Broadband in rural and remote areas: the impact of Scottish policy initiatives

The ability to participate in the Internet-based economy that is emerging requires access to broadband. However, in many countries, 'digital divides' occur, with those in geographically remote and rural areas being particularly disadvantaged. Through focusing on rural and remote Scotland, the paper identifies three different categories of policy initiatives that have been adopted and their interaction with broader UK and industry wide developments. Whilst these initiatives have encouraged the adoption of broadband, it is argued that UK initiatives are creating a new series of challenges to the adoption of broadband

Unethical informed consent caused by overlooking poorly measured nocebo effects

Unlike its friendly cousin the placebo effect, the nocebo effect (the effect of expecting a negative outcome) has been almost ignored. Epistemic and ethical confusions related to its existence have gone all but unnoticed. Contrary to what is often asserted, adverse events following from taking placebo interventions are not necessarily nocebo effects; they could have arisen due to natural history. Meanwhile, ethical informed consent (in clinical trials and clinical practice) has centred almost exclusively on the need to inform patients about intervention risks with patients to preserve their autonomy. Researchers have failed to consider the harm caused by the way in which the information is conveyed. In this paper, I argue that the magnitude of nocebo effects must be measured using control groups consisting of untreated patients. And, because the nocebo effect can produce harm, the principle of non-maleficence must be taken into account alongside autonomy when obtaining (ethical) informed consent and communicating intervention risks with patients

Positive messages may reduce patient pain: A meta-analysis

Introduction Current treatments for pain have limited benefits and worrying side effects. Some studies suggest that pain is reduced when clinicians deliver positive messages. However, the effects of positive messages are heterogeneous and have not been subject to meta-analysis. We aimed to estimate the efficacy of positive messages for pain reduction. Methods We included randomized trials of the effects of positive messages in a subset of the studies included in a recent systematic review of context factors for treating pain. Several electronic databases were searched. Reference lists of relevant studies were also searched. Two authors independently undertook study selection, data extraction, risk of bias assessment, and analyses. Our primary outcome measures were differences in patient- or observer-reported pain between groups who were given positive messages and those who were not. Results Of the 16 randomized trials (1703 patients) that met the inclusion criteria, 12 trials had sufficient data for meta-analysis. The pooled standardized effect size was −0.31 (95% confidence interval [CI] −0.61 to −0.01, p = 0.04, I2 = 82%). The effect size remained positive but not statistically significant after we excluded studies considered to have a high risk of bias (standard effect size −0.17, 95% CI −0.54 to 0.19, P = 0.36, I2 = 84%). Conclusion Care of patients with chronic or acute pain may be enhanced when clinicians deliver positive messages about possible clinical outcomes. However, we have identified several limitations of the present study that suggest caution when interpreting the results. We recommend further high-quality studies to confirm (or falsify) our result. FUNDING Alexander Mebius research has been funded through the ERC grant "Philosophy of Pharmacology: Safety, Statistical Standards, and Evidence Amalgamation" (GA: 639276

The dynamics of academic entrepreneurship : connecting universities and the ecosystem

To advance the field of academic entrepreneurship, the system, university and individual level can no longer be treated separately but need to be described and understood as an ecosystem in order to identify drivers and understand the dynamics. This conceptual paper proposes a framework based on feedback thinking, aggregation and complex adaptive systems that connects the university’s and the business’ perspective. A hybrid model with an integrated system dynamics (SD) / agent-based modelling (ABM) approach will then be proposed to operationalise the framework, in which universities are represented as SD modules that shape the environment for the established companies and start-ups, represented as a set of agents. The SD feedback structure acknowledges and reflects the consequences of entrepreneurial activities for and the influence of the ecosystem on the university. First, this framework advances our understanding of ecosystems by formulating a theoretical foundation for an ecosystem model that is capable of representing the interactions between its components. Furthermore, it will allow for the examination of dynamic interplays between universities and their ecosystem. The insights from this model have far-reaching implications for universities, intermediate organisations and policy makers at national and regional levels. Further research trajectories are outlined

Critical learning incidents in system dynamics modelling engagements

This paper reports in-depth behavioural operational research to explore how individual clients learned to resolve dynamically complex problems in system dynamics model-based engagements. Consultant-client dyads were interviewed in ten system dynamics consulting engagements to identify individual clients' Critical Learning Incidents—defined as the moment of surprise caused after one's mental model produces unexpected failure and a change in one’s mental model produces the desired result. The cases are reprised from interviews and include assessments of the nature of the engagement problem, the form of system dynamics model, and the methods employed by consultants during each phase of the engagement. Reported Critical Learning Incidents are noted by engagement phase and consulting method, and constructivist learning theory is used to describe a pattern of learning. Outcomes of the research include describing the role of different methods applied in engagement phases (for example, the role of concept models to commence problem identification and to introduce iconography and jargon to the engagement participants), how model form associates with timings of Critical Learning Incidents, and the role of social mediation and negotiation in the learning process

