Scaling-up a pharmacist-led information technology intervention (PINCER) to reduce hazardous prescribing in general practices: Multiple interrupted time series study.

BACKGROUND: We previously reported on a randomised trial demonstrating the effectiveness and cost-effectiveness of a pharmacist-led information technology intervention (PINCER). We sought to investigate whether PINCER was effective in reducing hazardous prescribing when rolled out at scale in UK general practices. METHODS AND FINDINGS: We used a multiple interrupted time series design whereby successive groups of general practices received the PINCER intervention between September 2015 and April 2017. We used 11 prescribing safety indicators to identify potentially hazardous prescribing and collected data over a maximum of 16 quarterly time periods. The primary outcome was a composite of all the indicators; a composite for indicators associated with gastrointestinal (GI) bleeding was also reported, along with 11 individual indicators of hazardous prescribing. Data were analysed using logistic mixed models for the quarterly event numbers with the appropriate denominator, and calendar time included as a covariate. PINCER was implemented in 370 (94.1%) of 393 general practices covering a population of almost 3 million patients in the East Midlands region of England; data were successfully extracted from 343 (92.7%) of these practices. For the primary composite outcome, the PINCER intervention was associated with a decrease in the rate of hazardous prescribing of 16.7% (adjusted odds ratio (aOR) 0.83, 95% confidence interval (CI) 0.80 to 0.86) at 6 months and 15.3% (aOR 0.85, 95% CI 0.80 to 0.90) at 12 months postintervention. The unadjusted rate of hazardous prescribing reduced from 26.4% (22,503 patients in the numerator/853,631 patients in the denominator) to 20.1% (11,901 patients in the numerator/591,364 patients in the denominator) at 6 months and 19.1% (3,868 patients in the numerator/201,992 patients in the denominator). The greatest reduction in hazardous prescribing associated with the intervention was observed for the indicators associated with GI bleeding; for the GI composite indicator, there was a decrease of 23.9% at both 6 months (aOR 0.76, 95% CI 0.73 to 0.80) and 12 months (aOR 0.76, 95% CI 0.70 to 0.82) postintervention. The unadjusted rate of hazardous prescribing reduced from 31.4 (16,185 patients in the numerator/515,879 patients in the denominator) to 21.2% (7,607 patients in the numerator/358,349 patients in the denominator) at 6 months and 19.5% (2,369 patients in the numerator/121,534 patients in the denominator). We adjusted for calendar time and practice, but since this was an observational study, the findings may have been influenced by unknown confounding factors or behavioural changes unrelated to the PINCER intervention. Data were also not collected for all practices at 6 months and 12 months postintervention. CONCLUSIONS: The PINCER intervention, when rolled out at scale in routine clinical practice, was associated with a reduction in hazardous prescribing by 17% and 15% at 6 and 12 months postintervention. The greatest reductions in hazardous prescribing were for indicators associated with risk of GI bleeding. These findings support the wider national rollout of PINCER in England.

The potential of multispectral imaging flow cytometry for environmental monitoring.

Environmental monitoring involves the quantification of microscopic cells and particles such as algae, plant cells, pollen, or fungal spores. Traditional methods using conventional microscopy require expert knowledge, are time-intensive and not well-suited for automated high throughput. Multispectral imaging flow cytometry (MIFC) allows measurement of up to 5000 particles per second from a fluid suspension and can simultaneously capture up to 12 images of every single particle for brightfield and different spectral ranges, with up to 60x magnification. The high throughput of MIFC has high potential for increasing the amount and accuracy of environmental monitoring, such as for plant-pollinator interactions, fossil samples, air, water or food quality that currently rely on manual microscopic methods. Automated recognition of particles and cells is also possible, when MIFC is combined with deep-learning computational techniques. Furthermore, various fluorescence dyes can be used to stain specific parts of the cell to highlight physiological and chemical features including: vitality of pollen or algae, allergen content of individual pollen, surface chemical composition (carbohydrate coating) of cells, DNA- or enzyme-activity staining. Here, we outline the great potential for MIFC in environmental research for a variety of research fields and focal organisms. In addition, we provide best practice recommendations.

Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study.

BACKGROUND: Health care-related harm is an internationally recognized threat to public health. The United Kingdom's national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. METHODS: We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of 'significant harm'. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define "avoidable harm" within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. RESULTS: Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. DISCUSSION: The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. CONCLUSION: We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients.

