Consent processes in cluster-randomised trials in residential facilities for older adults : a systematic review of reporting practices and proposed guidelines

Objective: To assess the quality of reported consent processes of cluster-randomised trials conducted in residential facilities for older people and to explore whether the focus on improving the general conduct and reporting of cluster-randomised trials influenced the quality of conduct and reporting of ethical processes in these trials. Design: Systematic review of cluster-randomised trials reports, published up to the end of 2010. Data sources: National Library of Medicine (Medline) via PubMed, hand-searches of BMJ, Journal of the American Medical Association, BMC Health Services Research, Age and Ageing and Journal of the American Geriatrics Society, reference search in Web of Knowledge and consultation with experts. Eligibility for selecting studies: Published cluster-randomised trials where the unit of randomisation is a part or the whole of a residential facility for older people, without language or year of publication restrictions. Results: We included 73 trials. Authors reported ethical approval in 59, obtaining individual consent in 51, and using proxies for this consent in 37, but the process to assess residents’ capacity to consent was clearly reported in only eight. We rated only six trials high for the quality of consent processes. We considered that individual informed consent could have been waived legitimately in 14 of 22 trials not reporting obtaining consent. The proportions reporting ethical approval and quality of consent processes were higher in recent trials. Conclusions: Recently published international recommendations regarding ethical conduct in cluster-randomised trials are much needed. In relation to consent processes when cognitively impaired individuals are included in these trials, we provide a six-point checklist and recommend the minimum information to be reported. Those who lack capacity in trials with complex designs should be afforded the same care in relation to consent as competent adults in trials with simpler designs

Retaining the general practitioner workforce in England : what matters to GPs? A cross-sectional study

Background: The general practice (GP) workforce in England is in crisis, reflected in increasing rates of early retirement and intentions to reduce hours of working. This study aimed to investigate underlying factors and how these might be mitigated. Methods: GPs in central England were invited to participate in an on-line survey exploring career plans and views and experiences of work-related pressures. Quantitative data were analysed using logistic regression analysis and principal components analysis. Qualitative data were analysed using a thematic framework approach. Results: Of 1,192 GPs who participated, 978 (82.0 %) stated that they intend to leave general practice, take a career break and/or reduce clinical hours of work within the next five years. This included 488 (41.9 %) who intend to leave practice, and almost a quarter (279; 23.2 %) intending to take a career break. Only 67 (5.6 %) planned to increase their hours of clinical work. For participants planning to leave practice, the issues that most influenced intentions were volume and intensity of workload, time spent on “unimportant tasks”, introduction of seven-day working and lack of job satisfaction. Four hundred fifty five participants responded to open questions (39128 words in total). The main themes were the cumulative impact of work-related pressures, the changing and growing nature of the workload, and the consequent stress. Reducing workload intensity, workload volume, administrative activities, with increased time for patient care, no out-of-hour commitments, more flexible working conditions and greater clinical autonomy were identified as the most important requirements to address the workforce crisis. In addition, incentive payments, increased pay and protected time for education and training were also rated as important. Conclusions: New models of professionalism and organisational arrangements may be needed to address the issues described here. Without urgent action, the GP workforce crisis in England seems set to worsen

Intrusion of warm Bering/Chukchi waters onto the shelf in the western Beaufort Sea

