudes of the annual signal in the low-degree gravity field coefficients derived from SLR agree with GRACE K-band results at a level of 77 %. This implies that SLR has a great potential to fill the gap between the current GRACE and the future GRACE Follow-On mission for recovering of the seasonal variations and secular trends of the longest wavelengths in gravity field, which are associated with the large-scale mass transport in the system Earth.

One-stage (Warsaw) and two-stage (Oslo) repair of unilateral cleft lip and palate: Craniofacial outcomes

The aim of this study was to compare facial development in subjects with complete unilateral cleft lip and palate (CUCLP) treated with two different surgical protocols. Lateral cephalometric radiographs of 61 patients (42 boys, 19 girls; mean age, 10.9 years; SD, 1) treated consecutively in Warsaw with one-stage repair and 61 age-matched and sex-matched patients treated in Oslo with two-stage surgery were selected to evaluate craniofacial morphology. On each radiograph 13 angular and two ratio variables were measured in order to describe hard and soft tissues of the facial region. The analysis showed that differences between the groups were limited to hard tissues – the maxillary prominence in subjects from the Warsaw group was decreased by almost 4° in comparison with the Oslo group (sella-nasion-A-point (SNA) = 75.3° and 79.1°, respectively) and maxillo-mandibular morphology was less favorable in the Warsaw group than the Oslo group (ANB angle = 0.8° and 2.8°, respectively). The soft tissue contour was comparable in both groups. In conclusion, inter-group differences suggest a more favorable outcome in the Oslo group. However, the distinctiveness of facial morphology in background populations (ie, in Poles and Norwegians) could have contributed to the observed results.