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The main effects of the e-Rx were analytical capacity of the pharmacists and physician and dissemination of knowledge purchase diabecon 60caps otc, integration of process tasks 60 caps diabecon mastercard, process automation generic diabecon 60 caps, facilitates interpretation of prescriptions buy 60 caps diabecon amex, improves relevance and meaningfulness of interaction and improves quality of information transmitted. Ongoing vendor involvement, acknowledgment of technology limitations, and attempts to address them were crucial in overcoming technology barriers. Staff resistance was addressed through clear communication, identifying champions, emphasizing new information provided by the system, and facilitating collaboration. N = 124 Health care implementation, concurrent changes, providers (mostly inadequate support, and social nurses and factors. On balance, Study End: 02/2004 time and be efficient (flexibility, inpatients seemed neither for nor comparisons with old system). And, more useful features synchronization and feedback Study End: 06/2007 such as safety alerts and the mechanisms between nurses and 257 possibility for physicians to prescribe physicians. The interviews electronically from everywhere in the revealed that both nurses and hospital greatly benefited the physicians considered the system prescription phase and improved the to be an improvement in their medication process. Nevertheless, medication work compared to the nurses and physicians listed many old paper-based system. It was verified that multiple variables affect a successful transition to an electronic order entry system and that workarounds and artifacts were used. The surveys Study End: 06/2003 collected post-implementation indicated that the staff felt there were fewer medication errors with a smoother administration of medication; however, it was perceived that more time was spent administering medications taking time away from patient care. We need a technology) interest, numerous, often unhelpful and new and more rational basis for human factor/user therefore ignored. Information the selection and presentation of experience overload may have a negative impact alerts that would help, not hinder, consultants and on cognitive performance. The problems that create work flow 00/0000 technology introduced intentional blocks ultimately leading to Study Start: blocks (safety features such as potential workarounds. Significantly more people from the successful hospital group reported supportive administration and supportive heads of medical sections; direct involvement of physicians, mandatory implementation, adequate training, and sufficient hardware facilitated success. In terms of barriers, only inadequate hardware and lack of ability to easily do patient transfer and advance admission orders (medical records package) differentiated the two groups and in both cases the item was mentioned more frequently by the successful hospitals. Study End: 00/0000 related to cueing, status, timing, communication, ownership, and linkage. Goals were associated with relevance screening, ensuring accuracy, minimizing memory load, and negotiating responsibility. Issues related to the Study End: 00/0000 presentation centered around rigidity of the system, alert fatigue, sources of potential errors. There Study Start: 04/2003 were error and security concerns, and issues related to Study End: 10/2003 alerts, workflow, ergonomics, interpersonal relations, and reimplementation. Clinical decision Study Start: 09/2004 support features introduced many of these unintended 374 Study End: 04/2005 consequences. Careful analysis of overdependence on technology data revealed 3 themes: (1) system downtime can create chaos when there are insufficient backup systems in place; (2) users have false expectations regarding data accuracy and processing; and 3) some clinicians cannot work 373 efficiently without computerized systems. Implementation: 00/0000 Study Start: 08/2004 Study End: 04/2005 C-257 Evidence Table 12. Three quarters of the house staff reported observing each of these error risks, indicating that they occur weekly or more often. Use of multiple qualitative and survey methods identified and quantified error risks not previously considered, offering many opportunities for error reduction. Rate of Implementation: system Long term care overrides for drug-allergy order checks increased 00/1997 (nursing homes) significantly from 2001 to 2006 (69% vs. Override rates remain high and drug- Study End: 01/2006 allergy override rates increased. To reduce workload, wristbands were not Study Start: 00/0000 (nursing homes) scanned and medication scanning was delayed. The 2 00/0000 predominant factors contributing to the decision to end Study Start: 01/2003 the intervention were the false-positive alerts resulting Study End: 04/2003 from misidentification of medications as contraindicated in pregnancy by the pharmacy information system and misidentification of pregnancy related to delayed transfer of diagnosis information. These intercepted errors were not prescriptions over 4 Academic administered to the patient because either the time points pharmacist intercepted the prescription before Implementation: administration or the nurse recognized the error. Drug dosage was the most Implementation: common inconsistent element among both groups. About 20% of errors could have resulted in moderate to severe harm, for which significant independent predictors were found. All of these 10/2002 errors were classified as minor, with 14 (61%) Study Start: 01/2002 constituting only potential errors. Twenty-one errors in Study End: 05/2003 computerized order entry (91%) were of severity category 1 or lower. Error types, causes and contributing factors were of errors/100000 further described. Practices were stratified for analysis according to whether the N = 19,450 patients Academic site was urban or suburban. Proportion of children with persistent asthma with at least 1 prescription for a controller medication in each time period; with persistent asthma with an up-to-date asthma care plan filed in the previous year; with documentation of spirometry performed were measured and compared. All