What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P <0.002) and orlistat for obesity (P <0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer’s disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context

Rocks Associated With the Mississippian-Pennsylvanian Unconformity in Southwestern Indiana

The purpose of this field conference is to acquaint participants with strata that are associated with the Mississippian-Pennsylvanian unconformity in southwestern Indiana. Criteria which aid in distinguishing between Mansfield strata of Pottsville (early Pennsylvanian) age and classic formations of Chester (late Mississippian) age will receive considerable attention in discussions at evening meetings and on the outcrop. Inspection of limestone and sandstone quarries will afford an insight into the economic products of Chester and Mansfield rocks

A new analysis of the GJ581 extrasolar planetary system

We have done a new analysis of the available observations for the GJ581 exoplanetary system. Today this system is controversial due to choices that can be done in the orbital determination. The main ones are the ocurrence of aliases and the additional bodies - the planets f and g - announced in Vogt et al. 2010. Any dynamical study of exoplanets requires the good knowledge of the orbital elements and the investigations involving the planet g are particularly interesting, since this body would lie in the Habitable Zone (HZ) of the star GJ581. This region,for this system, is very attractive of the dynamical point of view due to several resonances of two and three bodies present there. In this work, we investigate the conditions under which the planet g may exist. We stress the fact that the planet g is intimately related with the orbital elements of the planet d; more precisely, we conclude that it is not possible to disconnect its existence from the determination of the eccentricity of the planet d. Concerning the planet f, we have found one solution with period $\approx 450$ days, but we are judicious about any affirmation concernig this body because its signal is in the threshold of detection and the high period is in a spectral region where the ocorruence of aliases is very common. Besides, we outline some dynamical features of the habitable zone with the dynamical map and point out the role played by some resonances laying there.Comment: 12 pages, 9 figure

Characterizing Multi-planet Systems with Classical Secular Theory

Classical secular theory can be a powerful tool to describe the qualitative character of multi-planet systems and offer insight into their histories. The eigenmodes of the secular behavior, rather than current orbital elements, can help identify tidal effects, early planet-planet scattering, and dynamical coupling among the planets, for systems in which mean-motion resonances do not play a role. Although tidal damping can result in aligned major axes after all but one eigenmode have damped away, such alignment may simply be fortuitous. An example of this is 55 Cancri (orbital solution of Fischer et al., 2008) where multiple eigenmodes remain undamped. Various solutions for 55 Cancri are compared, showing differing dynamical groupings, with implications for the coupling of eccentricities and for the partitioning of damping among the planets. Solutions for orbits that include expectations of past tidal evolution with observational data, must take into account which eigenmodes should be damped, rather than expecting particular eccentricities to be near zero. Classical secular theory is only accurate for low eccentricity values, but comparison with other results suggests that it can yield useful qualitative descriptions of behavior even for moderately large eccentricity values, and may have advantages for revealing underlying physical processes and, as large numbers of new systems are discovered, for triage to identify where more comprehensive dynamical studies should have priority.Comment: Published in Celestial Mechanics and Dynamical Astronomy, 25 pages, 10 figure

Multisource noninvasive genetics of brown bears (Ursus arctos) in Greece reveals a highly structured population and a new matrilineal contact zone in southern Europe

