Crossing the Bridge of Size: Reaching a Deal at Nice

The Intergovernmental Conference which should conclude at Nice in December 2000 deals with issues of institutional reform which must be resolved before proceeding with enlargement. There are four main questions. Should all countries be able to name a Member of the European Commission, or should the number of Commissioners be ‘capped’ at a number lower than the number of Member States? How should the weighting of Member States’ votes in the Council be adjusted to ensure that winning coalitions under qualified-majority voting represent an adequate proportion of the total EU population – as well as to ‘compensate’ those five Member States which lose their second Commissioner? How far should qualified-majority voting be extended? Should the conditions for ‘closer cooperation’ be relaxed to make it easier to press ahead with integration in particular areas without the participation of all Member States? A deal must be reached at Nice, but the IGC has revealed serious differences between the Member States. There is likely to be an agreement: for one Commissioner per Member State, probably with an internal hierarchy; a significant reweighting of votes in favour of the big Member States; a moderate extension of qualified-majority voting; and at least the removal of the veto regarding closer cooperation. Yet relative size has emerged as a source of frictions and concerns about long-term solidarity. The big countries fear being tied down. The smaller ones have long-term concerns about being dominated or absorbed, as well as presentational problems. If all the results of the IGC are seen as concessions to the large countries, it will be hard to sell the Nice Treaty at home – and Denmark has again shown that people can say No. Too much intergovernmentalism is not the answer. The Community institutions cannot do everything, but they have played an essential role in overcoming fears about relative power. They need to be renewed, not replaced

Citizen Involvement in EU Policies: Impossible Dream or Work in Progress?

As the European Union has enlarged in terms of its membership, and expanded in terms of its competences, the idea of direct citizen participation in European policy-making has become both more important and more difficult. Given that many decisions are being taken at a level directly affecting over 500 million persons, and that EU institutional arrangements are so complex, is it really possible that citizens can become effectively engaged in EU decision-making? The Lisbon Treaty has introduced the European Citizens' Initiative (ECI) as one means to help involve citizens directly in EU issues. This contribution looks at the precise nature of the ECI as finally agreed. It places the ECI in the context of broader political trends, and argues that the new mechanism may not produce the specific results expected by its proponent but, even so, could well have a positive impact on the democratic deepening of the EU in other ways

What is Really at Stake in the Debate over Votes?

The December 2003 Brussels summit failed to agree on the draft Constitution for the EU which had been proposed by the European Convention. Spain and Poland rejected the proposal to move from the new voting arrangements agreed at Nice, which were still based mainly on weighted votes, to a system in which decisions could be adopted by a simple majority of states representing 60% of total population. The Nice arrangements are unnecessarily complex, whereas the dual majority is simpler and more efficient. Moreover, Spain and Poland have a special interest. They are very favourably treated under Nice, but are relative losers, compared to Germany and small states, in any move to a dual majority. Yet these countries’ weighting under Nice is not quite so disproportionate or inappropriate as is alleged, taking into account the characteristics of the EU system. Moreover, there are broader issues at stake. Does the EU still need weighted votes in order to maintain a balance between states? Are EU citizens ready for a system based largely on relative population? The best outcome on balance is to move to a dual majority, but only in November 2009 as proposed in the draft Constitution. This is not optimal from the perspective of efficiency. However, the EU can make use of this time to digest enlargement, establish its limits more clearly and conduct a more serious public debate, before introducing what would indeed be a major shift in the underlying premises of its institutional arrangements

Investigating the properties of AGN feedback in hot atmospheres triggered by cooling-induced gravitational collapse

