Oral anticoagulation in atrial fibrillation, the patients and physicians experiences of the consultation:a qualitative study

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF), however it is still underutilized and sometimes refused by patients. This project was divided in two inter-related studies. Study 1 explored the experiences that influence prescription of OAC by physicians. Study 2 explored the experiences which influence patients' decisions to accept, decline or discontinue OAC. Methods: Semi-structured individual interviews were conducted in both studies. In Study 1four sub-groups of physicians (n = 16) experienced with OAC in AF were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. In Study 2 three sub-groups of patients (n = 11) diagnosed with AF were interviewed; those who accepted, refused, and who discontinued warfarin. Results: Study 1: Two over-arching themes emerged from doctors' experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians still adopt a paternalistic approach to decision-making. They should instead motivate patients to take part in treatment discussions and choices should reflect the patient's needs and concerns. Physician education should focus more on communication skills, individualised care and time-management as these are critical for patient adherence. Continuous OAC education for AF should adopt a multi-disciplinary approach. Further, interpreters should also be educated on medical communication skills. Study 2: Three over-arching themes comprised patients' experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients' reflections. Patient education during the initial consultation was critical in increasing patient's knowledge of OAC. On-going patient education is imperative to maintain adherence. Patients valued physicians' concern for their needs during decision-making. Patients who had experience of stroke were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Patients' perceptions of warfarin are also influenced by the media. Comment: Qualitative research is crucial in exploring barriers to treatment as it provides an excellent insight into patients' experiences of healthcare. A patient-centred approach should be adopted and incorporated into physicians' education. Education and patient involvement in the decision-making process is essential to promote treatment acceptance and long-term adherence

Herbal medicines:physician's recommendation and clinical evaluation of St.John's Wort for depression

Why some physicians recommend herbal medicines while others do not is not well understood. We undertook a survey designed to identify factors, which predict recommendation of herbal medicines by physicians in Malaysia. About a third (206 out of 626) of the physicians working at the University of Malaya Medical Centre ' were interviewed face-to-face, using a structured questionnaire. Physicians were asked about their personal use of, recommendation of, perceived interest in and, usefulness and safety of herbal medicines. Using logistic regression modelling we identified personal use, general interest, interest in receiving training, race and higher level of medical training as significant predictors of recommendation. St. John's wort is one of the most widely used herbal remedies. It is also probably the most widely evaluated herbal remedy with no fewer than 57 randomised controlled trials. Evidence from the depression trials suggests that St. John's wort is more effective than placebo while its comparative efficacy to conventional antidepressants is not well established. We updated previous meta-analyses of St. John's wort, described the characteristics of the included trials, applied methods of data imputation and transformation for incomplete trial data and examined sources of heterogeneity in the design and results of those trials. Thirty randomised controlled trials, which were heterogeneous in design, were identified. Our meta-analysis showed that St. John's wort was significantly more effective than placebo [pooled RR 1.90 (1.54-2.35)] and [Pooled WMD 4.09 (2.33 to 5.84)]. However, the remedy was similar to conventional antidepressant in its efficacy [Pooled RR I. 0 I (0.93 -1.10)] and [Pooled WMD 0.18 (- 0.66 to 1.02). Subgroup analyses of the placebo-controlled trials suggested that use of different diagnostic classifications at the inclusion stage led to different estimates of effect. Similarly a significant difference in the estimates of efficacy was observed when trials were categorised according to length of follow-up. Confounding between the variables, diagnostic classification and length of trial was shown by loglinear analysis. Despite extensive study, there is still no consensus on how effective St. lohn's wort is in depression. However, most experts would agree that it has some effect. Our meta-analysis highlights the problems associated with the clinical evaluation of herbal medicines when the active ingredients are poorly defined or unknown. The problem is compounded when the target disease (e.g. depression) is also difficult to define and different instruments are available to diagnose and evaluate it.

Women beware women: detective fiction and critical discourse stylistics

This article examines the work of four contemporary writers of detective fiction (P.D. James, Amanda Cross, Sara Paretsky and Ruth Rendell/Barbara Vine) from a critical discourse stylistics perspective with the objective of raising the reader’s awareness of the ideological processes that are manifested in the language of these texts. It considers how these writers deal with stereotypical assumptions, how they cope with socially-determined traditional roles and verify whether their choices result in the articulation of an alternative discourse. The investigation arrives at some identifiable cultural and linguistic characteristics which may be singular to this new group of writers. We suggest that by challenging traditional representations of women, these writers may be offering a reconstruction of the genre.

