Jay Forrester

Jay Wright Forrester was an American engineer and management thinker. He founded System Dynamics, an approach based on computer modelling which arguably has done more than any other method to provide a practical and realistic analysis of change processes in systems. System Dynamics (SD) has been taken up across the world, initially by Forrester’s students and colleagues, but increasingly by a much wider community. It has had profound and influential applications in a range of fields, most prominently organisational management, urban planning and environmental policy. Forrester summed up his concerns and his understanding of SD in an ‘elevator pitch’ (a statement short enough to be spoken in an elevator ride) on an email list: System dynamics deals with how things change through time, which includes most of what most people find important. It uses computer simulation to take the knowledge we already have about details in the world around us and to show why our social and physical systems behave the way they do. System dynamics demonstrates how most of our own decision-making policies are the cause of the problems that we usually blame on others, and how to identify policies we can follow to improve our situation. (Forrester JW. System dynamics in the elevator. System-dynamics email list. https://www.ventanasystems.co.uk/forum/viewtopic.php?t=1787#p1964. Accessed 25 Sept 2019, 1997

Impact of proctoring on success rates for percutaneous revascularisation of coronary chronic total occlusions.

OBJECTIVE: To assess the impact of proctoring for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in six UK centres. METHODS: We retrospectively analysed 587 CTO procedures from six UK centres and compared success rates of operators who had received proctorship with success rates of the same operators before proctorship (pre-proctored) and operators in the same institutions who had not been proctored (non-proctored). There were 232 patients in the pre-proctored/non-proctored group and 355 patients in the post-proctored group. Complexity was assessed by calculating the Japanese CTO (JCTO) score for each case. RESULTS: CTO PCI success was greater in the post-proctored compared with the pre-proctored/non-proctored group (77.5% vs 62.1%, p<0.0001). In more complex cases where JCTO≥2, the difference in success was greater (70.7% vs 49.5%, p=0.0003). After proctoring, there was an increase in CTO PCI activity in centres from 2.5% to 3.5%, p<0.0001 (as a proportion of total PCI), and the proportion of very difficult cases with JCTO score ≥3 increased from 15.3% (35/229) to 29.7% (105/354), p<0.0001. CONCLUSIONS: Proctoring resulted in an increase in procedural success for CTO PCI, an increase in complex CTO PCI and an increase in total CTO PCI activity. Proctoring may be a valuable way to improve access to CTO PCI and the likelihood of procedural success

Analysis of clinical uncertainties by health professionals and patients: an example from mental health

<p>Abstract</p> <p>Background</p> <p>The first step in practising Evidence Based Medicine (EBM) has been described as translating clinical uncertainty into a structured and focused clinical question that can be used to search the literature to ascertain or refute that uncertainty. In this study we focus on questions about treatments for schizophrenia posed by mental health professionals and patients to gain a deeper understanding about types of questions asked naturally, and whether they can be reformulated into structured and focused clinical questions.</p> <p>Methods</p> <p>From a survey of uncertainties about the treatment of schizophrenia we describe, categorise and analyse the type of questions asked by mental health professionals and patients about treatment uncertainties for schizophrenia. We explore the value of mapping from an unstructured to a structured framework, test inter-rater reliability for this task, develop a linguistic taxonomy, and cross tabulate that taxonomy with elements of a well structured clinical question.</p> <p>Results</p> <p>Few of the 78 Patients and 161 clinicians spontaneously asked well structured queries about treatment uncertainties for schizophrenia. Uncertainties were most commonly about drug treatments (45.3% of clinicians and 41% of patients), psychological therapies (19.9% of clinicians and 9% of patients) or were unclassifiable.(11.8% of clinicians and 16.7% of patients). Few naturally asked questions could be classified using the well structured and focused clinical question format (i.e. PICO format). A simple linguistic taxonomy better described the types of questions people naturally ask.</p> <p>Conclusion</p> <p>People do not spontaneously ask well structured clinical questions. Other taxonomies may better capture the nature of questions. However, access to EBM resources is greatly facilitated by framing enquiries in the language of EBM, such as posing queries in PICO format. People do not naturally do this. It may be preferable to identify a way of searching the literature that more closely matches the way people naturally ask questions if access to information about treatments are to be made more broadly available.</p

MTN-001: Randomized Pharmacokinetic Cross-Over Study Comparing Tenofovir Vaginal Gel and Oral Tablets in Vaginal Tissue and Other Compartments

