Targeting medication non-adherence behavior in selected autoimmune diseases: a systematic approach to digital health program development

Background 29 autoimmune diseases, including Rheumatoid Arthritis, gout, Crohn’s Disease, and Systematic Lupus Erythematosus affect 7.6-9.4% of the population. While effective therapy is available, many patients do not follow treatment or use medications as directed. Digital health and Web 2.0 interventions have demonstrated much promise in increasing medication and treatment adherence, but to date many Internet tools have proven disappointing. In fact, most digital interventions continue to suffer from high attrition in patient populations, are burdensome for healthcare professionals, and have relatively short life spans. Objective Digital health tools have traditionally centered on the transformation of existing interventions (such as diaries, trackers, stage-based or cognitive behavioral therapy programs, coupons, or symptom checklists) to electronic format. Advanced digital interventions have also incorporated attributes of Web 2.0 such as social networking, text messaging, and the use of video. Despite these efforts, there has not been little measurable impact in non-adherence for illnesses that require medical interventions, and research must look to other strategies or development methodologies. As a first step in investigating the feasibility of developing such a tool, the objective of the current study is to systematically rate factors of non-adherence that have been reported in past research studies. Methods Grounded Theory, recognized as a rigorous method that facilitates the emergence of new themes through systematic analysis, data collection and coding, was used to analyze quantitative, qualitative and mixed method studies addressing the following autoimmune diseases: Rheumatoid Arthritis, gout, Crohn’s Disease, Systematic Lupus Erythematosus, and inflammatory bowel disease. Studies were only included if they contained primary data addressing the relationship with non-adherence. Results Out of the 27 studies, four non-modifiable and 11 modifiable risk factors were discovered. Over one third of articles identified the following risk factors as common contributors to medication non-adherence (percent of studies reporting): patients not understanding treatment (44%), side effects (41%), age (37%), dose regimen (33%), and perceived medication ineffectiveness (33%). An unanticipated finding that emerged was the need for risk stratification tools (81%) with patient-centric approaches (67%). Conclusions This study systematically identifies and categorizes medication non-adherence risk factors in select autoimmune diseases. Findings indicate that patients understanding of their disease and the role of medication are paramount. An unexpected finding was that the majority of research articles called for the creation of tailored, patient-centric interventions that dispel personal misconceptions about disease, pharmacotherapy, and how the body responds to treatment. To our knowledge, these interventions do not yet exist in digital format. Rather than adopting a systems level approach, digital health programs should focus on cohorts with heterogeneous needs, and develop tailored interventions based on individual non-adherence patterns.

A comparison of three different models for estimating relative risk in meta-analysis of clinical trials under unobserved heterogeneity

We focus on the comparison of three statistical models used to estimate the treatment effect in metaanalysis when individually pooled data are available. The models are two conventional models, namely a multi-level and a model based upon an approximate likelihood, and a newly developed model, the profile likelihood model which might be viewed as an extension of the Mantel-Haenszel approach. To exemplify these methods, we use results from a meta-analysis of 22 trials to prevent respiratory tract infections. We show that by using the multi-level approach, in the case of baseline heterogeneity, the number of clusters or components is considerably over-estimated. The approximate and profile likelihood method showed nearly the same pattern for the treatment effect distribution. To provide more evidence two simulation studies are accomplished. The profile likelihood can be considered as a clear alternative to the approximate likelihood model. In the case of strong baseline heterogeneity, the profile likelihood method shows superior behaviour when compared with the multi-level model. Copyright (C) 2006 John Wiley & Sons, Ltd.

Developing international business managers through international study visits to China

Globalization is a key factor in the success of business organizations today, impacting many aspects of management performance. Understanding the global business environment has therefore become a key objective in the teaching of international business on Executive MBA programs. Drawing on the theory of experiential learning, this study examines the relationship between program structure and learning activities of an international study visit (ISV) to China and the learning experience for Executive MBA students. The findings indicate that learning experience may be most effective where the structure of an ISV incorporates certain activities that promote experiential and deep-level learning. Educational implications are discussed.