'I expected just to walk in, get my tablets and then walk out': on framing new community pharmacy services in the English healthcare system.

Reconfiguration of the healthcare division of labour is becoming increasingly attractive in the context of increased patient demand and resource constraints. One example is the introduction of extended roles for pharmacists to provide patients additional support to manage their medicines, while also reducing work pressures experienced by other health professionals. Understanding how such policies are framed by those delivering and receiving care has been under-theorised. Using Goffman's frame theory, we examine one newly introduced community pharmacy service (New Medicines Service (NMS)) to illustrate how a policy intended to support patient medicine-taking through the extended roles of pharmacists is framed and where this deviates from its proposed aims. Three themes emerged: (i) the spatial-material artefacts; (ii) existing discursive culture and practice around medicine-taking; and (iii) the NMS interactions that shape and govern framing and subsequent interpretation of the NMS. Our study offers an explanatory and dynamic view of the framing process with important lessons for reconfiguring medicine management policy and practice. As well as illustrating framing as being variegated, complementary or conflicting, it also shows how this plurality and fragility had consequences for patient engagement and sense-making. The consequences for engagement and recommendations for implementing future initiatives are discussed.

Impact of a novel interprofessional dental and pharmacy student tobacco cessation education programme on dental patient outcomes.

The dental setting presents a unique opportunity to assist patients with tobacco cessation. Many dental providers do not feel prepared to provide tobacco cessation, particularly with regard to education on pharmacological treatments. An interprofessional practice experience with dental and pharmacy students provides a novel approach to tobacco cessation in the dental setting, but it is not known whether such methods affect patient outcomes. The goal of the study was to examine the impact of a novel dental and pharmacy student tobacco cessation education programme on patient knowledge gained, barriers to utilising cessation medications, quit intentions, and quit behaviours as compared to standard care. Dental patients who were seen at the dental admissions clinic of a dental school on interprofessional care (IPC) days and received tobacco cessation education from the dental-pharmacy student team (N = 25) were compared with dental patients at the clinic seen on Standard Care (SC) days (N = 25). Patients completed a post-appointment survey and a 4-week follow-up survey. IPC patients reported greater perceived knowledge post-appointment and at follow-up regarding tobacco cessation compared with SC patients and had greater intentions to utilise medication to assist with tobacco cessation. At follow-up there were no differences between groups in terms of quit attempts. Among patients who made a quit attempt those in the IPC group were more likely to have set a quit date and contacted a provider for assistance regarding tobacco cessation. Dental-pharmacy student interprofessional tobacco cessation may be an innovative way to provide tobacco cessation education to dental patients and provide students with interprofessional practice experiences.

Comparative Performance and Model Agreement of Three Common Photovoltaic Array Configurations.

Three grid-connected monocrystalline silicon arrays on the National Institute of Standards and Technology (NIST) campus in Gaithersburg, MD have been instrumented and monitored for 1 yr, with only minimal gaps in the data sets. These arrays range from 73 kW to 271 kW, and all use the same module, but have different tilts, orientations, and configurations. One array is installed facing east and west over a parking lot, one in an open field, and one on a flat roof. Various measured relationships and calculated standard metrics have been used to compare the relative performance of these arrays in their different configurations. Comprehensive performance models have also been created in the modeling software pvsyst for each array, and its predictions using measured on-site weather data are compared to the arrays' measured outputs. The comparisons show that all three arrays typically have monthly performance ratios (PRs) above 0.75, but differ significantly in their relative output, strongly correlating to their operating temperature and to a lesser extent their orientation. The model predictions are within 5% of the monthly delivered energy values except during the winter months, when there was intermittent snow on the arrays, and during maintenance and other outages.

High-Speed Monitoring of Multiple Grid-Connected Photovoltaic Array Configurations and Supplementary Weather Station.

