Effect of a protein and energy dense n-3 fatty acid enriched oral supplement on loss of weight and lean tissue in cancer cachexia:A randomised double blind trial

Aim: N-3 fatty acids, especially eicosapentaenoic acid (EPA), may possess anticachectic properties. This trial compared a protein and energy dense supplement enriched with n-3 fatty acids and antioxidants (experimental: E) with an isocaloric isonitrogenous control supplement (C) for their effects on weight, lean body mass (LBM), dietary intake, and quality of life in cachectic patients with advanced pancreatic cancer. Methods: A total of 200 patients (95 E; 105 C) were randomised to consume two cans/day of the E or C supplement (480 ml, 620 kcal, 32 g protein ± 2.2 g EPA) for eight weeks in a multicentre, randomised, double blind trial. Results: At enrolment, patients' mean rate of weight loss was 3.3 kg/month. Intake of the supplements (E or C) was below the recommended dose (2 cans/day) and averaged 1.4 cans/day. Over eight weeks, patients in both groups stopped losing weight (Δweight E: -0.25 kg/month versus C: -0.37 kg/month; p=0.74) and LBM (ΔLBM E: +0.27 kg/month versus C: +0.12 kg/month; p=0.88) to an equal degree (change from baseline E and C, p<0.001). In view of evident non-compliance in both E and C groups, correlation analyses were undertaken to examine for potential dose-response relationships. E patients demonstrated significant correlations between their supplement intake and weight gain (r=0.50, p<0.001) and increase in LBM (r=0.33, p=0.036). Such correlations were not statistically significant in C patients. The relationship of supplement intake with change in LBM was significantly different between E and C patients (p=0.043). Increased plasma EPA levels in the E group were associated with weight and LBM gain (r=0.50, p<0.001; r=0.51, p=0.001). Weight gain was associated with improved quality of life (p<0.01) only in the E group. Conclusion: Intention to treat group comparisons indicated that at the mean dose taken, enrichment with n-3 fatty acids did not provide a therapeutic advantage and that both supplements were equally effective in arresting weight loss. Post hoc dose-response analysis suggests that if taken in sufficient quantity, only the n-3 fatty acid enriched energy and protein dense supplement results in net gain of weight, lean tissue, and improved quality of life. Further trials are required to examine the potential role of n-3 enriched supplements in the treatment of cancer cachexia.

Impact of cholinesterase inhibitors on behavioral and psychological symptoms of Alzheimer's disease:a meta-analysis

Objective: To determine the efficacy of cholinesterase inhibitors (ChEIs) in improving the behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer’s disease (AD). Data sources: We searched MEDLINE, Cochrane Registry, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 1966 to 2007. We limited our search to English Language, full text, published articles and human studies. Data extraction: We included randomized, double-blind, placebo-controlled trials evaluating the efficacy of donepezil, rivastigmine, or galantamine in managing BPSD displayed by AD patients. Using the United States Preventive Services Task Force (USPSTF) guidelines, we critically appraised all studies and included only those with an attrition rate of less than 40%, concealed measurement of the outcomes, and intention to treat analysis of the collected data. All data were imputed into pre-defined evidence based tables and were pooled using the Review Manager 4.2.1 software for data synthesis. Results: We found 12 studies that met our inclusion criteria but only nine of them provided sufficient data for the meta-analysis. Among patients with mild to severe AD and in comparison to placebo, ChEIs as a class had a beneficial effects on reducing BPSD with a standard mean difference (SMD) of -0.10 (95% confidence interval [CI]; -0.18, -0.01) and a weighted mean difference (WMD) of -1.38 neuropsychiatry inventory point (95% CI; -2.30, -0.46). In studies with mild AD patients, the WMD was -1.92 (95% CI; -3.18, -0.66); and in studies with severe AD patients, the WMD was -0.06 (95% CI; -2.12, +0.57). Conclusion: Cholinesterase inhibitors lead to a statistical significant reduction in BPSD among patients with AD, yet the clinical relevance of this effect remains unclear.

