Implementation of Complex Interventions in UK General Practice

The pace of change in UK healthcare continues to be rapid with a drive to implement more clinically and cost-effective interventions in order to improve practice/care. Literature suggests that the take-up of these interventions is often slow. This delay in translation of evidence-based interventions into routine clinical practice is known as the ‘Evidence-to-Practice Gap’. Almost all changes to practice involve ‘complex interventions’. Such interventions can be particularly hard to implement as they are likely to require change at multiple levels. Initially a systematic review of reviews was conducted to synthesise the literature on a) explanation(s) as to why complex interventions are not implemented and b)the effectiveness of strategies in facilitating implementation. A key insight was that despite an increasing recognition of the role of context in implementation there is a lack of empirical evidence. None of the reviews addressed context and the contextual influences were largely reported as perceived barriers and facilitators. Studies tended to focus on one intervention when in reality more than one intervention is likely to be implemented simultaneously in any given setting. The systematic review led to a qualitative case study to investigate the implementation of multiple complex interventions in three GP practices, focusing on the role of context as an explanation. Initial practice meetings indicated all three practices were implementing various changes to improve patient access. The decision was taken to focus on online and telephone access and the Named GP scheme. Data from observation, interviews and documentations were analysed using thematic analysis. This study enhances understanding of the process in which multiple complex interventions are implemented into general practice. Paying particular attention to the ‘shifts’ of context and how changes in the ‘fit’ between the intervention and the context over time, may increase the likelihood of implementation success. The study reveals the importance of relative intervention prioritisation particularly when practices face competing intervention options, as a novel explanation of why some interventions get implemented/prioritised first before others

Tree biomass equations from terrestrial LiDAR : a case study in Guyana

Large uncertainties in tree and forest carbon estimates weaken national efforts to accurately estimate aboveground biomass (AGB) for their national monitoring, measurement, reporting and verification system. Allometric equations to estimate biomass have improved, but remain limited. They rely on destructive sampling; large trees are under-represented in the data used to create them; and they cannot always be applied to different regions. These factors lead to uncertainties and systematic errors in biomass estimations. We developed allometric models to estimate tree AGB in Guyana. These models were based on tree attributes (diameter, height, crown diameter) obtained from terrestrial laser scanning (TLS) point clouds from 72 tropical trees and wood density. We validated our methods and models with data from 26 additional destructively harvested trees. We found that our best TLS-derived allometric models included crown diameter, provided more accurate AGB estimates (R-2 = 0.92-0.93) than traditional pantropical models (R-2 = 0.85-0.89), and were especially accurate for large trees (diameter > 70 cm). The assessed pantropical models underestimated AGB by 4 to 13%. Nevertheless, one pantropical model (Chave et al. 2005 without height) consistently performed best among the pantropical models tested (R-2 = 0.89) and predicted AGB accurately across all size classes-which but for this could not be known without destructive or TLS-derived validation data. Our methods also demonstrate that tree height is difficult to measure in situ, and the inclusion of height in allometric models consistently worsened AGB estimates. We determined that TLS-derived AGB estimates were unbiased. Our approach advances methods to be able to develop, test, and choose allometric models without the need to harvest trees

Achieving change in primary care—causes of the evidence to practice gap : systematic reviews of reviews

Acknowledgements The Evidence to Practice Project (SPCR FR4 project number: 122) is funded by the National Institute of Health Research (NIHR) School for Primary Care Research (SPCR). KD is part-funded by the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Research and Care West Midlands and by a Knowledge Mobilisation Research Fellowship (KMRF-2014-03-002) from the NIHR. This paper presents independent research funded by the National Institute of Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Funding This study is funded by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).Peer reviewedPublisher PD

A patient with anaphylaxis to diphenhydramine without cross-reactivity to loratadine

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Dietary fibre, whole grains, and risk of colorectal cancer: systematic review and dose-response meta-analysis of prospective studies

Objective To investigate the association between intake of dietary fibre and whole grains and risk of colorectal cancer

