Implementation and evaluation of a collaborative clinical pharmacist's medications reconciliation and charting service for admitted medical inpatients in a metropolitan hospital.

WHAT IS KNOWN AND OBJECTIVE: Medication errors on admission can persist throughout the episode of care and on to discharge leading to inappropriate management that can compromise patients' care. The aim of the study was to develop, implement and evaluate the role of pharmacist-led medication reconciliation and charting service for patients admitted to an Acute Assessment and Admission Unit via the Emergency Department in an electronic medication management environment at a metropolitan Australian hospital. METHODS: Following the credentialing of an experienced clinical pharmacist to perform collaborative medication charting, a prospective parallel study of medication errors was undertaken. Patients were randomly allocated to an intervention (n = 56) or a usual care (control) (n = 54) arm. Medication orders were charted by the medical staff in the usual care arm, whereas the pharmacist charted the medications in the intervention arm. An independent clinical pharmacist reviewed all the medication orders at 24 h after admission and errors recorded. The severity of errors was rated by a 'blinded' consultant physician and an independent senior pharmacist according to a standardized matrix. The potential time saving for the medical staff was investigated. A survey was conducted to assess the perception, acceptance and satisfaction of the service. RESULTS AND DISCUSSION: The intervention arm (reconciliation performed by pharmacist) achieved an error reduction greater than 80%. The average error rate decreased from 4·41 to 0·52 errors per patient (P < 0·0001) and 0·43-0·05 errors per order (P < 0·005). The severity of the errors was also diminished. Time evaluation estimated that the pharmacist can save more than 30 min per patient for the admitting medical officers. Staff satisfaction survey indicated that the service was well received by the medical staff. WHAT IS NEW AND CONCLUSION: A model of a collaborative clinical pharmacist reconciliation and charting service for admitted medical patients in an Australian hospital was successfully implemented. The service was well received and has shown to save medical staff time allowing them to attend to other duties. Moreover, the pharmacist charting and reconciliation service has resulted in a statistically significant reduction in medication errors.

The limitations in implementing and operating a rapid response system.

Despite the widespread introduction of rapid response systems (RRS)/medical emergency teams (MET), there is still controversy regarding how effective they are. While there are some observational studies showing improved outcomes with RRS, there are no data from randomised controlled trials to support the effectiveness. Nevertheless, the MET system has become a standard of care in many healthcare organisations. In this review, we present an overview of the limitations in implementing and operating a RRS in modern healthcare.

Evaluation of the efficacy of transcricoid lignocaine as adjunctive local anaesthesia for fiberoptic bronchoscopy.

INTRODUCTION: Optimisation of patient comfort during flexible bronchoscopy is achieved with the use of intravenous sedation and vocal anaesthesia. METHODS: The effect of transcricoid lignocaine injection was investigated with regards to ease of procedure and frequency of cough. A single-blinded study was carried out and two visual analogue scales were used as markers of efficacy. Treatment groups were matched for age, gender and total dose of lignocaine administered. RESULTS: The results highlighted a significant improvement in the perceived ease of procedure (p < 0.0001) and frequency of coughing during the procedure (p < 0.0001). CONCLUSION: The findings of the study demonstrate that the use of transcricoid injection of lignocaine provided a safe adjunct for anaesthesia in flexible bronchoscopy.

Validation and method development of Tadalafil in bulk and tablet dosage form by RP-HPLC.

A novel, precise, rapid and sensitive reverse phase high performance liquid chromatographic method has been developed for the validated estimation of Tadalafil in bulk and tablet dosage form. The separation was achieved on Agilent Eclipse XDB C18 column (150 mm×4.6 mm, 5 µ) using a mobile phase that consists of the buffer (potassium dihydrogen orthophosphate) and acetonitrile in the ration of 50:50 V/V, pH 6 was adjusted with orthophosphoric acid. The flow rate was maintained at 1.2 ml/min and the detection wavelength was 285 nm. The method was validated for linearity, specificity, sensitivity as per ICH guidelines. The retention time was found to be 3.181 for Tadalafil. The calibration curve was linear over the concentration range of 10-150 µg/ml. The % RSD was satisfactory which showed the method found to be reliable. The high percentage recovery confirmed the suitability of the method for estimation of Tadalafil in pharmaceutical dosage form. The developed method could be applicable for routine analysis of Tadalafil in bulk and tablet dosage form.

