Partnership and privacy – tension or settlement? The case of adult mental health services

Mental health is a good example of a field where imperatives for partnership or collaborative working can be in tension with those for client confidentiality. Both imperatives have been reinforced by additional regulation in recent years, in response to major inquiries. Professionals face the dilemma that either sharing clients’ or patients’ information or not sharing it could lead to outcomes for which they might be blamed; any rule adopted risks one or other type of error. This article examines two cases from a larger interview-based study of how local organisations are trying practically to reconcile these competing pressures

Information sharing and confidentiality in social policy: regulating multi-agency working

In recent years, there has been growing concern in the UK that local services aimed at risky or vulnerable people are ineffective, because of persistent failure to share information about their clients. Despite considerable national policy effort to encourage better information-sharing, previous research indicates that there are many cases where information is still not shared when it should be, or where it is shared when it should not be, with potentially devastating results. This article uses data from the largest empirical study of local information-sharing yet undertaken to examine four policysectors where multi-agency working has come to the fore. It shows variations in their information-sharing and confidentiality practices can be explained by neo-Durkheimian institutional theory and uses insights from this theory to argue that current policy tools, emphasising formal regulation, are unlikely to lead to consistent and acceptable outcomes, not least because of unresolved conflicts in values and aims

Data sharing and personal privacy in contemporary public services: the social dynamics of ethical decision making

Amongst some of the most important and interesting ethical dilemmas facing street level bureaucrats in contemporary public services are those arising from conflicting imperatives in the use of personal data. On the one hand, public services are coming under pressure to retain and share more data about identifiable individuals, in order better to deal with their problems or to protect communities against the risks they pose. This pressure appears to conflict – at least to some degree - with confidentiality norms embedded in the codes of practice of public service professions as well as with privacy laws stemming from the European Data Protection Directive and the European Convention of Human Rights. Furthermore, the ethical dilemmas associated with these conflicting imperatives may be growing more acute, as a result of changes in the political and social environment in which public servants work. Firstly, there is a widespread perception that information and communication technologies can support the extensive networking of public service data systems: this perception is giving rise to pressures to achieve service improvements and cost savings associated with the pooling, re-use and exchange of personal data. Secondly, there is a growing view that many of problems experienced by individuals, families and very small neighbourhoods can best be addressed by multi-agency interventions: this view implies that agencies will share data about these individuals, families and neighbourhoods to a greater degree than hitherto. Thirdly, growing pressures on public services associated the influence of communitarian ideas about the management of risks may be leading to tendencies to favour the public good over individual rights, especially in such fields as policing, child protection, mental health and public health. If so, we would expect these pressures to lower thresholds for sharing personal data between agencies. This paper presents some provisional findings from a major research project funded by the UK’s Economic and Social Research Council. The project has collected qualitative data from over 200 interviews with street level professional workers, managers and information systems managers in 12 cases of local multi-agency arrangements (MAAs) in England and Scotland. The data presented in the present paper is from the 8 English cases, comprising 138 interviews. These cases were chosen from four policy fields, namely: • health and social care for the elderly • health and social care for the mentally ill • public protection arrangements managing risks associated with violent criminals and sex offenders; and, • crime and disorder reduction partnerships, which include organisations concerned with planning interventions against prolific offenders, domestic violence and drug-related crime. These fields have been chosen, for two main reasons. First, in all of these fields, decisions about what data to share, when to share them, who to share them with and how to interpret them and use them involve serious risks: the decisions made by individual workers may result in the abuse or death of a child, the loss of parole for a prisoner, the stigmatisation of a family or the refusal of employment for a job applicant. Decision-making in these fields therefore poses ethical problems with potentially serious outcomes for individual clients. Second, in the UK, all these fields are currently subject to central government initiatives designed to encourage greater sharing of personal data to support more effective multi-agency working. They are all fields, then, in which tensions with privacy are coming to the fore. The data collected for this project will eventually provide the most comprehensive, detailed evidence yet available about the ways in which street level professional workers cope on a day to day basis with the tensions between imperatives to share data about needy and risky people, and imperatives to respect their confidentiality and personal privacy. The data will also provide evidence about the ways in which the coping strategies of such workers may be changing under the influence of changes in the political environment outlined above. A particular facet of the analysis will be concerned with the intended and unintended behavioural consequences of the growing use of data sharing protocols and other ethical instruments. These instruments are designed to govern the practices of street level professionals, and in so doing to protect the privacy of clients, patients, offenders, victims, witnesses and other individuals who come into contact with public services in these fields. The overarching hypothesis framing this research is that individual decision-making will be shaped by the organisational, cultural dynamics in which it takes place. We are using neo-Durkheimian institutional theory as the analytical framework for a series of systematic comparisons: between MAAs in the four 3 different policy fields: between types of organisation (for example, police, health and social work agencies), between organisations that comprise these MAAs and between actors from different professions. These comparisons will enable us to assess the nature and influence of organisational dynamics in these fields, and to understand the ways that different mixes of institutional forms impinge on data sharing practices in different organisations and among different kinds of professional workers. We will also compare the ways in which risks to privacy are perceived and managed, and the ways organisational dynamics shape coping mechanisms adopted by individuals to manage the fear of blame. In turn, this analysis will help us understand the social influences on complex decision making by street level workers in policy fields that that are riven with important ethical issues

