What is the new medicines use review ‘patient survey’ attempting to capture in the context of existing patient satisfaction with pharmacy questionnaires and a new conceptual framework?

The community pharmacy service medicines use review (MUR) was introduced in 2005 ‘to improve patient knowledge, concordance and use of medicines’ through a private patient–pharmacist consultation. The MUR presents a fundamental change in community pharmacy service provision. While traditionally pharmacists are dispensers of medicines and providers of medicines advice, and patients as recipients, the MUR considers pharmacists providing consultation-type activities and patients as active participants. The MUR facilitates a two-way discussion about medicines use. Traditional patient–pharmacist behaviours transform into a new set of behaviours involving the booking of appointments, consultation processes and form completion, and the physical environment of the patient–pharmacist interaction moves from the traditional setting of the dispensary and medicines counter to a private consultation room. Thus, the new service challenges traditional identities and behaviours of the patient and the pharmacist as well as the environment in which the interaction takes place. In 2008, the UK government concluded there is at present too much emphasis on the quantity of MURs rather than on their quality.[1] A number of plans to remedy the perceived imbalance included a suggestion to reward ‘health outcomes’ achieved, with calls for a more focussed and scientific approach to the evaluation of pharmacy services using outcomes research. Specifically, the UK government set out the main principal research areas for the evaluation of pharmacy services to include ‘patient and public perceptions and satisfaction’as well as ‘impact on care and outcomes’. A limited number of ‘patient satisfaction with pharmacy services’ type questionnaires are available, of varying quality, measuring dimensions relating to pharmacists’ technical competence, behavioural impressions and general satisfaction. For example, an often cited paper by Larson[2] uses two factors to measure satisfaction, namely ‘friendly explanation’ and ‘managing therapy’; the factors are highly interrelated and the questions somewhat awkwardly phrased, but more importantly, we believe the questionnaire excludes some specific domains unique to the MUR. By conducting patient interviews with recent MUR recipients, we have been working to identify relevant concepts and develop a conceptual framework to inform item development for a Patient Reported Outcome Measure questionnaire bespoke to the MUR. We note with interest the recent launch of a multidisciplinary audit template by the Royal Pharmaceutical Society of Great Britain (RPSGB) in an attempt to review the effectiveness of MURs and improve their quality.[3] This template includes an MUR ‘patient survey’. We will discuss this ‘patient survey’ in light of our work and existing patient satisfaction with pharmacy questionnaires, outlining a new conceptual framework as a basis for measuring patient satisfaction with the MUR. Ethical approval for the study was obtained from the NHS Surrey Research Ethics Committee on 2 June 2008. References 1. Department of Health (2008). Pharmacy in England: Building on Strengths – Delivering the Future. London: HMSO. www. official-documents.gov.uk/document/cm73/7341/7341.pdf (accessed 29 September 2009). 2. Larson LN et al. Patient satisfaction with pharmaceutical care: update of a validated instrument. JAmPharmAssoc 2002; 42: 44–50. 3. Royal Pharmaceutical Society of Great Britain (2009). Pharmacy Medicines Use Review – Patient Audit. London: RPSGB. http:// qi4pd.org.uk/index.php/Medicines-Use-Review-Patient-Audit. html (accessed 29 September 2009).

The 2002 US Farm Bill: what's in it for CAP reform?

The 2002 U.S. Farm Bill (the Farm Security and Rural Investment Act or FSRIA) provides considerably more government subsidies for U.S. agriculture than Congress envisaged when it passed the preceding 1996–2002 FAIR Act. We review the FAIR record, showing how government subsidies increased greatly beyond those originally scheduled. For FSRIA, we outline key commodity, trade, and conservation and environmental provisions. We expect that the commodity programmes will: (a) encourage production when the market calls for less; (b) significantly increase subsidies over FAIR baseline subsidies; (c) press against current WTO and possible Doha Round support limits; and (d) aggravate trading partners. Finally, we suggest two lessons from the U.S. policy experience that might benefit those working on CAP and WTO reform. First, past research shows that farm programmes have little to do with the economic health of rural communities. Second, programme transparency, and especially public disclosure of the level of payments going to individual farmers, by name, influences the farm policy debate. Personalized data show what economists have long maintained—that the bulk of programme benefits go to a relatively few, large, producers—but do so in a way that captures the public and policy-makers' attention

Phylloxera and the grapevine: a sense of common purpose?

