Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to improve patient outcomes. Protocol for an observational study

INTRODUCTION: Medicines optimisation is a key role for hospital pharmacists, but with ever-increasing demands on services there is a need to increase efficiency while maintaining patient safety. The aim of this study is to develop a prognostic model, the Medicines Optimisation Assessment Tool (MOAT), which can be used to target patients most in need of pharmacists' input while in hospital. METHODS AND ANALYSIS: The MOAT will be developed following recommendations of the Prognosis Research Strategy partnership. Using a cohort study we will prospectively include 1500 adult patients from the medical wards of two UK hospitals. Data on medication-related problems (MRPs) experienced by study patients will be collected by pharmacists at the study sites as part of their routine daily clinical assessment of patients. Data on potential risk factors such as polypharmacy, renal impairment and the use of 'high risk' medicines will be collected retrospectively from the information departments at the study sites, laboratory reporting systems and patient medical records. Multivariable logistic regression models will then be used to determine the relationship between potential risk factors and the study outcome of preventable MRPs that are at least moderate in severity. Bootstrapping will be used to adjust the MOAT for optimism, and predictive performance will be assessed using calibration and discrimination. A simplified scoring system will also be developed, which will be assessed for sensitivity and specificity. ETHICS AND DISSEMINATION: This study has been approved by the Proportionate Review Service Sub-Committee of the National Health Service Research Ethics Committee Wales REC 7 (16/WA/0016) and the Health Research Authority (project ID 197298). We plan to disseminate the results via presentations at relevant patient/public, professional, academic and scientific meetings and conferences, and will submit findings for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02582463

Analysis of pharmacist‐identified medication‐related problems at two United Kingdom hospitals: a prospective observational study

OBJECTIVE: Hospital pharmacy is undergoing a period of rapid change, with pharmacists needing to focus where they add most value. Our aim was to identify where pharmacists have potential for greatest impact by analysing data on clinically relevant medication-related problems (MRPs). METHODS: We included consecutive admissions from adult medical wards at two UK hospitals between April and November 2016. MRPs were identified by pharmacists at the study sites as part of their routine daily patient assessments, validated and assessed for preventability and severity. Descriptive analyses were performed on clinically relevant (moderate or severe preventable) MRPs to establish the stage of inpatient stay where identified and their types/categories (overall and by stage of inpatient stay). KEY FINDINGS: Among 1503 eligible admissions, 2614 validated MRPs were identified, of which 1153 were moderate or severe, and preventable. Over 70% of these clinically relevant MRPs were identified during/before the first ward-based pharmacy review of patients. The most frequent MRP subcategory was 'indication not treated/missing therapy', accounting for 46% of clinically relevant MRPs. Dose selection issues were the next most common, accounting for 24%. The subcategory 'indication not treated/missing therapy' was identified more frequently at admission and discharge (53% and 45% of MRPs, respectively) compared with during the inpatient stay (14%), P < 0.001. CONCLUSIONS: This research suggests patients are at greatest need of pharmacist input in terms of identification/resolution of clinically relevant MRPs during early stages of inpatient stay; however, clinically relevant MRPs continue to occur throughout their stay, suggesting need for ongoing pharmacy review

Reconstructing pedigrees: some identifiability questions for a recombination-mutation model

Pedigrees are directed acyclic graphs that represent ancestral relationships between individuals in a population. Based on a schematic recombination process, we describe two simple Markov models for sequences evolving on pedigrees - Model R (recombinations without mutations) and Model RM (recombinations with mutations). For these models, we ask an identifiability question: is it possible to construct a pedigree from the joint probability distribution of extant sequences? We present partial identifiability results for general pedigrees: we show that when the crossover probabilities are sufficiently small, certain spanning subgraph sequences can be counted from the joint distribution of extant sequences. We demonstrate how pedigrees that earlier seemed difficult to distinguish are distinguished by counting their spanning subgraph sequences.Comment: 40 pages, 9 figure

Graphs Identified by Logics with Counting

We classify graphs and, more generally, finite relational structures that are identified by C2, that is, two-variable first-order logic with counting. Using this classification, we show that it can be decided in almost linear time whether a structure is identified by C2. Our classification implies that for every graph identified by this logic, all vertex-colored versions of it are also identified. A similar statement is true for finite relational structures. We provide constructions that solve the inversion problem for finite structures in linear time. This problem has previously been shown to be polynomial time solvable by Martin Otto. For graphs, we conclude that every C2-equivalence class contains a graph whose orbits are exactly the classes of the C2-partition of its vertex set and which has a single automorphism witnessing this fact. For general k, we show that such statements are not true by providing examples of graphs of size linear in k which are identified by C3 but for which the orbit partition is strictly finer than the Ck-partition. We also provide identified graphs which have vertex-colored versions that are not identified by Ck.Comment: 33 pages, 8 Figure

Rubella in South Africa: An impending Greek tragedy?

