Development and preliminary evaluation of a clinical guidance programme for the decision about prophylactic oophorectomy in women undergoing a hysterectomy

Objectives: To develop a decision analysis based and computerised clinical guidance programme (CGP) that provides patient specific guidance on the decision whether or not to undergo a prophylactic oophorectomy to reduce the risk of subsequent ovarian cancer and to undertake a preliminary pilot and evaluation. Subjects: Women who had already agreed to have a hysterectomy who otherwise had no ovarian pathology. Setting: Oophorectomy decision consultation at the outpatient or pre-admission clinic. Methods: A CGP was developed with advice from gynaecologists and patient groups, incorporating a set of Markov models within a decision analytical framework to evaluate the benefits of undergoing a prophylactic oophorectomy or not on the basis of quality adjusted life expectancy, life expectancy, and for varying durations of hormone replacement therapy. Sensitivity analysis and preliminary testing of the CGP were undertaken to compare its overall performance with established guidelines and practice. A small convenience sample of women invited to use the CGP were interviewed, the interviews were taped and transcribed, and a thematic analysis was undertaken. Results: The run time of the programme was 20 minutes, depending on the use of opt outs to default values. The CGP functioned well in preliminary testing. Women were able to use the programme and expressed overall satisfaction with it. Some had reservations about the computerised format and some were surprised at the specificity of the guidance given. Conclusions: A CGP can be developed for a complex healthcare decision. It can give evidence-based health guidance which can be adjusted to account for individual risk factors and reflects a patient’s own values and preferences concerning health outcomes. Future decision aids and support systems need to be developed and evaluated in a way which takes account of the variation in patients’ preferences for inclusion in the decision making process

Orthopaedic nurses’ engagement in clinical research; an exploration of ideas, facilitators and challenges

Background: Previous international studies have identified individual and organisational barriers to nurses’ research utilisation, but there is little data reporting on nurses’ engagement in research design and/or delivery, particularly within the orthopaedic speciality. Aim: To explore orthopaedic nurses’ views regarding the research priorities for neuro-musculoskeletal care and the perceived barriers and facilitators associated with their engagement in the research process. Methods: A single centre mixed methods study (n=75) collected data via a survey and 14 focus group discussions. Findings: Our sample of clinical orthopaedic nurses showed little evidence of research engagement. Research priorities focused on 1. Understanding and improving patient and staff experiences 2. Improving processes, systems and workload models 3. Interventions to improve clinical outcomes. Key themes arising from the focus group discussion data were research activity, priorities and motivation, culture and leadership, and resources. Conclusion: Our findings suggest that there is still significant work to do build sufficient research capacity and capability within the nursing workforce. Key to success will be developing effective leaders, who can create a positive and supportive research culture across an organisation to strengthen the research voice of nursing, which will drive improvements in future care

Using decision analysis: connecting "classroom" and "field"

This paper reports on the findings of a small-scale research project investigating the views of social work students on the use of decision analysis. After giving the context of the research, the article reports on what was found when students, who had just completed a Decision Making and Risk module, were asked for their opinions on the component parts of decision analysis, its use as a practice tool and their attitudes to using it on placement. The research found that the respondents in general took a critical and supportive stance towards the use of decision analysis in social work and, with extra teaching and a positive approach from their practice assessor, would be happy to use decision analysis. When the same group of students completed a follow-up questionnaire on a placement recall day, half of them had thought about using decision analysis but only three had gone on to discuss this with their practice assessors. Some issues in relation to connecting 'classroom' and 'field' are identified and the paper concludes that a number of further steps would be necessary to realise the potential of decision analysis to help students be more systematic and analytical in their approach to decision makin

Conservation Laws and Integral Relations for the Boussinesq Equation

We are concerned with conservation laws and integral relations associated with rational solutions of the Boussinesq equation, a soliton equation solvable by inverse scattering, which was first introduced by Boussinesq in 1871. The rational solutions are logarithmic derivatives of a polynomial, are algebraically decaying, and have a similar appearance to rogue-wave solutions of the focusing nonlinear Schrödinger equation. For these rational solutions, the constants of motion associated with the conserved quantities are zero and they have some interesting integral relations, which depend on the total degree of the associated polynomial

