A qualitative exploration of the underlying causes of preventable drug-related morbidity in primary care, resulting in hospitalisation

This study has explored the underlying causes of preventable drug-related admissions to hospital, from primary care through semi-structured interviews and review of patients’ medical records. Analysis of the data has revealed that communication failures between different groups of healthcare professionals and between healthcare professionals and patients contribute to preventable drug-related admissions, as do knowledge gaps about medication in both healthcare professionals and patients. In addition, working conditions for community pharmacists severely limit their ability to effectively act as a safety barrier to patients receiving inappropriate medication. Limitations include heavy workloads, lack of access to patients’ clinical information, poor relationships with general practitioners and time restrictions. The results of this study represent an important addition to our understanding of the contribution of human error as an underlying cause of preventable drug-related morbidity, and the factors which contribute to errors occurring in the primary healthcare setting.

Causes of the rapid warming of the North Atlantic ocean in the mid-1990s

In the mid-1990s the subpolar gyre of the North Atlantic underwent a remarkable rapid warming, with sea surface temperatures increasing by around 1C in just 2 years. This rapid warming followed a prolonged positive phase of the North Atlantic Oscillation (NAO), but also coincided with an unusually negative NAO index in the winter of 1995/96. By comparing ocean analyses and carefully designed model experiments we show that this rapid warming can be understood as a delayed response to the prolonged positive phase of the NAO, and not simply an instantaneous response to the negative NAO index of 1995/96. Furthermore, we infer that the warming was partly caused by a surge, and subsequent decline, in the Meridional Overturning Circulation and northward heat transport of the Atlantic Ocean. Our results provide persuasive evidence of significant oceanic memory on multi-annual timescales, and are therefore encouraging for the prospects of developing skillful predictions.

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.

The causes of prescribing errors in English general practices: a qualitative study

Aim: To examine the causes of prescribing and monitoring errors in English general practices and provide recommendations for how they may be overcome. Design: Qualitative interview and focus group study with purposive sampling and thematic analysis informed by Reason’s accident causation model. Participants: General practice staff participated in a combination of semi-structured interviews (n=34) and six focus groups (n=46). Setting: Fifteen general practices across three primary care trusts in England. Results: We identified seven categories of high-level error-producing conditions: the prescriber, the patient, the team, the task, the working environment, the computer system, and the primary-secondary care interface. Each of these was further broken down to reveal various error-producing conditions. The prescriber’s therapeutic training, drug knowledge and experience, knowledge of the patient, perception of risk, and their physical and emotional health, were all identified as possible causes. The patient’s characteristics and the complexity of the individual clinical case were also found to have contributed to prescribing errors. The importance of feeling comfortable within the practice team was highlighted, as well as the safety of general practitioners (GPs) in signing prescriptions generated by nurses when they had not seen the patient for themselves. The working environment with its high workload, time pressures, and interruptions, and computer related issues associated with mis-selecting drugs from electronic pick-lists and overriding alerts, were all highlighted as possible causes of prescribing errors and often interconnected. Conclusion: This study has highlighted the complex underlying causes of prescribing and monitoring errors in general practices, several of which are amenable to intervention.

The timing and causes of the Neolithic elm decline: new evidence from the Lower Thames Valley (London, UK)

Two new multi-proxy records of environmental change are provided from Horton Kirby Paper Mill and Old Seager Distillery in the Lower Thames Valley. Each site has evidence for a decline in elm woodland, which at Horton Kirby Paper Mill is recorded earlier than any other published record from the British Isles: sometime between 7320 and 7240 cal BP. Scolytus scolytus/S. multistriatus (the vectors for Dutch elm disease) are recorded after the decline in both sequences, adding to the number of sites with such evidence in the British Isles. Evidence of paludification and human activity are also recorded at the time of the elm decline reinforcing the multi-causal hypothesis. Integration of these results with 21 palaeoenvironmental records has produced a large number of well-dated, multiproxy records of the elm decline in this part of the UK. On the basis of this dataset, a classification system for categorising the relationships between the causal factors of the elm decline is proposed and recommended for future studies.