practices received copies of each clinical practice guideline, an introductory lecture, 1 performance feedback report, and 4 visits for intervention specific academic detailing. Data were abstracted at 61 practices from random samples of medical records of patients treated from June 1 2001, through May 31 2003 (baseline), and from May 1 2004, through April 30 2006 (follow-up). Effect on screening of lipid levels and appropriate management of lipid level test results were compared for 8,878 patients. Prompts included letters sent to patients about lipid Implementation: 04/2002 therapy prior to their scheduled visit, a progress note message within Study Start: 10/2001 the computerized patient record system notifications area and a Study End: 10/2003 computerized reminder screen within the specific patient chart during the patient’s visit. Compared change in N = 38 providers Academic prescribing behavior of the intervention and control providers before Implementation: 00/0000 and after implementation of the message pop-up. Prescribing Study Start: 03/0000 behavior change was measured as the change in the proportion of Study End: 05/0000 prescriptions of antibiotics for less than 10 days duration from baseline. The conditions included in the Study Start: 11/1999 intervention were acute otitis media, allergic rhinitis, sinusitis, Study End: 12/2003 constipation, pharyngitis, croup, urticaria, and bronchiolitis. One was the Pediatric Care Center (n = 36 Health Care Providers), an outpatient teaching clinic for pediatric residents and a clinical practice site staffed by full-time pediatric providers. The reminders were presented to intervention residents in the electronic chart in the examination room and a paper copy was put into the patient paper chart with the standard health summaries printed at each clinic visit. Antibiotics suggested by the antibiotic consultant with 482 N = 482 cultures associated antibiotic susceptibility results and the concurrent Implementation: 00/000 antibiotics ordered by physicians were compared. The antibiotics Study Start: 07/1990 ordered by randomized physicians were then compared between Study End: 01/1991 crossover periods of antibiotic consultant use. Eligible patients, identified from Implementation: 09/2004 electronic databases, had not received recommended laboratory Study Start: 09/2003 monitoring within 5 days after new dispensing of a study medication. Study End: 01/2005 Interventions were an electronic medical record reminder to the prescribing health care professional, an automated voice message to the patient, and a pharmacy team outreach to the patient. Physicians could continue with the care clinics prescription, change the medication or select from options presented. Implementation: 12/2002 The academic detailing included group educational session. The unit Study Start: 01/2000 of randomization was the primary care clinic; the unit of intervention Study End: 08/2004 was the primary care provider; and the unit of analysis was time (study month). The primary outcome was the “interacting prescription rate,” defined as the number of co-prescriptions of warfarin- interacting medications per 10,000 warfarin users per month. The effect of the interventions was evaluated using an interrupted time series design, analyzed with segmented regression models that control for pre-intervention trends. Alerts centered on maximum daily doses or physicians and 213,967 frequencies, medications to be avoided and missing values for patient days) creatinine clearance. Outcomes were the proportion of alerts that Implementation: 00/0000 lead to appropriate drug orders and rates of inappropriate drugs Study Start: 00/0000 avoided. A prospective, 20 N = 22,586 patients Academic primary care site, cluster-randomized, decision-support trial between Implementation: 00/0000 October 1, 2006, and March 31 2007 was conducted. At intervention Study Start: 10/2006 sites, electronic health record-based clinical alerts for influenza Study End: 05/2007 vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. For each site, captured opportunities for influenza vaccination and influenza vaccination rates were compared with those for the same period in the previous year. A letter summarizing the beneficial effects of anti-platelet Study Start: 05/2001 drugs in such type of patients were given to both the intervention and Study End: 11/2001 the control group. Data for patients receiving anti-platelet drug treatment in the control and the intervention group at the baseline and at the follow-up among the three risk groups were analyzed. Implementation: 00/0000 Changes in rates of ordering of antibiotics were compared between Study Start: 01/2000 the intervention and the control group for sore throat and urinary tract Study End: 01/2001 infection. Proportion of Study End: 03/2008 heavily marketed hypnotics prescribed before and after the implementation of computerized alerts and educational sessions were compared. Usual care included an alert of the copayment tier of the medication; the computer alerts recommended generic brands; group education sessions were held at 4 sites and an educational information packet was sent to all internal medicine clinicians from those sites. Physicians patients were randomly assigned to either a control group or an intervention Implementation: 00/0000 group. The intervention group received computerized and written Study Start: 03/1997 reminders for their patients with coronary artery disease, whereas Study End: 06/1997 those assigned to the control group were not contacted. Patients were the N = 10,507 patients unit of randomization; 5,118 in the intervention group and 5,389 in Implementation: 00/0000 the control group. Reminders appeared on the medical record screen Study Start: 03/1998 and pertained to 4 vaccine reminders and 8 non-medication related Study End: 03/1999 preventive care recommendations. The main outcomes Study End: 00/0000 were first time prescriptions for hypertension where thiazides were prescribed, patients assessed for cardiovascular risk before prescribing anti hypertensive or cholesterol-lowering agents, and patients treated for hypertension or high levels of cholesterol for 3 or more months who had achieved recommended