What factors affect patients’ access to healthcare? Protocol for an overview of systematic reviews

Background The importance of access to healthcare for all is internationally recognised as a global goal, high on the global agenda. Yet inequalities in health exist within and between countries which are exacerbated by inequalities in access to healthcare. In order to address these inequalities, we need to better understand what drives them. While there exists a wealth of research on access to healthcare in different countries and contexts, and for different patient groups, to date no attempt has been made to bring this evidence together through a global lens. This study aims to address that gap by bringing together evidence of what factors affect patients’ access to healthcare and exploring how those factors vary in different countries and contexts around the world. Methods An overview of reviews will be conducted using a comprehensive search strategy to search four databases: Medline, Embase, Global Health and Cochrane Systematic Reviews. Additional searches will be conducted on the Gates Foundation, the World Health Organisation (WHO) and World Bank websites. Titles and abstracts will be screened against the eligibility criteria and full-text articles will be obtained for all records that meet the inclusion criteria or where there is uncertainty around eligibility. A data extraction table will be developed during the review process and will be piloted and refined before full data extraction commences. Methodological quality/risk of bias will be assessed for each included study using the AMSTAR 2 tool. The quality assessment will be used to inform the narrative synthesis, but a low-quality score will not necessarily lead to study exclusion. Discussion Factors affecting patients’ ability to access healthcare will be identified and analysed according to different country and context characteristics to shed light on the importance of different factors in different settings. Results will be interpreted accounting for the usual challenges associated with conducting such reviews. The results may guide future research in this area and contribute to priority setting for development initiatives aimed at ensuring equitable access to healthcare for all

Mental practice with interactive 3D visual aids enhances surgical performance

Background: Evidence suggests that Mental Practice (MP) could be used to finesse surgical skills. However, MP is cognitively demanding and may be dependent on the ability of individuals to produce mental images. In this study, we hypothesised that the provision of interactive 3D visual aids during MP could facilitate surgical skill performance. Methods: 20 surgical trainees were case-matched to one of three different preparation methods prior to performing a simulated Laparoscopic Cholecystectomy (LC). Two intervention groups underwent a 25-minute MP session; one with interactive 3D visual aids depicting the relevant surgical anatomy (3D-MP group, n = 5) and one without (MP-Only, n = 5). A control group (n = 10) watched a didactic video of a real LC. Scores relating to technical performance and safety were recorded by a surgical simulator. Results: The Control group took longer to complete the procedure relative to the 3D&MP condition (p = .002). The number of movements was also statistically different across groups (p = .001), with the 3D&MP group making fewer movements relative to controls (p = .001). Likewise, the control group moved further in comparison to the 3D&MP condition and the MP-Only condition (p = .004). No reliable differences were observed for safety metrics. Conclusion: These data provide evidence for the potential value of MP in improving performance. Furthermore, they suggest that 3D interactive visual aids during MP could potentially enhance performance, beyond the benefits of MP alone. These findings pave the way for future RCTs on surgical preparation and performance

The effect of cultural and environmental factors on potato seed tuber morphology and subsequent sprout and stem development

Seed crops of the variety Estima were grown in each of 2 years using two planting dates, two harvest dates, two plant densities and two irrigation regimes to produce seed tubers which had experienced different cultural and environmental conditions. The effects of these treatments on tuber characteristics, sprout production and stem development in the ware crop were then determined in subsequent experiments using storage regimes of 3 and 10 °C. Time of planting the seed crop affected numbers of eyes, sprouts and above ground stems in the subsequent ware crop because environmental conditions around the time of tuber initiation appeared to alter tuber shape. Cooler, wetter conditions in the 7 days after tuber initiation were associated with tubers which were longer, heavier and had more eyes, sprouts and above ground stems. In contrast, the time of harvesting the seed crop did not affect tuber shape or numbers of above ground stems and there was no interaction with tuber size. The density of the seed crop had no effect on any character measured and irrigation well after tuber initiation did not affect tuber shape, numbers of sprouts or numbers of stems. Seed production treatments, which resulted in earlier dormancy break, were associated with tubers that produced more sprouts and above ground stems, in contrast to the conventional understanding of apical dominance. Storage at 3 °C gave fewer sprouts, a lower proportion of eyes with sprouts and fewer stems than storage at 10 °C. The major effects on stem production appear to result from environmental conditions at the time of tuber initiation of the seed crop and sprouting temperature

Development of a score for assessment of radiologic damage in large-vessel vasculitis (Combined Arteritis Damage Score, CARDS)

