Targets and self monitoring in hypertension: randomised controlled trial and cost effectiveness analysis

OBJECTIVES: To assess whether blood pressure control in primary care could be improved with the use of patient held targets and self monitoring in a practice setting, and to assess the impact of these on health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences, and costs. DESIGN: Randomised controlled trial. SETTING: Eight general practices in south Birmingham. PARTICIPANTS: 441 people receiving treatment in primary care for hypertension but not controlled below the target of < 140/85 mm Hg. INTERVENTIONS: Patients in the intervention group received treatment targets along with facilities to measure their own blood pressure at their general practice; they were also asked to visit their general practitioner or practice nurse if their blood pressure was repeatedly above the target level. Patients in the control group received usual care (blood pressure monitoring by their practice). MAIN OUTCOME MEASURES: Primary outcome: change in systolic blood pressure at six months and one year in both intervention and control groups. Secondary outcomes: change in health behaviours, anxiety, prescribed antihypertensive drugs, patients' preferences of method of blood pressure monitoring, and costs. RESULTS: 400 (91%) patients attended follow up at one year. Systolic blood pressure in the intervention group had significantly reduced after six months (mean difference 4.3 mm Hg (95% confidence interval 0.8 mm Hg to 7.9 mm Hg)) but not after one year (mean difference 2.7 mm Hg (- 1.2 mm Hg to 6.6 mm Hg)). No overall difference was found in diastolic blood pressure, anxiety, health behaviours, or number of prescribed drugs. Patients who self monitored lost more weight than controls (as evidenced by a drop in body mass index), rated self monitoring above monitoring by a doctor or nurse, and consulted less often. Overall, self monitoring did not cost significantly more than usual care (251 pounds sterling (437 dollars; 364 euros) (95% confidence interval 233 pounds sterling to 275 pounds sterling) versus 240 pounds sterling (217 pounds sterling to 263 pounds sterling). CONCLUSIONS: Practice based self monitoring resulted in small but significant improvements of blood pressure at six months, which were not sustained after a year. Self monitoring was well received by patients, anxiety did not increase, and there was no appreciable additional cost. Practice based self monitoring is feasible and results in blood pressure control that is similar to that in usual care.

Impact of just-in-time on job content, employee attitudes and well-being:a longitudinal study

Just-in-time (JIT) production systems are increasingly being seen as a vital way for manufacturing organizations to enhance their competitiveness. A number of commentators have suggested that this will simplify jobs and reduce employee well-being. This paper presents a conceptual framework for interpreting the effects of JIT and reports findings from a study of the impact of JIT on the content of workers'jobs and on job satisfaction and psychological strain. The introduction of JIT led to a reduction in control over work timing, an increase in production pressure, and a drop in job satisfaction. Contrary to claims in the literature, no changes were found in control over work methods, other aspects of cognitive demands and skill use, and in psychological strain. The study shows that JIT can be implemented without radical changes in job content or adverse impact in terms of employee strain, and the implications of these findings are discussed.

Structure-reactivity correlations in the selective aerobic oxidation of cinnamyl alcohol:in situ XAFS

The structural evolution of a Pd/C catalyst during the liquid phase selective aerobic oxidation of cinnamyl alcohol has been followed by in situ XAFS and XPS. The fresh catalyst comprised highly dispersed, heavily oxidised Pd particles. Cinnamyl alcohol oxidation resulted in the rapid reduction of surface palladium oxide and a small degree of concomitant particle growth. These structural changes coincided with a large drop in catalytic activity. Prereduced Pd/C exhibited a significantly lower initial oxidation rate demonstrating the importance of surface metal oxide in effecting catalytic oxidation. Use of a Pd black model system confirmed that the oxide→metal transformation was the cause, and not result, of catalyst deactivation.