Author Posting. © American Geophysical Union, 2009. This article is posted here by permission of American Geophysical Union for personal use, not for redistribution. The definitive version was published in Journal of Geophysical Research 114 (2009): C00A11, doi:10.1029/2008JC004870.Wind-driven changes in the path of warm Bering/Chukchi waters carried by the Alaska Coastal Current (ACC) through Barrow Canyon during late summer are described from high-resolution hydrography, acoustic Doppler current profiler–measured currents, and satellite-measured sea surface temperature imagery acquired from mid-August to mid-September 2005–2007 near Barrow, Alaska. Numerical simulations are used to provide a multidecadal context for these observational data. Four generalized wind regimes and associated circulation states are identified. When winds are from the east or east-southeast, the ACC jet tends to be relatively strong and flows adjacent to the shelf break along the southern flank of Barrow Canyon. These easterly winds drive inner shelf currents northwestward along the Alaskan Beaufort coast where they oppose significant eastward intrusions of warm water from Barrow Canyon onto the shelf. Because these easterly winds promote sea level set down over the Beaufort shelf and upwelling along the Beaufort slope, the ACC jet necessarily becomes weaker, broader, and displaced seaward from the Beaufort shelf break upon exiting Barrow Canyon. Winds from the northeast promote separation of the ACC from the southern flank of Barrow Canyon and establish an up-canyon current along the southern flank that is fed in part by waters from the western Beaufort shelf. When winds are weak or from the southwest, warm Bering/Chukchi waters from Barrow Canyon intrude onto the western Beaufort shelf.This work was supported in 2005 and 2006 by NSF grants OPP-0436131 and OPP-0436166. In 2007, this work received support through Woods Hole Oceanographic Institution- NOAA Cooperative Institute for Climate and Ocean Research Cooperative Agreement NA17RJ1223 and University of Alaska Fairbanks-NOAA Cooperative Institute for Arctic Research Cooperative Agreement NA17RJ1224. Additional support was provided by the James M. and Ruth P. Clark Arctic Research Initiative Fund at the Woods Hole Oceanographic Institution

Aquatic biosurvey of the Lovell River on UNH land

We assessed the physical, chemical and biological conditions at two sites along the Lovell River on University of New Hampshire (UNH) -owned conservation land. The discharge was 4.4 m3 s-1 at Site 1 and 5.7 m3 s -1 downstream at Site 2. Canopy coverage ranged from 8-25%. Canopy was dominated by Eastern Hemlock (79-84%). Much of the stream was strewn with large boulders and the substrate consisted of rocks of highly variable sizes ( 3-549 cm dia.). Specific conductivity (22.1-23.3 µS), pH (6.4) and temperature (7.9-8.3 °C) varied little between sites. Macro-invertebrate bio-indices indicated either excellent water quality with no apparent organic pollution (3.0/10) or good water quality with possible slight organic pollution (4.4/10)

“We Don’t Get Into All That”: an analysis of how teachers uphold heteronormative sex and relationship education

Legislation that applies to UK SRE currently advocates inclusive provision. Given the nonstatutory status of SRE, however, it is unclear how teachers incorporate sexual inclusivity, especially as research has shown that teachers’ discursive practices can promote a heteronormative SRE climate (Renn, 2010). Using a discursive psychological approach to analyze interview data, this study examined how teachers account for their provision as inclusive. It was revealed that even when promoting their inclusivity, teachers’ SRE provision upholds heteronormativity. In doing this, they positioned LGB and same-sex practices outside of the classroom, potentially leaving these young people without a sufficient sex education

Miniaturised SH EMATs for fast robotic screening of wall thinning in steel plates

Electromagnetic acoustic transducers (EMATs) are well suited to generating and detecting a variety of different ultrasonic wavemodes, without the need for couplant, and they can be operated through some coatings. EMATs can be used to generate shear horizontal (SH) waves, which show promise for fast screening of wall thinning and other defects. However, commercial SH-wave EMATs are not suitable for robotic implementation on ferritic steel due to the large magnetic drag force from the magnets. This article describes the design and characterisation of miniaturised SH guided wave EMATs, which significantly reduce the magnetic drag and enable mounting onto a small crawler robot for sample scanning. The performance of the miniaturised EMATs is characterised and compared to a commercial EMAT. It is shown that signal to noise ratio is reduced, but remains within an acceptable range to use on steel. The bandwidth and directivity are increased, depending on the exact design used. Their ability to detect flat bottomed holes mimicking wall thinning is also tested

Mendelian randomization study of B-type natriuretic peptide and type 2 diabetes: evidence of causal association from population studies

