The 'top 100' drugs and classes in England An updated 'starter formulary' for trainee prescribers.

AIMS: Prescribing is a complex skill required of doctors and, increasingly, other healthcare professionals. Use of a personal formulary can help to develop this skill. In 2006-9, we developed a core list of the 100 most commonly prescribed drugs. Our aim in the present study was to update this 'starter formulary' to ensure its continued relevance for prescriber training. METHODS: We analysed large contemporary primary and secondary care datasets to identify the most frequently prescribed medicinal products. Items were classified into natural groups, broadly following their British National Formulary classification. The resulting drug groups were included in the core list if they comprised ≥0.1% prescriptions in both settings or ≥0.2-0.3% prescriptions in one setting. Drugs from emergency guidelines that did not qualify by prescribing frequency completed the list. RESULTS: Over 1 billion primary care items and approximately 1.8 million secondary care prescriptions were analysed. The updated list comprises 81 drug groups commonly prescribed in both settings; 6 from primary care; 7 from secondary care; and 6 from emergency guidelines. 88% of the formulary was unchanged. Notable changes include entry of newer anti-epileptics and dipeptidyl peptidase-4 inhibitors and exit of phenytoin and thiazolidinediones. CONCLUSIONS: The relative stability of the core drug list over 9 years and the current update ensure that learning based on this list remains relevant to practice. Trainee prescribers may be encouraged to use this 'starter formulary' to develop a sound basis of prescribing knowledge and skills that they can subsequently apply more widely

Necromass in forests of Madre de Dios, Peru: a comparison between terra firme and lowland forests

Stocks of dead wood or necromass represent an important portion of biomass and nutrients in tropical forests. The objectives of this study were: 1) to evaluate and compare the necromass of "terra firme" and lowlands forests, (2) to study the relationship between necromass, above-ground biomass and wood density, and (3) to estimate the necromass of the department of Madre de Dios, Peru. Stocks of necromass and above-ground biomass were estimated at three different locations using permanent plots and line intercept transects. The average volume of necromass for the three sites was 72.9 m3 ha-1 with an average weight varying between 24.8 and 30.7 Mg ha-1, depending on the estimations of dead wood density used for the calculations. Terra firme forests had significantly higher stocks of necromass than lowland forests. The amount of necromass was 11% of the total above-ground biomass in Madre de Dios forests. The total stock of carbon stored in dead wood for the entire department of Madre de Dios was estimated to be approximately 100 mega tonnes of carbon. This is ten times more than the annual fossil fuel emissions of Peru between 2000 and 2008. The substantial stocks of necromass emphasize the importance of these types of field studies, considering that this component of tropical forest carbon cannot be detected using other methods such as satellite remote sensing

Randomized trials, generalizability, and meta-analysis: Graphical insights for binary outcomes

BACKGROUND: Randomized trials stochastically answer the question. "What would be the effect of treatment on outcome if one turned back the clock and switched treatments in the given population?" Generalizations to other subjects are reliable only if the particular trial is performed on a random sample of the target population. By considering an unobserved binary variable, we graphically investigate how randomized trials can also stochastically answer the question, "What would be the effect of treatment on outcome in a population with a possibly different distribution of an unobserved binary baseline variable that does not interact with treatment in its effect on outcome?" METHOD: For three different outcome measures, absolute difference (DIF), relative risk (RR), and odds ratio (OR), we constructed a modified BK-Plot under the assumption that treatment has the same effect on outcome if either all or no subjects had a given level of the unobserved binary variable. (A BK-Plot shows the effect of an unobserved binary covariate on a binary outcome in two treatment groups; it was originally developed to explain Simpsons's paradox.) RESULTS: For DIF and RR, but not OR, the BK-Plot shows that the estimated treatment effect is invariant to the fraction of subjects with an unobserved binary variable at a given level. CONCLUSION: The BK-Plot provides a simple method to understand generalizability in randomized trials. Meta-analyses of randomized trials with a binary outcome that are based on DIF or RR, but not OR, will avoid bias from an unobserved covariate that does not interact with treatment in its effect on outcome

Necromass in forests of Madre de Dios, Peru: A comparison between terra firme and lowland forests

This is the final version of the article. Available from Universidad Nacional Mayor de San Marcos, Facultad de Ciencias Biológicas via the DOI in this record.Stocks of dead wood or necromass represent an important portion of biomass and nutrients in tropical forests. The objectives of this study were: 1) to evaluate and compare the necromass of “terra firme” and lowlands forests, (2) to study the relationship between necromass, above-ground biomass and wood density, and (3) to estimate the necromass of the department of Madre de Dios, Peru. Stocks of necromass and above-ground biomass were estimated at three different locations using permanent plots and line intercept transects. The average volume of necromass for the three sites was 72.9 m3 ha-1 with an average weight varying between 24.8 and 30.7 Mg ha-1, depending on the estimations of dead wood density used for the calculations. Terra firme forests had significantly higher stocks of necromass than lowland forests. The amount of necromass was 11% of the total above-ground biomass in Madre de Dios forests. The total stock of carbon stored in dead wood for the entire department of Madre de Dios was estimated to be approximately 100 mega tonnes of carbon. This is ten times more than the annual fossil fuel emissions of Peru between 2000 and 2008. The substantial stocks of necromass emphasize the importance of these types of field studies, considering that this component of tropical forest carbon cannot be detected using other methods such as satellite remote sensing

Socio-economic status influences the relationship between obesity and antenatal depression: Data from a prospective cohort study

