A meta-synthesis of clinicians’ experiences and perceptions of benzodiazepine prescribing: implications for the integration of health services

Purpose: To investigate clinicians’ experiences and perceptions of benzodiazepine prescribing. Theory: To develop a theory for improving benzodiazepine prescribing practice, exploring implications for an integrated health services approach. Methods: A multidisciplinary team conducted a systematic review and metasynthesis of qualitative studies published in Western settings between January 1990 and August 2011 using ‘thematic synthesis’. Study quality was assessed using the Critical Appraisal Skills Programme (CASP) checklist. Findings: We included eight studies. Prescribing was complex and demanding within the constraints of daily practice, leading to variable prescribing by individual practitioners and between GPs. Decisions were influenced by the changing context of GPs’ work, their views of their own role and responsibilities, and their perceptions of benzodiazepines and alternative treatment options. Clinical practice was also influenced by GPs’ perception of patient expectations, the relationship with their patient, and whether they were initiating, continuing or withdrawing benzodiazepines. Discussion: Benzodiazepine prescribing could be improved in line with current guidance through improved communication with patients, ensuring GPs accept responsibility for deciding whether or not to continue prescribing for patients who were previously managed in secondary care, education and training of primary and secondary care clinicians on other treatments and greater provision of alternatives to drugs

General practitioners prescribing of benzodiazepines in Western Primary Care: metasynthesis of qualitative studies

Introduction: Benzodiazepines are widely prescribed in primary care to treat conditions such as insomnia, anxiety and chronic back pain. Despite guidance stating that they should only be used short-term in the UK and elsewhere, numerous studies have shown that these drugs are being prescribed for extended periods. This has led patients, policymakers and researchers to question why this is the case, what influences a clinician’s decision whether or not to initiate, continue or withdraw a benzodiazepine prescription and how inappropriate prescribing might be addressed. We aimed to explore GPs’ experiences and perceptions of benzodiazepine prescribing by conducting a meta-synthesis of qualitative studies to develop an explanatory framework of processes underlying benzodiazepine prescribing. Methods: A systematic review of the literature was conducted to identify studies using qualitative methods which examined GPs’ experiences of prescribing benzodiazepines in a primary care setting. We included studies published in Western settings in a European language, between January 1990 and August 2011. Studies were critically appraised using the Critical Appraisal Skills Programme Checklist (CASP). A thematic synthesis approach was used to synthesise findings. Results: A total of eight studies were included in the meta-synthesis. Analysis produced an explanatory framework detailing factors underlying benzodiazepine prescribing. This revealed that benzodiazepine prescribing is viewed as a complex task, and prescribing decisions are influenced by interaction between the following: the context within which benzodiazepine prescribing is taking place, the changing role and responsibility of GPs, variation in GPs’ attitudes towards benzodiazepines, a perceived lack of alternative treatment options, GPs’ perception of patient expectations, and the relationship between GPs and patients. Conclusion: Our findings help to explain reasons for prescribing and define key recommendations for improving adherence to clinical guidelines advocating short-term use of benzodiazepines including: education and training of professionals on benzodiazepine prescribing and withdrawal, improved communication with patients, and an increase in the availability of alternative treatment options

Clinicians’ experiences and perceptions of benzodiazepine prescribing in Western primary care settings: systematic review and meta-synthesis

The problem: Benzodiazepines are known to have limited long-term therapeutic benefits, and to have adverse effects including addiction. Consequently, clinical guidelines advocate strictly short-term use. However, benzodiazepines continue to be prescribed for extended periods for conditions such as insomnia, anxiety and chronic back pain. Whilst research suggests that this may be due to factors such as patient demographics, GP attributes and general practice structures, clinicians’ experiences, beliefs and attitudes have also been shown to impact on their prescribing practices. Qualitative studies have the potential to better understand this clinical area by revealing the processes underlying prescribing practices. The approach: We conducted a systematic review and meta-synthesis of qualitative research exploring GPs’ experiences and perceptions of benzodiazepine prescribing. Included studies needed to use both qualitative data and analysis, contain GP or nurse generated data on their experiences of prescribing benzodiazepines in Western primary care settings, and have been published between January 1990 and August 2011 in a European language. Findings from included studies were synthesised using the thematic synthesis approach in order to build an explanatory model of processes underlying prescribing practice. Findings: Eight studies were included in the review. Prescribing decisions were complex, uncomfortable and demanding, particularly within the constraints of daily practice. Overall, GPs showed ambivalent attitudes towards benzodiazepine prescribing, and inconsistently applied management strategies for their use. Variation in prescribing practice was attributed to: the changing context within which GPs work; the role and responsibility of the GP; their attitudes towards benzodiazepines and other interventions; the perceived lack of alternative treatments; and GPs’ relationships with their patients and perceptions of their patients’ expectations. Different challenges are faced in managing initiation, continuation and withdrawal of benzodiazepines. Consequences: The explanatory model produced from the themes identified within the metasynthesis can be used to propose ways to improve adherence to clinical guidelines which recommend short-term use of benzodiazepines only. Recommendations include: increasing education and training to change clinicians’ understanding and perceptions of both benzodiazepines and alternative treatments; increasing the availability of alternative treatments; encouraging clinicians to directly explore patients’ expectations with them to meet their expectations for clinical improvements

Psychometric qualities of the Educational Identity Processes Scale (EIPS)

