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Leading organisations recommend follow-up of acute kidney injury (AKI) survivors, as these patients are at risk of long-term complications and increased mortality. Information transfer between specialties and from tertiary to primary care is essential to ensure timely and appropriate follow-up. Our aim was to examine the association between completeness of discharge documentation and subsequent follow-up of AKI survivors who received kidney replacement therapy (KRT) in the Intensive Care Unit (ICU). We retrospectively analysed the data of 433 patients who had KRT for AKI during ICU admission in a tertiary care centre in the UK between June 2017 and May 2018 and identified patients who were discharged from hospital alive. Patients with pre-existing end-stage kidney disease and patients who were transferred from hospitals outside the catchment area were excluded. The primary objective was to assess the completeness of discharge documentation from critical care and hospital; secondary objectives were to determine cardiovascular medications reconciliation after AKI, and to investigate kidney care and outcomes at 1 year. The development of AKI and the need for KRT were mentioned in 85 and 82% of critical care discharge letters, respectively. Monitoring of kidney function post-discharge was recommended in 51.6% of critical care and 36.3% of hospital discharge summaries. Among 35 patients who were prescribed renin-angiotensin-aldosterone system inhibitors before hospitalisation, 15 (42.9%) were not re-started before discharge from hospital. At 3 months, creatinine and urine protein were measured in 88.2 and 11.8% of survivors, respectively. The prevalence of chronic kidney disease stage III or worse increased from 27.2% pre-hospitalisation to 54.9% at 1 year (p < 0.001). Our data demonstrate that discharge summaries of patients with AKI who received KRT lacked essential information. Furthermore, even in patients with appropriate documentation, renal follow-up was poor suggesting the need for more education and streamlined care pathways.

To develop and validate an improved risk model to predict acute hospital mortality for admissions to adult critical care units in the UK.155,239 admissions to 232 adult critical care units in England, Wales and Northern Ireland between January and December 2012 were used to develop a risk model from a set of 38 candidate predictors. The model was validated using 90,017 admissions between January and September 2013.The final model incorporated 15 physiological predictors (modelled with continuous nonlinear models), age, dependency prior to hospital admission, chronic liver disease, metastatic disease, haematological malignancy, CPR prior to admission, location prior to admission/urgency of admission, primary reason for admission and interaction terms. The model was well calibrated and outperformed the current ICNARC model on measures of discrimination (area under the receiver operating characteristic curve 0.885 versus 0.869) and model fit (Brier's score 0.108 versus 0.115). On average, the new model reclassified patients into more appropriate risk categories (net reclassification improvement 19.9; P0.0001). The model performed well across patient subgroups and in specialist critical care units.The risk model developed in this study showed excellent discrimination and calibration and when validated on a different period of time and across different types of critical care unit. This in turn allows improved accuracy of comparisons between UK critical care providers.

Purpose The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy. Materials and methods A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists. Results A total of 20 517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy. Conclusions This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

Mitigation of diffuse water pollution from agriculture is a key national environmental policy objective in England. With the recent introduction of the new agri-environment scheme, Countryside Stewardship, there is an increased emphasis on the macro-spatial targeting of on-farm mitigation measures to reduce pollutant pressures, and a concomitant need to forecast the technically feasible impacts of on-farm measures detailed in current policy and their associated costs and benefits. This paper reports the results of a modelling application to test these limits in the context of the associated costs and benefits for the reduction of diffuse water pollution from agriculture for each Water Framework Directive (WFD) water management catchment (WMC) and nationally. Four mitigation scenarios were modelled, including pollutant source control measures only (SC), mobilisation control measures only (MC), delivery control measures only (DC) and measures for source, mobilisation and delivery control (SMDC) combined. Projected impacts on nitrate, phosphorus and sediment export to water, ammonia, methane and nitrous oxide emissions to the atmosphere, together with the associated costs to the agricultural sector were estimated for each WFD WMC and nationally. Median WMC-scale reductions (with uncertainty ranges represented by 5th–95th percentiles) in current agricultural emissions, were predicted to be highest for the SMDC scenario; nitrate (18%, 11–23%), phosphorus (28%, 22–37%), sediment (25%, 18–43%), ammonia (26%, 17–32%), methane (13%, 7–18%) and nitrous oxide (18%, 16–20%). The median benefit-to-cost ratios (with uncertainty ranges represented by 5th–95th percentiles) were predicted to be in the following order; DC (0.15, 0.09–0.65), MC (0.19, 0.09–0.95), SMDC (0.31, 0.20–1.39) and SC (0.44, 0.19–2.48). Of the four scenarios simulated, the SC and SMDC suites of measures have the greatest potential to deliver reductions in BAU emissions from agriculture, and the best benefit:cost ratio.

