Mainstream technology as an occupational therapy tool: technophobe or technogeek?

Occupational therapists need to embrace the use of mainstream technology in their quest to ensure that therapy remains current and meaningful to their clients. Technology can be useful to improve both functional independence and occupational performance. This opinion piece introduces how occupational therapists can apply mainstream technologies, including information and communication technologies such as the internet, computer software, portable devices and computer games, in their everyday interventions.

Combining and choosing case base maintenance algorithms

Case-Based Reasoning (CBR) uses past experiences to solve new problems. The quality of the past experiences, which are stored as cases in a case base, is a big factor in the performance of a CBR system. The system's competence may be improved by adding problems to the case base after they have been solved and their solutions verified to be correct. However, from time to time, the case base may have to be refined to reduce redundancy and to get rid of any noisy cases that may have been introduced. Many case base maintenance algorithms have been developed to delete noisy and redundant cases. However, different algorithms work well in different situations and it may be difficult for a knowledge engineer to know which one is the best to use for a particular case base. In this thesis, we investigate ways to combine algorithms to produce better deletion decisions than the decisions made by individual algorithms, and ways to choose which algorithm is best for a given case base at a given time. We analyse five of the most commonly-used maintenance algorithms in detail and show how the different algorithms perform better on different datasets. This motivates us to develop a new approach: maintenance by a committee of experts (MACE). MACE allows us to combine maintenance algorithms to produce a composite algorithm which exploits the merits of each of the algorithms that it contains. By combining different algorithms in different ways we can also define algorithms that have different trade-offs between accuracy and deletion. While MACE allows us to define an infinite number of new composite algorithms, we still face the problem of choosing which algorithm to use. To make this choice, we need to be able to identify properties of a case base that are predictive of which maintenance algorithm is best. We examine a number of measures of dataset complexity for this purpose. These provide a numerical way to describe a case base at a given time. We use the numerical description to develop a meta-case-based classification system. This system uses previous experience about which maintenance algorithm was best to use for other case bases to predict which algorithm to use for a new case base. Finally, we give the knowledge engineer more control over the deletion process by creating incremental versions of the maintenance algorithms. These incremental algorithms suggest one case at a time for deletion rather than a group of cases, which allows the knowledge engineer to decide whether or not each case in turn should be deleted or kept. We also develop incremental versions of the complexity measures, allowing us to create an incremental version of our meta-case-based classification system. Since the case base changes after each deletion, the best algorithm to use may also change. The incremental system allows us to choose which algorithm is the best to use at each point in the deletion process.

Moral shielding: A grounded theory of integrity maintenance in multidisciplinary teams

Using a classic grounded theory methodology (CGT), this study explores the phenomenon of moral shielding within mental health multidisciplinary teams (MDTS). The study was located within three catchment areas engaged in acute mental health service practice. The main concern identified was the maintenance of a sense of personal integrity during situational binds. Through theoretical sampling thirty two practitioners, including; doctors, nurses, social workers, occupational therapists, counsellors and psychologists, where interviewed face to face. In addition, emergent concepts were identified through observation of MDTs in clinical and research practice. Following a classic grounded theory methodology, data collection and analysis occurred simultaneously. A constant comparative approach was adopted and resulted in the immergence of three sub- core categories; moral abdication, moral hinting and pseudo-compliance. Moral abdication seeks to re-position within an event in order to avoid or deflect the initial obligation to act, it is a strategy used to remove or reduce moral ownership. Moral gauging represents the monitoring of an event with the goal of judging the congruence of personal principles and commitments with that of other practitioners. This strategy is enacted in a bid to seek allies for the support of a given moral position. Pseudo-compliance represents behaviour that hides desired principles and commitments in order to shield them from challenge. This strategy portrays agreement with the dominant position within the MDT, whilst holding a contrary position. It seeks to preserve a reservoir of emotional energy required to maintain a sense of personal integrity. Practitioners who were successful in enacting moral shielding were found to not experience significant emotional distress associated with the phenomenon of moral distress; suggesting that these practitioners had found mechanisms to manage situational binds that threatened their sense of personal integrity.

Mesenchymal stem cell therapy for the treatment of myocardial infarction

Mesenchymal stem cells (MSCs) are currently under investigation as repair agents in the preservation of cardiac function following myocardial infarction (MI). However concerns have emerged regarding the safety of acute intracoronary (IC) MSC delivery specifically related to mortality, micro-infarction and microvascular flow restriction post cell therapy in animal models. This thesis aimed to firstly identify an optimal dose of MSC that could be tolerated when delivered via the coronary artery in a porcine model of acute MI (AMI). Initial dosing studies identified 25x106 MSC to be a safe MSC cell dose, however, angiographic observations from these studies recognised that on delivery of MSC there was a significant adverse decrease in distal blood flow within the artery. This observation along with additional supportive data in the literature (published during the course of this thesis) suggested MSC may be contributing to such adverse events through the propagation of thrombosis. Therefore further studies aimed to investigate the innate prothrombotic activity of MSC. Expression of the initiator of the coagulation cascade initiator tissue factor (TF) on MSC was detected in high levels on the surface of these cells. MSC-derived TF antigen was catalytically active, capable of supporting thrombin generation in vitro and enhancing platelet-driven thrombus deposition on collagen under flow. Infusion of MSC via IC route was associated with a decreased coronary flow reserve when delivered but not when coadministered with an antithrombin agent heparin. Heparin also reduced MSC-associated in situ thrombosis incorporating platelets and VWF in the microvasculature. Heparin-assisted MSC delivery reduced acute apoptosis and significantly improved infarct size, left ventricular ejection fraction, LV volumes, wall motion and scar formation at 6 weeks post AMI. In addition, this thesis investigated the paracrine factors secreted by MSC, in particular focusing on the effect on cardiac repair of a novel MSC-paracrine factor SPARCL1. In summary this work provides new insight into the mechanism by which MSC may be deleterious when delivered by an IC route and a means of abrogating this effect. Moreover we present new data on the MSC secretome with elucidation of the challenges encountered using a single paracrine factor cardiac repair strategy.