Application of IoT and BEMS to Visualise the Environmental Performance of an Educational Building

This paper presents the application of Internet of Things (IoT) Technology and Building Energy Management System (BEMS) within the Marylebone Campus of the University of Westminster, located in central London, to improve the environmental performance of the existing building as well as enhance the learning experience on energy and sustainability. Sixty IoT sensors connected to minicomputers were planned to be deployed within three floors of the building to continuously measure the real-time environmental parameters, such as dry-bulb temperature, relative humidity, illuminance level, carbon dioxide, and sound levels. Experimental workshops were also arranged with undergraduate and post-graduate students at their classrooms using IoT sensors, portable Bluetooth sensors and online questionnaires to increase awareness of the effect of environmental and behavioural changes on energy saving through real-time visualisation. Users’ subjective feedback on their workplace was also collected through Post Occupancy Evaluation (POE) questionnaire surveys. The results show the effectiveness of IoT systems and BEMS in supplying the building users and management with high-resolution, low-cost data acquisition systems highlighting the existing challenges and future scopes. The study also documents the process and the improvement in students’ awareness of environmental and energy performance of their building through IoT data visualizations and POE

Estimating the stability of heartbeat counting in middle childhood: a twin study

There is growing interest in interoception, the perception of the body’s internal state, and its relevance for health across development. Most evidence linking interoception to health has used the heartbeat counting task. However, the temporal stability of the measure, particularly during childhood, and the etiological factors that underlie stability, remain largely unexamined. Using data from the ECHO twin sample we estimated the magnitude of genetic and environmental influences on the stability of heartbeat counting across two years (age 8-10), the longest timeframe examined. Heartbeat counting accuracy was modestly correlated across time, (r=.35), and accuracy improved with age. Non-shared environmental factors accounted for the most variance at both time points and were the main contributors to temporal stability of heartbeat counting. Future research should seek to identify these non-shared environmental factors and elucidate whether this relatively modest stability reflects variability of interoception across development or unreliability of the heartbeat counting task

Platelet Glycoprotein lib: Chromosomal Localization and Tissue Expression

The GPIIb-IIIa complex functions as a receptor for cytoadhesive proteins on the platelet surface. Both GPIIb and GPIIIa are synthesized by a human erythroleukemia (HEL) cell line. We isolated several cDNA clones by screening a HEL cell cDNA library with an oligonucleotide derived from amino acid sequence of GPIIb. Nucleotide and amino acid sequences were determined from 703 bp of one of these clones. Amino acid sequence of purified platelet GPIIb peptides confirmed the identity of the clone. The cDNA encodes the carboxyl terminus of the large (a) subunit of GPIIb and all of the smaller (f6) subunit of GPIIb. By hybridizing the cDNA directly to chromosomes separated by dual laser chromosome sorting, the gene for GPIIb was mapped to chromosome 17. Northern blot analysis showed a - 3.4-kb GPIIb mRNA in HEL cells. We also compared the amino acid sequences determined from eight additional platelet GPIIb peptides with the derived amino acids from a published HEL cell GPIIb cDNA, and the platelet and HEL cell proteins appear to be the same. Despite previous reports that vascular endothelial cells and monocytes contain GPIIb, no GPIIb mRNA was observed in either type of cell. Thus, GPIIb appears to be specific for the platelet-megakaryocyte membrane and is distinct from the a subunits of the adhesion receptors in other normal tissues

The Discrete Representation of Continuously Moving Indeterminate Objects

AbstractTo incorporate indeterminacy in spatio-temporal database systems, grey modeling method is used for the calculations of the discrete models of indeterminate two dimension continuously moving objects. The Grey Model GM (1, 1) model generated from the snapshot sequence reduces the randomness of discrete snapshot and generates the holistic measure of object's movements. Comparisons to traditional linear models show that when information is limited this model can be used in the interpolation and near future prediction of uncertain continuously moving spatio-temporal objects