In the Interests of clients or commerce? Legal aid, supply, demand, and 'ethical indeterminacy' in criminal defence work

As a professional, a lawyer's first duty is to serve the client's best interests, before simple monetary gain. In criminal defence work, this duty has been questioned in the debate about the causes of growth in legal aid spending: is it driven by lawyers (suppliers) inducing unnecessary demand for their services or are they merely responding to increased demand? Research reported here found clear evidence of a change in the handling of cases in response to new payment structures, though in ways unexpected by the policy's proponents. The paper develops the concept of 'ethical indeterminacy' as a way of understanding how defence lawyers seek to reconcile the interests of commerce and clients. Ethical indeterminacy suggests that where different courses of action could each be said to benefit the client, the lawyer will tend to advise the client to decide in the lawyer's own interests. Ethical indeterminacy is mediated by a range of competing conceptions of 'quality' and 'need'. The paper goes on to question the very distinction between 'supply' and 'demand' in the provision of legal services

Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

Background: Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims: To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods: An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results: The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion: Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting

Preparation of Active Proteins, Vaccines and Pharmaceuticals as Fine Powders using Supercritical or Near-Critical Fluids

Supercritical or near-critical fluid processes for generating microparticles have enjoyed considerable attention in the past decade or so, with good success for substances soluble in supercritical fluids or organic solvents. In this review, we survey their application to the production of protein particles. A recently developed process known as CO2-assisted nebulization with a Bubble Dryer® (CAN-BD) has been demonstrated to have broad applicability to small-molecule as well as macromolecule substances (including therapeutic proteins). The principles of CAN-BD are discussed as well as the stabilization, micronization and drying of a wide variety of materials. More detailed case studies are presented for three proteins, two of which are of therapeutic interest: anti-CD4 antibody (rheumatoid arthritis), α1-antitrypsin (cystic fibrosis and emphysema), and trypsinogen (a model enzyme). Dry powders were formed in which stability and activity are maintained and which are fine enough to be inhaled and reach the deep lung. Enhancement of apparent activity after CAN-BD processing was also observed in some formulation and processing conditions

Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression - study protocol

<p>Abstract</p> <p>Background</p> <p>Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework.</p> <p>Methods/Design</p> <p>A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9.</p> <p>Discussion</p> <p>If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients.</p> <p>Trial Registration Number</p> <p>ISRCTN32829227</p

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Acupuncture and counselling for depression in primary care : a randomised controlled trial

Background: Depression is a significant cause of morbidity. Many patients have communicated an interest in nonpharmacological therapies to their general practitioners. Systematic reviews of acupuncture and counselling for depression in primary care have identified limited evidence. The aim of this study was to evaluate acupuncture versus usual care and counselling versus usual care for patients who continue to experience depression in primary care. Methods and Findings: In a randomised controlled trial, 755 patients with depression (Beck Depression Inventory BDI-II score $20) were recruited from 27 primary care practices in the North of England. Patients were randomised to one of three arms using a ratio of 2:2:1 to acupuncture (302), counselling (302), and usual care alone (151). The primary outcome was the difference in mean Patient Health Questionnaire (PHQ-9) scores at 3 months with secondary analyses over 12 months follow-up. Analysis was by intention-to-treat. PHQ-9 data were available for 614 patients at 3 months and 572 patients at 12 months. Patients attended a mean of ten sessions for acupuncture and nine sessions for counselling. Compared to usual care, there was a statistically significant reduction in mean PHQ-9 depression scores at 3 months for acupuncture (22.46, 95% CI 23.72 to 21.21) and counselling (21.73, 95% CI 23.00 to 20.45), and over 12 months for acupuncture (21.55, 95% CI 22.41 to 20.70) and counselling (21.50, 95% CI 22.43 to 20.58). Differences between acupuncture and counselling were not significant. In terms of limitations, the trial was not designed to separate out specific from non-specific effects. No serious treatment-related adverse events were reported. Conclusions: In this randomised controlled trial of acupuncture and counselling for patients presenting with depression, after having consulted their general practitioner in primary care, both interventions were associated with significantly reduced depression at 3 months when compared to usual care alone

