Patient perception of group consultations for knee osteoarthritis and influence of area-level deprivation: A service evaluation in a physiotherapy musculoskeletal setting.

INTRODUCTION: Group consultations are considered valuable for managing musculoskeletal (MSK) conditions. This service evaluation aimed to assess the perception of knee osteoarthritis (OA) patients regarding group consultations in NHS Lanarkshire's MSK service. It also explored the impact of area-level deprivation on patient engagement. METHODS: Surveys were developed to gauge patient satisfaction, preferences, and experiences in virtual and face-to-face (FTF) group consultations. Patients were categorised into opt-out, did not attend (DNA), or opt-in groups. We used the Scottish Index of Multiple Deprivation for area-level deprivation analysis. Descriptive statistics were used for quantitative data, while qualitative data were thematically analysed. RESULTS: A total of 84 patients participated, and area-level deprivation was similar across groups. Common engagement barriers included disinterest and transportation issues in opt-out and DNA groups, and IT problems in the DNA virtual group. Most patients expressed a preference for one-on-one consultations. FTF opt-in patients reported high satisfaction and increased confidence in managing their condition post-consultation. Virtual opt-in patients had a more neutral satisfaction level and mixed confidence. They were also less comfortable interacting with others during the consultation. Thematic analysis revealed positive experiences, and areas for improvement such as individual privacy concerns and additional resources. CONCLUSION: Overall, patients were generally satisfied with group consultations for knee OA. The evaluation identified strategies to enhance engagement. Area-level deprivation did not significantly impact patient participation in group consultations.

Acute stress symptoms 1-2 weeks after stroke predict the subsequent development of post-traumatic stress symptoms: A prospective cohort study.

OBJECTIVE: To date no research has examined the potential influence of acute stress symptoms (ASD) on subsequent development of post-traumatic stress disorder (PTSD) symptoms in stroke survivors. Our objective was to examine whether acute stress symptoms measured 1-2 weeks post-stroke predicted the presence of post-traumatic stress symptoms measured 6-12 weeks later. DESIGN: Prospective within-groups study. METHODS: Fifty four participants who completed a measure of acute stress disorder at 1-2 weeks following stroke (time 1) and 31 of these participants completed a measure of posttraumatic stress disorder 6-12 weeks later (time 2). Participants also completed measures of stroke severity, functional impairment, cognitive impairment, depression, anxiety, pre-morbid intelligence and pain across both time points. RESULTS: Some 22% met the criteria for ASD at baseline and of those, 62.5% went on to meet the criteria for PTSD at follow-up. Meanwhile two of the seven participants (28.6%) who met the criteria for PTSD at Time 2, did not meet the ASD criteria at Time 1 (so that PTSD developed subsequently). A hierarchical multiple regression analysis indicated that the presence of acute stress symptoms at baseline was predictive of post-traumatic stress symptoms at follow-up (R2 = .26, p < .01). Less severe stroke was correlated with higher levels of post-traumatic stress symptoms at Time 2 (rho = .42, p < .01). CONCLUSIONS: The results highlight the importance of early assessment and identification of acute stress symptoms in stroke survivors as a risk factor for subsequent PTSD. Both ASD and PTSD were prevalent and the presence of both disorders should be assessed.

Protocol for a systematic review of the validity of animal models of polydipsia with a basis in schizophrenia aetiology.

Objective: Primary polydipsia most commonly affects those with schizophrenia. The pathophysiology of this occurrence is not established. The aim of this systematic review is to critically assess the internal and external validity of the preclinical animal models available. Search strategy: PubMed and Embase will be searched systematically to identify all relevant animal studies that describe polydipsia induction with a basis in schizophrenia aetiology. The SYRCLE (SYstematic Review Center for Laboratory animal Experimentation) search filters to identify all animal studies in both databases will be used. All studies published up to the date of the search will be considered. Screening and annotation: Two independent reviewers will screen the retrieved studies for eligibility based on (1) title and abstract and (2) full text. Disagreements between researchers will be resolved by discussion and referral back to the predefined eligibility criteria with involvement of a third researcher if required.