Imaging biomarkers (IBs) are integral to the routine management of patients with cancer. IBs used daily in oncology include clinical TNM stage, objective response and left ventricular ejection fraction. Other CT, MRI, PET and ultrasonography biomarkers are used extensively in cancer research and drug development. New IBs need to be established either as useful tools for testing research hypotheses in clinical trials and research studies, or as clinical decision-making tools for use in healthcare, by crossing 'translational gaps' through validation and qualification. Important differences exist between IBs and biospecimen-derived biomarkers and, therefore, the development of IBs requires a tailored 'roadmap'. Recognizing this need, Cancer Research UK (CRUK) and the European Organisation for Research and Treatment of Cancer (EORTC) assembled experts to review, debate and summarize the challenges of IB validation and qualification. This consensus group has produced 14 key recommendations for accelerating the clinical translation of IBs, which highlight the role of parallel (rather than sequential) tracks of technical (assay) validation, biological/clinical validation and assessment of cost-effectiveness; the need for IB standardization and accreditation systems; the need to continually revisit IB precision; an alternative framework for biological/clinical validation of IBs; and the essential requirements for multicentre studies to qualify IBs for clinical use.

Background In addition to acute hospital mortality, sepsis is associated with higher risk of death following hospital discharge. We assessed the strength of epidemiological evidence supporting a causal link between sepsis and mortality after hospital discharge by systematically evaluating the available literature for strength of association, bias, and techniques to address confounding. Methods We searched Medline and Embase using the following ‘mp’ terms, MESH headings and combinations thereof - sepsis, septic shock, septicemia, outcome. Studies published since 1992 where one-year post-acute mortality in adult survivors of acute sepsis could be calculated were included. Two authors independently selected studies and extracted data using predefined criteria and data extraction forms to assess risk of bias, confounding, and causality. The difference in proportion between cumulative one-year mortality and acute mortality was defined as post-acute mortality. Meta-analysis was done by sepsis definition categories with post-acute mortality as the primary outcome. Results The literature search identified 11,156 records, of which 59 studies met our inclusion criteria and 43 studies reported post-acute mortality. In patients who survived an index sepsis admission, the post-acute mortality was 16.1 % (95 % CI 14.1, 18.1 %) with significant heterogeneity (p

Mitigation of agricultural diffuse pollution poses a significant policy challenge across Europe and particularly in the UK. Existing combined regulatory and voluntary approaches applied in the UK continue to fail to deliver the necessary environmental outcomes for a variety of reasons including failure to achieve high adoption rates. It is therefore logical to identify specific on-farm mitigation measures towards which farmers express positive attitudes for higher future uptake rates. Accordingly, a farmer attitudinal survey was undertaken during phase one of the Demonstration Test Catchment programme in England to understand those measures towards which surveyed farmers are most receptive to increasing implementation in the future. A total of 29 on-farm measures were shortlisted by this baseline farm survey. This shortlist comprised many low cost or cost-neutral measures suggesting that costs continue to represent a principal selection criterion for many farmers. The 29 measures were mapped onto relevant major farm types and input, assuming 95% uptake, to a national scale multi-pollutant modelling framework to predict the technically feasible impact on annual agricultural emissions to water and air, relative to business as usual. Simulated median emission reductions, relative to current practise, for water management catchments across England and Wales, were estimated to be in the order sediment (20%) > ammonia (16%) > total phosphorus (15%) ≫ nitrate/methane (11%) > nitrous oxide (7%). The corresponding median annual total cost of the modelled scenario to farmers was £3 ha− 1 yr− 1, with a corresponding range of -£84 ha− 1 yr− 1 (i.e. a net saving) to £33 ha− 1 yr− 1. The results suggest that those mitigation measures which surveyed farmers are most inclined to implement in the future would improve the environmental performance of agriculture in England and Wales at minimum to low cost per hectare.

