Chester Medical School run research programmes jointly with the Countess of Chester Hospital NHS Foundation Trust (COCH) and other hospital trusts that are relevant at regional, national and international level.

Recent Submissions

  • Second generation tyrosine kinase inhibitors prevent disease progression in high-risk (high CIP2A) chronic myeloid leukaemia patients.

    Lucas, Claire; Harris, Robert; Holcroft, Alison; Scott, Laura; Carmell, Natasha; McDonald, Elizabeth; polydoros, Fotis; Clark, Richard (Nature, 2015-03-13)
    High cancerous inhibitor of PP2A (CIP2A) protein levels at diagnosis of chronic myeloid leukaemia (CML) are predictive of disease progression in imatinib-treated patients. It is not known whether this is true in patients treated with second generation tyrosine kinase inhibitors (2G TKI) from diagnosis, and whether 2G TKIs modulate the CIP2A pathway. Here, we show that patients with high diagnostic CIP2A levels who receive a 2G TKI do not progress, unlike those treated with imatinib (P=<0.0001). 2G TKIs induce more potent suppression of CIP2A and c-Myc than imatinib. The transcription factor E2F1 is elevated in high CIP2A patients and following 1 month of in vivo treatment 2G TKIs suppress E2F1 and reduce CIP2A; these effects are not seen with imatinib. Silencing of CIP2A, c-Myc or E2F1 in K562 cells or CML CD34+ cells reactivates PP2A leading to BCR-ABL suppression. CIP2A increases proliferation and this is only reduced by 2G TKIs. Patients with high CIP2A levels should be offered 2G TKI treatment in preference to imatinib. 2G TKIs disrupt the CIP2A/c-Myc/E2F1 positive feedback loop, leading to lower disease progression risk. The data supports the view that CIP2A inhibits PP2Ac, stabilising E2F1, creating a CIP2A/c-Myc/E2F1 positive feedback loop, which imatinib cannot overcome.
  • Low leukotriene B4 receptor 1 leads to ALOX5 downregulation at diagnosis of chronic myeloid leukemia

    Lucas, Claire; Harris, Robert; McDonald, Elizabeth; Giannoudis, Athina; Clark, Richard; University of Liverpool, Royal Liverpool University hospital, (Ferrata Storti Foundation, 2014-11-01)
    ALOX5 is implicated in chronic myeloid leukemia development in mouse leukemic stem cells, but its importance in human chronic myeloid leukemia is unknown. Functional ALOX5 was assessed using an LTB4 ELISA and ALOX5, and LTB4R1 mRNA expression was determined via a TaqMan gene expression assay. LTB4R1 and 5-LOX protein levels were assessed by cell surface flow cytometry analysis. At diagnosis ALOX5 was below normal in both blood and CD34(+) stem cells in all patients. On treatment initiation, ALOX5 levels increased in all patients except those who were destined to progress subsequently to blast crisis. LTB4 levels were increased despite low ALOX5 expression, suggesting that the arachidonic acid pathway is functioning normally up to the point of LTB4 production. However, the LTB4 receptor (BLT1) protein in newly diagnosed patients was significantly lower than after a period of treatment (P<0.0001). The low level of LTB4R1 at diagnosis explains the downregulation of ALOX5. In the absence of LTB4R1, the arachidonic acid pathway intermediates (5-HEPTE and LTA4) negatively regulate ALOX5. ALOX5 regulation is aberrant in chronic myeloid leukemia patients and may not be important for the development of the disease. Our data suggest caution when extrapolating mouse model data into human chronic myeloid leukemia.
  • c-Myc inhibition decreases CIP2A and reduces BCR-ABL1 tyrosine kinase activity in chronic myeloid leukemia.

