Description of a multifaceted strategy for recruiting general practitioners and community pharmacists to talk about medication errors

Objective: To describe the use of a multifaceted strategy for recruiting general practitioners (GPs) and community pharmacists to talk about medication errors which have resulted in preventable drug-related admissions to hospital. This is a potentially sensitive subject with medicolegal implications. Setting: Four primary care trusts and one teaching hospital in the UK. Method: Letters were mailed to community pharmacists and general practitioners asking for provisional consent to be interviewed and permission to contact them again should a patient be admitted to hospital as a result of a medication error. In addition, GPs were asked for permission to approach their patients should they be admitted to hospital. A multifaceted approach to recruitment was used including gaining support for the study from professional defence agencies and local champions. Key findings: Eighty-five percent (310/385) of GPs and 62% (93/149) of community pharmacists responded to the letters. Eighty-five percent (266/310) of GPs who responded and 81% (75/93) of community pharmacists who responded gave provisional consent to participate in interviews. All GPs (14 out of 14) and community pharmacists (10 out of 10) who were subsequently asked to participate, when patients were admitted to hospital, agreed to be interviewed. Conclusion: The multifaceted approach to recruitment was associated with an impressive response when asking healthcare professionals to be interviewed about medication errors which have resulted in preventable drug-related morbidity.

Protocol for the PINCER trial: a cluster randomised trial comparing the 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 are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods: Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

Perceptions of psychological content in the GP consultation - the role of practice, personal and prescribing attributes

Objective: The aim of the present study was to determine the relationship between the characteristics of general practices and the perceptions of the psychological content of consultations by GPs in those practices. Methods: A cross-sectional survey was conducted of all GPs (22 GPs based in nine practices) serving a discrete inner city community of 41 000 residents. GPs were asked to complete a log-diary over a period of five working days, rating their perception of the psychological content of each consultation on a 4-point Likert scale, ranging from 0 (no psychological content) to 3 (entirely psychological in content). The influence of GP and practice characteristics on psychological content scores was examined. Results: Data were available for every surgery-based consultation (n = 2206) conducted by all 22 participating GPs over the study period. The mean psychological content score was 0.58 (SD 0.33). Sixty-four percent of consultations were recorded as being without any psychological content; 6% were entirely psychological in content. Higher psychological content scores were significantly associated with younger GPs, training practices (n = 3), group practices (n = 4), the presence of on-site mental health workers (n = 5), higher antidepressant prescribing volumes and the achievement of vaccine and smear targets. Training status had the greatest predictive power, explaining 51% of the variation in psychological content. Neither practice consultation rates, GP list size, annual psychiatric referral rates nor volumes of benzodiazepine prescribing were related to psychological content scores. Conclusion: Increased awareness by GPs of the psychological dimension within a consultation may be a feature of the educational environment of training practices.

Traditional Chinese medicine research in the post-genomic era: good practice, priorities, challenges and opportunities

Background and aims: GP-TCM is the 1st EU-funded Coordination Action consortium dedicated to traditional Chinese medicine (TCM) research. This paper aims to summarise the objectives, structure and activities of the consortium and introduces the position of the consortium regarding good practice, priorities, challenges and opportunities in TCM research. Serving as the introductory paper for the GPTCM Journal of Ethnopharmacology special issue, this paper describes the roadmap of this special issue and reports how the main outputs of the ten GP-TCM work packages are integrated, and have led to consortium-wide conclusions. Materials and methods: Literature studies, opinion polls and discussions among consortium members and stakeholders. Results: By January 2012, through 3 years of team building, the GP-TCM consortium had grown into a large collaborative network involving ∼200 scientists from 24 countries and 107 institutions. Consortium members had worked closely to address good practice issues related to various aspects of Chinese herbal medicine (CHM) and acupuncture research, the focus of this Journal of Ethnopharmacology special issue, leading to state-of-the-art reports, guidelines and consensus on the application of omics technologies in TCM research. In addition, through an online survey open to GP-TCM members and non-members, we polled opinions on grand priorities, challenges and opportunities in TCM research. Based on the poll, although consortium members and non-members had diverse opinions on the major challenges in the field, both groups agreed that high-quality efficacy/effectiveness and mechanistic studies are grand priorities and that the TCM legacy in general and its management of chronic diseases in particular represent grand opportunities. Consortium members cast their votes of confidence in omics and systems biology approaches to TCM research and believed that quality and pharmacovigilance of TCM products are not only grand priorities, but also grand challenges. Non-members, however, gave priority to integrative medicine, concerned on the impact of regulation of TCM practitioners and emphasised intersectoral collaborations in funding TCM research, especially clinical trials. Conclusions: The GP-TCM consortium made great efforts to address some fundamental issues in TCM research, including developing guidelines, as well as identifying priorities, challenges and opportunities. These consortium guidelines and consensus will need dissemination, validation and further development through continued interregional, interdisciplinary and intersectoral collaborations. To promote this, a new consortium, known as the GP-TCM Research Association, is being established to succeed the 3-year fixed term FP7 GP-TCM consortium and will be officially launched at the Final GP-TCM Congress in Leiden, the Netherlands, in April 2012.