treatment goals. Cost minimization framework was adopted, costs of intervention were set against reduced treatment costs. Prompts were generated at the point of care and Study Start: 00/0000 included 3 pages: screening, assessment and management Study End: 10/2006 information. Univariate (McNemar) and multivariate analysis (accounting for clustering) were performed. A total of 105 physicians from 25 practices and 64,150 patients were included in the study. In the intervention arm, a written clinics reminder with patient tailored recommendations was mailed to the Implementation: 00/0000 primary care physicians and nurses. The recommendations were Study Start: 01/2000 based on the last 6 months data for new patients, and 4 months for Study End: 12/2003 patients in periodic follow-up. Software features Implementation: 00/0000 included required fields, pick lists, standard drug doses, alerts, Study Start: 11/2004 reminders, and online reference information. The software prompted Study End: 01/2007 the discharging physician to enter pending tests and order tests after discharge. Hospital physicians used the software on the day of discharge and automatically generated 4 discharge documents. Proportion of patients readmitted at least once within 6 months of index hospitalization, emergency visits within 6 months and adverse events within 1 month were measured and compared. Perceptions about discharge from the perspective of patients, outpatient physicians and hospital physicians were examined by interview and survey. The number of adverse drug events, severity of Study Start: 00/2000 events, and whether the events were preventable were measured in Study End: 00/2000 this study.
You can prove this by providing oxygen from a tank; modern equipment is very easy to use and inexpensive proven diabecon 60 caps. If your loved one responds well to a few hours of oxygen 60 caps diabecon, you have proof of the problem diabecon 60caps on-line. Give it early in the morning buy generic diabecon 60caps line, upon rising, as soon as the feet are set on the floor. Keep it at the bedside, use small capsules or tablets and combine this chore with water drinking. Even the niacin-flush, which reddens the face and neck is welcomed since it gives a sensation of warmth. The flush is intensified by giving hot liquids or acids (even vitamin C) to drink. Do not use a prescription variety, since they are polluted with heavy metals; use only the brand in Sources, or a brand that you have tested pure. You can freely experiment with niacin to find the best dosage and variety; it is not toxic in this amount; but the size of the tablet should not turn it into an unpleasant chore. Immediately give a 100 mg tablet of niacin, 1 gram vi- tamin C, and a B-complex in this order of importance. If this causes them to spring a tiny leak somewhere, a part of the brain will not get its usual oxygen and nourishment. Cooking during the manufacturing of sorghum syrup kills the mold but its toxic byproducts (mycotoxins) are still present. Brown sugar is also polluted with sorghum molds, but fortunately you can detoxify this mold with vitamin C as usual. Purple patches, like bruises, on the hands or arms of an eld- erly person are called purpura, and is also caused by sorghum molds. Test in a saliva sample for all the sweetenings used recently (at least an hour ago). The kidney herbs (page 549), at half dose level (½ cup a day instead of a whole cup) can be given daily for three weeks and then on alternate days indefinitely. Try other kidney herbs from time to time: shave grass, cedar berries, juniper berries, butcher’s broom, cornsilk. Be prepared to use ex- tra paper padding in underwear to help catch the extra urine output. After the blood pressure comes up to 115 (systolic) mental performance will be greatly improved. Use an electronic device to measure blood pressure, one with a finger cuff, not an arm cuff which can itself induce broken blood vessels. Purchase a device that needs no adjustments of any kind and has automatic cuff tension control (see mail order catalogs if your pharmacy does not have one). Clean up the air according to the general principles of environmental cleanup (see Four Clean-ups, page 409). Shower water puts a lot of chlorine into the bathroom air which then distributes itself through the rest of the house. Notice whether your elderly person goes into the bathroom in fair shape mentally but comes out confused, unreasonable. Figure out how long it should last and write the date for replacement on the outside of it for your own convenience. Washing hands and face in chlorinated water can give off enough chlorine to trigger a manic episode in a manic-depressive person. It should not be used while the elderly person is in the house and never for his or her laundry. The body makes tumors out of them in order to stop them from cutting through your tissue. Air filters may remove some of the toxic elements but by blowing the air (and dust) around vigorously the remaining toxins are made much more vicious in their effect. The noise of a filter motor and fumes it may put out itself adds misery to the simple job of breathing. Make sure all fragrances are removed from the air, even though family members “like” them. The lungs treat them like toxins to be coughed up or removed by the kidneys and immune system. People who must use fragrance should apply it outdoors to keep the indoor air less polluted. They were meant to be an exact shape and size to fit the most oxygen molecules onto them. What a relief for the bone marrow whose job it is to make red blood cells to have enough vitamin B12 again! Killing Ascaris twice a week by zapping and taking B12 lozenges (see Sources) is a better solution. Provide vodka yourself in a small pocket flask or 70% grain alcohol for this purpose. Unfortunately, the shot itself may contain traces of this harmful solvent—take a sample home for testing. Most regular anemias, including low iron levels, are associ- ated with hookworm infestations. It is not wise to take iron pills, even if they do raise hemoglobin lev- els, except in life-threatening situations. Iron in the form of pills is too easily snatched up by bacteria who also need it, making them more virulent to the body. Use