Patients and consumers

Successive governments of the UK have strongly supported two policies: an NHS free at the point of delivery, and the encouragement of consumer choice. It was natural for governments to think that amalgamating the policies would increase patient satisfaction, improve efficiency and save money. There are many reasons why this has not been well-received by patients and doctors and has not saved money, but the underlying problem is that there is a conceptual misfit between healthcare as public policy and as individual responsibility. Patients in the NHS cannot become consumers and doctors cannot become suppliers of goods and services

Medical humanities: some uses and problems

The arts and humanities were allowed into the British medical curriculum in 1993 when the General Medical Council re-structured it in a paper entitled 'Tomorrow's Doctors'. Since then many medical schools have developed humanities modules and the broad term 'medical humanities' refers to these. They can contribute to medical education in at least three ways: as a supplement to what is already in the curriculum, especially for ethics and communication; as an outside critique of medical practice; and to personal and professional development. Nevertheless, there are practical problems concerning appropriate teachers and methods of assessment. Moreover, the dominant interest is now academic research rather than education

Finite strip analysis of curved plate structures

Bibliography: leaves 117-120.A finite difference based finite strip method of analysis is presented for the solution of curved plate structures subject to normal loading. By applying variational methods to the principle of minimum potential energy the governing differential equation for a curved finite strip element is formed. The set of simultaneous differential equations resulting from a system of such strips are then solved using finite difference and Gauss reduction techniques. Various boundary conditions including continuity over interior supports may be considered

Thermoelectric performance of multiphase XNiSn (X = Ti, Zr, Hf) half-Heusler alloys

Quantitative X-ray powder diffraction analysis demonstrates that mixing Ti, Zr and Hf on the ionic site in the half-Heusler structure, which is a common strategy to lower the lattice thermal conductivity in this important class of thermoelectric materials, leads to multiphase behaviour. For example, nominal Ti0.5Zr0.5NiSn has a distribution of Ti1−xZrxNiSn compositions between 0.24 ≤ x ≤ 0.70. Similar variations are observed for Zr0.50Hf0.5NiSn and Ti0.5Hf0.5NiSn. Electron microscopy and elemental mapping demonstrate that the main compositional variations occur over micrometre length scales. The thermoelectric power factors of the mixed phase samples are improved compared to the single phase end-members (e.g. S2/ρ = 1.8 mW m−1 K−2 for Ti0.5Zr0.5NiSn, compared to S2/ρ = 1.5 mW m−1 K−2 for TiNiSn), demonstrating that the multiphase behaviour is not detrimental to electronic transport. Thermal conductivity measurements for Ti0.5Zr0.5NiSn0.95 suggest that the dominant reduction comes from Ti/Zr mass and size difference phonon scattering with the multiphase behaviour a secondary effect

Charge asymmetry in high-energy μ+μ−\mu^+\mu^- photoproduction in the electric field of a heavy atom

The charge asymmetry in the differential cross section of high-energy $\mu^+\mu^-$ photoproduction in the electric field of a heavy atom is obtained. This asymmetry arises due to the Coulomb corrections to the amplitude of the process (next-to-leading term with respect to the atomic field). The deviation of the nuclear electric field from the Coulomb field at small distances is crucially important for the charge asymmetry. Though the Coulomb corrections to the total cross section are negligibly small, the charge asymmetry is measurable for selected final states of $\mu^+$ and $\mu^-$. We further discuss the feasibility for experimental observation of this effect.Comment: 6 pages, 3 figure

Blue-light filtering spectacle lenses for visual performance, sleep, and macular health in adults

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess whether blue-light filtering spectacle lenses impart effects on visual function, provide protection to the macula, or both. We will also examine potential effects on the sleep-wake cycle

Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews

Background Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. Objectives To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. Methods We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded. Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. Main results We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM. Effective Lifestyle versus usual care Lifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality). Promising No evidence for any outcome for any comparison could be classified to this category. Ineffective or possibly harmful Lifestyle versus usual care Lifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality). Exercise versus control Exercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality). Insulin versus oral therapy Insulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality). Probably ineffective or harmful interventions Insulin versus oral therapy For insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality). Inconclusive Lifestyle versus usual care The evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality). Exercise versus control The evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality). Insulin versus oral therapy The evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes. Insulin versus diet The evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality). Insulin versus insulin The evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality). No conclusions possible No conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low quality. Authors’ conclusions Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed

Statistical evaluation of the function of the 1992 International Continence Society scientific committee

Papers submitted to the International Confidence Society arc read by the six members of the scientific committee, who assign three scores to each paper, one for its originality, one for its scientific value, and one for its academic or clinical interest. Following discussion at the scientific committee meeting, a program is made from the abstracts with the highest scores. In this study statistical properties of the assigned score values for the 1992 ICS meeting are discussed It is concluded that the three scores do not measure independent properties of the abstracts, that different abstract types (for instance “clinical” and “basic” papers) are scored differently by the different committee members, that there is a significant consensus among the committee members, that the scientific committee meeting has a relatively small effect on the scores, and that different abstract types are not equally represented in the final program

A Critical Appraisal of National and International Clinical Practice Guidelines Reporting Nutritional Recommendations for Age-Related Macular Degeneration: Are Recommendations Evidence-Based?

Eye care professionals should have access to high quality clinical practice guidelines that ideally are underpinned by evidence from robust systematic reviews of relevant research. The aim of this study was to identify clinical guidelines with recommendations pertaining to dietary modification and/or nutritional supplementation for age-related macular degeneration (AMD), and to evaluate the overall quality of the guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. We also mapped recommendations to existing systematic review evidence. A comprehensive search was undertaken using bibliographic databases and other electronic resources for eligible guidelines. Quality appraisal was undertaken to generate scores for each of the six AGREE II domains, and mapping of extracted nutritional recommendations was performed for systematic reviews published up to March 2017. We identified 13 national and international guidelines, developed or updated between 2004 and 2019. These varied substantially in quality. The lowest scoring AGREE II domains were for 'Rigour of Development', 'Applicability' (which measures implementation strategies to improve uptake of recommendations), and 'Editorial Independence'. Only four guidelines used evidence from systematic reviews to support their nutritional recommendations. In conclusion, there is significant scope for improving current Clinical Practice Guidelines for AMD, and guideline developers should use evidence from existing high quality systematic reviews to inform clinical recommendations