Medicines optimisation for young people with juvenile arthritis and other long-term conditions:system-level barriers to engagement

To explore the views of pharmacy and rheumatology stakeholders about system-related barriers to medicines optimisation activities with young people with long-term conditions. A three-phase consensus-building study comprising (1) focus groups with community and hospital pharmacists; (2) semi-structured telephone interviews with lay and professional adolescent rheumatology stakeholders and pharmacy policymakers, and (3) multidisciplinary discussion groups with community and hospital pharmacists and rheumatology staff. Qualitative verbatim transcripts from phases 1 and 2 were subjected to framework analysis. Themes from phase 1 underpinned a briefing for phase 2 interviewees. Themes from phases 1 and 2 generated elements of good pharmacy practice and current/future pharmacy roles for ranking in phase 3. Results from phase 3 prioritisation and ranking exercises were captured on self-completion data collection forms, entered into an Excel spreadsheet and subjected to descriptive statistical analysis. Institutional ethical approval was given by Aston University Health and Life Sciences Research Ethics Committee. Four focus groups were conducted with 18 pharmacists across England, Scotland and Wales (7 hospital, 10 community and 1 community/public health). Fifteen stakeholders took part in telephone interviews (3 pharmacist commissioners; 2 pharmacist policymakers; 2 pharmacy staff members (1 community and 1 hospital); 4 rheumatologists; 1 specialist nurse, and 3 lay juvenile arthritis advocates). Twenty-five participants took part in three discussion groups in adolescent rheumatology centres across England and Scotland (9 community pharmacists; 4 hospital pharmacists; 6 rheumatologists; 5 specialist nurses, and 1 physiotherapist). In all phases of the study, system-level issues were acknowledged as barriers to more engagement with young people and families. Community pharmacists in the focus groups reported that opportunities for engaging with young people were low if parents collected prescriptions alone, which was agreed by other stakeholders. Moreover, institutional/company prescription collection policies – an activity largely disallowed for a young person under 16 without an accompanying parent - were identified by hospital and community pharmacists as barriers to open discussion and engagement. Few community pharmacists reported using Medicines Use Review (England/Wales) or Chronic Medication Service (Scotland) as a medicines optimisation activity with young people; many were unsure about consent procedures. Despite these limitations, rheumatology stakeholders ranked highly the potential of pharmacists empowering young people with general health care skills, such as repeat prescription ordering. The pharmacy profession lacks vision for its role in the care of young people with long-term conditions. Pharmacists and rheumatology stakeholders identified system-level barriers to more engagement with young people who take medicines regularly. We acknowledge that the modest number of participants may have had a specific interest and thus bias for the topic, but this underscores their frank admission of the challenges. Professional guidance and policy, practice frameworks and institutional/company policies must promote flexibility for pharmacy staff to recognise and empower young people who are able to give consent and take responsibility for medicines activities. This will increase mutual confidence and trust, and foster pharmacy’s role in teaching general health care skills. In this way, pharmacists will be able to build long-term relationships with young people and families.

Retrieving designs from a sketch using an automated GT coding and classification system

While the retrieval of existing designs to prevent unnecessary duplication of parts is a recognised strategy in the control of design costs the available techniques to achieve this, even in product data management systems, are limited in performance or require large resources. A novel system has been developed based on a new version of an existing coding system (CAMAC) that allows automatic coding of engineering drawings and their subsequent retrieval using a drawing of the desired component as the input. The ability to find designs using a detail drawing rather than textual descriptions is a significant achievement in itself. Previous testing of the system has demonstrated this capability but if a means could be found to find parts from a simple sketch then its practical application would be much more effective. This paper describes the development and testing of such a search capability using a database of over 3000 engineering components.

The use of flow control devices to improve the flow pattern and throughput of sieve trays

