Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

A generalised Bayesian instrumental variable approach under student t-distributed errors with application

Bayesian analysis is given of an instrumental variable model that allows for heteroscedasticity in both the structural equation and the instrument equation. Specifically, the approach for dealing with heteroscedastic errors in Geweke (1993) is extended to the Bayesian instrumental variable estimator outlined in Rossi et al. (2005). Heteroscedasticity is treated by modelling the variance for each error using a hierarchical prior that is Gamma distributed. The computation is carried out by using a Markov chain Monte Carlo sampling algorithm with an augmented draw for the heteroscedastic case. An example using real data illustrates the approach and shows that ignoring heteroscedasticity in the instrument equation when it exists may lead to biased estimates.

An historical perspective on forecast errors

Using annual observations on industrial production over the last three centuries, and on GDP over a 100-year period, we seek an historical perspective on the forecastability of these UK output measures. The series are dominated by strong upward trends, so we consider various specifications of this, including the local linear trend structural time-series model, which allows the level and slope of the trend to vary. Our results are not unduly sensitive to how the trend in the series is modelled: the average sizes of the forecast errors of all models, and the wide span of prediction intervals, attests to a great deal of uncertainty in the economic environment. It appears that, from an historical perspective, the postwar period has been relatively more forecastable.

Quantifying errors due to frequency changes and target location uncertainty for radar refractivity retrievals

Radar refractivity retrievals can capture near-surface humidity changes, but noisy phase changes of the ground clutter returns limit the accuracy for both klystron- and magnetron-based systems. Observations with a C-band (5.6 cm) magnetron weather radar indicate that the correction for phase changes introduced by local oscillator frequency changes leads to refractivity errors no larger than 0.25 N units: equivalent to a relative humidity change of only 0.25% at 20°C. Requested stable local oscillator (STALO) frequency changes were accurate to 0.002 ppm based on laboratory measurements. More serious are the random phase change errors introduced when targets are not at the range-gate center and there are changes in the transmitter frequency (ΔfTx) or the refractivity (ΔN). Observations at C band with a 2-μs pulse show an additional 66° of phase change noise for a ΔfTx of 190 kHz (34 ppm); this allows the effect due to ΔN to be predicted. Even at S band with klystron transmitters, significant phase change noise should occur when a large ΔN develops relative to the reference period [e.g., ~55° when ΔN = 60 for the Next Generation Weather Radar (NEXRAD) radars]. At shorter wavelengths (e.g., C and X band) and with magnetron transmitters in particular, refractivity retrievals relative to an earlier reference period are even more difficult, and operational retrievals may be restricted to changes over shorter (e.g., hourly) periods of time. Target location errors can be reduced by using a shorter pulse or identified by a new technique making alternate measurements at two closely spaced frequencies, which could even be achieved with a dual–pulse repetition frequency (PRF) operation of a magnetron transmitter.

Parent-child interactions and adolescent anxiety: a systematic review

Parental behaviours have been implicated in the development and maintenance of anxiety in children and young people; however the degree to which findings apply to adolescents specifically remains unclear. We conducted a systematic review of studies examining the evidence for an association between parental behaviours and adolescent anxiety. Twenty two studies were identified. The results of this systematic review provide fairly consistent preliminary evidence for an association between anxiety and perceived parental control and anxious rearing in adolescence. The findings relating to an association between adolescent anxiety and perceived parental rejection and lack of warmth are somewhat less consistent. Methodological shortcomings in the studies mean that these results should be interpreted with caution. Future research should be conducted using observational and experimental design with adolescents from referred, clinical populations to help identify the critical parental processes and clarify the direction of effects.

Impairments in glucose tolerance can have a negative impact on cognitive function: a systematic research review

There is an increasing body of research investigating whether abnormal glucose tolerance is associated with cognitive impairments, the evidence from which is equivocal. A systematic search of the literature identified twenty-three studies which assessed either clinically defined impaired glucose tolerance (IGT) or variance in glucose tolerance within the clinically defined normal range (NGT). The findings suggest that poor glucose tolerance is associated with cognitive impairments, with decrements in verbal memory being most prevalent. However, the evidence for decrements in other domains was weak. The NGT studies report a stronger glucose tolerance-cognition association than the IGT studies, which is likely to be due to the greater number of glucose tolerance parameters and the more sensitive cognitive tests in the NGT studies compared to the IGT studies. It is also speculated that the negative cognitive impact of abnormalities in glucose tolerance increases with age, and that glucose consumption is most beneficial to individuals with poor glucose tolerance compared to individuals with normal glucose tolerance. The role of potential mechanisms are discussed.

