Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice

Objective: To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice. Design: Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review. Setting: Four general practices. Participants: 1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community. Intervention: Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment. Main outcome measures: Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services. Results: 590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference £4.72 per 28 days, -£7.04 to -£2.41); equivalent to £61 per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference -0.2, -0.4 to -0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate. Conclusions: A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners

Comparing the economic value of virtual water with volumetric and stress-weighted approaches : a case for the tea supply chain

In this paper, we employ a new approach to assessing the impact and efficiency of virtual water use along the supply chain. This approach involves estimating the economic value of virtual water flows. A realistic tea supply chain case study is presented to test this new approach and compare it with alternative volumetric and stress-weighted methods. The case study is used to highlight the total value of the blue and grey water used to produce one tonne of tea as a finished good ($224). The case study also illustrates how variations in the relative unit value of water between geographies, in this case between multiple locations where crops are cultivated (India$0.08 m3, Indonesia $0.09 m3 and Kenya$0.27 m3), can be used to inform supply chain optimisation and allocative efficiency. Indeed, the case study suggests that taking into account the economic value of virtual water may provide differing prescriptions for the sustainable management of supply chains when compared to the traditional volumetric water footprint, and the stress-weighted water footprint used in LCA

Shifting from volume to economic value in virtual water allocation problems : a proposed new framework and methodology

Purpose: The water footprint provided a full methodology to operationalise the virtual water concept (the volume of water used along a supply chain to produce products and services). A key theme in the water footprint literature is the efficient allocation of water resources at the global scale given the feasibility of trading water intensive commodities from water rich to water poor areas: this is an economic problem of resource allocation between alternative and competing demands, albeit with a novel international component. Moreover, given that price signals indicating relative scarcity are usually either absent or distorted for water, it is also a problem that can be seen through the lens of environmental (or non-market) valuation. However, to date environmental valuation has not been used to inform the efficient use and allocation of water within and between the different locations encompassed by international supply chains. Methods: Drawing on an agri-food supply chain framework which we propose in this paper, we begin by conceptualising the economic values that accrue to water consumption (blue and green water) and degradation (grey water) at different points along a supply chain. Based on this conceptualisation, we assess the extent to which it is possible to approximate these economic values by relying on existing secondary data on the shadow value of water in different contexts. The use of secondary data in this way is known as benefit (or value) transfer. To achieve this, 706 unit estimates of the economic value of water are collected, standardised and reviewed encompassing off-stream water applications (agriculture, industry and municipal) and in-stream ecosystem services (waste assimilation, wildlife habitat, recreation, hydrological functions and passive uses). From this, a proposed methodology for valuing virtual water is presented and illustrated using the case study of global durum wheat pasta production. Results: The case study shows the total value of the virtual water used to produce one tonne of durum wheat pasta ($212). More importantly, the case study also highlights how variations in economic value between multiple locations where durum wheat is cultivated (Saskatchewan$0.10 m3, Arizona $0.08 m3 and Baja California$0.24 m3) indicate relative water scarcity and thus impact, as well as the potential for a more efficient allocation of virtual water. Conclusions: The main conclusion from this research is that when geographical disparities in the economic value of water use within a supply chain are accounted for, what was perhaps considered sustainable in volume terms, might not, in fact, represent the optimal allocation. However, future research opportunities highlight the need for additional data collection on the economic value of water in several contexts. This additional data would help the environmental valuation community to undertake a more comprehensive and robust approach to virtual water valuation. This paper is accompanied by the Data in Brief article entitled “Dataset on the in-stream and off-stream economic value of water.

3-D Perturbations in Conformal Turbulence

The effects of three-dimensional perturbations in two-dimensional turbulence are investigated, through a conformal field theory approach. We compute scaling exponents for the energy spectra of enstrophy and energy cascades, in a strong coupling limit, and compare them to the values found in recent experiments. The extension of unperturbed conformal turbulence to the present situation is performed by means of a simple physical picture in which the existence of small scale random forces is closely related to deviations of the exact two-dimensional fluid motion.Comment: Discussion of intermittency improved. Figure include

Cutaneous manifestations of hospitalized coronavirus disease 2019 patients: a report of six cases with clinicopathologic features and viral RNA in situ hybridization

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163863/1/jdv16741.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163863/2/jdv16741_am.pd