Compared to packings trays are more cost effective column internals because they create a large interfacial area for mass transfer by the interaction of the vapour on the liquid. The tray supports a mass of froth or spray which on most trays (including the most widely used sieve trays) is not in any way controlled. The two important results of the gas/liquid interaction are the tray efficiency and the tray throughput or capacity. After many years of practical experience, both may be predicted by empirical correlations, despite the lack of understanding. It is known that the tray efficiency is in part determined by the liquid flow pattern and the throughput by the liquid froth height which in turn depends on the liquid hold-up and vapour velocity. This thesis describes experimental work on sieve trays in an air-water simulator, 2.44 m in diameter. The liquid flow pattern, for flow rates similar to those used in commercial scale distillation, was observed experimentally by direct observation; by water-cooling, to simulate mass transfer; use of potassium permanganate dye to observe areas of longer residence time; and by height of clear liquid measurements across the tray and in the downcomer using manometers. This work presents experiments designed to evaluate flow control devices proposed to improve the gas liquid interaction and hence improve the tray efficiency and throughput. These are (a) the use of intermediate weirs to redirect liquid to the sides of the tray so as to remove slow moving/stagnant liquid and (b) the use of vapour-directing slots designed to use the vapour to cause liquid to be directed towards the outlet weir thus reducing the liquid hold-up at a given rate i.e. increased throughput. This method also has the advantage of removing slow moving/stagnant liquid. In the experiments using intermediate weirs, which were placed in the centre of the tray. it was found that in general the effect of an intermediate weir depends on the depth of liquid downstream of the weir. If the weir is deeper than the downstream depth it will cause the upstream liquid to be deeper than the downstream liquid. If the weir is not as deep as deep as the downstream depth it may have little or no effect on the upstream depth. An intermediate weir placed at an angle to the direction of flow of liquid increases the liquid towards the sides of the tray without causing an increase in liquid hold-up/ froth height. The maximum proportion of liquid caused to flow sideways by the weir is between 5% and 10%. Experimental work using vapour-directing slots on a rectangular sieve tray has shown that the horizontal momentum that is imparted to the liquid is dependent upon the size of the slot. If too much momentum is transferred to the liquid it causes hydraulic jumps to occur at the mouth of the slot coupled with liquid being entrained, The use of slots also helps to eliminate the hydraulic gradient across sieve trays and provides a more uniform froth height on the tray. By comparing the results obtained of the tray and point efficiencies, it is shown that a slotted tray reduces both values by approximately 10%. This reduction is due to the fact that with a slotted tray the liquid has a reduced residence time Ion the tray coupled also with the fact that large size bubbles are passing through the slots. The effectiveness of using vapour-directing slots on a full circular tray was investigated by using dye to completely colour the biphase. The removal of the dye by clear liquid entering the tray was monitored using an overhead camera. Results obtained show that the slots are successful in their aim of reducing slow moving liquid from the sides of the tray, The net effect of this is an increase in tray efficiency. Measurements of slot vapour-velocity found it to be approximately equal to the hole velocity.

Bioreaction and separation in batch chromatographic columns

The objective of this work has been to study the behaviour and performance of a batch chromatographic column under simultaneous bioreaction and separation conditions for several carbohydrate feedstocks. Four bioreactions were chosen, namely the hydrolysis of sucrose to glucose and fructose using the enzyme invertase, the hydrolysis of inulin to fructose and glucose using inulinase, the hydrolysis of lactose to glucose and galactose using lactase and the isomerization of glucose to fructose using glucose isomerase. The chromatographic columns employed were jacketed glass columns ranging from 1 m to 2 m long and the internal diameter ranging from 0.97 cm to 1.97 cm. The stationary phase used was a cation exchange resin (PUROLITE PCR-833) in the Ca2+ form for the hydrolysis and the Mg2+ form for the isomerization reactions. The mobile phase used was a diluted enzyme solution which was continuously pumped through the chromatographic bed. The substrate was injected at the top of the bed as a pulse. The effect of the parameters pulse size, the amount of substrate solution introduced into the system corresponding to a percentage of the total empty column volume (% TECV), pulse concentration, eluent flowrate and the enzyme activity of the eluent were investigated. For the system sucrose-invertase complete conversions of substrate were achieved for pulse sizes and pulse concentrations of up to 20% TECV and 60% w/v, respectively. Products with purity above 90% were obtained. The enzyme consumption was 45% of the amount theoretically required to produce the same amount of product as in a conventional batch reactor. A value of 27 kg sucrose/m3 resin/h for the throughput of the system was achieved. The systematic investigation of the factors affecting the performance of the batch chromatographic bioreactor-separator was carried out by employing a factorial experimental procedure. The main factors affecting the performance of the system were the flowrate and enzyme activity. For the system inulin-inulinase total conversions were also obtained for pulses sizes of up to 20 % TECV and a pulse concentration of 10 % w/v. Fructose rich fractions with 100 % purity and representing up to 99.4 % of the total fructose generated were obtained with an enzyme consumption of 32 % of the amount theoretically required to produce the same amount of product in a conventional batch reactor. The hydrolysis of lactose by lactase was studied in the glass columns and also in an SCCR-S unit adapted for batch operation, in co-operation with Dr. Shieh, a fellow researcher in the Chemical Engineering and Applied Chemistry Department at Aston University. By operating at up to 30 % w/v lactose feed concentrations complete conversions were obtained and the purities of the products generated were above 90%. An enzyme consumption of 48 % of the amount theoretically required to produce the same amount of product in a conventional batch reactor was achieved. On working with the system glucose-glucose isomerase, which is a reversible reaction, the separation obtained with the stationary phase conditioned in the magnesium form was very poor although the conversion obtained was compatible with those for conventional batch reactors. By working with a mixed pulse of enzyme and substrate, up to 82.5 % of the fructose generated with a purity of 100 % was obtained. The mathematical modelling and computer simulation of the batch chromatographic bioreaction-separation has been performed on a personal computer. A finite difference method was used to solve the partial differential equations and the simulation results showed good agreement with the experimental results.

