Exposing the evidence gap for complementary and alternative medicine to be integrated into science-based medicine.

When people who advocate integrating conventional science-based medicine with complementary and alternative medicine (CAM) are confronted with the lack of evidence to support CAM they counter by calling for more research, diverting attention to the 'package of care' and its non-specific effects, and recommending unblinded 'pragmatic trials'. We explain why these responses cannot close the evidence gap, and focus on the risk of biased results from open (unblinded) pragmatic trials. These are clinical trials which compare a treatment with 'usual care' or no additional care. Their risk of bias has been overlooked because the components of outcome measurements have not been taken into account. The components of an outcome measure are the specific effect of the intervention and non-specific effects such as true placebo effects, cognitive measurement biases, and other effects (which tend to cancel out when similar groups are compared). Negative true placebo effects ('frustrebo effects') in the comparison group, and cognitive measurement biases in the comparison group and the experimental group make the non-specific effect look like a benefit for the intervention group. However, the clinical importance of these effects is often dismissed or ignored without justification. The bottom line is that, for results from open pragmatic trials to be trusted, research is required to measure the clinical importance of true placebo effects, cognitive bias effects, and specific effects of treatments

A postal survey to identify and describe nurse led clinics in genitourinary medicine services across England

Background: Nurses in genitourinary medicine (GUM) services are progressively extending their roles to conduct "comprehensive care" nurse led clinics. In such roles the nurse coordinates the first line, comprehensive care of patients presenting with sexual health conditions and issues. Objectives: To identify and describe comprehensive care nurse led clinics in GUM services across England. Methods: A postal questionnaire consisting of 17 closed response questions was sent to 209 GUM services across England. A second questionnaire was sent to non-responders to increase the response rate. Data were single entered and analysed using SPSS. Results: Of the 190 GUM clinic respondents (91% response rate), 44 (23%) reported providing some form of comprehensive care nurse led clinic, 90% of which were initiated since 1995. Key results show staff development featured as the main reason for initiating such services and there was general consistency in the aspects of care undertaken by these nurses. There was evidence of guideline development specific to nurse led care and some patient group direction use for supplying medication. The level of support from medical staff while nurse led clinics were being conducted varied between services. Few services have conducted any audit or research to monitor/evaluate nurse led care. There was little consistency in the clinical experience and educational prerequisites to undertake comprehensive care nurse led clinics. Continuing professional development opportunities also varied between services. Conclusions: The steady growth of comprehensive care nurse led clinics indicates that the skills of GUM nurses are being recognised. Nurses working in advanced practice roles now require courses and study days reflecting these changes in practice. Locally agreed practice guidelines can define nursing practice boundaries and ensure accountability, as will the development of patient group directions to supply medication. Monitoring and evaluation of nurse led clinics also require attention

Large--Scale Outflows in Galaxies

We discuss massive outflows in galaxy bulges, particularly ones driven by accretion episodes where the central supermassive black hole reaches the Eddington limit. We show that the quasar radiation field Compton--cools the wind shock until this reaches distances $\sim 1$ kpc from the black hole, but becomes too dilute to do this at larger radii. Radiative processes cannot cool the shocked gas within the flow time at any radius. Outflows are therefore momentum-driven at small radii (as required to explain the $M - \sigma$ relation). At large radii they are energy-driven, contrary to recent claims. We solve analytically the motion of an energy--driven shell after the central source has turned off. This shows that the thermal energy in the shocked wind can drive further expansion for a time $\sim 10$ times longer than the active time of the central source. Outflows observed at large radii with no active central source probably result from an earlier short (few Myr) active phase of this source.Comment: 5 pages, 2 figures, accepted for publication in MNRA

When care is left to roam: Carers' experiences of grassroots nonprofit services in Ireland

Increasingly countries are turning to nonprofit organisations to provide health and social care, particularly for people with disabilities. Alongside this change, debates continue about how states should manage the relationship with such organisations. Should features of the old-style "welfare" model be retained? Should aspects of the "new public management" model be chosen to measure the impact of the work? Yet others argue that grassroots organisations should form the basis of a service provision system. In the context of these debates, Ireland serves as an interesting case study of the system of care that can emerge when the state operates a "relaxed control" approach. This paper takes the perspectives of users themselves: family carers who are accessing services for a disabled adult child, to examine the effects of this approach on the ground. We show how geography played a central role in shaping these experiences, and discuss how we can learn from the Irish context. Rather than arguing for narrowly defined contractual measures, we conclude by proposing a renewed focus on relationship building with the aim of effective system operation, in the future of care services

Reflexivity of the translation-dilation algebras on L^2(R)

The hyperbolic algebra A_h, studied recently by Katavolos and Power, is the weak star closed operator algebra on L^2(R) generated by H^\infty(R), as multiplication operators, and by the dilation operators V_t, t \geq 0, given by V_t f(x) = e^{t/2} f(e^t x). We show that A_h is a reflexive operator algebra and that the four dimensional manifold Lat A_h (with the natural topology) is the reflexive hull of a natural two dimensional subspace.Comment: 10 pages, no figures To appear in the International Journal of Mathematic

Guiding of Rydberg atoms in a high-gradient magnetic guide

We study the guiding of $^{87}$Rb 59D$_{5/2}$ Rydberg atoms in a linear, high-gradient, two-wire magnetic guide. Time delayed microwave ionization and ion detection are used to probe the Rydberg atom motion. We observe guiding of Rydberg atoms over a period of 5 ms following excitation. The decay time of the guided atom signal is about five times that of the initial state. We attribute the lifetime increase to an initial phase of $l$-changing collisions and thermally induced Rydberg-Rydberg transitions. Detailed simulations of Rydberg atom guiding reproduce most experimental observations and offer insight into the internal-state evolution