Lessons from mixing OR methods in practice : using DES and SD to explore a radiotherapy treatment planning process

Mixing Operational Research (OR) methods is becoming more commonplace. Discrete-Event Simulation (DES) and System Dynamics (SD) are popular modelling methods previously applied to a range of situations for various purposes, which are starting to be mixed in healthcare. However, the practicalities of mixing DES and SD in practice remain unclear. Radiotherapy treatment is a complex multi-stage process where technology and best practice continue to evolve. This paper describes a project undertaken to explore the treatment planning process using mixed OR methods. It presents insights obtained through mixing OR methods within a real world project. The model development process, the role of each modelling method, and the benefits of undertaking a mixed OR methods project design are described. Lessons for mixing DES and SD, and more generally mixing OR methods, are discussed

Neuraminidase inhibitors for preventing and treating influenza in healthy adults and children

BACKGROUND: Neuraminidase inhibitors (NIs) are stockpiled and recommended by public health agencies for treating and preventing seasonal and pandemic influenza. They are used clinically worldwide. OBJECTIVES: To describe the potential benefits and harms of NIs for influenza in all age groups by reviewing all clinical study reports of published and unpublished randomised, placebo-controlled trials and regulatory comments. SEARCH METHODS: We searched trial registries, electronic databases (to 22 July 2013) and regulatory archives, and corresponded with manufacturers to identify all trials. We also requested clinical study reports. We focused on the primary data sources of manufacturers but we checked that there were no published randomised controlled trials (RCTs) from non-manufacturer sources by running electronic searches in the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE (Ovid), EMBASE, Embase.com, PubMed (not MEDLINE), the Database of Reviews of Effects, the NHS Economic Evaluation Database and the Health Economic Evaluations Database. SELECTION CRITERIA: Randomised, placebo-controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza. DATA COLLECTION AND ANALYSIS: We extracted clinical study reports and assessed risk of bias using purpose-built instruments. We analysed the effects of zanamivir and oseltamivir on time to first alleviation of symptoms, influenza outcomes, complications, hospitalisations and adverse events in the intention-to-treat (ITT) population. All trials were sponsored by the manufacturers. MAIN RESULTS: We obtained 107 clinical study reports from the European Medicines Agency (EMA), GlaxoSmithKline and Roche. We accessed comments by the US Food and Drug Administration (FDA), EMA and Japanese regulator. We included 53 trials in Stage 1 (a judgement of appropriate study design) and 46 in Stage 2 (formal analysis), including 20 oseltamivir (9623 participants) and 26 zanamivir trials (14,628 participants). Inadequate reporting put most of the zanamivir studies and half of the oseltamivir studies at a high risk of selection bias. There were inadequate measures in place to protect 11 studies of oseltamivir from performance bias due to non-identical presentation of placebo. Attrition bias was high across the oseltamivir studies and there was also evidence of selective reporting for both the zanamivir and oseltamivir studies. The placebo interventions in both sets of trials may have contained active substances. Time to first symptom alleviation. For the treatment of adults, oseltamivir reduced the time to first alleviation of symptoms by 16.8 hours (95% confidence interval (CI) 8.4 to 25.1 hours, P 1000) and nausea whilst on treatment (RD 4.15%, 95% CI 0.86 to 9.51); NNTH = 25 (95% CI 11 to 116). AUTHORS' CONCLUSIONS: Oseltamivir and zanamivir have small, non-specific effects on reducing the time to alleviation of influenza symptoms in adults, but not in asthmatic children. Using either drug as prophylaxis reduces the risk of developing symptomatic influenza. Treatment trials with oseltamivir or zanamivir do not settle the question of whether the complications of influenza (such as pneumonia) are reduced, because of a lack of diagnostic definitions. The use of oseltamivir increases the risk of adverse effects, such as nausea, vomiting, psychiatric effects and renal events in adults and vomiting in children. The lower bioavailability may explain the lower toxicity of zanamivir compared to oseltamivir. The balance between benefits and harms should be considered when making decisions about use of both NIs for either the prophylaxis or treatment of influenza. The influenza virus-specific mechanism of action proposed by the producers does not fit the clinical evidence

Why include humanities in medical studies: comment

Five reasons why teaching medical humanities in medical schools improves student performance, enhances wellbeing, and ameliorates patient outcomes