Generating recipient-centred explanations about drug prescription

In this paper we describe how we generated written explanations to ‘indirect users’ of a knowledge-based system in the domain of drug prescription. We call ‘indirect users’ the intended recipients of explanations, to distinguish them from the prescriber (the ‘direct’ user) who interacts with the system. The Explanation Generator was designed after several studies about indirect users' information needs and physicians' explanatory attitudes in this domain. It integrates text planning techniques with ATN-based surface generation. A double modeling component enables adapting the information content, order and style to the indirect user to whom explanation is addressed. Several examples of computer-generated texts are provided, and they are contrasted with the physicians' explanations to discuss advantages and limits of the approach adopted.

Hypotensive effects of hawthorn for patients with diabetes taking prescription drugs: a randomised controlled trial

Background Hawthorn (Crataegus laevigata) leaves, flowers and berries are used by herbal practitioners in the UK to treat hypertension in conjunction with prescribed drugs. Small-scale human studies support this approach. Aim To investigate the effects of hawthorn for hypertension in patients with type 2 diabetes taking prescribed drugs. Design of study Randomised controlled trial. Setting General practices in Reading, UK. Method Patients with type 2 diabetes (n = 79) were randomised to daily 1200 mg hawthorn extract (n = 39) or placebo (n = 40) for 16 weeks. At baseline and outcome a wellbeing questionnaire was completed and blood pressure and fasting blood samples taken. A food frequency questionnaire estimated nutrient intake. Results Hypotensive drugs were used by 71% of the study population with a mean intake of 4.4 hypoglycaemic and/or hypotensive drugs. Fat intake was lower and sugar intake higher than recommendations, and low micronutrient intake was prevalent. There was a significant group difference in mean diastolic blood pressure reductions (P = 0.035): the hawthorn group showed greater reductions (baseline: 85.6 mmHg, 95% confidence interval [Cl] = 83.3 to 87.8; outcome: 83.0 mmHg, 95% Cl = 80.5 to 85.7) than the placebo group (baseline: 84.5 mmHg, 95% Cl = 82 to 87; outcome: 85.0 mmHg, 95% Cl = 82.2 to 87.8). There was no group difference in systolic blood pressure reduction from baseline (3.6 and 0.8 mmHg for hawthorn and placebo groups, respectively; P = 0.329). Although mean fat intake met current recommendations, mean sugar intake was higher and there were indications of potential multiple micronutrient deficiencies. No herb-drug interaction was found and minor health complaints were reduced from baseline in both groups. Conclusions This is the first randomised controlled trial to demonstrate a hypotensive effect of hawthorn in patients with diabetes taking medication.

Hypotensive effects of hawthorn for patients with diabetes taking prescription drugs: a randomised controlled trial

Background: Hawthorn (Crataegus laevigata) leaves, flowers and berries are used by herbal practitioners in the UK to treat hypertension in conjunction with prescribed drugs. Small-scale human studies support this approach. Aim: To investigate the effects of hawthorn for hypertension in patients with type 2 diabetes taking prescribed drugs. Design of study: Randomised controlled trial. Setting: General practices in Reading, UK. Method: Patients with type 2 diabetes (n = 79) were randomised to daily 1200 mg hawthorn extract (n = 39) or placebo (n = 40) for 16 weeks. At baseline and outcome a wellbeing questionnaire was completed and blood pressure and fasting blood samples taken. A food frequency questionnaire estimated nutrient intake. Results: Hypotensive drugs were used by 71% of the study population with a mean intake of 4.4 hypoglycaemic and/or hypotensive drugs. Fat intake was lower and sugar intake higher than recommendations, and low micronutrient intake was prevalent. There was a significant group difference in mean diastolic blood pressure reductions (P = 0.035): the hawthorn group showed greater reductions (baseline: 85.6 mmHg, 95% confidence interval [Cl] = 83.3 to 87.8; outcome: 83.0 mmHg, 95% Cl = 80.5 to 85.7) than the placebo group (baseline: 84.5 mmHg, 95% Cl = 82 to 87; outcome: 85.0 mmHg, 95% Cl = 82.2 to 87.8). There was no group difference in systolic blood pressure reduction from baseline (3.6 and 0.8 mmHg for hawthorn and placebo groups, respectively; P = 0.329). Although mean fat intake met current recommendations, mean sugar intake was higher and there were indications of potential multiple micronutrient deficiencies. No herb-drug interaction was found and minor health complaints were reduced from baseline in both groups. Conclusions: This is the first randomised controlled trial to demonstrate a hypotensive effect of hawthorn in patients with diabetes taking medication.