Reactive processing of polymers:melt grafting of glycidyl methacrylate on ethylene propylene copolymer in the presence of a coagent

Glycidyl methacrylate (GMA) was grafted on ethylene-propylene copolymer during melt processing with peroxide initiation in the presence and absence of a more reactive comonomer (coagent), trimethylolpropane triacrylate (Tris). The characteristics of the grafting systems in terms of the grafting reaction yield and the nature and extent of the competing side reactions were examined. The homopolymers of GMA (Poly-GMA) and Tris (Poly-Tris) and the GMA-Tris copolymer (GMA-co-Tris) were synthesized and characterized. In the absence of the coagent, high levels of poly-GMA, which constituted the major competing reaction, was formed, giving rise to low GMA grafting levels. Further, this grafting system resulted in a high extent of gel formation and polymer crosslinking due to the high levels of peroxide needed to achieve optimum GMA grafting and a consequent large drop in the melt index (increased viscosity) of the polymer. In the presence of the coagent, however, the grafting system required much lower peroxide concentration, by almost an order of magnitude, to achieve the optimum grafting yield. The coagent-containing GMA-grafting system has also resulted in a drastic reduction in the extent of all competing reactions, and in particular, the GMA homopolymerization, leading to improved GMA grafting efficiency with no detectable gel or crosslinking. The mechanisms of the grafting reactions, in the presence and absence of Tris, are proposed.

Relationship between changes in postprandial glucagon, patient characteristics, and response to lixisenatide as add-on to oral antidiabetics

Background and aims: Lixisenatide, a once-daily prandial glucagon-like peptide-1 receptor agonist, reduces postprandial (PP) glycaemic excursions and HbA 1c . We report an exploratory analysis of the GetGoal-M and S trials in patients with type 2 diabetes mellitus (T2DM) with different changes in PP glucagon levels in response to lixisenatide treatment. Materials and methods: Patients (n=423) were stratified by their change in 2 hour PP glucagon level between baseline evaluation and Week 24 of treat - ment with lixisenatide as add-on to oral antidiabetics (OADs) into groups of Greater Change (GC; n=213) or Smaller Change (SC; n=210) in plasma glucagon levels (median change -23.57 ng/L). ANOVA and Chi-squared tests were used for the comparison of continuous and categorical variables, respec - tively. Baseline and endpoint continuous measurements in each group were compared using paired t -tests. Results: Mean change from baseline in 2 hour PP glucagon levels for the GC vs SC groups was -47.19 vs -0.59 ng/L (p<0.0001), respectively. Patients in the GC group had a shorter mean duration of diabetes (7.3 vs 9.0 years; p=0.0036) and lesser OAD use (4.5 vs 5.7 years; p=0.0092) than those in the SC group. Patients in the GC group had a greater mean reduction in HbA 1c (-1.10 vs -0.67%; p<0.0001), fasting plasma glucose (FPG; -25.20 vs -9.30 mg/dL [p<0.0001]), PP plasma glucose (PPG; -129.40 vs -78.22 mg/dL [p<0.0001]), and a greater drop in weight (-2.27 vs -1.17 kg; p=0.0002) and body mass index (-0.84 vs -0.44 kg/m 2 ; p=0.0002) than those in the SC group. More patients in the GC group also achieved composite endpoints, including HbA 1c <7% with no symptomatic hypoglycaemia and no weight gain (40.38 vs 19.52%; p<0.0001), than in the SC group. Conclusion: Greater reductions in PP glucagon associated with lixisenatide as add-on to OADs in patients with T2DM are also associated with greater reductions in HbA1c, FPG, PPG, and greater weight loss, highlighting the importance of glucagon suppression on therapeutic response. Clinical Trial Registration Number: NCT00712673; NCT00713830 Supported by: Sanof

S100P dissociates myosin IIA filaments and focal adhesion sites to reduce cell adhesion and enhance cell migration