A practical approach to a multi-level analysis with a sparse binary outcome within a large surgical trial

Objectives: To assess the potential source of variation that surgeon may add to patient outcome in a clinical trial of surgical procedures. Methods: Two large (n = 1380) parallel multicentre randomized surgical trials were undertaken to compare laparoscopically assisted hysterectomy with conventional methods of abdominal and vaginal hysterectomy; involving 43 surgeons. The primary end point of the trial was the occurrence of at least one major complication. Patients were nested within surgeons giving the data set a hierarchical structure. A total of 10% of patients had at least one major complication, that is, a sparse binary outcome variable. A linear mixed logistic regression model (with logit link function) was used to model the probability of a major complication, with surgeon fitted as a random effect. Models were fitted using the method of maximum likelihood in SAS((R)). Results: There were many convergence problems. These were resolved using a variety of approaches including; treating all effects as fixed for the initial model building; modelling the variance of a parameter on a logarithmic scale and centring of continuous covariates. The initial model building process indicated no significant 'type of operation' across surgeon interaction effect in either trial, the 'type of operation' term was highly significant in the abdominal trial, and the 'surgeon' term was not significant in either trial. Conclusions: The analysis did not find a surgeon effect but it is difficult to conclude that there was not a difference between surgeons. The statistical test may have lacked sufficient power, the variance estimates were small with large standard errors, indicating that the precision of the variance estimates may be questionable.

A multi-level analytical approach for detection and visualization of intracellular NO production and nitrosation events using diaminofluoresceins

Diaminofluoresceins are widely used probes for detection and intracellular localization of NO formation in cultured/isolated cells and intact tissues. The fluorinated derivative, 4-amino-5-methylamino-2′,7′-difluorofluorescein (DAF-FM), has gained increasing popularity in recent years due to its improved NO-sensitivity, pH-stability, and resistance to photo-bleaching compared to the first-generation compound, DAF-2. Detection of NO production by either reagent relies on conversion of the parent compound into a fluorescent triazole, DAF-FM-T and DAF-2-T, respectively. While this reaction is specific for NO and/or reactive nitrosating species, it is also affected by the presence of oxidants/antioxidants. Moreover, the reaction with other molecules can lead to the formation of fluorescent products other than the expected triazole. Thus additional controls and structural confirmation of the reaction products are essential. Using human red blood cells as an exemplary cellular system we here describe robust protocols for the analysis of intracellular DAF-FM-T formation using an array of fluorescence-based methods (laser-scanning fluorescence microscopy, flow cytometry and fluorimetry) and analytical separation techniques (reversed-phase HPLC and LC-MS/MS). When used in combination, these assays afford unequivocal identification of the fluorescent signal as being derived from NO and are applicable to most other cellular systems without or with only minor modifications.

A mathematical approach to chemical equilibrium theory for gaseous systems—I: theory

Equilibrium theory occupies an important position in chemistry and it is traditionally based on thermodynamics. A novel mathematical approach to chemical equilibrium theory for gaseous systems at constant temperature and pressure is developed. Six theorems are presented logically which illustrate the power of mathematics to explain chemical observations and these are combined logically to create a coherent system. This mathematical treatment provides more insight into chemical equilibrium and creates more tools that can be used to investigate complex situations. Although some of the issues covered have previously been given in the literature, new mathematical representations are provided. Compared to traditional treatments, the new approach relies on straightforward mathematics and less on thermodynamics, thus, giving a new and complementary perspective on equilibrium theory. It provides a new theoretical basis for a thorough and deep presentation of traditional chemical equilibrium. This work demonstrates that new research in a traditional field such as equilibrium theory, generally thought to have been completed many years ago, can still offer new insights and that more efficient ways to present the contents can be established. The work presented here can be considered appropriate as part of a mathematical chemistry course at University level.