    Lucas, Claire; Harris, Robert; Giannoudis, Athina; Clark, Richard; University of Liverpool, Royal Liverpool University hospital (Ferrata Storti Foundation, 2015-05-01)
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  • High CIP2A levels correlate with an antiapoptotic phenotype that can be overcome by targeting BCL-XL in chronic myeloid leukemia. Leukemia

    Lucas, Claire; Milani, Mateus; Butterworth, Michael; Carmell, Natasha; Scott, Laura; Clark, Richard; Cohen, Gerald; Varadarajan, Shankar; University of Liverpool (Nature, 2016-02-29)
    Cancerous inhibitor of protein phosphatase 2A (CIP2A) is a predictive biomarker of disease progression in many malignancies, including imatinib-treated chronic myeloid leukemia (CML). Although high CIP2A levels correlate with disease progression in CML, the underlying molecular mechanisms remain elusive. In a screen of diagnostic chronic phase samples from patients with high and low CIP2A protein levels, high CIP2A levels correlate with an antiapoptotic phenotype, characterized by downregulation of proapoptotic BCL-2 family members, including BIM, PUMA and HRK, and upregulation of the antiapoptotic protein BCL-XL. These results suggest that the poor prognosis of patients with high CIP2A levels is due to an antiapoptotic phenotype. Disrupting this antiapoptotic phenotype by inhibition of BCL-XL via RNA interference or A-1331852, a novel, potent and BCL-XL-selective inhibitor, resulted in extensive apoptosis either alone or in combination with imatinib, dasatinib or nilotinib, both in cell lines and in primary CD34(+) cells from patients with high levels of CIP2A. These results demonstrate that BCL-XL is the major antiapoptotic survival protein and may be a novel therapeutic target in CML.
  • CIP2A- and SETBP1-mediated PP2A inhibition reveals AKT S473 phosphorylation to be a new biomarker in AML

    Hills, Robert; Burnett, Alan; Lucas, Claire; Scott, Laura; Carmell, Natasha; Holcroft, Alison; Clark, Richard; University of Liverpool, Royal Liverpool University hospital, University of Cardiff (American Society for Hematology, 2018-04-27)
    Key Points PP2A inhibition occurs in AML by 2 different pathways: CIP2A in normal karyotype patients and SETBP1 in adverse karyotype patients. AKTS473 phosphorylation is a predictor of survival, and diagnostic levels of AKTS473 could be a novel biomarker in AML.
  • High drug related mortality rates following prison release: Assessing the acceptance likelihood of a naltrexone injection and related concerns

    Murphy, Philip N.; Mohammed, Faizal; Wareing, Michelle; Cotton, Angela; McNeil, John; Irving, Paula; Jones, Steve; Sharples, Louisa; Monk, Rebecca; Elton, Peter; University of Chester (Elsevier, 2018-07-04)
    Background and aims. High drug related mortality amongst former prisoners in the 4 weeks following release is an internationally recognised problem. Naltrexone injections at release could diminish this by blockading opioid receptors, but naltrexone is not licenced for injection for treating opiate misuse in the United Kingdom and some other countries. This study examined the likelihood of accepting a naltrexone injection at release, and the relationship of this likelihood to other relevant variables. Method. Sixty-one male prisoners with a history of heroin use, who were approaching release from two prisons in the north-west of England, provided likelihood ratings for accepting a naltrexone injection if it were to have been available. Additional data was gathered regarding demographic and drug use histories, and also from psychometric instruments relevant to drug misuse and treatment preparedness. Results. Maximum likelihood ratings for accepting a naltrexone injection were recorded by 55.7% of the sample with only 9.8% indicating no likelihood of accepting an injection. Likelihood ratings were positively related to serving a current sentence for an acquisitive offence compared to drug related or violence offences, and negatively related to peak methadone dosages during the current sentence. Conclusions. Although naltrexone injections were not available to participants in this study, the findings suggest that the potential uptake for this intervention is sufficient to warrant a clinical trial with this population of British prisoners, with a view to potential changes to its current licencing status
  • The sedentary office: an expert statement on the growing case for change towards better health and productivity

