BACKGROUND:Some comprehensive cancer centers in industrialized countries have reported improved outcomes in their cardiopulmonary arrest (CPA) patients. Little is known about the outcomes and predictors of CPA in cancer centers in other parts of the world. The objective of this study was to examine the predictors of CPA outcome in a comprehensive cancer center closed medical-surgical intensive care unit (ICU) located in Amman, Jordan.METHODS:In this retrospective single-center cohort study, we identified 104 patients who had a CPA during their stay in the ICU between 1/1/2008 and 6/30/2009. Demographic data and CPA-related variables and outcome were extracted from medical records. Comparisons between different variables and CPA outcome were conducted using logistic regression.RESULTS:The mean age of the group was 49.7+/-15.3years. The mean APACHE II score was 23.7+/-8.0. Thirty six patients (34.6%) were resuscitated successfully but 8 of them (7.7% of the cohort) left the ICU alive and only 6 out of the 8 (5.8% of the cohort) left the hospital alive. The following variables predict resuscitation failure: acute kidney injury (OR 1.7, CI: 1.1 - 2.6), being on mechanical ventilation (OR 3.8, CI: 1.3 - 11), refractory shock (OR 4.7, CI: 1.8 - 12) and CPR duration (OR 1.1, CI: 1.1 - 1.2).CONCLUSION:Survival among cancer patients who develop CPA in the ICU continues to be poor. Once cancer patients suffered a CPA in the ICU multiple factors predicted resuscitation failure but CPR duration was the only factor that predicted resuscitation failure and ICU as well as hospital mortality.

The benefits of new IT-induced organisational changes, such as new organisational information systems (IS), depend on the degree that system users adapt by proactively changing themselves, their work routines, and even the technology itself in order to reap its strategic capabilities and advantages. However, researchers are increasingly concerned that IS research has provided very little indication about how IS users’ IT adaptive strategies are formed and evolved over time and how such adaptive behaviours employed by IS users influence subsequent IT use and individual-level performance outcomes. This thesis investigates in-depth the evolution of IT adaptation behaviours towards disruptive IT events in the case study of a Medical Clinic attached to one of Iran’s elite Oil and Gas industry companies. The case study investigated the individual coping behaviours of the employees of this Medical Centre as a consequence of the introduction of a mandatory Work System Computerisation (WSC) initiative. Work System Computerisation project refers to both the replacement of manual work processes with computers as well as modernisation of the existing out-dated computerised work systems in the medical centre under investigation. According to the case study, each of the seven sub-units of the Medical Centre implemented a different WSC scheme and the consequences of the introduction of the scheme resulted in differing outcomes among the employees of those sub-units, such outcomes being related to a complex interplay of the individuals’ coping behaviours, appraisals and emotional responses and the environment. The term ‘Disruptive IT event’ in this study refers to any enhanced or completely new information technology in different units within the medical centre (i.e. Work System Computerisation schemes) that replaced and disrupted existing work processes/practices and had resulted in disruptive and unpredictable changes to users’ daily routines. The theoretical lens used in this study is the Coping Model of User Adaptation (CMUA) elaborated by Coping Theory, which also underpins the model. CMUA provides a useful theoretical basis for deeper understanding of users’ adaptive responses to a new work information system (IS) as well as direct analysis of the impact of such adaptive responses on system usage. The other theoretical concept used, which addresses issues not readily covered by the CMUA, was a typology of adaptive behaviours from Roth and Cohen (1986): avoidance vs. approach. This allows for further clarification of how different types of individual-level adaptation acts evolve over time and affect individual-level IT use outcomes. Furthermore, how these various adaptive acts enhance or hinder the extent to which the new IT is used can also be explained. The research questions guiding this thesis are as follows: (1) How do IS users’ adaptation tactics and strategies evolve over time when dealing with a disruptive IT event? (2) How do alterations in users’ coping strategies subsequently influence their IT use outcomes and overall performance? The study’s methodological approaches and underlying philosophical assumptions followed an interpretive research approach. A broadly interpretive approach was adopted in this study with the aim of understanding the complexity of human sense making and their IT adaptation behaviours as the situation emerges. The research was carried out in one state of Iran, Mashhad, and took place during the period of 2011-2012. The findings of this thesis have both theoretical and managerial implications. From a theoretical perspective, this study expands on the work of Beaudry and Pinsonneault (2005) who suggested that the process of user adaptation could be understood in light of coping theory. The results of this study and the additional identified perspectives and enhancements which are represented in the following ways could help to advance the field of user IT adaptation behaviours in IS research. This study contributes to the existing IT adaptation literature by providing rich insights into the phenomenon of user IT adaptation behaviours within the context of Iran. Adopting an interpretive approach through a longitudinal process-oriented perspective has provided a greater understanding of the patterns of user adaptation to IS, users’ psychological constructs, initial patterns of their coping strategies, the alterations in such coping efforts over time, and the consequences of these evolutions on IT use outcomes in different divisions within a healthcare environment. The appraisal of ‘challenge’ is an influential contributor to the users’ subsequent adaptation process that CMUA is mute about it. The findings indicate that since the challenge appraisal represents a ‘positive stress’, some levels of challenge are useful to mobilise IS users towards IT adoption and use. The correlated concerns identified in the research (i.e. a web of complex personal, social and technical concerns) play a vital role on users’ adaptation processes following the IT implementation and over time. This highlights the importance of feedback loop in the adaptation process (which represents users’ revaluation process), and how the direct and indirect impacts of such interventions affect users’ reassessments of the IT event and their subsequent efforts and outcomes.  The concept of emotion that is missing from CMUA is influential especially where non-IT savvy users’ behaviours toward significant IT events may be influenced by extreme emotions.  Outcomes of this study highlight the theoretical importance of preserving the distinction between approach-, and avoidance-oriented emotion-focused behaviours in exploring how emotion-focused behaviours may influence behavioural outcomes such as system usage. The consideration of parallel processes for users’ IS appraisal is another area of theoretical expansion. The findings also suggest implications for practice as well as directions for future research. Understanding how employees’ IS appraisals considerably affect coping efforts and ultimately their technology performance outcome is critical for successful IT implementations and use in work settings. The results could assist decision makers in assessing user adaptation concerns and the intensity of such apprehensions at each phase of the change process and hence address them more effectively.