Three grid-connected monocrystalline silicon photovoltaic arrays have been instrumented with research-grade sensors on the Gaithersburg, MD campus of the National Institute of Standards and Technology (NIST). These arrays range from 73 kW to 271 kW and have different tilts, orientations, and configurations. Irradiance, temperature, wind, and electrical measurements at the arrays are recorded, and images are taken of the arrays to monitor shading and capture any anomalies. A weather station has also been constructed that includes research-grade instrumentation to measure all standard meteorological quantities plus additional solar irradiance spectral bands, full spectrum curves, and directional components using multiple irradiance sensor technologies. Reference photovoltaic (PV) modules are also monitored to provide comprehensive baseline measurements for the PV arrays. Images of the whole sky are captured, along with images of the instrumentation and reference modules to document any obstructions or anomalies. Nearly, all measurements at the arrays and weather station are sampled and saved every 1s, with monitoring having started on Aug. 1, 2014. This report describes the instrumentation approach used to monitor the performance of these photovoltaic systems, measure the meteorological quantities, and acquire the images for use in PV performance and weather monitoring and computer model validation.

Model (At Least) Twice, Build Once: Experiences With the Design-Bid-Build Process for Solar Photovoltaic Arrays.

Commercial-scale solar photovoltaic (PV) arrays were designed, constructed, and are now operational on the Gaithersburg, Maryland campus of the National Institute of Standards and Technology (NIST). A design-bid-build process was followed where the contractors used photovoltaic system modeling tools both during the initial design phase and during the postbid, prebuild phase. To help investigate the specific aspects of the contractors' evolving designs, the authors conducted their own independent photovoltaic system modeling. This independent modeling helped identify design elements that could be improved and so aided efforts to maximize the annual renewable energy generation. An estimated 2.5% gain in annual energy generation is being realized as a result of this independent modeling effort. To provide context for the modeling work and the lessons learned, key events impacting the design-bid-build process are described. The installed systems are summarized and also contrasted with the proposed designs. The power generation at three sites are compared over two different 12-month intervals.

Assessing the safety features of electronic patient medication record systems used in community pharmacies in England.

AIMS: To evaluate the ability of electronic patient medication record (ePMR) systems used in community pharmacies in England to detect and alert users about clinical hazards, errors and other safety problems. METHODS: Between September 2012 and November 2012, direct on-site observational data about the performance of ePMR systems were collected from nine sites. Twenty-eight scenarios were developed by consensus agreement between a general practitioner and two community pharmacists. Each scenario was entered into the ePMR system, and the results obtained from the assessment of six unique systems in nine sites, in terms of the presence or absence of an alert, were recorded onto a prespecified form. RESULTS: None of the systems produced the correct responses for all of the 28 scenarios tested. Only two systems provided an alert to penicillin sensitivity. No dose or frequency check was observed when processing a prescription for methotrexate. One system did not warn about nonsuitability of aspirin prescribed to a child of 14 years of age. In another system, it was not possible to record a patient's pregnancy status. None of the six systems provided any warning for diclofenac overdose, high initiation dose of morphine sulfate or significant dose increase. Only one of the systems did not produce any spurious alerts. CONCLUSIONS: The performance of the ePMR systems tested was variable and suboptimal. The findings suggest the need for minimum specifications and standards for ePMR systems to ensure consistency of performance.

What proportion of prescription items dispensed in community pharmacies are eligible for the New Medicine Service?

BACKGROUND: The payment structure for the New Medicine Service (NMS) in England is based on the assumption that 0.5% of prescription items dispensed in community pharmacies are eligible for the service. This assumption is based on a theoretical calculation. This study aimed to find out the actual proportion of prescription items eligible for the NMS dispensed in community pharmacies in order to compare this with the theoretical assumption. The study also aimed to investigate whether the proportion of prescription items eligible for the NMS is affected by pharmacies' proximity to GP practices. METHODS: The study collected data from eight pharmacies in Nottingham belonging to the same large chain of pharmacies. Pharmacies were grouped by distance from the nearest GP practice and sampled to reflect the distribution by distance of all pharmacies in Nottingham. Data on one thousand consecutive prescription items were collected from each pharmacy and the number of NMS eligible items recorded. All NHS prescriptions were included in the sample. Data were analysed and proportions calculated with 95% confidence intervals used to compare the study results against the theoretical figure of 0.5% of prescription items being eligible for the NMS. RESULTS: A total of 8005 prescription items were collected (a minimum of 1000 items per pharmacy) of which 17 items were eligible to receive the service. The study found that 0.25% (95% confidence intervals: 0.14% to 0.36%) of prescription items were eligible for the NMS which differs significantly from the theoretical assumption of 0.5%. The opportunity rate for the service was lower, 0.21% (95% confidence intervals: 0.10% to 0.32%) of items, as some items eligible for the NMS did not translate into opportunities to offer the service. Of all the prescription items collected in the pharmacies, 28% were collected by patient representatives. CONCLUSIONS: The results of this study show that the proportion of items eligible for the NMS dispensed in community pharmacies is lower than the Department of Health assumption of 0.5%. This study did not find a significant difference in the rate of NMS opportunities between pharmacies located close to GP practices compared to those further away.

