Objectives: Accreditation of clinical psychology programmes requires the involvement of service users in training. Little is known about service users’ views and preferences for their involvement in education. This study aimed to explore service users’ views about the training of mental health professionals. Design: This study used qualitative methods, specifically thematic analysis of focus group interviews. Methods: 31 participants took part in 5 focus group discussions. Participants had all used adult mental health services and focus groups were organised through service user organisations. Results: Three key themes emerged from participants’ discussions. 1. A meeting of two human beings: Participants described how they valued collaborative therapeutic relationships where they were listened to and understood as a whole person. 2. Interactions with the mental health system: Participants spoke about the impact of the system upon them and their desire for easier access to services and choice between treatments. 3. Considering involvement: Participants wanted their experience to have greater value in the education of health professionals, they wanted greater consideration over who should represent them to services and wanted support to be involved. Conclusions: Training should emphasise development of interpersonal skills and collaborative therapeutic relationships. Clinicians should be skilled in a number of therapeutic approaches to foster client choice. Training should incorporate the expertise that comes from personal experience, perhaps through further development of reflective practice.

The effectiveness of interview training was investigated in a study involving seventy-two lesser-qualified school-leavers, allocated to the following groups: (1) interview training (IVT); (2) interview training + videotape feedback (IVT + Video); (3) videotape feedback - 3 sessions (3 Video); (4) videotape feedback - 1 session (1 Video); (5) discussion (3 Disc.); (6) handout (Handout); (7) attention-only control (Att.C). For the IVT group a combination of modelling, coaching, roleplay, feedback and discussion was used to train both verbal and non-verbal interview skills in 3 sessions. This programme was modified to include videotape feedback for the IVT + Video group. Videotape feedback without the other components was administered to 3 Video, and 1 Video. The 3 Disc. group spent 3 sessions discussing problems at interview and how to resolve them (without the active components included in the IVT programme). The Handout group received only the written material used with the IVT group, together with a brief description of the appropriate use of such information. The Att.C group had 3 sessions of discussion of leisure interests etc., to control for the non-specific effects of being in therapy. Subjects were assessed using videotaped roleplayed interviews. Analyses of verbal and general items demonstrated the superiority of the two experimental groups (IVT, and IVT + Video) over the alternative procedures. A good degree of social validation was achieved, there was evidence of generalisation and at follow-up the post-training improvements were well-maintained. Interview training was shown to be effective irrespective of the subject's level of intelligence. The interview training programme was extended to eight clinical single case studies. The programme was found to be effective with this population also, especially for subjects without wider social skills problems. Training in verbal skills was particularly important, as was generalisation training. In contrast, relaxation training, and training of non-verbal skills contributed little. Videotape feedback had less effect than expected, however, this was possibly due to the adoption of a random allocation procedure.