grain alcohol rinse in the bathroom to kill Ascaris and hookworm eggs under fin- gernails. It takes nutritious food to build the blood back up to its normal hemoglobin level. Eggs and meats (all very well cooked) are the richest sources of iron and other minerals used in blood building. B and other vitamins are also involved and can be6 given as a B-complex (see Sources). Do not use black strap molasses as an iron source, or any molasses, since it contains toxic molds. However, I have not tested enough molasses for solvents and you cannot risk these. Now it has molds which cause platelet destruction, (purpuric spots) internal bleeding, and immune failure. Acid levels operate the latching system that decides whether oxygen will be attached to hemoglobin or let go! Acid was meant to be removed from the blood and loaded into the stomach at mealtime for digestion. If the body acid level is too high, help the kidneys excrete it by adding more water to the diet and more minerals to neutralize the acid. In this case, filter it with a small all-carbon unit that is changed right on sched- ule. A plastic pitcher (not clear plastic or flexible plastic) with a carbon pack fitted into the top is best. When blood is properly oxygenated it takes on a bright red color, unoxygenated blood is more purple. Weekly chelations can correct many problems of the elderly that no other treatment could. Because of hostility from insurance companies who do not wish to add another cost to their ledger and doctors indoctrinated with misinformation, bad publicity is given to this wonderful, life-prolonging mode of treatment. Clinical doctors who have no time to really investigate the statistics of chelation treatments and for whom this is purely competition may feel antagonistic to these treatments. For a young person it is a good sign to be as low as 60, provided no drug is involved. The heart is made of four separate “chambers” or compart- ments each pulsing in turn. A heart that is beating 100 times per minute, not unusual for a weak old heart, can be so irregular that it misses every fourth beat. Imagine your four cylinder car or lawnmower missing one out of four engine strokes! Beta-blockers have some quite undesirable side effects but heart regularity has a higher priority. Later, when heart health is improved, the heart will beat regularly without drug use. Take the pulse daily when a new drug has been added, or when you are working on heart health, without getting your loved one anxious about it. Heart Health To improve heart health, the first steps of course would be to go off caffeine and to kill parasites and bacteria. Their nesting place, though, will be under a missing tooth in the jaw (cavitation). You can have all these killed in a day, without side effects and your heart is once more free to beat regularly. Try to do this with diet by eating more potassium rich food and by conserving on potassium losses. The adrenals are situated right on top of the kidneys where all toxic things are being excreted. Urinary tract bacteria, small kidney stones, moldy foods and metal from dentalware are the chief offenders. Aluminum objects that must be touched should be wrapped in masking tape: this includes walker, shower door, bathroom sup- ports. Door knobs, taped walker handles, and cane handles should be wiped daily with a grain alcohol solution. Vitamin C: shake some into all foods that can absorb a bit of the sour taste, even cooked cereal and vinegar water. If no capsules or tablets can be swallowed put a three day supply in a heavy plastic bag. If you are trying to do all this in a nursing home, feed it to your loved one while visiting. Put the powder mix in a plastic (not styrofoam) cup, add honey and stir until you get a paste. Often the elderly prefer it this way in order not to bother with pill taking at meal time. When the brain problems are corrected for an elderly person, be sure to relate the improvement to him or her. This encourages the elderly, letting them know their existence and quality of life is important to you.
The views of consumers generic diabecon 60 caps on-line, carers and professionals from four different countries (England discount diabecon 60 caps on line, Germany purchase diabecon 60caps overnight delivery, Italy and the Netherlands) were combined in a study by Kikkert et al order diabecon 60caps on-line. The sample comprised of 27 people with schizophrenia, 29 carers and 28 professionals involved in the treatment of consumers. Participants were allocated selectively to groups which were comprised of members of each stakeholder group. The concept mapping procedure involved group discussions about factors that influence medication adherence. Brainstorming of factors related to adherence was conducted amongst groups and participants were asked to generate statements about influences on adherence. These statements were then reviewed by researchers and reduced to a manageable number via the combination of similar statements and deletion of statements regarded as least relevant. Individual group members then conducted clustering; the process of determining which factors emerged from the data and to what extent factors related to each other. This was followed by prioritising, or ordering of the data in terms of importance in relation to medication adherence. Ultimately, five clinically relevant codes were identified as affecting adherence: medication efficacy, external factors (such as patient support and therapeutic alliance), insight, side effects and attitudes towards medication. Interestingly, the importance of each of these factors differed 59 significantly between consumers, carers and professionals, indicating that these stakeholder groups do not have a shared understanding of what influences medication adherence behaviour. The greatest disparity in prioritising was observed between consumers and professionals (Kikkert et al. In the latter case, non-adherence is viewed as an illness symptom and, thus, negative attitudes to medication are seen as irrational and a direct consequence of the underlying psychoses. Despite the different study populations and research designs, some consistencies emerged across qualitative research related to adherence amongst people with