Melting as a String-Mediated Phase Transition

We present a theory of the melting of elemental solids as a dislocation-mediated phase transition. We model dislocations near melt as non-interacting closed strings on a lattice. In this framework we derive simple expressions for the melting temperature and latent heat of fusion that depend on the dislocation density at melt. We use experimental data for more than half the elements in the Periodic Table to determine the dislocation density from both relations. Melting temperatures yield a dislocation density of (0.61\pm 0.20) b^{-2}, in good agreement with the density obtained from latent heats, (0.66\pm 0.11) b^{-2}, where b is the length of the smallest perfect-dislocation Burgers vector. Melting corresponds to the situation where, on average, half of the atoms are within a dislocation core.Comment: 18 pages, LaTeX, 3 eps figures, to appear in Phys. Rev.

Froude supercritical flow processes and sedimentary structures: new insights from experiments with a wide range of grain sizes

Recognition of Froude supercritical flow deposits in environments that range from rivers to the ocean floor has triggered a surge of interest in their flow processes, bedforms and sedimentary structures. Interpreting these supercritical flow deposits is especially important because they often represent the most powerful flows in the geological record. Insights from experiments are key to reconstruct palaeo‐flow processes from the sedimentary record. So far, all experimentally produced supercritical flow deposits are of a narrow grain‐size range (fine to medium sand), while deposits in the rock record often consist of a much wider grain‐size distribution. This paper presents results of supercritical‐flow experiments with a grain‐size distribution from clay to gravel. These experiments show that cyclic step instabilities can produce more complex and a larger variety of sedimentary structures than the previously suggested backsets and ‘scour and fill’ structures. The sedimentary structures are composed of irregular lenses, mounds and wedges with backsets and foresets, as well as undulating planar to low‐angle upstream and downstream dipping laminae. The experiments also demonstrate that the Froude number is not the only control on the sedimentary structures formed by supercritical‐flow processes. Additional controls include the size and migration rate of the hydraulic jump and the substrate cohesion. This study further demonstrates that Froude supercritical flow promotes suspension transport of all grain sizes, including gravels. Surprisingly, it was observed that all grain sizes were rapidly deposited just downstream of hydraulic jumps, including silt and clay. These results expand the range of dynamic mud deposition into supercritical‐flow conditions, where local transient shear stress reduction rather than overall flow waning conditions allow for deposition of fines. Comparison of the experimental deposits with outcrop datasets composed of conglomerates to mudstones, shows significant similarities and highlights the role of hydraulic jumps, rather than overall flow condition changes, in producing lithologically and geometrically complex stratigraphy

A Cretaceous carbonate delta drift in the Montagna della Maiella, Italy

The Upper Cretaceous (Campanian\u2013Maastrichtian) bioclastic wedge of the Orfento Formation in the Montagna della Maiella, Italy, is compared to newly discovered contourite drifts in the Maldives. Like the drift deposits in the Maldives, the Orfento Formation fills a channel and builds a Miocene delta-shaped and mounded sedimentary body in the basin that is similar in size to the approximately 350 km 2 large coarse-grained bioclastic Miocene delta drifts in the Maldives. The composition of the bioclastic wedge of the Orfento Formation is also exclusively bioclastic debris sourced from the shallow-water areas and reworked clasts of the Orfento Formation itself. In the near mud-free succession, age-diagnostic fossils are sparse. The depositional textures vary from wackestone to float-rudstone and breccia/conglomerates, but rocks with grainstone and rudstone textures are the most common facies. In the channel, lensoid convex-upward breccias, cross-cutting channelized beds and thick grainstone lobes with abundant scours indicate alternating erosion and deposition from a high-energy current. In the basin, the mounded sedimentary body contains lobes with a divergent progradational geometry. The lobes are built by decametre thick composite megabeds consisting of sigmoidal clinoforms that typically have a channelized topset, a grainy foreset and a fine-grained bottomset with abundant irregular angular clasts. Up to 30 m thick channels filled with intraformational breccias and coarse grainstones pinch out downslope between the megabeds. In the distal portion of the wedge, stacked grainstone beds with foresets and reworked intraclasts document continuous sediment reworking and migration. The bioclastic wedge of the Orfento Formation has been variously interpreted as a succession of sea-level controlled slope deposits, a shoaling shoreface complex, or a carbonate tidal delta. Current-controlled delta drifts in the Maldives, however, offer a new interpretation because of their similarity in architecture and composition. These similarities include: (i) a feeder channel opening into the basin; (ii) an excavation moat at the exit of the channel; (iii) an overall mounded geometry with an apex that is in shallower water depth than the source channel; (iv) progradation of stacked lobes; (v) channels that pinch out in a basinward direction; and (vi) smaller channelized intervals that are arranged in a radial pattern. As a result, the Upper Cretaceous (Campanian\u2013Maastrichtian) bioclastic wedge of the Orfento Formation in the Montagna della Maiella, Italy, is here interpreted as a carbonate delta drift

