The presentation of information is central to decisions to engage in a treatment and the uptake of health care behaviours. Hence understanding the processes which are responsible for framing effects within the health domain is crucial to achieving effective and unbiased communication. Within the message framing literature decision making is considered being a function of the valence of the information which is presented. Research has shown that individuals are more likely to attend a screening examination when information is presented as a loss a frame and more likely to engage in preventative behaviour when information is presented as a gain frame. However according to Rothman and Salovey (1997); Rothman, Kelly, Hertel, and Salovey (2003) it is the degree to which performing a health behaviour presents risk to the individual that determines whether a positively or negatively valenced version of information is more likely to be effective in encouraging the behaviour advocated. To date, studies assessing the hypothesis by Rothman and Salovey (1997); Rothman et al (2003) have only considered framing effects in the case of decision making for the self, and have not considered how framing of information may influence choice tasks. Additionally emotional reactions to risk information may play a part in determining the influence of framing effects (Lowe and Ferguson, 2003). The first experiment explored the acceptance of a blood transfusion for the self and on the behalf of a family member and friend within the frameworks of Rothman and Salovey (1997). In relation to this, the risk – as - feelings hypothesis by Lowenstein, Weber, Hsee, and Welch (2001) which postulates a direct effect of feelings onto choice, was examined. In the second chapter a standardised(word study changed to chapter as this not an experiment and so it is correct not to call as such chapter) instrument to measure factors around which people decide to accept blood transfusion products was developed. The final two experiments tested the two hypotheses in relation to a choice task and under a time constraint. Under a time constraint the potential for cognitive processes to play a role in decision making is reduced and the role of hot cognitions (emotions) is heightened. Hence the last experiment aimed to expose the role that affect may contribute to message framing effects by investigating whether the same framing effects could be observed when choosing between two blood transfusion products with and without a time constraint. When making a decision on the behalf of the self, a family member and a friend to accept a blood transfusion or to choose between two blood transfusion types a gain frame effect was observed. The framing effect did not alter under a time constraint in the case of decision making on the behalf of any potential recipient. Investigations of affect (trait, anticipated and immediate emotion) and cognitive motivational factors important to decision making as potential mediators produced null results. However, direct effects of immediate emotion were observed when decision making was for the self, family member and a friend in the first experiment and in the case of the self in Experiment 3. The findings obtained lend support to the increasing call for both cognitive and emotive processes to be incorporated into models of decision making, and to the argument by Rothman and Salovey (1997) that the function of the treatment under consideration moderates framing effects. The blood transfusion service gains valuable information on the importance of psychological factors to aid in planning public information campaigns.

Clinical reasoning research has concluded that experts use less, but more selective, knowledge in a more efficient way, based on the construction of schema, scripts and other representations of the relation between signs, symptoms and diagnoses, derived from their experience. However, this conclusion does not help Medical Schools to decide which pedagogical strategies should be adopted to foster clinical reasoning in undergraduates. This study aims to investigate how medical students, approach clinical cases and the impact of three types of curriculum upon their clinical reasoning. Two studies were carried out. The first analysed 60 hours of Problem-Based Learning sessions using electronic content analysis and corpus analysis. A second used a cross-sectional approach assessing and comparing students’ clinical reasoning in three different medical schools (Derby, Nottingham and Coimbra)based on a Clinical Reasoning Test (CRT) developed and validated for the purposes of this research. The clinical reasoning test prove to be a valid and reliable tool to assess clinical reasoning. The analysis of the PBL sessions indicated that early contact with clinical cases might favour students’ encapsulation of knowledge. First year students use more words, are more descriptive and make significantly more use of explanations. Second year students are more focused using less words, focusing more on the biomedical sciences aspect of the cases and engaging more in questions. The comparisons between different medical curricula show some differences between groups, at the entry to practice level in favour of the PBL and the integrated curricula. However, at the graduation level only small differences remain between the groups. Clinical exposure has a significant impact in improving students’ clinical reasoning, with differences in exposure time between curricula possibly accounting for such results. Additionally, differences in the strategies used to approach the cases were noted. Students from the traditional curriculum seem to be waiting until all information is displayed to make a decision, while their peers from other curricula seem to be more willing to make decisions based on initial patient’s information. No significant correlations with knowledge about the cases, or confidence on the diagnosis were found; possible reasons for these results will be discussed and implications for curriculum development and future research highlighted.