schizophrenia. For example, all of the studies used qualitative interviews as the means of data collection. Adherence was frequently associated with the benefits of medication in terms of symptom control and the costs associated with non-adherence (such as relapse and rehospitalisation) (Rogers et al. Consumers generally talked about the effectiveness of medication in treating symptoms and the side effects associated with medication collectively and weighed the two against each other to determine their attitudes towards medication (Shoemaker & Ramahlo de Oliveira, 2008, 2008). Functioning and appearance to the 60 outside world were important considerations for consumers when discussing the benefits and costs of medication (Carrick et al. Once consumers acquired knowledge about their illnesses and medication, which typically occurred with time and experience, they reported to engage in more practices akin to self-medication, such as reducing their dosage of their own accord (Shoemaker & Ramahlo de Oliveira, 2008, 2008). Thus, in some instances, non-adherence can represent a means of expressing control over their treatment. Healthcare providers were generally viewed as exerting a significant amount of control over consumers’ treatment and a lack of involvement of consumers and family members in managing treatment was reported. Additionally, there were significant disparities between the views of consumers and healthcare providers regarding the relative impact of influences on adherence (Kikkert et al. A limitation of two of the studies discussed was that they synthesised the findings from studies that explored the medication experience across multiple chronic conditions including schizophrenia, rendering it difficult to discern the aspects of participants’ experiences related to the unique illness experience of schizophrenia. Additionally, interview plans were occasionally based on factors previously established in the literature to influence adherence, thus, potentially accounting for the emergence of some codes. Furthermore, none of the studies identified occurred within an Australian setting and thus, may be limited in their applicability to Australian populations, whereby the health care system and medications that are available may differ. Interviews only involved people who met diagnostic 61 criteria for schizophrenia, were semi-structured and contained general questions. It has been used in the present study because it implies greater agency for consumers in relation to their illness management than previously used terminology, such as ‘compliance’. Medication adherence amongst people with schizophrenia is consistently shown to be associated with positive outcomes, including symptom reduction, reduced relapse rates and improved general functioning. By contrast, non-adherence (including partial non-adherence) is frequently associated with symptom fluctuations and higher risks of relapse and hospitalisation. Despite the established knowledge that poorer outcomes are associated with medication non-adherence, rates of non-adherence are amongst people with schizophrenia remain high. Although true rates of adherence are difficult to quantify and there have been inconsistent findings, non-adherence has been estimated to be between 30 and 75% for oral medications. Lower rates of non-adherence amongst consumers prescribed depot medications could be explained by a greater number of consumers who take depot medication being on community treatment orders. Factors consistently proposed to influence adherence in quantitative studies include insight, substance use, consumer attitudes towards medication, the relationship between the prescriber and consumer, efficacy of medication and side effects. Although considerably less qualitative research has been conducted specifically focusing on adherence amongst people with 62 schizophrenia, those studies that have been conducted have produced enlightening results and revealed significant disparities between consumer and healthcare provider perspectives regarding the relative importance of various factors on adherence. Given that the present study aims to assess influences on medication adherence, some overlap with previous findings occurred. Reviews converge in concluding that non-adherence is better documented than understood and that a focus on individual consumers’ decision-making process is often an important, missing element in quantitative research (Fenton et al. In addition to offering scope for the elucidation of factors not previously researched in the literature, the present study, through its qualitative, interview design, aims to build on our understanding of medication adherence. Justification for, and elaboration of, the methodology of the research presented will be provided in the following chapter. A secondary purpose of the study was to illuminate consumers’ attributions to their subjective adherence or non-adherence, past or current, in order to gain an insight into the types of factors that influence adherence amongst this population. This chapter outlines the methodological procedure undertaken for the research presented in this thesis. Qualitative in approach, the research involved one to one, semi- structured interviews with consumers that focused on their experiences of taking antipsychotic medication. Interviews were then transcribed and analysed according to the principles of grounded theory. Whilst the analysis was informed by a grounded theory approach, a full grounded theory analysis, involving the generation of a theory, was outside the scope of the thesis. This chapter begins by providing a justification for the research followed by a discussion of grounded theory. Subsequently, relevant ethical considerations are addressed and the sample, data collection and data analysis are described. As emphasised in prior chapters, a review of the literature on medication adherence amongst people with schizophrenia yielded relatively little research from the consumer perspective. Some valuable qualitative research has been conducted (as outlined in Chapter 3) however, few studies 64 were found that focused specifically on adherence amongst people with schizophrenia. Furthermore, interview plans used in the qualitative