Chronic pain self-management in middle-aged and older adults: A collective intelligence approach to identifying barriers and user needs in eHealth interventions.

Objectives: eHealth refers to health services and health information delivered or enhanced through the internet and related technologies. The number of eHealth interventions for chronic pain self-management is increasing. However, little evidence has been found for the overall efficacy of these interventions for older adults. The aim of the current study was to use a Collective Intelligence approach to identify the barriers and specific user needs of middle-aged and older adults using eHealth for chronic pain self-management. Methods: A Collective Intelligence workshop was conducted with middle-aged and older adults to generate, clarify, select, and structure ideas in relation to barriers to eHealth use and specific design requirements for the purposes of chronic pain self-management. Prior to attending the workshop, participants received a trigger question requesting the identification of five barriers to eHealth use for chronic pain self-management. These barriers were categorised and presented to the group along with barrier-related scenarios and user need prompts, resulting in the generation of a set of ranked barriers and a set of user needs. Results: A total of 78 barriers were identified, from which six categories emerged: Content, Support, Technological, Personal, Computer Literacy and Accessibility. Additional idea-writing and group reflection in response to these barriers revealed 97 user needs. Conclusion: This is the first study to use Collective Intelligence methods to investigate barriers to eHealth technology use and the specific user needs of middle-aged and older adults in the context of chronic pain self-management. The results of the current study provide a platform for the design and development of enhanced eHealth interventions for this population.

Differences in Learning and Persistency Characterizing Behavior in Chronic Pain for the Iowa Gambling Task: Web-Based Laboratory-in-the-Field Study.

BACKGROUND: Chronic pain is a significant worldwide health problem. It has been reported that people with chronic pain experience decision-making impairments, but these findings have been based on conventional laboratory experiments to date. In such experiments, researchers have extensive control of conditions and can more precisely eliminate potential confounds. In contrast, there is much less known regarding how chronic pain affects decision-making captured via laboratory-in-the-field experiments. Although such settings can introduce more experimental uncertainty, collecting data in more ecologically valid contexts can better characterize the real-world impact of chronic pain. OBJECTIVE: We aim to quantify decision-making differences between individuals with chronic pain and healthy controls in a laboratory-in-the-field environment by taking advantage of internet technologies and social media. METHODS: A cross-sectional design with independent groups was used. A convenience sample of 45 participants was recruited through social media: 20 (44%) participants who self-reported living with chronic pain, and 25 (56%) people with no pain or who were living with pain for <6 months acting as controls. All participants completed a self-report questionnaire assessing their pain experiences and a neuropsychological task measuring their decision-making (ie, the Iowa Gambling Task) in their web browser at a time and location of their choice without supervision. RESULTS: Standard behavioral analysis revealed no differences in learning strategies between the 2 groups, although qualitative differences could be observed in the learning curves. However, computational modeling revealed that individuals with chronic pain were quicker to update their behavior than healthy controls, which reflected their increased learning rate (95% highest-posterior-density interval [HDI] 0.66-0.99) when fitted to the Values-Plus-Perseverance model. This result was further validated and extended on the Outcome-Representation Learning model as higher differences (95% HDI 0.16-0.47) between the reward and punishment learning rates were observed when fitted to this model, indicating that individuals with chronic pain were more sensitive to rewards. It was also found that they were less persistent in their choices during the Iowa Gambling Task compared with controls, a fact reflected by their decreased outcome perseverance (95% HDI -4.38 to -0.21) when fitted using the Outcome-Representation Learning model. Moreover, correlation analysis revealed that the estimated parameters had predictive value for the self-reported pain experiences, suggesting that the altered cognitive parameters could be potential candidates for inclusion in chronic pain assessments. CONCLUSIONS: We found that individuals with chronic pain were more driven by rewards and less consistent when making decisions in our laboratory-in-the-field experiment. In this case study, it was demonstrated that, compared with standard statistical summaries of behavioral performance, computational approaches offered superior ability to resolve, understand, and explain the differences in decision-making behavior in the context of chronic pain outside the laboratory.

