Special measures for child witnesses: a socio-legal study of criminal procedure reform

This thesis is a socio-legal study of police and prosecutorial decision-making in the context of special measures support for child witnesses in criminal proceedings. It presents the findings of an empirical research project conducted with the Crown Prosecution Service which examined the implementation of Part II of the Youth Justice and Criminal Evidence Act 1999. Under that Act children may be assisted to testify in criminal proceedings though any feasible combination of: video-recorded evidence; live television link; screens; communication aids; intermediaries; and giving evidence in private. Using a small-scale, primarily qualitative, study involving semi-structured interviews with Crown Prosecutors, this thesis investigates how the attitudes, beliefs, motivations and work practices of the police and prosecutors affect the provision of special measures to children. It does so in the context of a highly directive legal framework which purports to curtail prosecutorial and judicial discretion. The thesis explores the problems that child witnesses encounter within the criminal justice system and the legislative and policy response to their difficulties. It then presents the findings of the current research study in relation to, first, the video-interviewing patterns of police officers and, second, the rate of prosecutors’ applications for special measures. In addition to the statistical data, the thesis explores prosecutors’ own reflective accounts of the factors which shape police and prosecutors’ decision-making. The thesis concludes that where the rules on special measures are highly prescriptive, we have witnessed a radical expansion in their use for children, but that the rigid system has drawbacks which raise pressure for reform. Reform proposals must be carefully considered in the light of infrastructural weaknesses in inter-agency liaison and information-management identified in this thesis. We might also be wary that reform will undermine the criminal justice system’s recently consolidated cultural acceptance of special measures for child witnesses

Optimal distribution and utilization of donated human breast milk: a novel approach

Background: The nutritional content of donated expressed breast milk (DEBM) is variable. Using DEBM to provide for the energy requirements of neonates is challenging. Objective: The authors hypothesized that a system of DEBM energy content categorization and distribution would improve energy intake from DEBM. Methods: We compared infants’ actual cumulative energy intake with projected energy intake, had they been fed using our proposed system. Eighty-five milk samples were ranked by energy content. The bottom, middle, and top tertiles were classified as red, amber, and green energy content categories, respectively. Data on 378 feeding days from 20 babies who received this milk were analyzed. Total daily intake of DEBM was calculated in mL/kg/day and similarly ranked. Infants received red energy content milk, with DEBM intake in the bottom daily volume intake tertile; amber energy content milk, with intake in the middle daily volume intake tertile; and green energy content milk when intake reached the top daily volume intake tertile. Results: Actual median cumulative energy intake from DEBM was 1612 (range, 15-11 182) kcal. Using DEBM with the minimum energy content from the 3 DEBM energy content categories, median projected cumulative intake was 1670 (range 13-11 077) kcal, which was not statistically significant (P = .418). Statistical significance was achieved using DEBM with the median and maximum energy content from each energy content category, giving median projected cumulative intakes of 1859 kcal (P = .0006) and 2280 kcal (P = .0001), respectively. Conclusion: Cumulative energy intake from DEBM can be improved by categorizing and distributing milk according to energy content

Special measures for child witnesses: a socio-legal study of criminal procedure reform

This thesis is a socio-legal study of police and prosecutorial decision-making in the context of special measures support for child witnesses in criminal proceedings. It presents the findings of an empirical research project conducted with the Crown Prosecution Service which examined the implementation of Part II of the Youth Justice and Criminal Evidence Act 1999. Under that Act children may be assisted to testify in criminal proceedings though any feasible combination of: video-recorded evidence; live television link; screens; communication aids; intermediaries; and giving evidence in private. Using a small-scale, primarily qualitative, study involving semi-structured interviews with Crown Prosecutors, this thesis investigates how the attitudes, beliefs, motivations and work practices of the police and prosecutors affect the provision of special measures to children. It does so in the context of a highly directive legal framework which purports to curtail prosecutorial and judicial discretion. The thesis explores the problems that child witnesses encounter within the criminal justice system and the legislative and policy response to their difficulties. It then presents the findings of the current research study in relation to, first, the video-interviewing patterns of police officers and, second, the rate of prosecutors’ applications for special measures. In addition to the statistical data, the thesis explores prosecutors’ own reflective accounts of the factors which shape police and prosecutors’ decision-making. The thesis concludes that where the rules on special measures are highly prescriptive, we have witnessed a radical expansion in their use for children, but that the rigid system has drawbacks which raise pressure for reform. Reform proposals must be carefully considered in the light of infrastructural weaknesses in inter-agency liaison and information-management identified in this thesis. We might also be wary that reform will undermine the criminal justice system’s recently consolidated cultural acceptance of special measures for child witnesses

