Investigating the prevalence and causes of prescribing errors in general practice: the PRACtICe Study

Aim: To determine the prevalence and nature of prescribing errors in general practice; to explore the causes, and to identify defences against error. Methods: 1) Systematic reviews; 2) Retrospective review of unique medication items prescribed over a 12 month period to a 2% sample of patients from 15 general practices in England; 3) Interviews with 34 prescribers regarding 70 potential errors; 15 root cause analyses, and six focus groups involving 46 primary health care team members Results: The study involved examination of 6,048 unique prescription items for 1,777 patients. Prescribing or monitoring errors were detected for one in eight patients, involving around one in 20 of all prescription items. The vast majority of the errors were of mild to moderate severity, with one in 550 items being associated with a severe error. The following factors were associated with increased risk of prescribing or monitoring errors: male gender, age less than 15 years or greater than 64 years, number of unique medication items prescribed, and being prescribed preparations in the following therapeutic areas: cardiovascular, infections, malignant disease and immunosuppression, musculoskeletal, eye, ENT and skin. Prescribing or monitoring errors were not associated with the grade of GP or whether prescriptions were issued as acute or repeat items. A wide range of underlying causes of error were identified relating to the prescriber, patient, the team, the working environment, the task, the computer system and the primary/secondary care interface. Many defences against error were also identified, including strategies employed by individual prescribers and primary care teams, and making best use of health information technology. Conclusion: Prescribing errors in general practices are common, although severe errors are unusual. Many factors increase the risk of error. Strategies for reducing the prevalence of error should focus on GP training, continuing professional development for GPs, clinical governance, effective use of clinical computer systems, and improving safety systems within general practices and at the interface with secondary care.

Potential role of the quasi-biennial oscillation in the stratosphere-troposphere exchange as found in water vapor in general circulation model experiments

The tropical tropopause is considered to be the main region of upward transport of tropospheric air carrying water vapor and other tracers to the tropical stratosphere. The lower tropical stratosphere is also the region where the quasi-biennial oscillation (QBO) in the zonal wind is observed. The QBO is positioned in the region where the upward transport of tropospheric tracers to the overworld takes place. Hence the QBO can in principle modulate these transports by its secondary meridional circulation. This modulation is investigated in this study by an analysis of general circulation model (GCM) experiments with an assimilated QBO. The experiments show, first, that the temperature signal of the QBO modifies the specific humidity in the air transported upward and, second, that the secondary meridional circulation modulates the velocity of the upward transport. Thus during the eastward phase of the QBO the upward moving air is moister and the upward velocity is less than during the westward phase of the QBO. It was further found that the QBO period is too short to allow an equilibration of the moisture in the QBO region. This causes a QBO signal of the moisture which is considerably smaller than what could be obtained in the limiting case of indefinitely long QBO phases. This also allows a high sensitivity of the mean moisture over a QBO cycle to the El Niño-Southern Oscillation (ENSO) phenomena or major tropical volcanic eruptions. The interplay of sporadic volcanic eruptions, ENSO, and QBO can produce low-frequency variability in the water vapor content of the tropical stratosphere, which renders the isolation of the QBO signal in observational data of water vapor in the equatorial lower stratosphere difficult.

Description and process evaluation of pharmacists’ interventions in a pharmacist-led information technology-enabled multicentre cluster randomised controlled trial for reducing medication errors in general practice (PINCER trial)

