The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.

Diatom carbon export enhanced by silicate upwelling in the North East Atlantic.

Diatom carbon export enhanced by silicate upwelling in the northeast Atlantic John T. Allen1,2, Louise Brown1,3, Richard Sanders1, C. Mark Moore1, Alexander Mustard1, Sophie Fielding1, Mike Lucas1, Michel Rixen4, Graham Savidge5, Stephanie Henson1 and Dan Mayor1 Top of pageDiatoms are unicellular or chain-forming phytoplankton that use silicon (Si) in cell wall construction. Their survival during periods of apparent nutrient exhaustion enhances carbon sequestration in frontal regions of the northern North Atlantic. These regions may therefore have a more important role in the 'biological pump' than they have previously been attributed1, but how this is achieved is unknown. Diatom growth depends on silicate availability, in addition to nitrate and phosphate2, 3, but northern Atlantic waters are richer in nitrate than silicate4. Following the spring stratification, diatoms are the first phytoplankton to bloom2, 5. Once silicate is exhausted, diatom blooms subside in a major export event6, 7. Here we show that, with nitrate still available for new production, the diatom bloom is prolonged where there is a periodic supply of new silicate: specifically, diatoms thrive by 'mining' deep-water silicate brought to the surface by an unstable ocean front. The mechanism we present here is not limited to silicate fertilization; similar mechanisms could support nitrate-, phosphate- or iron-limited frontal regions in oceans elsewhere.

Integrating Land Use Planning and Transportation: Policy formulation in the Belfast Metropolitan Area

Much of the interest in sustainable cities relates to the inexorable rise in the demand for car travel and the contribution that certain urban forms and land-use relationships can make to reducing energy consumption. Indeed, this demand is fuelled more by increased spatial separation of homes and workplaces, shops and schools than by any rise in trip making. This paper evaluates recent efforts to integrate land-use planning and transportation policy in the Belfast Metropolitan Area by reviewing the policy formulation process at both a regional and city scale. The paper suggests that considerable progress has been made in integrating these two areas of public policy, both institutionally and conceptually. However, concerns are expressed that the rhetoric of sustainability may prove difficult to translate into implementation, leading to a further dislocation of land-use and transportation.