Utilising fiction to promote english language acquisition

Towards the end of the university stage, students residing in the United Arab Emirates and specialising in subjects other than English are expected- amongst other university requirements- to have acquired adequate communicative competence as well as a repertoire of critical thinking skills. Despite the efforts made within the field of teaching English to EFL university students in the country, the output gained in terms of acquired skills and competencies is still below expectations. The main concerns of the current thesis are, therefore, a) to investigate the factors which inhibit EFL university students’ progress in the areas of acquiring adequate communicative competence as well as critical thinking skills, and b) to propose a course book and pedagogic methods to improve students’ progress in the areas of acquiring adequate communicative competence as well as critical thinking skills. Believing in the essential role literature plays in enhancing critical thinking and promoting communicative competence on the part of EFL learners, the current study introduces a course, designed and implemented by the researcher: LEARN AND GAIN. The proposed course is fiction-based language teaching, adopting the view that literature is a resource rather than an object, thus advocating the use of literature as one of the main resources in foreign/second language acquisition. Investigating whether or not the proposed course was effective in promoting EFL university students’ communicative competence as well as enhancing their critical thinking skills, a study sample taken from the study population was selected. Adopting an experimental design, the research project involved two groups: experimental and control. The experimental group students were exposed to the proposed course whilst the control group students were exposed to a general English language course. To examine treatment effectiveness, the researcher set and administered a pre-post test. Divided into two main parts, communicative critical reading competence and communicative critical writing competence, the pre-post test measured subjects’ communicative critical reading competence and subjects’ communicative critical writing competence. In addition, a pre-post questionnaire was administered and a semi-structured interview was conducted involving the experimental group students, to gain an awareness of students’ attitudes towards learning literary texts in general, and the proposed course in particular. To examine issues of interest and relevance, gender differences: male vs. female, and university major: science vs. non-science, were also examined for enrichment purposes. For the purpose of gathering sufficient data about subjects’ achievements on the pre-post, the following statistical tests were conducted: Mann-Whitney test, and paired data t-test. Based on the statistical findings, the experimental group students’ performance on the communicative critical reading competence pre-post test and the communicative critical writing competence pre-post test was significantly better than their counterparts of the control group students. Speaking of gender differences in relation to language performance on the communicative critical reading competence pre-post test and the communicative critical writing competence pre-post test, no significant differences were cited. Neither did the researcher cite any significant performance differences between science/non-science students on the communicative critical reading competence pre-post test and the communicative critical writing competence pre-post test. As far as the questionnaire’s findings are concerned, the experimental group students’ responses to the post-questionnaire’s items were more positive than those of their responses to the pre-questionnaire’s, thus indicating some positive attitudes towards literature, which students possibly gained throughout the course of implementation. Relating the discussion to the interview’s results, students conveyed their satisfaction with the proposed course, emphasising that promoting English language skills through the use of literary texts was rewarding. In the light of findings and conclusions, a number of recommendations as well as implications have been proposed. The current study aimed to arrive at some appropriate suggestions to a number of enquiries, yet concluding with some areas of enquiry to be explored for further research.

Patients’ and physicians’ experiences of atrial fibrillation and anticoagulation therapy:a qualitative journey

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF) however it is often underutilized and sometimes refused by patients. This programme of work included a meta-synthesis and two inter-linking studies aiming to explore patients’ and physicians’ experiences of AF and OAC. Methods: A meta-synthesis of qualitative evidence was conducted which informed the empirical work. Semi-structured individual interviews were utilised. Study 1: Three AF patient sub-groups were interviewed; accepted (n=4), refused (n=4), or discontinued (n=3) warfarin. Study 2: Four physician sub-groups (n=4 each group) prescribing OAC to AF patients were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. Data was analysed using interpretative phenomenological analysis. Results: Study 1: Three over-arching themes comprised patients’ experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients’ reflections. Patients commented on the relief and reassurance experienced during the consultation but they perceived the decision making process mostly led by the physician. Lack of education and take-home materials distributed during the initial consultation was highlighted. Patients who had experienced stroke themselves or were caregivers, were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Warfarin monitoring was challenging for patients, however some patients perceived it as beneficial as it served to enhance patient-physician relationship. Study 2: Two over-arching themes emerged from physicians’ experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians’ approach to the consultation style shifted through a continuum of compliance-adherence-concordance during the consultation. They aimed for concordance, however challenges such as time and the perceived patient trust in them as the expert, led to physicians adopting a paternalistic approach. Physicians also pointed out challenges associated with guideline adherence and the need to adopt a multi-disciplinary approach, where other health professionals could provide on-going education. Conclusion: This programme of work has illustrated the benefit of taking an in depth phenomenological approach to understanding the lived experience of the physician-patient consultation. Together with the meta-synthesis, this work has strengthened the evidence base and demonstrated that there is a need to target patients' and physicians' ability to communicate with each other in a comprehensible way.

Online information seeking by patients with bipolar disorder:results from an international multisite survey

Background: Information seeking is an important coping mechanism for dealing with chronic illness. Despite a growing number of mental health websites, there is little understanding of how patients with bipolar disorder use the Internet to seek information. Methods: A 39 question, paper-based, anonymous survey, translated into 12 languages, was completed by 1222 patients in 17 countries as a convenience sample between March 2014 and January 2016. All patients had a diagnosis of bipolar disorder from a psychiatrist. Data were analyzed using descriptive statistics and generalized estimating equations to account for correlated data. Results: 976 (81 % of 1212 valid responses) of the patients used the Internet, and of these 750 (77 %) looked for information on bipolar disorder. When looking online for information, 89 % used a computer rather than a smartphone, and 79 % started with a general search engine. The primary reasons for searching were drug side effects (51 %), to learn anonymously (43 %), and for help coping (39 %). About 1/3 rated their search skills as expert, and 2/3 as basic or intermediate. 59 % preferred a website on mental illness and 33 % preferred Wikipedia. Only 20 % read or participated in online support groups. Most patients (62 %) searched a couple times a year. Online information seeking helped about 2/3 to cope (41 % of the entire sample). About 2/3 did not discuss Internet findings with their doctor. Conclusion: Online information seeking helps many patients to cope although alternative information sources remain important. Most patients do not discuss Internet findings with their doctor, and concern remains about the quality of online information especially related to prescription drugs. Patients may not rate search skills accurately, and may not understand limitations of online privacy. More patient education about online information searching is needed and physicians should recommend a few high quality websites.