    Buckley, John P.; Hedge, Alan; Yates, Thomas; Copeland, Robert J.; Loosemore, Michael; Hamer, Mark; Bradley, Gavin; Dunstan, David W.; University Centre Shrewsbury (BMJ, 2015-06-01)
    An international group of experts convened to provide guidance for employers to promote the avoidance of prolonged periods of sedentary work. The set of recommendations was developed from the totality of the current evidence, including long-term epidemiological studies and interventional studies of getting workers to stand and/or move more frequently. The evidence was ranked in quality using the four levels of the American College of Sports Medicine. The derived guidance is as follows: for those occupations which are predominantly desk based, workers should aim to initially progress towards accumulating 2 h/day of standing and light activity (light walking) during working hours, eventually progressing to a total accumulation of 4 h/day (prorated to part-time hours). To achieve this, seated-based work should be regularly broken up with standing-based work, the use of sit–stand desks, or the taking of short active standing breaks. Along with other health promotion goals (improved nutrition, reducing alcohol, smoking and stress), companies should also promote among their staff that prolonged sitting, aggregated from work and in leisure time, may significantly and independently increase the risk of cardiometabolic diseases and premature mortality. It is appreciated that these recommendations should be interpreted in relation to the evidence from which they were derived, largely observational and retrospective studies, or short-term interventional studies showing acute cardiometabolic changes. While longer term intervention studies are required, the level of consistent evidence accumulated to date, and the public health context of rising chronic diseases, suggest initial guidelines are justified. We hope these guidelines stimulate future research, and that greater precision will be possible within future iterations.
  • Cardiac Rehabilitation Delivery Model for Low-Resource Settings: An International Council of Cardiovascular Prevention and Rehabilitation Consensus Statement

    Grace, Sherry L.; Turk-Adawi, Karam I.; Contractor, Aashish; Atrey, Alison; Campbell, Norman R. C.; Derman, Wayne; Ghisi, Gabriela L. M.; Sarkar, Bidyut K.; Yeo, Tee J.; Lopez-Jimenenez, Francisco; Buckley, John; Hu, Dayi; Sarrafzadegan, Nizal; University Centre Shrewsbury (Elsevier, 2016-08-17)
    Cardiovascular disease (CVD) is a global epidemic, which is largely preventable. Cardiac rehabilitation (CR) is demonstrated to be efficacious and cost-effective for secondary prevention in high-income countries. Given its affordability, CR should be more broadly implemented in middle-income countries as well. Hence, the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) convened a writing panel to recommend strategies to deliver all core CR components in low-resource settings, namely: (1) initial assessment, (2) lifestyle risk factor management (i.e., diet, tobacco, mental health), (3) medical risk factor management (lipids, blood pressure), (4) education for self-management; (5) return to work; and (6) outcome evaluation. Approaches to delivering these components in alternative, arguably lower-cost settings, such as the home, community and primary care, are provided. Recommendations on delivering each of these components where the most-responsible CR provider is a non-physician, such as an allied healthcare professional or community health care worker, are also provided.
  • Heart rate and perceived muscle pain responses to a functional walking test in McArdle disease

    Buckley, John P.; Quinlivan, Ros M.; Sim, Julius; Eston, Roger G.; Short, Deborah S. (Routledge, 2014-04-14)
    The aim of this study was to assess a 12-min self-paced walking test in patients with McArdle disease. Twenty patients (44.7 ±11 years; 11 female) performed the walking test where walking speed, distance walked, heart rate (HR) and perceived muscle pain (Borg CR10 scale) were measured. Median (interquartile range) distance walked was 890 m (470–935). From 1 to 6 min, median walking speed decreased (from 75.0 to 71.4 m∙min–1) while muscle pain and %HR reserve increased (from 0.3 to 3.0 and 37% to 48%, respectively). From 7 to 12 min, walking speed increased to 74.2 m∙min–1, muscle pain decreased to 1.6 and %HR reserve remained between 45% and 48%. To make relative comparisons, HR and muscle pain were divided by walking speed and expressed as ratios. These ratios rose significantly between 1 and 6 min (HR:walking speed P = .001 and pain:walking speed P < .001) and similarly decreased between 6 and 11 min (P = .002 and P = .001, respectively). Peak ratios of HR:walking speed and pain:walking speed were inversely correlated to distance walked: rs (HR) = −.82 (P < .0001) and rs (pain) = −.55 (P = .012). Largest peak ratios were found in patients who walked < 650 m. A 12-min walking test can be used to assess exercise capacity and detect the second wind in McArdle disease.
  • Oxygen Costs of the Incremental Shuttle Walk Test in Cardiac Rehabilitation Participants: An Historical and Contemporary Analysis