Performance as social practice

Starting point for these outputs is a large scale research project in collaboration with the Zurich University for the Arts and the Kunstmuseum Thun, looking at a redefinition of Social Sculpture (Joseph Beuys/ Bazon Brock, 1970) as a functional device re-deployed to expand the art discourse into a societal discourse. Although Beuys‘ version of a social sculpture involved notions of abstruse mysticism and reformulations of a national identity these were never-the less part of a social transformation that shifted and re-arranged power relations. Following Laclau and Mouffe in their contention that democray is a fundamentally antagonistic process and contesting Grant Kester’s understanding of a ethically based relational practice, this work is alignes itself with Hirschhorn’s claim to an aesthetic practice within communities, following the possibility to view a socially based practice from both ends of the ethics debate, whereby ethical aspects fuels the aethetic to “create situations that are beautiful because they are ethical and shocking because they are ethical, thus in turn aesthetic because they are ethical” (O’Donnell). This project sets out to engage in activities which interact with surrounding communities and evoce new imaginations of site, thereby understanding site as a catalysts for subjective emergences. Performance is tested as a site for social practice. Archival research into local audio/visual resources, such as the Swiss Radio Archive, the Swiss Military Film Archives and zoological film archives of the Basel Zoo, was instrumental to the navigation of this work, under theme of crisis, catastrophy, landscape, fallout, in order to create a visual language for an active performance site. Commissioned by the Kunstmuseum Thun in collaboration with the University for the Arts in Zurich as part of a year long exhibition programme, (other artists are Jeanne Van Heeswijk (NL) and San Keller (CH), ) this project brings together a series of different works in a new performace installation. The performance process includes a performance workshop with 30 school children from local Swiss schools and their teachers, which was conducted publicly in the museum spaces. It enabled the children to engage with an unexpected set of tribal and animalistic behaviours, looking at situations of flight and rescue, resulting in a large performance choreography orchestration without an apparent conductor, it includes a collaboration with renowned Swiss zoologist, Prof Klaus Zuberbühler(University of St Andrews) and the Colonal General Haldimann commander of the military base in Thun. The installation included 2 static video images, shot in an around spectacular local cave site (Beatus Caves) including 3 children. The project will culminate in an edited edition of the Oncurating Journal, (issue no, tbc, in 2012) including interviews and essays from project collaborators. (Army Commander General, Thun, Jörg Hess, performance script, Timothy Long, and others)

Correlations of long-lived chemical species in a middle atmosphere general circulation model

Correlations between various chemical species simulated by the Canadian Middle Atmosphere Model, a general circulation model with fully interactive chemistry, are considered in order to investigate the general conditions under which compact correlations can be expected to form. At the same time, the analysis serves to validate the model. The results are compared to previous work on this subject, both from theoretical studies and from atmospheric measurements made from space and from aircraft. The results highlight the importance of having a data set with good spatial coverage when working with correlations and provide a background against which the compactness of correlations obtained from atmospheric measurements can be confirmed. It is shown that for long-lived species, distinct correlations are found in the model in the tropics, the extratropics, and the Antarctic winter vortex. Under these conditions, sparse sampling such as arises from occultation instruments is nevertheless suitable to define a chemical correlation within each region even from a single day of measurements, provided a sufficient range of mixing ratio values is sampled. In practice, this means a large vertical extent, though the requirements are less stringent at more poleward latitudes.

Visualizing probabilistic flood forecast information: expert preferences and perceptions of best practice in uncertainty communication

The aim of this article is to improve the communication of the probabilistic flood forecasts generated by hydrological ensemble prediction systems (HEPS) by understanding perceptions of different methods of visualizing probabilistic forecast information. This study focuses on interexpert communication and accounts for differences in visualization requirements based on the information content necessary for individual users. The perceptions of the expert group addressed in this study are important because they are the designers and primary users of existing HEPS. Nevertheless, they have sometimes resisted the release of uncertainty information to the general public because of doubts about whether it can be successfully communicated in ways that would be readily understood to nonexperts. In this article, we explore the strengths and weaknesses of existing HEPS visualization methods and thereby formulate some wider recommendations about the best practice for HEPS visualization and communication. We suggest that specific training on probabilistic forecasting would foster use of probabilistic forecasts with a wider range of applications. The result of a case study exercise showed that there is no overarching agreement between experts on how to display probabilistic forecasts and what they consider the essential information that should accompany plots and diagrams. In this article, we propose a list of minimum properties that, if consistently displayed with probabilistic forecasts, would make the products more easily understandable. Copyright © 2012 John Wiley & Sons, Ltd.