VEROTILI – KÄYTTÖÖNOTON HAASTEELLISUUS

VEROTILI – KÄYTTÖÖNOTON HAASTEELLISUUS Opinnäytetyön tavoitteena oli tutkia mielipiteitä verotilistä sekä haasteita ja ongelmia, joita verotilijärjestelmän käyttöönotossa ilmeni käyttäjille, lähinnä pienyritysten näkökulmasta. Mielenkiintoinen tutkimuskysymys oli myös, miten yrittäjä sai informaatiota verotilijärjestelmästä ja selviytyy muutostilanteessa. Ongelmia ja haasteita tutkiessa on pyritty selvittämään myös sitä, mistä syystä nämä aiheutuivat. Tutkimuksessa on myös käsitelty, ovatko kyseiset asiat tiedostettu verohallinnossa ja millaisia muutosehdotuksia tai muutoksia on tähän mennessä tehty verotilijärjestelmään. Tutkimusaineistona käytettiin sekundaariaineistona yritysjärjestön teettämää kyselytutkimusta käyttäjille sekä muita lähteitä, kuten esimerkiksi verkkojulkaisuja sekä lehtiartikkeleita ja haastattelua. Kyselytutkimuksessa oli kysymyksiä, joihin oli valmiit vastausvaihtoehdot sekä kysymys mahdollisista haasteista ja ongelmista, johon saattoi vastata vapaasti. Tutkimuksessa yhdisteltiin sekä laadullisen että määrällisen tutkimuksen menetelmiä. Tutkimus osoittaa, että haasteita ja ongelmia on esiintynyt verotilijärjestelmään liittyen. Haasteet ja ongelmat saattavat olla yksilöllisiä, mutta pääosin ne ovat olleet yh-denmukaisia liittyen tunnistautumiseen sekä ilmoittamis- ja veronmaksun ajankohtiin. Oman ongelmansa ovat tuoneet veroista vähennettävät hyvitykset, miten niitä voi käyttää hyödykseen ja milloin. Pääosin verotilijärjestelmän käyttäjät pitävät järjestelmää entistä käytäntöä parempana ja byrokratiaa vähentävänä järjestelmänä, kun tietyt ongelmakohdat saadaan selvitettyä. Käyttöönotto tapahtui nopeasti lain vahvistamisen jälkeen tiukalla aikataululla, mikä tutkimuksen mukaan aiheutti eniten ongelmia verotilijärjestelmään siirryttäessä. Verotilijärjestelmän käyttäjät eivät saaneet tarpeeksi informaatiota järjestelmästä ennen siirtymistä, jotta olisivat voineet toimia, kuten järjestelmä edellyttää. Ohjeistus on ollut osin puutteellista, osin sekavaa. Tämä aiheutti ongelmia ja sekaannuksia, mikä on aiheuttanut lisätyötä sekä yrittäjille että verohallinnolle. Verotilijärjestelmässä ja Katso-tunnistautumisessa esiintyneet ongelmat toivat oman lisänsä ongelmiin. Tehdyn tutkimuksen perusteella voidaan sanoa, että verotilijärjestelmä ei ole vielä toiminut niin kuin odotettiin, eikä verotilijärjestelmän tavoitteisiin ole vielä kokonaisuudessaan päästy.THE TAX ACCOUNT – CHALLENGES OF INTRODUCTION ABSTRACT The objective of this thesis was to find out user’s opinions of the Tax Account system and also research challenges and problems, which appeared to using system, mainly perspective of small business companies. The interesting research question was how entrepreneurs and other small business companies got information from the Tax Account system and how they survived in situation of change. On researching challenges and problems has also tried to clarify which caused the problems. In the report has also handled, has the Tax Administration recognized these problems and what kind of changes or amendments has made concerning the Tax Account system so far. The research material consists of the inquiry as secondary material which business organization had made. The other research sources, which has used, were web publishings, journal articles and an interview. There were multiple questions in the inquiry which the answer alternatives had been ready defined and a question of possible challenges and problems in which man could answer openly with own words. Thus both quantitative and qualitative methods were combined in the research. The study shows that there have been challenges and problems in the introduction of the Tax Account system. The challenges and problems could be individuals, but mainly they have been consistent with the other sources. Most of problems are related to identification to Tax Account system and both report and tax payment timings. The own problem in the Tax Account system are those rebates which man can reduce from taxes; how man can use them and when. Most of users of the Tax Account system think that the new system is better than the old one and they also think that the new system reduces bureaucracy as the problems would be solved. After verifying the Tax Account Act was the introduction happened fast by tight timetable, which caused most of problems moving to the Tax Account system according to the study. The users of the Tax Account system don’t get enough information of the system before moving that they could act like the system demands. This caused problems and confusion, which again caused more work to companies and also to the Tax Administration. The problems in the Katso- identification and technical problems in the Tax Account system brought more problems. According to the study can it be said that the Tax Account system doesn’t yet operate like expected and to the objectives hadn’t been yet gotten