In addition to identifying the presence of a specific controlled drug in an exhibit and measuring its concentration, forensic drug laboratories are requested in certain cases or as a routine to provide additional information that may be helpful to the investigation process. On the basis of their chemical and physical characteristics, seized drugs may be profiled and linked to common sources or routes of distribution. Chapter 1 is an introduction to the illicit drug production from cultivation to manufacturing and trafficking. Chapter 2 describes the role of the drug chemist and includes characterisation of seizures, that is identification, quantification, and comparison of illicit drugs. Chapter 3 provides a literature review of the different analytical methods used in the area of drug profiling. This project has been on the subject of drug profiling with focus on the ringsubstituted amphetamine, 3,4 methylenedioxymethamphetamine (MDMA) or ecstasy as it is widely called. Among the main objectives of this study was the development and optimisation of a new extraction procedure, solid phase extraction, for impurities in seized ecstasy tablets. The instrumental analysis of impurities found in ecstasy tablets usually require a preliminary process to extract, isolate, and concentrate these impurities from the total tablet content. In the process, interfering materials are removed, and the required substances are concentrated into a solvent that is suitable for introduction into the instrument. Chapter 4 describes the development of a solid phase extraction (SPE) procedure and also an evaluation of a comparison procedure of liquid-liquid extraction (LLE) and SPE for extracting impurities in ecstasy tablets for profiling purposes. Solid phase extraction of impurities in ecstasy tablets proved to be more efficient than the traditional liquidliquid extraction. SPE provided impurity peaks with higher intensities than did LLE and a shorter extraction time. Another area of research was the use of infrared technology as an additional tool for profiling ecstasy tablets as seen in Chapter 5. Infrared method can serve as an elimination or screening step for gross clustering or grouping of exhibits. In chapter 6 the synthesis of MDMA using different synthetic routes to acquire authentic samples of impurities which are usually present in street samples were performed. These authentic samples were analysed and their mass spectra and retention indices were used to identify impurities in actual street samples to determine their route of synthesis. In chapter 7 ecstasy tablets confiscated within the UK were analysed to establish their route(s) of synthesis using the data of the authentic compounds synthesised earlier. The main contributions of this project were: 1. Developing a solid phase extraction procedure as an alternative to the conventional liquid-liquid extraction procedure. SPE provided extraction with no cross contamination of phases and no emulsion problem, as with LLE, due to the presence of fatty acids in ecstasy tablets. 2. Developing a simple and fast infrared method as a screening or elimination tool for ecstasy profiling. 3. Study of the synthetic routes of ecstasy samples within the UK with the aid of route-specific authentic impurity compounds synthesised in-house.

<i>Background.</i> Bipolar disorder is characterised by recurrent acute episodes of mania and depression with the common occurrence of subsyndromal symptoms between episodes. Episode recurrence and frequent inter-episode symptoms have made identification of the factors that influence relapse an important focus for research in bipolar disorder. <i>Objective.</i> To determine whether dysregulation in bipolar disorder would be exhibited, outwith acute mania, in day-to-day variability and whether variability was associated with risk of relapse. <i>Design.</i> A prospective daily monitoring study was conducted with bipolar disorder and general population samples. Twenty participants with a bipolar episode experienced in the previous two years were recruited from a Lithium Clinic. A control group often participants from the general population were recruited by opportunity sampling. Main outcome measures. Biological, behaviour, cognition, and affect measures included self-report measures of behavioural activation/inhibition, social rhythms, self esteem, positive affect, negative affect, elation, depression and objective actigraph estimation of the sleep-wake cycle and circadian rhythms. <i>Results.</i> Lower self esteem, lower positive affect, higher negative affect, higher depression levels and greater variability in self esteem, night waking and sleep efficiency across 14 days were evident in bipolar disorder. Survival analyses suggested greater variability in self esteem and sleep efficiency predicted earlier admission in bipolar disorder. <i>Conclusions.</i> Greater day-to-day variability in bipolar disorder was observed compared to the general population. Underlying disturbances in biological, cognition and affect measures were evident in bipolar disorder. Findings were clinically important since sleep and self esteem disturbances may be considered as potentially modifiable in reducing risk of relapse in bipolar disorder.

No description available.

