Quality of medication use in primary care - mapping the problem, working to a solution: a systematic review of the literature

Background: The UK, USA and the World Health Organization have identified improved patient safety in healthcare as a priority. Medication error has been identified as one of the most frequent forms of medical error and is associated with significant medical harm. Errors are the result of the systems that produce them. In industrial settings, a range of systematic techniques have been designed to reduce error and waste. The first stage of these processes is to map out the whole system and its reliability at each stage. However, to date, studies of medication error and solutions have concentrated on individual parts of the whole system. In this paper we wished to conduct a systematic review of the literature, in order to map out the medication system with its associated errors and failures in quality, to assess the strength of the evidence and to use approaches from quality management to identify ways in which the system could be made safer. Methods: We mapped out the medicines management system in primary care in the UK. We conducted a systematic literature review in order to refine our map of the system and to establish the quality of the research and reliability of the system. Results: The map demonstrated that the proportion of errors in the management system for medicines in primary care is very high. Several stages of the process had error rates of 50% or more: repeat prescribing reviews, interface prescribing and communication and patient adherence. When including the efficacy of the medicine in the system, the available evidence suggested that only between 4% and 21% of patients achieved the optimum benefit from their medication. Whilst there were some limitations in the evidence base, including the error rate measurement and the sampling strategies employed, there was sufficient information to indicate the ways in which the system could be improved, using management approaches. The first step to improving the overall quality would be routine monitoring of adherence, clinical effectiveness and hospital admissions. Conclusion: By adopting the whole system approach from a management perspective we have found where failures in quality occur in medication use in primary care in the UK, and where weaknesses occur in the associated evidence base. Quality management approaches have allowed us to develop a coherent change and research agenda in order to tackle these, so far, fairly intractable problems

Antiplatelet treatment compared with anticoagulation treatment for cervical artery dissection (CADISS): a randomised trial

Background: Extracranial carotid and vertebral artery dissection is an important cause of stroke, especially in young people. In some observational studies it has been associated with a high risk of recurrent stroke. Both antiplatelet drugs and anticoagulant drugs are used to reduce risk of stroke but whether one treatment strategy is more effective than the other is unknown. We compared their efficacy in the Cervical Artery Dissection in Stroke Study (CADISS), with the additional aim of establishing the true risk of recurrent stroke. Methods: We did this randomised trial at hospitals with specialised stroke or neurology services (39 in the UK and seven in Australia). We included patients with extracranial carotid and vertebral dissection with onset of symptoms within the past 7 days. Patients were randomly assigned (1:1) by an automated telephone randomisation service to receive antiplatelet drugs or anticoagulant drugs (specific treatment decided by the local clinician) for 3 months. Patients and clinicians were not masked to allocation, but investigators assessing endpoints were. The primary endpoint was ipsilateral stroke or death in the intention-to-treat population. The trial was registered with EUDract (2006-002827-18) and ISRN (CTN44555237). Findings: We enrolled 250 participants (118 carotid, 132 vertebral). Mean time to randomisation was 3·65 days (SD 1·91). The major presenting symptoms were stroke or transient ischaemic attack (n=224) and local symptoms (headache, neck pain, or Horner's syndrome; n=26). 126 participants were assigned to antiplatelet treatment versus 124 to anticoagulant treatment. Overall, four (2%) of 250 patients had stroke recurrence (all ipsilateral). Stroke or death occurred in three (2%) of 126 patients versus one (1%) of 124 (odds ratio [OR] 0·335, 95% CI 0·006–4·233; p=0·63). There were no deaths, but one major bleeding (subarachnoid haemorrhage) in the anticoagulant group. Central review of imaging failed to confirm dissection in 52 patients. Preplanned per-protocol analysis excluding these patients showed stroke or death in three (3%) of 101 patients in the antiplatelet group versus one (1%) of 96 patients in the anticoagulant group (OR 0·346, 95% CI 0·006–4·390; p=0·66). Interpretation: We found no difference in efficacy of antiplatelet and anticoagulant drugs at preventing stroke and death in patients with symptomatic carotid and vertebral artery dissection but stroke was rare in both groups, and much rarer than reported in some observational studies. Diagnosis of dissection was not confirmed after review in many cases, suggesting that radiographic criteria are not always correctly applied in routine clinical practice. Funding: Stroke Association.H.S. Markus ... T. Kleinig ... et al. (CADISS trial investigators

Call and Response: SEM President’s Roundtable 2016, “Ethnomusicological Responses to the Contemporary Dynamics of Migrants and Refugees”

The privilege of organizing the SEM President’s Roundtable in 2016 and 2017 provided an opportunity to call attention to a topic that has concerned my teaching and research since graduate school. For the first iteration of “Ethnomusicological Responses to the Contemporary Dynamics of Migrants and Refugees” I convened a panel of people whose perspectives I admire. I wanted to learn from them, and I did. As someone who has been involved with Middle Eastern and more specifically Arab music and culture within my own academic and regional community, I was making new efforts in the fall of 2016 toward engaged ethnomusicology in Virginia among my own newest neighbors, and organizing this SEM President’s Roundtable gave me courage and inspiration. Our “Call and Response” presents snapshots from five colleagues who are engaged with communities of migrants and refugees in Africa, the Middle East, Europe, and North America..