S100 proteins promote cancer cell migration and metastasis. To investigate their roles in the process of migration we have constructed inducible systems for S100P in rat mammary and human HeLa cells that show a linear relationship between its intracellular levels and cell migration. S100P, like S100A4, differentially interacts with the isoforms of nonmuscle myosin II (NMIIA, K(d) = 0.5 µm; IIB, K(d) = 8 µm; IIC, K(d) = 1.0 µm). Accordingly, S100P dissociates NMIIA and IIC filaments but not IIB in vitro. NMIIA knockdown increases migration in non-induced cells and there is no further increase upon induction of S100P, whereas NMIIB knockdown reduces cell migration whether or not S100P is induced. NMIIC knockdown does not affect S100P-enhanced cell migration. Further study shows that NMIIA physically interacts with S100P in living cells. In the cytoplasm, S100P occurs in discrete nodules along NMIIA-containing filaments. Induction of S100P causes more peripheral distribution of NMIIA filaments. This change is paralleled by a significant drop in vinculin-containing, actin-terminating focal adhesion sites (FAS) per cell. The induction of S100P, consequently, causes significant reduction in cellular adhesion. Addition of a focal adhesion kinase (FAK) inhibitor reduces disassembly of FAS and thereby suppresses S100P-enhanced cell migration. In conclusion, this work has demonstrated a mechanism whereby the S100P-induced dissociation of NMIIA filaments leads to a weakening of FAS, reduced cell adhesion, and enhanced cell migration, the first major step in the metastatic cascade.

Feasibility of a solar panel-powered liquid desiccant cooling system for greenhouses

To investigate the technical feasibility of a novel cooling system for commercial greenhouses, knowledge of the state of the art in greenhouse cooling is required. An extensive literature review was carried out that highlighted the physical processes of greenhouse cooling and showed the limitations of the conventional technology. The proposed cooling system utilises liquid desiccant technology; hence knowledge of liquid desiccant cooling is also a prerequisite before designing such a system. Extensive literature reviews on solar liquid desiccant regenerators and desiccators, which are essential parts of liquid desiccant cooling systems, were carried out to identify their advantages and disadvantages. In response to the findings, a regenerator and a desiccator were designed and constructed in lab. An important factor of liquid desiccant cooling is the choice of liquid desiccant itself. The hygroscopicity of the liquid desiccant affects the performance of the system. Bitterns, which are magnesium-rich brines derived from seawater, are proposed as an alternative liquid desiccant for cooling greenhouses. A thorough experimental and theoretical study was carried out in order to determine the properties of concentrated bitterns. It was concluded that their properties resemble pure magnesium chloride solutions. Therefore, magnesium chloride solution was used in laboratory experiments to assess the performance of the regenerator and the desiccator. To predict the whole system performance, the physical processes of heat and mass transfer were modelled using gPROMS® advanced process modelling software. The model was validated against the experimental results. Consequently it was used to model a commercials-scale greenhouse in several hot coastal areas in the tropics and sub-tropics. These case studies show that the system, when compared to evaporative cooling, achieves 3oC-5.6oC temperature drop inside the greenhouse in hot and humid places (RH>70%) and 2oC-4oC temperature drop in hot and dry places (50%

Development of a novel magnetic resonance imaging contrast agent for pressure measurements using lipid-coated microbubbles

The aim of this study was to prepare gas-filled lipid-coated microbubbles as potential MRI contrast agents for imaging of fluid pressure. Air-filled microbubbles were produced with phospholipid 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC) in the presence or absence of cholesterol and/or polyethylene-glycol distearate (PEG-distearate). Microbubbles were also prepared containing a fluorinated phospholipid, perfluoroalkylated glycerol-phosphatidylcholine, F-GPC shells encompassing perfluorohexane-saturated nitrogen gas. These microbubbles were evaluated in terms of physico-chemical characteristics such as size and stability. In parallel to these studies, DSPC microbubbles were also formulated containing nitrogen (N2) gas and compared to air-filled microbubbles. By preventing advection, signal drifts were used to assess their stability. DSPC microbubbles were found to have a drift of 20% signal change per bar of applied pressure in contrast to the F-GPC microbubbles which are considerably more stable with a lower drift of 5% signal change per bar of applied pressure. By increasing the pressure of the system and monitoring the MR signal intensity, the point at which the majority of the microbubbles have been damaged was determined. For the DSPC microbubbles this occurs at 1.3 bar whilst the F-GPC microbubbles withstand pressures up to 2.6 bar. For the comparison between air-filled and N2-filled microbubbles, the MRI sensitivity is assessed by cycling the pressure of the system and monitoring the MR signal intensity. It was found that the sensitivity exhibited by the N2-filled microbubbles remained constant, whilst the air-filled microbubbles demonstrated a continuous drop in sensitivity due to continuous bubble damage.