Using a case-study approach to improve the Madden-Julian oscillation in the Hadley Centre model

In its default configuration, the Hadley Centre climate model (GA2.0) simulates roughly one-half the observed level of Madden–Julian oscillation activity, with MJO events often lasting fewer than seven days. We use initialised, climate-resolution hindcasts to examine the sensitivity of the GA2.0 MJO to a range of changes in sub-grid parameterisations and model configurations. All 22 changes are tested for two cases during the Years of Tropical Convection. Improved skill comes only from (a) disabling vertical momentum transport by convection and (b) increasing mixing entrainment and detrainment for deep and mid-level convection. These changes are subsequently tested in a further 14 hindcast cases; only (b) consistently improves MJO skill, from 12 to 22 days. In a 20-year integration, (b) produces near-observed levels of MJO activity, but propagation through the Maritime Continent remains weak. With default settings, GA2.0 produces precipitation too readily, even in anomalously dry columns. Implementing (b) decreases the efficiency of convection, permitting instability to build during the suppressed MJO phase and producing a more favourable environment for the active phase. The distribution of daily rain rates is more consistent with satellite data; default entrainment produces 6–12 mm/day too frequently. These results are consistent with recent studies showing that greater sensitivity of convection to moisture improves the representation of the MJO.

An ontological approach to competency management

Competency management is a very important part of a well-functioning organisation. Unfortunately competency descriptions are not uniformly specified nor defined across borders: National, sectorial or organisational, leading to an opaque competency description market with a multitude of competency frameworks and competency benchmarks. An ontology is a formalised description of a domain, which enables automated reasoning engines to be built which by utilising the interrelations between entities can make “intelligent” choices in different situations within the domain. Introducing formalised competency ontologies automated tools, such as skill gap analysis, training suggestion generation, job search and recruitment, can be developed, which compare and contrast different competency descriptions on the semantic level. The major problem with defining a common formalised ontology for competencies is that there are so many viewpoints of competencies and competency frameworks. Work within the TRACE project has focused on finding common trends within different competency frameworks in order to allow an intermediate competency description to be made, which other frameworks can reference. This research has shown that competencies can be divided up into “knowledge”, “skills” and what we call “others”. An ontology has been created based on this with a simple structure of different “kinds” of “knowledges” and “skills” using semantic interrelations to define the basic semantic structure of the ontology. A prototype tool for analysing a skill gap analysis has been developed. Personal profiles can be produced using the tool and a skill gap analysis is performed on a desired competency profile by using an ontologically based inference engine, which is able to list closest fit and possible proficiency gaps

Controlling nitrate pollution: an integrated approach

The introduction of the EU Water Framework Directive requires policy to address non-point source pollution as part of an overall integrated strategy to improve the ecological status of water bodies. In this paper, we combine an economic optimisation framework with a dynamic simulation model of N transport in the Kennet Catchment to link decisions taken at the farm level to reductions in nitrate concentrations in the River Kennet. We examine a variety of policies targeted at reducing fertiliser use and changing the way in which farm land is used. We find that a tax on nitrogen emerges as the best policy both in terms of cost- and environmental effectiveness. Such a policy involves a considerable reduction in fertiliser use, as well as, a restructuring of land-use away from arable towards increased use of set-aside. Budgetary implications of such a radical move towards set-aside would be huge and hence unlikely to be politically palatable given the objective of reducing the EU budgetary allocation to agriculture. Additionally, the current rise in world demand for food may also mitigate calls for increasing the proportion of land taken out of agricultural production. Although the study succeeds in establishing a link between actions on the farm and nitrate concentrations in the stream water, further work is required to explore the effect of the retention of nitrates in the unsaturated zone and groundwater on this link.