A United Kingdom national survey of trends in ectopic pregnancy management.

Our national survey demonstrates increased use of medical and laparoscopic management of ectopic pregnancy in the UK. In the UK in 2000, 35% of cases were managed by laparoscopy, 63% by laparotomy and 1% with medication. A recent review in the USA revealed increasing rates of medical management and decreasing rates of laparotomy; a trend driven by both cost-effectiveness and patient choice. A total of 119 early pregnancy units were surveyed regarding the nature and management of the three most recent cases of ectopic pregnancy; in addition, feasibility of training residents was also requested. Participants reported on 124 cases with a median of five cases per month per department. A total of 57% of cases were managed laparoscopically, 31% medically, 5% by laparotomy and 6% conservatively. Out of 44 centres, 29 have the facilities for training in both intermediate laparoscopic surgery and early pregnancy ultrasound.

A study into efficacy of omalizumab therapy in patients with severe persistent allergic asthma at a tertiary referral centre for asthma in Ireland.

BACKGROUND: Asthma is a chronic airway disease characterized by airway inflammation, bronchial hyperresponsiveness and airflow obstruction. Patients with persistent symptoms despite maximum standard treatment as per Global Initiative of Asthma guidelines are considered to have severe persistent asthma. Omalizumab is a recombinant humanized monoclonal antibody licenced for use as an add-on therapy in these patients. AIM: To assess the clinical benefit amongst responders to omalizumab therapy at a tertiary referral centre. METHODS: This was a retrospective audit assessing the effect of omalizumab therapy on asthma control, frequency of exacerbation and hospitalization rates over 6 months before and after therapy. RESULTS: The study included 30 responders (14 females). There was a reduction in exacerbation and hospitalization rates following initiation of omalizumab, 73 and 91%, respectively (P-value < 0.0001). The number of exacerbations decreased from 3.48 ± 2.20 to 0.93 ± 0.83 and the mean number of admissions decreased from 1.07 ± 1.1 to 0.1 ± 0.40 over the study duration (P < 0.001). There was 73% reduction in the weekly need for rescue salbutamol therapy with mean of 30.33 ± 6.49 puffs to 8.23 ± 1.51 puffs after omalizumab therapy (P < 0.0001). Seventy-nine per cent of patients were able to reduce their maintenance oral corticosteroid therapy. CONCLUSION: Overall, responders to omalizumab therapy are less likely to experience an asthma exacerbation and hospitalization. They were also more likely to reduce maintenance corticosteroid therapy and the need for rescue reliever therapy. These data suggest that omalizumab has proven effective in improving health outcomes for a cohort of carefully selected patients with severe allergic asthma in Ireland.

Interfacial edge dislocation interactions with free-surfaces in nanocrystals.

UNLABELLED: The configurational force experienced by a dislocation towards a free-surface is termed as the image force. In this work we consider a combination of two cases, wherein the image force experienced by an edge dislocation is considerably altered with respect to an edge dislocation in a semi-infinite body: (i) interfacial misfit edge dislocation in an epitaxial system and (ii) edge dislocation in a 2D nanocrystal. The interaction of an edge dislocation with a free-surface in a 2D nanocrystal can be: (i) attractive with a considerably altered magnitude and direction (as compared to the theoretically calculated value), (ii) neither attractive nor repulsive or (iii) even repulsive. To compute the image force on a misfit edge dislocation in a 2D nanocrystalline epitaxial system, a finite element model is constructed and stress-free strains are imposed in appropriate regions of the domain, to simulate an epitaxial system (Nb/Sapphire) and an interfacial dislocation. The results of the simulation are contrasted with the standard theoretical formulations, which are shown to be highly inadequate to handle such cases which involve epitaxial strains, two materials in the system and considerable domain deformations. KEYWORDS: Image Force, Finite Element Method, Interfacial Misfit Dislocation, Domain

Molecular ecology meets remote sensing: environmental drivers to population structure of humpback dolphins in the Western Indian Ocean.

