An n-of-1 trial service in clinical practice: Testing the effectiveness of stimulants for attention-deficit/hyperactivity disorder

OBJECTIVE. We sought to describe the clinical use of n-of-1 trials for attention-deficit/hyperactivity disorder in publicly and privately funded family and specialized pediatric practice in Australia. METHODS. We used a within-patient randomized, double-blind, crossover comparison of stimulant (dexamphetamine or methylphenidate) versus placebo or alternative stimulant using 3 pairs of treatment periods. Trials were conducted from a central location using mail and telephone communication, with local supervision by the patients' clinicians. PATIENTS. Our study population included children with clinically diagnosed attention-deficit/ hyperactivity disorder who were aged 5 to 16 years and previously stabilized on an optimal dose of stimulant. They were selected because treatment effectiveness was uncertain. MAIN OUTCOME MEASURES. Our measures included number of patients recruited, number of doctors who used the service, geographic spread, completion rates, response rate, and post-n-of-1 trial decisions. RESULTS. Forty-five doctors across Australia requested 108 n-of-1 trials, of which 86 were completed. In 69 drug-versus-placebo comparisons, 29 children responded better to stimulant than placebo. Immediately posttrial, 19 of 25 drug-versus-placebo responders stayed on the same stimulant, and 13 of 24 nonresponders ceased or switched stimulants. In 40 of 63 for which data were available, posttrial management was consistent with the trial results. For all types of n-of-1 trials, management changed for 28 of 64 children for whom information was available. DISCUSSION. Attention-deficit/hyperactivity disorder n-of-1 trials can be implemented successfully by mail and telephone communication. This type of trial can be valuable in clarifying treatment effect when it is uncertain, and in this series, they had a noticeable impact on short-term management.

The effectiveness of an organisations' equal opportunities policy for the role and training of women, particularly in the fire service

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A model to assess the cost effectiveness of statins in achieving the UK National Service Framework target cholesterol levels

Background: Coronary heart disease (CHD) is a public health priority in the UK. The National Service Framework (NSF) has set standards for the prevention, diagnosis and treatment of CHD, which include the use of cholesterol-lowering agents aimed at achieving targets of blood total cholesterol (TC) < 5.0 mmol/L and low density lipoprotein-cholesterol (LDL-C) < 3.0 mmol/L. In order to achieve these targets cost effectively, prescribers need to make an informed choice from the range of statins available. Aim: To estimate the average and relative cost effectiveness of atorvastatin, fluvastatin, pravastatin and simvastatin in achieving the NSF LDL-C and TC targets. Design: Model-based economic evaluation. Methods: An economic model was constructed to estimate the number of patients achieving the NSF targets for LDL-C and TC at each dose of statin, and to calculate the average drug cost and incremental drug cost per patient achieving the target levels. The population baseline LDL-C and TC, and drug efficacy and drug costs were taken from previously published data. Estimates of the distribution of patients receiving each dose of statin were derived from the UK national DIN-LINK database. Results: The estimated annual drug cost per 1000 patients treated with atorvastatin was £289 000, with simvastatin £315 000, with pravastatin £333 000 and with fluvastatin £167 000. The percentages of patients achieving target are 74.4%, 46.4%, 28.4% and 13.2% for atorvastatin, simvastatin, pravastatin and fluvastatin, respectively. Incremental drug cost per extra patient treated to LDL-C and TC targets compared with fluvastafin were £198 and £226 for atorvastatin, £443 and £567 for simvastatin and £1089 and £2298 for pravastatin, using 2002 drug costs. Conclusions: As a result of its superior efficacy, atorvastatin generates a favourable cost-effectiveness profile as measured by drug cost per patient treated to LDL-C and TC targets. For a given drug budget, more patients would achieve NSF LDL-C and TC targets with atorvastatin than with any of the other statins examined.

Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

OBJECTIVES: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

DESIGN: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING: Internet-based application.

PARTICIPANTS: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

INTERVENTIONS: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

MAIN OUTCOME MEASURES: Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

RESULTS: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

CONCLUSIONS: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

TRIAL REGISTRATION NUMBER: ISRCTN07479761; pre-results registration.

