Perioperative medication management: expanding the role of the preadmission clinic pharmacist in a single centre, randomised controlled trial of collaborative prescribing

Objectives Current evidence to support non-medical prescribing is predominantly qualitative, with little evaluation of accuracy, safety and appropriateness. Our aim was to evaluate a new model of service for the Australia healthcare system, of inpatient medication prescribing by a pharmacist in an elective surgery preadmission clinic (PAC) against usual care, using an endorsed performance framework. Design Single centre, randomised controlled, two-arm trial. Setting Elective surgery PAC in a Brisbane-based tertiary hospital. Participants 400 adults scheduled for elective surgery were randomised to intervention or control. Intervention A pharmacist generated the inpatient medication chart to reflect the patient's regular medication, made a plan for medication perioperatively and prescribed venous thromboembolism (VTE) prophylaxis. In the control arm, the medication chart was generated by the Resident Medical Officers. Outcome measures Primary outcome was frequency of omissions and prescribing errors when compared against the medication history. The clinical significance of omissions was also analysed. Secondary outcome was appropriateness of VTE prophylaxis prescribing. Results There were significantly less unintended omissions of medications: 11 of 887 (1.2%) intervention orders compared with 383 of 1217 (31.5%) control (p<0.001). There were significantly less prescribing errors involving selection of drug, dose or frequency: 2 in 857 (0.2%) intervention orders compared with 51 in 807 (6.3%) control (p<0.001). Orders with at least one component of the prescription missing, incorrect or unclear occurred in 208 of 904 (23%) intervention orders and 445 of 1034 (43%) controls (p<0.001). VTE prophylaxis on admission to the ward was appropriate in 93% of intervention patients and 90% controls (p=0.29). Conclusions Medication charts in the intervention arm contained fewer clinically significant omissions, and prescribing errors, when compared with controls. There was no difference in appropriateness of VTE prophylaxis on admission between the two groups.

Physical activity promotion as a school priority : what do parents think?

The demands and responsibilities placed on schools in contemporary education systems are vast. However, with growing obesity levels and physical inactivity, the prevention of chronic disease has focused on youth populations, with schools playing the focal educative asset in this strategy. Parents play a decisive role in their child’s educational setting, and as fee and tax payers, are ultimately a consumer. Parents (82 males and 208 females) of secondary school children were recruited from three private (n=151) and two government schools (n=150) in Brisbane, Australia. The mean (standard deviation) age was 44.57 (6.21) years. Participants responded to a series of questions about physical activity at their child’s school, in addition to completing the International Physical Activity Questionnaire. Data were analysed using descriptive statistics, frequency distributions and logistic regressions. Parents were deemed sufficiently physically active if they participated in at least 150 minutes of moderate-to-vigorous physical activity per week. Overall, 83 (59.7%) parents from private and 60 (50.8%) parents from government schools were deemed sufficiently physically active. Concerning whether physical activity promotion should be a priority at their child’s school, 111 (73.5%) parents from private schools either agreed or strongly agreed, as opposed to 97 (64.7%) parents from government schools. Logistic regressions indicated that the concept of physical activity promotion being prioritised at schools was dependent on whether the child attended a private school (OR =1.34, z = 2.30, p = 0.02), and whether the participant was sufficiently active (OR =.71, z = -2.48, p = 0.01). Physical activity promotion within schools may provide substantial future benefits on a population scale. The demands on schools may need to be addressed to meet the needs of students and the desires of their parents.

The impact of personal identity and intimacy on the use of social media

Personal identity and intimacy levels change over time and this can influence the way consumers buy and use goods and services. This thesis examined how levels of personal identity and intimacy influence the use of social media by consumers of different ages. A survey of 208 users of facebook demonstrated that consumers with weak levels of personal identity use social media to increase their identity and popularity, while consumers with strong levels of personal identity use social media for self-expression. Consumers with high intimacy levels use social media for socian connection and social investigation.