Chlorhexidine and the prevention of surgical site infection

Surgical site infections (SSI) are a prevalent health care-associated infection (HAl). Prior to the mid-19th century, surgical sites commonly developed postoperative wound complications. It was in the 1860's, after Joseph Lister introduced carbolic acid and the principles of antisepsis that postoperative wound infection significantly decreased. Today, patient preoperative skin preparation with an antiseptic agent prior to surgery is a standard of practice. Povidone-iodine and chlorhexidine gluconate are currently the most commonly used antimicrobial agents used to prep the patient's skin. In this current study, the epidemiology, diagnosis, surveillance and prevention of SSI with chlorhexidine were investigated. The antimicrobial activity of chlorhexidine was assessed. In in-vitro and in-vivo studies the antimicrobial efficacy of 2% (w/v) chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA) and 10% povidoneiodine (PVP-I) in the presence of 0.9% normal saline or blood were examined. The 2% CHG in 70% IPA solutions antimicrobial activity was not diminished in the presence of 0.9% normal saline or blood. In comparison, the traditional patient preoperative skin preparation, 10% PVP-I antimicrobial activity was not diminished in the presence of 0.9% normal saline, but was diminished in the presence of blood. In an in-vivo human volunteer study the potential for reduction of the antimicrobial efficacy of aqueous patient preoperative skin preparations compromised by mechanical removal of wet product from the application site (blot) was assessed. In this evaluation, 2% CHG and 10% povidone-iodine (PVP-I) were blotted from the patient's skin after application to the test site. The blotting, or mechanical removal, of the wet antiseptic from the application site did not produce a significant difference in product efficacy. In a clinical trial to compare 2% CHG in 70% IPA and PVP-! scrub and paint patient preoperative skin preparation for the prevention of SSI, there were 849 patients randomly assigned to the study groups (409 in the chlorhexidine-alcohol and 440 in the povidone-iodine group) in the intention-to-treat analysis. The overall surgical site infection was significantly lower in the 2% CHG in 70% IPA group than in the PVP-I group (9.5% versus 16.1 %, p=0.004; relative risk, 0.59 with 95% confidence interval of 0.41 to 0.85). Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to povidone-iodine in preventing surgical site infection after clean-contaminated surgery.

Description and preliminary results from a structured specialist behavioural weight management group intervention:Specialist Lifestyle Management (SLiM) programme

Background -  Specialist Lifestyle Management (SLiM) is a structured patient education and self-management group weight management programme. Each session is run monthly over a 6-month period providing a less intensive long-term approach. The groups are patient-centred incorporating educational, motivational, behavioural and cognitive elements. The theoretical background, programme structure and preliminary results of SLiM are presented. Subjects/methods - The study was a pragmatic service evaluation of obese patients with a body mass index (BMI) ≥35 kg/m2 with comorbidity or ≥40 kg/m2 without comorbidity referred to a specialist weight management service in the West Midlands, UK. 828 patients were enrolled within SLiM over a 48-month period. Trained facilitators delivered the programme. Preliminary anonymised data were analysed using the intention-to-treat principle. The primary outcome measure was weight loss at 3 and 6 months with comparisons between completers and non-completers performed. The last observation carried forward was used for missing data. Results - Of the 828 enrolled within SLiM, 464 completed the programme (56%). The mean baseline weight was 135 kg (BMI=49.1 kg/m2) with 87.2% of patients having a BMI≥40 kg/m2 and 12.4% with BMI≥60 kg/m2. The mean weight change of all patients enrolled was −4.1 kg (95% CI −3.6 to −4.6 kg, p=0.0001) at the end of SLiM, with completers (n=464) achieving −5.5 kg (95% CI −4.2 to −6.2 kg, p=0.0001) and non-completers achieving −2.3 kg (p=0.0001). The majority (78.6%) who attended the 6-month programme achieved weight loss with 32.3% achieving a ≥5% weight loss. Conclusions - The SLiM programme is an effective group intervention for the management of severe and complex obesity.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia:the ECLIPSE trial

