Inappropriate prescribing is particularly common in older patients and is associated with adverse drug events (ADEs), hospitalization, and wasteful utilization of resources. We randomized 400 ...hospitalized patients aged ≥65 years to receive either the usual pharmaceutical care (control) or screening with STOPP/START criteria followed up with recommendations to their attending physicians (intervention). The Medication Appropriateness Index (MAI) and Assessment of Underutilization (AOU) index were used to assess prescribing appropriateness, both at the time of discharge and for 6 months after discharge. Unnecessary polypharmacy, the use of drugs at incorrect doses, and potential drug–drug and drug–disease interactions were significantly lower in the intervention group at discharge (absolute risk reduction 35.7%, number needed to screen to yield improvement in MAI = 2.8 (95% confidence interval 2.2–3.8)). Underutilization of clinically indicated medications was also reduced (absolute risk reduction 21.2%, number needed to screen to yield reduction in AOU = 4.7 (95% confidence interval 3.4–7.5)). Significant improvements in prescribing appropriateness were sustained for 6 months after discharge.
Clinical Pharmacology & Therapeutics (2011) 89 6, 845–854. doi:10.1038/clpt.2011.44
This study deploys newly available data to examine the exposure of multinational companies' overseas investments to physical climate risks. Globally, foreign investments are significantly exposed to ...lower physical climate risks, compared with local firms across countries. Within countries however, the differences of physical climate risks between foreign and local facilities are small. We also examine China, as it is fast becoming one of the largest sources of outward foreign investment across the globe. We find that foreign direct investment from China is significantly more exposed to water stress, floods, hurricanes and typhoon risks across countries, compared with other foreign facilities. Within host countries however, once again the physical climate risks of Chinese overseas facilities are comparable to those of non-Chinese foreign investments.
• Cells are continuously exposed to chemical signals that they must discriminate between and respond to appropriately. In embryophytes, the leucine-rich repeat receptor-like kinases (LRR-RLKs) are ...signal receptors critical in development and defense. LRR-RLKs have diversified to hundreds of genes in many plant genomes. Although intensively studied, a well-resolved LRR-RLK gene tree has remained elusive.
• To resolve the LRR-RLK gene tree, we developed an improved gene discovery method based on iterative hidden Markov model searching and phylogenetic inference. We used this method to infer complete gene trees for each of the LRR-RLK subclades and reconstructed the deepest nodes of the full gene family.
• We discovered that the LRR-RLK gene family is even larger than previously thought, and that protein domain gains and losses are prevalent. These structural modifications, some of which likely predate embryophyte diversification, led to misclassification of some LRR-RLK variants as members of other gene families. Our work corrects this misclassification.
• Our results reveal ongoing structural evolution generating novel LRR-RLK genes. These new genes are raw material for the diversification of signaling in development and defense. Our methods also enable phylogenetic reconstruction in any large gene family.
Introduction: STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) is a new, systems-defined medicine review tool. We compared the performance of STOPP to that of ...established Beers’ criteria in detecting potentially inappropriate medicines (PIMs) and related adverse drug events (ADEs) in older patients presenting for hospital admission. Methods: we prospectively studied 715 consecutive acute admissions to a university teaching hospital. Diagnoses, reason for admission and concurrent medications were recorded. STOPP and Beers’ criteria were applied. PIMs with clear causal connection or contribution to the principal reason for admission were determined. Results: median patient age (interquartile range) was 77 (72–82) years. Median number of prescription medicines was 6 (range 0–21). STOPP identified 336 PIMs affecting 247 patients (35%), of whom one-third (n = 82) presented with an associated ADE. Beers’ criteria identified 226 PIMs affecting 177 patients (25%), of whom 43 presented with an associated ADE. STOPP-related PIMs contributed to 11.5% of all admissions. Beers’ criteria-related PIMs contributed to significantly fewer admissions (6%). Conclusion: STOPP criteria identified a significantly higher proportion of patients requiring hospitalisation as a result of PIM-related adverse events than Beers’ criteria. This finding has significant implications for hospital geriatric practice.
We analyze the spatial and technological distribution of China's overseas electric power investments around the world, and the pollution intensity of Chinese coal fired power plants relative to those ...held by non-Chinese entities. We find that Chinese firms hold approximately $115 billion USD in electric power assets globally, with an average of 73% ownership stake in a total capacity of 81 GW. Chinese power investments span the globe but are largely found in developing countries, particularly in Asia and Latin America. The vast majority of Chinese investment goes to coal (24.5 GW), gas (20.5 GW) and hydropower (18.1 GW), while the share of wind (7.2 GW) and solar (3.1 GW) is relatively small but may be rising. The energy mix of Chinese overseas investment is similar to the existing world portfolio. Within the coal sector, between 2011 and 2017, the majority of Chinese greenfield investment in coal used supercritical technologies (58 percent) while only 34 percent of non-Chinese coal plants built during this period were supercritical.
