Do we know the strength of the chorioamnion? A critical review and analysis

The chorioamnion is the membrane that surrounds the fetus during gestation. Normally, it must remain intact for the duration of pregnancy, 37-42 weeks, and only rupture during or just before labour and delivery of the fetus. In a significant number (3%) of all births, this does not happen, and membranes rupture before term, resulting in preterm birth and significant perinatal morbidity. It is known that the material properties of chorioamnion may play a major role in mechanical rupture; a number of studies have been undertaken to characterise the physical nature of chorioamnion and examine factors that may predispose to rupture. However, the existing literature is inconsistent in its choice of both physical testing methods and data analysis techniques, motivating the current review. Experimental data from a large number of chorioamnion mechanical studies were collated, and data were converted to standard engineering quantities. The failure strength of the chorioamnion membrane was found consistently to value approximately 0.9 MPa. It is hoped that past and future studies of membrane mechanics can provide insight into the role of chorioamnion in labour and delivery. In addition, biomechanical approaches can help elucidate the potential causes of early rupture, and suggest future protocols or treatments that could both diagnose and prevent its occurrence. © 2009 Elsevier Ireland Ltd.

Modelling cognitive impairment to improve universal access

The purpose of this study is to develop a model of cognitive impairment to help designers consider the range of issues which affect the lives of people living with such impairment. A series of interviews with experts of cognitive impairment was conducted to describe and assess the links between specific medical conditions, including learning disability, specific learning difficulties, autistic spectrum disorders, traumatic brain injury and schizophrenia, and the types of cognitive impairment associated with them. The results reveal some of the most prevalent and serious types of impairment, which - when transformed into design guidance - will help designers make mainstream products more inclusive also for people with cognitive impairment. © 2011 Springer-Verlag.

Status of the shrimp sector in Bangladesh in the context of HACCP and trade issues: a review

Shrimp culture in Bangladesh has emerged as an important aquaculture industry over the last three decades although its culture in greater parts of the farming area is done in traditional ways. In the meantime, the government of Bangladesh has taken necessary measures along with the private sectors to increase production, upgrade processing industries and to promote export performance. Long supply chain in raw material collection, inadequate infrastructure facilities, poor level of cool chain and lack of adequate HACCP-based training on hygiene and sanitation of different groups of people involved in the field level are the main problems of quality loss of raw materials. Shortage of raw materials results in poor capacity utilization of the processing plants. The growth of bagda (P. monodon) hatchery has expanded rapidly over the last few years, remaining mostly concentrated in Cox's Bazar region is enough to meet the target production. However, there is a shortage of pelleted shrimp feed in Bangladesh. A large number of export processors are now producing increasing amounts of value-added products such as individually quick-frozen, peeled and divined, butterfly cut shrimp, as well as cooked products. The export earnings from value added products is about half of the total export value. About 95% of total fish products are exported to European countries, USA and Japan and the remaining to the Southeast Asia and the Middle East. Most of the EU approved shrimp processing industries have been upgraded with laboratory facilities and provided HACCP training to their workers. As of now, HACCP is applied on the processing plants, but to ensure the quality of raw materials and to reduce risks, shrimp farms are also required to adopt HACCP plan. There is increased pressure time to time from importing countries for fish processors to establish effective quality assurance system in processing plants. Fish Inspection and Quality Control (FIQC) of the Department of Fisheries while having moderately equipped laboratories with chemical, bio-chemical and microbiological testing facilities and qualified technical personnel, the creation of facilities for testing of antibiotics is underway. FIQC mainly supervises quality aspects of the processing plants and has little or no control over raw material supply chains from farm to processing plants. Bangladesh export consignments sometimes face rejection due to reported poor quality of the products. Three types of barriers are reported for export of shrimp to EU countries. These are:(1) government participation in trade and restrictive practices (state aid, countervailing duties, state trading enterprises, government monopoly practices), customs and administrative entry procedures (anti-dumping duties, customs valuation, classification, formalities, rules of origin); (2) technical barriers to trade or TBT (technical regulations, standards, testing, certification arrangement); (3) specific limitations (quantitative restrictions, import licensing, embargoes, exchange control, discriminatory sourcing, export restraints, measures to regulate domestic prices, requirements concerning marking, labeling and packaging).

