A Cluster Randomized Controlled Trial of an Adapted U.S. Model of Pharmaceutical Care for Nursing Home Residents in Northern Ireland (Fleetwood Northern Ireland Study): A Cost-Effectiveness Analysis

OBJECTIVES: To evaluate the cost-effectiveness of an adapted U.S. model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in Northern Ireland (Fleetwood NI Study).
DESIGN: Economic evaluation alongside a cluster randomized controlled trial.
SETTING: Nursing homes in NI randomized to intervention (receipt of the adapted model of care; n511) or control (usual care continued; n511).
PARTICIPANTS: Residents aged 65 and older who provided informed consent (N5253; 128 intervention, 125 control) and who had full resource use data at 12 months.
INTERVENTION: Trained pharmacists reviewed intervention home residents’ clinical and prescribing information for 12 months, applied an algorithm that guided them in assessing the appropriateness of psychoactive medication, and worked with prescribers (general practitioners) to make changes. The control homes received usual care in which there was no pharmacist intervention.
MEASUREMENTS: The proportion of residents prescribed one or more inappropriate psychoactive medications (according to standardized protocols), costs, and a cost-effectiveness acceptability curve. The latter two outcomes are the focus for this article.
RESULTS: The proportions of residents receiving inappropriate psychoactive medication at 12 months in the intervention and control group were 19.5% and 50.4%, respectively. The mean cost of healthcare resources used per resident per year was $4,923 (95% con?dence interval.

The development of University Technology Transfer stakeholder relationships at a regional level: Lessons for the future

The increasing importance placed upon regional development and the knowledge-based economy as economic growth stimuli has led to a changing role for Universities and their interaction with the business community through (though not limited to) the transfer of technology from academia to industry. With the emergence of Local Enterprise Partnerships (LEPs) replacing the Regional Development Agencies (RDAs), there is a need for policy and practice going forward to be clearly informed by a critique of TTO (Technology Transfer Office)–RDA stakeholder relationship in a lessons learned approach so that LEPs can benefit from a faster learning curve. Thus, the aim of this paper is to examine the stakeholder relationship between three regional universities in the context of its TTO and the RDA with a view to determining lessons learned for the emerging LEP approach. Although the issues raised are contextual, the abstracted stakeholder conceptualisation of the TTO–RDA relationship should enable wider generalisation of the issues raised beyond the UK. Stakeholder theory relationship and stage development models are used to guide a repeat interview study of the TTO and RDA stakeholder groupings. The findings, interpreted using combined category and stage based stakeholder models, show how the longitudinal development of the TTO–RDA stakeholder relationship for each case has progressed through different stakeholder pathways, and stages where specific targeting of funding was dependant on the stakeholder stage. Greater targeted policy and funding, based on the stakeholder relationship approach, led to the development of joint mechanisms and a closer alignment of performance measures between the TTO and the RDA. However, over-reliance on the unitary nature of the TTO–RDA relationship may lead to a lack of cultivation and dependency for funding from other stakeholders.

Working across boundaries to improve health outcomes: a case study of a housing support and outreach service for homeless people living with HIV

This paper reports the findings of an evaluation of the ‘Housing Support, Outreach and Referral’ service developed to support people living with HIV who were homeless or at risk of homelessness. The service was set up as part of the Supporting People Health Pilot programme established to demonstrate the policy links between housing support services and health and social care services by encouraging the development of integrated services. The paper considers the role of housing support in improving people's health, and considers the challenges of working across housing, health and social care boundaries. The evaluation of the health pilot employed two main sources of data collection: quarterly project evaluation reports, which collected process data as well as reporting progress against aims and objectives, and semi-structured interviews with professionals from all key stakeholder groups and agencies, and with people who used services. Over the course of 15 months, 56 referrals were received of which 27 were accepted. Fifteen people received tenancy support of whom 12 were helped to access temporary accommodation. At the end of the 15 months, all of the tenancies had been maintained. In addition, 18 people registered with a general practitioner and 13 registered with an HIV clinic. Interviews with professionals emphasised the importance of the local joint working context, the involvement of the voluntary sector and the role of the support workers as factors that accounted for these outcomes. Those using services placed most emphasis on the flexibility of the support worker role. Importantly, interviews with professionals and those using services suggest that the role of support worker incorporates two dimensions – those of networker/navigator as well as advocate – and that both dimensions are important in determining the effectiveness of the service.

