What has postmodernism done to evidence-based medicine?

Peer reviewe

Breast self examination: a healthy approach: teaching manual

The theme of this health teaching package is breast care with an emphasis on step-by-step instruction f0r breast self examination. The package has been designed to guide health professionals in the facilitation of workshops and discussion groups promoting breast care for women. Materials included in the manual may be adapted to suit audience requirements..

Improving Transitions across SLT Services in [Anonymised HB] for Adults with Long-Term, Speech, Language, Swallowing or Communication (SLSC) Needs: a Qualitative Study of SLTs' and Service Users' Views : Moving between SLT Teams

Adults with long-term speech, language, swallowing or communication (SLSC) needs are sometimes known to SLT services from an early age and throughout their adult life, accessing SLT services at various periods, but SLSC needs can also arise later in life. Adults may require to access SLT services to develop their personal communication skills and/or to secure alternative and augmentative communication support, a clear and facilitative communication environment, and on-going support with eating and swallowing. The role of the SLT is often to advise others (such as volunteers, family and carers, health-care and other staff) on appropriate communication and safe swallowing approaches. SLT services in NHS [Anonymised HB] (NHS [HB]) are offered from around 37 locations, managed within community and hospital, adult and paediatric services. Specialist SLTs work in teams serving specified populations. As health needs alter, adults with long-term SLSC needs often move across SLT teams and effective procedures are needed to facilitate this process. This project is concerned with the care of adults with long-term SLSC needs as they move across SLT team boundaries. The project aimed to identify factors that affect such transitions positively and negatively, from the perspectives of SLTs and service users. It also aimed to provide a model of transfer that would be effective across NHS [HB] SLT structures. SLT services in [Anonymised HB] are keen to find ways to smooth and support the service user?s journey across SLT teams, and to build appropriate care pathways. This project asked service users and SLTs to identify factors that tend to facilitate or impede transitions. It then suggests ways in which transitions could be further improved, and provides a model of good practice for transitions

Conflicts of interest in healthcare - where are we now?

Conflicts of interest in healthcare - where are we now? This research aims to describe current practice in the declaration of interests in UK healthcare, in order to identify potential means to reduce the negative impacts of conflicts of interest. Three studies are presented as published works: 1) a cross sectional study assessing current declaration practice in Scotland and England 2) a cross sectional study assessing recommendations of a non-NHS approved intervention in lay media, online, and NHS material, and associated financial conflicts of interest and 3) a mixed methods study, set in the UK, assessing peoples’ ability to locate a health professionals’ declaration of interest, and citizen understanding of what such declarations mean and their potential impact. Clinical Commissioning Groups, NHS Trusts, NHS Scotland Health Boards, and private healthcare organisations; articles making recommendations about screening for atrial fibrillation from the UK (lay press, online and social media), and citizens, lay people, professionals and students in the UK were studied. Measured outcomes included 1) Adherence to NHS England guidelines on declarations of interests, and comparison of declaration registers in Scotland, 2) Proportion of references advocating for, against and presenting balanced/neutral views on screening for atrial fibrillation (AF), and proportion of references citing commentators/organisations with financial conflicts of interest 3) a) Participants’ level of trust in professionals with variable conflicts of interest, as expressed in vignettes, b) participants’ ability to locate the declarations of interest of a given well-known healthcare professional, c) laypeople’s understanding of healthcare professionals declarations and conflicts of interest. The research found that 1) 76% of registers published by Trusts did not routinely include all declarations of interest categories recommended by NHS England. In NHS Scotland 86% of Boards did not publish staff registers of interest. Trusts and Clinical Commissioning Groups in England have low levels of compliance with NHSE guidance on declarations of interest and in Scotland, few staff registers are public and transparency is overall lower. 2) 185/217 (85.3%) media articles were in favour of screening for AF. 194 commentators were identified; 44 were quoted more than once. 41/44 of these (93.2%) were in favour of screening. Of these 41, 37 (90.2%) had a direct or indirect financial conflict of interest, including that due to a work role. In 187 articles (85.7%) these were not disclosed. Of 23 NHS organisations holding information about funding and promoting AF screening online, 22 (96%) had industry funding. The top 10 patient information websites promoting AF screening were analysed: 9 (90%) had industry funding. 3) 85% of participants thought that knowing about professional declarations was definitely or probably important, but 76.8% were not confident they had found all relevant information after searching. Fictional scenarios found that increasing financial conflicts of interest were associated with decreased trust in professional advice. 297 participants agreed to search for a healthcare professionals’ ‘gold standard’ declaration of interest, and 169 reported some data. 5 (3%) of participants found all the information contained in the ‘gold standard’. Qualitative interviews with 21 citizens highlighted the importance of transparency but raised serious concerns about how useful declarations were in their current format, and whether they could improve patient care. In conclusion, current practice in declaring interests in England is not congruent with NHS England guidelines. Comparatively, in Scotland, there is less public information about health professionals’ interests. Most media coverage on screening for atrial fibrillation is favourable, but conflicts of interest held by supporters are mainly not declared. Most commentators recommending screening had a financial conflict of interest in doing so. Study participants consider professionals conflicts of interest important and want to know about them, but cannot effectively locate them. In qualitative interview, participants raise multiple questions about how effectively declarations can manage conflicts. This body of research describes contemporary practice and raises concerns that 1) current systems of declarations do not effectively achieve transparency and 2) the role of transparency in reducing conflicts of interests requires to be delineated to ensure that the intended purpose is met. The potential benefits from transparency as well as the risks, unintended consequences, burden and evidence gaps in current declaration systems is discussed, with questions raised as to whether transparency can reduce bias or, counter-intuitively, worsen it."I am grateful for funding from the University of St Andrews Research Fund, HealthSense, and the Chief Scientist Office Scotland; this would not have got done without it."--Acknowledgment