Accelerated partial irradiation for breast cancer: Systematic review and meta-analysis of 8653 women in eight randomized trials

Background and purpose: Accelerated partial breast irradiation (APBI) is the strategy that allows adjuvant treatment delivery in a shorter period of time in smaller volumes. This study was undertaken to assess the effectiveness and outcomes of APBI in breast cancer compared with whole-breast irradiation (WBI). Material and methods: Systematic review and meta-analysis of randomized controlled trials of WBI versus APBI. Two authors independently selected and assessed the studies regarding eligibility criteria. Results: Eight studies were selected. A total of 8653 patients were randomly assigned for WBI versus APBI. Six studies reported local recurrence outcomes. Two studies were matched in 5 years and only one study for different time of follow-up. Meta-analysis of two trials assessing 1407 participants showed significant difference in the WBI versus APBI group regarding the 5-year local recurrence rate (HR = 4.54, 95% CI: 1.78-11.61, p = 0.002). Significant difference in favor of WBI for different follow-up times was also found. No differences in nodal recurrence, systemic recurrence, overall survival and mortality rates were observed. Conclusions: APBI is associated with higher local recurrence compared to WBI without compromising other clinical outcomes. (C) 2014 Elsevier Ireland Ltd. All rights reserved.

Health-Related Quality of Life for individuals with hepatitis C: A narrative review.

BACKGROUND The assessment of Health-Related Quality of Life (HRQoL) in hepatitis C (HCV) infected individuals continues to gain importance. However, rarely do reviews of this literature consider quantitative and qualitative accounts of HRQoL collectively, which only allows partial insight into the topic. This narrative review aims to address this gap in the literature. METHODS Literature searches were conducted using seven databases with two separate search strategies, and results assessed for eligibility using specific inclusion/exclusion criteria; a data extraction sheet was used to identify the dominant themes for each research paradigm which were then distilled to key findings to construct the narrative. RESULTS Quantitative investigation reveals a low HRQoL in individuals with HCV due to a complex multifactorial cause. During treatment for HCV, a further transient reduction is observed, followed by improvement if a sustained virological response is achieved. Qualitative data provide a recognisable voice to the everyday challenges experienced by individuals with HCV including insights into diagnosis and stigmatisation, contextualising how a reduced HRQoL is experienced day-to-day. Methodological limitations of these findings are then discussed. Much of the quantitative data has little relevance to current substance users as they are excluded from most trials, and appraisal of the qualitative literature reveals a marked difference in the lived experience of HCV infected current substance users and that of other HCV groups. CONCLUSION Concurrent analysis of quantitative and qualitative paradigms provides a deeper understanding of the true burden of HCV illness on HRQoL. Greater utilisation of qualitative research within international clinical guidelines is likely to be of benefit in identifying relevant HRQoL outcomes for substance users.

Qualitative evaluation of KA24 (Knowledge Access 24)

Durbin, J. & Urquhart, C. (2003). Qualitative evaluation of KA24 (Knowledge Access 24). Aberystwyth: Department of Information Studies, University of Wales Aberystwyth. Sponsorship: Knowledge Access 24 (NHS)

Tratamento do traumatismo dentário em dentição primária

Projeto de Pós-Graduação/Dissertação apresentado à Universidade Fernando Pessoa como parte dos requisitos para obtenção do grau de Mestre em Medicina Dentária

Complying with the NIH Public Access Policy - Copyright Considerations and Options