Background. The incidence of congenital rubella syndrome (CRS) is unknown in South Africa. There is evidence that it may be significant and largely undetected, particularly in the upper socio-economic group. This may be due to incomplete routine administration of MMR vaccine in infancy and a build-up of susceptible females reaching the childbearing age group who could be exposed to the extensive reservoir of virus in the unimmunised public sector of the population.Objective. To assess the extent of the immunity gap to rubella by testing for protective IgG antibodies and the incidence of rubella infection by testing for IgM antibodies in sera. The data obtained would also be used to model the extent of CRS.Design. Residual laboratory serum specimens from public and private laboratories were serologically tested for rubella IgG antibodies to investigate the immunity gap in the population and IgM antibodies in sera collected from the measles rashlike illness surveillance programme. Modelling exercises calculated the force of infection and the predicted incidence of CRS in South Africa.Results. The serological immunity gap was significantly greater in the private sector specimens compared with the public sector – 10.7% versus 5.4%, respectively. In most years rubella caused much more rash-like illness than measles, with a significant number (5.1 - 9.6%) of rubella-positive IgM specimens occurring in women of childbearing age.Conclusion. Modelling of the data suggests that the extent of CRS may be grossly underestimated in South Africa. Approximately 654 cases are calculated to occur every year. It is suggested that selective immunisation of girls before puberty should be instituted together with a routine rubella immunisation programme of infants to forestall a possible future outbreak of CRS, as occurred in Greece in 1993

Unconstrained design: improving multitasking with in-vehicle information systems through enhanced situation awareness

In the age of information, in-vehicle multitasking is inevitable. The popularity of the automobile in combination with the demands of everyday life presents a demand to do more than simply focus on the road. Situation Awareness (SA) is a theory that allows designers to understand how operators interact in dynamic, complex environments. Unconstrained Design is proposed as a way of enhancing multitasking performance in-vehicle. This paper presents an experimental investigation into human-machine interface concepts that aim to support drivers to multitask in-vehicle when frequent task switching is required. Two SA-based approaches were investigated, one which focussed on supporting preparation for a Non-Driving Related Activity (NDRA), and one which focussed on supporting the Driving Related Activity (DRA) when an NDRA is active. While multitasking, Contextual Cueing, using a Head-up Display, produced significant reductions in NDRA response time while an auditory lane keeping aid increased the amount of time a driver spent in the central region of a lane. This provides evidence to suggest that using SA and Unconstrained Design as a philosophy for the design of IVIS that supports drivers’ ability to multitask in-vehicle, could lead to task performance improvements.Jaguar Land Rove

Dense Packings of Congruent Circles in Rectangles with a Variable Aspect Ratio

We use computational experiments to find the rectangles of minimum area into which a given number n of non-overlapping congruent circles can be packed. No assumption is made on the shape of the rectangles. Most of the packings found have the usual regular square or hexagonal pattern. However, for 1495 values of n in the tested range n =< 5000, specifically, for n = 49, 61, 79, 97, 107,... 4999, we prove that the optimum cannot possibly be achieved by such regular arrangements. The evidence suggests that the limiting height-to-width ratio of rectangles containing an optimal hexagonal packing of circles tends to 2-sqrt(3) as n tends to infinity, if the limit exists.Comment: 21 pages, 13 figure

Nondegenerate parametric down conversion in coherently prepared two-level atomic gas

We describe parametric down conversion process in a two-level atomic gas, where the atoms are in a superposition state of relevant energy levels. This superposition results in splitting of the phase matching condition into three different conditions. Another, more important, peculiarity of the system under discussion is the nonsaturability of amplification coefficients with increasing pump wave intensity, under "sideband" generation conditions

Do red deer stags (Cervus elaphus) use roar fundamental frequency (F0) to assess rivals?

It is well established that in humans, male voices are disproportionately lower pitched than female voices, and recent studies suggest that this dimorphism in fundamental frequency (F0) results from both intrasexual (male competition) and intersexual (female mate choice) selection for lower pitched voices in men. However, comparative investigations indicate that sexual dimorphism in F0 is not universal in terrestrial mammals. In the highly polygynous and sexually dimorphic Scottish red deer Cervus elaphus scoticus, more successful males give sexually-selected calls (roars) with higher minimum F0s, suggesting that high, rather than low F0s advertise quality in this subspecies. While playback experiments demonstrated that oestrous females prefer higher pitched roars, the potential role of roar F0 in male competition remains untested. Here we examined the response of rutting red deer stags to playbacks of re-synthesized male roars with different median F0s. Our results show that stags’ responses (latencies and durations of attention, vocal and approach responses) were not affected by the F0 of the roar. This suggests that intrasexual selection is unlikely to strongly influence the evolution of roar F0 in Scottish red deer stags, and illustrates how the F0 of terrestrial mammal vocal sexual signals may be subject to different selection pressures across species. Further investigations on species characterized by different F0 profiles are needed to provide a comparative background for evolutionary interpretations of sex differences in mammalian vocalizations