Effectiveness and uptake of screening programmes for coronary heart disease and diabetes:a realist review of design components used in interventions

Objective - To evaluate behavioural components and strategies associated with increased uptake and effectiveness of screening for coronary heart disease and diabetes with an implementation science focus. Design - Realist review. Data sources - PubMed, Web of Knowledge, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register and reference chaining. Searches limited to English language studies published since 1990. Eligibility criteria - Eligible studies evaluated interventions designed to increase the uptake of cardiovascular disease (CVD) and diabetes screening and examined behavioural and/or strategic designs. Studies were excluded if they evaluated changes in risk factors or cost-effectiveness only. Results - In 12 eligible studies, several different intervention designs and evidence-based strategies were evaluated. Salient themes were effects of feedback on behaviour change or benefits of health dialogues over simple feedback. Studies provide mixed evidence about the benefits of these intervention constituents, which are suggested to be situation and design specific, broadly supporting their use, but highlighting concerns about the fidelity of intervention delivery, raising implementation science issues. Three studies examined the effects of informed choice or loss versus gain frame invitations, finding no effect on screening uptake but highlighting opportunistic screening as being more successful for recruiting higher CVD and diabetes risk patients than an invitation letter, with no differences in outcomes once recruited. Two studies examined differences between attenders and non-attenders, finding higher risk factors among non-attenders and higher diagnosed CVD and diabetes among those who later dropped out of longitudinal studies. Conclusions - If the risk and prevalence of these diseases are to be reduced, interventions must take into account what we know about effective health behaviour change mechanisms, monitor delivery by trained professionals and examine the possibility of tailoring programmes according to contexts such as risk level to reach those most in need. Further research is needed to determine the best strategies for lifelong approaches to screening.

Public sector investment appraisal:the place of flexibility in the decision making process

This thesis reviews the main methodological developments in public sector investment appraisal and finds growing evidence that appraisal techniques are not fulfilling their earlier promise. It is suggested that an important reason for this failure lies in the inability of these techniques to handle uncertainty except in a highly circumscribed fashion. It is argued that a more fruitful approach is to strive for flexibility. Investment projects should be formulated with a view to making them responsive to a wide range of possible future events, rather than embodying a solution which is optimal for one configuration of circumstances only. The distinction drawn in economics between the short and the long run is used to examine the nature of flexibility. The concept of long run flexibility is applied to the pre-investment range of choice open to the decisionmaker. It is demonstrated that flexibility is reduced at a very early stage of decisionmaking by the conventional system of appraisal which evaluates only a small number of options. The pre-appraisal filtering process is considered further in relation to decisionmaking models. It is argued that for public sector projects the narrowing down of options is best understood in relation to an amended mixed scanning model which places importance on the process by which the 'national interest ' is determined. Short run flexibility deals with operational characteristics, the degree to which particular projects may respond to changing demands when the basic investment is already in place. The tension between flexibility and cost is noted. A short case study on the choice of electricity generating plant is presented. The thesis concludes with a brief examination of the approaches used by successive British governments to public sector investment, particularly in relation to the nationalised industries

Strategy as practice:recursiveness, adaptation, and practices-in-use

In this article, a social theory framework is developed to explain the common themes of recursive and adaptive practice underpinning the existing strategic management literature. In practice, there is a coexistent tension between recursive and adaptive forms of strategic action that spans multiple levels from macro-institutional and competitive contexts to within-firm levels of analysis to individual cognition. This tension may be better understood by examining how management practices are used to put strategy into practice. Such practices span multiple levels of context and are adaptable to their circumstances of use, serving to highlight both general characteristics and localized idiosyncrasies of strategy as practice. The article develops the concept of management practices-in-use into a research agenda and nine broad research questions that may be used to investigate empirically strategy as practice.

Flexibility in large scale projects

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Greater CD8+ TCR heterogeneity and functional flexibility in HIV-2 compared to HIV-1 infection

Virus-specific CD8+ T cells are known to play an important role in the control of HIV infection. In this study we investigated whether there may be qualitative differences in the CD8+ T cell response in HIV-1- and HIV-2-infected individuals that contribute to the relatively efficient control of the latter infection. A molecular comparison of global TCR heterogeneity showed a more oligoclonal pattern of CD8 cells in HIV-1- than HIV-2-infected patients. This was reflected in restricted and conserved TCR usage by CD8+ T cells recognizing individual HLA-A2- and HLA-B57-restricted viral epitopes in HIV-1, with limited plasticity in their response to amino acid substitutions within these epitopes. The more diverse TCR usage observed for HIV-2-specific CD8 T cells was associated with an enhanced potential for CD8+ expansion and IFN- production on cross-recognition of variant epitopes. Our data suggest a mechanism that could account for any possible cross-protection that may be mediated by HIV-2-specific CD8+ T cells against HIV-1 infection. Furthermore, they have implications for HIV vaccine development, demonstrating an association between a polyclonal, virus-specific CD8+ T cell response and an enhanced capacity to tolerate substitutions within T cell epitopes.