Objective To undertake a process evaluation of pharmacists' recommendations arising in the context of a complex IT-enabled pharmacist-delivered randomised controlled trial (PINCER trial) to reduce the risk of hazardous medicines management in general practices. Methods PINCER pharmacists manually recorded patients’ demographics, details of interventions recommended, actions undertaken by practice staff and time taken to manage individual cases of hazardous medicines management. Data were coded and double entered into SPSS v15, and then summarised using percentages for categorical data (with 95% CI) and, as appropriate, means (SD) or medians (IQR) for continuous data. Key findings Pharmacists spent a median of 20 minutes (IQR 10, 30) reviewing medical records, recommending interventions and completing actions in each case of hazardous medicines management. Pharmacists judged 72% (95%CI 70, 74) (1463/2026) of cases of hazardous medicines management to be clinically relevant. Pharmacists recommended 2105 interventions in 74% (95%CI 73, 76) (1516/2038) of cases and 1685 actions were taken in 61% (95%CI 59, 63) (1246/2038) of cases; 66% (95%CI 64, 68) (1383/2105) of interventions recommended by pharmacists were completed and 5% (95%CI 4, 6) (104/2105) of recommendations were accepted by general practitioners (GPs), but not completed at the end of the pharmacists’ placement; the remaining recommendations were rejected or considered not relevant by GPs. Conclusions The outcome measures were used to target pharmacist activity in general practice towards patients at risk from hazardous medicines management. Recommendations from trained PINCER pharmacists were found to be broadly acceptable to GPs and led to ameliorative action in the majority of cases. It seems likely that the approach used by the PINCER pharmacists could be employed by other practice pharmacists following appropriate training.

Chaotic synchronization in general network topology for scene segmentation

Chaotic synchronization has been discovered to be an important property of neural activities, which in turn has encouraged many researchers to develop chaotic neural networks for scene and data analysis. In this paper, we study the synchronization role of coupled chaotic oscillators in networks of general topology. Specifically, a rigorous proof is presented to show that a large number of oscillators with arbitrary geometrical connections can be synchronized by providing a sufficiently strong coupling strength. Moreover, the results presented in this paper not only are valid to a wide class of chaotic oscillators, but also cover the parameter mismatch case. Finally, we show how the obtained result can be applied to construct an oscillatory network for scene segmentation.

A criterion for unitary similarity of upper triangular matrices in general position

Each square complex matrix is unitarily similar to an upper triangular matrix with diagonal entries in any prescribed order. Let A = [a(ij)] and B = [b(ij)] be upper triangular n x n matrices that are not similar to direct sums of square matrices of smaller sizes, or are in general position and have the same main diagonal. We prove that A and B are unitarily similar if and only if parallel to h(A(k))parallel to = parallel to h(B(k))parallel to for all h is an element of C vertical bar x vertical bar and k = 1, ..., n, where A(k) := [a(ij)](i.j=1)(k) and B(k) := [b(ij)](i.j=1)(k) are the leading principal k x k submatrices of A and B, and parallel to . parallel to is the Frobenius norm. (C) 2011 Elsevier Inc. All rights reserved.

Computational Aspects of the Calculation of Isometry Groups in General Relativity

We describe the ideas behind the package 'isometry', implemented in Maple to calculate isometry groups of dimensions 2, 3 and 4 in General Relativity. The package extends the functionality of previous programs written to perform invariant classification of space-times in General Relativity. Programming solutions used to surmount problems encountered with the calculation of eigenvectors and the determination of the signs of expressions are described. We also show how the package can be used to find the Killing vectors of a space-time.

Spherically symmetric scalar field in general relativity

We analyze the presence of a scalar field around a spherically symmetric distribution of an ordinary matter, obtaining an exact solution for a given scalar field distribution.

On superfield covariant quantization in general coordinates

We propose a natural extension of the BRST-antiBRST superfield covariant scheme in general coordinates. Thus, the coordinate dependence of the basic tensor fields and scalar density of the formalism is extended from the base supermanifold to the complete set of superfield variables. © Springer-Verlag.

Validity of alcohol screening instruments in general population gender studies: an analytical review

The present study is an analytical review of the methodology used in studies of efficacy of screening instruments to detect harmful use/ alcohol dependence according to the gender in population surveys. Systematic review of bibliography was done, using data from Web of Science, Pubmed and PsycInfo. Population studies were included without date range, in English, Spanish or Portuguese languages, with sample of adults, evaluating psychometric characteristics of any alcohol screening instrument, whereas studies in special population or under treatment as well as prevalence of alcohol consumption were excluded. Thirteen studies were selected to be included in the present review. According to the studies, the instruments that presented a better performance among men were AUDIT and its derivatives (6 studies) and CAGE (2 studies), whereas among women, AUDIT and its derivatives (7 studies), followed by CAGE (3 studies). The increase of consumption and problems related to alcohol use and its implications for public health indicate the need and urgency for adequacy of screening instruments to differences of gender in general population. The population surveys in the area are scarce. Furthermore, the found studies present heterogeneous methodology which makes accurate comparisons difficult.