Intra‐clinothem variability in sedimentary texture and process regime recorded down slope profiles

Shelf‐margin clinothem successions can archive process interactions at the shelf to slope transition, and their architecture provides constraints on the interplay of factors that control basin‐margin evolution. However, detailed textural analysis and facies distributions from shelf to slope transitions remain poorly documented. This study uses quantitative grain‐size and sorting data from coeval shelf and slope deposits of a single clinothem that crops out along a 5 km long, dip‐parallel transect of the Eocene Sobrarbe Deltaic Complex (Ainsa Basin, south‐central Pyrenees, Spain). Systematic sampling of sandstone beds tied to measured sections has captured vertical and basinward changes in sedimentary texture and facies distributions at an intra‐clinothem scale. Two types of hyperpycnal flow‐related slope deposits, both rich in mica and terrestrial organic matter, are differentiated according to grain size, sorting and bed geometry: (i) sustained hyperpycnal flow deposits, which are physically linked to coarse channelized sediments in the shelf setting and which deposit sand down the complete slope profile; (ii) episodic hyperpycnal flow deposits, which are disconnected from, and incise into, shelf sands and which are associated with sediment bypass of the proximal slope and coarse‐grained sand deposition on the medial and distal slope. Both types of hyperpycnites are interbedded with relatively homogenous, organic‐free and mica‐free, well‐sorted, very fine‐grained sandstones, which are interpreted to be remobilized from wave‐dominated shelf environments; these wave‐dominated deposits are found only on the proximal and medial slope. Coarse‐grained sediment bypass into the deeper‐water slope settings is therefore dominated by episodic hyperpycnal flows, whilst sustained hyperpycnal flows and turbidity currents remobilizing wave‐dominated shelf deposits are responsible for the full range of grain sizes in the proximal and medial slope, thus facilitating clinoform progradation. This novel dataset highlights previously undocumented intra‐clinothem variability related to updip changes in the shelf process‐regime, which is therefore a key factor controlling downdip architecture and resulting sedimentary texture

Depositional setting, provenance and tectonic-volcanic setting of Eocene-Recent deep-sea sediments of the oceanic Izu-Bonin forearc, NW Pacific (IODP Expedition 352)

New biostratigraphical, geochemical, and magnetic evidence is synthesized with IODP Expedition 352 shipboard results to understand the sedimentary and tectono-magmatic development of the Izu–Bonin outer forearc region. The oceanic basement of the Izu–Bonin forearc was created by supra-subduction zone seafloor spreading during early Eocene (c. 50–51 Ma). Seafloor spreading created an irregular seafloor topography on which talus locally accumulated. Oxide-rich sediments accumulated above the igneous basement by mixing of hydrothermal and pelagic sediment. Basaltic volcanism was followed by a hiatus of up to 15 million years as a result of topographic isolation or sediment bypassing. Variably tuffaceous deep-sea sediments were deposited during Oligocene to early Miocene and from mid-Miocene to Pleistocene. The sediments ponded into extensional fault-controlled basins, whereas condensed sediments accumulated on a local basement high. Oligocene nannofossil ooze accumulated together with felsic tuff that was mainly derived from the nearby Izu–Bonin arc. Accumulation of radiolarian-bearing mud, silty clay, and hydrogenous metal oxides beneath the carbonate compensation depth (CCD) characterized the early Miocene, followed by middle Miocene–Pleistocene increased carbonate preservation, deepened CCD and tephra input from both the oceanic Izu–Bonin arc and the continental margin Honshu arc. The Izu–Bonin forearc basement formed in a near-equatorial setting, with late Mesozoic arc remnants to the west. Subduction-initiation magmatism is likely to have taken place near a pre-existing continent–oceanic crust boundary. The Izu–Bonin arc migrated northward and clockwise to collide with Honshu by early Miocene, strongly influencing regional sedimentation