There is increasing emphasis on the outcomes of research in terms of its impact on wider society. However in the social sciences the ways in which research is taken up and used, discussed, shared and applied in different policy, practice and wider settings is complex. This thesis set out to investigate the ways in which social research was used by various non-academic actors, and to explore what impact it had in order to develop methods for understanding and assessing impact. The research investigated what research impact is, how it occurs, and how it might be assessed. The research was in two phases: firstly, a case study of a research partnership between a research centre and a voluntary organisation; and, secondly, the development and seeking feedback on a framework to assess impact. The care study employed two main approaches: forward-tracking - from research to policy and/or practice - and backward tracking - from policy back to research. Both phases were conducted through a practitioner-research approach, bringing experience of working with the projects involved into the heart of the research model. The study found many ways the research from the partnership had been used in different sectors by different actors. Impacts from the research were harder to identify. In cases where there were clear impacts, the actors involved had adapted research to fit the context for research use in order to create impact. Research users continued to draw on the research for many years after publication, creating further impact as new policy or practice agendas arose. The framework used a 'pathways to impact' model to develop a theory-based approach to assessing impact and to create categories for data collection. The ways in which research might impact on policy and practice are many and cannot be easily predicted. Concepts from complexity theory, particularly a focus on relationships, an understanding of context and the concept of emergence have been useful in framing the picture of impact generated from this research. Any assessment of impact from social research needs to acknowledge that many actors are involved in the process of research being taken up and used, and impact cannot be achieved from the supply side alone. Partnership research, between an academic and voluntary sector organisation, facilitated the use and impact of the research in many ways. The thesis reconceptualises ideas about how research impacts on society, suggesting the concept of 'contribution' is more accurate and useful than attribution. It also adds to the body of empirical work on the processes of impact, and in particular of the role of research partnerships in increasing impact. It suggests that process-based approaches to assessing impact that acknowledge complexity may be fruitful in developing impact assessment methodology.

