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Summary 1Single species can have a disproportionate effect on ecosystem function and diversity, yet our understanding of the importance of single species in driving terrestrial ecosystems during succession remains poor. 2 Utilizing a long-term experiment, where birch was planted on heather moorland 20 years ago, the cascading effects of a single tree species ( Betula pubescens ) on ecosystem characteristics (plant species richness, soil chemistry, soil fauna and decomposition rates) were tested. 3 Under the birch, plant species richness decreased and the vegetation composition changed, with lower cover of grasses and Vaccinium myrtillus . The depth of the soil organic horizon, its moisture content and percentage carbon were all smaller under the birch than under the heather. Concentrations of available phosphorus and mineralizable-N were significantly greater in the soil under birch than under the heather plots. Decomposition was faster in the birch than in the heather plots. The abundance and species richness of collembola and oribatid, mesostigmatid and prostigmatid mites were all significantly greater under the birch than under the heather. 4 The durability of the engineering effects of the birch was studied in a second experiment. Plots were established in first generation birch woodland that had developed on Calluna -dominanted moorland. The plots were cleared of birch and planted with heather. After 20 years soil chemical properties, microarthropod communities and decomposition rates were not significantly different between plots with and without the birch. However, the mass of the soil O-horizon was significantly greater in the felled birch plots than in the control birch plots, providing the first indication of a change towards soil properties more typical of a Calluna moorland. Thus for most of the birch engineering effects measured here their durability in the absence of the engineering species is at least 20 years. 5 This work has provided experimental evidence that birch acts as a top-down engineer, driving cascading effects on both above-and below-ground communities, soil chemical and physical properties and ecosystem processes. The work also shows that the role of birch in driving changes in the ecosystem is durable 20 years after the removal of the birch.

Objectives: To establish the relation between new prescriptions for proton pump inhibitors and recorded upper gastrointestinal morbidity within a large computerised general practitioner database.

ObjectiveTo investigate healthcare professionals’ knowledge and attitudes towards infliximab and insulin glargine biosimilars and the factors influencing their prescribing. Then, to compare healthcare professionals’ attitudes with the utilisation of these biosimilars in UK hospitals.DesignSelf-administered, one-time web-based survey and drug utilisation analysis.Setting and data sourcesProfessional associations and societies in the field of dermatology, diabetology, gastroenterology and rheumatology in the UK, between 8 August 2016 and 8 January 2017. The volume of utilisation of branded and biosimilar infliximab and insulin glargine in UK hospitals was derived from the DEFINE database, between 2015 and 2016.OutcomesParticipants’ knowledge and awareness of biosimilars and factors influencing their use and corresponding usage of infliximab and insulin glargine biosimilars.ResultsResponses were obtained from 234 healthcare professionals across dermatology, diabetology, gastroenterology and rheumatology specialties. 75% of respondents were aware that biosimilars were available on their local formulary. 77% of respondents considered biosimilars extremely or very important to save costs for the NHS. Gastroenterologists had the highest utilisation of infliximab biosimilars (14%) in 2015 rising to (62%) in 2016. Healthcare professionals had greater concerns about safety and efficacy when switching patients to biosimilars than when starting biosimilars in biological naïve patients. Guidance from National Institute for Health and Care Excellence and robust pharmacovigilance studies on biosimilars were both considered important factors in increasing biosimilars use.ConclusionBritish healthcare professionals are well informed about biosimilars with high level of awareness. Safety and efficacy concerns were higher in switching than in initiating biosimilars among some prescribers. It is probable that personal experience of biologics as well as discipline-specific guidance influenced prescribers’ responses.