SLoMo: automated site localization of modifications from ETD/ECD mass spectra

Recently, software has become available to automate localization of phosphorylation sites from CID data and to assign associated confidence scores. We present an algorithm, SLoMo (Site Localization of Modifications), which extends this capability to ETD/ECD mass spectra. Furthermore, SLoMo caters for both high and low resolution data and allows for site-localization of any UniMod post-translational modification. SLoMo accepts input data from a variety of formats (e.g., Sequest, OMSSA). We validate SLoMo with high and low resolution ETD, ECD, and CID data

Prevalence of Sarcocystis calchasi in free-ranging host species: Accipiter hawks and Common Woodpigeon in Germany

The apicomplexan parasite Sarcocystis calchasi (S. calchasi) triggers pigeon protozoal encephalitis, a neurologic disease in columbids. Accipiter hawks have been identified as the final host, and Columbidae and Psittaciformes as intermediate hosts. In this study, 368 free-ranging Accipiter hawks and 647 free-ranging common woodpigeons were sampled in a country-wide study in order to identify the prevalence of S. calchasi in these populations. A semi-nested PCR specific for S. calchasi tested positive in 7.3% (4.9-10.5) of submitted samples from Accipiter hawks. Juvenile Accipiter hawks (13.7%; 7.7-22.0) had a significantly higher infection rate with S. calchasi than adult Accipiter hawks (5.8%; 2.7-9.3). The prevalence of S. calchasi in common woodpigeons was 3.3% (5.4-9.7). Positive pigeons were identified in 14/16 federal states, and a region-dependency was detected, with higher rates of infection in the eastern parts of Germany. The results of this study suggest that the common woodpigeon is a natural reservoir for S. calchasi. In a study of one region for four consecutive years, an increase in prevalence was not detected. Findings indicate that the parasite is not newly introduced to Germany, but rather long established. The prevalence suggests that there is a substantial risk of S. calchasi infections in other free-ranging as well as captive host species

Evaluation of preprocessing techniques for chief complaint classification

OBJECTIVE: To determine whether preprocessing chief complaints before automatically classifying them into syndromic categories improves classification performance. METHODS: We preprocessed chief complaints using two preprocessors (CCP and EMT-P) and evaluated whether classification performance increased for a probabilistic classifier (CoCo) or for a keyword-based classifier (modification of the NYC Department of Health and Mental Hygiene chief complaint coder (KC)). RESULTS: CCP exhibited high accuracy (85%) in preprocessing chief complaints but only slightly improved CoCo's classification performance for a few syndromes. EMT-P, which splits chief complaints into multiple problems, substantially increased CoCo's sensitivity for all syndromes. Preprocessing with CCP or EMT-P only improved KC's sensitivity for the Constitutional syndrome. CONCLUSION: Evaluation of preprocessing systems should not be limited to accuracy of the preprocessor but should include the effect of preprocessing on syndromic classification. Splitting chief complaints into multiple problems before classification is important for CoCo, but other preprocessing steps only slightly improved classification performance for CoCo and a keyword-based classifier

The cost effectiveness of peginterferon alfa and ribavirin for the treatment of hepatitis C in children and young people