Towards a synthesized critique of neoliberal biodiversity conservation

During the last three decades, the arena of biodiversity conservation has largely aligned itself with the globally dominant political ideology of neoliberalism and associated governmentalities. Schemes such as payments for ecological services are promoted to reach the multiple ‘wins’ so desired: improved biodiversity conservation, economic development, (international) cooperation and poverty alleviation, amongst others. While critical scholarship with respect to understanding the linkages between neoliberalism, capitalism and the environment has a long tradition, a synthesized critique of neoliberal conservation - the ideology (and related practices) that the salvation of nature requires capitalist expansion - remains lacking. This paper aims to provide such a critique. We commence with the assertion that there has been a conflation between ‘economics’ and neoliberal ideology in conservation thinking and implementation. As a result, we argue, it becomes easier to distinguish the main problems that neoliberal win-win models pose for biodiversity conservation. These are framed around three points: the stimulation of contradictions; appropriation and misrepresentation and the disciplining of dissent. Inspired by Bruno Latour’s recent ‘compositionist manifesto’, the conclusion outlines some ideas for moving beyond critique

ARTISTIC: A randomised trial of human papillomavirus (HPV) testing in primary cervical screening

The official published version of the article can be found at the link below.Objectives: Primary cervical screening uses cytology to detect cancer precursor lesions [cervical intraepithelial neoplasia stage 3 or beyond (CIN3+)]. Human papillomavirus (HPV) testing could add sensitivity as an adjunct to cytology or as a first test, reserving cytology for HPV-positive women. This study addresses the questions: Does the combination of cytology and HPV testing achieve a reduction in incident CIN3+?; Is HPV testing cost-effective in primary cervical screening?; Is its use associated with adverse psychosocial or psychosexual effects?; and How would it perform as an initial screening test followed by cytology for HPV positivity? Design: ARTISTIC was a randomised trial of cervical cytology versus cervical cytology plus HPV testing, evaluated over two screening rounds, 3 years apart. Round 1 would detect prevalent disease and round 2 a combination of incident and undetected disease from round 1. Setting: Women undergoing routine cervical screening in the NHS programme in Greater Manchester. Participants: In total 24,510 women aged 20–64 years were enrolled between July 2001 and September 2003. Interventions: HPV testing was performed on the liquid-based cytology (LBC) sample obtained at screening. Women were randomised in a ratio of 3:1 to have the HPV test result revealed and acted upon if persistently positive in cytology-negative cases or concealed. A detailed health economic evaluation and a psychosocial and psychosexual assessment were also performed. Main outcome measures: The primary outcome was CIN3+ in round 2. Secondary outcomes included an economic assessment and psychosocial effects. A large HPV genotyping study was also conducted. Results: In round 1 there were 313 CIN3+ lesions, representing a prevalence in the revealed and concealed arms of 1.27% and 1.31% respectively (p = 0.81). Round 2 (30–48 months) involved 14,230 (58.1%) of the women screened in round 1 and only 31 CIN3+ were detected; the CIN3 rate was not significantly different between the revealed and concealed arms. A less restrictive definition of round 2 (26–54 months) increased CIN3+ to 45 and CIN3+ incidence in the arms was significantly different (p = 0.05). There was no difference in CIN3+ between the arms when rounds 1 and 2 were combined. Prevalence of highrisk HPV types was age-dependent. Overall prevalence of HPV16/18 increased with severity of yskaryosis. Mean costs per woman in round 1 were £72 and £56 for the revealed and concealed arms (p < 0.001); an age-adjustment reduced these mean costs to £65 and £52. Incremental cost-effectiveness ratio for detecting additional CIN3+ by adding HPV testing to LBC screening in round 1 was £38,771. Age-adjusted mean cost for LBC primary screening with HPV triage was £39 compared with £48 for HPV primary screening with LBC triage. HPV testing did not appear to cause significant psychosocial distress. Conclusions: Routine HPV testing did not add significantly to the effectiveness of LBC in this study. No significant adverse psychosocial effects were detected. It would not be cost-effective to screen with cytology and HPV combined but HPV testing, as either triage or initial test triaged by cytology, would be cheaper than cytology without HPV testing. LBC would not benefit from combination with HPV; it is highly effective as primary screening but HPV testing has twin advantages of high negative predictive value and automated platforms enabling high throughput. HPV primary screening would require major contraction and reconfiguration of laboratory services. Follow-up continues in ARTISTIC while maintaining concealment for a further 3-year round of screening, which will help in screening protocol development for the post-vaccination era