The effects of flavonoid and other polyphenol consumption on cognitive performance: A systematic research review of human experimental and epidemiological studies

Literature reviews suggest flavonoids, a sub-class of polyphenols, are beneficial for cognition. This is the first review examining the effect of consumption of all polyphenol groups on cognitive function. Inclusion criteria were polyphenol vs. control interventions and epidemiological studies with an objective measure of cognitive function. Participants were healthy or mildly cognitively impaired adults. Studies were excluded if clinical assessment or diagnosis of Alzheimer’s disease, dementia, or cognitive impairment was the sole measure of cognitive function, or if the polyphenol was present with potentially confounding compounds such as caffeine (e.g. tea studies) or Ginkgo Biloba. 28 studies were identified; 4 berry juice studies, 4 cocoa studies, 13 isoflavone supplement studies, 3 other supplement studies, and 4 epidemiological surveys. Overall, 16 studies reported cognitive benefits following polyphenol consumption. Evidence suggests that consuming additional polyphenols in the diet can lead to cognitive benefits, however, the observed effects were small. Declarative memory and particularly spatial memory appear most sensitive to polyphenol consumption and effects may differ depending on polyphenol source. Polyphenol berry fruit juice consumption was most beneficial for immediate verbal memory, whereas isoflavone based interventions were associated with significant improvements for delayed spatial memory and executive function. Comparison between studies was hampered by methodological inconsistencies. Hence, there was no clear evidence for an association between cognitive outcomes and polyphenol dose response, duration of intervention, or population studied. In conclusion, however, the findings do imply that polyphenol consumption has potential to benefit cognition both acutely and chronically.

Transreal limits expose category errors in IEEE 754 floating-point arithmetic and in mathematics

The IEEE 754 standard for oating-point arithmetic is widely used in computing. It is based on real arithmetic and is made total by adding both a positive and a negative infinity, a negative zero, and many Not-a-Number (NaN) states. The IEEE infinities are said to have the behaviour of limits. Transreal arithmetic is total. It also has a positive and a negative infinity but no negative zero, and it has a single, unordered number, nullity. We elucidate the transreal tangent and extend real limits to transreal limits. Arguing from this firm foundation, we maintain that there are three category errors in the IEEE 754 standard. Firstly the claim that IEEE infinities are limits of real arithmetic confuses limiting processes with arithmetic. Secondly a defence of IEEE negative zero confuses the limit of a function with the value of a function. Thirdly the definition of IEEE NaNs confuses undefined with unordered. Furthermore we prove that the tangent function, with the infinities given by geometrical con- struction, has a period of an entire rotation, not half a rotation as is commonly understood. This illustrates a category error, confusing the limit with the value of a function, in an important area of applied mathe- matics { trigonometry. We brie y consider the wider implications of this category error. Another paper proposes transreal arithmetic as a basis for floating- point arithmetic; here we take the profound step of proposing transreal arithmetic as a replacement for real arithmetic to remove the possibility of certain category errors in mathematics. Thus we propose both theo- retical and practical advantages of transmathematics. In particular we argue that implementing transreal analysis in trans- floating-point arith- metic would extend the coverage, accuracy and reliability of almost all computer programs that exploit real analysis { essentially all programs in science and engineering and many in finance, medicine and other socially beneficial applications.

Estimate of the cutoff errors in the Ewald summation for dipolar systems

Theoretical estimates for the cutoff errors in the Ewald summation method for dipolar systems are derived. Absolute errors in the total energy, forces and torques, both for the real and reciprocal space parts, are considered. The applicability of the estimates is tested and confirmed in several numerical examples. We demonstrate that these estimates can be used easily in determining the optimal parameters of the dipolar Ewald summation in the sense that they minimize the computation time for a predefined, user set, accuracy.

Regional and monthly and clear-sky aerosol direct radiative effect (and forcing) derived from the GlobAEROSOL-AATSR satellite aerosol product

Using the GlobAEROSOL-AATSR dataset, estimates of the instantaneous, clear-sky, direct aerosol radiative effect and radiative forcing have been produced for the year 2006. Aerosol Robotic Network sun-photometer measurements have been used to characterise the random and systematic error in the GlobAEROSOL product for 22 regions covering the globe. Representative aerosol properties for each region were derived from the results of a wide range of literature sources and, along with the de-biased GlobAEROSOL AODs, were used to drive an offline version of the Met Office unified model radiation scheme. In addition to the mean AOD, best-estimate run of the radiation scheme, a range of additional calculations were done to propagate uncertainty estimates in the AOD, optical properties, surface albedo and errors due to the temporal and spatial averaging of the AOD fields. This analysis produced monthly, regional estimates of the clear-sky aerosol radiative effect and its uncertainty, which were combined to produce annual, global mean values of (−6.7±3.9)Wm−2 at the top of atmosphere (TOA) and (−12±6)Wm−2 at the surface. These results were then used to give estimates of regional, clear-sky aerosol direct radiative forcing, using modelled pre-industrial AOD fields for the year 1750 calculated for the AEROCOM PRE experiment. However, as it was not possible to quantify the uncertainty in the pre-industrial aerosol loading, these figures can only be taken as indicative and their uncertainties as lower bounds on the likely errors. Although the uncertainty on aerosol radiative effect presented here is considerably larger than most previous estimates, the explicit inclusion of the major sources of error in the calculations suggest that they are closer to the true constraint on this figure from similar methodologies, and point to the need for more, improved estimates of both global aerosol loading and aerosol optical properties.

