Pathway to clozapine use:a comparison between a patient cohort from New Zealand and a cohort from the United Kingdom

Background and Objective: Clozapine has been available since the early 1990s. Studies continue to demonstrate its superior efficacy in treatment-resistant schizophrenia. Despite this, numerous studies show under-utilisation, delayed access and reluctance by psychiatrists to prescribe clozapine. This retrospective cross-sectional study compared the prescribing of clozapine in two adult cohorts under the care of large public mental health services in Auckland (New Zealand) and Birmingham (United Kingdom) on 31 March 2007. Method: Time from first presentation to clozapine initiation, prior antipsychotics trialled and antipsychotic co-prescribing were compared. Data included demographics, psychiatric diagnosis, co-morbid conditions, year of first presentation, admissions and pharmacological treatment (clozapine dose, start date, prior antipsychotics, co-prescribed antipsychotic). Results: Overall, 664 people were prescribed clozapine (402 Auckland; 262 Birmingham); mean daily dose of 384 mg (Auckland) and 429 mg (Birmingham). 53 % presented after 1990 and the average duration of time before starting clozapine was significantly longer in the Birmingham cohort (6.5 vs. 5.3 years) but this reduced in both cohorts to a 1-year mean in those presenting within the last 3 years. The average number of antipsychotics trialled pre-clozapine for those presenting since 1990 was significantly higher in the Birmingham cohort (4.3 vs. 3.1) but in both cohorts this similarly reduced in those presenting within the last 3 years. Antipsychotic co-prescribing was significantly higher in the Birmingham cohort (22.9 vs. 10.7 %). Conclusions: There is evidence that access to clozapine has improved over time in both cohorts, with a reduction in the duration between presentation and initiation of clozapine and number of different antipsychotics trialled pre-clozapine. These are very positive findings in terms of optimising outcomes with clozapine and are possibly due to the impact of guideline recommendations, increasing clinician, consumer and carer knowledge, and experience with clozapine and funding changes. © 2014 Springer International Publishing.

Key Aspects and Approaches of Open Access, Open Data and Open Science

Overview of the key aspects and approaches to open access, open data and open science, emphasizing on sharing scientific knowledge for sustainable progress and development.

The complements towards developing a new risk management framework and Its applicability to the Nigerian power sector

The availability of regular supply has been identified as one of the major stimulants for the growth and development of any nation and is thus important for the economic well-being of a nation. The problems of the Nigerian power sector stems from a lot of factors culminating in her slow developmental growth and inability to meet the power demands of her citizens regardless of the abundance of human and natural resources prevalent in the nation. The research therefore had the main aim of investigating the importance and contributions of risk management to the success of projects specific to the power sector. To achieve this aim it was pertinent to examine the efficacy of risk management process in practice and elucidate the various risks typically associated with projects (Construction, Contractual, Political, Financial, Design, Human resource and Environmental risk factors) in the power sector as well as determine the current situation of risk management practice in Nigeria. To address this factors inhibiting the proficiency of the overarching and prevailing issue which have only been subject to limited in-depth academic research, a rigorous mixed research method was adopted (quantitative and qualitative data analysis). A review of the Nigeria power sector was also carried out as a precursor to the data collection stage. Using purposive sampling technique, respondents were identified and a questionnaire survey was administered. The research hypotheses were tested using inferential statistics (Pearson correlation, Chi-square test, t-test and ANOVA technique) and the findings revealed the need for the development of a new risk management implementation Framework. The proposed Framework was tested within a company project, for interpreting the dynamism and essential benefits of risk management with the aim of improving the project performances (time), reducing the level of fragmentation (quality) and improving profitability (cost) within the Nigerian power sector in order to bridge a gap between theory and practice. It was concluded that Nigeria’s poor risk management practices have prevented it from experiencing strong growth and development. The study however, concludes that the successful implementation of the developed risk management framework may help it to attain this status by enabling it to become more prepared and flexible, to face challenges that previously led to project failures, and thus contributing to its prosperity. The research study provides an original contribution theoretically, methodologically and practically which adds to the project risk management body of knowledge and to the Nigerian power sector.

