Reasons for non-adherence to antiretroviral therapy:patients' perspectives provide evidence of multiple causes

The objective of the study was to define common reasons for non-adherence (NA) to highly active antiretroviral therapy (HAART) and the number of reasons reported by non-adherent individuals. A confidential questionnaire was administered to HIV-seropositive patients taking proteinase inhibitor based HAART. Median self-reported adherence was 95% (n = 178, range = 60-100%). The most frequent reasons for at least 'sometimes' missing a dose were eating a meal at the wrong time (38.2%), oversleeping (36.3%), forgetting (35.0%) and being in a social situation (30.5%). The mean number of reasons occurring at least 'sometimes' was 3.2; 20% of patients gave six or more reasons; those reporting the lowest adherence reported a significantly greater numbers of reasons (ρ = - 0.59; p < 0.001). Three factors were derived from the data by principal component analysis reflecting 'negative experiences of HAART', 'having a low priority for taking medication' and 'unintentionally missing doses', accounting for 53.8% of the variance. On multivariate analysis only the latter two factors were significantly related to NA (odds ratios 0.845 and 0.849, respectively). There was a wide spectrum of reasons for NA in our population. The number of reasons in an individual increased as adherence became less. A variety of modalities individualized for each patient are required to support patients with the lowest adherence.

Design of an expandable manufacturing simulator through the application of object-oriented principles

In analysing manufacturing systems, for either design or operational reasons, failure to account for the potentially significant dynamics could produce invalid results. There are many analysis techniques that can be used, however, simulation is unique in its ability to assess detailed, dynamic behaviour. The use of simulation to analyse manufacturing systems would therefore seem appropriate if not essential. Many simulation software products are available but their ease of use and scope of application vary greatly. This is illustrated at one extreme by simulators which offer rapid but limited application whilst at the other simulation languages which are extremely flexible but tedious to code. Given that a typical manufacturing engineer does not posses in depth programming and simulation skills then the use of simulators over simulation languages would seem a more appropriate choice. Whilst simulators offer ease of use their limited functionality may preclude their use in many applications. The construction of current simulators makes it difficult to amend or extend the functionality of the system to meet new challenges. Some simulators could even become obsolete as users, demand modelling functionality that reflects the latest manufacturing system design and operation concepts. This thesis examines the deficiencies in current simulation tools and considers whether they can be overcome by the application of object-oriented principles. Object-oriented techniques have gained in popularity in recent years and are seen as having the potential to overcome any of the problems traditionally associated with software construction. There are a number of key concepts that are exploited in the work described in this thesis: the use of object-oriented techniques to act as a framework for abstracting engineering concepts into a simulation tool and the ability to reuse and extend object-oriented software. It is argued that current object-oriented simulation tools are deficient and that in designing such tools, object -oriented techniques should be used not just for the creation of individual simulation objects but for the creation of the complete software. This results in the ability to construct an easy to use simulator that is not limited by its initial functionality. The thesis presents the design of an object-oriented data driven simulator which can be freely extended. Discussion and work is focused on discrete parts manufacture. The system developed retains the ease of use typical of data driven simulators. Whilst removing any limitation on its potential range of applications. Reference is given to additions made to the simulator by other developers not involved in the original software development. Particular emphasis is put on the requirements of the manufacturing engineer and the need for Ihe engineer to carrv out dynamic evaluations.

On-off and multistate intermittencies in cascaded random distributed feedback fibre laser