In the educational domain, the development of identity becomes especially salient during school transition phases. To assess the specific identity processes that match the adolescents' experiences before and after the school transition, the Educational Identity Processes Scale (EIPS) was developed. The present study aimed to test the psychometric qualities of the EIPS by examining its factor structure, the internal and convergent validity of the identity dimensions, and whether the questionnaire was measurement invariant over time. The pre-transition version was tested in a Dutch sample (N = 242 early adolescents) and the post-transition version was tested in a Lithuanian sample (N = 1,268 mid-adolescents). Findings indicated good psychometric qualities for both the pre- and post-transition versions of the EIPS. Additionally, context dependencies were observed, as distance to the transition influenced the meaning of specific identity processes and determined whether specific processes could be considered as part of normative development

Hardware Sequencing of Inflatable Nonlinear Actuators for Autonomous Soft Robots

Soft robots are an interesting alternative for classic rigid robots in appli-cations requiring interaction with organisms or delicate objects. Elastic inflatable actuators are one of the preferred actuation mechanisms for soft robots since they are intrinsically safe and soft. However, these pneumatic actuators each require a dedicated pressure supply and valve to drive and control their actuation sequence. Because of the relatively large size of pres-sure supplies and valves compared to electrical leads and electronic control-lers, tethering pneumatic soft robots with multiple degrees of freedom is bulky and unpractical. Here, a new approach is described to embed hardware intelligence in soft robots where multiple actuators are attached to the same pressure supply, and their actuation sequence is programmed by the inter-action between nonlinear actuators and passive flow restrictions. How to model this hardware sequencing is discussed, and it is demonstrated on an 8-degree-of-freedom walking robot where each limb comprises two actua-tors with a sequence embedded in their hardware. The robot is able to carry pay loads of 800 g in addition to its own weight and is able to walk at travel speeds of 3 body lengths per minute, without the need for complex on-board valves or bulky tethers.ERC starting gran

The VORTEX project: first results and perspectives

(abridged) Vortex coronagraphs are among the most promising solutions to perform high contrast imaging at small angular separations. They feature a very small inner working angle, a clear 360 degree discovery space, have demonstrated very high contrast capabilities, are easy to implement on high-contrast imaging instruments, and have already been extensively tested on the sky. Since 2005, we have been designing, developing and testing an implementation of the charge-2 vector vortex phase mask based on concentric subwavelength gratings, referred to as the Annular Groove Phase Mask (AGPM). Science-grade mid-infrared AGPMs were produced in 2012 for the first time, using plasma etching on synthetic diamond substrates. They have been validated on a coronagraphic test bench, showing broadband peak rejection up to 500:1 in the L band, which translates into a raw contrast of about $6\times 10^{-5}$ at $2 \lambda/D$. Three of them have now been installed on world-leading diffraction-limited infrared cameras (VLT/NACO, VLT/VISIR and LBT/LMIRCam). During the science verification observations with our L-band AGPM on NACO, we observed the beta Pictoris system and obtained unprecedented sensitivity limits to planetary companions down to the diffraction limit ($0.1''$). More recently, we obtained new images of the HR 8799 system at L band during the AGPM first light on LMIRCam. After reviewing these first results obtained with mid-infrared AGPMs, we will discuss the short- and mid-term goals of the on-going VORTEX project, which aims to improve the performance of our vortex phase masks for future applications on second-generation high-contrast imagers and on future extremely large telescopes (ELTs).Comment: To appear in SPIE proceedings vol. 914

Membrane stripping enables effective electrochemical ammonia recovery from urine while retaining microorganisms and micropollutants

Ammonia recovery from urine avoids the need for nitrogen removal through nitrification/denitrification and re-synthesis of ammonia (NH3) via the Haber-Bosch process. Previously, we coupled an alkalifying electrochemical cell to a stripping column, and achieved competitive nitrogen removal and energy efficiencies using only electricity as input, compared to other technologies such as conventional column stripping with air. Direct liquid-liquid extraction with a hydrophobic gas membrane could be an alternative to increase nitrogen recovery from urine into the absorbent while minimizing energy requirements, as well as ensuring microbial and micropollutant retention. Here we compared a column with a membrane stripping reactor, each coupled to an electrochemical cell, fed with source-separated urine and operated at 20 A m−2. Both systems achieved similar nitrogen removal rates, 0.34 ± 0.21 and 0.35 ± 0.08 mol N L−1 d−1, and removal efficiencies, 45.1 ± 18.4 and 49.0 ± 9.3%, for the column and membrane reactor, respectively. The membrane reactor improved nitrogen recovery to 0.27 ± 0.09 mol N L−1 d−1 (38.7 ± 13.5%) while lowering the operational (electrochemical and pumping) energy to 6.5 kWhe kg N−1 recovered, compared to the column reactor, which reached 0.15 ± 0.06 mol N L−1 d−1 (17.2 ± 8.1%) at 13.8 kWhe kg N−1. Increased cell concentrations of an autofluorescent E. coli MG1655 + prpsM spiked in the urine influent were observed in the absorbent of the column stripping reactor after 24 h, but not for the membrane stripping reactor. None of six selected micropollutants spiked in the urine were found in the absorbent of both technologies. Overall, the membrane stripping reactor is preferred as it improved nitrogen recovery with less energy input and generated an E. coli- and micropollutant-free product for potential safe reuse. Nitrogen removal rate and efficiency can be further optimized by increasing the NH3 vapor pressure gradient and/or membrane surface area