    Buckley, John P.; Cardoso, Fernando, M. F.; Birkett, Stefan T.; Sandercock, Gavin R. H.; University Centre Shrewsbury (Springer, 2016-04-07)
    Background The incremental shuttle walk test (ISWT) is a standardised assessment for cardiac rehabilitation. Three studies have reported oxygen costs (VO2)/metabolic equivalents (METs) of the ISWT. In spite of classic rep- resentations from these studies graphically showing curvilinear VO2 responses to incremented walking speeds, linear regression techniques (also used by the American College of Sports Medicine [ACSM]) have been used to estimate VO2. Purpose The two main aims of this study were to (i) re- solve currently reported discrepancies in the ISWT VO2- walking speed relationship, and (ii) derive an appropriate VO2 versus walking speed regression equation. Methods VO2 was measured continuously during an ISWT in 32 coronary heart disease [cardiac] rehabilitation (CHD-CR) participants and 30 age-matched controls. Results Both CHD-CR and control group VO2 responses were curvilinear in nature. For CHD-CR VO2 = 4.4- e0.23 9 walkingspeed (km/h). The integrated area under the curve (iAUC) VO2 across nine ISWT stages was greater in the CHD-CR group versus the control group (p \ 0.001): & John P. Buckley j.buckley@chester.ac.uk 1 (±86) ml􏰀kg-1􏰀min-1􏰀km􏰀h-1; con- trol = 316 (±52) ml􏰀kg-1􏰀min-1􏰀km􏰀h-1. Conclusions CHD-CR group vs. control VO2 was up to 30 % greater at higher ISWT stages. The curvilinear nature of VO2 responses during the ISWT concur with classic studies reported over 100 years. VO2 estimates for walking using linear regression models (including the ACSM) clearly underestimate values in healthy and CHD-CR par- ticipants, and this study provides a resolution to this when the ISWT is used for CHD-CR populations.
  • Standards and core components for cardiovascular disease prevention and rehabilitation; BACPR

    Cowie, A; Buckley, John; Doherty, Patrick; Furze, Gill; Hayward, Jo; Jones, Jennifer; Speck, Linda; Dalal, Hayes; Mills, Joseph; University Centre Shrewsbury (BMJ, 2019-01-30)
    In 2017, the British Association for Cardiovascular Prevention and Rehabilitation published its official document detailing standards and core components for cardiovascular prevention and rehabilitation. Building on the success of previous editions of this document (published in 2007 and 2012), the 2017 update aims to further emphasise to commissioners, clinicians, politicians and the public the importance of robust, quality indicators of cardiac rehabilitation (CR) service delivery. Otherwise, its overall aim remains consistent with the previous publications—to provide a precedent on which all effective cardiovascular prevention and rehabilitation programmes are based and a framework for use in assessment of variation in service delivery quality. In this 2017 edition, the previously described seven standards and core components have both been revised to six, with a greater focus on measurable clinical outcomes, audit and certification. The principles within the updated document underpin the six-stage pathway of care for CR, and reflect the extensive evidence base now available within the field. To help improve current services, close collaboration between commissioners and CR providers is advocated, with use of the CR costing tool in financial planning of programmes. The document specifies how quality assurance can be facilitated through local audit, and advocates routine upload of individual-level data to the annual British Heart Foundation National Audit of Cardiac Rehabilitation, and application for national certification ensuring attainment of a minimum quality standard. Although developed for the UK, these standards and core components may be applicable to other countries.
  • Training nurses in Mental Health Assessment using GMHAT/PC in India

    Jones, S; Keenan, P; Danivas, V; Krishna, M; University of Chester (Indian Psychiatric Society, 2017-07-23)
    Book chapter; Training of Indian general nurses in a hospital setting required the structure offered by the Global Mental Health Assessment Tool (GMHAT) that would provide a framework to underpin mental health assessment training. Attitudes of those undertaking the training and current levels of knowledge and awareness to mental health issues was explored prior to any training occurring in the use of GMHAT, that we considered fundamental to good mental health practice
  • The ReSiT study (reducing sitting time): rationale and protocol for an exploratory pilot study of an intervention to reduce sitting time among office workers