Revision workshops in elementary mathematics enhance student performance in routine laboratory calculations.

The ability to understand and implement calculations required for molarity and dilution computations that are routinely undertaken in the laboratory are essential skills that should be possessed by all students entering an undergraduate Life Sciences degree. However, it is increasingly recognized that the majority of these students are ill equipped to reliably carry out such calculations. There are several factors that conspire against students' understanding of this topic, with the alien concept of the mole in relation to the mass of compounds and the engineering notation required when expressing the relatively small quantities typically involved being two key examples. In this report, we highlight teaching methods delivered via revision workshops to undergraduate Life Sciences students at the University of Nottingham. Workshops were designed to 1) expose student deficiencies in basic numeracy skills and remedy these deficiencies, 2) introduce molarity and dilution calculations and illustrate their workings in a step-by-step manner, and 3) allow students to appreciate the magnitude of numbers. Preworkshop to postworkshop comparisons demonstrated a considerable improvement in students' performance, which attenuated with time. The findings of our study suggest that an ability to carry out laboratory calculations cannot be assumed in students entering Life Sciences degrees in the United Kingdom but that explicit instruction in the form of workshops improves proficiency to a level of competence that allows students to prosper in the laboratory environment.

Perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in dermatology.

This research letter discusses the perspectives of community pharmacy staff on commonly encountered skin conditions and the key challenges towards enhancing their role in this area. A mixed methods online survey was created, and a total of 174 community pharmacy staff completed the survey. The results highlight the range of conditions currently encountered in community pharmacy and the breadth of challenges facing community pharmacy staff, in particular challenges surrounding providing a differential diagnosis. Community pharmacies are an integral part of the NHS and have a key role in managing skin conditions; however, in order to optimise this role, the perspectives of staff discussed in this letter need to be further explored and addressed.

Pilot and quantitative evaluation of the TARGET acne toolkit by UK pharmacy professionals working in general practice.

BACKGROUND: Acne vulgaris (acne) is a common skin condition sometimes needing topical or oral antibiotic treatment. Pharmacists and pharmacy technicians (together known as pharmacy professionals) working in general practice are well placed to ensure their appropriate use. OBJECTIVES: The objectives of this study are to pilot an evidence-based intervention ('How to…' tool) to review treatments in the management of acne and evaluate the capability, opportunity, motivation and behaviour (COM-B) of pharmacy professionals working in general practice before and after the use of this tool. DESIGN, SETTING AND PARTICIPANTS: A quantitative electronic survey was developed asking UK-based pharmacy professionals working in general practice to rate their agreement with 21 predefined statements related to the COM-B model. INTERVENTION: Participants were sent an initial survey, given time to access and use the 'How to…' acne resources and then sent a follow-up survey 2 weeks later. OUTCOME MEASURES: Primary outcome was change in 5-point Likert scale responses to statements on capability, opportunity and motivation in the management of acne. Secondary outcome was the perceived usefulness of the toolkit. RESULTS: 141 pharmacy professionals completed the initial survey; 19 completed the follow-up survey. Significant improvement in the 5-point Likert scale means that responses were observed after implementation of the acne 'How to' resource; capability 3.68 (SD 0.40) versus 4.11 (SD 0.29), t(189) =-5.10, p <0.001; opportunity 3.85 (SD 0.24) versus 4.07 (SD 0.29), t(94)=-2.50, p=0.007 and motivation 4.35 (SD 0.47) versus 4.51 (SD 0.32), t(113)=-2.51, p=0.007. The 'How to' resources were rated as being useful (4.06, SD 0.12) and supportive (4.08, SD 0.18) to help pharmacy professionals in all areas of managing acne. CONCLUSION: The acne 'How to' resources are useful to pharmacy professionals in managing acne in general practice and may improve their capability. Further work is needed with greater numbers of participants to demonstrate generalisability of this outcome.

How can community pharmacists be supported to manage skin conditions? A multistage stakeholder research prioritisation exercise.