Genetic analyses of population structure can be placed in explicit environmental contexts if appropriate environmental data are available. Here, we use high-coverage and high-resolution oceanographic and genetic sequence data to assess population structure patterns and their potential environmental influences for humpback dolphins in the Western Indian Ocean. We analyzed mitochondrial DNA data from 94 dolphins from the coasts of South Africa, Mozambique, Tanzania and Oman, employing frequency-based and maximum-likelihood algorithms to assess population structure and migration patterns. The genetic data were combined with 13 years of remote sensing oceanographic data of variables known to influence cetacean dispersal and population structure. Our analyses show strong and highly significant genetic structure between all putative populations, except for those in South Africa and Mozambique. Interestingly, the oceanographic data display marked environmental heterogeneity between all sampling areas and a degree of overlap between South Africa and Mozambique. Our combined analyses therefore suggest the occurrence of genetically isolated populations of humpback dolphins in areas that are environmentally distinct. This study highlights the utility of molecular tools in combination with high-resolution and high-coverage environmental data to address questions not only pertaining to genetic population structure, but also to relevant ecological processes in marine species.

Dapsone-associated methaemoglobinaemia in patients with a haematologic malignancy.

Methaemoglobinaemia is an uncommon problem which can significantly impact on oxygen carriage and may necessitate intensive care management. The occurrence of symptomatic methaemoglobinaemia over a three-month period in four patients with haematological malignancies on dapsone for Pneumocystis jiroveci pneumonia prophylaxis prompted a review of its use in this group of patients. We performed a retrospective audit to identify any contributing factors. Co-oximetry was employed to identify patients with methaemoglobinaemia. Thirty-four patients with haematological malignancies received dapsone between January and December 2008, of whom 53% (n = 18) had co-oximetry studies done. Raised methaemoglobin levels (> or = 1.5%) were seen in 13 patients, four of them symptomatic. Mean peak level was of 7.84% (range 1.9 to 26.8%). Eight patients required intensive care support. Mean onset of methaemoglobinaemia was 11.8 days (range 4 to 18 days) following dapsone commencement. All patients were anaemic with an average haemoglobin of 85.5 g/l (range 59 to 111 g/l). All patients were prescribed 'azole' antifungal agents and five patients were also on high-dose steroids, both agents known to induce cytochrome P-450 enzymes and hence potentiating dapsone toxicity. Our experience suggests that dapsone should be used with caution in patients with haematological malignancies as they are particularly at risk of developing symptomatic methaemoglobinaemia due to underlying anaemia, immunosuppression and potential drug interactions. The current recommendation of dapsone for Pneumocystis jiroveci pneumonia prophylaxis in this group of patients needs to be reviewed. When methaemoglobinaemia does occur early recognition is possible with routine co-oximetry testing and prompt treatment may lessen the need for or duration of intensive care supports.

Boundary multifractality at the integer quantum Hall plateau transition: implications for the critical theory.

We study multifractal spectra of critical wave functions at the integer quantum Hall plateau transition using the Chalker-Coddington network model. Our numerical results provide important new constraints which any critical theory for the transition will have to satisfy. We find a nonparabolic multifractal spectrum and determine the ratio of boundary to bulk multifractal exponents. Our results rule out an exactly parabolic spectrum that has been the centerpiece in a number of proposals for critical field theories of the transition. In addition, we demonstrate analytically exact parabolicity of the related boundary spectra in the two-dimensional chiral orthogonal "Gade-Wegner" symmetry class.

Amazon River enhances diazotrophy and carbon sequestration in the tropical North Atlantic Ocean.