Background: Oral and vaginal preparations of tenofovir as pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) infection have demonstrated variable efficacy in men and women prompting assessment of variation in drug concentration as an explanation. Knowledge of tenofovir concentration and its active form, tenofovir diphosphate, at the putative vaginal and rectal site of action and its relationship to concentrations at multiple other anatomic locations may provide key information for both interpreting PrEP study outcomes and planning future PrEP drug development. Objective: MTN-001 was designed to directly compare oral to vaginal steady-state tenofovir pharmacokinetics in blood, vaginal tissue, and vaginal and rectal fluid in a paired cross-over design. Methods and Findings: We enrolled 144 HIV-uninfected women at 4 US and 3 African clinical research sites in an open label, 3-period crossover study of three different daily tenofovir regimens, each for 6 weeks (oral 300 mg tenofovir disoproxil fumarate, vaginal 1% tenofovir gel [40 mg], or both). Serum concentrations after vaginal dosing were 56-fold lower than after oral dosing (p<0.001). Vaginal tissue tenofovir diphosphate was quantifiable in ≥90% of women with vaginal dosing and only 19% of women with oral dosing. Vaginal tissue tenofovir diphosphate was ≥130-fold higher with vaginal compared to oral dosing (p<0.001). Rectal fluid tenofovir concentrations in vaginal dosing periods were higher than concentrations measured in the oral only dosing period (p<0.03). Conclusions: Compared to oral dosing, vaginal dosing achieved much lower serum concentrations and much higher vaginal tissue concentrations. Even allowing for 100-fold concentration differences due to poor adherence or less frequent prescribed dosing, vaginal dosing of tenofovir should provide higher active site concentrations and theoretically greater PrEP efficacy than oral dosing; randomized topical dosing PrEP trials to the contrary indicates that factors beyond tenofovir's antiviral effect substantially influence PrEP efficacy. Trial Registration: ClinicalTrials.gov NCT00592124

Country differences in the diagnosis and management of coronary heart disease : a comparison between the US, the UK and Germany

Background The way patients with coronary heart disease (CHD) are treated is partly determined by non-medical factors. There is a solid body of evidence that patient and physician characteristics influence doctors' management decisions. Relatively little is known about the role of structural issues in the decision making process. This study focuses on the question whether doctors' diagnostic and therapeutic decisions are influenced by the health care system in which they take place. This non-medical determinant of medical decision-making was investigated in an international research project in the US, the UK and Germany. Methods Videotaped patients within an experimental study design were used. Experienced actors played the role of patients with symptoms of CHD. Several alternative versions were taped featuring the same script with patients of different sex, age and social status. The videotapes were shown to 384 randomly selected primary care physicians in the three countries under study. The sample was stratified on gender and duration of professional experience. Physicians were asked how they would diagnose and manage the patient after watching the video vignette using a questionnaire with standardised and open-ended questions. Results Results show only small differences in decision making between British and American physicians in essential aspects of care. About 90% of the UK and US doctors identified CHD as one of the possible diagnoses. Further similarities were found in test ordering and lifestyle advice. Some differences between the US and UK were found in the certainty of the diagnoses, prescribed medications and referral behaviour. There are numerous significant differences between Germany and the other two countries. German physicians would ask fewer questions, they would order fewer tests, prescribe fewer medications and give less lifestyle advice. Conclusion Although all physicians in the three countries under study were presented exactly the same patient, some disparities in the diagnostic and patient management decisions were evident. Since other possible influences on doctors treatment decisions are controlled within the experimental design, characteristics of the health care system seem to be a crucial factor within the decision making process

The role of ethnicity in the attainment and experiences of graduates in distance education

In the UK, the attainment of White graduates (as measured by the class of honours that they have been awarded) tends to be higher than that of graduates from other ethnic groups. This is apparent, in particular, in graduates who have taken courses by distance learning with the Open University. Analysis of data from Open University graduates over three successive years yielded no evidence that the latter trend could be attributed to confounded demographic variables. A postal survey found little variation in perceptions of academic quality or reports of personal development among Open University graduates from different ethnic groups. Quantitative variations in the attainment of graduates from different ethnic groups are not necessarily reflected in qualitative variations in their experience of distance education

Hygienic characteristics of radishes grown in soil contaminated with Stenotrophomonas maltophilia

Background: Stenotrophomonas maltophilia is a plant growth-promoter. This bacterium is also implicated in human diseases. Thus, after the use of this bacterium in agriculture, the safety of the final products has to be verified. Due to the ubiquitous presence of S. maltophilia in soil, in this study a massive contamination was simulated to evaluate the growth and safety of Raphanus sativus L.. Results: Different inoculums and soil treatment conditions were tested. Soils were analysed weekly and the radishes at harvest for their microbial loads and presence/persistence of S. maltophilia LMG 6606. The concentration of the bacterium added in the different trials decreased during the first week, but increased thereafter and determined a significant increase of growth parameters of radishes. Conclusions: The addition of S. maltophilia LMG 6606 to non-autoclaved soil enhanced the productivity of radishes. The bacterium did not internalize in the hypocotyls, but colonized the external surface ensuring the safety of the products. Thus, a sanitizing bath of hypocotyls before consumption is necessary