Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction

<b>Background</b> Meta-analysis of small trials suggests that pharmacist-led collaborative review and revision of medical treatment may improve outcomes in heart failure.<p></p> <b>Methods and results</b> We studied patients with left ventricular systolic dysfunction in a cluster-randomized controlled, event driven, trial in primary care. We allocated 87 practices (1090 patients) to pharmacist intervention and 87 practices (1074 patients) to usual care. The intervention was delivered by non-specialist pharmacists working with family doctors to optimize medical treatment. The primary outcome was a composite of death or hospital admission for worsening heart failure. This trial is registered, number ISRCTN70118765. The median follow-up was 4.7 years. At baseline, 86% of patients in both groups were treated with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. In patients not receiving one or other of these medications, or receiving less than the recommended dose, treatment was started, or the dose increased, in 33.1% of patients in the intervention group and in 18.5% of the usual care group [odds ratio (OR) 2.26, 95% CI 1.64–3.10; P< 0.001]. At baseline, 62% of each group were treated with a β-blocker and the proportions starting or having an increase in the dose were 17.9% in the intervention group and 11.1% in the usual care group (OR 1.76, 95% CI 1.31–2.35; P< 0.001). The primary outcome occurred in 35.8% of patients in the intervention group and 35.4% in the usual care group (hazard ratio 0.97, 95% CI 0.83–1.14; P = 0.72). There was no difference in any secondary outcome.<p></p> <b>Conclusion</b> A low-intensity, pharmacist-led collaborative intervention in primary care resulted in modest improvements in prescribing of disease-modifying medications but did not improve clinical outcomes in a population that was relatively well treated at baseline

Maximum-likelihood absorption tomography

Maximum-likelihood methods are applied to the problem of absorption tomography. The reconstruction is done with the help of an iterative algorithm. We show how the statistics of the illuminating beam can be incorporated into the reconstruction. The proposed reconstruction method can be considered as a useful alternative in the extreme cases where the standard ill-posed direct-inversion methods fail.Comment: 7 pages, 5 figure

Fluctuations of a Greenlandic tidewater glacier driven by changes in atmospheric forcing : observations and modelling of Kangiata Nunaata Sermia, 1859–present

Acknowledgements. The authors wish to thank Stephen Price, Mauri Pelto, and the anonymous reviewer for their reviews and comments that helped to improve the manuscript. RACMO2.1 data were provided by Jan van Angelen and Michiel van den Broeke, IMAU, Utrecht University. MAR v3.2 data used for runoff calculations were provided by Xavier Fettweis, Department of Geography, University of Liège. The photogrammetric DEM used in Figs. 1 and 3 was provided by Kurt H. Kjær, Centre for GeoGenetics, University of Copenhagen. This research was financially supported by J. M. Lea’s PhD funding, NERC grant number NE/I528742/1. Support for F. M. Nick was provided through the Conoco-Phillips/Lundin Northern Area Program CRIOS project (Calving Rates and Impact on Sea Level).Peer reviewedPublisher PD

Application of an equine composite pain scale and its association with plasma adrenocorticotropic hormone concentrations and serum cortisol concentrations in horses with colic

This study assessed the application of a modified equine composite pain scale (CPS) and identified the inter‐observer reliability. Associations between CPS scores and the measured concentrations of serum cortisol ([cortisol]) and plasma adrenocorticotrophic hormone ([ACTH]) in horses presenting with colic were determined. The study design was prospective, uni‐centred and observational. The inter‐observer reliability of the adapted CPS was determined for 59 horses hospitalised for a variety of conditions. The associations between CPS, ACTH and cortisol were assessed in a further 49 horses admitted for medical or surgical colic. During hospitalisation, blood samples were obtained each morning and analysed for serum [cortisol] and plasma [ACTH]. Horses were pain scored using the adapted CPS score. Data from the most painful time point (n = 48 horses; n = 48 [cortisol]; n = 44 [ACTH]) and all data time points (n = 49 horses and n = 133 time points) were used for analysis of association between [cortisol], [ACTH] and CPS score. The CPS score inter‐observer reliability was excellent (n = 59 horses; n = 102 pain scores; weighted kappa 0.863). CPS score and [cortisol] were positively associated at the most painful time point (P < 0.001) and at all data time points (P < 0.001). No significant association was found between CPS score and [ACTH]. [ACTH] was associated with [cortisol] (P = 0.034) when all time points were analysed but not when only the most painful point was analysed. The significant correlation identified between CPS score and [cortisol] in medical and surgical colic cases provides physiological validation of pain scores as a marker of underlying stress in horses with colic

