Supporting self-management: development and evaluation of a digital resource for adults with asthma

The problem: Around 300 million people worldwide have asthma and prevalence is increasing. Support for optimal self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. Aim: The purpose of this project was to explore the potential role of a digital intervention in promoting optimum self-management in adults with asthma. Methods: Following the MRC Guidance on the Development and Evaluation of Complex Interventions which advocates using theory, evidence, user testing and appropriate modelling and piloting, this project had 3 phases. Phase 1: Examination of the literature to inform phases 2 and 3, using systematic review methods and focussed literature searching. Phase 2: Developing the Living Well with Asthma website. A prototype (paper-based) version of the website was developed iteratively with input from a multidisciplinary expert panel, empirical evidence from the literature (from phase 1), and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process. The paper-based designs were converted to the website through an iterative user centred process (think aloud studies with adults with asthma). Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Phase 3: A pilot randomised controlled trial over 12 weeks to evaluate the feasibility of a Phase 3 trial of Living Well with Asthma to support self-management. Primary outcomes were 1) recruitment & retention; 2) website use; 3) Asthma Control Questionnaire (ACQ) score change from baseline; 4) Mini Asthma Quality of Life (AQLQ) score change from baseline. Secondary outcomes were patient activation, adherence, lung function, fractional exhaled nitric oxide (FeNO), generic quality of life measure (EQ-5D), medication use, prescribing and health services contacts. Results: Phase1: Demonstrated that while digital interventions show promise, with some evidence of effectiveness in certain outcomes, participants were poorly characterised, telling us little about the reach of these interventions. The interventions themselves were poorly described making drawing definitive conclusions about what worked and what did not impossible. Phase 2: The literature indicated that important aspects to cover in any self-management intervention (digital or not) included: asthma action plans, regular health professional review, trigger avoidance, psychological functioning, self-monitoring, inhaler technique, and goal setting. The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback during think aloud studies was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties. Phase 3: To achieve our recruitment target 5383 potential participants were invited, leading to 51 participants randomised (25 to intervention group). Age range 16-78 years; 75% female; 28% from most deprived quintile. Nineteen (76%) of the intervention group used the website for an average of 23 minutes. Non-significant improvements in favour of the intervention group observed in the ACQ score (-0.36; 95% confidence interval: -0.96, 0.23; p=0.225), and mini-AQLQ scores (0.38; -0.13, 0.89; p=0.136). A significant improvement was observed in the activity limitation domain of the mini-AQLQ (0.60; 0.05 to 1.15; p = 0.034). Secondary outcomes showed increased patient activation and reduced reliance on reliever medication. There was no significant difference in the remaining secondary outcomes. There were no adverse events. Conclusion: Living Well with Asthma has been shown to be acceptable to potential end users, and has potential for effectiveness. This intervention merits further development, and subsequent evaluation in a Phase III full scale RCT.

Burden of epilepsy: a prevalence-based cost of illness study of direct, indirect and intangible costs for epilepsy

OBJECTIVES: We aimed to gauge the burden of epilepsy in China from a societal perspective by estimating the direct, indirect and intangible costs. METHODS: Patients with epilepsy and controls were enrolled from two tertiary hospitals in China. Patients were asked to complete a Cost-of-Illness (COI), Willingness-to-Pay (WTP) questionnaires, two utility elicitation instruments and Mini Mental State Examination (MMSE). Healthy controls only completed WTP questionnaire, and utility instruments. Univariate analyses were performed to investigate the differences in cost on the basis of different variables, while multivariate analysis was undertaken to explore the predictors of cost/cost component. RESULTS: In total, 141 epilepsy patients and 323 healthy controls were recruited. The median total cost, direct cost and indirect cost due to epilepsy were US$949.29, 501.34 and 276.72, respectively. Particularly, cost of anti-epileptic drugs (AEDs) (US$394.53) followed by cost of investigations (US$59.34), cost of inpatient and outpatient care (US$9.62) accounted for the majority of the direct medical costs. While patients' (US$103.77) and caregivers' productivity costs (US$103.77) constituted the major component of indirect cost. The intangible costs in terms of WTP value (US$266.07 vs. 88.22) and utility (EQ-5D, 0.828 vs. 0.923; QWB-SA, 0.657 vs. 0.802) were both substantially higher compared to the healthy subjects. CONCLUSIONS: Epilepsy is a cost intensive disease in China. According to the prognostic groups, drug-resistant epilepsy generated the highest total cost whereas patients in seizure remission had the lowest cost. AED is the most costly component of direct medical cost probably due to 83% of patients being treated by new generation of AEDs.