Health care rights and NHS rationing: turning theory into practice

How should we understand the nature of patients’ right in public health care systems? Are health care rights different to rights under a private contract for car insurance? This article distinguishes between public and private rights and the relevance of community interests and notions of social solidarity. It discusses the distinction between political and civil rights, and social and economic rights and the inherently political and redistributive nature of the latter. Nevertheless, social and economic rights certainly give rise to “rights” enforceable by the courts. In the UK (as in many other jurisdictions), the courts have favoured a “procedural” approach to the question, in which the courts closely scrutinise decisions and demand high standards of rationality from decision-makers. However, although this is the general rule, the article also discusses a number of exceptional cases where “substantive” remedies are available which guarantee patients access to the care they need.

Adding a treatment arm to an ongoing clinical trial: a review of methodology and practice

Incorporating an emerging therapy as a new randomisation arm in a clinical trial that is open to recruitment would be desirable to researchers, regulators and patients to ensure that the trial remains current, new treatments are evaluated as quickly as possible, and the time and cost for determining optimal therapies is minimised. It may take many years to run a clinical trial from concept to reporting within a rapidly changing drug development environment; hence, in order for trials to be most useful to inform policy and practice, it is advantageous for them to be able to adapt to emerging therapeutic developments. This paper reports a comprehensive literature review on methodologies for, and practical examples of, amending an ongoing clinical trial by adding a new treatment arm. Relevant methodological literature describing statistical considerations required when making this specific type of amendment is identified, and the key statistical concepts when planning the addition of a new treatment arm are extracted, assessed and summarised. For completeness, this includes an assessment of statistical recommendations within general adaptive design guidance documents. Examples of confirmatory ongoing trials designed within the frequentist framework that have added an arm in practice are reported; and the details of the amendment are reviewed. An assessment is made as to how well the relevant statistical considerations were addressed in practice, and the related implications. The literature review confirmed that there is currently no clear methodological guidance on this topic, but that guidance would be advantageous to help this efficient design amendment to be used more frequently and appropriately in practice. Eight confirmatory trials were identified to have added a treatment arm, suggesting that trials can benefit from this amendment and that it can be practically feasible; however, the trials were not always able to address the key statistical considerations, often leading to uninterpretable or invalid outcomes. If the statistical concepts identified within this review are considered and addressed during the design of a trial amendment, it is possible to effectively assess a new treatment arm within an ongoing trial without compromising the original trial outcomes.

Muscle lesion treatment in Brazilian soccer players: Theory vs. Practice

Background: In this study we evaluated the rehabilitation profile of Brazilian soccer players which underwent lower limb muscle lesions.Methods: This is a descriptive investigation. We evaluated 139 professional soccer players (1724 years old). We evaluated the following variables: muscle lesion diagnosis, symptoms, non steroidal anti-inflammatory used, physiotherapy treatment, which physiotherapy recourses was used if treated and train adaptation.Results: In great part of the athletes muscle lesion remained between 2 weeks and 1 month. Around 54% were diagnosed by a physician; the other part was diagnosed by a physical therapist. Non steroidal anti-inflammatory were prescribed by physicians in 42% of the cases; in 7% the physical therapist prescribed the medication while in 49% of the cases the masseur prescribed the drug. More than 1/4 of the athletes received physiotherapy treatement between 48 hours and 5 days. Isometric exercise therapy was applied in 15% of the cases. 63% were not accompanied by the physiotherapist on their return to the field. 48% received massages immediately after injury.Conclusion: We presented discrepancy between the recommended theory described by several researches and the practice. We indicate the necessity of recycling in a general context the rehabilitation of muscle injuries.

Dental Practice and Musculoskeletal Disorders Association: A Look at the Evidence

Disorders localized to the musculoskeletal system are a common problem among dental personnel. This study has the aim of surveying epidemiological studies reporting positive associations between dental practice and musculoskeletal disorders (MSKDs). The focus was to evaluate the size of reported risk increase and the extent to what alternative causal explanations were considered. Reports with significant links (p value .05) were systematically selected from 2 electronic databases. Twenty-five studies were identified. Risk measures were reported in 8 studies, and all of them presented weak associations. The impact of at least 1 competing explanations was analyzed in 32% of studies, but adjustment was considered not adequate in half of them. The evidence on dentistry as a profession with potential risk for development of MSKDs remains questionable. Further research is needed to more carefully elucidate the risk and the impact of MSKDs in this particular occupational group.

Comprehensive national child protection systems: legal basis and current practice in Latin America and the Caribbean

Includes bibliography.