Sediment plays a pivotal role in determining the physical, chemical and biological integrity of aquatic ecosystems. A range of factors influences the impacts of sediment pressures on aquatic biota, including concentration, duration of exposure, composition and particle size. In recognition of the need to assess environmental status for sediment and mitigate excessive sediment pressures on aquatic habitats, both water column and river substrate metrics have been proposed as river sediment targets. Water column metrics include light penetration, turbidity, sediment concentration summary statistics and sediment regimes. Substrate metrics include embeddedness, the fredle index and riffle stability. Identification of meaningful numeric targets along these lines has, however, been undermined by various issues including the uncertainty associated with toxicological dose-response profiles and the impracticalities of deploying statistically robust sampling strategies capable of supporting catchment-scale targets. Many of the thresholds reported are based on correlative relationships that fail to capture the specific mechanisms controlling sediment impacts on aquatic habitats and are stationary in nature. Temporal windows represented by the key life stages of specific species must be given greater emphasis. Given such issues and the need to support the revision of sediment targets for river catchment management, it is proposed that greater emphasis should be placed on developing generic modelling toolkits with the functionality for coupling current or future projected sediment regimes with biological response for a range of biota. Such tools should permit the identification of river catchment-specific targets within a national context, based on biological effect and incorporate sufficient flexibility for utilizing updated physical, chemical, biological and catchment attribute data. Confidence will continue to be required in compliance screening to ensure cost-effective management programmes for avoiding disproportionate investment in impacted river catchments.

This paper is a preliminary investigation into the application of the formal-logical theory of normative positions to the characterisation of normative-informational positions, pertaining to rules that are meant to regulate the supply of information. First, we present the proposed framework. Next, we identify the kinds of nuances and distinctions that can be articulated in such a logical framework. Finally, we show how such nuances can arise in specific regulations. Reference is made to Data Protection Law and Contract Law, among others. The proposed approach is articulated around two essential steps. The first involves identifying the set of possible interpretations that can be given to a particular norm. This is done by using formal methods. The second involves picking out one of these interpretations as the most likely one. This second step can be resolved only by using further information (e.g., the context or other parts of the regulation).

This article aims to provide foundations for a new approach to Agent Communication Languages (ACLs). First, we present the theory of signalling acts. In contrast to current approaches to communication, this account is neither intention-based nor commitment-based, but convention-based. Next, we explore ways of embedding that theory within an account of conversation. We move here from an account of the basic types of communicative act (the statics of communication) to an account of their role in sequences of exchanges in communicative interaction (the dynamics of communication). Finally, we apply the framework to the analysis of conversational protocols such as the English auction protocol. We propose to give a compact expression of conversation protocols by means of a formula of the object-language. We also use this kind of representation to provide the basis for a procedure for keeping a record of the conventional effects achieved in a conversation. A corresponding axiomatic presentation is given, and shown to be sound and complete with respect to our proposed semantics.

Excessive sediment pressure on aquatic habitats is of global concern. A unique dataset, comprising instantaneous measurements of deposited fine sediment in 230 agricultural streams across England and Wales, was analysed in relation to 20 potential explanatory catchment and channel variables. The most effective explanatory variable for the amount of deposited sediment was found to be stream power, calculated for bankfull flow and used to index the capacity of the stream to transport sediment. Both stream power and velocity category were highly significant (p<

Considerable diversity is exhibited by current definitions of the concept of trust. This paper argues that there may nevertheless be an identifiable core to the concept. On the basis of an analysis of five scenarios in which some agent x trusts some other agent y, it is suggested that two beliefs--here called the 'rule-belief' and the 'conformity-belief'--form the core of the trusting attitude. The informal account of trust presented here identifies the kinds of modalities that would figure in a modal-logical specification of the conditions under which one agent can be said to trust another.

Objective Significant errors can be made during medication prescribing, dispensing and administration. One source of error and potential for harm is unintentional omission. Medicines reconciliation seeks to reduce the impact of this between transfer of care. In long-term hypothyroidism, patients are dependent upon levothyroxine and there are few contraindications to its prescription. We considered levothyroxine prescription in long-term hypothyroidism as a marker of medicines reconciliation on admission and during stay in the intensive care unit (ICU). Methods A retrospective chart review was undertaken in a tertiary referral university ICU with all patients who were receiving long-term levothyroxine therapy identified. Notes were reviewed for the presence of thyroid-replacement prescription and for thyroid function tests, in addition to demographic, length of stay and mortality data. Key findings Thyroid-replacement therapy was not prescribed for more than 7 days in 23/133 (17.3%) patients and omitted entirely in three patients. A further 28/133 (21.1%) patients were intolerant of enteral feeding for more than 7 days and were thus unable to have oral levothyroxine administered. None of these patients received parenteral therapy. Thyroid function tests were performed in 104/133 (78.2%) patients. Conclusions Prescription of chronic therapy, in this case thyroid-replacement therapy, was inadequate. This highlights the need for a progressive medicines-reconciliation process embedded within the daily ICU programme.