Effect of investigation intensity and treatment differences on prostate cancer survivor's physical symptoms, psychological well-being and health-related quality of life: a two country cross-sectional study.

Aim: To investigate effects on men's health and well-being of higher prostate cancer (PCa) investigation and treatment levels in similar populations. Participants: PCa survivors in Ireland where the Republic of Ireland (RoI) has a 50% higher PCa incidence than Northern Ireland (NI). Method: A cross-sectional postal questionnaire was sent to PCa survivors 2–18 years post-treatment, seeking information about current physical effects of treatment, health-related quality of life (HRQoL; EORTC QLQ-C30; EQ-5D-5L) and psychological well-being (21 question version of the Depression, Anxiety and Stress Scale, DASS-21). Outcomes in RoI and NI survivors were compared, stratifying into ‘late disease’ (stage III/IV and any Gleason grade (GG) at diagnosis) and ‘early disease’ (stage I/II and GG 2–7). Responses were weighted by age, jurisdiction and time since diagnosis. Between-country differences were investigated using multivariate logistic and linear regression. Results: 3348 men responded (RoI n=2567; NI n=781; reflecting population sizes, response rate 54%). RoI responders were younger; less often had comorbidities (45% vs 38%); were more likely to present asymptomatically (66%; 41%) or with early disease (56%; 35%); and less often currently used androgen deprivation therapy (ADT; 2%; 28%). Current prevalence of incontinence (16%) and impotence (56% early disease, 67% late disease) did not differ between RoI and NI. In early disease, only current bowel problems (RoI 12%; NI 21%) differed significantly in multivariate analysis. In late disease, NI men reported significantly higher levels of gynaecomastia (23% vs 9%) and hot flashes(41% vs 19%), but when ADT users were analysed separately, differences disappeared. For HRQoL, in multivariate analysis, only pain (early disease: RoI 11.1, NI 19.4) and financial difficulties (late disease: RoI 10.4, NI 7.9) differed significantly between countries. There were no significant between-country differences in DASS-21 or index ED-5D-5L score. Conclusions: Treatment side effects were commonly reported and increased PCa detection in RoI has left more men with these side effects. We recommended that men be offered a PSA test only after informed discussion.

Older adults' quality of life - exploring the role of the built environment and social cohesion in community-dwelling seniors on low income

The built environment and social cohesion are increasingly recognized as being associated with older adults' quality of life (QoL). However, limited research in this area still exists and the relationship has remained unexplored in the area of Metro Vancouver, Canada. This study examined the association between the built environment and social cohesion with QoL of 160 community-dwelling older adults (aged ≥ 65 years) on low income from Metro Vancouver. Cross-sectional data acquired from the Walk the Talk (WTT) study were used. Health-related QoL (HRQoL) and capability wellbeing were assessed using the EQ-5D-5L and the ICECAP-O, respectively. Measures of the environment comprised the NEWS-A (perceived built environment measure), the Street Smart Walk Score (objective built environment measure), and the SC-5PT (a measure of social cohesion). The primary analysis consists of Tobit regression models to explore the associations between environmental features and HRQoL as well as capability wellbeing. Key findings indicate that after adjusting for covariates, older adults' capability wellbeing was associated with street connectivity and social cohesion, while no statistically significant associations were found between environmental factors and HRQoL. Our results should be considered as hypothesis-generating and need confirmation in a larger longitudinal study.