Solar causes of the long-term increase in geomagnetic activity

We analyze the causes of the century-long increase in geomagnetic activity, quantified by annual means of the aa index, using observations of interplanetary space, galactic cosmic rays, the ionosphere, and the auroral electrojet, made during the last three solar cycles. The effects of changes in ionospheric conductivity, the Earth's dipole tilt, and magnetic moment are shown to be small; only changes in near-Earth interplanetary space make a significant contribution to the long-term increase in activity. We study the effects of the interplanetary medium by applying dimensional analysis to generate the optimum solar wind-magnetosphere energy coupling function, having an unprecedentedly high correlation coefficient of 0.97. Analysis of the terms of the coupling function shows that the largest contributions to the drift in activity over solar cycles 20-22 originate from rises in the average interplanetary magnetic field (IMF) strength, solar wind concentration, and speed; average IMF orientation has grown somewhat less propitious for causing geomagnetic activity. The combination of these factors explains almost all of the 39% rise in aa observed over the last three solar cycles. Whereas the IMF strength varies approximately in phase with sunspot numbers, neither its orientation nor the solar wind density shows any coherent solar cycle variation. The solar wind speed peaks strongly in the declining phase of even-numbered cycles and can be identified as the chief cause of the phase shift between the sunspot numbers and the aa index. The rise in the IMF magnitude, the largest single contributor to the drift in geomagnetic activity, is shown to be caused by a rise in the solar coronal magnetic field, consistent with a rise in the coronal source field, modeled from photospheric observations, and an observed decay in cosmic ray fluxes.

Causes of plasma flow bursts and dayside auroral transients: An evaluation of two models Invoking reconnection pulses and changes in the Y component of the magnetosheath field

Longitudinal flow bursts observed by the European Incoherent Scatter (EISCAT) radar, in association with dayside auroral transients observed from Svalbard, have been interpreted as resulting from pulses of enhanced reconnection at the dayside magnetopause. However, an alternative model has recently been proposed for a steady rate of magnetopause reconnection, in which the bursts of longitudinal flow are due to increases in the field line curvature force, associated with the By component of the magnetosheath field. We here evaluate these two models, using observations on January 20, 1990, by EISCAT and a 630-nm all-sky camera at Ny Ålesund. For both models, we predict the behavior of both the dayside flows and the 630-nm emissions on newly opened field lines. It is shown that the signatures of steady reconnection and magnetosheath By changes could possibly resemble the observed 630-nm auroral events, but only for certain locations of the observing site, relative to the ionospheric projection of the reconnection X line: however, in such cases, the flow bursts would be seen between the 630-nm transients and not within them. On the other hand, the model of reconnection rate pulses predicts that the flows will be enhanced within each 630-nm transient auroral event. The observations on January 20, 1990, are shown to be consistent with the model of enhanced reconnection rate pulses over a background level and inconsistent with the effects of periodic enhancements of the magnitude of the magnetosheath By component. We estimate that the reconnection rate within the pulses would have to be at least an order of magnitude larger than the background level between the pulses.

Determinants of satisfaction amongst tenants of UK Offices

Purpose – Corporate Occupiers require offices and services which meet their business needs, whilst landlords must attract and retain occupiers in order to maximise occupancy and rental income. The purpose of this research is to help landlords and corporate occupiers understand each other better, in order to achieve a mutually beneficial relationship. Design/methodology/approach - This paper analyses interviews with 1334 office tenants in the UK, conducted over an 11-year period, to investigate determinants of occupier satisfaction, loyalty and advocacy. Structural equation modelling and regressions are performed using respondents’ ratings of satisfaction with many aspects of occupancy as explanatory variables. The dependent variables include satisfaction with property management, value for money, overall occupier satisfaction, lease renewal intentions and occupiers’ willingness to recommend their landlord. Findings - The aspects with most impact on occupiers’ satisfaction are the office building itself, its location and amenities, and also communication with their property manager, a belief that their business needs are understood and the property manager’s responsiveness to occupiers’ requests. Occupiers’ loyalty depends mainly upon feeling that their rent and service charges provide value for money, an amicable leasing process, the professionalism of their property manager and the Corporate Social Responsibility of the Landlord. ‘Empathy’ is crucial to occupiers’ willingness to recommend their landlord, and clear documentation and efficient legal process improve occupiers’ perception of receiving ‘Value for Money’. Research Limitations - The sample is skewed towards occupiers of prime office buildings in the UK, owned by landlords who care sufficiently about their tenants to commission studies into occupier satisfaction. Practical implications - This research should help to improve the landlord – tenant relationship, benefitting the businesses that rent property and helping building managers understand where to focus their efforts to achieve maximum effect on occupier satisfaction, loyalty and advocacy. Originality/value - There has been little academic research into the determinants of satisfaction of occupiers of UK commercial property. This large-scale study enables the most influential factors to be identified and prioritised.