OBJECTIVES: To assess the cost-effectiveness of peginterferon ?-2a and peginterferon ?-2b in combination with ribavirin compared to best supportive care (BSC), for the treatment of chronic hepatitis C virus (HCV) in children and young people aged 3 to 17 years. METHODS: A Markov state-transition economic model of chronic HCV in children and young people was developed that extrapolated the impact of sustained virological response (SVR) on life expectancy, quality-adjusted life expectancy and lifetime costs. The model was adapted from one previously developed for adults. A systematic review was conducted of the clinical effectiveness of the treatments, and the health related quality of life for patients with hepatitis C. Uncertainty was explored through probabilistic and deterministic sensitivity analyses. RESULTS: Seven studies were identified that were relatively small and of generally poor quality. Estimates of SVR were similar for for peginterferon ?-2a (60%) and peginterferon ?-2b (58%) was similar, whilst the SVR for no treatment was assumed to be zero. From this model, peginterferon alfa (?-2a or ?-2b) in combination with ribavirin was more effective and cheaper than BSC. Sensitivity analyses suggest that the results were generally robust to all changes to the structural assumptions and input parameters. The model results were most sensitive to changes to the discount rate, time horizon, SVR and baseline fibrosis of the cohort. CONCLUSIONS: Treatment of children and young people with peginterferon alfa (?-2a or ?-2b) and ribavirin may be an effective therapy. Peginterferon alfa (?-2a or ?-2b) in combination with ribavirin is cost-effective compared with BSC. However, the available evidence is of poor quality. The views expressed in this paper are those of the authors and do not necessarily represent the views or policies of the UK HTA programme or Department of Health

Evaluation of preprocessing techniques for chief complaint classification

OBJECTIVE: To determine whether preprocessing chief complaints before automatically classifying them into syndromic categories improves classification performance. METHODS: We preprocessed chief complaints using two preprocessors (CCP and EMT-P) and evaluated whether classification performance increased for a probabilistic classifier (CoCo) or for a keyword-based classifier (modification of the NYC Department of Health and Mental Hygiene chief complaint coder (KC)). RESULTS: CCP exhibited high accuracy (85%) in preprocessing chief complaints but only slightly improved CoCo's classification performance for a few syndromes. EMT-P, which splits chief complaints into multiple problems, substantially increased CoCo's sensitivity for all syndromes. Preprocessing with CCP or EMT-P only improved KC's sensitivity for the Constitutional syndrome. CONCLUSION: Evaluation of preprocessing systems should not be limited to accuracy of the preprocessor but should include the effect of preprocessing on syndromic classification. Splitting chief complaints into multiple problems before classification is important for CoCo, but other preprocessing steps only slightly improved classification performance for CoCo and a keyword-based classifier

The clinical effectiveness and cost-effectiveness of peginterferon alfa and ribavirin for the treatment of chronic hepatitis C in children and young people:a systematic review and economic evaluation