Prescription software for recovery and rehabilitation using Microsoft Kinect

Brain injuries, including stroke, can be debilitating incidents with potential for severe long term effects; many people stop making significant progress once leaving in-patient medical care and are unable to fully restore their quality of life when returning home. The aim of this collaborative project, between the Royal Berkshire NHS Foundation Trust and the University of Reading, is to provide a low cost portable system that supports a patient's condition and their recovery in hospital or at home. This is done by providing engaging applications with targeted gameplay that is individually tailored to the rehabilitation of the patient's symptoms. The applications are capable of real-time data capture and analysis in order to provide information to therapists on patient progress and to further improve the personalized care that an individual can receive.

Communicating information about medication side effects: effects on satisfaction, perceived risk to health, and intention to comply

Previous research has shown that people's evaluations of explanations about medication and their intention to comply with the prescription are detrimentally affected by the inclusion of information about adverse side effects of the medication. The present study (Experiment 1) examined which particular aspects of information about side effects (their number, likelihood of occurrence, or severity) are likely to have the greatest effect on people's satisfaction, perception of risk, and intention to comply, as well as how the information about side effects interacts with information about the severity of the illness for which the medication was prescribed. Across all measures, it was found that manipulations of side effect severity had the greatest impact on people's judgements, followed by manipulations of side effect likelihood and then number. Experiments 2 and 3 examined how the severity of the diagnosed illness and information about negative side effects interact with two other factors suggested by Social Cognition models of health behaviour to affect people's intention to comply: namely, perceived benefit of taking the prescribed drug, and the perceived level of control over preventing or alleviating the side effects. It was found that providing people with a statement about the positive benefit of taking the medication had relatively little effect on judgements, whereas informing them about how to reduce the chances of experiencing the side effects had an overall beneficial effect on ratings.

Strengthening argumentation in medical explanations by text planning revision

Explanations are an important by-product of medical decisionsupport activities, as they have proved to favour compliance and correct treatment performance. To achieve this purpose, these texts should have a strong argumentation content and should adapt to emotional, as well as to rational attitudes of the Addressee. This paper describes how Rhetorical Sentence Planning can contribute to this aim: the rulebased plan discourse revision is introduced between Text Planning and Linguistic Realization, and exploits knowledge about the user personality and emotions and about the potential impact of domain items on user compliance and memory recall. The proposed approach originates from analytical and empirical evaluation studies of computer generated explanation texts in the domain of drug prescription. This work was partially supported by a British-Italian Collaboration in Research and Higher Education Project, which involved the Universities of Reading and of Bari, in 1996.

What do patients want to know about their medicines, and what do doctors want to tell them?: a comparative study

A two phase study is reported. In the first phase, we asked a number of doctors to rate a list of information categories (identified by Berry, Gillie and Banbury 1995) in terms of how important they felt it was for the items to be included in an explanation to a patient about a drug prescription. In the second phase, we presented a large sample of people with a scenario about visiting their doctor and being prescribed medication, together with an explanation about the prescription which was said to be provided by the doctor. Four different explanations were compared, which were either based on what people in our earlier study wanted to know about drug prescriptions or on what the doctors thought it was important lo tell them. We also manipulated whether or not the explanations conveyed negative information (e.g. about the possible side effects of the medication). The results showed that people 'preferred' the explanations based on what the participants in the earlier study wanted to know about their medicines, rather than those based on what the doctors thought they should be told. They also 'preferred' the explanations that did not convey negative information, rather than those that did convey some negative information. In addition, the inclusion of negative information affected ratings of likely compliance with the prescribed medication.