Radiative cooling may plausibly cause hot gas in the centre of a massive galaxy, or galaxy cluster, to become gravitationally unstable. The subsequent collapse of this gas on a dynamical timescale can provide an abundant source of fuel for AGN heating and star formation. Thus, this mechanism provides a way to link the AGN accretion rate to the global properties of an ambient cooling flow, but without the implicit assumption that the accreted material must have flowed onto the black hole from 10s of kiloparsecs away. It is shown that a fuelling mechanism of this sort naturally leads to a close balance between AGN heating and the radiative cooling rate of the hot, X-ray emitting halo. Furthermore, AGN powered by cooling-induced gravitational instability would exhibit characteristic duty cycles (delta) which are redolent of recent observational findings: delta is proportional to L_X/sigma_{*}^{3}, where L_X is the X-ray luminosity of the hot atmosphere, and sigma_{*} is the central stellar velocity dispersion of the host galaxy. Combining this result with well-known scaling relations, we deduce a duty cycle for radio AGN in elliptical galaxies that is approximately proportional to M_{BH}^{1.5}, where M_{BH} is the central black hole mass. Outburst durations and Eddington ratios are also given. Based on the results of this study, we conclude that gravitational instability could provide an important mechanism for supplying fuel to AGN in massive galaxies and clusters, and warrants further investigation.Comment: Accepted for publication in MNRAS. 8 page

Characteristics and outcomes of referrals to CAMHS for children who are thinking about or attempted suicide: A retrospective cohort study in two Scottish CAMHS

Suicide among children and young people (CYP) is a leading cause of death. In the UK children identified as suicidal are referred to Child and Adolescent Mental Health Services (CAMHS) for assessment and treatment. However, the number of children referred for suicidality, and their care journey is unknown. This retrospective cohort study conducted in two distinct CAMHS teams, in Scotland, UK, aimed to quantify the numbers of children referred for suicidality, describing this population and the outcomes of these referrals. All CAMHS referrals (n = 1159) over a 6-month period (Jan-June 2019) were screened to identify those referred primarily for suicidality. Data extracted included: age, gender, source of referral, reason for referral including underlying issues, whether offered an assessment, and referral outcome. Area based deprivation scores were attached to each referral. Associations between the referred CYP's characteristics (including source of referral and underlying issues) and referral outcomes were explored using Chi Square, Fishers Exact test, and one-way ANOVA. Referrals for 284 children were identified as being for suicidality across the two sites (Site A n = 104; Site B n = 180). These represented 25% of all referrals to these CAMHS over a six-month period. One third of these concerned children under 12. The underlying issues, referrals sources, and demographic indicators were similar in both sites. In site A 31% were offered an assessment, whilst in Site B which had a dedicated team for suicidal CYP, 82% were offered an assessment. Similarly, more children in Site B were offered treatment (47.8%), than Site A (7.7%). Referrals from A&E were prioritized in both areas, and those who had attempted suicide offered an assessment more often. Older children were more likely to be offered treatment, although they were more likely to present with a history of self-harming behavior and/or previous suicide attempt. There are high numbers of children being referred to CAMHS for suicidality, and many are young children (<12). There is variation within and between services in terms of assessment, referral outcomes and care pathways for these children. Having a dedicated team to respond to referrals for suicidality appears to support access to assessment and treatment

Observable consequences of kinetic and thermal AGN feedback in elliptical galaxies and galaxy clusters

We have constructed an analytical model of AGN feedback and studied its implications for elliptical galaxies and galaxy clusters. The results show that momentum injection above a critical value will eject material from low mass elliptical galaxies, and leads to an X-ray luminosity, $L_{\rm X}$, that is $\propto$ $\sigma^{8-10}$, depending on the AGN fuelling mechanism, where $\sigma$ is the velocity dispersion of the hot gas. This result agrees well with both observations and semi-analytic models. In more massive ellipticals and clusters, AGN outflows quickly become buoyancy-dominated. This necessarily means that heating by a central cluster AGN redistributes the intracluster medium (ICM) such that the mass of hot gas, within the cooling radius, should be $\propto L_{\rm X}(<r_{\rm cool})/[g(r_{\rm cool})\sigma]$, where $g(r_{\rm cool})$ is the gravitational acceleration at the cooling radius. This prediction is confirmed using observations of seven clusters. The same mechanism also defines a critical ICM cooling time of $\sim 0.5$ Gyr, which is in reasonable agreement with recent observations showing that star formation and AGN activity are triggered below a universal cooling time threshold.Comment: Accepted for publication in MNRAS, 11 pages, 2 figures and 2 table