Rules, regulations and policy statements quite frequently contain nested sequences of normative modalities as in, for example: The database manager is obliged to permit the deputy-manager to authorise access for senior departmental staff. Parking on highways ought to be forbidden. Accordingly, a knowledge-representation language for such sentences must be able to accommodate nesting of this kind. However, if--as some have proposed--normative modalities such as obligatory, permitted, and authorised are to be interpreted as first-order predicates of named actions, then nesting appears to present a problem, since the scope formula of obligatory in "obligatory that it is permitted that a " (where a names an action) is not a name but a sentence. The ‘disquotation' theory presented in Kimbrough ("A Note on Interpretations for Federated Languages and the Use of Disquotation", and elsewhere) may provide a candidate solution to this FOL problem. In this paper we rehearse parts of that theory and evaluate its efficacy for dealing with the indicated normative nesting problem.

Marek Sergot's technical contributions range over different subjects. He has developed a series of novel ideas and formal methods bridging different research domains, such as artificial intelligence, computational logic, philosophical logic, legal theory, artificial intelligence and law, multi-agent systems and bioinformatics. By combining his background in logic and computing with his interest in the law, deontic logic, action, and related areas, and applying to all his capacity to understand the subtleties of social interactions and normative reasoning, Marek has been able to open new directions of research, and has been a reference, an inspiration, and a model for many researchers in the many fields in which he has worked.

Effective timely antibiotic administration is associated with increased survival to discharge in patients with septic shock [1]. Time to antibiotic administration was the strongest predictor of outcome and is a key recommendation in sepsis management [2]. However, implementation faces barriers at clinician, patient and environmental levels [3].

The paper outlines the approach to the analysis of deontic conditionals taken in earlier work of Jones and Porn, comparing it briefly with two main trends within dyadic deontic logic, and discussing problems associated with the augmentation principle and the factual detachment principle. A modification of the Jones and Porn system is then presented, using a classical but not normal (in the sense of Chellas) deontic modality, to provide the basis for an alternative analysis of deontic conditionals. This new analysis validates neither the factual detachment nor the augmentation principles. However, influenced by the approach of Delgrande to default reasoning, it is shown how a restricted form of factual detachment might be accommodated within the revised system.

This paper presents a fully formal integration of Jones’s logical theory of speech acts as signalling conventions with Kimbrough’s Formal Language for Business Communication (FLBC). The work is part of a larger programme of logicism in the context of electronic commerce. Speech acts are an especially apt subject for this programme because of their pervasiveness and importance in communication for all commerce, electronic or not. The paper demonstrates that the conventionist view of speech acts, embodied in Jones’s logical theory, fits naturally with Kimbrough’s FLBC and with the Basic Messaging Framework for business communications. Further, the paper provides an illustration of how the resulting integrated theory might be implemented in practice through logic programming.

This paper is a preliminary investigation into the application of the formal-logical theory of normative positions to the characterisation of normative-informational positions, pertaining to rules that are meant to regulate the supply of information.

This article aims to provide foundations for a new approach to Agent Communication Languages (ACLs). First, we outline the theory of signalling acts. In contrast to current approaches to communication, this account is neither intention-based nor commitment-based, but convention-based. Next, we outline one way of embedding that theory within an account of conversation. We move here from an account of the basic types of communicative act (the statics of communication) to an account of their role in sequences of exchanges in communicative interaction (the dynamics of communication). Finally, we apply the framework to the analysis of a conversational protocol.

The main aim of this paper is to propose a set of action concepts useful for describing organised interaction. These action concepts focus on two distinctions: the distinction between direct and indirect action, and the distinction between successful and not necessarily successful action. The formal characterisation of these concepts is given by means of modal logic, following the same tradition in the logical characterisation of act descriptions as employed by Kanger (1972) and Porn (1970). The modal action operators proposed are also combined with a deontic logic and a conditional logic, in order to illustrate their application to the analysis of some simple organisations. The focus of interest is on the notion of transmission of agency, and on the characterisation of the conditions under which an organisation recognises that an agent has fulfilled the responsibilities assigned to him.

