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

Findings from a pilot randomised trial of an asthma internet self-management intervention (RAISIN)

<b>Objective </b>To evaluate the feasibility of a phase 3 randomised controlled trial (RCT) of a website (Living Well with Asthma) to support self-management.<p></p> <b>Design and setting</b> Phase 2, parallel group, RCT, participants recruited from 20 general practices across Glasgow, UK. Randomisation through automated voice response, after baseline data collection, to website access for minimum 12 weeks or usual care.<p></p> <b>Participants </b>Adults (age≥16 years) with physician diagnosed, symptomatic asthma (Asthma Control Questionnaire (ACQ) score ≥1). People with unstable asthma or other lung disease were excluded.<p></p> <b>Intervention</b> Living Well with Asthma’ is a desktop/ laptop compatible interactive website designed with input from asthma/ behaviour change specialists, and adults with asthma. It aims to support optimal medication management, promote use of action plans, encourage attendance at asthma reviews and increase physical activity.<p></p> <b>Outcome measures</b> Primary outcomes were recruitment/retention, website use, ACQ and mini- Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included patient activation, prescribing, adherence, spirometry, lung inflammation and health service contacts after 12 weeks. Blinding postrandomisation was not possible.<p></p> <b>Results </b>Recruitment target met. 51 participants randomised (25 intervention group). Age range 16–78 years; 75% female; 28% from most deprived quintile. 45/51 (88%; 20 intervention group) followed up. 19 (76% of the intervention group) used the website, for a mean of 18 min (range 0–49). 17 went beyond the 2 ‘core’ modules. Median number of logins was 1 (IQR 1–2, range 0–7). No significant difference in the prespecified primary efficacy measures of ACQ scores (−0.36; 95% CI −0.96 to 0.23; p=0.225), and mini-AQLQ scores (0.38; −0.13 to 0.89; p=0.136). No adverse events.<p></p> <b>Conclusions</b> Recruitment and retention confirmed feasibility; trends to improved outcomes suggest use of Living Well with Asthma may improve self-management in adults with asthma and merits further development followed by investigation in a phase 3 trial

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

The glacial geomorphology of upper Godthåbsfjord (Nuup Kangerlua) in south-west Greenland

© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group on behalf of Journal of Maps. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.The Greenland Ice Sheet (GrIS) is known to have experienced widespread retreat over the last century. Information on outlet glacier dynamics, prior to this, are limited due to both a lack of observations and a paucity of mapped or mappable deglacial evidence which restricts our understanding of centennial to millennial timescale dynamics of the GrIS. Here we present glacial geomorphological mapping, for upper Godthåbsfjord, covering 5800 km 2 at a scale of 1:92,000, using a combination of ASTER GDEM V2, a medium-resolution DEM (error < 10 m horizontal and < 6 m vertical accuracy), panchromatic orthophotographs and ground truthing. This work provides a detailed geomorphological assessment for the area, compiled as a single map, comprising of moraines, meltwater channels, streamlined bedrock, sediment lineations, ice-dammed lakes, trimlines, terraces, gullied sediment and marine limits. Whilst some of the landforms have been previously identified, the new information presented here improves our understanding of ice margin behaviour and can be used for future numerical modelling and landform dating programmes. Data also form the basis for palaeoglaciological reconstructions and contribute towards understanding of the centennial to millennial timescale record of this sector of the GrIS.Peer reviewedFinal Published versio

Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol

&lt;b&gt;Background&lt;/b&gt; Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Objectives&lt;/b&gt; The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users’ manual for the measures.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Discussion&lt;/b&gt; The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices

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

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.

From theory to 'measurement' in complex interventions: methodological lessons from the development of an e-health normalisation instrument

&lt;b&gt;Background&lt;/b&gt; Although empirical and theoretical understanding of processes of implementation in health care is advancing, translation of theory into structured measures that capture the complex interplay between interventions, individuals and context remain limited. This paper aimed to (1) describe the process and outcome of a project to develop a theory-based instrument for measuring implementation processes relating to e-health interventions; and (2) identify key issues and methodological challenges for advancing work in this field.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Methods&lt;/b&gt; A 30-item instrument (Technology Adoption Readiness Scale (TARS)) for measuring normalisation processes in the context of e-health service interventions was developed on the basis on Normalization Process Theory (NPT). NPT focuses on how new practices become routinely embedded within social contexts. The instrument was pre-tested in two health care settings in which e-health (electronic facilitation of healthcare decision-making and practice) was used by health care professionals.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Results&lt;/b&gt; The developed instrument was pre-tested in two professional samples (N = 46; N = 231). Ratings of items representing normalisation 'processes' were significantly related to staff members' perceptions of whether or not e-health had become 'routine'. Key methodological challenges are discussed in relation to: translating multi-component theoretical constructs into simple questions; developing and choosing appropriate outcome measures; conducting multiple-stakeholder assessments; instrument and question framing; and more general issues for instrument development in practice contexts.&lt;p&gt;&lt;/p&gt; &lt;b&gt;Conclusions&lt;/b&gt; To develop theory-derived measures of implementation process for progressing research in this field, four key recommendations are made relating to (1) greater attention to underlying theoretical assumptions and extent of translation work required; (2) the need for appropriate but flexible approaches to outcomes measurement; (3) representation of multiple perspectives and collaborative nature of work; and (4) emphasis on generic measurement approaches that can be flexibly tailored to particular contexts of study