Longitudinal assessment of neuropathy in diabetes using novel ophthalmic markers (LANDMark) : baseline findings

Purpose Over the past decade, corneal nerve morphology and corneal sensation threshold have been explored as potential surrogate markers for the evaluation of diabetic neuropathy. We present the baseline findings of a Longitudinal Assessment of Neuropathy in Diabetes using novel ophthalmic Markers (LANDMark). Methods The LANDMark Study is a 5-year, two-site, natural history (observational) study of individuals with Type 1 diabetes stratified into those with (T1W) and without (T1WO) neuropathy according to the Toronto criteria, and control subjects. All study participants undergo detailed annual assessment of neuropathy including corneal nerve parameters measured using corneal confocal microscopy and corneal sensitivity measured using non-contact corneal esthesiometry. Results 396 eligible individuals (208 in Brisbane and 188 in Manchester) were assessed: 76 T1W, 166 T1WO and 154 controls. Corneal sensation threshold (mbars) was significantly higher in T1W (1.0 ± 1.1) than T1WO (0.7 ± 0.7) and controls (0.6 ± 0.4) (P=0.002); post-hoc analysis (PHA) revealed no difference between T1WO and controls (Tukey HSD, P=0.502). Corneal nerve fiber length (mm/mm2) (CNFL) was lower in T1W (13.8 ± 6.4) than T1WO (19.1 ± 5.8) and controls (23.2 ± 6.3) (P<0.001); PHA revealed CNFL to be lower in T1W than T1WO, and lower in both of these groups than controls (P<0.001). Corneal nerve branch density (branches/mm2) (CNBD) was significantly lower in T1W (40 ± 32) than T1WO (62 ± 37) and controls (83 ± 46) (P<0.001); PHA showed CNBD was lower in T1W than T1WO, and lower in both groups than controls (P<0.001). Alcohol and cigarette consumption did not differ between groups, although age, BMI, BP, waist circumference, HbA1c, albumin-creatinine ratio, and cholesterol were slightly greater in T1W than T1WO (p<0.05). Some site differences were observed. Conclusions The LANDMark baseline findings confirm that corneal sensitivity and corneal nerve morphometry can detect differences in neuropathy status in individuals with Type 1 diabetes and healthy controls. Corneal nerve morphology is significantly abnormal even in diabetic patients ‘without neuropathy’ compared to control participants. Results of the longitudinal trial will assess the capability of these tests for monitoring change in these parameters over time as potential surrogate markers for neuropathy.

Hydrogel microwell arrays allow the assessment of protease-associated enhancement of cancer cell aggregation and survival

Current routine cell culture techniques are only poorly suited to capture the physiological complexity of tumor microenvironments, wherein tumor cell function is affected by intricate three-dimensional (3D), integrin-dependent cell-cell and cell-extracellular matrix (ECM) interactions. 3D cell cultures allow the investigation of cancer-associated proteases like kallikreins as they degrade ECM proteins and alter integrin signaling, promoting malignant cell behaviors. Here, we employed a hydrogel microwell array platform to probe using a high-throughput mode how ovarian cancer cell aggregates of defined size form and survive in response to the expression of kallikreins and treatment with paclitaxel, by performing microscopic, quantitative image, gene and protein analyses dependent on the varying microwell and aggregate sizes. Paclitaxel treatment increased aggregate formation and survival of kallikrein-expressing cancer cells and levels of integrins and integrin-related factors. Cancer cell aggregate formation was improved with increasing aggregate size, thereby reducing cell death and enhancing integrin expression upon paclitaxel treatment. Therefore, hydrogel microwell arrays are a powerful tool to screen the viability of cancer cell aggregates upon modulation of protease expression, integrin engagement and anti-cancer treatment providing a micro-scaled yet high-throughput technique to assess malignant progression and drug-resistance.

Accessibility of pores in coal to methane and carbon dioxide

Fluid–solid interactions in natural and engineered porous solids underlie a variety of technological processes, including geological storage of anthropogenic greenhouse gases, enhanced coal bed methane recovery, membrane separation, and heterogeneous catalysis. The size, distribution and interconnectivity of pores, the chemical and physical properties of the solid and fluid phases collectively dictate how fluid molecules migrate into and through the micro- and meso-porous media, adsorb and ultimately react with the solid surfaces. Due to the high penetration power and relatively short wavelength of neutrons, smallangle neutron scattering (SANS) as well as ultra small-angle scattering (USANS) techniques are ideally suited for assessing the phase behavior of confined fluids under pressure as well as for evaluating the total porosity in engineered and natural porous systems including coal. Here we demonstrate that SANS and USANS can be also used for determining the fraction of the pore volume that is actually accessible to fluids as a function of pore sizes and study the fraction of inaccessible pores as a function of pore size in three coals from the Illinois Basin (USA) and Bowen Basin (Australia). Experiments were performed at CO2 and methane pressures up to 780 bar, including pressures corresponding to zero average contrast condition (ZAC), which is the pressure where no scattering from the accessible pores occurs. Scattering curves at the ZAC were compared with the scattering from same coals under vacuum and analysed using a newly developed approach that shows that the volume fraction of accessible pores in these coals varies between �90% in the macropore region to �30% in the mesopore region and the variation is distinctive for each of the examined coals. The developed methodology may be also applied for assessing the volume of accessible pores in other natural underground formations of interest for CO2 sequestration, such as saline aquifers as well as for estimating closed porosity in engineered porous solids of technological importance.