Cellular responses of Candida albicans to phagocytosis and the extracellular activities of neutrophils are critical to counteract carbohydrate starvation, oxidative and nitrosative stress

Acknowledgments We thank Alexander Johnson (yhb1D/D), Karl Kuchler (sodD/D mutants), Janet Quinn (hog1D/D, hog1/cap1D/D, trx1D/D) and Peter Staib (ssu1D/D) for providing mutant strains. We acknowledge helpful discussions with our colleagues from the Microbial Pathogenicity Mechanisms Department, Fungal Septomics and the Microbial Biochemistry and Physiology Research Group at the Hans Kno¨ll Institute (HKI), specially Ilse D. Jacobsen, Duncan Wilson, Sascha Brunke, Lydia Kasper, Franziska Gerwien, Sea´na Duggan, Katrin Haupt, Kerstin Hu¨nniger, and Matthias Brock, as well as from our partners in the FINSysB Network. Author Contributions Conceived and designed the experiments: PM HW IMB AJPB OK BH. Performed the experiments: PM CD HW. Analyzed the data: PM HW IMB AJPB OK BH. Wrote the paper: PM HW OK AJPB BH.Peer reviewedPublisher PD

Biomarkers in Painful Symptomatic Knee OA Demonstrate That MRI Assessed Joint Damage and Type II Collagen Degradation Products Are Linked to Disease Progression

Background: Osteoarthritis (OA) is the most prevalent arthritis worldwide, but the evolution of pain in relation to joint damage and biochemical markers are not well understood. We evaluated the relation between clinical pain measures and evoked pain in relation to structural damage and biochemical biomarkers in knee OA. Methods: A cross-sectional study in people with knee OA and healthy controls was conducted. A total of 130 participants with advanced OA requiring total knee replacement (TKR) (n = 78), mild OA having standard care (n = 42) and non-OA controls (n = 6), with four drop-outs were assessed. Pain scoring was performed by the Western Ontario and McMaster Universities OA Index (WOMAC_P) and the Visual Analog Scale (VAS). Pain sensitization was assessed by pain pressure thresholds (PPTs). Knee magnetic resonance imaging (MRI) assessed joint damage using the MRI Knee OA Score (MOAKS). Overall MOAKS scores were created for bone marrow lesions (BMLs), cartilage degradation (CD), and effusion/Hoffa synovitis (tSyn). Type II collagen cleavage products (CTX-II) were determined by ELISA. Results: The advanced OA group had a mean age of 68.9 ± 7.7 years and the mild group 63.1 ± 9.6. The advanced OA group had higher levels of pain, with mean WOMAC_P of 58.8 ± 21.7 compared with the mild OA group of 40.6 ± 26.0. All OA subjects had pain sensitization by PPT compared with controls (p < 0.05). WOMAC_P correlated with the total number of regions with cartilage damage (nCD) (R = 0.225, p = 0.033) and total number of BMLs (nBML) (R = 0.195, p = 0.065) using body mass index (BMI), age, and Hospital Anxiety and Depression Scale (HADS) as covariates. Levels of CTX-II correlated with tSyn (R = 0.313, p = 0.03), nBML (R = 0.252, p = 0.019), number of osteophytes (R = 0.33, p = 0.002), and nCD (R = 0.218, p = 0.042), using BMI and age as covariates. A multivariate analysis indicated that BMI and HADS were the most significant predictors of pain scores (p < 0.05). Conclusion: People with both mild and advanced OA show features of pain sensitization. We found that increasing MRI-detected joint damage was associated with higher levels of CTX-II, suggesting that increasing disease severity can be assessed by MRI and CTX-II biomarkers to evaluate OA disease progression