studies described typically focused on factors established in the literature to influence adherence. Thus, the research presented in this thesis will contribute to strengthening existent qualitative evidence. As previously mentioned, whilst medication adherence amongst people with schizophrenia represents a topic of extensive research, the majority of published studies in the field have incorporated quantitative designs. Whilst such quantitative studies require the participation of consumers, they preclude the identification of consumers’ own ways of making sense of medication adherence by not providing consumers with opportunities to express their subjective experiences of medication adherence. Whilst the utility of the results of quantitative studies in contributing to our knowledge of medication adherence is not disputed here, such designs afford limited (if any) scope for information beyond that which is being directly measured to be communicated. Through its reliance on hypotheses generated by existing theories, quantitative adherence research has, thus, foreclosed the possibility of generating completely new theories on adherence; in particular, theories from the perspectives of consumers (Willig, 2001). It is highly likely that previous quantitative research has failed to capture the complexity of medication adherence amongst people with schizophrenia, potentially overlooking important influences on adherence which could then be addressed through intervention. One rationale for qualitative research is to expand our theoretical understanding of phenomena, which depend on the context-specific collection and interpretation of richer and deeper forms of data (Rogers et al. According to Hesse-Biber and Leavy (2004) and Ezzy (2002), qualitative researchers are motivated to understand the world of the research participants through the eyes of participants, as human behaviour, unlike that of physical objects, cannot be understood without reference to the meanings and purposes attached by humans to their activities. Whilst it is acknowledged that there are multiple forms of qualitative research, Jones, Torres and Arminio (2006) summarise the intent of qualitative research as to illuminate and attain a deeper, improved understanding of the rich lives of humans and the world. It is acknowledged that there are a multiplicity of forms of qualitative research, which do not all have the same rationales, however. By utilising a form of qualitative analysis here, this research addresses the limited voices of consumers in adherence research in the literature. Qualitative data are non-numerical and are usually obtained from unstructured or semi-structured research methods (Hesse-Biber & Leavy, 2004). Consistently, the current research involved conducting in-depth, semi-structured interviews with outpatients with schizophrenia. Interviews explored consumers’ understandings of the meanings and uses of medication, potential obstacles and incentives to adherence, useful strategies to facilitate adherence as well as other topics spontaneously raised in relation to the topic, with the ultimate aim of gaining an insight into interviewees’ lives. Analysis remained close to the data, in order to provide a rich, descriptive account of experiences. A more detailed account of the analytic procedure will be provided later in this chapter. Although some overlap with previous findings occurred, research findings added to the qualitative research in the area and helped to contextualize the ample statistical data available on adherence. The method of data collection was face-to-face, semi-structured interviews with outpatients with schizophrenia who had experiences with taking antipsychotic medications. Interviews were conducted at day centres and medication clinics in the Northern and Eastern metropolitan areas of Adelaide and at a public hospital in Northern metropolitan Adelaide. Interviews were conducted between 31/07/2008 and 25/2/2009, and varied in length from 30 minutes to approximately two hours. Qualitative interviews were initially conducted with a view to designing an intervention to assist with medication adherence, based on interviewees’ responses. Upon analysis, however, it became clear that the data did not lend themselves to a clear-cut intervention. Furthermore, data highlighted the inter-subjectivity of medication experiences amongst consumers and interviewees frequently directly opposed one generalised intervention to address adherence on these grounds. Indeed, the developers of grounded theory, Barney Glaser and Anselm Strauss, were schooled in opposing research traditions. Glaser studied in the department of sociology at Columbia University which was renowned for a reliance on quantitative methodology whereas Strauss was schooled in the Chicago tradition, which was associated with down-to-earth, qualitative research (Glaser & Strauss, 1967). In 1967, a critical point in social science history, Glaser and Strauss co-authored the book, “The Discovery of Grounded Theory: Strategies for Qualitative Research”. At the time, there was an overwhelming preoccupation with the quantitative testing of propositions derived from a few, highly abstract “grand” theories. This lead to impoverished theory, with limited relevance to any substantive content domain and compromised the scope for the emergence of new theories (Pidgeon, 1996). Glaser and Strauss’ grounded theory, thus, served at the front of the qualitative revolution (Charmaz, 2003). In their book, Glaser and Strauss challenged the dominant view that quantitative research represents the only form of systematic social scientific inquiry. More specifically, they attempted to bridge the gap between theory and empirical research; to generate theory that is relevant to research (Glaser & Strauss, 1967). In summary, through grounded theory, Glaser and Strauss proposed a radical philosophical shift, aimed at generating more local, contextual theory that would, as a consequence, be of relevance to those studied (Pidgeon, 1996). A grounded theory approach to inquiry involves intimate engagement with the data which typically results in the generation of a theory that is 68 grounded in the data. The resultant theory is inductively developed during a study and in constant interaction with the data from that study (Ezzy, 2002; Maxwell, 2005).