Retooling Chinese primary school teachers to use technology creatively to promote innovation and problem solving skills in science classrooms

This paper reports on the initial phase of a Professional Learning Program (PLP) undertaken by 100 primary school teachers in China that aimed to facilitate the development of adaptive expertise in using technology to facilitate innovative science teaching and learning such as that envisaged by the Chinese Ministry of Education’s (2010-2020) education reforms. Key principles derived from literature about professional learning and scaffolding of learning informed the design of the PLP. The analysis of data revealed that the participants had made substantial progress towards the development of adaptive expertise. This was manifested not only by advances in the participants’ repertoires of Subject Matter Knowledge and Pedagogical Content Knowledge but also in changes to their levels of confidence and identities as teachers. By the end of the initial phase of the PLP, the participants had coalesced into a professional learning community that readily engaged in the sharing, peer review, reuse and adaption, and collaborative design of innovative science learning and assessment activities. The findings from the study indicate that those engaged in the development of PLPs for teachers in China need to take cognizance of certain cultural factors and traditions idiosyncratic to the Chinese educational system. A set of revised principles is then presented to inform the future design and implementation of PLPs for teachers in China.

A systematic review and meta-analysis : tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils)

Asthma severity and control can be measured both subjectively and objectively. Traditionally asthma treatments have been individualised using symptoms and spirometry/peak flow. Increasingly treatment tailored in accordance with inflammatory markers (sputum eosinophil counts or fractional exhaled nitric oxide (FeNO) data) is advocated as an alternative strategy. The objective of this review was to evaluate the efficacy of tailoring asthma interventions based on inflammatory markers (sputum analysis and FeNO) in comparison with clinical symptoms (with or without spirometry/peak flow) for asthma-related outcomes in children and adults. Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and reference lists of articles were searched. The last searches were in February 2009. All randomised controlled comparisons of adjustment of asthma treatment based on sputum analysis or FeNO compared with traditional methods (primarily clinical symptoms and spirometry/peak flow) were selected. Results of searches were reviewed against predetermined criteria for inclusion. Relevant studies were selected, assessed and data extracted independently by at least two people. The trial authors were contacted for further information. Data were analysed as 'intervention received' and sensitivity analyses performed. Six (2 adults and 4 children/adolescent) studies utilising FeNO and three adult studies utilising sputum eosinophils were included. These studies had a degree of clinical heterogeneity including definition of asthma exacerbations, duration of study and variations in cut-off levels for percentage of sputum eosinophils and FeNO to alter management in each study. Adults who had treatment adjusted according to sputum eosinophils had a reduced number of exacerbations compared with the control group (52 vs. 77 patients with >=1 exacerbation in the study period; p=0.0006). There was no significant difference in exacerbations between groups for FeNO compared with controls. The daily dose of inhaled corticosteroids at the end of the study was decreased in adults whose treatment was based on FeNO in comparison with the control group (mean difference -450.03 mug, 95% CI -676.73 to -223.34; p<0.0001). However, children who had treatment adjusted according to FeNO had an increase in their mean daily dose of inhaled corticosteroids (mean difference 140.18 mug, 95% CI 28.94 to 251.42; p=0.014). It was concluded that tailoring of asthma treatment based on sputum eosinophils is effective in decreasing asthma exacerbations. However, tailoring of asthma treatment based on FeNO levels has not been shown to be effective in improving asthma outcomes in children and adults. At present, there is insufficient justification to advocate the routine use of either sputum analysis (due to technical expertise required) or FeNO in everyday clinical practice.

