Diabetes, insulin treatment, and cancer risk:what is the evidence?

Diabetes, in particular type 2, is associated with an increased incidence of cancer. Although the mortality attributable to cancer in type 2 diabetes is overshadowed by that due to cardiovascular disease, emerging data from epidemiologic studies suggest that insulin therapy may confer added risk for cancer, perhaps mediated by signaling through the IGF-1 (insulin-like growth factor-1) receptor. Co-administered metformin seems to mitigate the risk associated with insulin. A recent series of publications in Diabetologia addresses the possibility that glargine, the most widely used long-acting insulin analogue, may confer a greater risk than other insulin preparations, particularly for breast cancer. This has led to a heated controversy. Despite this, there is a consensus that the currently available data are not conclusive and should not be the basis for any change in practice. Further studies and more thorough surveillance of cancer in diabetes are needed to address this important issue.

Faire parler les morts. Sur Jan Karski et la controverse Lanzmann-Haenel

The Second World War has inspired many French novelists since 1945. Yet, very few of these novels have been harshly criticized by either historians or other critics, Les Bienveillantes (2006) by Jonathan Littell and Jan Karski (2009) by Yannick Haenel being two notable exceptions. This article revisits the controversy between the novelist Yannick Haenel and the critic and film-maker Claude Lanzmann. First, it shows that the important questions raised by Lanzmann are not void of ambiguity, notably because key terms at the heart of this controversy (truth, fiction or even history) were used loosely. Second, this article compares the documentary Le Rapport Karski (2010) to other texts written by Karski and to the full transcription of the interview he gave to Lanzmann in 1978: it shows how Lanzmann's 2010 documentary distorts Karski's testimony to make it comply with historical perspectives that most historians would agree with today. Finally, the author of this article regrets that this controversy did not allow the debate to move beyond the military non-intervention of the Allies.

Complexity of concern: Social acceptance of wind energy and the inevitability of dissensus

This presentation will explore the  role that social acceptance of onshore wind can play in understanding and progressing the low carbon transition in Europe. Although this is commonly perceived as arising simply from the overall level of renewable energy generated (and ‘dirty’ energy displaced), its significance goes well beyond this as it helps us understand some of the key issues facing the electricity sector as a social-technical system.  As such it is not only a matter of delivering the necessary infrastructure, but requires the long term mediation of complex multi-governmental arrangements involving a very wide range of actors. The interests of these actors engage hugely different timescales, geographic scales of concern and rationalities that make the arena of social acceptance a cauldron of complexity, mediating between overlapping and incompatible concerns. The presentation will briefly review the nature of some of these relationships and discuss what this means for how we conceive and act on the social acceptance of wind, and what this means for the long term low carbon transition

Factors affecting the successful implementation and sustainability of the Liverpool Care Pathway for dying patients – a realist evaluation

Objectives: The Liverpool Care Pathway for the dying patient (LCP) was designed to improve end-of-life care in generalist health care settings. Controversy has led to its withdrawal in some jurisdictions. The main objective of this research was to identify the influences that facilitated or hindered successful LCP implementation.

Method: An organisational case study using realist evaluation in one health and social care trust in Northern Ireland. Two rounds of semi-structured interviews were conducted with two policy makers and twenty two participants with experience and/or involvement in management of the LCP during 2011 and 2012.

Results: Key resource inputs included facilitation with a view to maintaining LCP ‘visibility’, reducing anxiety among nurses and increasing their confidence regarding the delivery of end-of-life care; and nurse and medical education designed to increase professional self-efficacy and reduce misuse and misunderstanding of the LCP. Key enabling contexts were consistent senior management support; ongoing education and training tailored to the needs of each professional group; and an organisational cultural change in the hospital setting that encompassed end-of-life care.

Conclusion: There is a need to appreciate the organizationally complex nature of intervening to improve end-of-life care. Successful implementation of evidence-based interventions for end-of-life care requires commitment to planning, training and ongoing review that takes account of different perspectives, institutional hierarchies and relationships and the educational needs of professional disciplines. There is a need also to recognise that medical consultants require particular support in their role as gatekeepers and as a lead communication channel with patients and their relatives.