1-D hydrogen-bonded organization of hexanuclear {3d-4f-5d} complexes: evidence for slow relaxation of the magnetization for [{LMe2Ni(H2O)Ln(H2O)4.5}2{W(CN)8}2] with Ln = Tb and Dy

Heterometallic {3d-4f-5d} aggregates with formula [{LMe2Ni(H2O)Ln(H2O)4.5}2{W(CN)8}2]·15H2O, (LMe2 stands for N,N-2,2-dimethylpropylenedi(3-methoxysalicylideneiminato) Schiff-base ligand) with Ln = Gd, Tb, Dy, have been obtained by reacting bimetallic [LMe2Ni(H2O)2Ln(NO3)3] and Cs3{W(CN)8} in H2O. The hexanuclear complexes are organized in 1-D arrays by means of hydrogen bonds established between the solvent molecules coordinated to Ln and the CN ligands of an octacyanometallate moiety. The X-ray structure was solved for the Tb derivative. Magnetic behavior indicates ferromagnetic {W–Ni} and {Ni–Ln} interactions (JNiW = 18.5 cm-1, JNiGd = 1.85 cm-1) as well as ferromagnetic intermolecular interactions mediated by the H-bonds. Dynamic magnetic susceptibility studies reveal slow magnetic relaxation processes for the Tb and Dy derivatives, suggesting SMM type behavior for these compounds.

Motivation, development and validation of a new spectral greenness index : a spectral dimension related to foliage projective cover

A method is presented for the development of a regional Landsat-5 Thematic Mapper (TM) and Landsat-7 Enhanced Thematic Mapper plus (ETM+) spectral greenness index, coherent with a six-dimensional index set, based on a single ETM+ spectral image of a reference landscape. The first three indices of the set are determined by a polar transformation of the first three principal components of the reference image and relate to scene brightness, percent foliage projective cover (FPC) and water related features. The remaining three principal components, of diminishing significance with respect to the reference image, complete the set. The reference landscape, a 2200 km2 area containing a mix of cattle pasture, native woodland and forest, is located near Injune in South East Queensland, Australia. The indices developed from the reference image were tested using TM spectral images from 19 regionally dispersed areas in Queensland, representative of dissimilar landscapes containing woody vegetation ranging from tall closed forest to low open woodland. Examples of image transformations and two-dimensional feature space plots are used to demonstrate image interpretations related to the first three indices. Coherent, sensible, interpretations of landscape features in images composed of the first three indices can be made in terms of brightness (red), foliage cover (green) and water (blue). A limited comparison is made with similar existing indices. The proposed greenness index was found to be very strongly related to FPC and insensitive to smoke. A novel Bayesian, bounded space, modelling method, was used to validate the greenness index as a good predictor of FPC. Airborne LiDAR (Light Detection and Ranging) estimates of FPC along transects of the 19 sites provided the training and validation data. Other spectral indices from the set were found to be useful as model covariates that could improve FPC predictions. They act to adjust the greenness/FPC relationship to suit different spectral backgrounds. The inclusion of an external meteorological covariate showed that further improvements to regional-scale predictions of FPC could be gained over those based on spectral indices alone.

The neglected dimension of community liveability : impact on social connectedness and active ageing in higher density accommodation