Coxibs are a major advance in the therapy of patients with painful and inflammatory conditions. At present, the theoretical harm that derives from inhibiting vascular COX-2 has not emerged as a significant risk, although more research is needed. What has emerged is that some NSAIDs, particularly naproxen, may have an aspirin-like effect in reducing the risk of vascular disease, although more research is needed. Whether this finding is sufficient to recommend naproxen for the management of patients with arthritis who also require vascular protection is intriguing and worth further evaluation. It is widely believed and maintained that coxibs have the greatest potential value in patients with other risk factors for ulcer disease, and this seems likely to be the case for patients taking corticosteroids or anticoagulants and probably those who are elderly. Dosing should be [figure: see text] cautious in old patients, however, because of the ability of NSAIDs and coxibs to cause fluid retention, heart failure, and hypertension. It is less clear that coxibs reduce risk sufficiently in patients with previous ulceration (particularly recent) to make them a better strategy than acid co-therapy. This possibility requires further evaluation, as does the competing value of the 2 strategies for patients infected with H. pylori. If coxibs are used in patients with H. pylori-associated risks, there are grounds to recommend eradication. For patients taking aspirin or drugs [figure: see text] with an aspirin-like effect, the intrinsic risk of these drugs may mandate use of acid suppression and obviate the use of coxibs (Fig. 8). Available data suggest that the risk reduction in patients with no risk factors who use coxibs may be almost as great as in patients with risk factors, with the added advantage that patients may be taken to a state that is virtually free of any risk of ulcer complications that otherwise might require additional therapy. Contrary to current popular truisms, the greatest value of coxibs may be in patients without risk factors because it is in this unconfounded group that the ability of coxibs to free patients of ulcer risk appears to be delivered in full.

Background Healthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. Methods We conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions. Results Contaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common. Conclusions Clinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.

The rapid increase in the use of open distributed systems has given rise to a number of important issues for computer scientists, some of which concern the organisation of interactions between computers, between humans, and between humans and computers. For instance, such interactions are the focus of attention in access control policies (Abadi et al., 1993), and in cryptographic protocols (Burrows et al., 1990), both of which specify the actions that are to be performed by the participating agents.

The acute respiratory distress syndrome (ARDS) is characterized by refractory hypoxemia in the presence of bilateral pulmonary infiltrates on chest radiography1. It was recognised that ARDS probably represents only the extreme manifestation of a range of pulmonary insults. Hence, acute lung injury (ALI) was similarly defined but with less severe indices of hypoxemia (Table 1). A wide variety of serious medical and surgical conditions can precipitate the syndrome, only some of which involve the lung (Table 2). Although the mortality associated with ARDS has fallen in recent years (from approximately 70% to 50%) in a number of large centres, it is undoubtedly influenced by the underlying pathology. Furthermore, epidemiological studies have suggested for many years that the majority of patients succumb not to refractory hypoxemia, but rather to sepsis and associated multiple organ failure (MOF). MOF is defined by a constellation of symptoms and clinical signs of which multiple organs (e,g, kidney, heart, GIT, etc) are in a state of dysfunction or failure. Indeed, given that respiratory failure accounts for only 16% of ARDS deaths, improvements in outcome of ARDS may depend more on treatment of sepsis and further understandingJprevention of MOF than on improvements in oxygenation and pulmonary haemodynamics2,3.

The objective of this paper is to offer a first proposal about the definition of integrity constraints in the context of data and knowledge bases. In order to provide a uniform representation of the different kinds of constraints, we adopt a logical framework. In this framework, database content is represented by a set db of formulas in a language of classical first order logic. The world which the database is supposed to represent is itself represented by a set w of formulas of the same language. In what follows, we call the world a correct representation of the world in the language used for a given application domain.

We introduce our framework for logic-based compositional e-commerce interaction. We aim to provide open-source software which adds a lightweight formal messaging layer to business communications, to increase the accessibility of e-commerce infrastructure to smaller business players. In the process, we hope to develop a comprehensive theory of business communication. We present the logical structures and techniques we apply and provide initial prototype testing results.

Some transformational grammarians, supporters of the theory of gen erative semantics, have recently made strong claims about the relation ship between the deep-structure of a sentence and its logical form. These claims are so strong, in fact, that if they are correct one consequence will be that the methods of transformational analysis will themselves provide a procedure for determining the logical form of sentences. Consider, for example, the following remark by George Lakoff

In two interesting papers ((1983), (1986)) Thorne McCarty has presented a semantics for the central deontic concepts, permission and obligation, based upon a semantics for an action language. The latter, in turn, was constructed along lines deriving from Pratt-Harel dynamic logic.I shall here offer some critical comments on McCarty's analysis of the relationship between obligation and permission, and of his account of so-called “free-choice” permissions; these come in section II, below. In section I an outline sketch is given of the main features of McCarty's semantics with which the criticism will be concerned.