Service evaluation of telehealth in a physiotherapy musculoskeletal setting: Patient outcomes and results from risk stratification.

INTRODUCTION: Due to COVID-19 the ability to see all patients face-to-face (FTF) was removed. Services implemented telehealth to cater for patients requiring musculoskeletal care. A service evaluation was undertaken to assess the effectiveness of a mixed telehealth/FTF approach and identify if stratifying patients could help tailor intervention. METHODS: Retrospective analysis of data collected from patients who were assessed by Musculoskeletal Physiotherapists in one Scottish health board was undertaken. Patients were divided into low, medium and high risk sub-groups through the Keele STarT MSK tool. Outcome measures for pain and musculoskeletal health were taken at baseline/discharge along with satisfaction/preference. Descriptive and Inferential statistical analysis was conducted to establish whether changes in the outcome measures within and between risk sub-groups were statistically significant. RESULTS: Pain level difference from baseline to discharge demonstrated clinically and statistically significant improvements across all risk groups (N = 89). Musculoskeletal health demonstrated clinically significant improvements across all risk groups and statistically significant improvements in the medium/high risk groups but not the low risk. Patients with knee osteoarthritis and low back pain in the medium risk group had fewest appointments while patients with chronic shoulder pain had the most. The majority of patients were satisfied with all mediums but preferred FTF or an option between telehealth/FTF in the future. CONCLUSION: Telehealth is a promising model of care when utilised in combination with FTF for patients with musculoskeletal conditions. Through stratification, identifying specific conditions and shared decision making it may be possible to treat certain patient groups via telehealth.

Effects of Biopsychosocial Education on the Clinical Judgments of Medical Students and GP Trainees Regarding Future Risk of Disability in Chronic Lower Back Pain: A Randomized Control Trial.

BACKGROUND: Chronic lower back pain (CLBP) is a major health care burden and often results in workplace absenteeism. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions informed by the flags approach, which integrates cognitive and behavioral approaches via identification of biopsychosocial barriers to recovery, have resulted in reduced pain-related work absences and increased return to work for individuals with CLBP. However, research indicates that physicians' adherence to biopsychosocial guidelines is low. OBJECTIVE: The current study examined the effects of a flags approach-based educational intervention on clinical judgments of medical students and general practitioner (GP) trainees regarding the risk of future disability of CLBP patients. DESIGN: Randomized controlled trial (trial registration number: ISRCTN53670726). SETTING: University classroom. SUBJECTS: Medical students and GP trainees. METHODS: Using 40 fictional CLBP cases, differences in clinical judgment accuracy, weighting, and speed (experimental N = 32) were examined pre- and postintervention, as were flags approach knowledge, pain attitudes and beliefs, and empathy, in comparison with a no-intervention control group (control N = 31). RESULTS: Results revealed positive effects of the educational intervention on flags approach knowledge, pain-related attitudes and beliefs, and judgment weighting of psychologically based cues; results are discussed in light of existing theory and research. CONCLUSIONS: Short flags approach-based educational video interventions on clinical judgment-making regarding the risk of future disability of CLBP patients may provide opportunities to gain biopsychosocial knowledge, overcome associated attitude barriers, and facilitate development of clinical judgment-making more aligned with psychological cues.

An Evaluation of the Effectiveness of the Modalities Used to Deliver Electronic Health Interventions for Chronic Pain: Systematic Review With Network Meta-Analysis.