On January 11, 2008, the National Institutes of Health ('NIH') adopted a revised Public Access Policy for peer-reviewed journal articles reporting research supported in whole or in part by NIH funds. Under the revised policy, the grantee shall ensure that a copy of the author's final manuscript, including any revisions made during the peer review process, be electronically submitted to the National Library of Medicine's PubMed Central ('PMC') archive and that the person submitting the manuscript will designate a time not later than 12 months after publication at which NIH may make the full text of the manuscript publicly accessible in PMC. NIH adopted this policy to implement a new statutory requirement under which: The Director of the National Institutes of Health shall require that all investigators funded by the NIH submit or have submitted for them to the National Library of Medicine's PubMed Central an electronic version of their final, peer-reviewed manuscripts upon acceptance for publication to be made publicly available no later than 12 months after the official date of publication: Provided, That the NIH shall implement the public access policy in a manner consistent with copyright law. This White Paper is written primarily for policymaking staff in universities and other institutional recipients of NIH support responsible for ensuring compliance with the Public Access Policy. The January 11, 2008, Public Access Policy imposes two new compliance mandates. First, the grantee must ensure proper manuscript submission. The version of the article to be submitted is the final version over which the author has control, which must include all revisions made after peer review. The statutory command directs that the manuscript be submitted to PMC 'upon acceptance for publication.' That is, the author's final manuscript should be submitted to PMC at the same time that it is sent to the publisher for final formatting and copy editing. Proper submission is a two-stage process. The electronic manuscript must first be submitted through a process that requires input of additional information concerning the article, the author(s), and the nature of NIH support for the research reported. NIH then formats the manuscript into a uniform, XML-based format used for PMC versions of articles. In the second stage of the submission process, NIH sends a notice to the Principal Investigator requesting that the PMC-formatted version be reviewed and approved. Only after such approval has grantee's manuscript submission obligation been satisfied. Second, the grantee also has a distinct obligation to grant NIH copyright permission to make the manuscript publicly accessible through PMC not later than 12 months after the date of publication. This obligation is connected to manuscript submission because the author, or the person submitting the manuscript on the author's behalf, must have the necessary rights under copyright at the time of submission to give NIH the copyright permission it requires. This White Paper explains and analyzes only the scope of the grantee's copyright-related obligations under the revised Public Access Policy and suggests six options for compliance with that aspect of the grantee's obligation. Time is of the essence for NIH grantees. As a practical matter, the grantee should have a compliance process in place no later than April 7, 2008. More specifically, the new Public Access Policy applies to any article accepted for publication on or after April 7, 2008 if the article arose under (1) an NIH Grant or Cooperative Agreement active in Fiscal Year 2008, (2) direct funding from an NIH Contract signed after April 7, 2008, (3) direct funding from the NIH Intramural Program, or (4) from an NIH employee. In addition, effective May 25, 2008, anyone submitting an application, proposal or progress report to the NIH must include the PMC reference number when citing articles arising from their NIH funded research. (This includes applications submitted to the NIH for the May 25, 2008 and subsequent due dates.) Conceptually, the compliance challenge that the Public Access Policy poses for grantees is easily described. The grantee must depend to some extent upon the author(s) to take the necessary actions to ensure that the grantee is in compliance with the Public Access Policy because the electronic manuscripts and the copyrights in those manuscripts are initially under the control of the author(s). As a result, any compliance option will require an explicit understanding between the author(s) and the grantee about how the manuscript and the copyright in the manuscript are managed. It is useful to conceptually keep separate the grantee's manuscript submission obligation from its copyright permission obligation because the compliance personnel concerned with manuscript management may differ from those responsible for overseeing the author's copyright management. With respect to copyright management, the grantee has the following six options: (1) rely on authors to manage copyright but also to request or to require that these authors take responsibility for amending publication agreements that call for transfer of too many rights to enable the author to grant NIH permission to make the manuscript publicly accessible ('the Public Access License'); (2) take a more active role in assisting authors in negotiating the scope of any copyright transfer to a publisher by (a) providing advice to authors concerning their negotiations or (b) by acting as the author's agent in such negotiations; (3) enter into a side agreement with NIH-funded authors that grants a non-exclusive copyright license to the grantee sufficient to grant NIH the Public Access License; (4) enter into a side agreement with NIH-funded authors that grants a non-exclusive copyright license to the grantee sufficient to grant NIH the Public Access License and also grants a license to the grantee to make certain uses of the article, including posting a copy in the grantee's publicly accessible digital archive or repository and authorizing the article to be used in connection with teaching by university faculty; (5) negotiate a more systematic and comprehensive agreement with the biomedical publishers to ensure either that the publisher has a binding obligation to submit the manuscript and to grant NIH permission to make the manuscript publicly accessible or that the author retains sufficient rights to do so; or (6) instruct NIH-funded authors to submit manuscripts only to journals with binding deposit agreements with NIH or to journals whose copyright agreements permit authors to retain sufficient rights to authorize NIH to make manuscripts publicly accessible.

Patient Retention in Antiretroviral Therapy Programs in Sub-Saharan Africa: A Systematic Review

Paper published in PLoS Medicine in 2007.