A range of physical and engineering systems exhibit an irregular complex dynamics featuring alternation of quiet and burst time intervals called the intermittency. The intermittent dynamics most popular in laser science is the on-off intermittency [1]. The on-off intermittency can be understood as a conversion of the noise in a system close to an instability threshold into effective time-dependent fluctuations which result in the alternation of stable and unstable periods. The on-off intermittency has been recently demonstrated in semiconductor, Erbium doped and Raman lasers [2-5]. Recently demonstrated random distributed feedback (random DFB) fiber laser has an irregular dynamics near the generation threshold [6,7]. Here we show the intermittency in the cascaded random DFB fiber laser. We study intensity fluctuations in a random DFB fiber laser based on nitrogen doped fiber. The laser generates first and second Stokes components 1120 nm and 1180 nm respectively under an appropriate pumping. We study the intermittency in the radiation of the second Stokes wave. The typical time trace near the generation threshold of the second Stokes wave (Pth) is shown at Fig. 1a. From the number of long enough time-traces we calculate statistical distribution between major spikes in time dynamics, Fig. 1b. To eliminate contribution of high frequency components of spikes we use a low pass filter along with the reference value of the output power. Experimental data is fitted by power law, ~(P-Pth)y, where is a mean time between pikes. There are two different intermittency regimes. Just above Pth, the mean time is approximated by the -3/2 power law. The -3/2 power law is typical to the on-off intermittency with hopping between two states (first and second Stokes waves in our case) [7]. At higher power, the mean time is approximated by -4 power law, that indicates a change in intermittency type to multistate. Multistable dynamics is observed in erbium-doped fiber lasers [8]. The origin of multiples states in our system could be probably connected with polarization hopping or other reasons and should be further investigated. We have presented a first experimental statistical characterisation of the on-off and multistate intermittencies that occur in the generation of the second Stokes wave in nitrogen doped random DFB fiber laser. References [1] H. Fujisaka and T. Yamada, “A New Intermittency in Coupled Dynamical Systems,” Prog. Theor. Phys. 74, 918 (1985). [2] S. Osborne, A. Amann, D. Bitauld, and S. O’Brien, “On-off intermittency in an optically injected semiconductor laser,” Phys. Rev. E 85, 056204 (2012). [3] S. Sergeyev, K. O'Mahoney, S. Popov, and A. T. Friberg, “Coherence and anticoherence resonance in high-concentration erbium-doped fiber laser,” Opt. Lett. 35, 3736 (2010). [4] A.E. El-Taher, S.V. Sergeyev, E.G. Turitsyna, P. Harper, and S. K. Turitsyn, “Intermittent Self-Pulsing in a Fiber Raman Laser”, In proc. Conf. Nonlin. Photon., paper ID 1367139, Colorado Springs, USA, 2012 [5] S.K. Turitsyn, S.A. Babin, A.E. El-Taher, P. Harper, D.V. Churkin, S.I. Kablukov, J.D. Ania-Castañón, V. Karalekas, and E.V. Podivilov, “Random distributed feedback fibre laser”, Nat. Photon..4, 231 (2010). [6] I. D. Vatnik, D. V. Churkin, S. A. Babin, and S. K. Turitsyn, "Cascaded random distributed feedback Raman fiber laser operating at 1.2 μm," Opt. Express 19, 18486 (2011). [7] W. Feller, An introduction to probability theory and its applications, Vol. 1, 3rd ed. (Wiley, New-York, 1968). [8] G. Huerta-Cuellar, A.N. Pisarchik, and Y.O. Barmenkov, “Experimental characterization of hopping dynamics in a multistable fiber laser,” Phys. Rev. E 78, 035202(R) (2008).

Science or practice? UK undergraduate experiences and attitudes to the MPharm degree

Objective: The debate surrounding the science/practice balance in the teaching of undergraduate pharmacy has been played out in the professional literature for years. The objective of this work was to explore the attitudes of pharmacy undergraduates on the practice-science debate. Setting: The study was undertaken as part of a national study of teaching, learning and assessment methods in United Kingdom (UK) schools of pharmacy. Method: Six focus groups were carried out. The sample was 44 volunteer students from nine UK schools of pharmacy, representing all 4 years of the MPharm programme. Groups were tape recorded and transcribed. Analysis of the transcripts was theme based by topic. Main Outcome Measure: Qualitative data on student attitudes and experiences. Results: Most students thought that there was too strong an emphasis placed on the science components of the course in the early part of their studies. Later in the course they realised that the majority of the science was necessary; it just had not been apparent to them at the time. There were strongly held attitudes across all 4 years that it would be beneficial to include more practice-related material at the beginning of their studies. This would be beneficial for three reasons: to make the course more interesting, to aid in the contextualisation of the science component and to assist the students in any early placement or vacational work. Conclusion: Internationally, changes to the role of the pharmacist from a traditional supply function to a more clinical role has resulted in differing educational needs for the pharmacist of the future. Pharmacy will remain a degree built on a strong scientific background, but students advise that the contextualisation and sequencing of material within the degree could make a considerable improvement to their learning. Consulting students helps us to understand the teaching, learning and assessment experience better by giving insights into ways of improving the delivery. In the case of the UK, there are legislative changes impending which may provide an opportunity to review the balance of practice-and science in the curriculum. © 2006 Springer Science+Business Media B.V.