Brain activity during ankle proprioceptive stimulation predicts balance performance in young and older adults

Proprioceptive information from the foot/ankle provides important information regarding body sway for balance control, especially in situations where visual information is degraded or absent. Given known increases in catastrophic injury due to falls with older age, understanding the neural basis of proprioceptive processing for balance control is particularly important for older adults. In the present study, we linked neural activity in response to stimulation of key foot proprioceptors (i.e., muscle spindles) with balance ability across the lifespan. Twenty young and 20 older human adults underwent proprioceptive mapping; foot tendon vibration was compared with vibration of a nearby bone in an fMRI environment to determine regions of the brain that were active in response to muscle spindle stimulation. Several body sway metrics were also calculated for the same participants on an eyes-closed balance task. Based on regression analyses, multiple clusters of voxels were identified showing a significant relationship between muscle spindle stimulation-induced neural activity and maximum center of pressure excursion in the anterior-posterior direction. In this case, increased activation was associated with greater balance performance in parietal, frontal, and insular cortical areas, as well as structures within the basal ganglia. These correlated regions were age- and foot-stimulation side-independent and largely localized to right-sided areas of the brain thought to be involved in monitoring stimulus-driven shifts of attention. These findings support the notion that, beyond fundamental peripheral reflex mechanisms, central processing of proprioceptive signals from the foot is critical for balance control.

Evidence and Spatial Planning for Sustainable Development: A Model for Spatially Allocating Material Flows

The aspiration the spatial planning should act as the main coordinating function for the transition to a sustainable society is grounded on the assumption that it is capable of incorporating both a strong evidence base of environmental accounting for policy, coupled with opportunities for open, deliberative decision-making. While there are a number of increasingly sophisticated methods (such as material flow analysis and ecological footprinting) that can be used to longitudinally determine the impact of policy, there are fewer that can provide a robust spatial assessment of sustainability policy. In this paper, we introduce the Spatial Allocation of Material Flow Analysis (SAMFA) model, which uses the concept of socio-economic metabolism to extrapolate the impact of local consumption patterns that may occur as a result of the local spatial planning process at multiple spatial levels. The initial application the SAMFA model is based on County Kildare in the Republic of Ireland, through spatial temporal simulation and visualisation of construction material flows and associated energy use in the housing sector. Thus, while we focus on an Ireland case study, the model is applicable to spatial planning and sustainability research more generally. Through the development and evaluation of alternative scenarios, the model appears to be successful in its prediction of the cumulative resource and energy impacts arising from consumption and development patterns. This leads to some important insights in relation to the differential spatial distribution of disaggregated allocation of material balance and energy use, for example that rural areas have greater resource accumulation (and are therefore in a sense “less sustainable”) than urban areas, confirming that rural housing in Ireland is both more material and energy intensive. This therefore has the potential to identify hotspots of higher material and energy use, which can be addressed through targeted planning initiatives or focussed community engagement. Furthermore, due to the ability of the model to allow manipulation of different policy criteria (increased density, urban conservation etc), it can also act as an effective basis for multi-stakeholder engagement.

Physical activity and the rejuvenation of Connswater (PARC study): protocol for a natural experiment investigating the impact of urban regeneration on public health

Background: There is a dearth of evidence regarding the impact of urban regeneration projects on public health, particularly the nature and degree to which urban regeneration impacts upon health-related behaviour change. Natural experiment methodology enables comprehensive large-scale evaluations of such interventions. The Connswater Community Greenway in Belfast is a major urban regeneration project involving the development of a 9 km linear park, including the provision of new cycle paths and walkways. In addition to the environmental improvements, this complex intervention involves a number of programmes to promote physical activity in the regenerated area. The project affords a unique opportunity to investigate the public health impact of urban regeneration.