Fish farm effluent control and the development of an expert system

In recent years, freshwater fish farmers have come under increasing pressure from the Water Authorities to control the quality of their farm effluents. This project aimed to investigate methods of treating aquacultural effluent in an efficient and cost-effective manner, and to incorporate the knowledge gained into an Expert System which could then be used in an advice service to farmers. From the results of this research it was established that sedimentation and the use of low pollution diets are the only cost effective methods of controlling the quality of fish farm effluents. Settlement has been extensively investigated and it was found that the removal of suspended solids in a settlement pond is only likely to be effective if the inlet solids concentration is in excess of 8 mg/litre. The probability of good settlement can be enhanced by keeping the ratio of length/retention time (a form of mean fluid velocity) below 4.0 metres/minute. The removal of BOD requires inlet solids concentrations in excess of 20 mg/litre to be effective, and this is seldom attained on commercial fish farms. Settlement, generally, does not remove appreciable quantities of ammonia from effluents, but algae can absorb ammonia by nutrient uptake under certain conditions. The use of low pollution, high performance diets gives pollutant yields which are low when compared with published figures obtained by many previous workers. Two Expert Systems were constructed, both of which diagnose possible causes of poor effluent quality on fish farms and suggest solutions. The first system uses knowledge gained from a literature review and the second employs the knowledge obtained from this project's experimental work. Consent details for over 100 fish farms were obtained from the public registers kept by the Water Authorities. Large variations in policy from one Authority to the next were found. These data have been compiled in a computer file for ease of comparison.

Bandwidth management of WiMAX systems and performance modeling

WiMAX has been introduced as a competitive alternative for metropolitan broadband wireless access technologies. It is connection oriented and it can provide very high data rates, large service coverage, and flexible quality of services (QoS). Due to the large number of connections and flexible QoS supported by WiMAX, the uplink access in WiMAX networks is very challenging since the medium access control (MAC) protocol must efficiently manage the bandwidth and related channel allocations. In this paper, we propose and investigate a cost-effective WiMAX bandwidth management scheme, named the WiMAX partial sharing scheme (WPSS), in order to provide good QoS while achieving better bandwidth utilization and network throughput. The proposed bandwidth management scheme is compared with a simple but inefficient scheme, named the WiMAX complete sharing scheme (WCPS). A maximum entropy (ME) based analytical model (MEAM) is proposed for the performance evaluation of the two bandwidth management schemes. The reason for using MEAM for the performance evaluation is that MEAM can efficiently model a large-scale system in which the number of stations or connections is generally very high, while the traditional simulation and analytical (e.g., Markov models) approaches cannot perform well due to the high computation complexity. We model the bandwidth management scheme as a queuing network model (QNM) that consists of interacting multiclass queues for different service classes. Closed form expressions for the state and blocking probability distributions are derived for those schemes. Simulation results verify the MEAM numerical results and show that WPSS can significantly improve the network's performance compared to WCPS.

Visual signs and symptoms of multiple system atrophy

Multiple system atrophy (MSA) is a rare movement disorder and a member of the 'parkinsonian syndromes', which also include Parkinson's disease (PD), progressive supranuclear palsy (PSP), dementia with Lewy bodies (DLB) and corticobasal degeneration (CBD). Multiple system atrophy is a complex syndrome, in which patients exhibit a variety of signs and symptoms, including parkinsonism, ataxia and autonomic dysfunction. It can be difficult to separate MSA from the other parkinsonian syndromes but if ocular signs and symptoms are present, they may aid differential diagnosis. Typical ocular features of MSA include blepharospasm, excessive square-wave jerks, mild to moderate hypometria of saccades, impaired vestibular-ocular reflex (VOR), nystagmus and impaired event-related evoked potentials. Less typical features include slowing of saccadic eye movements, the presence of vertical gaze palsy, visual hallucinations and an impaired electroretinogram (ERG). Aspects of primary vision such as visual acuity, colour vision or visual fields are usually unaffected. Management of the disease to deal with problems of walking, movement, daily tasks and speech problems is important in MSA. Optometrists can work in collaboration with the patient and health-care providers to identify and manage the patient's visual deficits. A more specific role for the optometrist is to correct vision to prevent falls and to monitor the anterior eye to prevent dry eye and control blepharospasm.