Knowledge acquisition and research evidence in autism:researcher and practitioner perspectives and engagement

Background: Government policy and national practice guidelines have created an increasing need for autism services to adopt an evidence-based practice approach. However, a gap continues to exist between research evidence and its application. This study investigated the difference between autism researchers and practitioners in their methods of acquiring knowledge. Methods: In a questionnaire study, 261 practitioners and 422 researchers reported on the methods they use and perceive to be beneficial for increasing research access and knowledge. They also reported on their level of engagement with members of the other professional community. Results: Researchers and practitioners reported different methods used to access information. Each group, however, had similar overall priorities regarding access to research information. While researchers endorsed the use of academic journals significantly more often than practitioners, both groups included academic journals in their top three choices. The groups differed in the levels of engagement they reported; researchers indicated they were more engaged with practitioners than vice versa. Conclusions: Comparison of researcher and practitioner preferences led to several recommendations to improve knowledge sharing and translation, including enhancing access to original research publications, facilitating informal networking opportunities and the development of proposals for the inclusion of practitioners throughout the research process.

Doctor-Patient Knowledge Transfer: Innovative Technologies and Policy Implications

The aim of this study was to empirically investigate the barriers in doctor-patient communication and knowledge transfer and the role of innovative technologies in overcoming these barriers. We applied qualitative research methods. Our results show that patients extensively use information sources, primarily the Internet before the visits. Patients regularly apply a self-diagnosis regarding their diseases. This implies several risks as many of them are not able to properly interpret the found information and at the same time the information might not be reliable. To overcome these risks efforts are required within the fields of technology developments for making web sites more reliable and improvement of the health culture of patients, as well. Our research identified the most significant barriers of doctor-patient communication including limited time, the patients’ distress, inadequate health culture and prior knowledge, as well as poor communication skills of some clinicians. Technology might help clinicians to use their limited time more effectively. In the long term, innovative technology solutions might take over some tasks of the health care personnel if they provide reliable health information adapted to the patient’s health, emotional and psychosocial status. Barriers of access to the new technology should be identified and addressed otherwise it would increase the already existing knowledge gap between patients and doctors.

Organizational response to employment under the ADA of workers with psychiatric disabilities: Four case studies

Title 1 of the Americans with Disabilities Act (ADA) requires all employers, public and private, with more than fifteen employees to provide reasonable accommodation to qualified individuals with disabilities if the accommodation would, within limits, allow the individual to perform the essential functions of the job. Seven years after Congress enacted the law and five years after the initial provisions became effective, little information is available about the experience of organizations faced with requests for workplace accommodation.^ The question addressed in this study is: How are organizations responding to the ADA mandate to fit individuals with psychiatric disabilities in the workplace? The data sources are three organizations that allowed access to this sensitive information, and a fourth that had two disability discrimination charges filed against it.^ A brute-force case method approach applied to the four organizations yields the following information: Attorneys are hesitant to allow inquiry into company policy owing to fear of litigation; workers are not disclosing and requesting accommodation; tacit accommodation of long-standing employees appears to be a regular practice; knowledge of the intent of the ADA makes a difference in terms of equality of treatment; and insensitivity to employee privacy results in an adversarial situation.^ Implications are relevant to the need to improve lines of communication between human resource, EEO, supervisory, and legal staff; consequences of failure to address accommodations on an explicit level; need for better understanding of the availability and use of outside resources for achieving accommodation; and improvement of self-advocacy and disclosure by the employees with disabilities. ^