Methods/Design: The evaluation framework was informed by the socio-ecological model and guided by the RE-AIM Framework. Key components include: (1) a quasi-experimental before-and-after survey of the Greenway population (repeated cross-sectional design), in tandem with data from a parallel Northern Ireland-wide survey for comparison; (2) an assessment of changes in the local built environment and of walkability using geographic information systems; (3) semi-structured interviews with a purposive sample of survey respondents, and a range of community stakeholders, before and after the regeneration project; and (4) a cost-effectiveness analysis. The primary outcome is change in proportion of individuals identified as being regularly physically active, according to the current UK recommendations. The RE-AIM Framework will be used to make an overall assessment of the impact of the Greenway on the physical activity behaviour of local residents.

Discussion: The Connswater Community Greenway provides a significant opportunity to achieve long-term, population level behaviour change. We argue that urban regeneration may be conceptualised meaningfully as a complex intervention comprising multiple components with the potential, individually and interactively, to affect the behaviour of a diverse population. The development and implementation of our comprehensive evaluation framework reflects this complexity and illuminates an approach to the empirical, rigorous evaluation of urban regeneration. More specifically, this study will add to the much needed evidence-base about the impact of urban regeneration on public health as well as having important implications for the development of natural experiment methodology.

Adaptive Measurement-Based Policy-Driven QoS Management with Fuzzy-Rule-based Resource Allocation

Fixed and wireless networks are increasingly converging towards common connectivity with IP-based core networks. Providing effective end-to-end resource and QoS management in such complex heterogeneous converged network scenarios requires unified, adaptive and scalable solutions to integrate and co-ordinate diverse QoS mechanisms of different access technologies with IP-based QoS. Policy-Based Network Management (PBNM) is one approach that could be employed to address this challenge. Hence, a policy-based framework for end-to-end QoS management in converged networks, CNQF (Converged Networks QoS Management Framework) has been proposed within our project. In this paper, the CNQF architecture, a Java implementation of its prototype and experimental validation of key elements are discussed. We then present a fuzzy-based CNQF resource management approach and study the performance of our implementation with real traffic flows on an experimental testbed. The results demonstrate the efficacy of our resource-adaptive approach for practical PBNM systems

Extremely Complex Populations of Small RNAs in the Mouse Retina and RPE/Choroid

Purpose: MicroRNAs (miRNAs) are small non-coding RNAs of ~18-22 nucleotides in length that regulate gene expression. They are widely expressed in the retina, being both required for its normal development and perturbed in disease. The aim of this study was to apply new high-throughput sequencing techniques to more fully characterise the microRNAs and other small RNAs expressed in the retina and retinal pigment epithelium (RPE)/choroid of the mouse.

Methods: Retina and RPE/choroid were dissected from eyes of 3 month-old C57BL/6J mice. Small RNA libraries were prepared and deep sequencing performed on a Genome Analyzer (Illumina). Reads were annotated by alignment to miRBase, other non-coding RNA databases and the mouse genome.

Results: Annotation of 9 million reads to 320 microRNAs in retina and 340 in RPE/choroid provides the most comprehensive profiling of microRNAs to date. Two novel microRNAs were identified in retina. Members of the sensory organ specific miR-183,-182,-96 cluster were amongst the most highly expressed, retina-enriched microRNAs. Remarkably, microRNA 'isomiRs', which vary slightly in length and are differentially detected by Taqman RT-PCR assays, existed for all the microRNAs identified in both tissues. More variation occurred at the 3' ends, including non-templated additions of T and A. Drosha-independent mirtron microRNAs and other small RNAs derived from snoRNAs were also detected.

Conclusions: Deep sequencing has revealed the complexity of small RNA expression in the mouse retina and RPE/choroid. This knowledge will improve the design and interpretation of future functional studies of the role of microRNAs and other small RNAs in retinal disease.

Government decisions before and during the First World War and the living standards in Germany during a drastic natural experiment

The First World War hit Germany severely, particularly the agricultural sector, because the outbreak came unexpected and its duration exceeded all expectations. Many resources necessary for agricultural production were required by the war economy and led to shortages and shrinking supplies. Many agricultural laborers were drafted and the blockade imposed by the allies prevented Germany from a great deal of imports. As a consequence, the nutritional situation was devastating, particularly after 1916, and hit all groups of the German society. The period under observation provides one of most drastic natural experiments in the 20th century. This study uses anthropometric data from German soldiers who served in the Second World War to trace living standards between the 1900s and the 1920s. In contrast to other approaches, this paper is able to distinguish between social groups by occupation, religious denominatio\n, regional origin, and city size. The results suggest that although all social strata were hit by famine conditions, the height of farmers, urban citizens, Catholics, and especially individuals born in the highly integrated food-import regions along the coast and the banks of the Rhine declined most.

