A qualitative exploration of barriers to efficient and effective structured medication reviews in primary care: Findings from the DynAIRx study.

INTRODUCTION: Structured medication reviews (SMRs), introduced in the United Kingdom (UK) in 2020, aim to enhance shared decision-making in medication optimisation, particularly for patients with multimorbidity and polypharmacy. Despite its potential, there is limited empirical evidence on the implementation of SMRs, and the challenges faced in the process. This study is part of a larger DynAIRx (Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity) project which aims to introduce Artificial Intelligence (AI) to SMRs and develop machine learning models and visualisation tools for patients with multimorbidity. Here, we explore how SMRs are currently undertaken and what barriers are experienced by those involved in them. METHODS: Qualitative focus groups and semi-structured interviews took place between 2022-2023. Six focus groups were conducted with doctors, pharmacists and clinical pharmacologists (n = 21), and three patient focus groups with patients with multimorbidity (n = 13). Five semi-structured interviews were held with 2 pharmacists, 1 trainee doctor, 1 policy-maker and 1 psychiatrist. Transcripts were analysed using thematic analysis. RESULTS: Two key themes limiting the effectiveness of SMRs in clinical practice were identified: 'Medication Reviews in Practice' and 'Medication-related Challenges'. Participants noted limitations to the efficient and effectiveness of SMRs in practice including the scarcity of digital tools for identifying and prioritising patients for SMRs; organisational and patient-related challenges in inviting patients for SMRs and ensuring they attend; the time-intensive nature of SMRs, the need for multiple appointments and shared decision-making; the impact of the healthcare context on SMR delivery; poor communication and data sharing issues between primary and secondary care; difficulties in managing mental health medications and specific challenges associated with anticholinergic medication. CONCLUSION: SMRs are complex, time consuming and medication optimisation may require multiple follow-up appointments to enable a comprehensive review. There is a need for a prescribing support system to identify, prioritise and reduce the time needed to understand the patient journey when dealing with large volumes of disparate clinical information in electronic health records. However, monitoring the effects of medication optimisation changes with a feedback loop can be challenging to establish and maintain using current electronic health record systems.

The DynAIRx Project Protocol: Artificial Intelligence for dynamic prescribing optimisation and care integration in multimorbidity.

Background: Structured Medication Reviews (SMRs) are intended to help deliver the NHS Long Term Plan for medicines optimisation in people living with multiple long-term conditions and polypharmacy. It is challenging to gather the information needed for these reviews due to poor integration of health records across providers and there is little guidance on how to identify those patients most urgently requiring review. Objective: To extract information from scattered clinical records on how health and medications change over time, apply interpretable artificial intelligence (AI) approaches to predict risks of poor outcomes and overlay this information on care records to inform SMRs. We will pilot this approach in primary care prescribing audit and feedback systems, and co-design future medicines optimisation decision support systems. Design: DynAIRx will target potentially problematic polypharmacy in three key multimorbidity groups, namely, people with (a) mental and physical health problems, (b) four or more long-term conditions taking ten or more drugs and (c) older age and frailty. Structured clinical data will be drawn from integrated care records (general practice, hospital, and social care) covering an ∼11m population supplemented with Natural Language Processing (NLP) of unstructured clinical text. AI systems will be trained to identify patterns of conditions, medications, tests, and clinical contacts preceding adverse events in order to identify individuals who might benefit most from an SMR. Discussion: By implementing and evaluating an AI-augmented visualisation of care records in an existing prescribing audit and feedback system we will create a learning system for medicines optimisation, co-designed throughout with end-users and patients.

A 35 ka record of groundwater recharge in south-west Australia using stable water isotopes.

The isotopic composition of groundwater can be a useful indicator of recharge conditions and may be used as an archive to infer past climate variability. Groundwater from two largely confined aquifers in south-west Australia, recharged at the northernmost extent of the westerly wind belt, can help constrain the palaeoclimate record in this region. We demonstrate that radiocarbon age measurements of dissolved inorganic carbon are appropriate for dating groundwater from the Leederville aquifer and Yarragadee aquifer within the Perth Basin. Variations in groundwater δ18O values with mean residence time were examined using regional and flow line data sets, which were compared. The trends in the regional groundwater data are consistent with the groundwater flow line data supporting the hypothesis that groundwater δ18O is a robust proxy for palaeo-recharge in the Perth Basin. A comparison between modern groundwater and rainfall water isotopes indicates that recharge is biased to months with high volume and/or intense rainfall from the westerly wind circulation and that this has been the case for the last 35 ka. Lower stable water isotope values are interpreted to represent recharge from higher volume and/or more intense rainfall from 35 ka through the Last Glacial Maximum period although potentially modulated by changes in recharge thresholds. The Southern Perth Basin groundwater isotopic record also indicates a trend towards higher volume and/or intense rainfall during the Mid- to Late Holocene. The long-term stable water isotope record provides an understanding of groundwater palaeo-recharge. Knowledge of recharge dynamics over long time scales can be used to improve current water sharing plans and future groundwater model predictions.