The binding of nuclear factors to the as-1 element in the CaMV 35S promoter is affected by cytosine methylation in vitro

Transcriptional gene silencing (TCS) is often associated with an increased level of cytosine methylation in the affected promoters. The effect of methylation of the cauliflower mosaic virus (CaMV) 35S promoter sequence on its binding to factors present in the nuclei was analyzed by electrophoretic mobility shift assays using extracts of petunia flowers. Specific DNA-protein interactions were detected in the region of the CaMV 35S promoter that contains the as-1 element and the region between -345 and -208. The binding of protein factor(s) to the as-1 element was influenced by cytosine methylation, whereas the binding to the region between -345 and -208 was unaffected. The results suggest that cytosine methylation of the as-1 element potentially affects the activity of the CaMV 35S promoter. © Georg Thieme Verlag KG Stuttgart.

Interaction modeling using BPMN

Process choreographies describe interactions between different business partners and the dependencies between these interactions. While different proposals were made for capturing choreographies at an implementation level, it remains unclear how choreographies should be described on a conceptual level.While the Business Process Modeling Notation (BPMN) is already in use for describing choreographies in terms of interconnected interface behavior models, this paper will introduce interaction modeling using BPMN. Such interaction models do not suffer from incompatibility issues and are better suited for human modelers. BPMN extensions are proposed and a mapping from interaction models to interface behavior models is presented.

Conclusion

In his January 2009 report, ‘Implementing the Responsibility to Protect’, UN Secretary General Ban Ki-moon noted that the protection of refugees and the internally displaced were important goals tied to R2P. 1 The Secretary General has suggested that the time has come for the international community to translate R2P from words to deeds. It would seem that the improvement of the protection of displaced persons ought to be a central component of this task. How useful a concept is R2P for advancing the protection of refugees and IDPs? What challenges confront attempts to reconcile R2P and the protection of the displaced? How might these challenges be overcome? These are the kinds of questions that have motivated the contributors to this volume. The volume has brought together some of the leading thinkers and practitioners on refugee, IDP and R2P issues in order to examine the relationship between R2P and the protection of the displaced, and to consider the conceptual and practical challenges that confront the international community if R2P is to add value to efforts to protect displaced persons.

Computational strategies for surface fitting using thin plate spline finite element methods

Thin plate spline finite element methods are used to fit a surface to an irregularly scattered dataset [S. Roberts, M. Hegland, and I. Altas. Approximation of a Thin Plate Spline Smoother using Continuous Piecewise Polynomial Functions. SIAM, 1:208--234, 2003]. The computational bottleneck for this algorithm is the solution of large, ill-conditioned systems of linear equations at each step of a generalised cross validation algorithm. Preconditioning techniques are investigated to accelerate the convergence of the solution of these systems using Krylov subspace methods. The preconditioners under consideration are block diagonal, block triangular and constraint preconditioners [M. Benzi, G. H. Golub, and J. Liesen. Numerical solution of saddle point problems. Acta Numer., 14:1--137, 2005]. The effectiveness of each of these preconditioners is examined on a sample dataset taken from a known surface. From our numerical investigation, constraint preconditioners appear to provide improved convergence for this surface fitting problem compared to block preconditioners.

A comparison of techniques for the reconstruction of leaf surfaces from scanned data

The foliage of a plant performs vital functions. As such, leaf models are required to be developed for modelling the plant architecture from a set of scattered data captured using a scanning device. The leaf model can be used for purely visual purposes or as part of a further model, such as a fluid movement model or biological process. For these reasons, an accurate mathematical representation of the surface and boundary is required. This paper compares three approaches for fitting a continuously differentiable surface through a set of scanned data points from a leaf surface, with a technique already used for reconstructing leaf surfaces. The techniques which will be considered are discrete smoothing D2-splines [R. Arcangeli, M. C. Lopez de Silanes, and J. J. Torrens, Multidimensional Minimising Splines, Springer, 2004.], the thin plate spline finite element smoother [S. Roberts, M. Hegland, and I. Altas, Approximation of a Thin Plate Spline Smoother using Continuous Piecewise Polynomial Functions, SIAM, 1 (2003), pp. 208--234] and the radial basis function Clough-Tocher method [M. Oqielat, I. Turner, and J. Belward, A hybrid Clough-Tocher method for surface fitting with application to leaf data., Appl. Math. Modelling, 33 (2009), pp. 2582-2595]. Numerical results show that discrete smoothing D2-splines produce reconstructed leaf surfaces which better represent the original physical leaf.