Background: The volume of empirical literature and national reports with accordance amongst findings suggests there is strong evidence for the proposition that established work-related factors for healthcare professionals may also be strong predictors of stress and associated adverse health outcomes for physiotherapists and occupational therapists employed by the NHS. The extent of published research specific to physiotherapists and occupational therapists is limited. Research targeting therapists is therefore, a prerequisite for improving knowledge and understanding the nature of therapists psychosocial work environment and work-related stress. Research objective: The objective of this research is to investigate the psychosocial work environment and nature of work-related stress of NHS physiotherapists and occupational therapists. And in doing so establish: a) how work-related stress is experienced by physiotherapy and occupational therapy employees in the NHS, and b) how we understand the determinants of stress and structural and social resources that counteract stress, and c) the implications of these for therapists' health. Research design: This programme of research is a multi-site, multi-method (quantitative and qualitative) design. It is composed of three studies each designed to make possible (in part) the overall research objective. The first study is a quantitative self-report survey of psychosocially determined work-related stress amongst NHS physiotherapists and occupational therapists. The second study is a qualitative exploration of therapists' experiences of the physical and psychosocial work environment and personal meanings prescribed to the experience of work-related stress. The third study; designed to shed light on anomalous results and findings from the first two studies, is a quantitative self-report survey of physiotherapy and occupational therapy managers' understanding and management of workplace stress. Results and findings: Study one and two suggest that the clinical psychosocial work environment of therapists is experienced as rewarding. Work-related factors, such as high work-related demands, have the potential to determine stress, but at the time of the research, were not reported to be experienced as stressful. The in-depth interviews revealed that rapid and ongoing organisational change, lack of effective top-down communication, together with issues relating to demands for heightened effectiveness were determinants of stress for NHS therapists interviewed. Results from the study one and findings from study two reveal differences in perceptions and reporting of supportive line management. Study one indicates that therapists' self-report high level of supportive line management, whilst the in-depth interviews (study two) exposed a lack of straightforward, regular, accessible instrumental and emotional line management support. Study three, found that line-managers have some or most of the knowledge required to identify, prevent and tackle stress at work. Importantly, they report an understanding of the critical role of line managers in tackling stress and appropriate line manager behaviours for minimising and managing employee stress. Conclusion: Conceptually integrated results and findings illustrate that whilst satisfied with their clinical role, therapists are experiencing work-related stress as a consequence of organisational aspects of their working environment.

This study examines the experiences of a small number of coaches who work on an exercise referral scheme for children with special health care needs (SHCNs) such as attention deficit hyperactivity disorder (ADHD) and autistic spectrum disorders (ASD). Children with SHCNs can face significant barriers to involvement with peers in extracurricular physical activity and sports. These barriers arise due to difficulties directly related to a condition, such as immaturity in motor skills, problems with concentration and impulsivity, and because of the social stigma associated with these difficulties.