Purpose This thesis is about liveability, place and ageing in the high density urban landscape of Brisbane, Australia. As with other major developed cities around the globe, Brisbane has adopted policies to increase urban residential densities to meet the main liveability and sustainability aim of decreasing car dependence and therefore pollution, as well as to minimise the loss of greenfield areas and habitats to developers. This objective hinges on urban neighbourhoods/communities being liveable places, which residents do not have to leave for everyday living. Community/neighbourhood liveability is an essential ingredient in healthy ageing in place and has a substantial impact upon the safety, independence and well-being of older adults. It is generally accepted that ageing in place is optimal for both older people and the state. The optimality of ageing in place generally assumes that there is a particular quality to environments or standard of liveability in which people successfully age in place. The aim of this thesis was to examine if there are particular environmental qualities or aspects of liveability that test optimality and to better understand the key liveability factors that contribute to successful ageing in place. Method A strength of this thesis is that it draws on two separate studies to address the research question of what makes high density liveable for older people. In Chapter 3, the two methods are identified and differentiated as Method 1 (used in Paper 1) and Method 2 (used in Papers 2, 3, 4 and 5). Method 1 involved qualitative interviews with 24 inner city high density Brisbane residents. The major strength of this thesis is the innovative methodology outlined in the thesis as Method 2. Method 2 involved a case study approach employing qualitative and quantitative methods. Qualitative data was collected using semi-structured, in-depth interviews and time-use diaries completed by participants during the week of tracking. The quantitative data was gathered using Global Positioning Systems for tracking and Geographical Information Systems for mapping and analysis of participants’ activities. The combination of quantitative and qualitative analysis captured both participants’ subjective perceptions of their neighbourhoods and their patterns of movement. This enhanced understanding of how neighbourhoods and communities function and of the various liveability dimensions that contribute to active ageing and ageing in place for older people living in high density environments. Both studies’ participants were inner-city high density residents of Brisbane. The study based on Method 1 drew on a wider age demographic than the study based on Method 2. Findings The five papers presented in this thesis by publication indicate a complex inter-relationship of the factors that make a place liveable. The first three papers identify what is comparable and different between the physical and social factors of high density communities/neighbourhoods. The last two papers explore relationships between social engagement and broader community variables such as infrastructure and the physical built environments that are risk or protective factors relevant to community liveability, active ageing and ageing in place in high density. The research highlights the importance of creating and/or maintaining a barrier-free environment and liveable community for ageing adults. Together, the papers promote liveability, social engagement and active ageing in high density neighbourhoods by identifying factors that constitute liveability and strategies that foster active ageing and ageing in place, social connections and well-being. Recommendations There is a strong need to offer more support for active ageing and ageing in place. While the data analyses of this research provide insight into the lived experience of high density residents, further research is warranted. Further qualitative and quantitative research is needed to explore in more depth, the urban experience and opinions of older people living in urban environments. In particular, more empirical research and theory-building is needed in order to expand understanding of the particular environmental qualities that enable successful ageing in place in our cities and to guide efforts aimed at meeting this objective. The results suggest that encouraging the presence of more inner city retail outlets, particularly services that are utilised frequently in people’s daily lives such as supermarkets, medical services and pharmacies, would potentially help ensure residents fully engage in their local community. The connectivity of streets, footpaths and their role in facilitating the reaching of destinations are well understood as an important dimension of liveability. To encourage uptake of sustainable transport, the built environment must provide easy, accessible connections between buildings, walkways, cycle paths and public transport nodes. Wider streets, given that they take more time to cross than narrow streets, tend to .compromise safety - especially for older people. Similarly, the width of footpaths, the level of buffering, the presence of trees, lighting, seating and design of and distance between pedestrian crossings significantly affects the pedestrian experience for older people and impacts upon their choice of transportation. High density neighbourhoods also require greater levels of street fixtures and furniture for everyday life to make places more useable and comfortable for regular use. The importance of making the public realm useful and habitable for older people cannot be over-emphasised. Originality/value While older people are attracted to high density settings, there has been little empirical evidence linking liveability satisfaction with older people’s use of urban neighbourhoods. The current study examined the relationships between community/neighbourhood liveability, place and ageing to better understand the implications for those adults who age in place. The five papers presented in this thesis add to the understanding of what high density liveable age-friendly communities/ neighbourhoods are and what makes them so for older Australians. Neighbourhood liveability for older people is about being able to age in place and remain active. Issues of ageing in Australia and other areas of the developed world will become more critical in the coming decades. Creating livable communities for all ages calls for partnerships across all levels of government agencies and among different sectors within communities. The increasing percentage of older people in the community will have increasing political influence and it will be a foolish government who ignores the needs of an older society.

The psychometric properties of the Spanish version of the Foot Health Status Questionnaire

Purpose: Clinical studies suggest that foot pain may be problematic in one-third of patients in early disease. The Foot Health Status Questionnaire (FHSQ) was developed and validated to evaluate the effectiveness of conservative (orthoses, taping, stretching) and surgery interventions. Despite this fact, there are few validated instruments that measure foot health status in Spanish. Thus, the primary aim of the current study was to translate and evaluate psychometrically a Spanish version of FHSQ. Methods: A cross-sectional study was designed in a university community-based podiatric clinic located in south of Spain. All participants (n = 107) recruited consecutively completed a Spanish version of FHSQ and EuroQoL Health Questionnaire 5 dimensions, and 29 participants repeated these same measures 48 h later. Data analysis included test–retest reliability, construct and criterion-related validity and factor analyses. Results: Construct validity was appropriate with moderate-to-high corrected item–subscale correlations (α = ≥0.739) for all subscales. Test–retest reliability was satisfactory (ICC > 0.932). Factor analysis revealed four dimensions with 86.6 % of the common variance explained. The confirmatory factor analysis findings demonstrated that the proposed structure was well supported (comparative fit index = 0.92, standardized root mean square = 0.09). The Spanish EuroQoL 5D score negatively correlated with the FHSQ pain (r = −0.445) and positively with general foot health and function (r = 0.261 − 0.579), confirming criterion-related validity. Conclusion: The clinimetric properties of the Spanish version of FHSQ were satisfactory.