Information systems design for the community health services

This system is concerned with the design and implementation of a community health information system which fulfils some of the local needs of fourteen nursing and para-medical professions in a district health authority, whilst satisfying the statutory requirements of the NHS Korner steering group for those professions. A national survey of community health computer applications, documented in the form of an applications register, shows the need for such a system. A series of general requirements for an informations systems design methodology are identified, together with specific requirements for this problem situation. A number of existing methodologies are reviewed, but none of these were appropriate for this application. Some existing approaches, tools and techniques are used to define a more suitable methodology. It is unreasonable to rely on one single general methodology for all types of application development. There is a need for pragmatism, adaptation and flexibility. In this research, participation in the development stages by those who will eventually use the system was thought desirable. This was achieved by forming a representative design group. Results would seem to show a highly favourable response from users to this participation which contributed to the overall success of the system implemented. A prototype was developed for the chiropody and school nursing staff groups of Darlington health authority, and evaluations show that a significant number of the problems and objectives of those groups have been successfully addressed; the value of community health information has been increased; and information has been successfully fed back to staff and better utilised.

Some aspects of system design for production management in the rolling-mill industry

Case studies in copper-alloy rolling mill companies showed that existing planning systems suffer from numerous shortcomings. Where computerised systems are in use, these tend to simply emulate older manual systems and still rely heavily on modification by experienced planners on the shopfloor. As the size and number of orders increase, the task of process planners, while seeking to optimise the manufacturing objectives and keep within the production constraints, becomes extremely complicated because of the number of options for mixing or splitting the orders into batches. This thesis develops a modular approach to computerisation of the production management and planning functions. The full functional specification of each module is discussed, together with practical problems associated with their phased implementation. By adapting the Distributed Bill of Material concept from Material Requirements Planning (MRP) philosophy, the production routes generated by the planning system are broken down to identify the rolling stages required. Then to optimise the use of material at each rolling stage, the system generates an optimal cutting pattern using a new algorithm that produces practical solutions to the cutting stock problem. It is shown that the proposed system can be accommodated on a micro-computer, which brings it into the reach of typical companies in the copper-alloy rolling industry, where profit margins are traditionally low and the cost of widespread use of mainframe computers would be prohibitive.

Ontologies for crisis management:a review of state of the art in ontology design and usability

The growing use of a variety of information systems in crisis management both by non-governmental organizations (NGOs) and emergency management agencies makes the challenges of information sharing and interoperability increasingly important. The use of semantic web technologies is a growing area and is a technology stack specifically suited to these challenges. This paper presents a review of ontologies, vocabularies and taxonomies that are useful in crisis management systems. We identify the different subject areas relevant to crisis management based on a review of the literature. The different ontologies and vocabularies available are analysed in terms of their coverage, design and usability. We also consider the use cases for which they were designed and the degree to which they follow a variety of standards. While providing comprehensive ontologies for the crisis domain is not feasible or desirable there is considerable scope to develop ontologies for the subject areas not currently covered and for the purposes of interoperability.

Implications of high power losses in IR femtosecond laser inscribed fibre Bragg gratings

We report on high power issues related to the reliability of fibre Bragg gratings inscribed with an infrared femtosecond laser using the point-by-point writing method. Conventionally, fibre Bragg gratings have usually been written in fibres using ultraviolet light, either holographically or using a phase mask. Since the coating is highly absorbing in the UV, this process normally requires that the protective polymer coating is stripped prior to inscription, with the fibre then being recoated. This results in a time consuming fabrication process that, unless great care is taken, can lead to fibre strength degradation, due to the presence of surface damage. The recent development of FBG inscription using NIR femtosecond lasers has eliminated the requirement for the stripping of the coating. At the same time the ability to write gratings point-by-point offers the potential for great flexibility in the grating design. There is, however, a requirement for reliability testing of these gratings, particularly for use in telecommunications systems where high powers are increasingly being used in long-haul transmission systems making use of Raman amplification. We report on a study of such gratings which has revealed the presence of broad spectrum power losses. When high powers are used, even at wavelengths far removed from the Bragg condition, these losses produce an increase in the fibre temperature due to absorption in the coating. We have monitored this temperature rise using the wavelength shift in the grating itself. At power levels of a few watts, various temperature increases were experienced ranging from a few degrees up to the point where the buffer completely melts off the fibre at the grating site. Further investigations are currently under way to study the optical loss mechanisms in order to optimise the inscription mechanism and minimise such losses.