Flowback of solids through distribution plates of gas fluidized beds and associated phenomena

This work is concerned with a study of certain phenomena related to the performance and design of distributors in gas fluidized beds with particular regard to flowback of solid particles. The work to be described is divided into two parts. I. In Part one, a review of published material pertaining to distribution plates, including details from the patent specifications, has been prepared. After a chapter on the determination of the incipient fluidizing velocity, the following aspects of multi-orifice distributor plates in gas fluidized beds have been studied: (i) The effect of the distributor on bubble formation related to the way in which even distribution of bubbles on the top surface of the fluidized bed is obtained, e.g. the desirable pressure drop ratio ?PD/?PB for the even distribution of gas across the bed. Ratios of distributor pressure drop ?PD to bed pressure drop at which stable fluidization occurs show reasonable agreement with industrial practice. There is evidence that larger diameter beds tend to be less stable than smaller diameter beds when these are operated with shallow beds. Experiments show that in the presence of the bed the distributor pressure drop is reduced relative to the pressure drop without the bed, and this pressure drop in the former condition is regarded as the appropriate parameter for the design of the distributor. (ii) Experimental measurements of bubble distribution at the surface has been used to indicate maldistribution within the bed. Maldistribution is more likely at low gas flow rates and with distributors having large fractional free area characteristics (i.e. with distributors having low pressure drops). Bubble sizes obtained from this study, as well as those of others, have been successfully correlated. The correlation produced implies the existence of a bubble at the surface of an orifice and its growth by the addition of excess gas from the fluidized bed. (iii) For a given solid system, the amount of defluidized particles stagnating on the distributor plate is influenced by the orifice spacing, bed diameter and gas flow rate, but independent of the initial bed height and the way the orifices are arranged on the distributor plate. II. In Part two, solids flowback through single and multi-orifice distributors in two-dimensional and cylindrical beds of solids fluidized with air has been investigated. Distributors equipped with long cylindrical nozzles have also been included in the study. An equation for the prediction of free flowback of solids through multi-orifice distributors has been derived. Under fluidized conditions two regimes of flowback have been differentiated, namely Jumping and weeping. Data in the weeping regime have been successfully correlated. The limiting gas velocity through the distributor orifices at which flowback is completely excluded is found to be indepnndent of bed height, but a function of distributor design and physical properties of gas and solid used. A criterion for the prediction of this velocity has been established. The decisive advantage of increasing the distributor thickness or using nozzles to minimize solids flowback in fluidized beds has been observed and the opportunity taken to explore this poorly studied subject area. It has been noted, probably for the first time, that with long nozzles, there exists a critical nozzle length above which uncontrollable downflow of solids occurs. A theoretical model for predicting the critical length of a bundle of nozzles in terms of gas velocity through the nozzles has been set up. Theoretical calculations compared favourably with experiments.

Studies of the shellside performance of shell-and-tube heat exchangers

Accurate prediction of shellside pressure drop in a baffled shell-and-tube heat exchanger is very difficult because of the complicated shellside geometry. Ideally, all the shellside fluid should be alternately deflected across the tube bundle as it traverses from inlet to outlet. In practice, up to 60% of the shellside fluid may bypass the tube bundle or leak through the baffles. This short-circuiting of the main flow reduces the efficiency of the exchanger. Of the various shellside methods, it is shown that only the multi-stream methods, which attempt to obtain the shellside flow distribution, predict the pressure drop with any degree of accuracy, the various predictions ranging from -30% to +70%, generally overpredicting. It is shown that the inaccuracies are mainly due to the manner in which baffle leakage is modelled. The present multi-stream methods do not allow for interactions of the various flowstreams, and yet it is shown that three main effects are identified, a) there is a strong interaction between the main cross flow and the baffle leakage streams, enhancing the crossflow pressure drop, b) there is a further short-circuit not considered previously i.e. leakage in the window, and c) the crossflow does not penetrate as far, on average, as previously supposed. Models are developed for each of these three effects, along with a new windowflow pressure drop model, and it is shown that the effect of baffle leakage in the window is the most significant. These models developed to allow for various interactions, lead to an improved multi-stream method, named the "STREAM-INTERACTION" method. The overall method is shown to be consistently more accurate than previous methods, with virtually all the available shellside data being predicted to within ±30% and over 60% being within ±20%. The method is, thus, strongly recommended for use as a design method.