The current state of abortion law and practice in Northern Ireland

This paper reviews current abortion law and practice in Northern Ireland (NI). It explores the origins of NI's abortion law and its complexity in relation to current practice. it reviews issues relating to women seeking terminations in NI and Great Britain and reviews attempts by the Family Planning Association NI to require the Department of Health and Social Services and Public Safety NI to provide guidance for health professionals engaged in this practice. The paper also discusses some of the issues surrounding abortion in NI and seeks to explain why this subject is causing controversy and debate, especially following a judicial review in February and Marie Stopes opening a termination service in Belfast.

Comparative Law and European Harmonisation - a Match Made in Heaven or Uneasy Bedfellows?

Developing the controversy indicated in the heading, this article will proceed as follows. It establishes a notion of critical comparative law, by showing how comparative law may be capable of providing critique and analysis of law-making through judicial and legislative activity at a European level. This is followed by an exemplary discussion of how comparative law is actually used in relation to European harmonisation through case law, legislation and “soft law”. The question will then be asked whether and how these uses would change under a critical approach to comparative law. The discussion will focus on industrial relations and equality law.
In both fields, recent ECJ case law has proved controversial: This article submits that such controversy could partly be avoided by making better use of critical comparative law in deciding cases and in choosing adequate forms and content of legislation.

Molecular pathology - The value of an integrative approach

Molecular Pathology (MP) is at the heart of modern diagnostics and translational research, but the controversy on how MP is best developed has not abated. The lack of a proper model or trained pathologists to support the diagnostic and research missions makes MP a rare commodity overall. Here we analyse the scientific and technology areas, in research and diagnostics, which are encompassed by MP of solid tumours; we highlight the broad overlap of technologies and analytical capabilities in tissue research and diagnostics; and we describe an integrated model that rationalizes technical know-how and pathology talent for both. The model is based on a single, accredited laboratory providing a single standard of high-quality for biomarker discovery, biomarker validation and molecular diagnostics.

Legalizing physician-assisted suicide and/or euthanasia: Pragmatic implications

Objective: Despite the availability of palliative care in many countries, legalization of euthanasia and physician-assisted suicide (EAS) continues to be debated-particularly around ethical and legal issues-and the surrounding controversy shows no signs of abating. Responding to EAS requests is considered one of the most difficult healthcare responsibilities. In the present paper, we highlight some of the less frequently discussed practical implications for palliative care provision if EAS were to be legalized. Our aim was not to take an explicit anti-EAS stance or expand on findings from systematic reviews or philosophical and ethico-legal treatises, but rather to offer clinical perspectives and the potential pragmatic implications of legalized EAS for palliative care provision, patients and families, healthcare professionals, and the broader community.

Method: We provide insights from our multidisciplinary clinical experience, coupled with those from various jurisdictions where EAS is, or has been, legalized.

Results: We believe that these issues, many of which are encountered at the bedside, must be considered in detail so that the pragmatic implications of EAS can be comprehensively considered.

Significance of Results: Increased resources and effort must be directed toward training, research, community engagement, and ensuring adequate resourcing for palliative care before further consideration is given to allocating resources for legalizing euthanasia and physician-assisted suicide.

Size matters: plasticity in metabolic scaling shows body-size may modulate responses to climate change

Variability in metabolic scaling in animals, the relationship between metabolic rate (R) and body mass (M), has been a source of debate and controversy for decades. R is proportional to M-b, the precise value of b much debated, but historically considered equal in all organisms. Recent metabolic theory, however, predicts b to vary among species with ecology and metabolic level, and may also vary within species under different abiotic conditions. Under climate change, most species will experience increased temperatures, and marine organisms will experience the additional stressor of decreased seawater pH ('ocean acidification'). Responses to these environmental changes are modulated by myriad species-specific factors. Body-size is a fundamental biological parameter, but its modulating role is relatively unexplored. Here, we show that changes to metabolic scaling reveal asymmetric responses to stressors across body-size ranges; b is systematically decreased under increasing temperature in three grazing molluscs, indicating smaller individuals were more responsive to warming. Larger individuals were, however, more responsive to reduced seawater pH in low temperatures. These alterations to the allometry of metabolism highlight abiotic control of metabolic scaling, and indicate that responses to climate warming and ocean acidification may be modulated by body-size.

Blood eosinophils as a marker of likely corticosteroid response in children with preschool wheeze: time for an eosinophil guided clinical trial?