QoS-Based Web Service Scheduling Accommodating Inter-Service Dependencies Using Minimal-Conflict Hill-Climbing Repair Genetic Algorithm

In the filed of semantic grid, QoS-based Web service scheduling for workflow optimization is an important problem.However, in semantic and service rich environment like semantic grid, the emergence of context constraints on Web services is very common making the scheduling consider not only quality properties of Web services, but also inter service dependencies which are formed due to the context constraints imposed on Web services. In this paper, we present a repair genetic algorithm, namely minimal-conflict hill-climbing repair genetic algorithm, to address scheduling optimization problems in workflow applications in the presence of domain constraints and inter service dependencies. Experimental results demonstrate the scalability and effectiveness of the genetic algorithm.

A Penalty-based Genetic Algorithm for QoS-AwareWeb Service Composition with Inter-Service Dependencies and Conflicts

In Web service based systems, new value-added Web services can be constructed by integrating existing Web services. A Web service may have many implementations, which are functionally identical, but have different Quality of Service (QoS) attributes, such as response time, price, reputation, reliability, availability and so on. Thus, a significant research problem in Web service composition is how to select an implementation for each of the component Web services so that the overall QoS of the composite Web service is optimal. This is so called QoS-aware Web service composition problem. In some composite Web services there are some dependencies and conflicts between the Web service implementations. However, existing approaches cannot handle the constraints. This paper tackles the QoS-aware Web service composition problem with inter service dependencies and conflicts using a penalty-based genetic algorithm (GA). Experimental results demonstrate the effectiveness and the scalability of the penalty-based GA.

A thematic approach to integrating maths and science for pre-service primary teachers via sustainability

Efforts to improve mathematics and science content knowledge have in many institutions required redefining teacher education through new teaching and learning. See, for example, Peard & Pumadevi (2007) for an account of one such attempt involving the development of a Foundations Unit, Scientific and Quantitative Literacy. This unit is core for all first year pre-service primary teacher education students at Queensland University of Technology (QUT) and two Education Institutes in Malaysia, Institute Perguruan Raja Melewar (IPRM), and Institute Perguruan Teknik (IPT) Kuala Lumpur. Since then, QUT has modified the unit to adopt a thematic approach to the same content. An aim of the unit rewrite was the development of a positive attitude and disposition to the teaching and learning of mathematics and science, with a curiosity and willingness to speculate about and explore the world. Numeracy was specifically identified within the mathematics encountered and appropriately embedded in the science learning area. The importance of the ability to engage in communication of and about mathematics and science was considered crucial to the development of pre-service primary teachers. Cognisance was given to the appropriate selection and use of technology to enhance learning - digital technologies were embedded in the teaching, learning and assessment of the unit to avoid being considered as an optional extra. This was achieved around the theme of “the sustainable school”. This „sustainability‟ theme was selected due to its prominence in Australia‟s futures-oriented National Curriculum which will be implemented in 2011. This paper outlines the approach taken to the implementation of the unit and discusses early indicators of its effectiveness.

A thematic approach to integrating maths and science for pre-service primary teachers via sustainability

Efforts to improve mathematics and science content knowledge have in many institutions required redefining teacher education through new teaching and learning. See, for example, Peard & Pumadevi (2007) for an account of one such attempt involving the development of a Foundations Unit, Scientific and Quantitative Literacy. This unit is core for all first year pre-service primary teacher education students at Queensland University of Technology (QUT) and two Education Institutes in Malaysia, Institute Perguruan Raja Melewar (IPRM), and Institute Perguruan Teknik (IPT) Kuala Lumpur. Since then, QUT has modified the unit to adopt a thematic approach to the same content. An aim of the unit rewrite was the development of a positive attitude and disposition to the teaching and learning of mathematics and science, with a curiosity and willingness to speculate about and explore the world. Numeracy was specifically identified within the mathematics encountered and appropriately embedded in the science learning area. The importance of the ability to engage in communication of and about mathematics and science was considered crucial to the development of pre-service primary teachers. Cognisance was given to the appropriate selection and use of technology to enhance learning - digital technologies were embedded in the teaching, learning and assessment of the unit to avoid being considered as an optional extra. This was achieved around the theme of “the sustainable school”. This ‘sustainability’ theme was selected due to its prominence in Australia’s futures-oriented National Curriculum which will be implemented in 2011. This paper outlines the approach taken to the implementation of the unit and discusses early indicators of its effectiveness.