BACKGROUND: Electronic health (eHealth) is the use of information and communication technology in the context of health care and health research. Recently, there has been a rise in the number of eHealth modalities and the frequency with which they are used to deliver technology-assisted self-management interventions for people living with chronic pain. However, there has been little or no research directly comparing these eHealth modalities. OBJECTIVE: The aim of this systematic review with a network meta-analysis (NMA) is to compare the effectiveness of eHealth modalities in the context of chronic pain. METHODS: Randomized controlled trials (N>20 per arm) that investigated interventions for adults with chronic pain, delivered via an eHealth modality, were included. Included studies were categorized into their primary node of delivery. Data were extracted on the primary outcome, pain interference, and secondary outcomes, pain severity, psychological distress, and health-related quality of life. Pairwise meta-analyses were undertaken where possible, and an NMA was conducted to generate indirect comparisons and rankings of modalities for reducing pain interference. RESULTS: The search returned 18,470 studies with 18,349 being excluded (duplicates=2310; title and abstract=16,039). Of the remaining papers, 30 studies with 5394 randomized participants were included in the review. Rankings tentatively indicated that modern eHealth modalities are the most effective, with a 43% chance that mobile apps delivered the most effective interventions, followed by a 34% chance that interventions delivered via virtual reality were the most effective. CONCLUSIONS: This systematic review with an NMA generated comparisons between eHealth modalities previously not compared to determine which delivered the most effective interventions for the reduction of pain interference in chronic pain patients. There are limitations with this review, in particular, the underrepresented nature of some eHealth modalities included in the analysis. However, in the event that the review is regularly updated, a clear ranking of eHealth modalities for the reduction of pain interference will emerge.

Investigating the effectiveness of an online acceptance and commitment therapy (ACT) intervention versus a waiting list control condition on pain interference and quality of life in adults with chronic pain and multimorbidity: protocol for a randomised controlled trial.

INTRODUCTION: Multimorbidity refers to the presence of two or more chronic health conditions within one person, where no one condition is primary. Research suggests that multimorbidity is highly correlated with chronic pain, which is pain lasting longer than 3 months. Psychotherapeutic interventions for people living with chronic illness have resulted in reduced symptom reporting and improved psychological well-being. There is a dearth of research, however, using online psychotherapy for people living with multimorbidity where chronic pain is a central condition. This study will compare the effectiveness of an online acceptance and commitment therapy (ACT) intervention with a waiting list control condition in terms of improving health-related quality of life (HRQoL) and reducing levels of pain interference in people with chronic pain and at least one other condition. METHODS AND ANALYSIS: 192 adult participants with non-malignant pain that persists for at least 3 months and at least one other medically diagnosed condition will be randomised to one of two study conditions. The experimental group will undergo an eight-session internet-delivered ACT programme over an 8-week period. A waiting list group will be offered the ACT intervention after the 3-month follow-up period. HRQoL and pain interference will act as the primary outcomes. Data will be analysed using a linear mixed model and adjusted to account for demographic and clinical variables as necessary. A Study Within a Trial will be incorporated to examine the effect on recruitment and retention of showing participants an animated educational video. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Research Ethics Committee of the National University of Ireland, Galway. Dissemination of results will be via peer reviewed journal articles and conference presentations. TRIAL REGISTRATION NUMBER: ISRCTN22343024.

The relative effectiveness of psychotherapeutic techniques and delivery modalities for chronic pain: a protocol for a systematic review and network meta-analysis.

Introduction: There is increasing evidence for the use of psychotherapies, including cognitive behavioural therapy, acceptance and commitment therapy, and mindfulness based stress reduction therapy, as an approach to management of chronic pain. Similarly, online psychotherapeutic interventions have been shown to be efficacious, and to arguably overcome practical barriers associated with traditional face-to-face treatment for chronic pain. This is a protocol for a systematic review and network meta-analysis aiming to evaluate and rank psychotherapies (delivered in person and online) for chronic pain patients. Methods/ design: Four databases, namely the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO will be searched from inception. Randomised controlled trials that have evaluated psychological interventions for pain management delivered online or in person will be included in the review. Data will be independently extracted in duplicate and the Cochrane Collaboration Risk of Bias Tool will be used to assess study quality. Measures of pain interference will be extracted as the primary outcome and measures of psychological distress will be extracted as the secondary outcome. A network meta-analysis will generate indirect comparisons of psychotherapies across treatment trials. Rankings of psychotherapies for chronic pain will be made available.   Discussion: A variety of psychotherapies, delivered both online and in person, have been used in an attempt to help manage chronic pain. Although occasional head to head trials have been conducted, little evidence exists to help identify which psychotherapy is most effective in reducing pain interference. The current review will address this gap in the literature and compare the psychotherapies used for internet delivered and in person interventions for chronic pain in relation to the reduction of pain interference and psychological distress. Results will provide a guide for clinicians when determining treatment course and will inform future research into psychotherapies for chronic pain. PROSPERO registration: CRD42016048518 01/11/16.

