Second order perturbation theory for spin-orbit resonances

We implement Lie transform perturbation theory to second order for the planar spin-orbit problem. The perturbation parameter is the asphericity of the body, with the orbital eccentricity entering as an additional parameter. We study first and second order resonances for different values of these parameters. For nearly spherical bodies like Mercury and the Moon first order perturbation theory is adequate, whereas for highly aspherical bodies like Hyperion the spin is mostly chaotic and perturbation theory is of limited use. However, in between, we identify a parameter range where second order perturbation theory is useful and where as yet unidentified objects may be in second order resonances.Comment: To appear in A

Solidarity and collectivism in the context of COVID-19

The coronavirus pandemic has impacted health care, economies and societies in ways that are still being measured across the world. To control the spread of the virus, governments continue to appeal to citizens to alter their behaviours and act in the interests of the collective public good so as to protect the vulnerable. Demonstrations of collective solidarity are being consistently sought to control the spread of the virus. Catchphrases, soundbites and hashtags such as ‘we’re all in this together’, ‘stronger together’ and other messages of unity are employed, invoking the sense of a collective struggle. However, this approach is fundamentally challenged as collectivist attitudes run contrary to the individualism of neoliberal ideology, to which citizens have been subjected. This paper argues that attempting to employ the concept of solidarity is inherently challenged by the deep impact of neoliberalism in health policies and draws on the work of Durkheim to examine the concept in a context in which health care has become established as an individual responsibility. The paper will argue that a dominant private-responsibility model and an underfunded public system have eroded solidarity weakening its effectiveness in generating concerns for the collective

General Practitioners’ Experiences of Providing Lifestyle Advice to Patients with Depression:A Qualitative Focus Group Study

Objective: Depression is an increasingly common mental health disorder in the UK,managed predominantly in the community by GPs. Emerging evidence suggestslifestyle medicine is a key component in the management of depression. We aimed toexplore GPs’ experiences, attitudes, and challenges to providing lifestyle advice topatients with depression.Method: Focus groups were conducted virtually with UK GPs (May-July 2022). A topicguide facilitated the discussion and included questions on experiences, currentpractices, competence, challenges, and service provision. Data were analysed usingtemplate analysis.Results: ‘Supporting Effective Conversations’; ‘Willing, but Blocked from EstablishingRelational Care’; ‘Working Towards Patient Empowerment’; and ‘Control Over thePrognosis’ were all elements of how individualised lifestyle advice was key to themanagement of depression. Establishing a doctor-patient relationship by building trust and rapport was fundamental to having effective conversations about lifestylebehaviours. Empowering patients to make positive lifestyle changes required tailoringadvice using a patient-centred approach. Confidence varied across participants,depending on education, experience, type of patient, and severity of depression.Conclusions: GPs play an important role in managing depression using lifestylemedicine and a patient-centred approach. Organisational and educational changes arenecessary to facilitate GPs in providing optimal care to patients with depression

Pharmacy-led implementation of evidence based medicine in primary care : Evaluating Diuretics in Usual Care study (EVIDENCE)

Introduction Obtaining evidence of comparative effectiveness and safety of widely prescribed drugs in a timely cost-effective way is emerging as a major global challenge for healthcare systems. The Evaluating Drugs in Normal Care (EVIDENCE) programme addresses this challenge through novel methodology. We describe an exemplar pilot study comparing thiazide type diuretics for hypertension. Method Patients prescribed either indapamide or bendroflumethiazide for hypertension were identified in each primary care practice recruited. Random allocation of a prescribing policy for one or other of these drugs was then applied to the whole practice and where required repeat prescriptions were switched to comply with randomised policy. Patients were informed of the potential switch by letter with the option to discuss further with the study team and/or opt-out of the switch. Routinely collected hospitalization and death data in NHS will be used to compare cardiovascular event rates between the two policies. Results We found bendroflumethiazide was prescribed to 78% of patients prescribed either of these drugs despite recent NICE preference for indapamide. 29 primary care practices in 5 Scottish NHS boards were recruited and 14 randomised to indapamide and 15 to bendroflumethiazide creating a study population of 5985 patients. Less than 0.23% of patients opted out. Conclusion This pilot study demonstrated the feasibility and cost efficiency of the EVIDENCE approach. A relatively large study was generated rapidly with negligible disruption to practice workflows. EVIDENCE methodology offers a novel way to compare the effectiveness of a wide range of medicines where there is clinical equipoise.Non peer reviewe

Cluster randomised trials of prescribing policy:an ethical approach to generating drug safety evidence? A discussion of the ethical application of a new research method

For most chronic medical conditions, multiple medications are available and prescribers often have limited evidence about which therapy is likely to be the most effective and safe for an individual patient. As many patients are exposed every day to medicines that may be less effective than available alternatives, this is of public health importance. Cluster randomised trials of prescribing policy offer an opportunity to rapidly obtain evidence of comparative effectiveness and safety. These trials can pose a low risk to patients and cause minimal disruption to usual care. Despite the potential scientific value of this approach, there remain valid concerns about consent, medication switching and the use of routinely collected data in research. We discuss these concerns with reference to an ongoing pilot study (Evaluating Diuretics in Normal Care (EVIDENCE) - a cluster randomised evaluation of hypertension prescribing policy, ISRCTN 46635087, registered 11 August 2017)

Evaluating Diuretics in Normal Care (EVIDENCE):Protocol of a cluster randomised controlled equivalence trial of prescribing policy to compare the effectiveness of thiazide-type diuretics in hypertension

Abstract Introduction Healthcare systems must use treatments that are effective and safe. Regulators licensed many currently used older medications before introducing the stringent evidential requirements imposed on modern treatments. Also, there has been little encouragement to carry out within-class, head-to-head comparisons of licensed medicines. For commonly prescribed drugs, even small differences in effectiveness or safety could have significant public health implications. However, conventional clinical trials that randomise individual subjects are costly and unwieldy. Such trials are also often criticised as having low external validity. We describe an approach to rapidly generate externally valid evidence of comparative safety and effectiveness using the example of two widely used diuretics for the management of hypertension. Methods and analysis The EVIDENCE (Evaluating Diuretics in Normal Care) study has a prospective, cluster-randomised, open-label, blinded end-point design. By randomising prescribing policy in primary care practices, the study compares the safety and effectiveness of commonly used diuretics in treating hypertension. Participating practices are randomised 1:1 to a policy of prescribing either indapamide or bendroflumethiazide when clinically indicated. Suitable patients who are not already taking the policy diuretic are switched accordingly. All patients taking the study medications are written to explaining the rationale for changing the prescribing policy and notifying them they can opt-out of any switch. The prescribing policies’ effectiveness and safety will be compared using rates of major adverse cardiovascular events (hospitalisation with myocardial infarction, heart failure or stroke or cardiovascular death), routinely collected in national healthcare administrative datasets. The study will seek to recruit 250 practices to provide a study population of approximately 50,000 individuals with a mean follow-up time of two years. A primary intention-to-treat time-to-event analysis will be used to estimate the relative effect of the two policies. Ethics and dissemination EVIDENCE has been approved by the East of Scotland Research Ethics Service (17/ES/0016, current approved protocol version 5, 26 August 2021). The results will be disseminated widely in peer reviewed journals, guideline committees, National Health Service (NHS) organisations and patient groups. Trial registration ISRCTN 46635087 . Registered on 11 August 2017 (pre-recruitment)