Background: Current demographic trends giving rise to an ageing population worldwide, and changes in disease patterns, are increasing demands for palliative and end of life care. Nurses play a fundamental role in the care of patients with chronic and life-threatening illnesses, making it critical that nurses entering the profession should be competent and confident to provide palliative care. However, some preregistration nursing curricula, particularly those in resource-poor settings, do not include any palliative care content. Existing research identifies a lack of palliative care competencies among practising nurses, both newly graduated and student nurses. Aim: The aim of this study was to develop, pilot and evaluate the impact of a palliative care course on Cameroonian preregistration nursing students’ palliative care knowledge and self-perceived competence and confidence in palliative care provision, using Kirkpatrick’s (1967) framework for training programme evaluation. Design: This study is situated within the World Health Organisation’s public health model for palliative care as an overarching theoretical framework. It employed a longitudinal quasi-experimental pretest/posttest design, using both quantitative and qualitative methods. It was conducted in 3 phases. In the first phase, a 30 hours classroom based palliative care course, underpinned by experiential learning theory, was developed. In the second phase, the course was delivered to second and third year nursing students in one University in Cameroon, by nurse educators, a chaplain and palliative care trained nurses in Cameroon. In the third phase, an evaluation of the impact of the course on students’ palliative care knowledge, self-perceived competence and confidence in palliative care, and transfer of learning to practice was conducted. Course evaluation data was collected via a pretest/posttest survey, 3 focus groups and 10 individual critical incident interviews. Both descriptive and inferential statistics were used to analyse the quantitative data. The qualitative data was analysed thematically using the framework approach. Findings: This study revealed a deficiency in the palliative care content of the pilot University’s preregistration nurse training curriculum, and very poor palliative care knowledge and self-perceived competence and confidence in palliative care provision, among preregistration nursing students of this University. A 30 hour classroom based palliative care course, delivered by nurse educators, palliative care nurses and a chaplain in Cameroon was found to statistically significantly improve students’ overall palliative care knowledge. In this study students’ also had improvements in their self-perceived competence and confidence in palliative care provision, though this was not statistically significant. Student nurses in receipt of palliative care education were able to transfer their learning to practice. They reported recognizing patients with palliative care needs, providing patients with physical, psychosocial and spiritual support and communicating patient information to the wider care team. Notwithstanding this positive finding, some factors, related to the student themselves, the qualified nurses, the practice setting or the patient and family, were found to negatively impact on the learning transfer process. The students generally felt that the course was an ‘eye opener’ and met with their expectations. They perceived the major strength of the course was the use of interactive and stimulating educational strategies, but felt that the absence of a supervised clinical practice component with dying patients was a major weakness of this course. Conclusion: There is a need for a curriculum revision to include palliative care content in the preregistration nurse training curricula of the pilot University. This seems to reflect a general need by all preregistration nursing students in this country. This study’s findings reveal the need to advocate for palliative care education and practice policies, and for adequately preparing clinical placement sites for nursing students’ palliative care learning and transfer of learning in Cameroon, and possibly other resource poor settings.

Medication monitoring is used in primary care to guide treatment and protect the patient from adverse drug events (ADEs). Early detection of ADEs may prevent their development and avoid serious or permanent effects to patient health. Published guidelines for the conduct of medication monitoring in UK primary care recommend monitoring in patients with long-term prescription of certain cardiovascular medications, including angiontensin-converting enzyme inhibitors (ACEI), loop diuretics and amiodarone. Although much evidence exists on the practice of monitoring of these medications in primary care, few studies have considered the effect of carrying out monitoring at different frequencies during long-term therapy on the risk of ADEs. Similarly, evidence of the economic effect of regular monitoring of these medications is sparse. As a consequence, policy-makers rely primarily on evidence from expert opinion as a basis for recommendations and compliance to guidelines in practice is poor. This programme of research aimed to gain an understanding of the nature of monitoring of ACEI, loop diuretics and amiodarone in primary care in England, and investigate the effectiveness and cost-effectiveness of monitoring in accordance with current guidelines. Using electronic health records from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), a cohort study was carried out in order to quantify the effect of monitoring the study medications at different frequencies during the course of long-term therapy. Weights based on propensity scores were used to control for confounding arising from non-random assignment into alternative monitoring regimens in retrospectively observed data. The time-to-event analysis found that conducting thyroid function tests (TFT) in amiodarone therapy below the recommended interval of once in 6 months was associated with more than a two-fold increase in the hazard rate of hypothyroidism (HR 2.79; 95% CI 1.42,5.47), thyrotoxicity (HR 2.57; 1.40,4.74) and major adverse cardiovascular events (HR 2.13; 1.31,3.45), when comparing against a group of patients monitored according to guidelines. Conversely, conducting urea & electrolyte monitoring in ACEI therapy below recommended frequency was associated with a reduced rate of hyperkalaemia treated in primary care (HR 0.57; 0.42,0.77) and hospital admission (HR 0.13;0.02,0.95). In addition, monitoring urea & electrolytes during loop diuretic therapy below recommended frequency was associated with a lower hazard rate of hypokalaemia or hyponatraemia treated in primary care (HR 0.17; 0.06,0.45). These findings support current recommendations on frequency of regular monitoring in the case of amiodarone TFT monitoring, but not in the case of ACEI or loop diuretics. The results of the time-to-event analysis of amiodarone monitoring were used to populate a decision-analytic model designed in order to estimate the cost-effectiveness of different strategies of monitoring medication, compared to recommended practice. This analysis demonstrated that conducting TFT at recommended frequency yielded modest cost savings per patient (£129, compared to less frequent monitoring and £192 compared to more frequent monitoring option) and utility gains per patient (0.0245 quality-adjusted life-years (QALYs) compared to less frequent monitoring and 0.0543 QALYs compared to more frequent monitoring option). The probabilistic model estimated that the recommended frequency strategy had a 97% probability of being a cost saving option compared to the two alternatives. These findings support the current policy of encouraging 6-monthly monitoring of TFT in amiodarone therapy. This programme of research has demonstrated that medication monitoring is potentially effective and cost-effective in amiodarone therapy, but did not find regular monitoring of ACEI or loop diuretic therapy to be effective. Observational research using routinely collected electronic health records can be used to gauge both the clinical and cost-effectiveness of medication monitoring in order to guide practice in this area and improve the safety of medications in primary care.