The importance of health and quality health care in people’s daily lives is widely recognised. Physicians play a key role in delivering quality health care and improved patient outcomes. However, the evidence regarding physicians’ decision making and their perception of quality of health care delivery and its influencers is inconclusive. The overall aim of this thesis is to increase the understanding of quality in health care delivery and the factors that influence it from a physician’s perspective. This aim is fulfilled by conducting three interlinked research projects. The first research project comprises a systematic review of the literature that identifies the factors, contexts and theoretical underpinnings influencing physician decision making. The synthesis of 160 studies reveals two main categories of influencing factors. The first is ‘Contexts’, which refers to the set of circumstances or facts surrounding a particular event or situation. The second category is ‘Interventions’, which are the techniques, processes or actions introduced to create changes in how physicians make decisions while performing their clinical duties. Although extant literature provides ample evidence on factors influencing physician decision making the link to quality in health care is under researched. In the second research project, the author explores how physicians construct quality of health care delivery by means of investigating 162 clinical cases with 27 repertory gird interviews that yield eleven key constructs representing a classification of physicians’ conception of quality. The third research project examines physicians’ perceptions of enablers and barriers to quality in health care delivery, employing semi-structured interviews. Findings indicate that physician’s effort in delivering quality health care is largely influenced by factors affecting behavioural control (freedom to act). This research makes five contributions to knowledge. First, a novel classification of factors influencing physician decision making when prescribing is developed, providing new understanding of the link between these factors and quality of health care. Second, the systematic review shows an innovative application of factor analysis to structure the findings of a complex phenomenon. Third, the study presents a new conceptualisation of physicians’ construction of quality in health care. Fourth, the research provides a categorization of physicians’ perceived enablers and barriers to quality health care and the mechanisms by which they operate. Finally, this research develops a theoretically-grounded and empirically-informed conceptual model that incorporates three hitherto separate domains: agency, planned behaviour, and decision theories. This model provides a new integrated lens to better understand the complexities influencing quality in health care delivery. This study also makes two significant contributions to practice. First, the findings have helped initiate a transformation in the pharmaceutical industry’s business model, evolving from business-to-person to business-to-business. Second, the findings serve as a catalyst to drive organizational changes at Norway’s largest emergency hospital. As a result, a national debate was initiated, involving the Prime Minister and Minister of Health, on how hospital emergency care can best be provided at a national level.

Located in the mesopontine tegmentum, the pedunculopontine tegmental nucleus (PPTg) is comprised principally of glutamatergic, cholinergic and GABAergic neurons. In addition to being fully integrated into basal ganglia, PPTg projects to thalamus and motor output sites in the brainstem. Previous studies have shown a range of behavioural changes after PPTg manipulation. Prominent amongst these is an apparent deficit in the ability to learn the consequences of actions. PPTg is divisible into a posterior component (pPPTg) in receipt of rapid polymodal sensory input and projecting into VTA/SNc dopamine neurons and an anterior component (aPPTg) in receipt of basal ganglia outflow and projecting into SNc and lower brainstem structures. The research described here assesses the role of the pPPTg in instrumental learning. Using a contingency degradation paradigm, it was shown that inactivation of the pPPTg (by muscimol microinfusion) specifically blocked the updating of associations between actions and outcomes, without the affecting the ability to re-execute previously learned instrumental actions. Selective bilateral destruction of pPPTg cholinergic neurons (with the fusion toxin diphtheria toxin – urotensin II [Dtx-UII]) resulted in >90% loss of pPPTg cholinergic neurons. These lesions produced no detectable changes on any measured aspect of an instrumental learning task consisting of various fixed and variable ratio schedules of reinforcement and extinction. Subsequent experiments found that the same selective cholinergic pPPTg lesions also produced no changes in the locomotor response to nicotine or rate of nicotine sensitisation. These results are the first to demonstrate a brainstem role in action-outcome learning. Results support the view that PPTg performs a ‘first pass' analysis on incoming sensory data and interfaces salient aspects of this with appropriate basal ganglia and brainstem circuitry, with glutamatergic pPPTg projections sending an essential signal and cholinergic projections performing as part of a wider modulatory system.