The human dimension of nosocomial wound infection : a study in liminality

Nosocomial wound infection is a disease that has to date been primarily understood through the language of science and biomedicine. This paper reports on findings from a sociological, interpretive study that focused on the experiential dimension of this phenomenon. The illness experience of a nosocomial wound infection is examined within a cultural milieu that values the smooth, untroubled body and alternatively ascribes cultural meaning to a body that has a definable illness. Within this context the person with a chronic wound from nosocomial infection defies normative categorisation and is thus situated outside the patterning of society. The human dimension of nosocomial wound infection includes the private, existential and embodied aspects of living with a chronic, infected wound. This report indicates that the experiential dimension is characterised by an embodied state of liminality. People with this illness live an indeterminate existence that is in-between health and illness, cure and disease. As such they have no recognised place in the medical or social world.

“Freer than we Feel” : Applying the Critical Dimension of Consciousness to Children’s Multimodal Encoding

Reports of children and teachers taking transformative social action in schools are becoming rare. This session illustrates how teachers, while feeling the weight of accountability testing in schools, are active agents who can re-imagine literacy pedagogy to change elements of their community. It reports the critical dimensions of a movie-making unit with Year 5 students within a school reform project. The students filmed interviews with people in the local shops to gather lay-knowledge and experiences of the community. The short documentaries challenged stereotypes about what it is like to live in Logan, and critically identified potential improvements to public spaces in the local community. A student panel presented these multimodal texts at a national conference of social activists and community leaders. The report does not valorize or privilege local or lay knowledge over dominant knowledge, but argues that prescribed curriculum should not hinder the capacity for critical consciousness.

A randomised, concentration-controlled, comparison of standard (5-day) vs. prolonged (15-day) infusions of etoposide phosphate in small-cell lung cancer

Purpose: This randomised trial was designed to investigate the activity and toxicity of continuous infusion etoposide phosphate (EP), targeting a plasma etoposide concentration of either 3 μg/ml for five days (5d) or 1 μg/ml for 15 days (15d), in previously untreated SCLC patients with extensive disease. Patients and methods: EP was used as a single agent. Plasma etoposide concentration was monitored on days 2 and 4 in patients receiving 5d EP and on days 2, 5, 8 and 11 in patients receiving 15d EP, with infusion modification to ensure target concentrations were achieved. Treatment was repeated every 21 days for up to six cycles, with a 25% reduction in target concentration in patients with toxicity. Results: The study has closed early after entry of 29 patients (14 with 5d EP, 15 with 15d EP). Objective responses were seen in seven of 12 (58%, confidence interval (CI): 27%-85%) evaluable patients after 5d EP, and two of 14 (14%, CI: 4%42%) evaluable patients after 15d EP (P = 0.038). Grade 3 or 4 neutropenia or leucopenia during the first cycle of treatment was observed in six of 12 patients after 5d EP and 0/14 patients after 15d EP (P = 0.004), with median nadir WBC count of 2.6 x 109/1 after 5d and 5.0 x 109/1 after 15d EP (P = 0.017). Only one of 49 cycles of 15d EP was associated with grade 3 or worse haematological toxicity, compared to 14 of 61 cycles of 5d EP. Conclusions: Although the number of patients entered into this trial was small, the low activity seen at 1 μg/ml in the 15d arm suggests that this concentration is below the therapeutic window in this setting. Further concentration- controlled studies with prolonged EP infusions are required.