Efficacy and safety of acupuncture for chronic pain caused by gonarthrosis: A study protocol of an ongoing multi-centre randomised controlled clinical trial [ISRCTN27450856]

BACKGROUND: Controlled clinical trials produced contradictory results with respect to a specific analgesic effect of acupuncture. There is a lack of large multi-centre acupuncture trials. The German Acupuncture Trial represents the largest multi-centre study of acupuncture in the treatment of chronic pain caused by gonarthrosis up to now. METHODS: 900 patients will be randomised to three treatment arms. One group receives verum acupuncture, the second sham acupuncture, and the third conservative standard therapy. The trial protocol is described with eligibility criteria, detailed information on the treatment definition, blinding, endpoints, safety evaluation, statistical methods, sample size determination, monitoring, legal aspects, and the current status of the trial. DISCUSSION: A critical discussion is given regarding the considerations about standardisation of the acupuncture treatment, the choice of the control group, and the blinding of patients and observers

Safety and immunogenicity of the ChAdOx1 nCoV-19 vaccine against SARS-CoV-2: a preliminary report of a phase 1/2, single-blind, randomised controlled trial.

BACKGROUND: The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) might be curtailed by vaccination. We assessed the safety, reactogenicity, and immunogenicity of a viral vectored coronavirus vaccine that expresses the spike protein of SARS-CoV-2. METHODS: We did a phase 1/2, single-blind, randomised controlled trial in five trial sites in the UK of a chimpanzee adenovirus-vectored vaccine (ChAdOx1 nCoV-19) expressing the SARS-CoV-2 spike protein compared with a meningococcal conjugate vaccine (MenACWY) as control. Healthy adults aged 18-55 years with no history of laboratory confirmed SARS-CoV-2 infection or of COVID-19-like symptoms were randomly assigned (1:1) to receive ChAdOx1 nCoV-19 at a dose of 5 × 1010 viral particles or MenACWY as a single intramuscular injection. A protocol amendment in two of the five sites allowed prophylactic paracetamol to be administered before vaccination. Ten participants assigned to a non-randomised, unblinded ChAdOx1 nCoV-19 prime-boost group received a two-dose schedule, with the booster vaccine administered 28 days after the first dose. Humoral responses at baseline and following vaccination were assessed using a standardised total IgG ELISA against trimeric SARS-CoV-2 spike protein, a muliplexed immunoassay, three live SARS-CoV-2 neutralisation assays (a 50% plaque reduction neutralisation assay [PRNT50]; a microneutralisation assay [MNA50, MNA80, and MNA90]; and Marburg VN), and a pseudovirus neutralisation assay. Cellular responses were assessed using an ex-vivo interferon-γ enzyme-linked immunospot assay. The co-primary outcomes are to assess efficacy, as measured by cases of symptomatic virologically confirmed COVID-19, and safety, as measured by the occurrence of serious adverse events. Analyses were done by group allocation in participants who received the vaccine. Safety was assessed over 28 days after vaccination. Here, we report the preliminary findings on safety, reactogenicity, and cellular and humoral immune responses. The study is ongoing, and was registered at ISRCTN, 15281137, and ClinicalTrials.gov, NCT04324606. FINDINGS: Between April 23 and May 21, 2020, 1077 participants were enrolled and assigned to receive either ChAdOx1 nCoV-19 (n=543) or MenACWY (n=534), ten of whom were enrolled in the non-randomised ChAdOx1 nCoV-19 prime-boost group. Local and systemic reactions were more common in the ChAdOx1 nCoV-19 group and many were reduced by use of prophylactic paracetamol, including pain, feeling feverish, chills, muscle ache, headache, and malaise (all p<0·05). There were no serious adverse events related to ChAdOx1 nCoV-19. In the ChAdOx1 nCoV-19 group, spike-specific T-cell responses peaked on day 14 (median 856 spot-forming cells per million peripheral blood mononuclear cells, IQR 493-1802; n=43). Anti-spike IgG responses rose by day 28 (median 157 ELISA units [EU], 96-317; n=127), and were boosted following a second dose (639 EU, 360-792; n=10). Neutralising antibody responses against SARS-CoV-2 were detected in 32 (91%) of 35 participants after a single dose when measured in MNA80 and in 35 (100%) participants when measured in PRNT50. After a booster dose, all participants had neutralising activity (nine of nine in MNA80 at day 42 and ten of ten in Marburg VN on day 56). Neutralising antibody responses correlated strongly with antibody levels measured by ELISA (R2=0·67 by Marburg VN; p<0·001). INTERPRETATION: ChAdOx1 nCoV-19 showed an acceptable safety profile, and homologous boosting increased antibody responses. These results, together with the induction of both humoral and cellular immune responses, support large-scale evaluation of this candidate vaccine in an ongoing phase 3 programme. FUNDING: UK Research and Innovation, Coalition for Epidemic Preparedness Innovations, National Institute for Health Research (NIHR), NIHR Oxford Biomedical Research Centre, Thames Valley and South Midland's NIHR Clinical Research Network, and the German Center for Infection Research (DZIF), Partner site Gießen-Marburg-Langen