OBJECTIVE: To establish research priorities which will support the development and delivery of community pharmacy initiatives for the management of skin conditions. DESIGN: An iterative, multistage stakeholder consultation consisting of online survey, participant workshops and prioritisation meeting. SETTING: All data collection took place online with participants completing a survey (delivered via the JISC Online Survey platform, between July 2021 and January 2022) and participating in online workshops and meetings (hosted on Microsoft Teams between April and July 2022). PARTICIPANTS: 174 community pharmacists and pharmacy staff completed the online survey.53 participants participated in the exploratory workshops (19 community pharmacists, 4 non-pharmacist members of pharmacy staff and 30 members of the public). 4 healthcare professionals who were unable to attend a workshop participated in a one-to-one interview.29 participants from the workshops took part in the prioritisation meeting (5 pharmacists/pharmacy staff, 1 other healthcare professional and 23 members of the public). RESULTS: Five broad areas of potential research need were identified in the online survey: (1) identifying and diagnosing skin conditions; (2) skin conditions in skin of colour; (3) when to refer skin conditions; (4) disease-specific concerns and (5) product-specific concerns.These were explored and refined in the workshops to establish 10 potential areas for research, which will support pharmacists in managing skin conditions. These were ranked in the prioritisation meeting. Among those prioritised were topics which consider how pharmacists work with other healthcare professionals to identify and manage skin conditions. CONCLUSIONS: Survey responses and stakeholder workshops all recognised the potential for community pharmacists to play an active role in the management of common skin conditions. Future research may support this in the generation of resources for pharmacists, in encouraging public take-up of pharmacy services, and in evaluating the most effective provision for dealing with skin conditions.

A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis.

BACKGROUND: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention. METHODS: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; ß blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299. FINDINGS: 72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38-0·89); a ß blocker if they had asthma (0·73, 0·58-0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34-0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months. INTERPRETATION: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records. FUNDING: Patient Safety Research Portfolio, Department of Health, England.

The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review.

BACKGROUND: Electronic Patient Medication Record (ePMR) systems have important safety features embedded to alert users about potential clinical hazards and errors. To date, there is no synthesis of evidence about the effectiveness of these safety features and alerts at the point of pharmacy order entry. This review aims to systematically explore the literature and synthesise published evidence about the effectiveness of safety features and alerts in ePMR systems at the point of pharmacy order entry, in primary and secondary care. METHODS: We searched MEDLINE, EMBASE, Inspec, International Pharmaceutical Abstracts, PsycINFO, CINHAL (earliest entry to March 2012) and reference lists of articles. Two reviewers examined the titles and abstracts, and used a hierarchical template to identify comparative design studies evaluating the effectiveness of safety features and alerts at the point of pharmacy order entry. The two reviewers independently assessed the quality of the included studies using Cochrane Collaboration's risk of bias tool. RESULTS: Three randomised trials and two before-after studies met our criteria. Four studies involved integrated care facilities and one was hospital-based. The studies were all from the United States (US). The five studies demonstrated statistically significant reduction in medication errors in patients with renal insufficiency, pregnant women dispensed US Food Drug and Administration (FDA) risk category D (evidence of fetal risk but therapeutic benefits can outweigh the risk) or X (evidence suggests that risk to the fetus outweighs therapeutic benefits) medication, first dispensing of inappropriate medications in patients aged 65 and above, co-dispensing of interacting drugs, and adverse drug events related to hyperkalaemia. CONCLUSIONS: This systematic review shows that the safety features of ePMR systems are effective in alerting users about potential clinical hazards and errors during pharmacy order entry. There are however, problems such as false alerts and inconsistencies in alert management. More studies are needed from other countries and pharmacy practice settings to assess the effectiveness of electronic safety features and alerts in preventing error and reducing harm to patients.

Perceived current and future roles of UK-based community pharmacy professionals in the long-term management of acne.

Introduction: Acne is a common skin condition treated in community pharmacy but moderate to severe cases may need referral to general practice for treatment that may include topical or oral antimicrobial treatments. Pharmacy teams working in the community are well-placed to manage acne treatments in line with NICE guidance. Objectives: To explore the perceived current and future roles of community pharmacy (CP) teams alongside needs to achieve potential future roles. Additionally, usefulness of the TARGET acne 'How to' toolkit to support these roles was sought. Methods: A mixed-methods electronic survey of UK-based CP professionals and stakeholders in March 2023. Results: 54 pharmacy professionals and stakeholders responded to the survey. The current confidence of pharmacy professionals in managing acne was rated as moderate and reviewing long-term medications for acne prescribed by another healthcare professional was seen as a future role. The needs identified to undertake such a role were: training, availability of prescribing or supply frameworks, and appropriate remuneration. The TARGET acne resources were thought of as being very useful for acne management. Conclusions: Potential future roles for CP have been identified, alongside additional needs to undertake these roles; the TARGET acne 'How to' resources could support pharmacy professionals in the management and review of antimicrobial treatment for acne.