The role of the community service order and the suspended sentence in Ireland: a judicial perspective

Imprisonment is the most severe penalty utilised by the criminal courts in Ireland. In recent decades the prison population has grown significantly despite expressions both official and public to reduce the use of the sanction. Two other sanctions are available to the Irish sentencer which may be used as a direct and comparable sentence in lieu of a term of imprisonment namely, the community service order and the suspended sentence. The community service order remains under-utilised as an alternative to the custodial sentence. The suspended sentence is used quite liberally but its function may be more closely related to the aim of deterrence rather than avoiding the use of the custodial sentence. Thus the aim of decarceration may not be optimal in practice when either sanction is utilised. The decarcerative effect of either sanction is largely dependent upon the specific purpose which judges invest in the sanction. Judges may also be inhibited in the use of either sanction if they lack confidence that the sentence will be appropriately monitored and executed. The purpose of this thesis is to examine the role of the community service order and the suspended sentence in Irish sentencing practice. Although community service and the suspended sentence present primarily as alternatives to the custodial sentence, the manner in which the judges utilise or fail to utilise the sanctions may differ significantly from this primary manifestation. Therefore the study proceeds to examine the judges' cognitions and expectations of both sanctions to explore their underlying purposes and to reveal the manner in which the judges use the sanctions in practice. To access this previously undisclosed information a number of methodologies were deployed. An extensive literature review was conducted to delineate the purpose and functionality of both sanctions. Quantitative data was gathered by way of sampling for the suspended sentence and the part-suspended sentence where deficiencies were apparent to show the actual frequency in use of that sanction. Qualitative methodologies were used by way of focus groups and semi-structured interviews of judges at all jurisdictional levels to elucidate the purposes of both sanctions. These methods allowed a deeper investigation of the factors which may promote or inhibit such usage. The relative under-utilisation of the community service order as an alternative to the custodial sentence may in part be explained by a reluctance by some judges to equate it with a real custodial sentence. For most judges who use the sanction, particularly at summary level, community service serves a decarcerative function. The suspended sentence continues to be used extensively. It operates partly as a decarcerative penalty but the purpose of deterrence may in practice overtake its theoretical purpose namely the avoidance of custody. Despite ongoing criticism of executive agencies such as the Probation Service and the Prosecution in the supervision of such penalties both sanctions continue to be used. Engagement between the Criminal Justice actors may facilitate better outcomes in the use of either sanction. The purposes for which both sanctions are deployed find their meaning essentially in the practices of the judges themselves as opposed to any statutory or theoretical claims upon their use or purpose.

Issues in the prescribing of psychotropic and psychoactive medication for persons with learning disability: quantitative and qualitative perspectives

The administration of psychotropic and psychoactive medication for persons with learning disability and accompanying mental illness and/or challenging behaviour has undergone much critical review over the past two decades. Assessment and diagnosis of mental illness in this population continues to be psychopharmacological treatment include polypharmacy, irrational prescription procedures and frequent over-prescription. It is clear that all forms of treatment including non-pharmacological interventions need to be driven by accurate and appropriate diagnoses. Where a psychiatric diagnosis has been identified, it greatly aides the selection of appropriate medication, although a specific medication for each diagnosis, as was once hoped, is simply no longer a reality in practice. Part one of the present thesis seeks to address many of the current issues in mental health problems and pharmacological treatment to date. The author undertook a drug prevalence study within both residential and community facilities for persons with learning disability within the Mid-West region of Ireland in order to ascertain the current level of prescribing of psychotropic and psychoactive medications for this population. While many attempts have been made to account for the variation in prescribing, little systematic and empirical research has been undertaken to investigate the factors thought to influence such prescribing. While studies investigating the prescribing behaviours of General Practitioners (GP's) have illustrated the complex nature of the decision making process in the context of general practice, no similar efforts have yet been directed at examining the prescribing behaviours of Consultant Psychiatrists. Using The Critical Incident Technique, the author interviewed Consultant Psychiatrists in the Republic of Ireland to gather information relating not only to their patterns of prescribing for learning disabled populations, but also to examine reasons influencing their prescribing in addition to several related factors. Part two of this thesis presents the findings from this study and a number of issues are raised, not only in relation to attempting to account for the findings from part one of the thesis, but also with respect to implications for improved management and clinical practice.

Cesarean section and rate of subsequent stillbirth, miscarriage and ectopic pregnancy: a Danish register-based cohort study