Objective-To investigate the ratio of inhaled corticosteroid to bronchodilator as a measure of the quality of asthma prescribing by general practitioners.Design-Ecological cross sectional study linking general practitioner asthma prescribing with hospital admission data and a measure of deprivation.Subjects-11 family health services authorities in the West Midlands region and 99 general practices in North Staffordshire.Main outcome measures-Hospital admission rates for asthma; the ratio of inhaled corticosteroid to bronchodilator; and Townsend deprivation scores.Results-No overall significant correlation was found between admission rates for asthma and corticosteroid:bronchodilator ratios for family health services authorities (Spearman's rs = -0.109, P = 0.750) or general practices (rs = -0.084, P = 0.407). In deprived family health services authority areas and general practices an inverse non-significant correlation existed between admission rates for asthma and corticosteroid:bronchodilator ratios (rs = -0.300, P = 0.624; rs = -0.218, P = 0.136). In contrast, in more affluent areas and general practices a positive non-significant correlation existed between admission rates and corticosteroid:bronchodilator ratios (rs = 0.371, P = 0.468; rs = 0.038, P = 0.792).Conclusion-Although the corticosteroid:bronchodilator ratio may be a valid indicator of the quality of prescribing for individual patients with asthma, caution should be applied in interpreting aggregated ratios. Differences in the severity of asthma or the prevalence of chronic obstructive pulmonary disease may explain inconsistent associations between admission rates for asthma and corticosteroid:bronchodilator ratios in family health services authorities and general practices with different deprivation scores. IntroductionThe ratio of inhaled corticosteroid to bronchodilator is a potential indicator of the quality of prescribing for asthma at aggregated family health services authority and general practice level.' A higher ratio reflects greater prescribing of inhaled corticosteroids relative to bronchodilators, a feature regarded as good practice.2 Nevertheless, few studies have validated the corticosteroid:bronchodilator ratio as an indicator of good quality prescribing because of the paucity of asthma outcome measures. At aggregated level, hospital admission rates for asthma are the only available outcome measure of asthma morbidity.At practice level two recent studies in the United Kingdom have found an association between hospital admission rates for asthma and corticosteroid:bronchodilator ratios.3 4 Both showed that practices with

Background In the United Kingdom, nurses and pharmacists who have undertaken additional post-registration training can prescribe medicines for any medical condition within their competence (nonmedical prescribers, NMPs), but little is known about patients' experiences and perceptions of this service.

ObjectivesTo identify the authentication and detection rate of serialised medicines using medicines authentication technology.Design and intervention4192 serialised medicines were entered into a hospital dispensary over two separate 8-week stages in 2015. Medicines were authenticated using secure external database cross-checking, triggered by the scanning of a two-dimensional data matrix with a unit specific 12-digit serial code. 4% of medicines included were preprogrammed with a message to identify the product as either expired, pack recalled, product recalled or counterfeit.SettingA site within a large UK National Health Service teaching hospital trust.ParticipantsAccredited checking staff, pharmacists and dispensers in a pharmacy department.Primary outcome measuresAuthentication and detection rate of counterfeit expired and recalled medicines.ResultsThe operational detection rate of counterfeit, recalled and expired medicines scanned as a combined group was 81.4% (stage 1 (S1)) and 87% (stage 2 (S2)). The technology's technical detection rate (TDR) was 100%; however, not all medicines were scanned and of those that were scanned not all that generated a warning message were quarantined. Owing to an operational authentication rate (OAR) of 66.3% (over both stages), only 31.8% of counterfeit medicines, 58% of recalled drugs and 64% of expired medicines were detected as a proportion of those entered into the study. Response times (RTs) of 152 ms (S1) and 165 ms (S2) were recorded, meeting the falsified medicines directive-mandated 300 ms limit.ConclusionsTDRs and RTs were not a limiting factor in this study. The suboptimal OAR poses significant quality and safety issues with this detection approach. Authentication at the checking stage, however, demonstrated higher OARs. There is a need for further qualitative research to establish the reasons for less than absolute authentication and detection rates in the hospital environment to improve this technology in preparation for the incumbent European Union regulative deadline.

The global incidence of asbestos-related lung diseases is expected to continue to rise. Although much attention is devoted to malignant diseases induced by asbestos, benign asbestos pleural diseases (pleural plaques, benign asbestos-related pleural effusion, diffuse pleural thickening, and rounded atelectasis) are common in clinical practice and often produce diagnostic difficulties. The authors describe the clinical features of benign asbestos-related pleural disease, before focusing on recent advances in radiology and on controversies surrounding the pathogenesis of asbestos-induced pleural injury. Advances in computed tomography have assisted the understanding and diagnosis of these diseases, and increasing evidence suggests radiologic appearances on computed tomography can predict impairment in pulmonary function tests. The pathogenesis of asbestos-induced pleural diseases has also been subject to extensive investigation. Asbestos fibers can provoke pleural inflammation from direct toxicity to mesothelial cells. Inhaled asbestos fibers can also elicit pleural injury indirectly via the release of growth factors and inflammatory cytokines from within the lung. Although progress has been made in the understanding of the mechanisms of asbestos pleural injury, many important questions remain unanswered. The role of genetic factors and possible environmental cofactors (eg, simian virus 40) in the pathogenesis of benign asbestos pleural diseases requires further research.