In silico adjuvant design and validation

Adjuvants are substances that boost the protective immune response to vaccine antigens. The majority of known adjuvants have been identified through the use of empirical approaches. Our aim was to identify novel adjuvants with well-defined cellular and molecular mechanisms by combining a knowledge of immunoregulatory mechanisms with an in silico approach. CD4 + CD25 + FoxP3 + regulatory T cells (Tregs) inhibit the protective immune responses to vaccines by suppressing the activation of antigen presenting cells such as dendritic cells (DCs). In this chapter, we describe the identification and functional validation of small molecule antagonists to CCR4, a chemokine receptor expressed on Tregs. The CCR4 binds the chemokines CCL22 and CCL17 that are produced in large amounts by activated innate cells including DCs. In silico identified small molecule CCR4 antagonists inhibited the migration of Tregs both in vitro and in vivo and when combined with vaccine antigens, significantly enhanced protective immune responses in experimental models.

Strain distributionand electronic property modifications in Si/Ge axial nanowires hetrostructures

Molecular dynamics simulations were carried out for Si/Ge axial nanowire heterostructures using modified effective atom method (MEAM) potentials. A Si–Ge MEAM interatomic cross potential was developed based on available experimental data and was used for these studies. The atomic distortions and strain distributions near the Si/Ge interfaces are predicted for nanowires with their axes oriented along the [111] direction. The cases of 10 and 25 nm diameter Si/Ge biwires and of 25 nm diameter Si/Ge/Si axial heterostructures with the Ge disk 1 nm thick were studied. Substantial distortions in the height of the atoms adjacent to the interface were found for the biwires but not for the Ge disks. Strains as high as 3.5% were found for the Ge disk and values of 2%–2.5% were found at the Si and Ge interfacial layers in the biwires. Deformation potential theory was used to estimate the influence of the strains on the band gap, and reductions in band gap to as small as 40% of bulk values are predicted for the Ge disks. The localized regions of increased strain and resulting energy minima were also found within the Si/Ge biwire interfaces with the larger effects on the Ge side of the interface. The regions of strain maxima near and within the interfaces are anticipated to be useful for tailoring band gaps and producing quantum confinement of carriers. These results suggest that nanowire heterostructures provide greater design flexibility in band structure modification than is possible with planar layer growth.

A structural method for the design of fault tolerant distributed control systems

Distributed digital control systems provide alternatives to conventional, centralised digital control systems. Typically, a modern distributed control system will comprise a multi-processor or network of processors, a communications network, an associated set of sensors and actuators, and the systems and applications software. This thesis addresses the problem of how to design robust decentralised control systems, such as those used to control event-driven, real-time processes in time-critical environments. Emphasis is placed on studying the dynamical behaviour of a system and identifying ways of partitioning the system so that it may be controlled in a distributed manner. A structural partitioning technique is adopted which makes use of natural physical sub-processes in the system, which are then mapped into the software processes to control the system. However, communications are required between the processes because of the disjoint nature of the distributed (i.e. partitioned) state of the physical system. The structural partitioning technique, and recent developments in the theory of potential controllability and observability of a system, are the basis for the design of controllers. In particular, the method is used to derive a decentralised estimate of the state vector for a continuous-time system. The work is also extended to derive a distributed estimate for a discrete-time system. Emphasis is also given to the role of communications in the distributed control of processes and to the partitioning technique necessary to design distributed and decentralised systems with resilient structures. A method is presented for the systematic identification of necessary communications for distributed control. It is also shwon that the structural partitions can be used directly in the design of software fault tolerant concurrent controllers. In particular, the structural partition can be used to identify the boundary of the conversation which can be used to protect a specific part of the system. In addition, for certain classes of system, the partitions can be used to identify processes which may be dynamically reconfigured in the event of a fault. These methods should be of use in the design of robust distributed systems.

Representation and parameterisation issues in genetic algorithms

A multi-chromosome GA (Multi-GA) was developed, based upon concepts from the natural world, allowing improved flexibility in a number of areas including representation, genetic operators, their parameter rates and real world multi-dimensional applications. A series of experiments were conducted, comparing the performance of the Multi-GA to a traditional GA on a number of recognised and increasingly complex test optimisation surfaces, with promising results. Further experiments demonstrated the Multi-GA's flexibility through the use of non-binary chromosome representations and its applicability to dynamic parameterisation. A number of alternative and new methods of dynamic parameterisation were investigated, in addition to a new non-binary 'Quotient crossover' mechanism. Finally, the Multi-GA was applied to two real world problems, demonstrating its ability to handle mixed type chromosomes within an individual, the limited use of a chromosome level fitness function, the introduction of new genetic operators for structural self-adaptation and its viability as a serious real world analysis tool. The first problem involved optimum placement of computers within a building, allowing the Multi-GA to use multiple chromosomes with different type representations and different operators in a single individual. The second problem, commonly associated with Geographical Information Systems (GIS), required a spatial analysis location of the optimum number and distribution of retail sites over two different population grids. In applying the Multi-GA, two new genetic operators (addition and deletion) were developed and explored, resulting in the definition of a mechanism for self-modification of genetic material within the Multi-GA structure and a study of this behaviour.