Background: Optimal therapy for children with chronic hepatitis C is unclear. Two treatment regimens are currently licensed in children. Objectives: To assess the clinical effectiveness and cost-effectiveness of peginterferon alfa-2a (Pegasys®, Roche) and peginterferon alfa-2b [ViraferonPeg®, Merck Sharp & Dohme (MSD)] in combination with ribavirin (RBV), within their licensed indications, for the treatment of chronic hepatitis C virus (HCV) in children and young people aged 3–17 years. Data sources: Twelve electronic bibliographic databases, including The Cochrane Library, MEDLINE and EMBASE, were searched from inception to November 2012. Bibliographies of retrieved papers, key hepatitis C websites and symposia and manufacturers’ submissions to the National Institute for Health and Care Excellence were also searched, and clinical experts were contacted. Review methods: Systematic reviews of clinical effectiveness and cost-effectiveness were conducted, including studies of health-related quality of life (HRQoL), following standard guidelines to ensure methodological rigour. Clinical effectiveness studies were included if they were in children and young people aged 3–17 years with chronic compensated HCV of any severity, including those with human immunodeficiency virus co-infection and those who were treatment naive or had been previously treated. Eligible interventions were peginterferon alfa-2a or peginterferon alfa-2b, each in combination with RBV, compared against best supportive care (BSC) or against each other, and study designs were randomised controlled trials (RCTs) or non-RCTs, or uncontrolled cohort studies. Outcomes included sustained virological response (SVR) and adverse events. Previously published Markov state-transition economic models of chronic HCV in adults were adapted to estimate the cost-effectiveness of peginterferon alfa-2a and -2b (in combination with RBV), compared with BSC and with one another in children. The model extrapolated the impact of SVR on life expectancy, quality-adjusted life expectancy and lifetime costs. Uncertainty was explored through probabilistic and deterministic sensitivity analyses. Results: Seven studies [two peginterferon alfa-2a and RBV (Copegus®, Roche), and five peginterferon alfa-2b and RBV (Rebetol®, MSD)] were included in the review of clinical effectiveness. Six were single-arm cohort studies and one was a RCT for which only those data for a single arm met the inclusion criteria. Overall, the studies were relatively small and of generally poor quality. SVR rates ranged from 53% to 66% (peginterferon alfa-2a) and 29% to 75% (peginterferon alfa-2b) (49% to 65% if excluding two studies with very small sample sizes). Rates of non-response and relapse were variable and adverse events were generally mild. No studies of cost-effectiveness or HRQoL in children and young people met the inclusion criteria. HRQoL, utilities and costs of treatment were therefore taken from studies of adults with chronic HCV. From this model, peginterferon alfa (-2a or -2b) in combination with RBV was more effective and had lower lifetime costs than BSC. Peginterferon alfa-2a had slightly lower lifetime costs and higher quality-adjusted life-years than peginterferon alfa-2b; therefore, peginterferon alfa-2b was dominated by peginterferon alfa-2a. Results were robust to changes in the sensitivity analyses. Limitations: There were few good quality studies and parameter data had to be taken from adult studies, which is a limitation of the work. Conclusions: Treatment of children and young people with peginterferon (alfa-2a or -2b) and RBV may be an effective therapy. Results from the independent Markov model suggest that peginterferon (alfa-2a or -2b) in combination with RBV is cost-effective compared with BSC. However, the available evidence is of poor quality. Future research into the impact of these treatments on growth and quality of life in children and young people is recommended. Study registration: This study is registered as PROSPERO CRD42012002743. Funding: The National Institute for Health Research Health Technology Assessment programme

Infliximab for the treatment of adults with psoriasis. Evidence Review Group Report for NICE's Single Technology Appraisal process

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of infliximab for the treatment of moderate to severe plaque psoriasis, in accordance with the licensed indication, based on the evidence submission from Schering-Plough to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The outcomes stated in the manufacturer's definition of the decision problem were severity [Psoriasis Area and Severity Index (PASI) score], remission rates, relapse rates and health-related quality of life. The main evidence in the submission comes from four randomised controlled trials (RCT) comparing infliximab with placebo and eight RCTs comparing either etanercept or efalizumab with placebo. At week 10, patients on infliximab had a significantly higher likelihood of attaining a reduction in PASI score than placebo patients. There were also statistically significant differences between infliximab and placebo in the secondary outcomes. In the comparator trials both the efalizumab and etanercept arms included a significantly higher proportion of patients who achieved a reduction in PASI score at week 12 than the placebo arms. No head-to-head studies were identified directly comparing infliximab with etanercept or efalizumab. The manufacturer carried out an indirect comparison, but the ERG had reservations about the comparison because of the lack of information presented and areas of uncertainty in relation to the included data. The economic model presented by the manufacturer was appropriate for the disease area and given the available data. The cost-effectiveness analysis estimates the mean length of time that an individual would respond to infliximab compared with continuous etanercept and the utility gains associated with this response. The base-case incremental cost-effectiveness ratio (ICER) for infliximab compared with continuous etanercept for patients with severe psoriasis was £26,095 per quality-adjusted life-year. A one-way sensitivity analysis, a scenario analysis and a probabilistic sensitivity analysis were undertaken by the ERG. The ICER is highly sensitive to assumptions about the costs and frequency of inpatient stays for non-responders of infliximab. The guidance issued by NICE in August 2007 as a result of the STA states that infliximab within its licensed indication is recommended for the treatment of adults with very severe plaque psoriasis, or with psoriasis that has failed to respond to standard systematic therapies. Infliximab treatment should be continued beyond 10 weeks in people whose psoriasis has shown an adequate response to treatment within 10 weeks. In addition, when using the Dermatology Life Quality Index (DLQI), care should be taken to take into account the patient's disabilities, to ensure DLQI continues to be an accurate measure