Judgement analysis of case severity and future risk of disability regarding chronic low back pain by general practitioners in Ireland.

Chronic low back pain is a major healthcare burden that has wide ranging effects on the individual, their family, society and the workplace. However, appropriate management and treatment is often difficult, as a majority of cases are non-specific in terms of underlying pathology. As a result, there are extensive differences in both individual patient preferences for treatment and treatment decisions amongst general practitioners. The current study examined the clinical judgements of GPs in Ireland, regarding fictional patients' case severity and future risk of disability, through judgement analysis. Judgement analysis (JA) is an idiographic regression modelling technique that has been utilised in extant healthcare research for the purpose of allocating weighting to judgement criteria, or cues, observed by professionals in their clinical decision-making. The primary aim of the study was to model two critical information utilisation tasks performed by GPs with regard to CLBP-in combining information cues to form a judgement about current case severity and a judgement about the same patient's risk of future disability. It was hypothesised that the judgement weighting would differ across the two judgements and that judgements regarding future risk of disability would be less consistent among GPs than judgements about case severity. Results from the regression-based judgement analysis and subsequent follow-up statistical analysis provided support for both study hypotheses. Study findings are discussed in light of theory and research on judgement, clinical decision-making and chronic low back pain.

Factors Influencing the Application of a Biopsychosocial Perspective in Clinical Judgement of Chronic Pain: Interactive Management with Medical Students.

BACKGROUND: Though there is wide support for the application of biopsychosocial perspectives in clinical judgement of chronic pain cases, such perspectives are often overlooked due to either inadequate training or attitudes favoring a biomedical approach. Recent research has indicated that despite such explanations, both established general practitioners (GP) and medical students account for some psychosocial factors when making clinical judgements regarding chronic pain cases, but report not being likely to apply these in real-world, clinical settings due to numerous factors, including available time with patients. Thus, it is evident that a greater understanding of clinical judgement-making processes and the factors that affect application of these processes is required, particularly regarding chronic pain. OBJECTIVES: The aims of the current study were to investigate medical students' conceptualizations of the factors that influence application of a biopsychosocial approach to clinical judgement-making in cases of chronic pain using interactive management (IM), model the relationships among these factors, and make recommendations to chronic pain treatment policy in light of the findings. STUDY DESIGN: The current study used IM to identify and model factors that influence the application of a biopsychosocial approach to clinical judgement-making in cases of chronic pain, based on medical students' conceptualizations of these factors. SETTING: Two university classrooms. METHODS: IM is a systems thinking and action mapping strategy used to aid groups in developing outcomes regarding complex issues, through integrating contributions from individuals with diverse views, backgrounds, and perspectives. IM commonly utilizes the nominal group technique and interpretive structural modeling, which in this context were employed to help medical students identify, clarify, and model influences on the application of biopsychosocial perspectives in treating chronic pain patients. RESULTS: Results of IM group work revealed 7 core biopsychosocial approach application categories: GP attitudes, cost, GP knowledge, time, patient-doctor relationship, biomedical factors. and patient perception. GP attitudes was the most critical driver of all other competencies in the system, with cost and GP knowledge revealed as secondary drivers. LIMITATIONS: Potential differences in level of prior biopsychosocial perspective knowledge across participants and a potentially small sample size (though consistent with past research and appropriate for an exploratory study of this nature - for purposes of achieving the depth and richness of the deliberation and qualitative insights revealed by participants using the IM methodology). CONCLUSIONS: Results from this study may be used to both recommend further research on the identified factors influencing application of biopsychosocial perspectives in treatment of chronic pain and support amendment to extant health care policy, particularly with respect to cost, GP attitudes, and knowledge. Though this research claims neither that the influences identified are the only influences on biopsychosocial application, nor the order of their importance, the research does contribute to an on-going effort to better understand the factors that influence doctors in their treatment of chronic pain.Key words: Chronic pain, biopsychosocial, medical education, clinical judgement, interactive management, pain management.