Background: With cesarean section rates increasing worldwide, clarity regarding negative effects is essential. This study aimed to investigate the rate of subsequent stillbirth, miscarriage, and ectopic pregnancy following primary cesarean section, controlling for confounding by indication. Methods and Findings: We performed a population-based cohort study using Danish national registry data linking various registers. The cohort included primiparous women with a live birth between January 1, 1982, and December 31, 2010 (n = 832,996), with follow-up until the next event (stillbirth, miscarriage, or ectopic pregnancy) or censoring by live birth, death, emigration, or study end. Cox regression models for all types of cesarean sections, sub-group analyses by type of cesarean, and competing risks analyses for the causes of stillbirth were performed. An increased rate of stillbirth (hazard ratio [HR] 1.14, 95% CI 1.01, 1.28) was found in women with primary cesarean section compared to spontaneous vaginal delivery, giving a theoretical absolute risk increase (ARI) of 0.03% for stillbirth, and a number needed to harm (NNH) of 3,333 women. Analyses by type of cesarean section showed similarly increased rates for emergency (HR 1.15, 95% CI 1.01, 1.31) and elective cesarean (HR 1.11, 95% CI 0.91, 1.35), although not statistically significant in the latter case. An increased rate of ectopic pregnancy was found among women with primary cesarean overall (HR 1.09, 95% CI 1.04, 1.15) and by type (emergency cesarean, HR 1.09, 95% CI 1.03, 1.15, and elective cesarean, HR 1.12, 95% CI 1.03, 1.21), yielding an ARI of 0.1% and a NNH of 1,000 women for ectopic pregnancy. No increased rate of miscarriage was found among women with primary cesarean, with maternally requested cesarean section associated with a decreased rate of miscarriage (HR 0.72, 95% CI 0.60, 0.85). Limitations include incomplete data on maternal body mass index, maternal smoking, fertility treatment, causes of stillbirth, and maternally requested cesarean section, as well as lack of data on antepartum/intrapartum stillbirth and gestational age for stillbirth and miscarriage. Conclusions: This study found that cesarean section is associated with a small increased rate of subsequent stillbirth and ectopic pregnancy. Underlying medical conditions, however, and confounding by indication for the primary cesarean delivery account for at least part of this increased rate. These findings will assist women and health-care providers to reach more informed decisions regarding mode of delivery.

Private health care coverage and increased risk of obstetric intervention

Background: When clinically indicated, common obstetric interventions can greatly improve maternal and neonatal outcomes. However, variation in intervention rates suggests that obstetric practice may not be solely driven by case criteria. Methods: Differences in obstetric intervention rates by private and public status in Ireland were examined using nationally representative hospital discharge data. A retrospective cohort study was performed on childbirth hospitalisations occurring between 2005 and 2010. Multivariate logistic regression analysis with correction for the relative risk was conducted to determine the risk of obstetric intervention (caesarean delivery, operative vaginal delivery, induction of labour or episiotomy) by private or public status while adjusting for obstetric risk factors. Results: 403,642 childbirth hospitalisations were reviewed; approximately one-third of maternities (30.2%) were booked privately. After controlling for relevant obstetric risk factors, women with private coverage were more likely to have an elective caesarean delivery (RR: 1.48; 95% CI: 1.45-1.51), an emergency caesarean delivery (RR: 1.13; 95% CI: 1.12-1.16) and an operative vaginal delivery (RR: 1.25; 95% CI: 1.22-1.27). Compared to women with public coverage who had a vaginal delivery, women with private coverage were 40% more likely to have an episiotomy (RR: 1.40; 95% CI: 1.38-1.43). Conclusions: Irrespective of obstetric risk factors, women who opted for private maternity care were significantly more likely to have an obstetric intervention. To better understand both clinical and non-clinical dynamics, future studies of examining health care coverage status and obstetric intervention would ideally apply mixed-method techniques.

Access to modified geiparvarins using Pd(0)-mediated C-C bond forming reactions

Geiparvarin is a natural product which contains both a 3(2H)-furanone and a coumarin moiety in its structure. The aim of this project was to investigate the use of Pd(0)-mediated C–C bondforming reactions to produce structurally modified geiparvarins. Chapter 1 consists of a review of the relevant literature, including that pertaining to the syntheses of selected naturally occurring 3(2H)-furanones. The known syntheses of geiparvarin and closely related analogues are examined, along with the documented biological activity of these compounds. The synthetic routes which allow access to 4-substituted-3(2H)-furanones are also described. Chapter 2 describes in detail the synthesis of a variety of novel structurally modified geiparvarins by two complementary routes, both approaches utilising Pd(0)-mediated crosscoupling reactions, and discusses the characterisation of these compounds. The preparation of 5-ethyl-3(2H)-furanones is described, as is their incorporation into geiparvarin and the corresponding 5″-alkylgeiparvarin analogues via formation and dehydration of intermediate alcohols. Halogenation of 5-ethyl-3(2H)-furanones and the corresponding geiparvarin derivatives is discussed, along with further reactions of the resulting halides. Preparation of 3″-arylgeiparvarins involving both Suzuki–Miyura and Stille reactions, using the appropriate intermediate iodides and bromides, is described. The application of Stille and Heck conditions to give 3″-ethenylgeiparvarin analogues and Sonogashira conditions to produce 3″-ethynylgeiparvarin analogues, using the relevant intermediate iodides, is also extensively outlined. Chapter 3 contains all of the experimental data and details of the synthetic methods employed for the compounds prepared during the course of this research. All novel compounds prepared were fully characterised using NMR spectroscopy, IR spectroscopy, mass spectrometry and elemental analysis; the details of which are included.