Mediating between hearer's and speaker's views in the generation of adaptive explanations

In this article, we examine the case of a system that cooperates with a “direct” user to plan an activity that some “indirect” user, not interacting with the system, should perform. The specific application we consider is the prescription of drugs. In this case, the direct user is the prescriber and the indirect user is the person who is responsible for performing the therapy. Relevant characteristics of the two users are represented in two user models. Explanation strategies are represented in planning operators whose preconditions encode the cognitive state of the indirect user; this allows tailoring the message to the indirect user's characteristics. Expansion of optional subgoals and selection among candidate operators is made by applying decision criteria represented as metarules, that negotiate between direct and indirect users' views also taking into account the context where explanation is provided. After the message has been generated, the direct user may ask to add or remove some items, or change the message style. The system defends the indirect user's needs as far as possible by mentioning the rationale behind the generated message. If needed, the plan is repaired and the direct user model is revised accordingly, so that the system learns progressively to generate messages suited to the preferences of people with whom it interacts.

What do patients want to know? An empirical approach to explanation generation and validation

This article describes an empirical, user-centred approach to explanation design. It reports three studies that investigate what patients want to know when they have been prescribed medication. The question is asked in the context of the development of a drug prescription system called OPADE. The system is aimed primarily at improving the prescribing behaviour of physicians, but will also produce written explanations for indirect users such as patients. In the first study, a large number of people were presented with a scenario about a visit to the doctor, and were asked to list the questions that they would like to ask the doctor about the prescription. On the basis of the results of the study, a categorization of question types was developed in terms of how frequently particular questions were asked. In the second and third studies a number of different explanations were generated in accordance with this categorization, and a new sample of people were presented with another scenario and were asked to rate the explanations on a number of dimensions. The results showed significant differences between the different explanations. People preferred explanations that included items corresponding to frequently asked questions in study 1. For an explanation to be considered useful, it had to include information about side effects, what the medication does, and any lifestyle changes involved. The implications of the results of the three studies are discussed in terms of the development of OPADE's explanation facility.

The imminent availability of a potent weight-loss medicine in pharmacies: public perception of effectiveness

Orlistat is an effective weight-loss medicine, which will soon be available for purchase in pharmacies. We used a factorial experiment and found that informing people about the availability for purchase of this medicinal product previously only available on prescription resulted in higher ratings of perceived value and effectiveness compared to a natural health supplement even though we used the same statement about effectiveness. This positive perception of orlistat was not impaired by the provision of side-effect information. Orlistat will soon be available in pharmacies. Health professionals must act to prevent its misuse by those not overweight.

The impact of a closed-loop electronic prescribing and automated dispensing system on the ward pharmacist’s time and activities

Objective To assess the impact of a closed-loop electronic prescribing and automated dispensing system on the time spent providing a ward pharmacy service and the activities carried out. Setting Surgical ward, London teaching hospital. Method All data were collected two months pre- and one year post-intervention. First, the ward pharmacist recorded the time taken each day for four weeks. Second, an observational study was conducted over 10 weekdays, using two-dimensional work sampling, to identify the ward pharmacist's activities. Finally, medication orders were examined to identify pharmacists' endorsements that should have been, and were actually, made. Key findings Mean time to provide a weekday ward pharmacy service increased from 1 h 8 min to 1 h 38 min per day (P = 0.001; unpaired t-test). There were significant increases in time spent prescription monitoring, recommending changes in therapy/monitoring, giving advice or information, and non-productive time. There were decreases for supply, looking for charts and checking patients' own drugs. There was an increase in the amount of time spent with medical and pharmacy staff, and with 'self'. Seventy-eight per cent of patients' medication records could be assessed for endorsements pre- and 100% post-intervention. Endorsements were required for 390 (50%) of 787 medication orders pre-intervention and 190 (21%) of 897 afterwards (P < 0.0001; chi-square test). Endorsements were made for 214 (55%) of endorsement opportunities pre-intervention and 57 (30%) afterwards (P < 0.0001; chi-square test). Conclusion The intervention increased the overall time required to provide a ward pharmacy service and changed the types of activity undertaken. Contact time with medical and pharmacy staff increased. There was no significant change in time spent with patients. Fewer pharmacy endorsements were required post-intervention, but a lower percentage were actually made. The findings have important implications for the design, introduction and use of similar systems.

