The self-extinguishing despot: Millian Democratization

Although there is no more iconic, stalwart, and eloquent defender of liberty and representative democracy than J. S. Mill, he sometimes endorses nondemocratic forms of governance. This article explains the reasons behind this seeming aberration and shows that Mill actually has complex and nuanced views of the transition from nondemocratic to democratic government, including the comprehensive and parallel material, cultural, institutional, and character reforms that must occur, and the mechanism by which they will be enacted. Namely, an enlightened despot must cultivate democratic virtues such as obedience, industriousness, spirit of nationality, and resistance to tyranny in the population and simultaneously prepare the way for his own demise and secure his own legitimacy by transitioning to the rule of law. This challenges recent scholarship that paints Mill's nondemocratic views as crudely and uncritically imperialist, because it fails to recognize and engage seriously with his sophisticated (if ultimately problematic) theory of individual and institutional development under enlightened colonialism. © Copyright Southern Political Science Association 2011.published_or_final_versio

Predictors of pain relief following spinal cord stimulation in chronic back and leg pain and failed back surgery syndrome: a systematic review and meta-regression analysis

This is the final version of the article. Available from the publisher via the DOI in this record.We sought to assess the extent to which pain relief in chronic back and leg pain (CBLP) following spinal cord stimulation (SCS) is influenced by patient-related factors, including pain location, and technology factors. A number of electronic databases were searched with citation searching of included papers and recent systematic reviews. All study designs were included. The primary outcome was pain relief following SCS, we also sought pain score (pre- and post-SCS). Multiple predictive factors were examined: location of pain, history of back surgery, initial level of pain, litigation/worker's compensation, age, gender, duration of pain, duration of follow-up, publication year, continent of data collection, study design, quality score, method of SCS lead implant, and type of SCS lead. Between-study association in predictive factors and pain relief were assessed by meta-regression. Seventy-four studies (N = 3,025 patients with CBLP) met the inclusion criteria; 63 reported data to allow inclusion in a quantitative analysis. Evidence of substantial statistical heterogeneity (P < 0.0001) in level of pain relief following SCS was noted. The mean level of pain relief across studies was 58% (95% CI: 53% to 64%, random effects) at an average follow-up of 24 months. Multivariable meta-regression analysis showed no predictive patient or technology factors. SCS was effective in reducing pain irrespective of the location of CBLP. This review supports SCS as an effective pain relieving treatment for CBLP with predominant leg pain with or without a prior history of back surgery. Randomized controlled trials need to confirm the effectiveness and cost-effectiveness of SCS in the CLBP population with predominant low back pain.This study was sponsored by Medtronic, Inc

Disease management interventions for heart failure.