The simplest experiment that these two Japanese microbiologists performed was to mix multiresistant E diabecon 60 caps low cost. Corresponding experiments were performed on patients by introducing multiresistant E order 60 caps diabecon. This interpretation was supported by the experimental observation that the resistance-carrying bacteria could be cured from resistance by treatment with acridine orange 60caps diabecon sale, which was known to be able to eliminate an episome generic diabecon 60 caps overnight delivery, an extrachromo- somal genetic element, from a bacterium. The name was later changed to R plasmid, which is more in line with present knowl- edge. Akiba and Ochiai published their results in the Japanese language, which meant that their observations did not become known in the Western world until 1963, when Tsutomu Watan- abe published a review article, ‘‘Infective Heredity of Multiple Drug Resistance in Bacteria,’’ in Bacteriological Reviews (American Society of Microbiology). While this review article was in press in 1962, Naomi Datta in London reported on the appearance of R plasmids in strains of Salmonella typhimurium isolated in Eng- land. Very soon thereafter, R plasmids were observed all over the world, revealing their great potential for the spread of resistance and the consequences for the medical use of antibiotics. The latter regulatory link is of course very important, since a faster replication would overcrowd the cell with plasmids, and kill it, while a slower replication would very quickly dilute the plasmid away. Bacterial plasmids vary dramatically in size, from a few thousand base pairs to half a million base pairs (0. These genes, together with the replication initiation of the plasmid, comprise what is called a replicon. For a more detailed description of the function of these regulatory genes, see textbooks on bacterial genetics. As mentioned, the transfer and spread of antibiotic resistance genes with R plasmids depend on the conjugation ability of these plasmids. That is the ability to transfer a copy of itself from its host bacterium to a recipient bacterium. Also as mentioned earlier, conjugation depends on contact between bacterial cells via a pilus, pulling donor and recipient together to close cell contact. As a simple rule of thumb, the size of this genetic space is about 30 kb (30 kilo base pairs). According to the same simple rule, this means that plasmids below a size of 30 kb cannot conjugate. Small plasmids can all the same transfer from bacterium to bacterium together with larger conjugating plasmids. This phenomenon, called mobilization, means that the small plasmid is transferred via the transfer channel that the larger plasmid has formed for its own transfer (Fig. Experimentally, it is thus possible to arrange a triple cross, where a small nonconjugatable plasmid is transferred to a recipient. In the ﬁrst cross, a conjugatable plasmid is transferred to a recipient hosting the small plasmid. In a second cross, the small plasmid is transferred via the transfer channel that the large conjugatable plasmid forms when transferring to a recipient, which at the end will host both plasmids. The mobilization phenomenon is limited to certain plasmid classes and related to their characteristics of replication. A small nontransferable plas- mid is mobilized from one bacterial cell to another with the help of a larger transferable plasmid in a triple cross. In the upper left a large conjugatable plasmid is introduced by conjugation into the bacterium harboring the small nontransferable plasmid. The lower left part illustrates how the large transferable plasmid mobilizes the small plasmid into the ﬁnal recipient by another conjugation. After the original discoveries regarding R plasmids at the beginning of the 1960s, a very large number of R plasmids carrying all sorts of resistance genes have been characterized. They can largely be characterized and classiﬁed by the char- acteristic genes of their replicons. The name inc is derived from the word incompatibil- ity, and the classiﬁcation is based on the inability of different plasmid replicons to exist stably in the same host bacterium, which is in turn related to the characteristics of the correspond- ing replicon genes. An example is the rifampicin- resistance-carrying R plasmid inferred in Chapter 9. Besides rifampicin resistance, this R plasmid carries resistance against betalactams, netilmicin, tobramycin, amikacin, gentamicin, strep- tomycin, spectinomycin, sulfonamides, and chloramphenicol. This means that a pathogenic bacterial strain taking up this plas- mid by conjugation at the same time becomes resistant to 10 antibiotics, and that treatment of an infection with this bacterium using one of these 10 agents also selects for resistance against the other nine. The very large multitude and variety of both resistance genes and plasmid replicons that has been observed makes it very interesting to ask questions about the origin of R plasmids and their structure. This is the case particularly because it can be surmised that the development of R plasmids has for decades been driven to a large extent by the very large distribution of antibacterial agents in the microbial environment. Three very interesting questions could be discerned: The ﬁrst regards the origin of the R-plasmid replicons, the second is about the origin of resistance genes, and the third asks about those genetic mech- anisms that have been able to transport resistance genes and to insert them into plasmids. The Origin of R Plasmids A very large number of different R plasmids have been observed. R plasmids were ﬁrst observed and characterized by the British bacteriologist Naomi Datta at the beginning of the 1960s. She asked if the great multitude of R plasmids had devel- oped under the selection pressure of our antibiotics. To approach this question, she turned to a collection of enterobacterial isolates which had been collected before the year 1940 (i. The enterobacterial strains were originally col- lected from many different parts of the world, including Europe, the Middle East, Russia, and North America. The strain