Healthcare in Ireland and Britain 1850-1970: Voluntary, regional and comparative perspectives

This volume explores developments in health and social care in Ireland and Britain during the nineteenth and twentieth centuries. The central objectives are to highlight the role of voluntarism in healthcare, to examine healthcare in local and regional contexts, and to provide comparative perspectives. The collection is based on two interconnected and overlapping research themes: voluntarism and healthcare, and regionalism/localism and healthcare. It includes two synoptic overviews by leading authorities in the field, and ten case studies focusing on particular aspects of voluntary and/or regional healthcare in Ireland and Britain.

The CACTOS Vision of Context-Aware Cloud Topology Optimization and Simulation

Recent advances in hardware development coupled with the rapid adoption and broad applicability of cloud computing have introduced widespread heterogeneity in data centers, significantly complicating the management of cloud applications and data center resources. This paper presents the CACTOS approach to cloud infrastructure automation and optimization, which addresses heterogeneity through a combination of in-depth analysis of application behavior with insights from commercial cloud providers. The aim of the approach is threefold: to model applications and data center resources, to simulate applications and resources for planning and operation, and to optimize application deployment and resource use in an autonomic manner. The approach is based on case studies from the areas of business analytics, enterprise applications, and scientific computing.

On the antioxidant properties of erythropoietin and its association with the oxidative-nitrosative stress response to hypoxia in humans

Aim: The aim of this study was to examine if erythropoietin (EPO) has the potential to act as a biological antioxidant and determine the underlying mechanisms.

Methods: The rate at which its recombinant form (rHuEPO) reacts with hydroxyl (HO center dot), 2,2-diphenyl-1-picrylhydrazyl (DPPH center dot) and peroxyl (ROO center dot) radicals was evaluated in-vitro. The relationship between the erythopoietic and oxidative-nitrosative stress response to poikilocapneic hypoxia was determined separately in-vivo by sampling arterial blood from eleven males in normoxia and following 12 h exposure to 13% oxygen. Electron paramagnetic resonance spectroscopy, ELISA and ozone-based chemiluminescence were employed for direct detection of ascorbate (A(center dot-)) and N-tert-butyl-a-phenylnitrone spin-trapped alkoxyl (PBN-OR) radicals, 3-nitrotyrosine (3-NT) and nitrite (NO2-).

Results: We found rHuEPO to be a potent scavenger of HO center dot (k(r) = 1.03-1.66 x 10(11) M-1 s(-1)) with the capacity to inhibit Fenton chemistry through catalytic iron chelation. Its ability to scavenge DPPH. and ROO center dot was also superior compared to other more conventional antioxidants. Hypoxia was associated with a rise in arterial EPO and free radical-mediated reduction in nitric oxide, indicative of oxidative-nitrosative stress. The latter was confirmed by an increased systemic formation of A(center dot-), PBN-OR, 3-NT and corresponding loss of NO2- (P <0.05 vs. normoxia). The erythropoietic and oxidative-nitrosative stress responses were consistently related (r =-0.52 to 0.68, P <0.05).

Conclusion: These findings demonstrate that EPO has the capacity to act as a biological antioxidant and provide a mechanistic basis for its reported cytoprotective benefits within the clinical setting.