Statistical analysis of Seoul air quality to assess the efficacy of emission abatement strategies since 1987.

The combined influences of recent mitigation measures on urban air quality have been assessed using hourly observations of the criteria air pollutants (NO, NO2, O3, CO, and SO2) made from the Yongsan district of Seoul, Korea, over 26years (1987 to 2013). A number of data selection criteria are proposed in order to minimize variability associated with temporal changes (at diurnal, weekly, and seasonal timescales) in source strengths, their spatial distribution, and the atmospheric volume into which they mix. The temporal constraints required to better characterize relationships between observed air quality and changes in source strengths in Seoul were identified as: (i) a 5-hour diurnal sampling window (1300-1700h), (b) weekday measurements (Monday to Friday only), and (c) summer measurements (when pollutant fetch is mostly Korea-specific, and mean wind speeds are the lowest). Using these selection criteria, we were able to closely relate long-term trends identified in criteria pollutants to a number of published changes to traffic-related source strengths brought about by mitigation measures adopted over the last 10-15years.

Atmospheric stability effects on potential radiological releases at a nuclear research facility in Romania: Characterising the atmospheric mixing state.

A radon-based nocturnal stability classification scheme is developed for a flat inland site near Bucharest, Romania, characterised by significant local surface roughness heterogeneity, and compared with traditional meteorologically-based techniques. Eight months of hourly meteorological and atmospheric radon observations from a 60 m tower at the IFIN-HH nuclear research facility are analysed. Heterogeneous surface roughness conditions in the 1 km radius exclusion zone around the site hinder accurate characterisation of nocturnal atmospheric mixing conditions using conventional meteorological techniques, so a radon-based scheme is trialled. When the nocturnal boundary layer is very stable, the Pasquill-Gifford "radiation" scheme overestimates the atmosphere's capacity to dilute pollutants with near-surface sources (such as tritiated water vapour) by 20% compared to the radon-based scheme. Under these conditions, near-surface wind speeds drop well below 1 m s(-1) and nocturnal mixing depths vary from ∼ 25 m to less than 10 m above ground level (a.g.l.). Combining nocturnal radon with daytime ceilometer data, we were able to reconstruct the full diurnal cycle of mixing depths. Average daytime mixing depths at this flat inland site range from 1200 to 1800 m a.g.l. in summer, and 500-900 m a.g.l. in winter. Using tower observations to constrain the nocturnal radon-derived effective mixing depth, we were able to estimate the seasonal range in the Bucharest regional radon flux as: 12 mBq m(-2) s(-1) in winter to 14 mBq m(-2) s(-1) in summer.

Interscalene brachial plexus block: can the risk of entering the spinal canal be reduced? A study of needle angles in volunteers undergoing magnetic resonance imaging.

BACKGROUND: Spinal cord damage during interscalene brachial plexus block has been attributed to needle entry into the spinal canal. The purpose of this study was to identify the angles and depths of needle insertion that increase the likelihood of such an event, using the traditional classic interscalene approach and two more proximal entry points. METHOD: Magnetic resonance images of the neck from 10 healthy volunteers were used to obtain the three-dimensional spatial coordinates of three skin markers and the right-sided cervical nerves at the exiting neural foramina. The distance of the intervertebral foramina from the skin markers and the angles of the needle vector and the foramina were calculated. RESULTS: The distance from the skin to the intervertebral foramen may be as short as 2.5 cm with the classic approach. A caudal angulation greater than 50 degrees seemed to eliminate the risk of needle entry through the foramen. CONCLUSION: With the classic approach to the interscalene block, there is a greater possibility of the needle passing through the intervertebral foramen if the needle is advanced too deeply. More proximal entry points and techniques that use a more steeply angled needle may reduce the risk of entry into the spinal space.

Diode laser absorption spectroscopy of water vapor in a scramjet combustor.

A sensor based on tunable diode laser absorption spectroscopy was constructed for time-resolved temperature and water vapor concentration measurements in a scramjet combustor. The sensor probed two absorption lines near 1390 nm with two time-multiplexed lasers used to measure temperature and water vapor concentration at up to 20 kHz. A demonstration experiment was performed in the supersonic, expanding exhaust region of the combustor, showing the measurement to be repeatable, able to resolve temporal trends during tunnel operation, and sensitive to changes in combustor operating conditions.