BACKGROUND: Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena(®), Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. DESIGN: A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. SETTING: Women who presented in primary care. PARTICIPANTS: A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. INTERVENTIONS: LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. OUTCOME MEASURES: The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. RESULTS: The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. CONCLUSIONS: The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86566246. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Brain drain:inclination to stay abroad after studies

'Brain drain' is a phenomenon in which people of a high level of skills, qualifications, and competence, leave their countries and emigrate. One major case of the brain drain happens when students from developing countries studying in the developed countries decide not to return home after their studies. We examined the reasons for international students' inclination to stay in their host countries in a sample of 949 management students who came to study in the United Kingdom and the United States. The results support a three-fold model of factors that influenced this inclination. Students' perceptions of ethnic differences and labor markets, their adjustment process to the host country, and their family ties in host and home countries all affect their intention to stay. © 2006 Elsevier Inc. All rights reserved.

Causality and synchronisation in complex systems with applications to neuroscience

This thesis presents an investigation, of synchronisation and causality, motivated by problems in computational neuroscience. The thesis addresses both theoretical and practical signal processing issues regarding the estimation of interdependence from a set of multivariate data generated by a complex underlying dynamical system. This topic is driven by a series of problems in neuroscience, which represents the principal background motive behind the material in this work. The underlying system is the human brain and the generative process of the data is based on modern electromagnetic neuroimaging methods . In this thesis, the underlying functional of the brain mechanisms are derived from the recent mathematical formalism of dynamical systems in complex networks. This is justified principally on the grounds of the complex hierarchical and multiscale nature of the brain and it offers new methods of analysis to model its emergent phenomena. A fundamental approach to study the neural activity is to investigate the connectivity pattern developed by the brain’s complex network. Three types of connectivity are important to study: 1) anatomical connectivity refering to the physical links forming the topology of the brain network; 2) effective connectivity concerning with the way the neural elements communicate with each other using the brain’s anatomical structure, through phenomena of synchronisation and information transfer; 3) functional connectivity, presenting an epistemic concept which alludes to the interdependence between data measured from the brain network. The main contribution of this thesis is to present, apply and discuss novel algorithms of functional connectivities, which are designed to extract different specific aspects of interaction between the underlying generators of the data. Firstly, a univariate statistic is developed to allow for indirect assessment of synchronisation in the local network from a single time series. This approach is useful in inferring the coupling as in a local cortical area as observed by a single measurement electrode. Secondly, different existing methods of phase synchronisation are considered from the perspective of experimental data analysis and inference of coupling from observed data. These methods are designed to address the estimation of medium to long range connectivity and their differences are particularly relevant in the context of volume conduction, that is known to produce spurious detections of connectivity. Finally, an asymmetric temporal metric is introduced in order to detect the direction of the coupling between different regions of the brain. The method developed in this thesis is based on a machine learning extensions of the well known concept of Granger causality. The thesis discussion is developed alongside examples of synthetic and experimental real data. The synthetic data are simulations of complex dynamical systems with the intention to mimic the behaviour of simple cortical neural assemblies. They are helpful to test the techniques developed in this thesis. The real datasets are provided to illustrate the problem of brain connectivity in the case of important neurological disorders such as Epilepsy and Parkinson’s disease. The methods of functional connectivity in this thesis are applied to intracranial EEG recordings in order to extract features, which characterize underlying spatiotemporal dynamics before during and after an epileptic seizure and predict seizure location and onset prior to conventional electrographic signs. The methodology is also applied to a MEG dataset containing healthy, Parkinson’s and dementia subjects with the scope of distinguishing patterns of pathological from physiological connectivity.