Clinical trials for treatment of acute ischaemic stroke require large numbers of patients and are expensive to conduct. Treatment is typically administered within the first hours or days after stroke onset. Outcome is usually assessed by a single measure, the most common being the modified Rankin scale (mRS) at day 90. Any strategy that can reduce cost or deliver more reliable answers on safety and efficacy of the investigational treatment would be welcome for future exploratory testing of novel treatments. This thesis focused on the impact of applying different methods of design, inclusion and outcome measurement to limit sample size and strengthen analysis in clinical trials in acute stroke. Firstly, inclusion criteria were investigated to assess the impact on functional outcome. By assessing how the effect of thrombolysis changes over onset time to treatment (OTT) the relationship between OTT and age could be investigated. By looking across the entire range of OTT and assessing the interaction between the two covariates this provided complementary data to a previous VISTA analysis conducted by Mishra et al. It was found that across the full range of OTT, up to 3.5h, the treatment effect of thrombolysis in very elderly stroke patients (>80 years old) was comparable to that of their younger counterparts. The association of AF and modified Rankin Scale (mRS) at day 90 was then assessed. Multiple logistic regression analysis adjusted for age and baseline National Institutes of Health Stroke Scale (NIHSS) showed that history of AF had no independent impact on stroke outcome. Deferred selection of subjects for neurorestorative therapies from hyperacute (<6h) to 24h was then explored using a simulation approach. The sample size required to detect a ‘shift’ in mRS outcome equivalent to a 5% absolute difference in proportion achieving mRS 0-2 versus 3-6 was modelled, setting power at 80% and assuming adjustment for entry age and NIHSS. It was found that extending the time window for patient selection provides a measurement which has a stronger more predictive relationship with outcome. Trial inclusion was explored further by investigating selection for delayed treatment with thrombolysis. Prognostic scoring methods were proposed to identify a strategy for patient selection to be applied first to an existing trial dataset and then validated in the pooled RCT 4.5-6h data. ). Prognostic score limits were chosen to optimise the sample for a net treatment benefit significant at p=0.01 by Cochran Mantel Haenszel test and by ordinal logistic regression. More inclusive limits were also defined based on p=0.05 criteria. After finalising prognostic score limits, for validation they were applied by an independent statistician to the pooled RCT data for 4.5-6h. The validation analysis based on ordinal outcomes failed to deliver a population in whom treatment >4.5h was safe and effective; analysis based on net benefit (mRS 0-1) showed significance. Secondly, different strategies for endpoint selection were considered. In the past some trialists have investigated the use of earlier endpoints on single trial datasets and taken advantage of the fact that numerous outcome scales are available to measure various domains of neurological and functional recovery. The use of an earlier neurological endpoint for detecting futility in a trial was considered with validation on external RCT data. Global endpoints, investigating different aspects of functional recovery at different time-points were then considered. Simulations were undertaken to assess the relationship between sample size and power for ordinal scales and the corresponding global outcomes. Day 7 NIHSS was found to be the most sensitive individual ordinal endpoint. Dichotomised analyses supported these results. However this needed validation in a randomised trial dataset for use in exploratory stroke trials. The validation study reinforced the results from the non-randomised VISTA study. The global test combination of NIHSS90 with NIHSS7 appeared to offer incremental sensitivity to treatment effect compared to the ordinal scales alone. The combination of mRS90 with NIHSS7 did not increase the sensitivity to treatment effect when compared to NIHSS alone, but offers a broader clinical measure without loss of statistical power. Finally, alternatives to the traditional RCT were considered. Abandoning the rigour of the blinded RCT carries substantial penalty in loss of reliability and should not be undertaken lightly. If a placebo control is deemed impractical or unethical, investigators often consider comparisons against historical controls. A within-VISTA exploration of case-control matching is presented. The reliability of different matching methods and covariate combinations were assessed using a simulation approach. The results indicate that caution must be taken when using historical controls to generate a matched control group. Substantial further work matching to external data and validation to RCT data is needed. Cluster randomised trials, which randomise patients by groups, are becoming a more widely used approach. When evaluating strategies to promote the transfer of research findings into clinical practice, i.e. in "Implementation Research", an RCT is impractical and a cluster randomised trial design is of advantage. Some elements in the design and sample size calculation of cluster randomised trials were considered. Intra cluster correlation coefficients (ICCs) were estimated from linear and generalised linear mixed models using maximum likelihood estimation for common measures used in stroke research. These estimates of relevant ICCs should assist in the design and planning of cluster randomised trials. In conclusion, this research has shown that there are several areas in the design of clinical trials of acute stroke that merit further investigation. Several strategies have been highlighted that could potentially reduce sample size whilst retaining optimal levels of statistical power. However other aspects such as patient selection and the nature of the intervention under study can affect trial cost and statistical power and need to be taken under consideration.