Mainstreaming sustainability into pre-service teacher edcuation in Australia

There is a growing interest in and support for education for sustainability in Australian schools. Australian Government schemes such as the Australian Sustainable Schools Initiative (AuSSI), along with strategies such as Educating for a Sustainable Future: A National Environmental Education Statement for Australian Schools(NEES(Australian Government and Curriculum Corporation (2005) and Living Sustainably: The Australian Government’s National Action Plan for Education for Sustainability (Australian Government 2009), recognise the need and offer support for education for sustainability in Australian schools. The number of schools that have engaged with AuSSI indicates that this interest also exists within Australian schools. Despite this, recent research indicates that pre-service teacher education institutions and programs are not doing all they can to prepare teachers for teaching education for sustainability or for working within sustainable schools. The education of school teachers plays a vital role in achieving changes in teaching and learning in schools. Indeed, the professional development of teachers in education for sustainability has been identified as ‘the priority of priorities’. Much has been written about the need to ‘reorient teacher education towards sustainability’. Teacher education is seen as a key strategy that is yet to be effectively utilised to embed education for sustainability in schools. Mainstreaming sustainability in Australian schools will not be achieved without the preparation of teachers for this task. The Mainstreaming Sustainability model piloted in this study seeks to engage a range of stakeholder organisations and key agents of change within a system to all work simultaneously to bring about a change, such as the mainstreaming of sustainability. The model is premised on the understanding that sustainability will be mainstreamed within teacher education if there is engagement with key agents of change across the wider teacher education system and if the key agents of change are ‘deeply’ involved in making the change. The model thus seeks to marry broad engagement across a system with the active participation of stakeholders within that system. Such a systemic approach is a way of bringing together diverse viewpoints to make sense of an issue and harness that shared interpretation to define boundaries, roles and relationships leading to a better defined problem that can be acted upon more effectively. Like action research, the systemic approach is also concerned with modelling change and seeking plausible solutions through collaboration between stakeholders. This is important in ensuring that outcomes are useful to the researchers/stakeholders and the system being researched as it creates partnerships and commitments to the outcomes by stakeholder participants. The study reported on here examines whether the ‘Mainstreaming Sustainability’ model might be effective as a means to mainstream sustainability in pre-service teacher education. This model, developed in an earlier study, was piloted in the Queensland teacher education system in order to examine its effectiveness in creating organisational and systemic change. The pilot project in Queensland achieved a number of outcomes. The project: • provided useful insights into the effectiveness of the Mainstreaming Sustainability model in bringing about change while also building research capacity within the system • developed capacities within the teacher education community: o developing competencies in education for sustainability o establishing more effective interactions between decision-makers and other stakeholders o establishing a community of inquiry • changed teaching and learning approaches used in participating teacher education institutions through: o curriculum and resource development o the adoption of education for sustainability teaching and learning processes o the development of institutional policies • improved networks within the teacher education system through: o identifying key agents of change within the system o developing new, and building on existing, partnerships between schools, teacher education institutions and government agencies • engaged relevant stakeholders such as government agencies and non-government organisations to understand and support the change Our findings indicate that the Mainstreaming Sustainability model is able to facilitate organisational and systemic change – over time – if: • the individuals involved have the conceptual and personal capacities needed to facilitate change, that is, to be a key agent of change • stakeholders are engaged as participants in the process of change, not simply as ‘interested parties’ • there is a good understanding of systemic change and the opportunities for leveraging change within systems. In particular, in seeking to mainstream sustainability in pre-service teacher education in Queensland it has become clear that one needs to build capacity for change within participants such as knowledge of education for sustainability, conceptual skills in systemic thinking, action research and organisational change, and leadership skills. It is also of vital importance that key agents of change – those individuals who are ‘hubs’ within a system and can leverage for change across a wide range of the system – are identified and engaged with as early as possible. Key agents of change can only be correctly identified, however, if the project leaders and known participants have clearly identified the boundary to their system as this enables the system, sub-system and environment of the system to be understood. Through mapping the system a range of key organisations and stakeholders will be identified, including government and nongovernment organisations, teacher education students, teacher education academics, and so on. On this basis, key agents of change within the system and sub-system can be identified and invited to assist in working for change. A final insight is that it is important to have time – and if necessary the funding to ‘buy time’ – in seeking to bring about system-wide change. Seeking to bring about system-wide change is an ambitious project, one that requires a great deal of effort and time. These insights provide some considerations for those seeking to utilise the Mainstreaming Sustainability model to bring about change within and across a pre-service teacher education system.