<p>Genetically determined differences in drug metabolism and disposition and drug targets play a pivotal role in the interindividual variability in the clinical outcome of antipsychotic treatment. The aim of this thesis was to study the impact of polymorphisms in genes involved in the pharmacokinetics and pharmacodynamics of antipsychotics, with special focus on their extrapyramidal and metabolic adverse effects. </p><p>Polymorphisms in serotonin 2A and 2C receptor coding genes (<i>HTR2A</i> and <i>HTR2C</i>) were found to be associated with the risk to develop extrapyramidal side effects (EPS) in patients on short term perphenazine treatment. A further study in a larger group of patients on long term treatment with various classical antipsychotics confirmed the association between occurrence of EPS and <i>HTR2C</i> polymorphisms. In another study, dose corrected steady state serum clozapine and N-desmethylclozapine concentrations (C/D) and insulin elevation during clozapine therapy were found to correlate with <i>CYP1A2</i> but not with <i>CYP2D6</i> polymorphisms. Furthermore, <i>HTR2C</i> and <i>HTR2A</i> polymorphisms were found to have significant influences on BMI and C-peptide levels in patients treated with olanzapine and clozapine. Evaluation of the impact of polymorphisms in genes encoding CYP3A4, CYP3A5 and P-glycoprotein (<i>ABCB1</i>) in addition to CYP2D6 on the steady state plasma levels of risperidone, 9-hydroxyrisperidone and their active moiety revealed a significant influence of <i>ABCB1 </i>genotype on 9-hydroxyrisperidone and active moiety C/Ds, while <i>CYP2D6</i> genotype associated with risperidone C/Ds but not with 9-hydroxyrisperidone or active moiety C/D. </p><p>We have shown that polymorphisms in genes involved in the pharmacokinetics and the pharmacodynamics of antipsychotic drugs play a role in the occurrence of adverse effects, both EPS and metabolic disturbances, induced by antipsychotic treatment. Genotyping for <i>HTR2A</i>, <i>HTR2C</i>, <i>CYP1A2</i>, <i>CYP2D6</i> and <i>ABCB1</i> polymorphisms may therefore potentially provide useful information to identify patients at higher risk to develop EPS or metabolic adverse during schizophrenia treatment with antipsychotic drugs.</p>

The effectiveness of a Group CBT programme for Social Phobia was assessed using 18 participants recruited from a routine practice setting. Therapy was based on CBT techniques as practiced routinely by the clinical practice, and were not modified for the study by factors such as strict exclusion criteria and adherence to rigid manualised treatments. Pre- to post-treatment effect sizes compared favourably with those reported in a meta-analysis (Taylor, 1996). The findings provide support for the accessibility and effectiveness of group CBT techniques for Social Phobia in field settings. While some individuals within the sample experienced dramatic improvement, some remained severely impaired even at post-treatment. The results of Hierarchical Multiple Regressions indicated that lower levels of pre-treatment depression severity, higher levels of attendance, and greater homework compliance, were predictive of more improvement on some, but not all, measures of outcome. Implications for treatment are discussed.

The purpose of this study was to begin testing of a downward cross-level model for studying the ability of older adults to transition from a nursing home after a Medicare Part A reimbursed stay. Transitions are known to be a weak point in the provision of healthcare to older adults and thus far, research has not identified those factors that influence older adult's transitions i.e., from the nursing home after a post acute stay. The theoretical background for this study was supported by Resource Dependency Theory which is a theory that contends that organizations are externally controlled by activities outside the organization such as the "free-market" economic model that predominates the nursing home industry. It was thought that nursing homes may prioritize their need for resident census above the resident's need for discharge. The hypothesis was that both individual resident characteristics and organizational characteristics might influence the ability of older adults to transfer from the nursing home after a Medicare Part A stay. The method of analysis in this study was contextual regression. Individual and facility characteristics were the independent variables and length of stay was the dependent variable. For this project, emphasis was placed on the development of a methodology for using the MDS in this and future research studies. Selection of variables and methods for variable computation were highlighted. Individual and facility characteristics and discharge disposition (level of care) were reported descriptively. Although facility characteristics did not contribute significantly to the model, individual characteristics explained 28% of the variance in the length of stay. Fifteen percent of individuals in the sample died during their Medicare Part A stay and 18% were readmitted to the hospital. The most prevalent diagnoses of the sample were hypertension (35%), falls (34%) and arthritis (32%). Findings suggest that individual characteristics account for only a portion of the length of stay for post acute nursing home residents. Further model testing is needed and should include a larger facility sample size and market characteristics to determine if those factors significantly influence the ability of older adults to transfer after the Medicare Part A stay ends.