Smokers with asthma represent an important sub-group of asthmatics displaying both reduced response to inhaled and oral corticosteroids as well as demonstrating accelerated decline in lung function and increased use of health care services. Clinical and laboratory studies have suggested that macrolide antibiotics may exhibit anti-inflammatory properties in a variety of airways disease including asthma. The anti-inflammatory properties of macrolides have been recognised for almost 50 years. Indirect evidence from both pre-clinical and clinical studies suggests that the mechanism of action may be of particular benefit in smokers with asthma. A proof of concept study was designed to test the hypothesis that the macrolide antibiotic azithromycin improves measures of asthma control, airway inflammation and bacterial colonisation in smokers with asthma. Azithromycin was chosen for its convenience of once daily dosing and its oral tolerability in addition to its more limited interactions. Seventy-seven adults with allergic asthma were recruited to a 12-week parallel group randomised controlled trial comparing the effects on asthma control, airway inflammation and bacterial colonisation of oral azithromycin 250 mg daily with matched placebo. The primary outcome measure was peak expiratory flow at the final study visit. Secondary outcome measures included spirometry, asthma control questionnaire [ACQ] score, asthma quality of life questionnaire [AQLQ], Leicester cough questionnaire [LCQ] score, provocation concentration to methacholine PC20, and inflammatory markers: exhaled nitric oxide, sputum differential cell counts, sputum supernatant and serum inflammatory markers such as interleukin-1β [IL-1β], IL-2, -4, -5, -6, -10, TNF-α, IFN-γ, GM-CSF, Leukotriene B4, and high sensitivity C-reactive protein. Microbiological culture and PCR of sputum was also performed to assess for any changes associated with treatment. At 12 weeks, the change in PEF at the final study visit, as compared with baseline, did not differ significantly between the azithromycin and placebo treatment groups [mean difference azithromycin-placebo -10.3L/min, 95% CI -47.1 to 26.4, p=0.58]. No statistically significant difference was observed between the azithromycin and placebo groups in each of the measures of spirometry, ACQ, AQLQ, LCQ, PC20, or evening PEF. The LCQ-psychological domain did reach statistical significance, [mean difference azithromycin-placebo -0.46, 95%CI -0.9 to 0.02 p=0.04], however this indicates a deterioration in the treatment group. No change was seen in exhaled nitric oxide. The total cell counts recovered from sputum were similar following treatment with azithromycin compared to placebo. In addition, differential cell counts remained unchanged and lymphocyte proliferation assays did not demonstrate any statistically significant changes following 12 weeks of treatment with azithromycin when compared to placebo. There was no substantial difference in any of the measured sputum supernatant or plasma cytokines. Peripheral blood monocyte stimulation was performed, with supernatant being measured against a panel of cytokines. There was again no substantial difference in any of the measured panel of cytokines collected from the monocyte stimulation assays when the azithromycin group was compared to placebo. There was no correlation between changes in ACQ, AQLQ, LCQ, PC20, sputum macrophage count, sputum neutrophil count, sputum eosinophil count, and PEF. Adverse event rates were similar in patients taking azithromycin compared with placebo. A total of 4 patients were lost to follow up [1 in the azithromycin group, 3 in the placebo group]. One patient died of a cardiovascular cause. This occurred following completion of the study but within the pre-specified regulatory reporting period. In conclusion there were no clinically important improvements in a range of clinical indices of asthma control, airway inflammation or bacterial colonisation following 12 weeks treatment with azithromycin when compared with placebo in smokers with asthma. The lack of any evidence of clinical benefit of azithromycin in smokers with asthma is a new finding and extends the current knowledge base and evidence for the use of macrolides in asthma. There exists no firm evidence to suggest the widespread use of macrolides in asthma and the current study suggests that no benefit will be observed in the sub-group of asthmatics whom are current smokers.