The fresh water discharged by large rivers such as the Amazon is transported hundreds to thousands of kilometers away from the coast by surface plumes. The nutrients delivered by these river plumes contribute to enhanced primary production in the ocean, and the sinking flux of this new production results in carbon sequestration. Here, we report that the Amazon River plume supports N(2) fixation far from the mouth and provides important pathways for sequestration of atmospheric CO(2) in the western tropical North Atlantic (WTNA). We calculate that the sinking of carbon fixed by diazotrophs in the plume sequesters 1.7 Tmol of C annually, in addition to the sequestration of 0.6 Tmol of C yr(-1) of the new production supported by NO(3) delivered by the river. These processes revise our current understanding that the tropical North Atlantic is a source of 2.5 Tmol of C to the atmosphere [Mikaloff-Fletcher SE, et al. (2007) Inverse estimates of the oceanic sources and sinks of natural CO(2) and the implied oceanic carbon transport. Global Biogeochem Cycles 21, doi:10.1029/2006GB002751]. The enhancement of N(2) fixation and consequent C sequestration by tropical rivers appears to be a global phenomenon that is likely to be influenced by anthropogenic activity and climate change.

Multifractality and conformal invariance at 2D metal-insulator transition in the spin-orbit symmetry class.

We study the multifractality (MF) of critical wave functions at boundaries and corners at the metal-insulator transition (MIT) for noninteracting electrons in the two-dimensional (2D) spin-orbit (symplectic) universality class. We find that the MF exponents near a boundary are different from those in the bulk. The exponents at a corner are found to be directly related to those at a straight boundary through a relation arising from conformal invariance. This provides direct numerical evidence for conformal invariance at the 2D spin-orbit MIT. The presence of boundaries modifies the MF of the whole sample even in the thermodynamic limit.

Surface criticality and multifractality at localization transitions.

We develop the concept of surface multifractality for localization-delocalization (LD) transitions in disordered electronic systems. We point out that the critical behavior of various observables related to wave functions near a boundary at a LD transition is different from that in the bulk. We illustrate this point with a calculation of boundary critical and multifractal behavior at the 2D spin quantum Hall transition and in a 2D metal at scales below the localization length.

Aspects regarding measurement of thickness of intergranular glassy films.

Materials such as Si(3)N(4), SiC and SrTiO(3) can have grain boundaries characterized by the presence of a thin intergranular amorphous film of nearly constant thickness, in some cases (e.g. Si(3)N(4)) almost independent of the orientation of the bounding grains, but dependent on the composition of the ceramic. Microscopy techniques such as high-resolution lattice fringe imaging, Fresnel fringe imaging and diffuse dark field imaging have been applied to the study of intergranular glassy films. The theme of the current investigation is the use of Fresnel fringes and Fourier filtering for the measurement of the thickness of intergranular glassy films. Fresnel fringes hidden in high-resolution micrographs can be used to objectively demarcate the glass-crystal interface and to measure the thickness of intergranular glassy films. Image line profiles obtained from Fourier filtering the high-resolution micrographs can yield better estimates of the thickness. Using image simulation, various kinds of deviation from an ideal square-well potential profile and their effects on the Fresnel image contrast are considered. A method is also put forth to objectively retrieve Fresnel fringe spacing data by Fourier filtering Fresnel contrast images. Difficulties arising from the use of the standard Fresnel fringe extrapolation technique are outlined and an alternative method for the measurement of the thickness of intergranular glassy films, based on zero-defocus (in-focus) Fresnel contrast images is suggested. The experimental work is from two ceramic systems: Lu-Mg-doped Si(3)N(4) and SrTiO(3) (stoichiometric and nonstoichiometric). Further, a comparison is made between the standard high-resolution lattice fringe technique, the standard Fresnel fringe extrapolation technique and the methods of analyses introduced in the current work, to illustrate their utility and merits. Taking experimental difficulties into account, this work is intended to be a practical tool kit for the study of intergranular glassy films.