The purpose of life is its continuation: survival is the reason things live. Here we explore this 'basic' of biology, by reference to the extraordinary life-cycle of the aphid-like pest phylloxera, and the complexity of its relationship with its host the grapevine. The effort and ingenuity that phylloxera employs to continue itself leads to a doubt that survival alone is sufficient reason. It has frequently been suggested that the reduction of life to a catalogue of facts (by science) creates this doubt, because it robs existence of its essence (which is something other than its mechanics). The part that science is said to steal is what Robert Pirsig calls Quality-the harmonious balance of things. Pirsig seems to imply that this is something inherent in things-and independent from us. A more mundane explanation is that the difference between facts and the complete reality is us-the tendency of mind to connect freely between different kinds of information. This possibility is briefly illustrated here by a myth based on the facts of phylloxera.

The challenges of creating actionable knowledge: an action research perspective

Academia has a critical role in developing new knowledge which construction industry practitioners need to envision, undertake and sustain successful innovation. The new knowledge produced by academia, however, often does not satisfy the needs of practitioners. This unsatisfactory state of affairs is frequently taken to be the consequence of the cultural, motivational and operational differences between the two communities. Actionable knowledge is presented as a useful concept which can fuse the expectations, contributions and outputs of academia and practitioners. Within this context, action research is argued to be an appropriate methodology to develop successful actionable knowledge. Results from an action research project are given which provide researchers and practitioners greater understanding of the key factors that shape the degree to which action research produces actionable knowledge: change focus, collaboration capabilities and systematic process. The criteria intrinsic to Mode 2 research (Gibbons et al., 1994) are demonstrated to have utility in evidencing actionable knowledge. The implication for policy is that there is a need to develop and use appropriate actionable knowledge frameworks and measures to design funding calls, and to evaluate research proposals and outputs.

Is NHS Direct meeting the needs of mental health callers?

Background: NHS Direct is a new service that offers 24-hour advice from trained nurses. The National Service Framework for Mental Health and the National Strategy for Carers both mention NHS Direct as an important source of support for people with mental health problems. Aims: This paper reports findings from an evaluation of the Department of Health's NHS Direct mental health initiative. This initiative was established to ensure that NHS Direct can meet the needs of callers with mental health problems by offering additional training to all staff and improving the database of mental health services. Method: The findings reported here are based on routine computer data provided by 12 out of 17 NHS Direct sites, 552 data forms completed by nurse advisers from the 17 sites, and 111 questionnaires administered over the telephone with callers to the 17 sites. Results: Mental health calls accounted for 3% of NHS Direct's workload, although these calls were often longer and more complex than other calls. The majority of callers to the service were in touch with other services for their mental health problems (59%), typically their GP. Most callers had 'moderate' mental health problems, as indicated by the Global Assessment of Functioning Scale. Generally callers were satisfied with the service they received, although satisfaction was lower in some areas than previous studies of NHS Direct. Conclusions: Improvements could be made in the mechanisms for referring callers on to other services, and training to increase nurse advisers' knowledge of mental health problems.

Distinguishing novelty and familiarity effects in infant preference procedures

This paper considers possible problems researchers might face when interpreting the results of studies that employ variants of the preference procedure. Infants show a tendency to shift their preference from familiar to novel stimuli with increasing exposure to the familiar stimulus, a behaviour that is exploited by the habituation paradigm. This change in attentional preference with exposure leads us to suggest that researchers interested in infants' pre-experimental or spontaneous preferences should beware of the potentially confounding effects of exposing infants to familiarization trials prior to employing the preference procedure. The notion that infant attentional preference is dynamic also calls into question the use of the direction of post-familiarization preference per se when interpreting the knowledge or strategies available to infants. We look into the results of a cross-modal word learning study to show how the interpretation of results may be difficult when infants exhibit a significant preference in an unexpected direction. As a possible solution to this problem we propose that significant preferences in both directions should be sought at multiple intervals over time. Copyright (C) 2004 John Wiley Sons, Ltd.