Li-CaO catalysed tri-glyceride transesterification for biodiesel applications

A series of Li-promoted CaO catalysts with Li loadings in the range 0.26–4.0 wt% have been prepared which are effective in the transesterification of glyceryl tributyrate and methanol to methyl butanoate. A Li content of 1.23 wt% provides the optimum activity towards methyl butanoate formation. Li doping increases the base strength of CaO, and XPS and DRIFTS measurements reveal that the optimum loading correlates with the formation of an electron deficient surface Li+ species and associated –OH species at defect sites on the support. High Li loadings result in bulk LiNO3 formation and a drop in surface area and corresponding catalytic activity.

Evaluating the effect of splitting cylindrical power on improving patient tolerance to toric lens misalignment

Purpose: Evaluating the impact of splitting toric power on patient tolerance to misorientation such as with intraocular lens rotation. Setting: University vision clinic. Methods: Healthy, non astigmats had +1.50D astigmatism induced with spectacle lenses at 90°, 135°, 180° and +3.00D at 90°. Two correcting cylindrical lenses of the opposite sign and half the power each were subsequently added to the trial frame misaligned by 0°, 5° or 10° in a random order and misorientated from the initial axis in a clockwise direction by up to 15° in 5° steps. A second group of adapted astigmats with between 1.00 and 3.00DC had their astigmatism corrected with two toric spectacle lenses of half the power separated by 0°, 5° or 10° and misorientated from the initial axis in both directions by up to 15° in 5° steps. Distance, high contrast visual acuity was measured using a computerised test chart at each lens misalignment and misorientation. Results: Misorientation of the split toric lenses caused a statistically significant drop in visual acuity (F= 70.341; p< 0.001). Comparatively better acuities were observed around 180°, as anticipated (F= 3.775; p= 0.035). Misaligning the split toric power produced no benefit in visual acuity retention with axis misorientation when subjects had astigmatism induced with a low (F= 2.190, p= 0.129) or high cylinder (F= 0.491, p= 0.617) or in the adapted astigmats (F= 0.120, p= 0.887). Conclusion: Misalignment of toric lens power split across the front and back lens surfaces had no beneficial effect on distance visual acuity, but also no negative effect. © 2013 British Contact Lens Association.

A novel concentration dependent amino acid ion pair strategy to mediate drug permeation using indomethacin as a model insoluble drug

Assessment of oral drug bioavailability is an important parameter for new chemical entities (NCEs) in drug development cycle. After evaluating the pharmacological response of these new molecules, the following critical stage is to investigate their in vitro permeability. Despite the great success achieved by prodrugs, covalent linking the drug molecule with a hydrophobic moiety might result in a new entity that might be toxic or ineffective. Therefore, an alternative that would improve the drug uptake without affecting the efficacy of the drug molecule would be advantageous. The aim of the current study is to investigate the effect of ion-pairing on the permeability profile of a model drug: indomethacin (IND) to understand the mechanism behind the permeability improvement across Caco-2 monolayers. Arginine and lysine formed ion-pairs with IND at various molar ratios 1:1, 1:2, 1:4 and 1:8 as reflected by the double reciprocal graphs. The partitioning capacities of the IND were evaluated using octanol/water partitioning studies and the apparent permeabilities (P app) were measured across Caco-2 monolayers for the different formulations. Partitioning studies reflected the high hydrophobicity of IND (Log P = 3) which dropped upon increasing the concentrations of arginine/lysine in the ion pairs. Nevertheless, the prepared ion pairs improved IND permeability especially after 60 min of the start of the experiment. Coupling partitioning and permeability results suggest a decrease in the passive transcellular uptake due to the drop in IND portioning capacities and a possible involvement of active carriers. Future work will investigate which transport gene might be involved in the absorption of the ion paired formulations using molecular biology technologies. © 2014 Elsevier B.V. All rights reserved.