Protocol for a systematic review with network meta-analysis of the modalities used to deliver eHealth interventions for chronic pain.

BACKGROUND: As eHealth interventions prove both efficacious and practical, and as they arguably overcome certain barriers encountered by traditional face-to-face treatment for chronic pain, their number has increased dramatically in recent times. However, there is a dearth of research that focuses on evaluating and comparing the different types of technology-assisted interventions. This is a protocol for a systematic review that aims to evaluate the eHealth modalities in the context of psychological and non-psychological (other than non-drug) interventions for chronic pain. METHODS/DESIGN: We will search the Cochrane Central Register of Controlled Trials (CENTRAL: The Cochrane Library), MEDLINE, Embase and PsycINFO. Randomised controlled trials (RCTs) with more than 20 participants per trial arm that have evaluated non-drug psychological or non-psychological interventions delivered via an eHealth modality and have pain as an outcome measure will be included. Two review authors will independently extract data and assess the study suitability in accordance with the Cochrane Collaboration Risk of Bias Tool. Studies will be included if they measure at least one outcome variable in accordance with the IMMPACT guidelines (i.e. pain severity, pain interference, physical functioning, symptoms, emotional functioning, global improvement and disposition). Secondary outcomes will be measures of depression and health-related quality of life (HRQoL). A network meta-analysis will be conducted based on direct comparisons to generate indirect comparisons of modalities across treatment trials, which will return rankings for the eHealth modalities in terms of their effectiveness. DISCUSSION: Most trials that use an eHealth intervention to manage chronic pain typically use one modality. As a result, little evidence exists to support which modality type is the most effective. The current review will address this gap in the literature and compare the different eHealth modalities used for technology-assisted interventions for chronic pain. With the growing reliance and use of technology as a medium for delivering treatment for chronic conditions more generally, it is imperative that research identify the most efficacious eHealth modalities and systematically identify the most important features of such treatment types, so they may be replicated and used for research and in the provision of care. TRIAL REGISTRATION: PROSPERO, CRD42016035595.

Prevalence, impact and cost of multimorbidity in a cohort of people with chronic pain in Ireland: a study protocol.

INTRODUCTION: Multimorbidity (MM) refers to the coexistence of two or more chronic conditions within one person, where no one condition is considered primary. As populations age and healthcare provision improves, MM is becoming increasingly common and poses a challenge to the single morbidity approach to illness management, usually adopted by healthcare systems. Indeed, recent research has shown that 66.2% of the people in primary care in Ireland are living with MM. Healthcare usage and cost is significantly associated with MM, and additional chronic conditions lead to exponential increases in service usage and financial costs, and decreases in physical and mental well-being. Certain conditions, for example, chronic pain, are highly correlated with MM. This study aims to assess the extent, profile, impact and cost of MM among Irish adults with chronic pain. METHODS AND ANALYSIS: Using cluster sampling, participants aged 18 years and over will be recruited from Irish pain clinics and provided an information package and questionnaire asking them to participate in our study at three time points, 1 year apart. The questionnaire will include our specially developed checklist to assess the prevalence and impact of MM, along with validated measures of quality of life, pain, depression and anxiety, and illness perception. Economic data will also be collected, including direct and indirect costs. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Research Ethics Committee of the National University of Ireland, Galway. Dissemination of results will be via journal articles and conference presentations.

Effectiveness of a biopsychosocial e-learning intervention on the clinical judgements of medical students and GP trainees regarding future risk of disability in patients with chronic lower back pain: study protocol for a randomised controlled trial.