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in communication and socialization, as well as by repetitive and stereotyped behaviours and interests. The ASD phenotype is also characterized by impairments in cognition. A growing body of literature points to attention and executive functioning as being key elements of cognition that are impaired in individuals with ASD. It is very possible that these cognitive difficulties are related to the functional deficits in academic achievement, daily living skills and socialization that are experienced by individuals with ASD throughout their lifetime. Associations between these cognitive and functional abilities have been identified in TD populations; however, this relationship is not well understood in ASD. This is especially true for adolescents with ASD who are a vastly understudied population within the field. The research in this thesis aimed to investigate the nature of cognitive and functional impairments in high-functioning adolescents with ASD, and to better understand the relationship between these deficits. This study made use of a multi-method approach, by obtaining behavioural and parent-report data related to cognition and functioning for both ASD and TD populations. The results indicated that adolescents with ASD may have some impairment in executive functioning, particularly with shifting and planning abilities, and score significantly lower than TD adolescents on measures of academic achievement, adaptive behaviour and social skills. Surprisingly, no evidence was found for attentional deficits in the ASD group. Multiple regression analyses did not reveal any significant predictive relationships of attention and executive functioning with academic ability, adaptive behaviour, or social skills. Limitations of this research are discussed. The results may lend themselves to the development of theoretical frameworks for understanding functional abilities in adolescents with ASD. / Thesis (Master, Psychology) -- Queen's University, 2013-10-07 10:10:42.215

Maternal obesity is associated with adverse effects for mothers and offspring. The primary aim of this thesis was to assess food intake and physical activity (PA) using validated self-administered questionnaires, and whether these were associated with gestational weight gain (GWG) and birthweight (BWT), in severely obese (body mass index, BMI≥40kg/m2) compared with lean pregnant women (BMI 20-25kg/m2). The secondary aims were to validate self-reports against food diary (FD) and accelerometry; to assess the prevalence of under or over-reporting of energy intake; and to carry out a pilot study to assess total energy expenditure, as well as self-reporting accuracy, by using doubly-labelled water (DLW) technique, in subgroups of participants. Pregnant women were recruited from an ongoing study of severe obesity in pregnancy at the Royal Infirmary of Edinburgh, UK. Assessments were done in early (12-20 weeks) and late (28-32 weeks) pregnancy. A subgroup of women also completed questionnaires on appetite, general nutrition knowledge, and eating behaviours. All results were adjusted for age, parity, ethnic origin and deprivation category score. Self-reported total energy intake was not significantly different between obese and lean during early (median 2,444 vs 2,312 kcal/day) and late (2,173 vs 2,354 kcal/day) pregnancy. However when validated with FD, the relative validity of the food frequency questionnaire was lower in obese compared to lean. Under-reporting of total energy intake was higher in obese compared to lean (49% vs 15%, P<0.01) through comparison of selfreported energy intake with estimated total energy expenditure, and this was supported by the DLW pilot study results. The DLW also showed possible over-reporting of PA by the obese group. Obese women reported significantly lower appetite than lean throughout pregnancy (P<0.01). They also had lower scores in general nutrition knowledge, but these were no longer significant after controlling for confounders. Obese women had significantly higher scores of restrained and emotional eating behaviours than, and similar scores of external eating behaviours to, lean. Appetite, nutrition knowledge, restraint and emotional eating behaviours scores were not associated with food intake in either obese or lean. On the other hand, increased intakes of total calories and fats were influenced by increasing score of external eating behaviour in both groups. Obese women reported doing similar amounts of total PA but significantly less of vigorous and sports and exercise activities than lean (P<0.05). Accelerometry showed obese women had lower average activity counts/day, although they did have significantly greater energy expenditure in light-intensity activity than lean (P<0.01). Obese women had less GWG than lean (Mean ± SD, 5.3± 52 vs 10.8±3.7kg, P<0.001). Increased GWG was associated with increased self-reported total energy intake in lean, but this was not seen in obese. GWG was not associated with PA in either group. BWT was not significantly different between obese and lean (3,547±549g vs 3,567±516g). In lean, increased BWT was associated with increased energy intake and total PA. BWT in obese was not associated with diet but with increased with PA in early pregnancy. In conclusion, self-reported methods were less reliable in assessment of diet and PA in severely obese compared to lean pregnant women. These exploratory studies found that obese women did not appear to have the same factors as lean women affecting GWG and BWT, though this may be complicated by the poor reliability of self-reports. Therefore, quantitative assessments such as measurement of serum micronutrient levels (to evaluate nutritional status), and accelerometry (to assess physical activity) may be necessary in this poorly understood population.