Constraining H-0 in general dark energy models from Sunyaev-Zeldovich/X-ray technique and complementary probes

In accelerating dark energy models, the estimates of the Hubble constant, Ho, from Sunyaev-Zerdovich effect (SZE) and X-ray surface brightness of galaxy clusters may depend on the matter content (Omega(M)), the curvature (Omega(K)) and the equation of state parameter GO. In this article, by using a sample of 25 angular diameter distances of galaxy clusters described by the elliptical beta model obtained through the SZE/X-ray technique, we constrain Ho in the framework of a general ACDM model (arbitrary curvature) and a flat XCDM model with a constant equation of state parameter omega = p(x)/rho(x). In order to avoid the use of priors in the cosmological parameters, we apply a joint analysis involving the baryon acoustic oscillations (BA()) and the (MB Shift Parameter signature. By taking into account the statistical and systematic errors of the SZE/X-ray technique we obtain for nonflat ACDM model H-0 = 74(-4.0)(+5.0) km s(-1) Mpc(-1) (1 sigma) whereas for a fiat universe with constant equation of state parameter we find H-0 = 72(-4.0)(+5.5) km s(-1) Mpc(-1)(1 sigma). By assuming that galaxy clusters are described by a spherical beta model these results change to H-0 = 6(-7.0)(+8.0) and H-0 = 59(-6.0)(+9.0) km s(-1) Mpc(-1)(1 sigma), respectively. The results from elliptical description are in good agreement with independent studies from the Hubble Space Telescope key project and recent estimates based on the Wilkinson Microwave Anisotropy Probe, thereby suggesting that the combination of these three independent phenomena provides an interesting method to constrain the Bubble constant. As an extra bonus, the adoption of the elliptical description is revealed to be a quite realistic assumption. Finally, by comparing these results with a recent determination for a, flat ACDM model using only the SZE/X-ray technique and BAO, we see that the geometry has a very weak influence on H-0 estimates for this combination of data.

Stellar Models in General Relativity

Neutron stars are some of the most fascinating objects in Nature. Essentially all aspects of physics seems to be represented inside them. Their cores are likely to contain deconfined quarks, hyperons and other exotic phases of matter in which the strong interaction is the dominant force. The inner region of their solid crust is penetrated by superfluid neutrons and their magnetic fields may reach well over 1012 Gauss. Moreover, their extreme mean densities, well above the densities of nuclei, and their rapid rotation rates makes them truly relativistic both in the special as well as in the general sense. This thesis deals with a small subset of these phenomena. In particular the exciting possibility of trapping of gravita-tional waves is examined from a theoretical point of view. It is shown that the standard condition R < 3M is not essential to the trapping mechanism. This point is illustrated using the elegant tool provided by the optical geometry. It is also shown that a realistic equation of state proposed in the literature allows stable neutron star models with closed circular null orbits, something which is closely related to trapped gravitational waves. Furthermore, the general relativistic theory of elasticity is reviewed and applied to stellar models. Both static equilibrium as well as radially oscillating configurations with elasticsources are examined. Finally, Killing tensors are considered and their applicability to modeling of stars is discussed

Comparing expectations and experiences of care for sexually transmitted infections in general practice: a qualitative study

Background A key aim of England's National Strategy for Sexual Health is to extend high-quality sexual health services in primary care. Objectives To explore the expectations and experiences of men and women who initially presented at their general practice with a suspected sexually transmitted infection in order to identify areas where change could improve service delivery. Methods Semi-structured interviews were carried out in six general practices and two genitourinary medicine (GUM) clinics in Brent primary care trust (London) and Bristol (southwest England). Patients within general practice, and GUM patients who had initially attended general practice were eligible to participate. Interview transcripts were analysed using thematic analysis. Results 49 patients (29 women, 20 men) were interviewed. Patients approaching their GP practice typically expected written referral or in-house care, but this expectation was often not met. Absence of formal referral, lack of information and perceived avoidance of sexual health matters by practitioners were commonly cited as reasons for disappointment. However, a dedicated service within general practice met expectations well. Conclusion Purchasers and providers of all general practice services should ensure that any patient consulting in primary care with a suspected sexually transmitted infection can either receive appropriate care there, or a formal and supported referral to a specialised GUM clinic or primary care service.