    Gardner, Benjamin; Dewitt, Stephen; Smith, Lee; Biddle, Stuart J.H.; Mansfield, Louise; Buckley, John P.; University Centre Shrewsbury (BMC, 2017-11-28)
    Background: Desk-based workers engage in long periods of uninterrupted sitting time, which has been associated with morbidity and premature mortality. Previous workplace intervention trials have demonstrated the potential of providing sit-stand workstations, and of administering motivational behaviour change techniques, for reducing sitting time. Yet, few studies have combined these approaches or explored the acceptability of discrete sitting-reduction behaviour change strategies. This paper describes the rationale for a sitting-reduction intervention that combines sit-stand workstations with motivational techniques, and procedures for a pilot study to explore the acceptability of core intervention components among university office workers. Methods: The intervention is based on a theory and evidence-based analysis of why office workers sit, and how best to reduce sitting time. It seeks to enhance motivation and capability, as well as identify opportunities, required to reduce sitting time. Thirty office workers will participate in the pilot study. They will complete an initial awareness-raising monitoring and feedback task and subsequently receive a sit-stand workstation for a 12-week period. They will also select from a ‘menu’ of behaviour change techniques tailored to self-declared barriers to sitting reduction, effectively co-producing and personally tailoring their intervention. Interviews at 1, 6, and 12 weeks post-intervention will explore intervention acceptability. Discussion: To our knowledge, this will be the first study to explore direct feedback from office workers on the acceptability of discrete tailored sitting-reduction intervention components that they have received. Participants’ choice of and reflections on intervention techniques will aid identification of strategies suitable for inclusion in the next iteration of the intervention, which will be delivered in a self-administered format to minimise resource burden.
  • The Differences in Acute Management of Asthma in Adults and Children

    Chavasse, Richard; Scott, Stephen; email: stephenscott2@nhs.net (Frontiers Media S.A., 2019-03-11)
    Acute asthma or wheeze is a common presentation to emergency services for both adults and children. Although there are phenotypic differences between asthma syndromes, the management of acute symptoms follow similar lines. This article looks at the similarities and differences in approaches for children and adults. Some of these may be age dependent, such as the physiological parameters used to define the severity of the attack or the use of age appropriate inhaler devices. Other differences may reflect the availability of evidence. In other areas there is conflicting evidence between adult and pediatric studies such as a temporary increase in dose of inhaled corticosteroids during an acute attack. Overall there are more similarities than differences.
  • In vitro cyto-toxic assessment of heavy metals and their binary mixtures on mast cell-like, rat basophilic leukemia (RBL-2H3) cells.

    ThankGod Eze, Chukwuebuka; email: thankgod.eze@fuoye.edu.ng; Michelangeli, Francesco; email: f.michelangeli@chester.ac.uk; Otitoloju, Adebayo Akeem; email: aotitoloju@unilag.edu.ng (2019-02-11)
    We investigated the cytotoxicity and mechanisms of cell death induced by salts of Cadmium (Cd ), Lead (Pb ), Arsenic (AsO ) and Chromium (Cr ) on RBL-2H3 cells (a model mast cell line). In addition, cyto-toxic effect on cell viability was assessed to reveal their nature of interaction in binary mixture. The individual cytotoxic characteristics of these metals on RBL-2H3 cell viability showed a concentration-dependent reduction of cell viability. We observed that concentration-dependent cytotoxic potency on RBL-2H3 cells of these metals range in the following order Cd >Cr >As O > Pb with LC values of 0.11 μM, 93.58 μM, 397.9 μM and 485.3 μM respectively. Additive effects were observed with Pb  + Cd , Pb  + AsO , Pb  + Cr and AsO  + Cr . The study revealed that Pb , Cd , AsO and Cr could induce significant (P < 0.01) cell death by apoptosis in RBL-2H3. Highly significant necrotic cell death was observed with Pb and Cr (P < 0.01) than Cd and AsO (P < 0.05). Overall, it can be deduced that several cell death executing pathways may be concomitantly activated on exposure to heavy metals and the predominance of one over others might depend on the type of heavy metal, concentration and the metabolic state of the cell. Eventually, binary mixtures of some of these metals showed less cytotoxicity than would be expected from their individual actions and may depend on the co-exposure of the metal ions and their modes of action. [Abstract copyright: Copyright © 2019 Elsevier Ltd. All rights reserved.]
  • Will Plan S put learned societies in jeopardy?