Robust automatic mapping algorithms in a network monitoring scenario

Automatically generating maps of a measured variable of interest can be problematic. In this work we focus on the monitoring network context where observations are collected and reported by a network of sensors, and are then transformed into interpolated maps for use in decision making. Using traditional geostatistical methods, estimating the covariance structure of data collected in an emergency situation can be difficult. Variogram determination, whether by method-of-moment estimators or by maximum likelihood, is very sensitive to extreme values. Even when a monitoring network is in a routine mode of operation, sensors can sporadically malfunction and report extreme values. If this extreme data destabilises the model, causing the covariance structure of the observed data to be incorrectly estimated, the generated maps will be of little value, and the uncertainty estimates in particular will be misleading. Marchant and Lark [2007] propose a REML estimator for the covariance, which is shown to work on small data sets with a manual selection of the damping parameter in the robust likelihood. We show how this can be extended to allow treatment of large data sets together with an automated approach to all parameter estimation. The projected process kriging framework of Ingram et al. [2007] is extended to allow the use of robust likelihood functions, including the two component Gaussian and the Huber function. We show how our algorithm is further refined to reduce the computational complexity while at the same time minimising any loss of information. To show the benefits of this method, we use data collected from radiation monitoring networks across Europe. We compare our results to those obtained from traditional kriging methodologies and include comparisons with Box-Cox transformations of the data. We discuss the issue of whether to treat or ignore extreme values, making the distinction between the robust methods which ignore outliers and transformation methods which treat them as part of the (transformed) process. Using a case study, based on an extreme radiological events over a large area, we show how radiation data collected from monitoring networks can be analysed automatically and then used to generate reliable maps to inform decision making. We show the limitations of the methods and discuss potential extensions to remedy these.

The effect of age, gender and driver status on pedestrians' intentions to cross the road in risky situations

The theory of planned behaviour (TPB) has been used successfully in the past to account for pedestrians' intentions to cross the road in risky situations. However, accident statistics show age and gender differences in the likelihood of adult pedestrian accidents. This study extends earlier work by examining the relative importance of the model components as predictors of intention to cross for four different adult age groups, men, women, drivers and nondrivers. The groups did not differ in the extent to which they differentiated between two situations of varying perceived risk. The model fit was good, but accounted for less of the variance in intention for the youngest group (17-24) than for other age groups. Differences between the age groups in intention to cross seemed to be due to differences in perceived value of crossing rather than differences in perceived risk. Women were less likely to intend to cross than men and perceived more risk, and there were important age, gender and driver status differences in the importance of the TPB variables as predictors of intention. A key implication of these findings is that road safety interventions need to be designed differently for different groups. © 2006 Elsevier Ltd. All rights reserved.

Staying in nursing:what factors determine whether nurses intend to remain employed?

Aim. To test a model of eight thematic determinants of whether nurses intend to remain in nursing roles. Background. Despite the dramatic increase in the supply of nurses in England over the past decade, a combination of the economic downturn, funding constraints and more generally an ageing nursing population means that healthcare organizations are likely to encounter long-term problems in the recruitment and retention of nursing staff. Design. Survey. Method. Data were collected from a large staff survey conducted in the National Health Service in England between September-December 2009. A multi-level model was tested using MPlus statistical software on a sub-sample of 16,707 nurses drawn from 167 healthcare organizations. Results. Findings were generally supportive of the proposed model. Nurses who reported being psychologically engaged with their jobs reported a lower intention to leave their current job. The perceived availability of developmental opportunities, being able to achieve a good work-life balance and whether nurses' encountered work pressures were also influencing factors on their turnover intentions. However, relationships formed with colleagues and patients displayed comparatively small relationships with turnover intentions. Conclusion. The focus at the local level needs to be on promoting employee engagement by equipping staff with the resources (physical and monetary) and control to enable them to perform their tasks to standards they aspire to and creating a work environment where staff are fully involved in the wider running of their organizations, communicating to staff that patient care is important and the top priority of the organization. © 2012 Blackwell Publishing Ltd.

“I didn’t mean to steal someone else’s words!”:a forensic linguistic approach to detecting intentional plagiarism