Testing for sexually transmitted infections in general practice: cross-sectional study

Background Primary care is an important provider of sexual health care in England. We sought to explore the extent of testing for chlamydia and HIV in general practice and its relation to associated measures of sexual health in two contrasting geographical settings. Methods We analysed chlamydia and HIV testing data from 64 general practices and one genitourinary medicine (GUM) clinic in Brent (from mid-2003 to mid-2006) and 143 general practices and two GUM clinics in Avon (2004). We examined associations between practice testing status, practice characteristics and hypothesised markers of population need (area level teenage conception rates and Index of Multiple Deprivation, IMD scores). Results No HIV or chlamydia testing was done in 19% (12/64) of general practices in Brent, compared to 2.1% (3/143) in Avon. In Brent, the mean age of general practitioners (GPs) in Brent practices that tested for chlamydia or HIV was lower than in those that had not conducted testing. Practices where no HIV testing was done had slightly higher local teenage conception rates (median 23.5 vs. 17.4/1000 women aged 15-44, p = 0.07) and served more deprived areas (median IMD score 27.1 vs. 21.8, p = 0.05). Mean yearly chlamydia and HIV testing rates, in practices that did test were 33.2 and 0.6 (per 1000 patients aged 15-44 years) in Brent, and 34.1 and 10.3 in Avon, respectively. In Brent practices only 20% of chlamydia tests were conducted in patients aged under 25 years, compared with 39% in Avon. Conclusions There are substantial geographical differences in the intensity of chlamydia and HIV testing in general practice. Interventions to facilitate sexually transmitted infection and HIV testing in general practice are needed to improve access to effective sexual health care. The use of routinely-collected laboratory, practice-level and demographic data for monitoring sexual health service provision and informing service planning should be more widely evaluated.

Study protocol: Transition from localized low back pain to chronic widespread pain in general practice: identification of risk factors, preventive factors and key elements for treatment--a cohort study

Background Chronic localized pain syndromes, especially chronic low back pain (CLBP), are common reasons for consultation in general practice. In some cases chronic localized pain syndromes can appear in combination with chronic widespread pain (CWP). Numerous studies have shown a strong association between CWP and several physical and psychological factors. These studies are population-based cross-sectional and do not allow for assessing chronology. There are very few prospective studies that explore the predictors for the onset of CWP, where the main focus is identifying risk factors for the CWP incidence. Until now there have been no studies focusing on preventive factors keeping patients from developing CWP. Our aim is to perform a cross sectional study on the epidemiology of CLBP and CWP in general practice and to look for distinctive features regarding resources like resilience, self-efficacy and coping strategies. A subsequent cohort study is designed to identify the risk and protective factors of pain generalization (development of CWP) in primary care for CLBP patients. Methods/Design Fifty-nine general practitioners recruit consecutively, during a 5 month period, all patients who are consulting their family doctor because of chronic low back pain (where the pain is lasted for 3 months). Patients are asked to fill out a questionnaire on pain anamnesis, pain-perception, co-morbidities, therapy course, medication, socio demographic data and psychosomatic symptoms. We assess resilience, coping resources, stress management and self-efficacy as potential protective factors for pain generalization. Furthermore, we raise risk factors for pain generalization like anxiety, depression, trauma and critical life events. During a twelve months follow up period a cohort of CLBP patients without CWP will be screened on a regular basis (3 monthly) for pain generalization (outcome: incident CWP). Discussion This cohort study will be the largest study which prospectively analyzes predictors for transition from CLBP to CWP in primary care setting. In contrast to the typically researched risk factors, which increase the probability of pain generalization, this study also focus intensively on protective factors, which decrease the probability of pain generalization.