Background Obesity has been associated with increased risk of antenatal depression, but little is known about this relationship. This study tested whether socio-economic status (SES) influences the relationship between obesity and antenatal depression. Methods Data were taken from the Screening for Pregnancy Endpoints (SCOPE) cohort. BMI was calculated from measured height and weight at 15±1 weeks' gestation. Underweight women were excluded. SES was indicated by self-reported household income (dichotomised around the median: low SES ≤£45,000; high SES >£45,000). Antenatal depression was defined as scoring ≥13 on the Edinburgh Postnatal Depression Scale at both 15±1 and 20±1 weeks' gestation, to identify persistently elevated symptoms of depression. Results Five thousand five hundred and twenty two women were included in these analyses and 5.5% had persistently elevated antenatal depression symptoms. There was a significant interaction between SES and BMI on the risk of antenatal depression (p=0.042). Among high SES women, obese women had approximately double the odds of antenatal depression than normal weight controls (AOR 2.11, 95%CI 1.16–3.83, p=0.014, adjusted for confounders). Among low SES women there was no association between obesity and antenatal depression. The interaction effect was robust to alternative indicators of SES in sensitivity analyses. Limitations 1) Antenatal depression was assessed with a self-reported screening measure; and 2) potential mediators such as stigma and poor body-image could not be examined. Conclusions Obesity was only associated with increased risk of antenatal depression among high SES women in this sample. Healthcare professionals should be aware that antenatal depression is more common among low SES women, regardless of BMI category

Freezing and water availability structure the evolutionary diversity of trees across the Americas

The historical course of evolutionary diversification shapes the current distribution of biodiversity, but the main forces constraining diversification are still a subject of debate. We unveil the evolutionary structure of tree species assemblages across the Americas to assess whether an inability to move or an inability to evolve is the predominant constraint in plant diversification and biogeography. We find a fundamental divide in tree lineage composition between tropical and extratropical environments, defined by the absence versus presence of freezing temperatures. Within the Neotropics, we uncover a further evolutionary split between moist and dry forests. Our results demonstrate that American tree lineages tend to retain their ancestral environmental relationships and that phylogenetic niche conservatism is the primary force structuring the distribution of tree biodiversity. Our study establishes the pervasive importance of niche conservatism to community assembly even at intercontinental scales

Firms' Main Market, Human Capital and Wages

Recent international trade literature emphasizes two features in characterizing the current patterns of trade: efficiency heterogeneity at the firm level and quality differentiation. This paper explores human capital and wage differences across firms in that context. We build a partial equilibrium model predicting that firms selling in more-remote markets employ higher human capital and pay higher wages to employees within each education group. The channel linking these variables is firms’ endogenous choice of quality. Predictions are tested using Spanish employer-employee matched data that classify firms according to four main destination markets: local, national, European Union, and rest of the World. Employees’ average education is increasing in the remoteness of firm’s main output market. Market–destination wage premia are large, increasing in the remoteness of the market, and increasing in individual education. These results suggest that increasing globalization may play a significant role in raising wage inequality within and across education groups

Scalable magnet geometries enhance tumour targeting of magnetic nano-carriers

Targeted drug delivery systems aim to increase therapeutic effect within the target tissue or organ, while reducing off-target toxicity associated with systemic delivery. Magnetic drug targeting has been shown to be an effective strategy by manipulating therapeutics inside the body using a magnetic field and an iron oxide carrier. However, the effective targeting range of current magnets limits this method to small animal experiments or superficial parts of the human body. Here we produce clinically translatable magnet designs capable of increasing exposure of tissue to magnetic fields and field gradients, leading to increased carrier accumulation. The iron oxide nanoparticle capturing efficiency was first assessed in vitro using a simple vascular flow system. Secondly, accumulation of these particles, following magnetic targeting, was evaluated in vivo using a range of different magnet designs. We observed that our bespoke magnet produced a 4-fold increase in effective targeting depth when compared to a conventional 1 T disk magnet. Finally, we show that this magnet is readily scalable to human size proportions and has the potential to target 100 nm particles up to a depth of 7 cm at specific locations of human body

Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies

Objectives To compare the prevalence and predictors of alcohol use in multiple cohorts. Design Cross-cohort comparison of retrospective and prospective studies. Setting Population-based studies in Ireland, the UK, Australia and New Zealand. Participants 17 244 women of predominantly Caucasian origin from two Irish retrospective studies (Growing up in Ireland (GUI) and Pregnancy Risk Assessment Monitoring System Ireland (PRAMS Ireland)), and one multicentre prospective international cohort, Screening for Pregnancy Endpoints (SCOPE) study. Primary and secondary outcome measures Prevalence of alcohol use pre-pregnancy and during pregnancy across cohorts. Sociodemographic factors associated with alcohol consumption in each cohort. Results Alcohol consumption during pregnancy in Ireland ranged from 20% in GUI to 80% in SCOPE, and from 40% to 80% in Australia, New Zealand and the UK. Levels of exposure also varied substantially among drinkers in each cohort ranging from 70% consuming more than 1–2 units/week in the first trimester in SCOPE Ireland, to 46% and 15% in the retrospective studies. Smoking during pregnancy was the most consistent predictor of gestational alcohol use in all three cohorts, and smokers were 17% more likely to drink during pregnancy in SCOPE, relative risk (RR)=1.17 (95% CI 1.12 to 1.22), 50% more likely to drink during pregnancy in GUI, RR=1.50 (95% CI 1.36 to 1.65), and 42% more likely to drink in PRAMS, RR=1.42 (95% CI 1.18 to 1.70). Conclusions Our data suggest that alcohol use during pregnancy is prevalent and socially pervasive in the UK, Ireland, New Zealand and Australia. New policy and interventions are required to reduce alcohol prevalence both prior to and during pregnancy. Further research on biological markers and conventions for measuring alcohol use in pregnancy is required to improve the validity and reliability of prevalence estimates