Changes in disability, physical/mental health states and quality of life during an 8-Week multimodal physiotherapy programme in patients with chronic non-specific neck pain: A prospective cohort study

Aim The aim of this study was to analyse the effect of an 8-week multimodal physiotherapy programme (MPP), integrating physical land-based therapeutic exercise (TE), adapted swimming and health education, as a treatment for patients with chronic non-specific neck pain (CNSNP), on disability, general health/mental states and quality of life. Methods 175 CNSNP patients from a community-based centre were recruited to participate in this prospective study. Intervention: 60-minute session (30 minutes of land-based exercise dedicated to improving mobility, motor control, resistance and strengthening of the neck muscles, and 30 minutes of adapted swimming with aerobic exercise keeping a neutral neck position using a snorkel). Health education was provided using a decalogue on CNSNP and constant repetition of brief advice by the physiotherapist during the supervision of the exercises in each session. Study outcomes: primary: disability (Neck Disability Index); secondary: physical and mental health states and quality of life of patients (SF-12 and EuroQoL-5D respectively). Differences between baseline data and that at the 8-week follow-up were calculated for all outcome variables. Results Disability showed a significant improvement of 24.6% from a mean (SD) of 28.2 (13.08) at baseline to 16.88 (11.62) at the end of the 8-week intervention. All secondary outcome variables were observed to show significant, clinically relevant improvements with increase ranges between 13.0% and 16.3% from a mean of 0.70 (0.2) at baseline to 0.83 (0.2), for EuroQoL-5D, and from a mean of 40.6 (12.7) at baseline to 56.9 (9.5), for mental health state, at the end of the 8-week intervention. Conclusion After 8 weeks of a MPP that integrated land-based physical TE, health education and adapted swimming, clinically-relevant and statistically-significant improvements were observed for disability, physical and mental health states and quality of life in patients who suffer CNSNP. The clinical efficacy requires verification using a randomised controlled study design.

Distortion of Dimension under Quasiconformal Mappings

Quasiconformal mappings are natural generalizations of conformal mappings. They are homeomorphisms with 'bounded distortion' of which there exist several approaches. In this work we study dimension distortion properties of quasiconformal mappings both in the plane and in higher dimensional Euclidean setting. The thesis consists of a summary and three research articles. A basic property of quasiconformal mappings is the local Hölder continuity. It has long been conjectured that this regularity holds at the Sobolev level (Gehring's higher integrabilty conjecture). Optimal regularity would also provide sharp bounds for the distortion of Hausdorff dimension. The higher integrability conjecture was solved in the plane by Astala in 1994 and it is still open in higher dimensions. Thus in the plane we have a precise description how Hausdorff dimension changes under quasiconformal deformations for general sets. The first two articles contribute to two remaining issues in the planar theory. The first one concerns distortion of more special sets, for rectifiable sets we expect improved bounds to hold. The second issue consists of understanding distortion of dimension on a finer level, namely on the level of Hausdorff measures. In the third article we study flatness properties of quasiconformal images of spheres in a quantitative way. These also lead to nontrivial bounds for their Hausdorff dimension even in the n-dimensional case.

Knoevenagel condensation of 2-carbethoxycyclohexanone and malononitrile: Synthesis of 4-cyano-3-ethoxy-1-hydroxy-5,6,7,8-tetrahydroisoquinoline, an isomer of the abnormal product

The structure of the abnormal product 1a formed in the Knoevenagel condensation of 2-carbethoxycyclohexanone and malononitrile has been further confirmed. Oxidation of the tetrahydroisoquinoline 3b using Na2Cr2O-AcOH-H2SO4 gave the keto isoquinoline 3d and the isoquinoline-1-carboxylic acid 5a. The acid chloride of 5a was condensed with diethyl ethoxymagnesiomalonate to afford after decarbethoxylation the methyl ketone 5d which on Baeyer-Villiger oxidation gave a mixture of the acetate 1g and the title compound 1b. The unambiguous synthesis of 1b confirms the structure assigned earlier to the title compound also formed during the partial hydrolysis of the diethoxy compound 1c. Condensation of 2-acetylcyclohexane-1,3-dione with malononitrile gave the quinoline derivative 4c which on ethylation yielded the ketoquinoline 4d. The present studies have confirmed that the quinoline compound 4a is also formed in the condensation of 2-acetylcyclohexanone and cyanoacetamide.