An instructional design model for constructivist learning

The emergent requirements for effective e-learning calls for a paradigm shift for instructional design. Constructivist theory and semiotics offer a sound underpinning to enable such revolutionary change by employing the concepts of Learning Objects. E-learning guidelines adopted by the industry have led successfully to the development of training materials. Inadequacy and deficiency of those methods for Higher Education have been identified in this paper. Based on the best practice in industry and our empirical research, we present an instructional design model with practical templates for constructivist learning.

Howard Barker’s ‘monstrous assaults’: eroticism, death and the antique text

Howard Barker is a writer who has made several notable excursions into what he calls ‘the charnel house…of European drama.’ David Ian Rabey has observed that a compelling property of these classical works lies in what he calls ‘the incompleteness of [their] prescriptions’, and Barker’s Women Beware Women (1986), Seven Lears (1990) and Gertrude: The Cry (2002), are in turn based around the gaps and interstices found in Thomas Middleton’s Women Beware Women (c1627), Shakespeare’s King Lear (c1604) and Hamlet (c1601) respectively. This extends from representing the missing queen from King Lear, who Barker observes, ‘is barely quoted even in the depths of rage or pity’, to his new ending for Middleton’s Jacobean tragedy and the erotic revivification of Hamlet’s mother. This paper will argue that each modern reappropriation accentuates a hidden but powerful feature in these Elizabethan and Jacobean plays – namely their clash between obsessive desire, sexual transgression and death against the imposed restitution of a prescribed morality. This contradiction acts as the basis for Barker’s own explorations of eroticism, death and tragedy. The paper will also discuss Barker’s project for these ‘antique texts’, one that goes beyond what he derisively calls ‘relevance’, but attempts instead to recover ‘smothered genius’, whereby the transgressive is ‘concealed within structures that lend an artificial elegance.’ Together with Barker’s own rediscovery of tragedy, the paper will assert that these rewritings of Elizabethan and Jacobean drama expose their hidden, yet unsettling and provocative ideologies concerning the relationship between political corruption / justice through the power of sexuality (notably through the allure and danger of the mature woman), and an erotics of death that produces tragedy for the contemporary age.

Zinc metabolism in pregnant and lactating rats and the effect of varying iron: Zn in the diet

Pregnant rats were given control (46 mg iron/kg, 61 mg zinc/kg), low-Zn (6.9 mg Zn/kg) or low-Zn plus Fe (168 mg Fe/kg) diets from day 1 of pregnancy. The animals were allowed to give birth and parturition times recorded. Exactly 24 h after the end of parturition the pups were killed and analysed for water, fat, protein, Fe and Zn contents and the mothers' haemoglobin (Hb) and packed cell volume (PCV) were measured. There were no differences in weight gain or food intakes throughout pregnancy. Parturition times were similar (mean time 123 (SE 15) min) and there were no differences in the number of pups born. Protein, water and fat contents of the pups were similar but the low-Zn Fe-supplemented group had higher pup Fe than the low-Zn unsupplemented group, and the control group had higher pup Zn than both the low-Zn groups. The low-Zn groups had a greater incidence of haemorrhaged or deformed pups, or both, than the controls. Pregnant rats were given diets of adequate Zn level (40 mg/kg) but with varying Fe:Zn (0.8, 1.7, 2.9, 3.7). Zn retention from the diet was measured using 65Zn as an extrinsic label on days 3, 10 and 17 of pregnancy with a whole-body gamma-counter. A group of non-pregnant rats was also included as controls. The 65Zn content of mothers and pups was measured 24-48 h after birth and at 14, 21 and 24 d of age. In all groups Zn retention was highest from the first meal, fell in the second meal and then rose in the third meal of the pregnant but not the non-pregnant rats. There were no differences between the groups given diets of varying Fe:Zn level. Approximately 25% of the 65Zn was transferred from the mothers to the pups by the time they were 48 h old, and a further 17% during the first 14 d of lactation. The pup 65Zn content did not significantly increase after the first 20 d of lactation but the maternal 65Zn level continued to fall gradually.