Representation errors and retrievals in linear and nonlinear data assimilation

This article shows how one can formulate the representation problem starting from Bayes’ theorem. The purpose of this article is to raise awareness of the formal solutions,so that approximations can be placed in a proper context. The representation errors appear in the likelihood, and the different possibilities for the representation of reality in model and observations are discussed, including nonlinear representation probability density functions. Specifically, the assumptions needed in the usual procedure to add a representation error covariance to the error covariance of the observations are discussed,and it is shown that, when several sub-grid observations are present, their mean still has a representation error ; socalled ‘superobbing’ does not resolve the issue. Connection is made to the off-line or on-line retrieval problem, providing a new simple proof of the equivalence of assimilating linear retrievals and original observations. Furthermore, it is shown how nonlinear retrievals can be assimilated without loss of information. Finally we discuss how errors in the observation operator model can be treated consistently in the Bayesian framework, connecting to previous work in this area.

Global burned-land estimation in Latin America using MODIS composite data

This paper presents results of the AQL2004 project, which has been develope within the GOFC-GOLD Latin American network of remote sensing and forest fires (RedLatif). The project intended to obtain monthly burned-land maps of the entire region, from Mexico to Patagonia, using MODIS (moderate-resolution imaging spectroradiometer) reflectance data. The project has been organized in three different phases: acquisition and preprocessing of satellite data; discrimination of burned pixels; and validation of results. In the first phase, input data consisting of 32-day composites of MODIS 500-m reflectance data generated by the Global Land Cover Facility (GLCF) of the University of Maryland (College Park, Maryland, U.S.A.) were collected and processed. The discrimination of burned areas was addressed in two steps: searching for "burned core" pixels using postfire spectral indices and multitemporal change detection and mapping of burned scars using contextual techniques. The validation phase was based on visual analysis of Landsat and CBERS (China-Brazil Earth Resources Satellite) images. Validation of the burned-land category showed an agreement ranging from 30% to 60%, depending on the ecosystem and vegetation species present. The total burned area for the entire year was estimated to be 153 215 km2. The most affected countries in relation to their territory were Cuba, Colombia, Bolivia, and Venezuela. Burned areas were found in most land covers; herbaceous vegetation (savannas and grasslands) presented the highest proportions of burned area, while perennial forest had the lowest proportions. The importance of croplands in the total burned area should be taken with reserve, since this cover presented the highest commission errors. The importance of generating systematic products of burned land areas for different ecological processes is emphasized.

Systematic selection of analogue redesign method for forward-type digital power converters

This article proposes a systematic approach to determine the most suitable analogue redesign method to be used for forward-type converters under digital voltage mode control. The focus of the method is to achieve the highest phase margin at the particular switching and crossover frequencies chosen by the designer. It is shown that at high crossover frequencies with respect to switching frequency, controllers designed using backward integration have the largest phase margin; whereas at low crossover frequencies with respect to switching frequency, controllers designed using bilinear integration with pre-warping have the largest phase margins. An algorithm has been developed to determine the frequency of the crossing point where the recommended discretisation method changes. An accurate model of the power stage is used for simulation and experimental results from a Buck converter are collected. The performance of the digital controllers is compared to that of the equivalent analogue controller both in simulation and experiment. Excellent closeness between the simulation and experimental results is presented. This work provides a concrete example to allow academics and engineers to systematically choose a discretisation method.

Computerised therapies for anxiety and depression in children and young people: a systematic review and meta-anaylsis

One quarter of children and young people (CYP) experience anxiety and/or depression before adulthood, but treatment is sometimes unavailable or inadequate. Self-help interventions may have a role in augmenting treatment and this work aimed to systematically review the evidence for computerised anxiety and depression interventions in CYP aged 5–25 years old. Databases were searched for randomised controlled trials and 27 studies were identified. For young people (12–25 years) with risk of diagnosed anxiety disorders or depression, computerised CBT (cCBT) had positive effects for symptoms of anxiety (SMD −0.77, 95% CI −1.45 to −0.09, k = 6, N = 220) and depression (SMD −0.62, 95% CI −1.13 to −0.11, k = 7, N = 279). In a general population study of young people, there were small positive effects for anxiety (SMD −0.15, 95% CI −0.26 to −0.03; N = 1273) and depression (SMD −0.15, 95% CI −0.26 to −0.03; N = 1280). There was uncertainty around the effectiveness of cCBT in children (5–11 years). Evidence for other computerised interventions was sparse and inconclusive. Computerised CBT has potential for treating and preventing anxiety and depression in clinical and general populations of young people. Further program development and research is required to extend its use and establish its benefit in children.