The concept of plagiarism is not uncommonly associated with the concept of intellectual property, both for historical and legal reasons: the approach to the ownership of ‘moral’, nonmaterial goods has evolved to the right to individual property, and consequently a need was raised to establish a legal framework to cope with the infringement of those rights. The solution to plagiarism therefore falls most often under two categories: ethical and legal. On the ethical side, education and intercultural studies have addressed plagiarism critically, not only as a means to improve academic ethics policies (PlagiarismAdvice.org, 2008), but mainly to demonstrate that if anything the concept of plagiarism is far from being universal (Howard & Robillard, 2008). Even if differently, Howard (1995) and Scollon (1994, 1995) argued, and Angèlil-Carter (2000) and Pecorari (2008) later emphasised that the concept of plagiarism cannot be studied on the grounds that one definition is clearly understandable by everyone. Scollon (1994, 1995), for example, claimed that authorship attribution is particularly a problem in non-native writing in English, and so did Pecorari (2008) in her comprehensive analysis of academic plagiarism. If among higher education students plagiarism is often a problem of literacy, with prior, conflicting social discourses that may interfere with academic discourse, as Angèlil-Carter (2000) demonstrates, we then have to aver that a distinction should be made between intentional and inadvertent plagiarism: plagiarism should be prosecuted when intentional, but if it is part of the learning process and results from the plagiarist’s unfamiliarity with the text or topic it should be considered ‘positive plagiarism’ (Howard, 1995: 796) and hence not an offense. Determining the intention behind the instances of plagiarism therefore determines the nature of the disciplinary action adopted. Unfortunately, in order to demonstrate the intention to deceive and charge students with accusations of plagiarism, teachers necessarily have to position themselves as ‘plagiarism police’, although it has been argued otherwise (Robillard, 2008). Practice demonstrates that in their daily activities teachers will find themselves being required a command of investigative skills and tools that they most often lack. We thus claim that the ‘intention to deceive’ cannot inevitably be dissociated from plagiarism as a legal issue, even if Garner (2009) asserts that generally plagiarism is immoral but not illegal, and Goldstein (2003) makes the same severance. However, these claims, and the claim that only cases of copyright infringement tend to go to court, have recently been challenged, mainly by forensic linguists, who have been actively involved in cases of plagiarism. Turell (2008), for instance, demonstrated that plagiarism is often connoted with an illegal appropriation of ideas. Previously, she (Turell, 2004) had demonstrated by comparison of four translations of Shakespeare’s Julius Caesar to Spanish that the use of linguistic evidence is able to demonstrate instances of plagiarism. This challenge is also reinforced by practice in international organisations, such as the IEEE, to whom plagiarism potentially has ‘severe ethical and legal consequences’ (IEEE, 2006: 57). What plagiarism definitions used by publishers and organisations have in common – and which the academia usually lacks – is their focus on the legal nature. We speculate that this is due to the relation they intentionally establish with copyright laws, whereas in education the focus tends to shift from the legal to the ethical aspects. However, the number of plagiarism cases taken to court is very small, and jurisprudence is still being developed on the topic. In countries within the Civil Law tradition, Turell (2008) claims, (forensic) linguists are seldom called upon as expert witnesses in cases of plagiarism, either because plagiarists are rarely taken to court or because there is little tradition of accepting linguistic evidence. In spite of the investigative and evidential potential of forensic linguistics to demonstrate the plagiarist’s intention or otherwise, this potential is restricted by the ability to identify a text as being suspect of plagiarism. In an era with such a massive textual production, ‘policing’ plagiarism thus becomes an extraordinarily difficult task without the assistance of plagiarism detection systems. Although plagiarism detection has attracted the attention of computer engineers and software developers for years, a lot of research is still needed. Given the investigative nature of academic plagiarism, plagiarism detection has of necessity to consider not only concepts of education and computational linguistics, but also forensic linguistics. Especially, if intended to counter claims of being a ‘simplistic response’ (Robillard & Howard, 2008). In this paper, we use a corpus of essays written by university students who were accused of plagiarism, to demonstrate that a forensic linguistic analysis of improper paraphrasing in suspect texts has the potential to identify and provide evidence of intention. A linguistic analysis of the corpus texts shows that the plagiarist acts on the paradigmatic axis to replace relevant lexical items with a related word from the same semantic field, i.e. a synonym, a subordinate, a superordinate, etc. In other words, relevant lexical items were replaced with related, but not identical, ones. Additionally, the analysis demonstrates that the word order is often changed intentionally to disguise the borrowing. On the other hand, the linguistic analysis of linking and explanatory verbs (i.e. referencing verbs) and prepositions shows that these have the potential to discriminate instances of ‘patchwriting’ and instances of plagiarism. This research demonstrates that the referencing verbs are borrowed from the original in an attempt to construct the new text cohesively when the plagiarism is inadvertent, and that the plagiarist has made an effort to prevent the reader from identifying the text as plagiarism, when it is intentional. In some of these cases, the referencing elements prove being able to identify direct quotations and thus ‘betray’ and denounce plagiarism. Finally, we demonstrate that a forensic linguistic analysis of these verbs is critical to allow detection software to identify them as proper paraphrasing and not – mistakenly and simplistically – as plagiarism.