The effects of copayment policies on adherence to prescription medicines in publicly insured populations

Introduction: Copayments for prescriptions are associated with decreased adherence to medicines resulting in increased health service utilisation, morbidity and mortality. In October 2010 a 50c copayment per prescription item was introduced on the General Medical Services (GMS) scheme in Ireland, the national public health insurance programme for low-income and older people. The copayment was increased to €1.50 per prescription item in January 2013. To date, the impact of these copayments on adherence to prescription medicines on the GMS scheme has not been assessed. Given that the GMS population comprises more than 40% of the Irish population, this presents an important public health problem. The aim of this thesis was to assess the impact of two prescription copayments, 50c and €1.50, on adherence to medicines.Methods: In Chapter 2 the published literature was systematically reviewed with meta-analysis to a) develop evidence on cost-sharing for prescriptions and adherence to medicines and b) develop evidence for an alternative policy option; removal of copayments. The core research question of this thesis was addressed by a large before and after longitudinal study, with comparator group, using the national pharmacy claims database. New users of essential and less-essential medicines were included in the study with sample sizes ranging from 7,007 to 136,111 individuals in different medication groups. Segmented regression was used with generalised estimating equations to allow for correlations between repeated monthly measurements of adherence. A qualitative study involving 24 individuals was conducted to assess patient attitudes towards the 50c copayment policy. The qualitative and quantitative findings were integrated in the discussion chapter of the thesis. The vast majority of the literature on this topic area is generated in North America, therefore a test of generalisability was carried out in Chapter 5 by comparing the impact of two similar copayment interventions on adherence, one in the U.S. and one in Ireland. The method used to measure adherence in Chapters 3 and 5 was validated in Chapter 6. Results: The systematic review with meta-analysis demonstrated an 11% (95% CI 1.09 to 1.14) increased odds of non-adherence when publicly insured populations were exposed to copayments. The second systematic review found moderate but variable improvements in adherence after removal/reduction of copayments in a general population. The core paper of this thesis found that both the 50c and €1.50 copayments on the GMS scheme were associated with larger reductions in adherence to less-essential medicines than essential medicines directly after the implementation of policies. An important exception to this pattern was observed; adherence to anti-depressant medications declined by a larger extent than adherence to other essential medicines after both copayments. The cross country comparison indicated that North American evidence on cost-sharing for prescriptions is not automatically generalisable to the Irish setting. Irish patients had greater immediate decreases of -5.3% (95% CI -6.9 to -3.7) and -2.8% (95% CI -4.9 to -0.7) in adherence to anti-hypertensives and anti-hyperlipidaemic medicines, respectively, directly after the policy changes, relative to their U.S. counterparts. In the long term, however, the U.S. and Irish populations had similar behaviours. The concordance study highlighted the possibility of a measurement bias occurring for the measurement of adherence to non-steroidal anti-inflammatory drugs in Chapter 3. Conclusions: This thesis has presented two reviews of international cost-sharing policies, an assessment of the generalisability of international evidence and both qualitative and quantitative examinations of cost-sharing policies for prescription medicines on the GMS scheme in Ireland. It was found that the introduction of a 50c copayment and its subsequent increase to €1.50 on the GMS scheme had a larger impact on adherence to less-essential medicines relative to essential medicines, with the exception of anti-depressant medications. This is in line with policy objectives to reduce moral hazard and is therefore demonstrative of the value of such policies. There are however some caveats. The copayment now stands at €2.50 per prescription item. The impact of this increase in copayment has yet to be assessed which is an obvious point for future research. Careful monitoring for adverse effects in socio-economically disadvantaged groups within the GMS population is also warranted. International evidence can be applied to the Irish setting to aid in future decision making in this area, but not without placing it in the local context first. Patients accepted the introduction of the 50c charge, however did voice concerns over a rising price. The challenge for policymakers is to find the ‘optimal copayment’ – whereby moral hazard is decreased, but access to essential chronic disease medicines that provide advantages at the population level is not deterred. This evidence presented in this thesis will be utilisable for future policy-making in Ireland.