•A comprehensive database is compiled to record all Chinese overseas power generating projects.•By 2017, China invested a total of $115 billion USD in 81 GW of power generating assets overseas.•Chinese investment is largely found in emerging economies and is dominated by coal, gas and hydro power.
ABSTRACT The nature of quasi-periodic pulsations (QPP) in solar flares is poorly constrained, and critically the general prevalence of such signals in solar flares is unknown. Therefore, we perform a ...large-scale search for evidence of signals consistent with QPP in solar flares, focusing on the 1-300 s timescale. We analyze 675 M- and X-class flares observed by the Geostationary Operational Environmental Satellite (GOES) series in 1-8 soft X-rays between 2011 February 1 and 2015 December 31. Additionally, over the same era we analyze Fermi/Gamma-ray Burst Monitor (GBM) 15-25 keV X-ray data for each of these flares associated with a Fermi/GBM solar flare trigger, a total of 261 events. Using a model comparison method, we determine whether there is evidence for a substantial enhancement in the Fourier power spectrum that may be consistent with a QPP signature, based on three tested models; a power-law plus a constant, a broken power-law plus constant, and a power-law-plus-constant with an additional QPP signature component. From this, we determine that ∼30% of GOES events and ∼8% of Fermi/GBM events show strong signatures consistent with classical interpretations of QPP. For the remaining events either two or more tested models cannot be strongly distinguished from each other, or the events are well-described by single power-law or broken power-law Fourier power spectra. For both instruments, a preferred characteristic timescale of ∼5-30 s was found in the QPP-like events, with no dependence on flare magnitude in either GOES or GBM data. We also show that individual events in the sample show similar characteristic timescales in both GBM and GOES data sets. We discuss the implications of these results for our understanding of solar flares and possible QPP mechanisms.
Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such ...as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment).
A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets.
STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START.
STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses.
ABSTRACT Solar flares produce radiation that can have an almost immediate effect on the near-Earth environment, making it crucial to forecast flares in order to mitigate their negative effects. The ...number of published approaches to flare forecasting using photospheric magnetic field observations has proliferated, with varying claims about how well each works. Because of the different analysis techniques and data sets used, it is essentially impossible to compare the results from the literature. This problem is exacerbated by the low event rates of large solar flares. The challenges of forecasting rare events have long been recognized in the meteorology community, but have yet to be fully acknowledged by the space weather community. During the interagency workshop on "all clear" forecasts held in Boulder, CO in 2009, the performance of a number of existing algorithms was compared on common data sets, specifically line-of-sight magnetic field and continuum intensity images from the Michelson Doppler Imager, with consistent definitions of what constitutes an event. We demonstrate the importance of making such systematic comparisons, and of using standard verification statistics to determine what constitutes a good prediction scheme. When a comparison was made in this fashion, no one method clearly outperformed all others, which may in part be due to the strong correlations among the parameters used by different methods to characterize an active region. For M-class flares and above, the set of methods tends toward a weakly positive skill score (as measured with several distinct metrics), with no participating method proving substantially better than climatological forecasts.
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the etiologic agent for the 2019 coronavirus disease (COVID-19) pandemic, has caused a public health emergency. The need for additional ...research in viral pathogenesis is essential as the number of cases and deaths rise. Understanding the virus and its ability to cause disease has been the main focus of current literature; however, there is much unknown. Studies have revealed new findings related to the full transmission potential of SARS-CoV-2 and its subsequent ability to cause infection by different means. The virus is hypothesized to be of increased virulence compared with previous coronavirus that caused epidemics, in part due to its overall structural integrity and resilience to inactivation. To date, many studies have discussed that the rationale behind its transmission potential is that viral RNA has unexpectedly been detected in multiple bodily fluids, with some samples having remained positive for extended periods of time. Additionally, the receptor by which the virus gains cellular entry, ACE2, has been found to be expressed in different human body systems, thereby potentiating its infection in those locations. In this evidence-based comprehensive review, we discuss various potential routes of transmission of SARS-CoV-2—respiratory/droplet, indirect, fecal-oral, vertical, sexual, and ocular. Understanding these different routes is important as they pertain to clinical practice, especially in taking preventative measures to mitigate the spread of SARS-CoV-2.
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