Depression: An Important Comorbidity With Metabolic Syndrome in a General Population

OBJECTIVE—There is a recognized association among depression, diabetes, and cardiovascular disease. The aim of this study was to examine in a sample representative of the general population whether depression, anxiety, and psychological distress are associated with metabolic syndrome and its components

Pelvic floor muscle training for women with pelvic organ prolapse: the PROPEL realist evaluation

Background Pelvic organ prolapse is estimated to affect 41–50% of women aged > 40 years. A multicentre randomised controlled trial of individualised pelvic floor muscle training found that pelvic floor muscle training was effective in reducing symptoms of prolapse, improved quality of life and showed clear potential to be cost-effective. Provision of pelvic floor muscle training for prolapse has continued to vary across the UK, with limited availability of specialist physiotherapists to deliver it. Objectives This project aimed to study the implementation and outcomes of different models of delivery to increase the service provision of pelvic floor muscle training, and to follow up treatment outcomes for the original trial participants. Design A realist evaluation of pelvic floor muscle training implementation conducted within three full case study sites and two partial case study sites; an observational prospective cohort study comparing patient-reported outcomes pre and post intervention in all five sites; and a long-term follow-up study linking previous trial participants to routine NHS hospital data. Setting The setting for the realist evaluation was pelvic floor muscle training service delivery models in three NHS sites. The setting for the patient-reported outcome measures study was pelvic floor muscle training services in five NHS sites. Methods Realist evaluation qualitative data were collected at four time points in three case study sites to understand the implementation models, uptake, adherence and impact. Interviews involved service managers/leads, consultants, staff delivering pelvic floor muscle training and women receiving pelvic floor muscle training. Main outcomes measures Patient-reported outcomes were collected at baseline and at 6 and 12 months across five sites, including the Pelvic Organ Prolapse Symptom Score, health-related quality of life (measured using the EuroQol-5 Dimensions, five-level version, questionnaire), prolapse severity (measured using the Pelvic Organ Prolapse Quantification System), urinary incontinence (measured using International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form) and need for further treatment. Results A total of 102 women were recruited to the patient-reported outcome measures cohort study (target, n = 120), and 65 women had matched baseline and 6-month Pelvic Organ Prolapse Symptom Scores. The mean Pelvic Organ Prolapse Symptom Score was 10.18 (standard deviation 5.63) at baseline and 6.98 (standard deviation 5.23) at 6 months, representing a statistically significant and clinically meaningful difference. There was no statistically significant difference between the outcomes obtained from delivery by specialist physiotherapists and the outcomes obtained from delivery by other health-care professionals (mean change in Pelvic Organ Prolapse Symptom Score: –3.95 vs. –2.81, respectively). Services delivered using higher-band physiotherapists only were more costly than services delivered using other staff mixes. The effect of the original pelvic floor muscle training intervention, over a post-intervention period of > 10 years, was a reduction in the odds of any treatment during follow-up (odds ratio 0.61, 95% confidence interval 0.37 to 0.99). The realist evaluation revealed stark differences in implementation. The site with a specialist physiotherapy service resisted change because of perceived threats to the specialist role and concerns about care quality. Pelvic floor muscle training delivery by other health-care staff was easier when there was a lack of any existing specialist service; staff had prior training and interest in pelvic health; staff had support, autonomy, time and resources to deliver pelvic floor muscle training as part of their core role; and surrounding services supported a flow of pelvic floor muscle training referrals. Limitations The number of available matched pre and post outcomes for women and the lack of Pelvic Organ Prolapse Quantification System examinations were limitations of this study. Conclusions It is possible to train different staff to effectively deliver pelvic floor muscle training to women. Women’s self-reported outcomes significantly improved across all service models. Training should be adequately tailored to differential skill mix needs. Future work Future work should include further implementation of pelvic floor muscle training and should include pre- and post-outcome data collection using the Pelvic Organ Prolapse Symptom Score