Single versus two-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up

Background: The majority of coronary bifurcation lesions are treated with a provisional single‐stent strategy rather than an up‐front 2‐stent strategy. This approach is supported by multiple randomized controlled clinical trials with short‐ to medium‐term follow‐up; however, long‐term follow‐up data is evolving from many data sets. Methods and Results: Meta‐analysis of randomized controlled trials evaluating long‐term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long‐term clinical outcomes at mean weighted follow‐up of 3.1±1.8 years. Provisional single stenting was associated with lower all‐cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48–1.00; P=0.049; I2=0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P=0.79), myocardial infarction (4.8% versus 5.5%; P=0.51), target lesion revascularization (9.3% versus 7.6%; P=0.19), or stent thrombosis (1.8% versus 1.6%; P=0.28) between the groups. Prespecified sensitivity analysis of long‐term mortality at a mean of 4.7 years of follow‐up showed that the provisional single‐stent strategy was associated with reduced all‐cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42–0.97; P=0.036; I2=0). Conclusions: Coronary bifurcation percutaneous coronary intervention using a provisional single‐stent strategy is associated with a reduction in all‐cause mortality at long‐term follow‐up

Mitigating the wider health effects of covid-19 pandemic response

No abstract available

Tackling population health challenges as we build back from the pandemic

Gerry McCartney and colleagues argue for a new model of equitable, holistic, and sustainable public health should be central to recovery plan

Policies on doctors’ declaration of interests in medical organisations : a thematic analysis

ObjectivesThere has been growing concern about doctors? conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement.DesignThematic analysis.Setting and ParticipantsWe studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings.Main outcome measures:Organisational policy similarities and differences.ResultsMost policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential.ConclusionsThe analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.Publisher PDFPeer reviewe

How are declarations of interest working?:A cross-sectional study in declarations of interest in healthcare practice in Scotland and England in 2020/2021

MM is funded by the Chief Scientist Office Scotland, RBH and RMcD had summer medical studentships from the University of St Andrews.Objective To understand arrangements for healthcare organisations’ declarations of staff interest in Scotland and England in the context of current recommendations. Design Cross-sectional study of a random selection of National Health Service (NHS) hospital registers of interest by two independent observers in England, all NHS Boards in Scotland and a random selection of Clinical Commissioning Groups (CCGs) in England. Setting NHS Trusts in England (NHSE), NHS Boards in Scotland, CCGs in England, and private healthcare organisations. Participants Registers of declarations of interest published in a random sample of 67 of 217 NHS Trusts, a random sample of 15 CCGs of in England, registers held by all 14 NHS Scotland Boards and a purposeful selection of private hospitals/clinics in the UK. Main outcome measures Adherence to NHSE guidelines on declarations of interests, and comparison in Scotland. Results 76% of registers published by Trusts did not routinely include all declaration of interest categories recommended by NHS England. In NHS Scotland only 14% of Boards published staff registers of interest. Of these employee registers (most obtained under Freedom of Information), 27% contained substantial retractions. In England, 96% of CCGs published a Gifts and Hospitality register, with 67% of CCG staff declaration templates and 53% of governor registers containing full standard NHS England declaration categories. Single organisations often held multiple registers lacking enough information to interpret them. Only 35% of NHS Trust registers were organised to enable searching. None of the private sector organisations studied published a comparable declarations of interest register. Conclusion Despite efforts, the current system of declarations frequently lacks ability to meaningfully obtain complete healthcare professionals’ declaration of interests.Publisher PDFPeer reviewe