The impact of two arable field margin management schemes on litter decomposition

A primary objective of agri-environment schemes is the conservation of biodiversity; in addition to increasing the value of farmland for wildlife, these schemes also aim to restore natural ecosystem functioning. The management of scheme options can influence their value for delivering ecosystem services by modifying the composition of floral and faunal communities. This study examines the impact of an agri-environment scheme prescription on ecosystem functioning by testing the hypothesis that vegetation management influences decomposition rates in grassy arable field margins. The effects of two vegetation management practices in arable field margins - cutting and soil disturbance (scarification) - on litter decomposition were compared using a litterbag experimental approach in early April 2006. Bags had either small mesh designed to restrict access to soil macrofauna, or large mesh that would allow macrofauna to enter. Bags were positioned on the soil surface or inserted into the soil in cut and scarified margins, retrieved after 44, 103 and 250 days and the amount of litter mass remaining was calculated. Litter loss from the litterbags with large mesh was greater than from the small mesh bags, providing evidence that soil macrofauna accelerate rates of litter decomposition. In the large mesh bags, the proportion of litter remaining in bags above and belowground in the cut plots was similar, while in the scarified plots, there was significantly more litter left in the aboveground bags than in the belowground bags. This loss of balance between decomposition rates above and belowground in scarified margins may have implications for the development and maintenance of grassy arable field margins by influencing nutrient availability for plant communities. (C) 2008 Elsevier B.V. All rights reserved.

Effects of grazing management on beetle and plant assemblages during the re-creation of a flood-plain meadow

Flood-plain meadows (Alopecurus-Sanguisorba grassland) are a floristically rich community of conservation importance throughout Europe. Declines in their distribution due in part to modern farming practices mean they now cover less than 1500 ha in the UK. To investigate the effect of grazing regime during the re-creation of this grassland type, target plant species were sown onto ex-arable land during 1985. Traditional management, based on a July hay cut followed by aftermath grazing was subsequently instigated, and the site was divided into replicated grazing regimes of cattle, sheep and an un-grazed control. Plant and beetle assemblages were sampled and compared to those of target flood-plain meadows and improved grassland communities. Within the re-creation treatments the absence of aftermath grazing reduced beetle abundances and species richness. Assemblages of plants were closest to that of the target flood-plain meadow under sheep grazing, although this differed little from cattle grazing. Beetle species assemblages and functional group structure were, however, closest to the target grassland under cattle grazing. For all taxa the greatest resilience to succession to the target flood-plain meadow occurred when grazing was not part of the management prescription. Although successful re-creation had not been achieved for either the plants or beetles, cutting followed by aftermath cattle grazing has provided the best management to date. (c) 2006 Elsevier B.V. All rights reserved.

Fecal microbiota in patients receiving enteral feeding are highly variable and may be altered in those who develop diarrhea

Background: The pathogenesis of diarrhea in patients receiving enteral feeding includes colonic water secretion, antibiotic prescription, and enteropathogenic colonization, each of which involves an interaction with the gastrointestinal microbiota. Objective: The objective was to investigate temporal changes in the concentrations of fecal microbiota and short-chain fatty acids (SCFAs) in patients starting 14-d of enteral feeding and to compare these changes between patients who do and do not develop diarrhea. Design: Twenty patients starting exclusive nasogastric enteral feeding were monitored for 14 d. Fecal samples were collected at the start, middle, and end of this period and were analyzed for major bacterial groups by using culture independent fluorescence in situ hybridization and for SCFAs by using gas-liquid chromatography. Results: Although no significant changes in fecal microbiota or SCFAs were observed during enteral feeding, stark alterations occurred within individual patients. Ten patients (50%) developed diarrhea, and these patients had significantly higher concentrations of clostridia (P = 0.026) and lower concentrations (P = 0.069) and proportions (P = 0.029) of bifidobacteria. Patients with and without diarrhea had differences in the proportion of bifidobacteria (median: 0.4% and 3.7%; interquartile range: 0.8 compared with 4.3; P = 0.035) and clostridia (median: 10.4% and 3.7%; interquartile range: 14.7 compared with 7.0; P = 0.063), respectively, even at the start of enteral feeding. Patients who developed diarrhea had higher concentrations of total fecal SCFAs (P = 0.044), acetate (P = 0.029), and butyrate (P = 0.055). Conclusion: Intestinal dysbiosis occurs in patients who develop diarrhea during enteral feeding and may be involved in its pathogenesis. Am J Clin Nutr 2009; 89: 240-7.