An ichnofabric approach to the depositional interpretation of the intensely burrowed Bateig Limestone, Miocene, SE Spain

The foraminiferal-rich pelagic Bateig Limestone forms several varieties of the important building stones quarried at Bateig Hill in southeastern Spain. Three principal ichnofabrics (Bichordites, mottled-Palaeophycus and mottled-Ophiomorpha) are recognized, which are present in at least two (possibly up to four) repeated successions (cycles). Each succession begins with an erosional event. The Bichordites ichnofabric represents a new type of facies, formed as thin turbidity/grain flow, stratiform units derived from sediment slips off a fault into deep water. Each slipped unit became almost completely bioturbated by infaunal echinoids, colonizing by lateral migration. Because of the thinness of the units, successive colonizations tended to truncate the underlying burrows giving rise to a pseudo-stratification. As the Bichordites ichnofabric accumulated on the fault apron, thus reducing the effective height of the fault scarp, the substrate gradually came under the influence of currents traversing the shelf. This led to a change in hydraulic regime, and to the mottled-Palaeophycus and mottled-Ophiomorpha ichnofabrics in sediment deposited under bed load transport, and associated with laminar and cross-stratified beds and local muddy intervals. Reactivation of the fault triggered erosion and channeling and a return to grain flow sedimentation, and to the Bichordites ichnofabric of the succeeding cycle. The highest unit of the Bateig Limestone is formed entirely of cross-stratified calcarenites with occasional Ophiomorpha (Ophiomorpha-primary lamination ichnofabric) and is similar to many shallow marine facies but they still bear a significant content of pelagic foraminifera. The sedimentary setting bears resemblance with that described for the Pleistocene Monte Torre Paleostrait and the modem Strait of Messina (Italy), where the narrow morphology of the depositional area enhanced tidal currents and allowed for high-energy sandy deposition in relatively deep areas. More data on the Miocene paleogeography of the Bateig area should provide further testing for this hypothesis. The ichnofacies and stacking of the Bateig Limestone differ from the classic Seilacherian model in that they reflect changes in hydraulic process and are associated with faulting and subsidence and changes in sediment supply. Recognition of the unusual ichnofabrics and their relationships provides a clear indication of the overall dynamic setting. (c) 2006 Elsevier B.V. All rights reserved.

Mechanisms of midlatitude cross-tropopause transport using a potential vorticity budget approach

[ 1] A potential vorticity (PV) budget method has been used to attribute vertical transport across the near-tropopause ( 1 PVU surface) in extratropical weather systems to radiative, latent heating and cooling, and mixing processes. Sources and sinks of PV due to nonconservative processes are calculated online and advected as passive tracers. There is reasonable agreement between the spatial distribution of transport determined from the PV budget method and the transport across the 1 - 2 PVU zone from a passive tracer and trajectories, but different aspects of exchange can be diagnosed with each method. Stratosphere-to-troposphere transport occurred in the broad upper level PV anomalies and was attributed mainly to latent heating and cooling processes; troposphere-to-stratosphere transport occurred toward the tail of a PV filament and in a ridge region and was attributed mainly to radiative processes. The contribution of mixing processes to transport was comparatively small. Using the PV budget method, the domain integrated exchange across the 1 PVU surface was from stratosphere to troposphere, and the magnitude of 1 x 10(15) kg over a 2 day winter integration in a large North Atlantic domain is consistent with stratosphere-troposphere exchange calculations from other studies. This exchange arises from an approximate balance between the dominant stratosphere-to-troposphere transport due to latent heating and cooling processes and troposphere-to-stratosphere transport due to radiative processes. The direction of transport across the tropopause in a fold was found to be critically dependent on the PV surface considered to represent the tropopause.