<p>Background: Genetic and epidemiological evidence suggests an inverse association between B-type natriuretic peptide (BNP) levels in blood and risk of type 2 diabetes (T2D), but the prospective association of BNP with T2D is uncertain, and it is unclear whether the association is confounded.</p> <p>Methods and Findings: We analysed the association between levels of the N-terminal fragment of pro-BNP (NT-pro-BNP) in blood and risk of incident T2D in a prospective case-cohort study and genotyped the variant rs198389 within the BNP locus in three T2D case-control studies. We combined our results with existing data in a meta-analysis of 11 case-control studies. Using a Mendelian randomization approach, we compared the observed association between rs198389 and T2D to that expected from the NT-pro-BNP level to T2D association and the NT-pro-BNP difference per C allele of rs198389. In participants of our case-cohort study who were free of T2D and cardiovascular disease at baseline, we observed a 21% (95% CI 3%-36%) decreased risk of incident T2D per one standard deviation (SD) higher log-transformed NT-pro-BNP levels in analysis adjusted for age, sex, body mass index, systolic blood pressure, smoking, family history of T2D, history of hypertension, and levels of triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. The association between rs198389 and T2D observed in case-control studies (odds ratio = 0.94 per C allele, 95% CI 0.91-0.97) was similar to that expected (0.96, 0.93-0.98) based on the pooled estimate for the log-NT-pro-BNP level to T2D association derived from a meta-analysis of our study and published data (hazard ratio = 0.82 per SD, 0.74-0.90) and the difference in NT-pro-BNP levels (0.22 SD, 0.15-0.29) per C allele of rs198389. No significant associations were observed between the rs198389 genotype and potential confounders.</p> <p>Conclusions: Our results provide evidence for a potential causal role of the BNP system in the aetiology of T2D. Further studies are needed to investigate the mechanisms underlying this association and possibilities for preventive interventions.</p&gt

Evaluation of stroke services in Anglia Stroke Clinical Network to examine the variation in acute services and stroke outcomes.

BACKGROUND: Stroke is the third leading cause of death in developed countries and the leading cause of long-term disability worldwide. A series of national stroke audits in the UK highlighted the differences in stroke care between hospitals. The study aims to describe variation in outcomes following stroke and to identify the characteristics of services that are associated with better outcomes, after accounting for case mix differences and individual prognostic factors. METHODS/DESIGN: We will conduct a cohort study in eight acute NHS trusts within East of England, with at least one year of follow-up after stroke. The study population will be a systematically selected representative sample of patients admitted with stroke during the study period, recruited within each hospital. We will collect individual patient data on prognostic characteristics, health care received, outcomes and costs of care and we will also record relevant characteristics of each provider organisation. The determinants of one year outcome including patient reported outcome will be assessed statistically with proportional hazards regression models. Self (or proxy) completed EuroQol (EQ-5D) questionnaires will measure quality of life at baseline and follow-up for cost utility analyses. DISCUSSION: This study will provide observational data about health service factors associated with variations in patient outcomes and health care costs following hospital admission for acute stroke. This will form the basis for future RCTs by identifying promising health service interventions, assessing the feasibility of recruiting and following up trial patients, and provide evidence about frequency and variances in outcomes, and intra-cluster correlation of outcomes, for sample size calculations. The results will inform clinicians, public, service providers, commissioners and policy makers to drive further improvement in health services which will bring direct benefit to the patients.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

'I was just gobsmacked': care workers responses to BBC Panoramas 'Undercover care: the abuse exposed': invoking mental states as a means of distancing from abusive practices

This paper draws upon discourse analytic techniques and discursive psychology to examine how care workers build accounts of viewing the BBC Panorama programme “Undercover Care: The Abuse Exposed” which graphically documented the abuse of people with learning disabilities in a residential care setting. 56 interviews were conducted as part of a project concerning adult safeguarding. The analysis considers how careworkers report their reactions and the interactional strategies they use to construct themselves as shocked and disbelieving and thus, as oppositional to the extreme practices in the programme. Their role as careworkers, and therefore as ‘insiders’ of the industry that allowed such abuse to happen, makes matters of stake and agency live issues for this particular group; and constructions of ‘shock’ and ‘disbelief’ are potential ways for participants to distance themselves from the abuse shown in the programme. More broadly, these data show how the invocation of mental states contributes to the management of other discursive business, namely, that of fending off any association with the aforementioned extreme practices