Absence of geochemical evidence for an impact event at the Bølling-Allerød/Younger Dryas transition.

High concentrations of iridium have been reported in terrestrial sediments dated at 12.9 ka and are interpreted to support an extraterrestrial impact event as the cause of the observed extinction in the Rancholabrean fauna, changes in the Paleoindian cultures, and the onset of the Younger Dryas cooling [Firestone RB, et al. (2007) Proc Natl Acad Sci USA 104:16016-16021]. Here, we report platinum group element (PGE: Os, Ir, Ru, Rh, Pt, Pd), gold (Au) concentrations, and (187)Os/(188)Os ratios in time-equivalent terrestrial, lacustrine, and marine sections to seek robust evidence of an extraterrestrial contribution. First, our results do not reproduce the previously reported elevated Ir concentrations. Second, (187)Os/(188)Os isotopic ratios in the sediment layers investigated are similar to average crustal values, indicating the absence of a significant meteoritic Os contribution to these sediments. Third, no PGE anomalies distinct from crustal signatures are present in the marine record in either the Gulf of California (DSDP 480, Guaymas Basin) or the Cariaco Basin (ODP 1002C). Our data show no evidence of an extraterrestrial (ET)-PGE enrichment anomaly in any of the investigated depositional settings investigated across North America and in one section in Belgium. The lack of a clear ET-PGE signature in this sample suite is inconsistent with the impact of a large chondritic projectile at the Bølling-Allerød/Younger Dryas transition.

An ethnographic evaluation of a speciality training pathway for general practice nursing in the UK.

AIMS: The aim of the study was to evaluate the implementation and impact of the General Practice Nurse - Specialty Training (GPN-ST) programme across seven sites in one geographical location in the UK. The objectives were to understand, describe and evaluate: 1) the implementation of the 'proof of concept' training scheme; 2) the learning undertaken during the training; and 3) the impact of the training scheme on individual nurses. These objectives offer the opportunity to describe the potential return on investment for General Practices supporting nurses new to General Practice through the programme. BACKGROUND: General Practice Nurses (GPNs) play a vital role in delivering primary and community care. In the UK there is a shortfall in the GPN workforce. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. An ethnographic evaluation was undertaken of a one-year speciality training programme (GPN-ST). The programme, aimed at nurses new to General Practice, included formal higher education training and funded supported learning and mentoring whilst in practice. METHODS: A qualitative ethnographic evaluation was undertaken. Observations were conducted of programme implementation, network and education meetings in the scheme. In-depth, semi-structured, interviews and focus groups were conducted with a wide range of professionals (n = 40) including nurse mentors, nursing students, academic providers, commissioners and the programme managers. These data were supplemented by documentary analysis of meeting notes, learning materials, internal student feedback and locally collected evaluation material in line with ethnographic approaches to research. Kirkpatrick's model for course evaluation and complimentary inductive emergent thematic analysis was used. FINDINGS: There is evidence of learning at every level of the Kirkpatrick model from reaction through to changes in behaviour and results in practice for patients. The speciality training route offered opportunities for deep learning for GPNs. The scheme offered a comprehensive career pathway to General Practice nursing which in turn benefited General Practices. Practices benefitted from confident, independent nurses who were able to contribute to patient care, practice safely and also contributed widely in the long-term for example in research, workforce development and mentoring. CONCLUSIONS: General Practice needs to invest in developing a workforce of GPNs, there are significant benefits to investing in the development of GPNs through a training pathway. This scheme provides scope for application in other clinical settings as well in other countries where there is a gap in career progression into GP practices. TWEETABLE ABSTRACT: GPNs play a vital role in delivering primary and community care. Unlike training for other clinical professions there is currently no standardised training pathway or entry route for nurses wishing to work in General Practice. There are significant benefits to investing in the development of GPNs through a training pathway.