Effects of patch size and density on flower visitation and seed set of wild plants: a pan-European approach

1. Habitat fragmentation can affect pollinator and plant population structure in terms of species composition, abundance, area covered and density of flowering plants. This, in turn, may affect pollinator visitation frequency, pollen deposition, seed set and plant fitness. 2. A reduction in the quantity of flower visits can be coupled with a reduction in the quality of pollination service and hence the plants’ overall reproductive success and long-term survival. Understanding the relationship between plant population size and⁄ or isolation and pollination limitation is of fundamental importance for plant conservation. 3. Weexamined flower visitation and seed set of 10 different plant species fromfive European countries to investigate the general effects of plant populations size and density, both within (patch level) and between populations (population level), on seed set and pollination limitation. 4. Wefound evidence that the effects of area and density of flowering plant assemblages were generally more pronounced at the patch level than at the population level. We also found that patch and population level together influenced flower visitation and seed set, and the latter increased with increasing patch area and density, but this effect was only apparent in small populations. 5. Synthesis. By using an extensive pan-European data set on flower visitation and seed set we have identified a general pattern in the interplay between the attractiveness of flowering plant patches for pollinators and density dependence of flower visitation, and also a strong plant species-specific response to habitat fragmentation effects. This can guide efforts to conserve plant–pollinator interactions, ecosystem functioning and plant fitness in fragmented habitats.

A tractable means of correcting sector level TFP calculations in the face of biased technological change.

The measurement of the impact of technical change has received significant attention within the economics literature. One popular method of quantifying the impact of technical change is the use of growth accounting index numbers. However, in a recent article Nelson and Pack (1999) criticise the use of such index numbers in situations where technical change is likely to be biased in favour of one or other inputs. In particular they criticise the common approach of applying observed cost shares, as proxies for partial output elasticities, to weight the change in quantities which they claim is only valid under Hicks neutrality. Recent advances in the measurement of product and factor biases of technical change developed by Balcombe et al (2000) provide a relatively straight-forward means of correcting product and factor shares in the face of biased technical progress. This paper demonstrates the correction of both revenue and cost shares used in the construction of a TFP index for UK agriculture over the period 1953 to 2000 using both revenue and cost function share equations appended with stochastic latent variables to capture the bias effect. Technical progress is shown to be biased between both individual input and output groups. Output and input quantity aggregates are then constructed using both observed and corrected share weights and the resulting TFPs are compared. There does appear to be some significant bias in TFP if the effect of biased technical progress is not taken into account when constructing the weights

Farming systems methodology for efficient resource management at the farm level: a review from an Indian perspective

Farming systems research is a multi-disciplinary holistic approach to solve the problems of small farms. Small and marginal farmers are the core of the Indian rural economy Constituting 0.80 of the total farming community but possessing only 0.36 of the total operational land. The declining trend of per capita land availability poses a serious challenge to the sustainability and profitability of farming. Under such conditions, it is appropriate to integrate land-based enterprises such as dairy, fishery, poultry, duckery, apiary, field and horticultural cropping within the farm, with the objective of generating adequate income and employment for these small and marginal farmers Under a set of farm constraints and varying levels of resource availability and Opportunity. The integration of different farm enterprises can be achieved with the help of a linear programming model. For the current review, integrated farming systems models were developed, by Way Of illustration, for the marginal, small, medium and large farms of eastern India using linear programming. Risk analyses were carried out for different levels of income and enterprise combinations. The fishery enterprise was shown to be less risk-prone whereas the crop enterprise involved greater risk. In general, the degree of risk increased with the increasing level of income. With increase in farm income and risk level, the resource use efficiency increased. Medium and large farms proved to be more profitable than small and marginal farms with higher level of resource use efficiency and return per Indian rupee (Rs) invested. Among the different enterprises of integrated farming systems, a chain of interaction and resource flow was observed. In order to make fanning profitable and improve resource use efficiency at the farm level, the synergy among interacting components of farming systems should be exploited. In the process of technology generation, transfer and other developmental efforts at the farm level (contrary to the discipline and commodity-based approaches which have a tendency to be piecemeal and in isolation), it is desirable to place a whole-farm scenario before the farmers to enhance their farm income, thereby motivating them towards more efficient and sustainable fanning.