OBJECTIVES: Outcome assessment in large-vessel vasculitis (LVV) remains challenging and this impairs patient management and the conduct of clinical studies. Previous proposals for outcome tools have not included imaging. This study aimed to develop an imaging score to quantify damage in LVV and to assess the difference between Takayasu (TAK) and giant cell arteritis (GCA). METHODS: Ninety-six patients (41 TAK, 55 GCA) were identified from local registries at two University Hospitals in the UK. Radiologic lesions including stenosis, occlusion and aneurysm were evaluated in 25 arterial regions by enhanced computed tomography or magnetic resonance angiography. Lesion correlation with combined damage assessment scores was employed in a multiple regression analysis to define the weight of individual lesions and develop a damage index. RESULTS: A numerical damage index was developed: the “Combined Arteritis Damage Score (CARDS)”. The index was derived from a formula: number of regions with mild stenosis × 0.6 + number of regions with moderate to severe stenosis × 1.2 + number with occlusions × 1.6 + number with aneurysms × 0.8 in 25 arterial regions. The median CARDS was higher in TAK than GCA (4.1 and 0.6, interquartile range 1.3-5.7 and 0-3, p<0.001). CONCLUSIONS: We have developed a damage assessment tool, CARDS, based on imaging in LVV of potential value to clinical studies and patient management. TAK and GCA differ in the radiologic severity of disease.Dr. Daiki Nakagomi is supported by the Japan College of Rheumatology and Shimoshizu Hospital, National Hospital Organization. This project was supported by the Cambridge Biomedical Research Centre

Response to: "Renal biopsies should be performed whenever treatment strategies depend on renal involvement"

We thank Chemouny et al for their letter and concur with their conclusions. As we state (1): “A positive biopsy for AAV is helpful when considering an initial diagnosis or recurrent disease.” In our view, renal biopsy is important to establish diagnosis and may also provide an indication of prognostic trajectory and although existing classification systems need further validation, changes like glomerular sclerosis have obvious adverse prognostic value for patients with AAV (2-4). The Delphi process, for the scope of the current recommendations, identified the role of biopsy at both diagnosis and follow-up as an important item for update. Histopathological evidence of vasculitis, such as pauci-immune glomerulonephritis or necrotising vasculitis in any organ, remains the gold standard for diagnostic purposes. The likely diagnostic yield varies and is dependent on the organ targeted and in patients with GPA with renal involvement can be as high as 91.5% from renal biopsy (5). As Chemouny and colleagues have demonstrated, a renal biopsy was definitive in determining their management decisions. However during follow-up when relapses occur, it may be prudent to consider judicious use of further kidney biopsy during suspected renal relapse since the cause for acute kidney injury may be due to another cause other than AAV (6). Kind regards, M Yates, C Mukhtyar and DR Jayne on behalf of co-authors

Smart Drugs “As Common As Coffee”: Media Hype about Neuroenhancement

Background: The use of prescription drugs to improve cognitive functioning in normal persons -"neuroenhancement" - has gained recent attention from bioethicists and neuroscientists. Enthusiasts claim that the practice is widespread and increasing, and has many potential benefits; however recent evidence provides weak support for these claims. In this study we explored how the newsprint media portrays neuroenhancement

Micro-Tubular Fuel Cells

Micro-tubular fuel cells that would operate at power levels on the order of hundreds of watts or less are under development as alternatives to batteries in numerous products - portable power tools, cellular telephones, laptop computers, portable television receivers, and small robotic vehicles, to name a few examples. Micro-tubular fuel cells exploit advances in the art of proton-exchange-membrane fuel cells. The main advantage of the micro-tubular fuel cells over the plate-and-frame fuel cells would be higher power densities: Whereas the mass and volume power densities of low-pressure hydrogen-and-oxygen-fuel plate-and-frame fuel cells designed to operate in the targeted power range are typically less than 0.1 W/g and 0.1 kW/L, micro-tubular fuel cells are expected to reach power densities much greater than 1 W/g and 1 kW/L. Because of their higher power densities, micro-tubular fuel cells would be better for powering portable equipment, and would be better suited to applications in which there are requirements for modularity to simplify maintenance or to facilitate scaling to higher power levels. The development of PEMFCs has conventionally focused on producing large stacks of cells that operate at typical power levels >5 kW. The usual approach taken to developing lower-power PEMFCs for applications like those listed above has been to simply shrink the basic plate-and-frame configuration to smaller dimensions. A conventional plate-and-frame fuel cell contains a membrane/electrode assembly in the form of a flat membrane with electrodes of the same active area bonded to both faces. In order to provide reactants to both electrodes, bipolar plates that contain flow passages are placed on both electrodes. The mass and volume overhead of the bipolar plates amounts to about 75 percent of the total mass and volume of a fuel-cell stack. Removing these bipolar plates in the micro-tubular fuel cell significantly increases the power density

Effects of Hydrogen Annealing, Sulfur Segregation and Diffusion on the Cyclic Oxidation Resistance of Superalloys: a Review

This review is based on the phenomenon of improved oxide scale adhesion for desulfurized superalloys. The proposed adhesion mechanism involves sulfur interfacial segregation and scale-metal bond weakening. Sulfur surface segregation on superalloys is examined as a function of temperature and sulfur content and related to classical behavior predicted by the McLean isotherm. Effective desulfurization to less than 1 ppmw can be accomplished by hydrogen annealing and is governed by sulfur diffusion kinetics in nickel. Hydrogen annealing results in excellent cyclic oxidation resistance for a number of advanced superalloys. The concept of a critical sulfur content is discussed in terms of practical annealing conditions and section thicknesses