Microarray analysis of bone marrow lesions in osteoarthritis demonstrates upregulation of genes implicated in osteochondral turnover, neurogenesis and inflammation

Objective Bone marrow lesions (BMLs) are well described in osteoarthritis (OA) using MRI and are associated with pain, but little is known about their pathological characteristics and gene expression. We evaluated BMLs using novel tissue analysis tools to gain a deeper understanding of their cellular and molecular expression. Methods We recruited 98 participants, 72 with advanced OA requiring total knee replacement (TKR), 12 with mild OA and 14 non-OA controls. Participants were assessed for pain (using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)) and with a knee MRI (using MOAKS). Tissue was then harvested at TKR for BML analysis using histology and tissue microarray. Results The mean (SD) WOMAC pain scores were significantly increased in advanced OA 59.4 (21.3) and mild OA 30.9 (20.3) compared with controls 0.5 (1.28) (p<0.0001). MOAKS showed all TKR tissue analysed had BMLs, and within these lesions, bone marrow volume was starkly reduced being replaced by dense fibrous connective tissue, new blood vessels, hyaline cartilage and fibrocartilage. Microarray comparing OA BML and normal bone found a significant difference in expression of 218 genes (p<0.05). The most upregulated genes included stathmin 2, thrombospondin 4, matrix metalloproteinase 13 and Wnt/Notch/catenin/chemokine signalling molecules that are known to constitute neuronal, osteogenic and chondrogenic pathways. Conclusion Our study is the first to employ detailed histological analysis and microarray techniques to investigate knee OA BMLs. BMLs demonstrated areas of high metabolic activity expressing pain sensitisation, neuronal, extracellular matrix and proinflammatory signalling genes that may explain their strong association with pain

Evolving norms of protection: China, Libya and the problem of intervention in armed conflict

This article examines the influence of civilian protection norms on China’s response to the 2011 crisis in Libya. It argues that Responsibility to Protect—an emerging norm commonly associated with the Libyan case—did not play a major role in China’s abstention on Resolution 1973 (2011) authorizing international intervention in Libya. For China, Responsibility to Protect is merely a concept and could not serve as the basis for intervention. Instead, Protection of Civilians in Armed Conflict, as a normative foundation for civilian protection endorsed by China, offers a more appropriate lens for understanding China’s vote. Protection of Civilians, however, does not accommodate China’s unprecedented evacuation of Chinese nationals from Libya. This operation proceeded from a third logic of Protection of Nationals Abroad, which poses dilemmas for China’s strict adherence to the principles of sovereignty and non-interference and brings to bear domestic interests and notions of protection