collection included 433 isolates, which were examined for antibiotic resis- tance genes and for conjugatable plasmid replicons. Regarding resistance, they were tested for some 10 different antibiotics, which are used clinically today. Only two resistance traits were found, and neither was transferable in conjugation experiments. Of the 30 strains of Klebsiella in the collection, only one showed resistance to ampicillin, which was shown to be mediated by a chromosomal betalactamase known to be normally present in that particular Klebsiella biotype, Friedlander’s bacillus¨, which was found in the collection. It was observed in nine of the 16 Proteus strains identiﬁed in the collection of 433 isolates. Tetracycline resistance located on the chromosome is found as a normal Proteus trait. This was performed with the help of the mobilization phenomenon, described earlier in the chapter. That is, they were tested for their ability to transfer a small well-characterized but in itself nonconjugatable plasmid to a well-deﬁned recipient by a triple cross. The ﬁrst is the one tested for harboring a conju- gatable plasmid; the second carries the small, well-known, and nonconjugatable plasmid; and the third is a recipient that can be identiﬁed by selection markers. These isolates were collected in the period 1917–1941, that is, before antibiotics came into general use. Further investigations also showed that those plasmids were of the same inc types (see earlier in the chapter) as those we see among R plasmids today. The important interpretation of these results is that conjugatable plasmids were as common among enterobacteria before the antibiotics era as they are today. Resistance genes that are seen on conjugatable plasmids today, and which are spread horizontally very efﬁciently by these plasmids, have been taken up by genetic mechanisms under the selection pressure of heavy antibiotics distribution. A deﬁnition of these mechanisms then becomes very important for an understanding of resistance development. The localization of resistance genes on plasmids is, in turn, dependent on being carried by transposons that could locate in plasmids by recombination. Bacterial transposons were originally observed in the laboratory of Naomi Datta, ‘‘the Grand Lady of R plasmids. More extensive studies of this phenomenon later led to the proposition of transposons in bacteria. They must rely on other genetic elements by being borne on them and replicate with them. Transposons have the ability to move from plasmid to plasmid, or from plasmid to chromosome, or from chromosome to plasmid, and since they can carry antibiotic resistance genes, transposons and transpo- sition form another level of the spread of antibiotic resistance. That parts of the genome could move between different local- izations within the genome was known as early as the 1950s. However, precise observations at the molecular level regarding transposons, as the deﬁned genetic elements were called, were not made until the 1970s. The movability of these insertion sequences was shown to be connected to speciﬁed nucleotide sequences at their ends. The sizes of these ends were up to several tens of nucleotides and their sequences were palindromic; that is, they were invertedly repeated. The sequence at one end is identical to that of the other end but in the opposite direction. As mentioned in the text, transposons are important vehicles for the spread of antibiotics resistance, and as an illustration of this, a structural gene for betalactamase is represented here. The transposon with its trans- position mechanism is, of course, a very efﬁcient vehicle for the dissemination of antibiotic resistance, creating movability in dif- ferent directions between bacterial chromosomes and bacterial plasmids. One of them, ‘‘cut and paste,’’ is effected by the transposase simply cutting out the transposon from its original location, cutting up its recipient site, and placing the transposon at its new site on the recipient (Fig. The transposon is replicated while the donor and the recipient are bound together. This will result in a cointegrate structure, where donor and recipient are linked together covalently. The donor and recipient will then resolve into the original donor plasmid, with the recipient plasmid now carrying a copy of the transposon. The integron can, however, give mobility to those resistance genes, which it harbors as movable cassettes, which makes it a natural genetic engineering platform. The cassette can be looked upon as a very efﬁcient package for resistance genes in that the cassette structure mediates a genetic movability to single resistance genes, a powerful recombination machinery. The cas- sette has only two functional components; one is the structural resistance gene without a promoter, the other is a recombination component called 59be (base element). Despite its name, the latter can vary in size between 57 and 141 base pairs and is located downstream of the structural gene. The cassette can exist in two forms: either as a circular nonreplicating molecule, or integrated in the attI site of the integron (Fig. Cassette integration or excision is effected by an integrase, expressed from a gene int also located on the integron. The integrase catalyzes a site-speciﬁc recombination, which includes recognition of the 59be of the cassette by the integrase, which by recombination integrates it at the speciﬁc attI site located at the upstream end of the int gene. The 59be end of the integrated cassette forms a new speciﬁc recombination site, attC, which is recognized by the integrase, particularly at the cutting out of cassettes. The integrase gene int is expressed from right to left, while the resistance genes (in this case, Tp for trimethoprim resistance via drug-resistant dihydrofolate reductase, and Oxa for oxacillin resistance via oxacillin-degrading betalactamase) are expressed from left to right and from the promoter P located in the upstream part of the int gene. Further cassettes can be inserted at the attI site, giving the integron the ability to form an assortment of integron-borne combinations of antibiotic resistance genes. A single integron has been observed to carry eight different antibiotic resistance cassettes.