An aspect-oriented approach to designing role-based access control services

Access control (AC) limits access to the resources of a system only to authorized entities. Given that information systems today are increasingly interconnected, AC is extremely important. The implementation of an AC service is a complicated task. Yet the requirements to an AC service vary a lot. Accordingly, the design of an AC service should be flexible and extensible in order to save development effort and time. Unfortunately, with conventional object-oriented techniques, when an extension has not been anticipated at the design time, the modification incurred by the extension is often invasive. Invasive changes destroy design modularity, further deteriorate design extensibility, and even worse, they reduce product reliability. ^ A concern is crosscutting if it spans multiple object-oriented classes. It was identified that invasive changes were due to the crosscutting nature of most unplanned extensions. To overcome this problem, an aspect-oriented design approach for AC services was proposed, as aspect-oriented techniques could effectively encapsulate crosscutting concerns. The proposed approach was applied to develop an AC framework that supported role-based access control model. In the framework, the core role-based access control mechanism is given in an object-oriented design, while each extension is captured as an aspect. The resulting framework is well-modularized, flexible, and most importantly, supports noninvasive adaptation. ^ In addition, a process to formalize the aspect-oriented design was described. The purpose is to provide high assurance for AC services. Object-Z was used to specify the static structure and Predicate/Transition net was used to model the dynamic behavior. Object-Z was extended to facilitate specification in an aspect-oriented style. The process of formal modeling helps designers to enhance their understanding of the design, hence to detect problems. Furthermore, the specification can be mathematically verified. This provides confidence that the design is correct. It was illustrated through an example that the model was ready for formal analysis. ^

Space division multiple access for wireless sensor networks

This dissertation proposed a self-organizing medium access control protocol (MAC) for wireless sensor networks (WSNs). The proposed MAC protocol, space division multiple access (SDMA), relies on sensor node position information and provides sensor nodes access to the wireless channel based on their spatial locations. SDMA divides a geographical area into space divisions, where there is one-to-one map between the space divisions and the time slots. Therefore, the MAC protocol requirement is the sensor node information of its position and a prior knowledge of the one-to-one mapping function. The scheme is scalable, self-maintaining, and self-starting. It provides collision-free access to the wireless channel for the sensor nodes thereby, guarantees delay-bounded communication in real time for delay sensitive applications. This work was divided into two parts: the first part involved the design of the mapping function to map the space divisions to the time slots. The mapping function is based on a uniform Latin square. A Uniform Latin square of order k = m 2 is an k x k square matrix that consists of k symbols from 0 to k-1 such that no symbol appears more than once in any row, in any column, or in any m x in area of main subsquares. The uniqueness of each symbol in the main subsquares presents very attractive characteristic in applying a uniform Latin square to time slot allocation problem in WSNs. The second part of this research involved designing a GPS free positioning system for position information. The system is called time and power based localization scheme (TPLS). TPLS is based on time difference of arrival (TDoA) and received signal strength (RSS) using radio frequency and ultrasonic signals to measure and detect the range differences from a sensor node to three anchor nodes. TPLS requires low computation overhead and no time synchronization, as the location estimation algorithm involved only a simple algebraic operation.

Scottsdale Community College Provides their Students Open Access with End-to-End Virtualization

Due to shrinking budgets and new demands for technology, Scottsdale Community College (SCC) IT department needed an effective, sustainable solution that would provide ubiquitous access to technology for students, faculty, and staff, both on- and off-campus. This paper explores how SCC implemented a complete virtualized computing environment.

Employee perceptions of workplace empowerment in relation to self -reported intent to stay on the job

As the nursing profession faces a shortage of nurses, workplace initiatives focused on retaining employees are critical to the United States healthcare industry (Sochalski, 2002). The purpose of this research was to determine whether self-reported intent to stay on the job was related to perceptions of workplace empowerment using Kanter's (1977) theory of organizational empowerment as a framework. ^ The sample consisted of 206 Florida registered nurses. Four self-report scales and a demographic questionnaire were administered by mail. The Conditions for Work Effectiveness Questionnaire (CWEQ; Chandler, 1987), Job Activity Scale (JAS; Laschinger, Kutzscher, & Sabiston, 1993), Organizational Relationships Scale (ORS; Laschinger, Sabiston, & Kutzscher, 1993) and an intent to stay instrument (Kim, Price, Mueller & Watson, 1996) were used to measure perceived access to empowerment structures, perceived formal power, perceived informal power, and intent to stay, respectively. The data were analyzed using descriptive statistics, correlational analysis, and hierarchical regression. ^ Twenty-eight percent of the variance of intent to stay was explained by perceived access to empowerment structures, perceived formal power, and perceived informal power when holding age, gender, education, overall nursing experience, and number of years on current job constant. Perceived access to empowerment structures (CWEQ total score) was the best predictor of self-reported intent to stay for this sample. Of the four components of perceived access to work empowerment structures, perceived access to opportunity and resources were the best predictors of nurses' intent to stay on the job. ^ This study was the first step in establishing the relationship between Kanter's full model and intent to remain on the job, which is a stepping stone for the development of effective retention strategies based on a workplace empowerment model. This knowledge is particularly important in today's healthcare industry where healthcare administrators and human resource development practitioners are ideally positioned to implement organizational strategies to enhance access to work empowerment structures and potentially reduce turnover and mitigate the effects of nursing shortage. ^