Chagas disease-related mortality trends, state of Sao Paulo, Brazil, 1985 to 2006: a study using multiple causes of death

Objectives. To study mortality trends related to Chagas disease taking into account all mentions of this cause listed on any line or part of the death certificate. Methods. Mortality data for 1985-2006 were obtained from the multiple cause-of-death database maintained by the Sao Paulo State Data Analysis System (SEADE). Chagas disease was classified as the underlying cause-of-death or as an associated cause-of-death (non-underlying). The total number of times Chagas disease was mentioned on the death certificates was also considered. Results. During this 22-year period, there were 40 002 deaths related to Chagas disease: 34 917 (87.29%) classified as the underlying cause-of-death and 5 085 (12.71%) as an associated cause-of-death. The results show a 56.07% decline in the death rate due to Chagas disease as the underlying cause and a stabilized rate as associated cause. The number of deaths was 44.5% higher among men. The fact that 83.5% of the deaths occurred after 45 years of age reflects a cohort effect. The main causes associated with Chagas disease as the underlying cause-of-death were direct complications due to cardiac involvement, such as conduction disorders, arrhythmias and heart failure. Ischemic heart disease, cerebrovascular disorders and neoplasms were the main underlying causes when Chagas was an associated cause-of-death. Conclusions. For the total mentions to Chagas disease, a 51.34% decline in the death rate was observed, whereas the decline in the number of deaths was only 5.91%, being lower among women and showing a shift of deaths to older age brackets. Using the multiple cause-of-death method contributed to the understanding of the natural history of Chagas disease.

Paracoccidioidomycosis-related mortality trend, state of Sao Paulo, Brazil: a study using multiple causes of death

Objective. To investigate mortality in which paracoccidioidomycosis appears on any line or part of the death certificate. Method. Mortality data for 1985-2005 were obtained from the multiple cause-of-death database maintained by the Sao Paulo State Data Analysis System (SEADE). Standardized mortality coefficients were calculated for paracoccidioidomycosis as the underlying cause-of-death and as an associated cause-of-death, as well as for the total number of times paracoccidioidomycosis was mentioned on the death certificates. Results. During this 21-year period, there were 1950 deaths related to paracoccidioidomycosis; the disease was the underlying cause-of-death in 1 164 cases (59.69%) and an associated cause-of-death in 786 (40.31%). Between 1985 and 2005 records show a 59.8% decline in the mortality coefficient due to paracoccidioidomycosis as the underlying cause and a 53.0% decline in the mortality as associated cause. The largest number of deaths occurred among men, in the older age groups, and among rural workers, with an upward trend in winter months. The main causes associated with paracoccidioidomycosis as the underlying cause-of-death were pulmonary fibrosis, chronic lower respiratory tract diseases, and pneumonias. Malignant neoplasms and AIDS were the main underlying causes when paracoccidioidomycosis was an associated cause-of-death. The decision tables had to be adapted for the automated processing of causes of death in death certificates where paracoccidioidomycosis was mentioned. Conclusions. Using the multiple cause-of-death method together with the traditional underlying cause-of-death approach provides a new angle on research aimed at broadening our understanding of the natural history of paracoccidioidomycosis.