The role of optometry in the delivery of eye healthcare in the UK is well recognised by the state and the British people. Optometry in Britain works very closely with medicine and is steadily moving forward as a profession complimentary to ophthalmology. However, with the exception of Ireland, the role of optometry in the rest of the European Union is restricted by national laws, decrees or acts like Actus Medicus to those professional activities which are normally carried out by dispensing opticians in the UK. From a British perspective there are no equivalent working optometrists in the EU except in Ireland. British optometrists provide an increasing amount of primary eye healthcare working closely with hospital based ophthalmologists who provide secondary care. In the rest of the European Union primary eye care is generally provided by practising ophthalmologists who refer patients to hospitals or university clinics for secondary care. With the growing elderly population and changing demography, the UK will remain short of human resources for the management of sight threatening conditions. It is not realistic to expect 750 British ophthalmologists to be responsible for secondary eye care for the entire population of the UK British standards in eye healthcare must be maintained and optometry in the EU must be reformed effectively and improve to British standards before freedom of movement is implemented under any EU legislation especially under the new directive which would allow healthcare professionals to work in the EU for 16 weeks without registration from the year 2005. British optometrists with appropriate additional training could be given the responsibility for the specific task of ophthalmic intervention to avoid blindness and visual impairment and this would provide a pragmatic solution to a human resources problem in the eye care field in the UK. Hopefully, such a model would then be adopted by the future optometrists trained throughout the European Union.

'Looked after' children have high rates of emotional/behavioural disturbance, but it remains uncertain whether this derives from genetic risk, adverse experiences before reception into care, or from risks associated with substitute care experiences. Methods: The study was a 'natural experiment' comparing two different patterns of rearing after breakdown in early parenting, using teacher and parent questionnaires, interviews, systematic observations and standardised cognitive testing. 19 primary school children raised in institutional care from before the age of 1 year were compared with 19 children, matched for age and gender and comparable in biological background, who had experienced uninterrupted family foster care from that age. Both groups were compared with classroom controls. Results: The combined group of 'looked after' children differed from their classroom controls in showing a high level of inattention/overactivity. The teacher questionnaire and observational measures showed, however, that the increased rate was substantially higher in the institutional group than the family foster group. This difference was not explained by cognitive deficits. Also, the heightened level of inattention/overactivity was associated with a marked lack of selectivity in social relationships. This profile was found only in the institutional group, characterising about a third of them, all boys. At school, this elevated level of inattention was a specific response to cognitively demanding tasks, and partially accounted for the lower reading attainment of the institutional group compared with the family foster care group, whereas variation in IQ accounted for the lower reading scores of the family foster care group compared with their matched classroom controls. Out of school, the children in institutional care were rated by carers as having more emotional and unsociable difficulties; help with homework was associated with higher reading attainment in the family foster care group only. Conclusions: Against a background of genetic and early environmental risk, the type of care does matter. Institutional rearing was associated with a pattern of inattention/overactivity that for a significant minority included a marked lack of selectivity in social relationships. Further institutional upbringing was related to poorer reading attainment both directly and indirectly through this heightened inattention. Possible reasons, and implications for social policy and future research, are discussed.

Sign bilingualism is one of several approaches to the education of deaf children in the UK Sign bilingualism seeks to introduce British Sign Language (BSL) to deaf children from an early age in order to establish a first language from which English, the majority language, can be acquired. However, there is little concensus on how deaf children's BSL development should be measured and no practical tools available to assist practitioners in this task. BSL assessments are needed to make baseline assessments, facilitate identification of language difficulties, indicate targets for remediation and evaluate the outcome of educational and therapy programmes for deaf children. This study describes the development of an assessment of British Sign Language development. Issues relating to the type of test required and which aspects of BSL to include are raised. Selection of subjects upon whom to base test development and standardisation are discussed. The BSL test of receptive grammar was initially piloted on 40 children from native signing backgrounds. Revisions were made to the test procedure and a number of unsuccessful items were eliminated prior to standardising the test on 135 children aged 3-13 years. Subjects were carefully selected from the wider population of deaf children as being those who were in optimal language learning contexts. Although this may be considered a small sample for standardising a test, it reflects a high proportion of the population of children who are developing BSL under ideal conditions. Following publication of the test, analysis of data from its use with a larger unselected sample of deaf children allowed comparisons to be made with those in the standardisation study. The results provide insights into the conditions under which deaf children may acquire BSL naturally, even when BSL is not the home language. Areas explored by the study include the comparative language acquisition paths, as measured by the test, of deaf and hearing children from deaf families and deaf children from hearing families with diverse experiences of BSL input.