The analysis of volatile organic compounds (VOCs) in breath may be a useful non-invasive tool in the Intensive Care Unit (ICU) to monitor metabolic and oxidative stress or diagnose pulmonary infection. Acetone is produced during starvation and metabolic stress, hydrogen sulphide (H2S) may be a marker of inflammation and infection and hydrogen cyanide (HCN) may also act as a marker of infection, particularly caused by Pseudomonas aeruginosa. Firstly, the effects on measured VOC concentrations of the breath collection equipment and storage were assessed. Sample humidity declined faster than any analyte. Sample losses of 21%, 25% and 24% for acetone, H2S and HCN, respectively, were seen as a result of being passed through the sampling apparatus. Over 90% of initial breath VOC concentrations were detectable after 90 min storage in Tedlar bags at 40°C. Secondly, a breath collection method for off-line analysis was validated in 20 mechanically ventilated patients in the ICU. The effect on VOC concentrations of breath sampling from two locations after two breathing manoeuvres was explored, revealing significantly higher analyte concentrations in samples from the airways than from a T-piece in the breathing circuit, and after tidal breathing compared to a recruitment-style breath. Practical difficulties were encountered using direct airway sampling and delivering recruitment style breaths; end-tidal breath sampling from the T-piece was simplest to perform and results equally reproducible. Breath samples from 26 healthy anaesthetised controls were used to validate a breath collection method in the operating theatre. The effects of altering anaesthesia machine settings on inspiratory and exhaled acetone concentrations were explored. A difference in median inspiratory, but not exhaled, acetone concentrations was observed between the anaesthesia machines (ADU Carestation 276 ppb, Aysis Carestation 131 ppb, p=0.0005). Closing the adjustable pressure limiting (APL) valve resulted in a reduction in exhaled acetone concentration, as did breath sampling distal to the circuit filter, due to dilution by dead space air. Median (range) breath concentrations for samples collected on the patient side of the circuit filter with the APL valve open (n=22): acetone 738 ppb (257–6594 ppb), H2S 1.00 ppb (0.71-2.49 ppb), HCN 0.82 ppb (0.60-1.51 ppb). Breath acetone concentration was related to plasma acetone (rs=0.80, p<0.0001) and beta-hydroxybutyrate concentrations (rs=0.55, p=0.0075). Finally, breath and blood samples were collected daily from 32 mechanically ventilated patients in the ICU with stress hyperglycaemia (n=11) and/or new pulmonary infiltrates on chest radiograph (n=28). Samples were collected over a median 3 days (1-8 days). Median (range) breath VOC concentrations of all samples collected: acetone 853 ppb (162–11,375 ppb), H2S 0.96 ppb (0.22-5.12 ppb), HCN 0.76 ppb (0.31-11.5 ppb). Median initial breath acetone concentration was higher than in anaesthetised controls (1451 ppb versus 812 ppb; p=0.038). There was a trend towards a reduction in breath acetone concentration over time. Relationships were seen between breath acetone and arterial acetone (rs=0.64, p<0.0001) and beta-hydroxybutyrate (rs=0.52, p<0.0001) concentrations. Several patients remained ketotic despite insulin therapy and normal, or near normal, arterial glucose concentrations. Inspired and exhaled H2S and HCN concentrations were not significantly different. Breath H2S and HCN concentrations could not be used to differentiate between patients with pneumonia and those with pulmonary infiltrates due to other conditions. In conclusion, losses due to the sampling apparatus were determined and linear over the range of concentrations tested. End-tidal breath sampling via the T-piece was the simplest technique, with reproducibility comparable to other methods. It was possible to replicate the breath sampling method in the operating theatre; pre-filter samples with inspiratory gas flow rate 6 L/min and APL valve open provided repeatable results avoiding rebreathing. There was no role for the use of breath H2S or HCN in the diagnosis or monitoring of pneumonia in critical illness. There was no relationship between breath acetone concentration and illness severity, however the utility of breath acetone in the modulation of insulin and feeding in critical illness merits further study.