Causes of death of thoroughbred racehorses at Octavio Dupont Veterinary Hospital, Brazilian Jockey Club, Rio de Janeiro

Existem poucas pesquisas que abordam estudos epidemiológicos de mortes em cavalos de corrida de uma forma ampla. A maioria restringe-se a uma afecção ou procedimento específico. O Brasil não possui um programa de monitoramento de mortes instituído. Através de um estudo descritivo em associação a metodologia multivariada de análise, realizou-se um estudo epidemiológico de causa mortis relacionadas com afecções musculosqueléticas (MS), gastrointestinais (GI), sistema respiratório (RES), neurológico (NEU) e mortes súbitas (SD) durante os anos de 2002 a 2008 no Hospital Octavio Dupont, Rio de Janeiro. Os machos representaram o sexo mais afetado e a causa mortis relacionada com a taxa geral de mortalidade por grandes grupos de causas determinadas apresentou a seguinte ordem decrescentemente: MS>GI>SD>NEU>RES. A maioria dos óbitos registrados foi de cavalos na faixa etária de quatro a cinco anos (ID4-ID5). Seguidamente, observaram-se as seguintes relações de correspondência: (Triênio = SM-ID>5-SD; ID>5-GI; ID4-5-MS; SF-ID<4-RES/NEU); (Quatriênio = SM - ID>5 - GI; SF - ID<4 - NEU; ID4-5 - MS; GI - ID>5). O presente estudo aponta a importância e necessidade de estudos epidemiológicos sobre lesões em cavalos atletas, objetivando o diagnostico, reconhecimento de fatores predisponentes e prevenção.

Prevalence and causes of visual impairment in a Brazilian population: The Botucatu Eye Study

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Evaluation of Satisfaction of Patients Rehabilitated With Zygomatic Fixtures

Purpose: The aim of this study was to evaluate the satisfaction of patients rehabilitated with zygomatic fixtures and prosthesis with immediate loading.Materials and Methods: The study selected patients who were rehabilitated with zygomatic implants at the clinic of the Latin American Institute for Dental Research and Education (ILAPEO. Curitiba-PR. Brasil) between 2005 and 2009. The patients were asked to answer a control-questionnaire during their follow-up visits. Data were collected regarding the level of patient satisfaction, reason for dissatisfaction, number of post-operative clinical sessions, and the type of complication. Sixteen patients were selected: 10 females and 6 males.Results: Half of the patients were completely satisfied while the other half were satisfied with some complaints. The complaints were related to hygiene, esthetics, phonetics, and discomfort during chewing. Regarding the post-operative evaluation, 50% of the patients were attended due to the prosthesis (62.5%) and the implant (37.5%).Conclusions: The treatment with zygomatic fixtures is predictable and reliable. The patients were satisfied both with implants and prosthesis. (C) 2012 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 70: 314-319, 2012

Possible causes of spatial variability in Diatraea saccharalis Fabr. (Lep., Crambidae) and its parasitoid populations in sugarcane fields in Brazil

Based on the large data set stored in some sugarcane mills regarding the biological control programme of Diatraea saccharalis using the parasitoids Cotesia flavipes and tachinid flies, the aim of the present study was to determine whether sugarcane varieties, number of cuts and plant ages are major determinants in promoting spatial variability in D. saccharalis, C. flavipes and tachinid fly populations in sugarcane fields in the state of São Paulo (Brazil). The data set used to support this study was provided by the Sao Joao and Barra sugarcane mills. Coefficient of variation was adopted as a measure of the spatial variability of population density. Spatial variability was estimated for the total density of D. saecharalis (parasitized + unparasitized larvae), and also for D. saccharalis larvae parasitized by tachinids and by C. flavipes. Statistical analysis revealed that the spatial variation in D. saccharalis populations was influenced by the number of cuts and by plant ages in the Barra and Sao Joao Mills, respectively. Similar results were obtained for D. saccharalis larvae parasitized by tachinids; however, in the Sao Joao Mill, the spatial variability of these populations was also influenced by the different number of varieties. Finally, considering D. saccharalis larvae parasitized by C. flavipes, no significant regressions with any of the three categories were observed for both sugarcane mills. The multitrophic implications for this agricultural system are also discussed.