A survey of the management of patients with temporomandibular disorders by general dental practitioners in southern Brazil

Purpose: Temporomandibular disorders (TMD) are recognized as one of the mostcontroversial topics in dentistry, despite the fact that both basic science and clinicalresearchers have currently reached some degree of consensus. This study aimed toconduct a questionnaire-based survey about the management of TMD patients bygeneral dental practitioners (GDPs).Materials and Methods: One hundred fifty-one GDPs with a private practice in a cityof southern Brazil were included, independent of school of origin, gender, graduationyear, and curriculum content. All participants were administered a questionnaire aboutthe management of patients with TMD, and the responses were analyzed by binomialand chi-square tests (α = 0.05).Results: Of the GDPs, 88.7% received TMD patients, who were primarily diagnosedon the basis of medical history (36.6%) or physical examination (30.4%). Of these,65.4% referred the patients elsewhere, primarily to specialists in occlusion (36.1%) ororthodontics (29.7%). Occlusal splinting was the most commonly used managementmodality (20.8%), followed by occlusal adjustment (18.1%) and pharmacotherapy(16.6%). Splints were fabricated in maximum habitual intercuspation or centric re-lation depending on individual patient (54.8%). The hard stabilization form was themost common type of appliance used (35.0%). Moreover, 73.8% of the GDPs didnot employ semi-adjustable articulators, and 69.5% adjusted the appliances at thetime of fixing. The duration of splint use and the frequency of follow-up were con-sidered patient dependent by 62.1% and 72.8%, respectively. GDPs considered thetwo major TMD etiologic categories as multifactorial (20.8%) and occlusion (19.9%).Multidisciplinary medical and dental treatment was considered necessary by 97.9%.Conclusions: The evaluated general dental practitioners manage TMD patients ac-cording to international guidelines.

Possible underestimation by sports medicine of the effects of early physical exercise practice on the prevention of diseases in adulthood

In modern society, combatting cardiovascular and metabolic diseases has been highlighted as an urgent global challenge. In recent decades, the scientific literature has identified that behavioral variables (e.g. smoking, unhealthy diet and physical inactivity) are related to the development of these outcomes and, therefore, preventive actions should focus on the promotion of physical exercise practice and a healthy diet, as well as combatting the smoking habit from an early age. The promotion of physical exercise in the general population has been suggested as a relevant goal by significant health organizations around the world. On the other hand, recent literature has indicated that physical exercise performed in early life prevents the development of diabetes mellitus, dyslipidemia and arterial hypertension during adulthood, although this protective effect seems to be independent of the physical activity performed during adulthood. Apparently, the interaction between physical exercise and human growth in early life constitutes an issue which is not completely understood by sports medicine. The aim of the present review was therefore to discuss recent evidence on the effects of physical exercise performed during childhood and adolescence on cardiovascular and metabolic outcomes in adulthood.

Noninvasive positive-pressure ventilation in clinical practice at a large university-affiliated Brazilian hospital

OBJECTIVES: To describe noninvasive positive-pressure ventilation use in intensive care unit clinical practice, factors associated with NPPV failure and the associated prognosis. METHODS: A prospective cohort study. RESULTS: Medical disorders (59%) and elective surgery (21%) were the main causes for admission to the intensive care unit. The main indications for the initiation of noninvasive positive-pressure ventilation were the following: post-extubation, acute respiratory failure and use as an adjunctive technique to chest physiotherapy. The noninvasive positive-pressure ventilation failure group was older and had a higher Simplified Acute Physiology Score II score. The noninvasive positive-pressure ventilation failure rate was 35%. The main reasons for intubation were acute respiratory failure (55%) and a decreased level of consciousness (20%). The noninvasive positive-pressure ventilation failure group presented a shorter period of noninvasive positive-pressure ventilation use than the successful group [three (2-5) versus four (3-7) days]; they had lower levels of pH, HCO3 and base excess, and the FiO(2) level was higher. These patients also presented lower PaO2:FiO2 ratios; on the last day of support, the inspiratory positive airway pressure and expiratory positive airway pressure were higher. The failure group also had a longer average duration of stay in the intensive care unit [17 (10-26) days vs. 8 (5-14) days], as well as a higher mortality rate (9 vs. 51%). There was an association between failure and mortality, which had an odds ratio (95% CI) of 10.6 (5.93 - 19.07). The multiple logistic regression analysis using noninvasive positive pressure ventilation failure as a dependent variable found that treatment tended to fail in patients with a Simplified Acute Physiology Score II >= 34, an inspiratory positive airway pressure level >= 15 cmH2O and pH<7.40. CONCLUSION: The indications for noninvasive positive-pressure ventilation were quite varied. The failure group had a longer intensive care unit stay and higher mortality. Simplified Acute Physiology Score II >= 34, pH<7.40 and higher inspiratory positive airway pressure levels were associated with failure.