Nitrogen processes in aquatic ecosystems

Executive summary Nature of the problem (science/management/policy) • Freshwater ecosystems play a key role in the European nitrogen (N) cycle, both as a reactive agent that transfers, stores and processes N loadings from the atmosphere and terrestrial ecosystems, and as a natural environment severely impacted by the increase of these loadings. Approaches • This chapter is a review of major processes and factors controlling N transport and transformations for running waters, standing waters, groundwaters and riparian wetlands. Key findings/state of knowledge • The major factor controlling N processes in freshwater ecosystems is the residence time of water, which varies widely both in space and in time, and which is sensitive to changes in climate, land use and management. • The effects of increased N loadings to European freshwaters include acidification in semi-natural environments, and eutrophication in more disturbed ecosystems, with associated loss of biodiversity in both cases. • An important part of the nitrogen transferred by surface waters is in the form of organic N, as dissolved organic N (DON) and particulate organic N (PON). This part is dominant in semi-natural catchments throughout Europe and remains a significant component of the total N load even in nitrate enriched rivers. • In eutrophicated standing freshwaters N can be a factor limiting or co-limiting biological production, and control of both N and phosphorus (P) loading is oft en needed in impacted areas, if ecological quality is to be restored. Major uncertainties/challenges • The importance of storage and denitrifi cation in aquifers is a major uncertainty in the global N cycle, and controls in part the response of catchments to land use or management changes. In some aquifers, the increase of N concentrations will continue for decades even if efficient mitigation measures are implemented now. • Nitrate retention by riparian wetlands has oft en been highlighted. However, their use for mitigation must be treated with caution, since their effectiveness is difficult to predict, and side effects include increased DON emissions to adjacent open waters, N2O emissions to the atmosphere, and loss of biodiversity. • In fact, the character and specific spatial origins of DON are not fully understood, and similarly the quantitative importance of indirect N2O emissions from freshwater ecosystems as a result of N leaching losses from agricultural soils is still poorly known at the regional scale. • These major uncertainties remain due to the lack of adequate monitoring (all forms of N at a relevant frequency), especially – but not only – in the southern and eastern EU countries. Recommendations (research/policy) • The great variability of transfer pathways, buffering capacity and sensitivity of the catchments and of the freshwater ecosystems calls for site specific mitigation measures rather than standard ones applied at regional to national scale. • The spatial and temporal variations of the N forms, the processes controlling the transport and transformation of N within freshwaters, require further investigation if the role of N in influencing freshwater ecosystem health is to be better understood, underpinning the implementation of the EU Water Framework Directive for European freshwaters.

Cognitive and bodily selves: how do they interact following brain lesion?

Dualism has long distinguished between the mental and the body experiences. Probing the structure and organisation of the self traditionally calls for a distinction between these two sides of the self coin. It is far beyond the scope of this chapter to address these philosophical issues, and our starting point will be the simple distinction between reflective processes involved in the elaboration of body image, self awareness and self-recognition (i.e. ‘the self’) and the sensori-motor dialogues involved in action control, reactions and automatisms (i.e. ‘the body’ schema). This oversimplification does not take into account the complex interactions taking place between these two levels of description, but our initial aim will be to distinguish between them, before addressing the question of their interactions. Cognitive and sensori-motor processes have frequently been distinguished (review: Rossetti and Revonsuo 2000), and it may be proposed that a similar dissociation can be put forward, a priori, between a central representation of self and a bodily representation corresponding to body schema (Figure 1).

Sociality and money

This is a translation of ‘Socialité et argent’, a text by Emmanuel Levinas originally published in 1987. Levinas describes the emergence of money out of interhuman relations of exchange and the social relations – sociality – that result. While elsewhere he has presented sociality as ‘nonindifference to alterity’ it appears here as ‘proximity of the stranger’ and points to the tension between an economic system based on money and the basic human disposition to respond to the face of the other person. Money both encodes and effaces sociality, both designates and disguises social relations. It arises from the way that needs and interests are manifested in exchange relations, in what he calls the ‘interestedness’ of economic life. But interests are always already cut through by the fact that being is always ‘being with others’. Being is always ‘interbeing’. Interestedness is always confronted by disinterestedness, that is, by a sociality marked by the ‘goodness of giving’, attachment to and concern for the poverty of the other person. Levinas concludes with a discussion of sociality and justice, posing questions about the tension between the demand to respond to an Other immediately before me and at the same time to respond to the demands of an other Other (the third person) who also invites a response.

