Intentional and unintentional non-adherence in community dwelling people with type 2 diabetes: the effect of varying numbers of medicines

People with type 2 diabetes are often prescribed multiple medicines which can be difficult to manage. Nonadherence to medicines can be intentional (e.g. active decision) or unintentional (e.g. forgetting). The objective of this study was to measure intentional and unintentional non-adherence to differing numbers of medicines prescribed in type 2 diabetes. A cross sectional survey using the Morisky medication adherence scale (with intentional and unintentional non-adherence subscales) was completed by 480 people prescribed oral antidiabetic drugs (OADs), antihypertensive agents and statins. A within-subject analysis of variance (ANOVA) showed that intentional non-adherence did not vary between OADs, anti-hypertensives and statins. Intentional non-adherence to statins significantly increased when the number of medicines prescribed was included as a between-subjects variable (p<0.05). Another within-subject ANOVA on unintentional non-adherence found a significant difference between OADs, anti-hypertensives and statins; unintentional non-adherence to OADs was significantly higher (p<0.05). When the number of medicines was added as a between-subject variable unintentional non-adherence was associated with higher numbers of medicines. This study shows the difference between intentional and unintentional non-adherence behaviours, and the effect that varying numbers of medicines can have on these behaviours

Salt enhanced solvent relaxation and particle surface area determination via rapid spin-lattice NMR

This paper demonstrates the influence of surface charge chemistry on the application of nuclear magnetic relaxation measurements (NMR relaxometry) for the in situ determination of particle surface area, in the presence of high electrolyte concentration. Specifically, dispersions of titania, calcite and silica with and without 1 M KCl were investigated. The addition of salt, showed no significant change to relaxation measurements for titanium dioxide; however, a significant rate enhancement was observed for both calcite and silica systems. These differences were attributed to counterion layers forming as a result of the particles surface charge, leading to an increase in the relaxation rate of bound surface layer water. Further, changes appeared to be more pronounced in the silica systems, due to their larger charge. No enhancement was observed for titania, which was assumed to be due to the particles being at their isoelectric point, with no resulting counterion layer formation. Solvent relaxation was further used to successfully determine the surface area of particles in a dispersion using a silica standard reference material, with results compared to Brunauer-Emmett-Teller (BET) and spherical equivalent estimations. Two different dispersions of titanium dioxide, of different crystal phases, were shown to have NMR surface area measurements in good agreement with BET. Thus showing the technique was able to measure changes in surface charge when surface chemistry remained relatively similar, due to the reference silica material also being an oxide. In contrast, the NMR technique appeared to overestimate the calcite surface areas in reference to BET, which was assumed to occur due to both better dispersion in the liquid state of nanocrystallites and potential ion enhancement from the solubility of the calcite. These results highlight the potential of this technique as a fast, non-destructive and non-invasive method for dispersion analysis, but also show the competition between surface area and surface chemistry interactions on measured relaxation rates

Outcomes following the surgical management of left ventricular outflow tract obstruction; A systematic review and meta-analysis

BACKGROUND: Left ventricular outflow tract obstruction (LVOTO) causes exertional symptoms in two thirds of patients with hypertrophic cardiomyopathy (HCM). Consensus guidelines recommend surgical intervention in patients with drug refractory symptoms. The primary aim of this study was to perform a systematic review and meta-analysis to determine morbidity and mortality after surgery. METHODS: Study Selection: Studies reporting outcomes following surgical intervention for symptomatic LVOTO in HCM. RESULTS: 85 studies were included in the systematic review and 35 studies in the meta-analysis. Contemporary early (30 days) mortality following septal myectomy were 1.4% (CI 0.8, 2.4) I^{2} 9.0%, p = 0.36 and 0.7% (CI 0.3, 1.2) I^{2} 70.7%, p < 0.05 respectively. Sixty-eight studies (80%) reported perioperative complications. The contemporary rate of a perioperative ventricular septal defect was 1.4% (0.8, 2.3) I^{2} 0%, p < 0.05. Late morbidities including atrial fibrillation, stroke, heart failure and transplant were reported in fewer than 22% of studies and few studies compared mortality and clinical outcomes using different surgical approaches to LVOTO. The incidence rate (IR) of reintervention with a further surgical procedure was 0.3% (CI 0.2, 0.4) I^{2} 52.5%, p < 0.05. CONCLUSIONS: Contemporary surgical management of LVOTO is associated with low operative mortality rates but further studies are needed to investigate the impact of surgical therapy on non-fatal early and late complications

Development and validation of the Cambridge Multimorbidity Score

BACKGROUND: Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources. METHODS: We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index. RESULTS: Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731-0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737-0.747) and death at 1 year (C-index 0.912, 95% CI 0.905-0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725-0.728; 0.738, 95% CI 0.732-0.743; and 0.910, 95% CI 0.904-0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734-0.736, and 0.889, 95% CI 0.885-0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705-0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690-0.693) and admissions (C-index 0.703, 95% CI 0.697-0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900-0.914). INTERPRETATION: The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity

Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study

Background Polypharmacy is increasing and managing large number of medicines may create a burden for patients. Many patients have negative views of medicines and their use can adversely affect quality of life. No studies have specifically explored the impact of general long-term medicines use on quality of life. Objective To determine the issues which patients taking long-term medicines consider affect their day-to-day lives, including quality of life. Setting Four primary care general practices in North West England Methods Face-to-face interviews with adults living at home, prescribed four or more regular medicines for at least 1 year. Interviewees were identified from primary care medical records and purposively selected to ensure different types of medicines use. Interviews were recorded, transcribed and analysed thematically. Results Twenty-one interviews were conducted and analysed. Patients used an average of 7.8 medicines, 51 % were preventive, 40 % for symptom relief and 9 % treatment. Eight themes emerged: relationships with health professionals, practicalities, information, efficacy, side effects, attitudes, impact and control. Ability to discuss medicines with health professionals varied and many views were coloured by negative experiences, mainly with doctors. All interviewees had developed routines for using multiple medicines, some requiring considerable effort. Few felt able to exert control over medicines routines specified by health professionals. Over half sought additional information about medicines whereas others avoided this, trusting in doctors to guide their medicines use. Patients recognised their inability to assess efficacy for many medicines, notably those used for prophylaxis. All were concerned about possible side effects and some had poor experiences of discussing concerns with doctors. Medicines led to restrictions on social activities and personal life to the extent that, for some, life can revolve around medicines. Conclusion There is a multiplicity and complexity of issues surrounding medicines use, which impact on day-to-day lives for patients with long-term conditions. While most patients adapt to long-term medicines use, others did so at some cost to their quality of life

The egiin davaa prehistoric rupture, central mongolia: A large magnitude normal faulting earthquake on a reactivated fault with little cumulative slip located in a slowly deforming intraplate setting

The prehistoric Egiin Davaa earthquake rupture is well-preserved in late Quaternary deposits within the Hangay Mountains of central Mongolia. The rupture is expressed by a semicontinuous 80 km-long topographic scarp. Geomorphological reconstructions reveal a relatively constant scarp height of 4-4.5 m and a NW-directed slip vector. Previous researchers have suggested that the scarp's exceptional geomorphological preservation indicates that it may correspond to an earthquake that occurred in the region c. 500 years ago. However, we constrain the last rupture to have been at least 4 ka ago from morphological dating and < 7.4 ka ago based on radiocarbon dating from one of two palaeoseismic trenches. Our study shows that discrete earthquake ruptures, along with details such as the locations of partially infilled fissures, can be preserved for periods well in excess of 1000 years in the interior of Asia, providing an archive of fault movements that can be directly read from the Earth's surface over a timescale appropriate for the study of slowly deforming continental interiors. The Egiin Davaa rupture involved c. 8 m of slip which, along with the observations that it is largely unsegmented along its length and that the ratio of cumulative slip (c. 250 m) to fault length (c. 80 km) is small, suggests relatively recent reactivation of a pre-existing geological structure

Simulating Dynamical Features of Escape Panic

One of the most disastrous forms of collective human behaviour is the kind of crowd stampede induced by panic, often leading to fatalities as people are crushed or trampled. Sometimes this behaviour is triggered in life-threatening situations such as fires in crowded buildings; at other times, stampedes can arise from the rush for seats or seemingly without causes. Tragic examples within recent months include the panics in Harare, Zimbabwe, and at the Roskilde rock concert in Denmark. Although engineers are finding ways to alleviate the scale of such disasters, their frequency seems to be increasing with the number and size of mass events. Yet, systematic studies of panic behaviour, and quantitative theories capable of predicting such crowd dynamics, are rare. Here we show that simulations based on a model of pedestrian behaviour can provide valuable insights into the mechanisms of and preconditions for panic and jamming by incoordination. Our results suggest practical ways of minimising the harmful consequences of such events and the existence of an optimal escape strategy, corresponding to a suitable mixture of individualistic and collective behaviour.Comment: For related information see http://angel.elte.hu/~panic, http://www.helbing.org, http://angel.elte.hu/~fij, and http://angel.elte.hu/~vicse

Mexico City and the biogeochemistry of global urbanization

Mexico City is far advanced in its urban evolution, and cities in currently developing nations may soon follow a similar course. This paper investigates the strengths and weaknesses of infrastructures for the emerging megacities. The major driving force for infrastructure change in Mexico City is concern over air quality. Air chemistry data from recent field campaigns have been used to calculate fluxes in the atmosphere of the Valley of Mexico, for compounds that are important to biogeochemistry including methane (CH4), carbon monoxide (CO), nonmethane hydrocarbons (NMHCs), ammonia (NH3), sulfur dioxide (SO2), nitrogen oxides (NOx and NOy), soot, and dust. Leakage of liquified petroleum gas approached 10% during sampling periods, and automotive pollutant sources in Mexico City were found to match those in developed cities, despite a lower vehicle-to-person ratio of 0.1. Ammonia is released primarily from residential areas, at levels sufficient to titrate pollutant acids into particles across the entire basin. Enhancements of reduced nitrogen and hydrocarbons in the vapor phase skew the distribution of NOy species towards lower average deposition velocities. Partly as a result, downwind nutrient deposition occurs on a similar scale as nitrogen fixation across Central America, and augments marine nitrate upwelling. Dust suspension from unpaved roads and from the bed of Lake Texcoco was found to be comparable to that occurring on the periphery of the Sahara, Arabian, and Gobi deserts. In addition, sodium chloride (NaCl) in the dust may support heterogeneous chlorine oxide (ClOx) chemistry. The insights from our Mexico City analysis have been tentatively applied to the upcoming urbanization of Asia