INTRODUCTION: Chronic lower back pain (CLBP) is a major healthcare problem with wide ranging effects. It is a priority for appropriate management of CLBP to get individuals back to work as early as possible. Interventions that identify biopsychosocial barriers to recovery have been observed to lead to successfully reduced pain-related work absences and increased return to work for individuals with CLBP. Modern conceptualisations of pain adopt a biopsychosocial approach, such as the flags approach. Biopsychosocial perspectives have been applied to judgements about future adjustment, recovery from pain and risk of long-term disability; and provide a helpful model for understanding the importance of contextual interactions between psychosocial and biological variables in the experience of pain. Medical students and general practitioner (GP) trainees are important groups to target with education about biopsychosocial conceptualisations of pain and related clinical implications. AIM: The current study will compare the effects of an e-learning intervention that focuses on a biopsychosocial model of pain, on the clinical judgements of medical students and trainees. METHODS AND ANALYSIS: Medical student and GP trainee participants will be randomised to 1 of 2 study conditions: (1) a 20 min e-learning intervention focused on the fundamentals of the flags approach to clinical judgement-making regarding risk of future pain-related disability; compared with a (2) wait-list control group on judgement accuracy and weighting (ie, primary outcomes); flags approach knowledge, attitudes and beliefs towards pain, judgement speed and empathy (ie, secondary outcomes). Participants will be assessed at preintervention and postintervention. ETHICS AND DISSEMINATION: The study will be performed in agreement with the Declaration of Helsinki and is approved by the National University of Ireland Galway Research Ethics Committee. The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN53670726; Pre-results.

Hierarchical classification as relational framing.

The purpose of this study was to model hierarchical classification as contextually controlled, generalized relational responding or relational framing. In Experiment 1, a training procedure involving nonarbitrarily related multidimensional stimuli was used to establish two arbitrary shapes as contextual cues for 'member of' and 'includes' relational responding, respectively. Subsequently those cues were used to establish a network of arbitrary stimuli in particular hierarchical relations with each other, and then test for derivation of further untrained hierarchical relations as well as for transformation of functions. Resultant patterns of relational framing showed properties of transitive class containment, asymmetrical class containment, and unilateral property induction, consistent with conceptions of hierarchical classification as described within the cognitive developmental literature. Experiment 2 extended the basic model by using "fuzzy category" stimuli and providing a better controlled test of transformation of functions. Limitations and future research directions are discussed.

Testing for transitive class containment as a feature of hierarchical classification.

Three experiments investigated responding consistent with transitive class containment, a feature of hierarchical classification. Experiment 1 replicated key components of a preliminary attempt to model hierarchical classification (Griffee & Dougher, 2002) and tested for responding consistent with transitive class containment. Only 2 out of 5 participants showed the expected pattern. Experiment 2 tested whether repeated exposures to the Experiment 1 protocol would give rise to the expected pattern more reliably. None of 3 novel participants demonstrated the pattern. In Experiment 3, physically similar stimuli used in Experiments 1 and 2 were replaced across testing cycles by arbitrary stimuli. Transitive-class-containment-consistent responding was observed in all 3 novel participants. Implications, limitations and future research are discussed.

Tandem Enyne Allene-Radical Cyclization: Low-Temperature Approaches to Benz[e]indene and Indene Compounds.

In an effort to lower the temperatures required to prepare multicyclic compounds using the tandem enediyne-radical cyclization, we have developed the tandem enyne allene-radical cyclization which proceeds at temperatures as low as 37 degrees C. The reactions were carried out using three different methods for the preparation of the enyne allenes. The first method involved the [3,3] sigmatropic rearrangement of an enediyne followed by a tandem enyne allene-radical cyclization. This reaction could be effected either by thermolysis (150 degrees C) or by AgBF(4) rearrangement followed by heating at 75 degrees C. A second technique utilized a [2,3] sigmatropic shift of an enediyne at -78 degrees C followed by tandem cyclization at 37 or 75 degrees C depending on the substrate. The final method involved the base-catalyzed isomerization of propargyl sulfones which yielded enyne allenes that underwent cyclization at 37 degrees C. These three sequences provide a method for the synthesis of ring systems using conditions that may be compatible with the sensitive functionality needed during the synthesis of complex natural products.