Regional integration of biogas – developing an intersectoral research action plan for Northern Ireland

Bioenergy is a key component of the European Union long term energy strategy across all sectors, with a target contribution of up to 14% of the energy mix by 2020. It is estimated that there is the potential for 1TWh of primary energy from biogas per million persons in Europe, derived from agricultural by-products and waste. With an agricultural sector that accounts for 75% of land area and a large number of advanced engineering firms, Northern Ireland is a region with considerable potential for an integrated biogas industry. Northern Ireland is also heavily reliant on imported fossil fuels. Despite this, the industry is underdeveloped and there is a need for a collaborative approach from research, business and policy-makers across all sectors to optimise Northern Ireland’s abundant natural resources. ‘Developing Opportunities in Bio-Energy’ (i.e. Do Bioenergy) is a recently completed project that involved both academic and specialist industrial partners. The aim was to develop a biogas research action plan for 2020 to define priorities for intersectoral regional development, co-operation and knowledge transfer in the field of production and use of biogas. Consultations were held with regional stakeholders and working groups were established to compile supporting data, decide key objectives and implementation activities. Within the context of this study it was found that biogas from feedstocks including grass, agricultural slurry, household and industrial waste have the potential to contribute from 2.5% to 11% of Northern Ireland’s total energy consumption. The economics of on-farm production were assessed, along with potential markets and alternative uses for biogas in sectors such as transport, heat and electricity. Arising from this baseline data, a Do Bioenergy was developed. The plan sets out a strategic research agenda, and details priorities and targets for 2020. The challenge for Northern Ireland is how best to utilise the biogas – as electricity, heat or vehicle fuel and in what proportions. The research areas identified were: development of small scale solutions for biogas production and use; solutions for improved nutrient management; knowledge supporting and developing the integration of biogas into the rural economy; and future crops and bio-based products. The human resources and costs for the implementation were estimated as 80 person-years and £25 million respectively. It is also clear that the development of a robust bio-gas sector requires some reform of the regulatory regime, including a planning policy framework and a need to address social acceptance issues. The Action Plan was developed from a regional perspective but the results may be applicable to other regions in Europe and elsewhere. This paper presents the methodology, results and analysis, and discussion and key findings of the Do Bioenergy report for Northern Ireland.

A techno-economic feasibility study of high altitude wind power in Northern Ireland

Globally the amount of installed terrestrial wind power both onshore and offshore has grown rapidly over the last twenty years. Most large onshore and offshore wind turbines are designed to harvest winds within the atmospheric boundary layer, which can be vary variable due to terrain and weather effects. The height of the neutral atmospheric boundary layer is estimated at above 1300m. A relatively new concept is to harvest more consistent wind conditions above the atmospheric boundary layer using high altitude wind harvesting devices such as tethered kites, air foils and dirigible rotors. This paper presents a techno-economic feasibility study of high altitude wind power in Northern Ireland. First this research involved a state of the art review of the resource and the technologies proposed for high altitude wind power. Next the techno-economic analysis involving four steps is presented. In step one, the potential of high altitude wind power in Northern Ireland using online datasets (e.g. Earth System Research Laboratory) is estimated. In step two a map for easier visualisation of geographical limitations (e.g. airports, areas of scenic beauty, flight paths, military training areas, settlements etc.) that could impact on high altitude wind power is developed. In step three the actual feasible resource available is recalculated using the visualisation map to determine the ‘optimal’ high altitude wind power locations in Northern Ireland. In the last step four the list of equipment, resources and budget needed to build a demonstrator is provided in the form of a concise techno-economic appraisal using the findings of the previous three steps.

Ecological differences and coexistence in a guild of microparasites: Bartonella in wild rodents

The study of ecological differences among coexisting microparasites has been largely neglected, but it addresses important and unusual issues because there is no clear distinction in such cases between conventional (resource) and apparent competition. Here patterns in the population dynamics are examined for four species of Bartonella (bacterial parasites) coexisting in two wild rodent hosts, bank voles (Clethrionomys glareolus) and wood mice (Apodemus sylvaticus). Using generalized linear modeling and mixed effects models, we examine, for these four species, seasonal patterns and dependencies on host density (both direct and delayed) and, having accounted for these, any differences in prevalence between the two hosts. Whereas previous studies had failed to uncover species differences, here all four were different. Two, B. doshiae and B. taylorii, were more prevalent in wood mice, and one, B. birtlesii, was more prevalent in bank voles. B. birtlesii, B. grahamii, and B. taylorii peaked in prevalence in the fall, whereas B. doshiae peaked in spring. For B. birtlesii in bank voles, density dependence was direct, but for B. taylorii in wood mice density dependence was delayed. B. birtlesii prevalence in wood mice was related to bank vole density. The implications of these differences for species coexistence are discussed.