Are HRM practices related with patient mortality in NHS hospitals?:A study examining the underlying reasons for such an association

This thesis will report details of two studies conducted within the National Health Service in the UK that examined the association between HRM practices related to training and appraisal with health outcomes within NHS Trusts. Study one represents the organisational analysis of 61 NHS Trusts, and will report training and appraisal practices were significantly associated with lower patient mortality. Specifically, the research will show significantly lower patient mortality within NHS Trusts that: a) had achieved Investors in People accreditation; b) had a formal strategy document relating to training; c) had tailored training policy documents across occupational groups; d) had integrated training and appraisal practices; e) had a high percentage of staff receiving either an appraisal or updated personal development plan. There was also evidence of an additive effect where NHS Trusts that displayed more of these characteristics had significantly lower patient mortality. Study one in this thesis will also report significantly lower patient mortality within the NHS Trusts where there was broad level representation for the HR function. Study two will report details of a study conducted to examine the potential reasons why HR practices may be related to hospital performance. Details are given of the results of a staff attitudinal survey within five NHS Trusts. This study examined will show that a range of developmental activity, the favourability of the immediate work environment (in relation to social support and role stressors) and motivational outcomes are important antecedents to citizenship behaviours. Furthermore, the thesis will report that principles of the demand-control model were adopted to examine the relationship between workplace support and role stressors, and workplace support, influence, and an understanding of role expectation help mitigate against the negative effects of work demands upon motivational outcomes.

An exploration of pharmacy-specific reasons for non-adherence to prescribed medicines in a socioeconomically deprived, ethnically diverse UK cohort

Methods - Ethical approval for the study was granted by both the local National Health Service (NHS) Research Ethics Committee (REC) and Aston University’s REC. Seven focus groups were conducted between October and December 2011 in medical or community settings within inner-city Birmingham (UK). Discussions were guided by a theme plan which was developed from key themes identified by a literature review and piloted via a Patient Consultation Group. Each focus group had between 3 and 7 participants. The groups were digitally recorded and subsequently transcribed verbatim. The transcriptions were then subjected to thematic analysis via constant comparison in order to identify emerging themes. Results - Participants recognised the pharmacist as an expert source of advice about prescribed medicines, a source they frequently felt a need to consult as a result of the inadequate supply of medicines information from the prescriber. However, an emerging theme was a perception that pharmacists had an oblique profit motive relating to the supply of generic medicines with frequent changes to the ‘brand’ of generic supplied being attributed to profit-seeking by pharmacists. Such changes had a negative impact on the patient’s perceived efficacy of the therapy which may make non-adherence more likely. Conclusions - Whilst pharmacists were recognised as medicines experts, trust in the pharmacist was undermined by frequent changes to generic medicines. Such changes have the potential to adversely impact adherence levels. Further, quantitative research is recommended to examine if such views are generalisable to the wider population of Birmingham and to establish if such views impact on adherence levels.

Deliberate and spontaneous sensations of disembodiment:capacity or flaw?

Introduction: Hallucinations that involve shifts in the subjectively experienced location of the self, have been termed “out-of-body experiences” (OBEs). Early psychiatric accounts cast OBEs as a specific instance of depersonalisation and derealisation disorder (DPD-DR). However, during feelings of alienation and lack of body realism in DPD-DR the self is experienced within the physical body. Deliberate forms of “disembodiment” enable humans to imagine another’s visuo-spatial perspective taking (VPT), thus, if a strong relationship between deliberate and spontaneous forms of disembodiment could be revealed, then uncontrolled OBEs could be “the other side of the coin” of a uniquely human capacity. Methods: We present a narrative review of behavioural and neuroimaging work emphasising methodological and theoretical aspects of OBE and VPT research and a potential relationship. Results: Results regarding a direct behavioural relationship between VPT and OBE are mixed and we discuss reasons by pointing out the importance of using realistic tasks and recruiting genuine OBEers instead of general DPD-DR patients. Furthermore, we review neuroimaging evidence showing overlapping neural substrates between VPT and OBE, providing a strong argument for a relationship between the two processes. Conclusions: We conclude that OBE should be regarded as a necessary implication of VPT ability in humans, or even as a necessary and potentially sufficient condition for the evolution of VPT.