Childhood wheezing is common particularly in children under the age of six years and in this age-group is generally referred to as preschool wheezing. Particular diagnostic and treatment uncertainties exist in these young children due to the difficulty in obtaining objective evidence of reversible airways narrowing and inflammation. A diagnosis of asthma depends on the presence of relevant clinical signs and symptoms and the demonstration of reversible airways narrowing on lung function testing, which is difficult to perform in young children. Few treatments are available and inhaled corticosteroids are the recommended preventer treatment in most international asthma guidelines. There is however considerable controversy about its effectiveness in children with preschool wheeze and a corticosteroid responder phenotype has not been established. These diagnostic and treatment uncertainties in conjunction with the knowledge of corticosteroid side-effects, in particular the reduction of growth velocity, has resulted in a variable approach to inhaled corticosteroid prescribing by medical practitioners and a reluctance in carers to regularly administer the treatment. Identifying children who are likely responders to corticosteroid therapy would be a major benefit in the management of this condition. Eosinophils have emerged as a promising biomarker of corticosteroid responsive airways disease and evaluation of this biomarker in sputum has successfully been employed to direct management in adults with asthma. Obtaining sputum from young children is time-consuming and difficult and it is hard to justify more invasive procedures such as a bronchoscopy in young children routinely. Recently, in children, interest has shifted to assessing the value of less invasive biomarkers of likely corticosteroid response and the biomarker 'blood eosinophils' has emerged as an attractive candidate. The aim of this review is to summarise the evidence for blood eosinophils as a predictive biomarker for corticosteroid responsive disease with a particular focus on the difficult area of preschool wheeze. 

Practical guidelines: Lung transplantation in patients with cystic fibrosis

There are no European recommendations on issues specifically related to lung transplantation (LTX) in cystic fibrosis (CF). The main goal of this paper is to provide CF care team members with clinically relevant CF-specific information on all aspects of LTX, highlighting areas of consensus and controversy throughout Europe. Bilateral lung transplantation has been shown to be an important therapeutic option for end-stage CF pulmonary disease. Transplant function and patient survival after transplantation are better than in most other indications for this procedure. Attention though has to be paid to pretransplant morbidity, time for referral, evaluation, indication, and contraindication in children and in adults. This review makes extensive use of specific evidence in the field of lung transplantation in CF patients and addresses all issues of practical importance. The requirements of pre-, peri-, and postoperative management are discussed in detail including bridging to transplant and postoperative complications, immune suppression, chronic allograft dysfunction, infection, and malignancies being the most important. Among the contributors to this guiding information are 19 members of the ECORN-CF project and other experts. The document is endorsed by the European Cystic Fibrosis Society and sponsored by the Christiane Herzog Foundation. 

Portraying Human Dignity

I consider whether Diego Velázquez (1599-1660) in his painting Las Meninas has conveyed several aspects of the idea of human dignity in ways that not only echo some aspects of contemporary philosophical and legal analysis, but transcend them, bringing into our understanding aspects of dignity, and the controversy surrounding it, that otherwise might be underestimated.

The Intersection of Religious Autonomy and Religious Symbols: Setting the Stage

Two sets of issues in the area of law and religion have generated a large share of attention and controversy across a wide number of countries and jurisdictions in recent years. The first set of issues relates to the autonomy of churches and other religiously affiliated entities such as schools and social service organisations in their hiring and personnel decisions, involving the question of how far, if at all, such entities should be free from the influence and oversight of the state. The second set of issues involves the presence of religious symbols in the public sphere, such as in state schools or on public lands, involving the question of how far the state should be free from the influence of religion. Although these issues – freedom of religion from the state, and freedom of the state from religion – could be viewed as opposite sides of the same coin, they are almost always treated as separate lines of inquiry, and the implications of each for the other have not been the subject of much scrutiny. In this Introduction, we consider whether insights might be drawn from thinking about these issues both from a comparative law perspective and also from considering these two lines of cases together.

The Historical Use of Amnesties, Immunities, and Sentence Reductions in Northern Ireland

While it is widely believed that the use of amnesties and similar measures would mark a new departure in NI and the UK, so that speculation about their introduction causes public controversy and threatens political instability, the report demonstrates that such measures have in fact been repeatedly used in a wide range of circumstances since the foundation of the NI state. The paper offers definitions of the key measures which have been employed, including amnesties, sentence reductions linked to peace building and use immunities. It explores their historical use and its consequences.