The annexin-7 (ANX7) gene is located on human chromosome 10q21, a site long been hypothesized to harbor a tumor suppressor gene (TSG) associated with brain, prostate, breast and other cancers. To test whether ANX7 might be a candidate TSG, and its role in the molecular pathogenesis of malignant glioma. We examined the ANX7 expression levels in several kinds of cell lines, 139 glioma specimens and 84 gastric cancer specimences. Consistently, analysis of ANX7 protein expression in human glioma tumor a significantly higher rate (2.14 times) of loss of ANX7 expression in glioblastoma multiformes (GBM) as compared with low grade astrocytoma (p=0.04). The striking correlation ANX7 expression and the differentiation of gastric carcinoma (p = 0.001). ANX7 may play an important role in the tumor progression. Loss or reduced expression of ANX7 is possibly a biomarker for tumor cell progression

Background: Research does not always translate into improved patient outcomes because of difficulties implementing complex health interventions. Distinguishing between effectiveness and factors affecting implementation is critical to improving trials of rehabilitation interventions. Understanding barriers and facilitators encountered when delivering complex interventions, such as rehabilitation, in the research environment requires examination. Implementation research is the study of methods to promote the uptake of research findings into routine practice and can help identify and explain barriers and facilitators. The aim of this project was to understand factors that affect the delivery of complex rehabilitation interventions in research, focussing on vocational rehabilitation for people with traumatic brain injury. Methods: Exploratory mixed methods were used to understand factors (barriers and facilitators) affecting the implementation of rehabilitation interventions delivered in research for people with long term neurological conditions including traumatic brain injury. In study 1, a systematic review investigated barriers and facilitators to the implementation of complex rehabilitation interventions delivered in clinical trials and other research. The review method involved developing search terms and searches included 11 databases, trial registries and author citations. All research methodologies were included. After screening titles and abstracts, two reviewers independently shortlisted studies. A third resolved discrepancies. Studies were appraised using the Mixed Methods Appraisal Tool. One reviewer extracted data in two stages; 1) descriptive study data, 2) units of text describing barriers and facilitators to implementation. Data were synthesised by; 1) mapping determinants to the Conceptual Framework for Implementation Fidelity and the Consolidated Framework for Implementation Research; 2) thematic analysis. Study 2 describes the development of a training package, used as an implementation strategy, to train NHS occupational therapists to deliver Early Specialist Traumatic brain injury Vocational Rehabilitation in three English NHS sites in the context of a rehabilitation trial. The training package was developed by "experts" in vocational rehabilitation and traumatic brain injury. It included a manual, direct instruction and mentoring. The confidence of the occupational therapists to deliver the intervention to trial participants with traumatic brain injury was measured before and after training and its usefulness examined via mentoring records and through early and late interviews with the trained occupational therapists. Implementation issues were mapped to the Consolidated Framework for Implementation Research and Comprehensive Framework for Implementation Fidelity. In Study 3 the extent to which the intervention was delivered as intended was investigated. A content form and fidelity checklist were developed. Fidelity was measured using these tools and triangulated with clinical and mentoring records. Barriers and facilitators were explored in interviews with the occupational therapists, trial participants, their employers and NHS staff in each site and triangulated with clinical and mentoring records and mapped to CFIR and CFIF. Results: Study 1 found it was possible to identify factors affecting the implementation of complex interventions in rehabilitation trials, even when researchers had not set out to report these. Treatment adherence, its acceptability and causes of attrition were the most frequently reported barriers and facilitators. The quality of intervention delivery, the preparedness of organisations to implement an intervention as part of a trial and the developmental readiness or ‘trialability’ of interventions were rarely reported. The findings from this study highlighted the potential barriers that trial occupational therapists might encounter when delivering Early Specialist Traumatic brain injury