Linking genomics and ecology to investigate the complex evolution of an invasive Drosophila pest

Drosophilid fruit flies have provided science with striking cases of behavioural adaptation and genetic innovation. A recent example is the invasive pest Drosophila suzukii, which, unlike most other Drosophila, lays eggs and feeds on undamaged, ripening fruits. This poses a serious threat for fruit cultivation, but also offers an interesting model to study evolution of behavioural innovation. We developed genome and transcriptome resources for D. suzukii. Coupling analyses of these data with field observations, we propose a hypothesis of the origin of its peculiar ecology. Using nuclear and mitochondrial phylogenetic analyses, we confirm its Asian origin, and reveal a surprising sister relationship between the eugracilis and the melanogaster subgroups. While the D. suzukii genome is comparable in size and repeat content to other Drosophila species, it has the lowest nucleotide substitution rate among the species analysed in this study. This finding is compatible with the overwintering diapause of D. suzukii, which results in a reduced number of generations per year compared to its sister species. Genome-scale relaxed clock analyses support a late Miocene origin of D. suzukii, concomitant with paleogeological and climatic conditions that suggest an adaptation to temperate montane forests, a hypothesis confirmed by field trapping. We propose a causal link between the ecological adaptations of D. suzukii in its native habitat and its invasive success in Europe and North America

Tiny grains shining bright in the gaps of Herbig Ae transitional discs

This is the final version. Available from the publisher via the DOI in this record.This work has made use of data from the European Space Agency (ESA) mission Gaia (https://www.cosmos.esa.int/gaia), processed by the Gaia Data Processing and Analysis Consortium (DPAC, https://www.cosmos.esa.int/web/gaia/dpac/consortium). Funding for the DPAC has been provided by national institutions, in particular the institutions participating in the Gaia Multilateral Agreement.This work presents a study of two Herbig Ae transitional discs, Oph IRS 48 and HD 169142; which both have reported rings in their dust density distributions. We use Keck-II/NIRC2 adaptive optics imaging observations in the L' filter (3.8 micron) to probe the regions of these discs inwards of ~20AU from the star. We introduce our method for investigating these transitional discs, which takes a forward modelling approach: making a model of the disc (using the Monte Carlo radiative transfer code RADMC), convolving it with point-spread functions of calibrator stars, and comparing the convolved models with the observational data. The disc surface density parameters are explored with a Monte Carlo Markov Chain technique. Our analysis recovers emission from both of the discs interior to the well known optically thick walls, modelled as a ring of emission at ~15AU in Oph IRS 48, and ~7AU for HD 169142, and identifies asymmetries in both discs. Given the brightness of the near-symmetric rings compared to the reported companion candidates, we suggest that the reported companion candidates can be interpreted as slightly asymmetric disc emission or illumination.European Research Council (ERC)Science and Technology Facilities Council Rutherford Fellowshi

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

A Qualitative Descriptive Study of Rural Primary Healthcare Professionals’ Capacity for Disaster Health Management Before and During the COVID-19 Pandemic

Introduction: Rural areas face additional challenges in preventing, preparing for, responding to, and recovering from disasters. This study aimed to understand how rural primary healthcare professionals (PHCPs) perceive their roles, involvement, and capacity in disaster health management. Methods: For this qualitative descriptive research, semi-structured interviews were carried out with convenience and purposive samples of rural PHCPs before and during the COVID-19 pandemic. Open, axial, and selective coding were employed to analyse the data inductively. Results: Five interviews were conducted before the pandemic, and ten interviews were conducted during the second and third waves of the COVID-19 pandemic in Australia. The themes identified were similar between the two periods. Rural PHCPs were underutilised due to a lack of awareness of their capacity and a lack of infrastructure and support for greater involvement. Conclusions: Rural PHCPs can be better integrated and supported in readiness for a whole-system response to future disasters. This study recommends empowering PHCPs in disaster management to promote the health and continuity of care in rural communities.</jats:p

CACHE (Critical Assessment of Computational Hit-finding Experiments): A public–private partnership benchmarking initiative to enable the development of computational methods for hit-finding

One aspirational goal of computational chemistry is to predict potent and drug-like binders for any protein, such that only those that bind are synthesized. In this Roadmap, we describe the launch of Critical Assessment of Computational Hit-finding Experiments (CACHE), a public benchmarking project to compare and improve small-molecule hit-finding algorithms through cycles of prediction and experimental testing. Participants will predict small-molecule binders for new and biologically relevant protein targets representing different prediction scenarios. Predicted compounds will be tested rigorously in an experimental hub, and all predicted binders as well as all experimental screening data, including the chemical structures of experimentally tested compounds, will be made publicly available and not subject to any intellectual property restrictions. The ability of a range of computational approaches to find novel binders will be evaluated, compared and openly published. CACHE will launch three new benchmarking exercises every year. The outcomes will be better prediction methods, new small-molecule binders for target proteins of importance for fundamental biology or drug discovery and a major technological step towards achieving the goal of Target 2035, a global initiative to identify pharmacological probes for all human proteins. [Figure not available: see fulltext.