Photodynamic therapy with verteporfin for juxtafoveal choroidal neovascularisation secondary to pathological myopia

The treatment of choroidal neovascularisation (CNV) secondary to pathological myopia has presented a number of problems to ophthalmologists over the years, but the advent of photodynamic therapy (PDT) with verteporfin has changed how we manage these patients. Until PDT became available, the use of laser photocoagulation for extra and juxtafoveal lesions had been shown to be effective in the short term in preventing loss of vision, although the risk of regrowth of CNV and undertreatment were well recognised. However, even in apparent successful cases of photocoagulation, laser scar enlargement and creepage into the fovea in the mid-to-long term often occurred with resulting loss of central vision.1 Other options for treatment were very limited with little evidence that other modalities such as transpupillary thermotherapy or submacular surgery and macular transplantation surgery would be successful in highly myopic eyes. The evidence for the role of PDT and verteporfin CNV secondary to pathological myopia comes from the verteporfin in photodynamic therapy (VIP) study that has shown how effective this treatment is in eyes with subfoveal CNV.2, 3 Now in this publication, Lam et al4 from Hong Kong have shown that PDT is also effective in juxtafoveal CNV, with high myopia. They performed a small prospective study of 11 patients of mean age 44.8 years, with 12 months of follow-up. They found that there was a mean improvement of 1.8 lines of LogMAR best-corrected visual acuity (BCVA) at 12 months, with a mean number of 2.3 PDT treatments. The most rapid improvement occurred within the first 3 months of treatment and by 12 months none of the patients had suffered a deterioration in BCVA from baseline. There were no cases of adverse effects from the infusion or laser treatment. For ophthalmologists dealing with patients with CNV secondary to causes other than AMD, this is further evidence of the effectiveness of PDT with verteporfin in maintaining vision. These patients are likely to be younger than those with AMD and are likely to be in active employment and supporting families, and clearly the preservation of best vision possible is imperative in this group. It is therefore encouraging for ophthalmologists in the United Kingdom that the verteporfin in PDT Cohort Study (VPDT Study) includes the ability to treat patients with subfoveal CNV secondary to high myopia if they fulfill National Institute of Clinical Excellence guidelines, and will allow representations to be made on an individual basis for treatment of juxtafoveal lesions.5 For those ophthalmologists used to juggling increased patient expectations with scarce NHS resources, this is promising news and will allow us to offer a better standard of care to our patients.

Entrepreneurial intention and entrepreneurial behaviour:a social psychological perspective