Nutrition Knowledge of Amateur Bicyclists in South Florida, USA

Nutrition is an important component in chronic disease prevention. Diet plays an important role in the athletic performance and the overall health of the amateur bicyclists; yet information concerning diet and amateur bicyclists is lacking. This was a cross-sectional, convenience sample of 125 amateur bicyclists ages 18-65 years from South Florida who consented to SurveyMonkey, web-designed survey on nutrition knowledge. The survey was validated for endurance runners. Less than one-quarter of the participants had adequate nutrition knowledge (score of 75% or higher). Female bicyclists scored higher on nutrition knowledge as compared to males. There were no differences in nutrition knowledge by race, marital status, education or income. Accessibility to nutrition information is abundant, yet the validity of this information is questionable. Amateur bicyclist may not have access to the health professionals available to professional athletes. There is a need for nutrition counseling targeting amateur athletes.

A PHR system with policy-based fine-grained access control and revocation mechanism

Collaborative sharing of information is becoming much more needed technique to achieve complex goals in today's fast-paced tech-dominant world. Personal Health Record (PHR) system has become a popular research area for sharing patients informa- tion very quickly among health professionals. PHR systems store and process sensitive information, which should have proper security mechanisms to protect patients' private data. Thus, access control mechanisms of the PHR should be well-defined. Secondly, PHRs should be stored in encrypted form. Cryptographic schemes offering a more suitable solution for enforcing access policies based on user attributes are needed for this purpose. Attribute-based encryption can resolve these problems, we propose a patient-centric framework that protects PHRs against untrusted service providers and malicious users. In this framework, we have used Ciphertext Policy Attribute Based Encryption scheme as an efficient cryptographic technique, enhancing security and privacy of the system, as well as enabling access revocation. Patients can encrypt their PHRs and store them on untrusted storage servers. They also maintain full control over access to their PHR data by assigning attribute-based access control to selected data users, and revoking unauthorized users instantly. In order to evaluate our system, we implemented CP-ABE library and web services as part of our framework. We also developed an android application based on the framework that allows users to register into the system, encrypt their PHR data and upload to the server, and at the same time authorized users can download PHR data and decrypt it. Finally, we present experimental results and performance analysis. It shows that the deployment of the proposed system would be practical and can be applied into practice.

Using knowledge management to give context to analytics and big data and reduce strategic risk

At the moment, the phrases “big data” and “analytics” are often being used as if they were magic incantations that will solve all an organization’s problems at a stroke. The reality is that data on its own, even with the application of analytics, will not solve any problems. The resources that analytics and big data can consume represent a significant strategic risk if applied ineffectively. Any analysis of data needs to be guided, and to lead to action. So while analytics may lead to knowledge and intelligence (in the military sense of that term), it also needs the input of knowledge and intelligence (in the human sense of that term). And somebody then has to do something new or different as a result of the new insights, or it won’t have been done to any purpose. Using an analytics example concerning accounts payable in the public sector in Canada, this paper reviews thinking from the domains of analytics, risk management and knowledge management, to show some of the pitfalls, and to present a holistic picture of how knowledge management might help tackle the challenges of big data and analytics.