In human‐dominated landscapes, connectivity is crucial for maintaining demographically stable mammalian populations. Here, we provide a comprehensive noninvasive genetic study for the brown bear population in the Hellenic Peninsula. We analyze its population structuring and connectivity, estimate its population size throughout its distribution, and describe its phylogeography in detail for the first time. Our results, based on 150 multilocus genotypes and on 244‐bp sequences of the mtDNA control region, show the population is comprised by three highly differentiated genetic clusters, consistent with geographical populations of Pindos, Peristeri, and Rhodope. By detecting two male bears with Rhodopean ancestry in the western demes, we provide strong evidence for the ongoing genetic connectivity of the geographically fragmented eastern and western distributions, which suggests connectivity of the larger East Balkan and Pindos‐Dinara populations. Total effective population size (Ne) was estimated to be 199 individuals, and total combined population size (NC) was 499, with each cluster showing a relatively high level of genetic variability, suggesting that migration has been sufficient to counteract genetic erosion. The mtNDA results were congruent with the microsatellite data, and the three genetic clusters were matched predominantly with an equal number of mtDNA haplotypes that belong to the brown bear Western mitochondrial lineage (Clade 1), with two haplotypes being globally new and endemic. The detection of a fourth haplotype that belongs to the Eastern lineage (Clade 3a1) in three bears from the western distribution places the southernmost secondary contact zone between the Eastern and Western lineages in Greece and generates new hypotheses about postglacial maxima migration routes. This work indicates that the genetic composition and diversity of Europe's low‐latitude fringe population are the outcome of ancient and historical events and highlight its importance for the connectivity and long‐term persistence of the species in the Balkans

Anisotropy studies around the galactic centre at EeV energies with the Auger Observatory

Data from the Pierre Auger Observatory are analyzed to search for anisotropies near the direction of the Galactic Centre at EeV energies. The exposure of the surface array in this part of the sky is already significantly larger than that of the fore-runner experiments. Our results do not support previous findings of localized excesses in the AGASA and SUGAR data. We set an upper bound on a point-like flux of cosmic rays arriving from the Galactic Centre which excludes several scenarios predicting sources of EeV neutrons from Sagittarius $A$. Also the events detected simultaneously by the surface and fluorescence detectors (the `hybrid' data set), which have better pointing accuracy but are less numerous than those of the surface array alone, do not show any significant localized excess from this direction.Comment: Matches published versio

Evidence for a mixed mass composition at the `ankle' in the cosmic-ray spectrum

We report a first measurement for ultra-high energy cosmic rays of the correlation between the depth of shower maximum and the signal in the water Cherenkov stations of air-showers registered simultaneously by the fluorescence and the surface detectors of the Pierre Auger Observatory. Such a correlation measurement is a unique feature of a hybrid air-shower observatory with sensitivity to both the electromagnetic and muonic components. It allows an accurate determination of the spread of primary masses in the cosmic-ray flux. Up till now, constraints on the spread of primary masses have been dominated by systematic uncertainties. The present correlation measurement is not affected by systematics in the measurement of the depth of shower maximum or the signal in the water Cherenkov stations. The analysis relies on general characteristics of air showers and is thus robust also with respect to uncertainties in hadronic event generators. The observed correlation in the energy range around the `ankle' at $\lg(E/{\rm eV})=18.5-19.0$ differs significantly from expectations for pure primary cosmic-ray compositions. A light composition made up of proton and helium only is equally inconsistent with observations. The data are explained well by a mixed composition including nuclei with mass $A > 4$. Scenarios such as the proton dip model, with almost pure compositions, are thus disfavoured as the sole explanation of the ultrahigh-energy cosmic-ray flux at Earth.Comment: Published version. Added journal reference and DOI. Added Report Numbe

Search for displaced vertices arising from decays of new heavy particles in 7 TeV pp collisions at ATLAS

We present the results of a search for new, heavy particles that decay at a significant distance from their production point into a final state containing charged hadrons in association with a high-momentum muon. The search is conducted in a pp-collision data sample with a center-of-mass energy of 7 TeV and an integrated luminosity of 33 pb^-1 collected in 2010 by the ATLAS detector operating at the Large Hadron Collider. Production of such particles is expected in various scenarios of physics beyond the standard model. We observe no signal and place limits on the production cross-section of supersymmetric particles in an R-parity-violating scenario as a function of the neutralino lifetime. Limits are presented for different squark and neutralino masses, enabling extension of the limits to a variety of other models.Comment: 8 pages plus author list (20 pages total), 8 figures, 1 table, final version to appear in Physics Letters