BACKGROUND: Despite advances in treatment, the increasing and ageing population makes heart failure an important cause of morbidity and death worldwide. It is associated with high healthcare costs, partly driven by frequent hospital readmissions. Disease management interventions may help to manage people with heart failure in a more proactive, preventative way than drug therapy alone. This is the second update of a review published in 2005 and updated in 2012. OBJECTIVES: To compare the effects of different disease management interventions for heart failure (which are not purely educational in focus), with usual care, in terms of death, hospital readmissions, quality of life and cost-related outcomes. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL for this review update on 9 January 2018 and two clinical trials registries on 4 July 2018. We applied no language restrictions. SELECTION CRITERIA: We included randomised controlled trials (RCTs) with at least six months' follow-up, comparing disease management interventions to usual care for adults who had been admitted to hospital at least once with a diagnosis of heart failure. There were three main types of intervention: case management; clinic-based interventions; multidisciplinary interventions. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Outcomes of interest were mortality due to heart failure, mortality due to any cause, hospital readmission for heart failure, hospital readmission for any cause, adverse effects, quality of life, costs and cost-effectiveness. MAIN RESULTS: We found 22 new RCTs, so now include 47 RCTs (10,869 participants). Twenty-eight were case management interventions, seven were clinic-based models, nine were multidisciplinary interventions, and three could not be categorised as any of these. The included studies were predominantly in an older population, with most studies reporting a mean age of between 67 and 80 years. Seven RCTs were in upper-middle-income countries, the rest were in high-income countries.Only two multidisciplinary-intervention RCTs reported mortality due to heart failure. Pooled analysis gave a risk ratio (RR) of 0.46 (95% confidence interval (CI) 0.23 to 0.95), but the very low-quality evidence means we are uncertain of the effect on mortality due to heart failure. Based on this limited evidence, the number needed to treat for an additional beneficial outcome (NNTB) is 12 (95% CI 9 to 126).Twenty-six case management RCTs reported all-cause mortality, with low-quality evidence indicating that these may reduce all-cause mortality (RR 0.78, 95% CI 0.68 to 0.90; NNTB 25, 95% CI 17 to 54). We pooled all seven clinic-based studies, with low-quality evidence suggesting they may make little to no difference to all-cause mortality. Pooled analysis of eight multidisciplinary studies gave moderate-quality evidence that these probably reduce all-cause mortality (RR 0.67, 95% CI 0.54 to 0.83; NNTB 17, 95% CI 12 to 32).We pooled data on heart failure readmissions from 12 case management studies. Moderate-quality evidence suggests that they probably reduce heart failure readmissions (RR 0.64, 95% CI 0.53 to 0.78; NNTB 8, 95% CI 6 to 13). We were able to pool only two clinic-based studies, and the moderate-quality evidence suggested that there is probably little or no difference in heart failure readmissions between clinic-based interventions and usual care (RR 1.01, 95% CI 0.87 to 1.18). Pooled analysis of five multidisciplinary interventions gave low-quality evidence that these may reduce the risk of heart failure readmissions (RR 0.68, 95% CI 0.50 to 0.92; NNTB 11, 95% CI 7 to 44).Meta-analysis of 14 RCTs gave moderate-quality evidence that case management probably slightly reduces all-cause readmissions (RR 0.92, 95% CI 0.83 to 1.01); a decrease from 491 to 451 in 1000 people (95% CI 407 to 495). Pooling four clinic-based RCTs gave low-quality and somewhat heterogeneous evidence that these may result in little or no difference in all-cause readmissions (RR 0.90, 95% CI 0.72 to 1.12). Low-quality evidence from five RCTs indicated that multidisciplinary interventions may slightly reduce all-cause readmissions (RR 0.85, 95% CI 0.71 to 1.01); a decrease from 450 to 383 in 1000 people (95% CI 320 to 455).Neither case management nor clinic-based intervention RCTs reported adverse effects. Two multidisciplinary interventions reported that no adverse events occurred. GRADE assessment of moderate quality suggested that there may be little or no difference in adverse effects between multidisciplinary interventions and usual care.Quality of life was generally poorly reported, with high attrition. Low-quality evidence means we are uncertain about the effect of case management and multidisciplinary interventions on quality of life. Four clinic-based studies reported quality of life but we could not pool them due to differences in reporting. Low-quality evidence indicates that clinic-based interventions may result in little or no difference in quality of life.Four case management programmes had cost-effectiveness analyses, and seven reported cost data. Low-quality evidence indicates that these may reduce costs and may be cost-effective. Two clinic-based studies reported cost savings. Low-quality evidence indicates that clinic-based interventions may reduce costs slightly. Low-quality data from one multidisciplinary intervention suggested this may be cost-effective from a societal perspective but less so from a health-services perspective. AUTHORS' CONCLUSIONS: We found limited evidence for the effect of disease management programmes on mortality due to heart failure, with few studies reporting this outcome. Case management may reduce all-cause mortality, and multidisciplinary interventions probably also reduce all-cause mortality, but clinic-based interventions had little or no effect on all-cause mortality. Readmissions due to heart failure or any cause were probably reduced by case-management interventions. Clinic-based interventions probably make little or no difference to heart failure readmissions and may result in little or no difference in readmissions for any cause. Multidisciplinary interventions may reduce the risk of readmission for heart failure or for any cause. There was a lack of evidence for adverse effects, and conclusions on quality of life remain uncertain due to poor-quality data. Variations in study location and time of occurrence hamper attempts to review costs and cost-effectiveness.The potential to improve quality of life is an important consideration but remains poorly reported. Improved reporting in future trials would strengthen the evidence for this patient-relevant outcome

Critical appraisal skills training for health care professionals: a randomized controlled trial [ISRCTN46272378].