    Purton, Mary; Michelangeli, Francesco; Fésüs, László (Wiley, 2019-02-25)
  • Tuberculosis notification in a private tertiary care teaching hospital in South India: a mixed-methods study

    Siddaiah, Archana; Ahmed, Mohammad Naseer; Kumar, Ajay M V; D’Souza, George; Wilkinson, Ewan; Maung, Thae Maung; orcid: 0000-0002-1265-3813; Rodrigues, Rashmi (BMJ Publishing Group, 2019-02-05)
    Objectives India contributes approximately 25% of the ‘missing’ cases of tuberculosis (TB) globally. Even though ~50% of patients with TB are diagnosed and treated within India’s private sector, few are notified to the public healthcare system. India’s TB notification policy mandates that all patients with TB are notified through Nikshay (TB notification portal). We undertook this study in a private hospital to assess the proportion notified and factors affecting TB notifications. We explored barriers and probable solutions to TB notification qualitatively from health provider’s perspective. Study setting Private, tertiary care, teaching hospital in Bengaluru, South India. Methodology This was a mixed-methods study. Quantitative component comprised a retrospective review of hospital records between 1 January 2015 and 31 December 2017 to determine TB notifications. The qualitative component comprised key informant interviews and focus groups to elicit the barriers and facilitators of TB notification. Results Of 3820 patients diagnosed and treated, 885 (23.2%) were notified. Notifications of sputum smear-positive patients were significantly more likely, while notifications of children were less likely. Qualitative analysis yielded themes reflecting the barriers to TB notification and their solutions. Themes related to barriers were: (1) basic diagnostic procedures and treatment promote notification; (2) misconceptions regarding notification and its process are common among healthcare providers; (3) despite a national notification system other factors have prevented notification of all patients; and (4) establishing hospital systems for notification will go a long way in improving notifications. Conclusions The proportion of patients with TB notified by the hospital was low. A comprehensive approach both by the hospital management and the national TB programme is necessary for improving notification. This includes improving awareness among healthcare providers about the requirement for TB notifications, establishing a single notification portal in hospital, digitally linking hospital records to Nikshay and designating one person to be responsible for notification.
  • Stent Frame Movement Following Endovascular Aneurysm Sealing in the Abdominal Aorta

    Yafawi, Asma; orcid: 0000-0002-8390-9951; McWilliams, Richard G.; Fisher, Robert K.; England, Andrew; Karouki, Maria; Torella, Francesco (SAGE Publications, 2018-11-28)
  • Conscientious objection and physician-assisted suicide: a viable option in the UK?

    Willis, Derek; email: derekwillis35@hotmail.com; George, Rob (2018-11-15)
    Conscience objection is a proposed way of ensuring that medical practitioners who object to physician-assisted suicide may avoid having to be involved in such a procedure if this is legalised. This right on the part of healthcare professionals already exists in certain circumstances. This paper examines the ethical and legal grounds for conscientious objection for medical professionals and shows how it is heavily criticised in circumstances where it is already used. The paper comes to the conclusion that as the grounds and application of conscience objection are no longer as widely accepted, its future application in any legislation can be called into question. [Abstract copyright: © Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.]
  • Patients’ Perspectives of Oral and Injectable Type 2 Diabetes Medicines, Their Body Weight and Medicine-Taking Behavior in the UK: A Systematic Review and Meta-Ethnography

    Psarou, Aikaterini; orcid: 0000-0002-0447-4452; email: kpsarou@yahoo.co.uk; Cooper, Helen; Wilding, John P. H. (Springer Healthcare, 2018-08-17)
    AbstractThe aim of this review is to identify peoples’ perspectives of their glucose-lowering and anti-obesity drugs in relation to diabetes and weight control and to explore how these views affect medication adherence. Theoretical perspectives associated with medicine-taking behavior are also explored. The systematic review was based on a meta-ethnography of qualitative studies identified through a search of 12 medical and social science databases and subsequent citation searches. The quality of all studies was assessed. Sixteen studies were included with data from 360 UK individuals. No relevant studies were identified which focused on anti-obesity and non-insulin injectable drugs. The review revealed that the patients’ perspectives and emotional state were influenced by starting and/or changing to a new glucose-lowering medicine. These were also influenced by prior medication experience, disease perceptions and interactions with clinicians. Despite reports of positive experiences with and positive perceptions of medicines, and of participation in strategies to regain life control, medication non-adherence was common. Accepting glucose-lowering medicines impacted on the individual’s perception of lifestyle changes, and it was notable that weight loss was not perceived as a strategy to support diabetes management. Synthesis revealed that more than one theory is required to explain medicine-taking behavior. New insights into the underlying factors of poor adherence and the specific practical issues identified in this review can help in the development of patient-centered interventions.Funding: Diabetes UK.

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