Vocational Rehabilitation. Study 2 found that experienced occupational therapists can be trained to deliver a complex intervention in a rehabilitation trial. Barriers and facilitators identified individual and organisational level barriers and facilitators. Soon after being trained, occupational therapists identified that direct instruction and the training manual were important in helping them implement the intervention. However, later they indicated that the manual was not used. Mentoring was identified as the most useful element of the training package in both early and late interviews. Study 3 found that occupational therapists delivered Early Specialist Traumatic brain injury Vocational Rehabilitation with fidelity. Factors facilitating implementation fidelity included expert mentoring, community rehabilitation experience and an intervention that could be tailored to individual need. Barriers included lack of access to NHS systems, backfill and support from NHS managers. The following factors both helped and hindered; communication with participants, acceptability of the intervention, individual and changing needs of study participants and interagency working. Conclusion: Using implementation research frameworks, such as Consolidated Framework for Implementation Research and Conceptual Framework for Implementation Fidelity, to identify, measure and describe barriers and facilitators can elicit important information to assist researchers in improving rehabilitation trial design, ensuring more robust trial outcomes, reduce the risk of type III errors and expedite translation of research into improved patient outcomes. Expert mentoring was considered essential to ensuring implementation fidelity, alongside case discussions and direct instruction about research contamination issues. Implementation of complex rehabilitation interventions, such as Early Specialist Traumatic brain injury Vocational Rehabilitation, is affected by a number of factors acting as barriers and or facilitators at the individual and organisational level.

This study explored the experiences of Jordanian critical care staff about the transition to, and provision of, end of life care. It examined the difficulties they encountered, and how they sought to care for and communicate with the families of patients who were approaching the end of life. The study took place in two University hospitals in different cities. A mixed methods design in two phases was adopted. The first phase employed the “National Survey of Critical Care Nurses' Perceptions of End-of-Life Care” (adapted with permission) to elicit the views of critical care staff (N=104) about the obstacles and facilitators to providing end of life care for critically ill patients and their families. In the second phase, qualitative interviews were conducted with staff (15 nurses; 10 junior doctors; 5 head nurses). The key overarching finding from the study is that staff experience moral distress when working with critically ill patients whom they perceive to be dying. There were three main dimensions to the experience of moral distress: First, nurses experience moral distress when they are aware when the patients are likely to die, know that continuing life sustaining treatment is futile and yet are expected to continue to provide treatment as normal to the patients. Aggressive modalities of treatments are usually pursued for most terminally ill patients, with both nurses and doctors perceiving there to be no planned, clear or distinct transition from curative focused care to end of life care. Second, with regard to their relationship with patients’ families, the staff found themselves to be in a problematic and paradoxical situation. One the one hand, they expected patients’ families to take the lead in the care decision making process and perceived that the power in decision-making should lie with patients’ relatives; but on the other hand, they also perceived that it is difficult and sometimes impossible to disclose bad news openly to families meaning that families are not fully informed in a way that would enable them to take the lead in the care decision making process. Third, staff have an appreciation of the principles of end of life decision making as a team activity and as a collaborative venture, but they are not able to put these principles into practice for many reasons, ranging from difficulties in their relationships with each other to health care system factors. This study sheds light on two central ethical problems in end of life decision-making in Jordan: the problem of disclosure of terminal prognosis at the end of life and limited involvement of nurses and junior doctors in the process of end of life communication and decision making. The study recommendations focus on developing practice in and disseminating understanding of ethically sound end of life decision-making.