Conceptualizing change in the Portuguese footwear industry: regional voices and cognitive spaces of agency

Expanding national services sectors and global competition aggravate current and perceived future market pressures on traditional manufacturing industries. These perceptions of change have provoked a growing intensification of geo-political discourses on technological innovation and ‘learning’, and calls for competency in design among other professional skills. However, these political discourses on innovation and learning have paralleled public concerns with the apparent ‘growth pains’ from factory closures and subsequent increases in unemployment, and its debilitating social and economic implications for local and regional development. In this respect the following investigation sets out to conceptualize change through the complementary and differing perceptions of industry and regional actors’ experiences or narratives, linking these perceptions to their structure-determined spheres of agent-environment interactivity. It aims to determine whether agents’ differing perceptions of industry transformation can have a role in the legitimization of their interests in, and in sustaining their organizational influence over the process of industry-regional transformation. It argues that industry and regional agent perceptions are among the cognitive aspects of agent-environment interactivity that permeate agency. It stresses agents’ ability to reason and manipulate their work environments to preserve their self-regulating interests in, and task representative influence over the multi-jurisdictional space of industry-regional transformation. The contributions of this investigation suggest that agents’ varied perceptions of industry and regional change inform or compete for influence over the redirection of regional, industry and business strategies. This claim offers a greater appreciation for the reflexive and complex institutional dimensions of industry planning and development, and the political responsibility to socially just forms of regional development. It positions the outcomes of this investigation at the nexus of intensifying geo-political discourses on the efficiency and equity of territorial development in Europe.

Integrated cytokine and metabolic analysis of pathological responses to parasite exposure in rodents

Parasitic infections cause a myriad of responses in their mammalian hosts, on immune as well as on metabolic level. A multiplex panel of cytokines and metabolites derived from four parasite-rodent models, namely, Plasmodium berghei-mouse, Trypanosoma brucei brucei-mouse, Schistosoma mansoni-mouse, and Fasciola hepatica-rat were statistically coanalyzed. 1H NMR spectroscopy and multivariate statistical analysis were used to characterize the urine and plasma metabolite profiles in infected and noninfected animals. Each parasite generated a unique metabolic signature in the host. Plasma cytokine concentrations were obtained using the ‘Meso Scale Discovery’ multi cytokine assay platform. Multivariate data integration methods were subsequently used to elucidate the component of the metabolic signature which is associated with inflammation and to determine specific metabolic correlates with parasite-induced changes in plasma cytokine levels. For example, the relative levels of acetyl glycoproteins extracted from the plasma metabolite profile in the P. berghei-infected mice were statistically correlated with IFN-γ, whereas the same cytokine was anticorrelated with glucose levels. Both the metabolic and the cytokine data showed a similar spatial distribution in principal component analysis scores plots constructed for the combined murine data, with samples from all infected animals clustering according to the parasite species and whereby the protozoan infections (P. berghei and T. b. brucei) grouped separately from the helminth infection (S. mansoni). For S. mansoni, the main infection-responsive cytokines were IL-4 and IL-5, which covaried with lactate, choline, and D-3-hydroxybutyrate. This study demonstrates that the inherently differential immune response to single and multicellular parasites not only manifests in the cytokine expression, but also consequently imprints on the metabolic signature, and calls for in-depth analysis to further explore direct links between immune features and biochemical pathways.

Re-thinking stakeholder management in construction: theory & research

From its roots in strategic management theory, stakeholder management has been adopted by the construction management academic community and applied as a valid paradigm around which research work has been generated aiming to improve project effi ciencies and effectiveness. However, academics have argued that stakeholder management should move away from purely theoretical discussions and engage more with the realities of construction project work. This paper re-appraises the stakeholder management concept for the construction domain by re-thinking some of the fundamental principles and ideals present within the more general stakeholder theory literature. It engages with issues which researchers have arguably failed to acknowledge and calls for a re-evaluation of construction stakeholder management research by presenting a review around four distinctive themes: the moral obligations of engaging with stakeholders against the business and efficiency driven imperatives of construction organisations; the contrast between theoretical abstractions and empirically grounded research; the tensions between theoretical convergence versus calls for multiple and divergent perspectives on stakeholder management and the practicalities of conducting stakeholder management in the construction domain. Such a critical re-appraisal of stakeholder management thinking both generates new lines of enquiry and promises to help inform and shape current and future industry practice.