The Barriers to the Integration of the Uterine Balloon Tamponade into South Africa and Ghana's Health Systems for the Management of Postpartum Hemorrhage

Background

Postpartum hemorrhage is the most significant contributor to maternal mortality globally, claiming 140,000 lives annually. Postpartum hemorrhage is a leading cause of maternal death in South Africa, with the literature indicating that 80 percent of the postpartum hemorrhage deaths in South Africa are avoidable. Ghana, as of 2010, witnesses 2700 maternal deaths annually, primarily because of poor quality of care in health facilities and services being difficult to access. As per WHO recommendations, uterotonics are integral to treating postpartum hemorrhage as soon as it is diagnosed. In case of persistent bleeding or limited availability of uterotonics, the uterine balloon tamponade (UBT) can be used as a second line of defense. If both these measures are unable to counter the bleeding, providers must perform surgical interventions. Literature on the UBT, as one tool in the protocol to address postpartum hemorrhage, has shown it to have success rates ranging from 60 to 100 percent. Despite the potential to lower the number of postpartum hemorrhage deaths in South Africa and Ghana, the UBT has not been incorporated widely in South Africa and Ghana. The aim of this study is to describe the barriers involved with integrating the UBT into South Africa and Ghana’s health systems to address postpartum hemorrhage.

Methods

The study took place in multiple sites in South Africa (Cape Town, Johannesburg, Durban and Mpumalanga) and in Accra, Ghana. South Africa and Ghana were selected because postpartum hemorrhage contributes greatly to their maternal mortality numbers and there is potential in both countries to lower those rates through greater use of the UBT. A total of 25 participants were interviewed through purposive sampling, snowball sampling and participant referrals, and included various categories of stakeholders integral to the integration process of a medical device. Individual in-depth interviews were used for data collection, with interview questions being tailored to each stakeholder category. The focus of the interviews was on the protocol used to counter postpartum hemorrhage, the frequency with which the UBT is used as part of the protocol, and the process of integrating it into the South Africa and Ghana’s health systems. The data collected were coded using NVivo and analyzed using content analysis.

Results

The barriers to integration of the uterine balloon tamponade to address postpartum hemorrhage in South Africa and Ghana were evident on the political, economic and health delivery levels. The results indicated that the barriers to integration in South Africa included the low recognition of postpartum hemorrhage as a problem, the lack of clarity surrounding the role of the Medicines Control Council as a regulatory body for medical devices, and low awareness of the UBT as an intervention to control postpartum hemorrhage. The barriers in Ghana were the cash constraints experienced by the Ghana Health Services to fund medical devices, a heavy reliance on donors for funding, and the lack of consistent knowledge on processes involving clinical trials for new medical devices in Ghana.

Conclusion

Existing literature on methods to counter postpartum hemorrhage to reduce maternal mortality has focused on and emphasized the efficacy of the UBT. Despite overwhelming evidence supporting the use of the UBT, many health systems across the world, particularly low-income countries, do not have access to the device owing to numerous barriers in integrating the device into obstetric care. This study illustrates the need to focus on incorporating the UBT into health systems for greater availability to health workers and its use as standard of care. Ultimately, this study can be used as a stepping-stone for more research on this subject, providing evidence to influence policymakers to integrate the UBT into their protocols for postpartum hemorrhage response.

A Framework to Support the Sharing and Reuse of Computable Phenotype Definitions Across Health Care Delivery and Clinical Research Applications.

INTRODUCTION: The ability to reproducibly identify clinically equivalent patient populations is critical to the vision of learning health care systems that implement and evaluate evidence-based treatments. The use of common or semantically equivalent phenotype definitions across research and health care use cases will support this aim. Currently, there is no single consolidated repository for computable phenotype definitions, making it difficult to find all definitions that already exist, and also hindering the sharing of definitions between user groups. METHOD: Drawing from our experience in an academic medical center that supports a number of multisite research projects and quality improvement studies, we articulate a framework that will support the sharing of phenotype definitions across research and health care use cases, and highlight gaps and areas that need attention and collaborative solutions. FRAMEWORK: An infrastructure for re-using computable phenotype definitions and sharing experience across health care delivery and clinical research applications includes: access to a collection of existing phenotype definitions, information to evaluate their appropriateness for particular applications, a knowledge base of implementation guidance, supporting tools that are user-friendly and intuitive, and a willingness to use them. NEXT STEPS: We encourage prospective researchers and health administrators to re-use existing EHR-based condition definitions where appropriate and share their results with others to support a national culture of learning health care. There are a number of federally funded resources to support these activities, and research sponsors should encourage their use.