Why is it difficult to implement e-health initiatives? A qualitative study

&lt;b&gt;Background&lt;/b&gt; The use of information and communication technologies in healthcare is seen as essential for high quality and cost-effective healthcare. However, implementation of e-health initiatives has often been problematic, with many failing to demonstrate predicted benefits. This study aimed to explore and understand the experiences of implementers - the senior managers and other staff charged with implementing e-health initiatives and their assessment of factors which promote or inhibit the successful implementation, embedding, and integration of e-health initiatives.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; We used a case study methodology, using semi-structured interviews with implementers for data collection. Case studies were selected to provide a range of healthcare contexts (primary, secondary, community care), e-health initiatives, and degrees of normalization. The initiatives studied were Picture Archiving and Communication System (PACS) in secondary care, a Community Nurse Information System (CNIS) in community care, and Choose and Book (C&#38;B) across the primary-secondary care interface. Implementers were selected to provide a range of seniority, including chief executive officers, middle managers, and staff with 'on the ground' experience. Interview data were analyzed using a framework derived from Normalization Process Theory (NPT).&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; Twenty-three interviews were completed across the three case studies. There were wide differences in experiences of implementation and embedding across these case studies; these differences were well explained by collective action components of NPT. New technology was most likely to 'normalize' where implementers perceived that it had a positive impact on interactions between professionals and patients and between different professional groups, and fit well with the organisational goals and skill sets of existing staff. However, where implementers perceived problems in one or more of these areas, they also perceived a lower level of normalization.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; Implementers had rich understandings of barriers and facilitators to successful implementation of e-health initiatives, and their views should continue to be sought in future research. NPT can be used to explain observed variations in implementation processes, and may be useful in drawing planners' attention to potential problems with a view to addressing them during implementation planning

Optical modes within III-nitride multiple quantum well microdisk cavities

Optical resonance modes have been observed in optically pumped microdisk cavitiesfabricated from 50 Å/50 Å GaN/AlxGa1−xN(x∼0.07) and 45 Å/45 Å InxGa1−xN/GaN(x∼0.15)multiple quantum well structures. Microdisks, approximately 9 μm in diameter and regularly spaced every 50 μm, were formed by an ion beametch process. Individual disks were pumped at 300 and 10 K with 290 nm laser pulses focused to a spot size much smaller than the disk diameter. Optical modes corresponding to (i) the radial mode type with a spacing of 49–51 meV (both TE and TM) and (ii) the Whispering Gallery mode with a spacing of 15–16 meV were observed in the GaN microdisk cavities. The spacings of these modes are consistent with those expected for modes within a resonant cavity of cylindrical symmetry, refractive index, and dimensions of the microdisks under investigation. The GaN-based microdisk cavity is compared with its GaAs counterpart and implications regarding future GaN-based microdisk lasers are discussed

Nonperturbative versus perturbative effects in generalized parton distributions

Generalized parton distributions (GPDs) are studied at the hadronic (nonperturbative) scale within different assumptions based on a relativistic constituent quark model. In particular, by means of a meson-cloud model we investigate the role of nonperturbative antiquark degrees of freedom and the valence quark contribution. A QCD evolution of the obtained GPDs is used to add perturbative effects and to investigate the GPDs' sensitivity to the nonperturbative ingredients of the calculation at larger (experimental) scale.Comment: 17 pages, 10 figures; submitted to Phys. Rev.

Orbital Angular Momentum Parton Distributions in Light-Front Dynamics

We study the quark angular momentum distribution in the nucleon within a light-front covariant quark model. Special emphasis is put into the orbital angular momentum: a quantity which is very sensitive to the relativistic treatment of the spin in a light-front dynamical approach. Discrepancies with the predictions of the low-energy traditional quark models where relativistic spin effects are neglected, are visible also after perturbative evolution to higher momentum scales. Orbital angular momentum distributions and their contribution to the spin sum rule are calculated for different phenomenological mass operators and compared with the results of the MIT bag model.Comment: 14 pages; latex; 3 ps figure

Shear band dynamics from a mesoscopic modeling of plasticity

The ubiquitous appearance of regions of localized deformation (shear bands) in different kinds of disordered materials under shear is studied in the context of a mesoscopic model of plasticity. The model may or may not include relaxational (aging) effects. In the absence of relaxational effects the model displays a monotonously increasing dependence of stress on strain-rate, and stationary shear bands do not occur. However, in start up experiments transient (although long lived) shear bands occur, that widen without bound in time. I investigate this transient effect in detail, reproducing and explaining a t^1/2 law for the thickness increase of the shear band that has been obtained in atomistic numerical simulations. Relaxation produces a negative sloped region in the stress vs. strain-rate curve that stabilizes the formation of shear bands of a well defined width, which is a function of strain-rate. Simulations at very low strain-rates reveal a non-trivial stick-slip dynamics of very thin shear bands that has relevance in the study of seismic phenomena. In addition, other non-stationary processes, such as stop-and-go, or strain-rate inversion situations display a phenomenology that matches very well the results of recent experimental studies.Comment: 10 pages, 10 figure