Weight loss strategies, stress, and cognitive function:supervised versus unsupervised dieting

The early stages of dieting to lose weight have been associated with neuro-psychological impairments. Previous work has not elucidated whether these impairments are a function solely of unsupported or supported dieting. Raised cortico-steroid levels have been implicated as a possible causal mechanism. Healthy, overweight, pre-menopausal women were randomised to one of three conditions in which they dieted either as part of a commercially available weight loss group, dieted without any group support or acted as non-dieting controls for 8 weeks. Testing occurred at baseline and at 1, 4 and 8 weeks post baseline. During each session, participants completed measures of simple reaction time, motor speed, vigilance, immediate verbal recall, visuo-spatial processing and (at Week 1 only) executive function. Cortisol levels were gathered at the beginning and 30 min into each test session, via saliva samples. Also, food intake was self-recorded prior to each session and fasting body weight and percentage body fat were measured at each session. Participants in the unsupported diet condition displayed poorer vigilance performance (p=0.001) and impaired executive planning function (p=0.013) (along with a marginally significant trend for poorer visual recall (p=0.089)) after 1 week of dieting. No such impairments were observed in the other two groups. In addition, the unsupported dieters experienced a significant rise in salivary cortisol levels after 1 week of dieting (p<0.001). Both dieting groups lost roughly the same amount of body mass (p=0.011) over the course of the 8 weeks of dieting, although only the unsupported dieters experienced a significant drop in percentage body fat over the course of dieting (p=0.016). The precise causal nature of the relationship between stress, cortisol, unsupported dieting and cognitive function is, however, uncertain and should be the focus of further research. © 2005 Elsevier Ltd. All rights reserved.

Application of Naïve Bayesian sequential analysis to primary care optometry

The objective of this study was to investigate the effects of circularity, comorbidity, prevalence and presentation variation on the accuracy of differential diagnoses made in optometric primary care using a modified form of naïve Bayesian sequential analysis. No such investigation has ever been reported before. Data were collected for 1422 cases seen over one year. Positive test outcomes were recorded for case history (ethnicity, age, symptoms and ocular and medical history) and clinical signs in relation to each diagnosis. For this reason only positive likelihood ratios were used for this modified form of Bayesian analysis that was carried out with Laplacian correction and Chi-square filtration. Accuracy was expressed as the percentage of cases for which the diagnoses made by the clinician appeared at the top of a list generated by Bayesian analysis. Preliminary analyses were carried out on 10 diagnoses and 15 test outcomes. Accuracy of 100% was achieved in the absence of presentation variation but dropped by 6% when variation existed. Circularity artificially elevated accuracy by 0.5%. Surprisingly, removal of Chi-square filtering increased accuracy by 0.4%. Decision tree analysis showed that accuracy was influenced primarily by prevalence followed by presentation variation and comorbidity. Analysis of 35 diagnoses and 105 test outcomes followed. This explored the use of positive likelihood ratios, derived from the case history, to recommend signs to look for. Accuracy of 72% was achieved when all clinical signs were entered. The drop in accuracy, compared to the preliminary analysis, was attributed to the fact that some diagnoses lacked strong diagnostic signs; the accuracy increased by 1% when only recommended signs were entered. Chi-square filtering improved recommended test selection. Decision tree analysis showed that accuracy again influenced primarily by prevalence, followed by comorbidity and presentation variation. Future work will explore the use of likelihood ratios based on positive and negative test findings prior to considering naïve Bayesian analysis as a form of artificial intelligence in optometric practice.