User-generated content and the future of public broadcasting : a case study of the special broadcasting service

This thesis presents a case study of the Special Broadcasting Service documenting the broadcasting challenges posed by user-generated content initiatives and the work-place approach to strategies for participation. Using the action research method, the project findings reveal that limitations to resources and funding determined the scope for innovation and that the practice of executive editorial control over content was considered fundamental to fulfilling the responsibilities of the public service mandate. Media workers were overwhelmingly positive about the enhanced productive capabilities of the audience and willing to facilitate moderated interactions, however the effectiveness of these initiatives differed according to the level of skills required. This thesis demonstrates how participatory initiatives can enhance aspects of the public service remit relating to cultural diversity, the servicing of niche interests, and broader social representation, and help reinvigorate the relevance of public service broadcasting in the digitalised media sphere.

QoS-based web service composition accommodating inter-service dependencies using minimal-conflict , hill-climbing repair genetic algorithm

In the field of semantic grid, QoS-based Web service composition is an important problem. In semantic and service rich environment like semantic grid, the emergence of context constraints on Web services is very common making the composition consider not only QoS properties of Web services, but also inter service dependencies and conflicts which are formed due to the context constraints imposed on Web services. In this paper, we present a repair genetic algorithm, namely minimal-conflict hill-climbing repair genetic algorithm, to address the Web service composition optimization problem in the presence of domain constraints and inter service dependencies and conflicts. Experimental results demonstrate the scalability and effectiveness of the genetic algorithm.

Service staff attitudes, organisational practices and performance drivers

We provide conceptual and empirical insights elucidating how organizational practices influence service staff attitudes and behaviors and how the latter set affects organizational performance drivers. Our analyses suggest that service organizations can enhance their performance by putting in place strategies and practices that strengthen the service-oriented behaviors of their employees and reduce their intentions to leave the organization. Improved performance is accomplished through both the delivery of high quality services (enhancing organizational effectiveness) and the maintenance of frontline staff(increasing organizational efficiency). Specifically, service-oriented business strategies in the form of organizational-level service orientation and practices in the form of training directly influence the manifest service-oriented behaviors of staff. Training also indirectly affects the intention of frontline staff to leave the organization; it increases job satisfaction, which, in turn has an impact on affective commitment. Both affective and instrumental commitment were hypothesized to reduce the intentions of frontline staff to leave the organization, however only affective commitment had a significant effect.

The promoting adult resilience (PAR) program : the effectiveness of the second, shorter pilot of a workplace prevention program

This article details the second, successful pilot of the Promoting Adult Resilience (PAR) program in the human-services departments of a local government organization. The PAR program is a strengths-based resilience building program that integrates Interpersonal and CBT perspectives and this pilot use a shorter, 7-week version of the program. Pre, post and follow-up measures on PAR participants from a resource-sector company were compared with a non-intervention matched comparison group. Post-test, PAR participants reported greater self-efficacy, more family satisfaction, greater f\work-life fit and balance and less negative family to work spillover than the comparison group. At the 6-month follow-up, these gains were maintained to a lesser degree, although work-life balance was strengthened, and negative spillover in both directions reduced. Participants also reported greater optimism for the future, greater work satisfaction and promisingly for human service workers, exhaustion was reduced and more vigour, important for human services as burnout, exhaustion is part of this is a serious work hazard