This is the final version of the article. Available from BioMed Central via the DOI in this record.INTRODUCTION: Critical appraisal skills are believed to play a central role in an evidence-based approach to health practice. The aim of this study was to evaluate the effectiveness and costs of a critical appraisal skills educational intervention aimed at health care professionals. METHODS: This prospective controlled trial randomized 145 self-selected general practitioners, hospital physicians, professions allied to medicine, and healthcare managers/administrators from the South West of England to a half-day critical appraisal skills training workshop (based on the model of problem-based small group learning) or waiting list control. The following outcomes were assessed at 6-months follow up: knowledge of the principles necessary for appraising evidence; attitudes towards the use of evidence about healthcare; evidence seeking behaviour; perceived confidence in appraising evidence; and ability to critically appraise a systematic review article. RESULTS: At follow up overall knowledge score [mean difference: 2.6 (95% CI: 0.6 to 4.6)] and ability to appraise the results of a systematic review [mean difference: 1.2 (95% CI: 0.01 to 2.4)] were higher in the critical skills training group compared to control. No statistical significant differences in overall attitude towards evidence, evidence seeking behaviour, perceived confidence, and other areas of critical appraisal skills ability (methodology or generalizability) were observed between groups. Taking into account the workshop provision costs and costs of participants time and expenses of participants, the average cost of providing the critical appraisal workshops was approximately pound 250 per person. CONCLUSIONS: The findings of this study challenge the policy of funding 'one-off' educational interventions aimed at enhancing the evidence-based practice of health care professionals. Future evaluations of evidence-based practice interventions need to take in account this trial's negative findings and methodological difficulties.NHS R&D Executive: Evaluating methods to practice the implementation of R&D [project no. IMP 12-9

Board Roles in Nonprofit Sport Organisations with a Dual Board System

Governance is a critical component of the effective management of a nonprofit sport organisation. Boards in this governance system play an important role to guide their organisations. While a number of agencies have provided documents of what boards should perform in their organisations, these documents remain descriptive. Empirical research on board roles particularly in a dual board system has been deficient. The purpose of this research therefore was to empirically investigate board roles in nonprofit sport organisations with a dual board system in Taiwan. 158 directors and 103 supervisors from 24 nonprofit sport organisations completed questionnaire regarding board roles. Two factor analyses were conducted. A 20-variable/4-factor scale of roles of directors and a 9-variable/2-factor scale of roles of supervisors were generated. Several conclusions were made based on results of this stud

True Neutrality as a New Type of Flavour

A classification of leptonic currents with respect to C-operation requires the separation of elementary particles into the two classes of vector C-even and axial-vector C-odd character. Their nature has been created so that to each type of lepton corresponds a kind of neutrino. Such pairs are united in families of a different C-parity. Unlike the neutrino of a vector type, any C-noninvariant Dirac neutrino must have his Majorana neutrino. They constitute the purely neutrino families. We discuss the nature of a corresponding mechanism responsible for the availability in all types of axial-vector particles of a kind of flavour which distinguishes each of them from others by a true charge characterized by a quantum number conserved at the interactions between the C-odd fermion and the field of emission of the corresponding types of gauge bosons. This regularity expresses the unidenticality of truly neutral neutrino and antineutrino, confirming that an internal symmetry of a C-noninvariant particle is described by an axial-vector space. Thereby, a true flavour together with the earlier known lepton flavour predicts the existence of leptonic strings and their birth in single and double beta decays as a unity of flavour and gauge symmetry laws. Such a unified principle explains the availability of a flavour symmetrical mode of neutrino oscillations.Comment: 19 pages, LaTex, Published version in IJT

Effect of exercise referral schemes in primary care on physical activity and improving health outcomes: Systematic review and meta-analysis