Increasing the supply of entrepreneurs reduces unemployment and accelerates economic growth (Acs, 2006; Audretsch, 2007; Santarelli et el. 2009; Campbell, 1996; Carree & Thurik, 1996). The supply of entrepreneurs depends on the entrepreneurial intention and activity of the people (Kruger & Brazeal, 1994). Existing behavioural theories explain that entrepreneurial activity is an attitude driven process which is mediated by intention and regulated by behavioural control. These theories are: Theory of Planned Behaviour (Ajzen, 1991; 2002, 2012); Entrepreneurial Event Model (Shapiro & Shokol, 1982), and Social Cognitive Theory (Bandura, 1977; 1986; 2012). Meta-analysis of existing behavioural theories in different fields found that the theories are more effective to analyse behavioural intention and habitual behaviour, but less effective to analyse long-term and risky behaviour (McEachan et al., 2011). The objective of this dissertation is to improve entrepreneurship behaviour theory to advance our understanding of the determinants of the entrepreneurial intention and activity. To achieve this objective we asked three compelling questions in our research. These are: Firstly, why do differences exist in entrepreneurship among age groups. Secondly, how can we improve the theory to analyse entrepreneurial intention and behaviour? And, thirdly, is there any relationship between counterfactual or regretful thinking and entrepreneurial intention? We address these three questions in Chapters 2, 3 and 4 of the dissertation. Earlier studies have identified that there is an inverse U shaped relationship between age and entrepreneurship (Parker, 2004; Hart et al., 2004). In our study, we explain the reasons for this inverse U shape (Chapter 2). To analyse the reasons we use Cognitive Life Cycle theory and Disuse theory. We assume that the stage in the life cycle of an individual moderates the influence of opportunity identification and skill to start a business. In our study, we analyse the moderation effect in early stage entrepreneurship and in serial entrepreneurship. In Chapter 3, the limitations of existing psychological theories are discussed, and a competency value theory of entrepreneurship (CVTE) is proposed to overcome the limitations and extend existing theories. We use a ‘weighted competency’ variable instead of a ‘perceived behavioural control’ variable for the theory of planned behaviour (TPB) and self-efficacy variable for social cognitive theory. Weighted competency is the perceived competency ranking assigned by an individual for his total competencies to be an entrepreneur. The proposed theory was tested in a pilot survey in the UK and in a national adult population survey in a South Asian Country. The results show a significant relationship between competencies and entrepreneurial intention, and weighted competencies and entrepreneurial behaviour as per CVTE. To improve the theory further, in Chapter 4, we test the relationship between counterfactual thinking and entrepreneurial intention. Studies in cognitive psychology identify that ‘upward counterfactual thinking’ influences intention and behaviour (Epstude & Rose, 2008; Smallman & Roese, 2009). Upward counterfactual thinking is regretful thinking for missed opportunities of a problem. This study addresses the question of how an individual’s regretful thinking affects his or her future entrepreneurial career intention. To do so, we conducted a study among students in a business school in the UK, and we found that counterfactual thinking modifies the influence of attitude and opportunity identification in entrepreneurial career intention.

Should topical opioid analgesics be regarded as effective and safe when applied to chronic cutaneous lesions?

Objectives: The induction of analgesia for many chronic cutaneous lesions requires treatment with an opioid analgesic. In many patients suffering with these wounds such drugs are either contraindicated or shunned because of their association with death. There are now case reports involving over 100 patients with many different types of chronic superficial wounds, which suggest that the topical application of an opioid in a suitable gel leads to a significant reduction in the level of perceived pain. Key findings: Some work has been undertaken to elucidate the mechanisms by which such a reduction is achieved. To date there have been no proven deleterious effects of such an analgesic system upon wound healing. Although morphine is not absorbed through the intact epidermis, an open wound provides no such barrier and for large wounds drug absorption can be problematic. However, for most chronic cutaneous lesions, where data has been gathered, the blood levels of the drug applied ranges from undetectable to below that required for a systemic effect. Summary If proven, the use of opioids in this way would provide adequate analgesia for a collection of wounds, which are difficult to treat in patients who are often vulnerable. Proof of this concept is now urgently required. © 2011 Royal Pharmaceutical Society.

Using an Infra-red sensor to measure the dynamic behaviour of N2O gas escaping through different sized holes

An anastomosis is a surgical procedure that consists of the connection of two parts of an organ and is commonly required in cases of colorectal cancer. About 80% of the patients diagnosed with this problem require surgery. The malignant tissue located on the gastrointestinal track must be resected and the most common procedure adopted is the anastomosis. Therefore, an anastomotic leak represents a significant problem and increases the duration of hospital stay, which is associated with remedial treatment and recovery, causing, as a result, a negative financial impact. A number of techniques to treat, prevent and even detect an anastomotic leakage are under investigation. However, studies show that these techniques are not always able to prevent an anastomotic leak from occurring. This paper discusses the monitoring of leakage through differently sized and differently positioned leak holes in phantom colons, using physical experiments and a Computational Fluid Dynamics package called FloWorks. © 2011 Taylor & Francis Group.