This is an open access article - Copyright @ 2011 BMJObjective: To assess the impact of exercise referral schemes on physical activity and health outcomes. Design: Systematic review and meta-analysis. Data sources Medline, Embase, PsycINFO, Cochrane Library, ISI Web of Science, SPORTDiscus, and ongoing trial registries up to October 2009. We also checked study references. Study selection Design: randomised controlled trials or non-randomised controlled (cluster or individual) studies published in peer review journals. Population: sedentary individuals with or without medical diagnosis. Exercise referral schemes defined as: clear referrals by primary care professionals to third party service providers to increase physical activity or exercise, physical activity or exercise programmes tailored to individuals, and initial assessment and monitoring throughout programmes. Comparators: usual care, no intervention, or alternative exercise referral schemes. Results Eight randomised controlled trials met the inclusion criteria, comparing exercise referral schemes with usual care (six trials), alternative physical activity intervention (two), and an exercise referral scheme plus a self determination theory intervention (one). Compared with usual care, follow-up data for exercise referral schemes showed an increased number of participants who achieved 90-150 minutes of physical activity of at least moderate intensity per week (pooled relative risk 1.16, 95% confidence intervals 1.03 to 1.30) and a reduced level of depression (pooled standardised mean difference −0.82, −1.28 to −0.35). Evidence of a between group difference in physical activity of moderate or vigorous intensity or in other health outcomes was inconsistent at follow-up. We did not find any difference in outcomes between exercise referral schemes and the other two comparator groups. None of the included trials separately reported outcomes in individuals with specific medical diagnoses. Substantial heterogeneity in the quality and nature of the exercise referral schemes across studies might have contributed to the inconsistency in outcome findings. Conclusions Considerable uncertainty remains as to the effectiveness of exercise referral schemes for increasing physical activity, fitness, or health indicators, or whether they are an efficient use of resources for sedentary people with or without a medical diagnosis.This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number 08/72/01) (www.hta.ac.uk/)

Changes in the severity and subtype of Guillain-Barré syndrome admitted to a specialist Neuromedical ICU over a 25 year period

We report a retrospective review of 110 patients with acute Guillain-Barré syndrome (GBS) admitted to a specialised intensive care unit (ICU) in a tertiary referral centre over a 25 year period, the start of which coincided with the widespread introduction of plasma exchange (PE) and intravenous immunoglobulin (IVIG). The results were analysed by comparing 52 patients admitted in the first decade (1991-2000; Group 1) with 58 patients admitted between 2001-2014 (Group 2). Patients in both groups were comparable with respect to age and sex, and had a similar incidence and range of ICU complications. They received a comparable range of immunomodulatory treatments including IVIG and PE. However, the delay from presentation to referral to the tertiary ICU was longer in patients in Group 2. They also required mechanical ventilation for a longer duration, and had longer ICU and hospital stays. In Group 2, there was a higher incidence of axonal neuropathy (51%, compared to 24% in Group 1). Despite the longer delay to referral, the prevalence of axonal neuropathy and the duration of ventilation, overall mortality showed a downward trend (Group 1: 13.5%; Group 2: 5.2%). There was no late mortality in either group after step-down to neuro-rehabilitation or following discharge home or to the referring hospital. The rehabilitation outcomes were similar. This data show a shift in the pattern of referral to a tertiary referral ICU between the first and second decades following the wider availability of IVIG and PE for the treatment of GBS. The possible causes and implications of these findings are discussed

Integumentary remains and abdominal contents in the Early Cretaceous Chinese lizard, Yabeinosaurus (Squamata), demonstrate colour banding and a diet including crayfish

The Early Cretaceous lizard Yabeinosaurus is well-represented in the Jehol Biota of northeast China, with specimens yielding information on ontogenetic development, reproductive strategy, and diet, as well as skeletal morphology. However, a large, well-preserved, new specimen of Yabeinosaurus robustus from the Lamadong locality, Liaoning, provides further insights into the morphology and biology of this species. Integumentary traces demonstrate that, in life, Y. robustus was coloured with well-defined light and dark banding through both the body and the tail. The integumentary traces also confirm that Yabeinosaurus was covered with thin, non-overlapping osteoderms. Previous specimens have contained fish remains, suggesting that Yabeinosaurus foraged in, or close, to the water. The new specimen supports that hypothesis as it contains the remains of a large crayfish, identified as belonging to the species Palaeocambarus licenti Taylor et al. 1999. Body parts of the crayfish provide an estimated original total length of 120–140 mm

One size does not fit all - Application of accelerometer thresholds in chronic disease

This is the author accepted manuscript. The final version is available from Oxford University Press via the DOI in this record National Institute for Health Research (NIHR