Comparison of two methods of presenting risk information to patients about the side effects of medicines

Objective: To determine whether the use of verbal descriptors suggested by the European Union (EU) such as "common" (1-10% frequency) and "rare" (0.01-0.1%) effectively conveys the level of risk of side effects to people taking a medicine. Design: Randomised controlled study with unconcealed allocation. Participants: 120 adults taking simvastatin or atorvastatin after cardiac surgery or myocardial infarction. Setting: Cardiac rehabilitation clinics at two hospitals in Leeds, UK. Intervention: A written statement about one of the side effects of the medicine (either constipation or pancreatitis). Within each side effect condition half the patients were given the information in verbal form and half in numerical form (for constipation, "common" or 2.5%; for pancreatitis, "rare" or 0.04%). Main outcome measure: The estimated likelihood of the side effect occurring. Other outcome measures related to the perceived severity of the side effect, its risk to health, and its effect on decisions about whether to take the medicine. Results: The mean likelihood estimate given for the constipation side effect was 34.2% in the verbal group and 8.1% in the numerical group; for pancreatitis it was 18% in the verbal group and 2.1% in the numerical group. The verbal descriptors were associated with more negative perceptions of the medicine than their equivalent numerical descriptors. Conclusions: Patients want and need understandable information about medicines and their risks and benefits. This is essential if they are to become partners in medicine taking. The use of verbal descriptors to improve the level of information about side effect risk leads to overestimation of the level of harm and may lead patients to make inappropriate decisions about whether or not they take the medicine.

Peroxynitrite-modified collagen-II induces p38/ERK and NF-kappa B-dependent synthesis of prostaglandin E-2 and nitric oxide in chondrogenically differentiated mesenchyrnal progenitor cells

Objective: Peroxynitrite (ONOO-) is formed in the inflamed and degenerating human joint. Peroxynitrite-modified collagen-II (PMC-II) was recently discovered in the serum of patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Therefore we investigated the cellular effects of PMC-II on human mesenchymal progenitor cells (MPCs) as a model of cartilage and cartilage repair cells in the inflamed and degenerating joint. Design: MPCs were isolated from the trabecular bone of patients undergoing reconstructive surgery and were differentiated into a chondrogenic lineage. Cells were exposed to PMC-II and levels of the proinflammatory mediators nitric oxide (NO) and prostaglandin E-2 (PGE(2)) measured. Levels of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2), phosphorylated mitogen activated protein kinases (MAPKs) and nuclear factor kappa B (NF-kappa B) activation were measured by enzyme linked immunosorbent assay (ELISA) together with specific MAPK and NF-kappa B inhibitors. Results: PMC-II induced NO and PGE(2) synthesis through upregulation of iNOS and COX-2 proteins. PMC-II also lead to the phosphorylation of MAPKs, extracellularly regulated kinase 1/2 (ERK1/2) and p38 [but not c-Jun NH2-terminal kinase (JNK1/2)] and the activation of proinflammatory transcription factor NF-kappa B. Inhibitors of p38, ERK1/2 and NF-kappa B prevented PMC-II induced NO and PGE(2) synthesis, NOS and COX-2 protein expression and NF-kappa B activation. Conclusion: iNOS, COX-2, NF-KB and MAPK are known to be activated in the joints of patients with OA and RA. PMC-II induced iNOS and COX-2 synthesis through p38, ERK1/2 and NF-KB dependent pathways suggesting a previously unidentified pathway for the synthesis of the proinflammatory mediators, NO and PGE(2), further suggesting that inhibitors of these pathways may be therapeutic in the inflamed and degenerating human joint. (c) 2005 OsteoArthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Advances in upper limb stroke rehabilitation: a technology push

Strokes affect thousands of people worldwide leaving sufferers with severe disabilities affecting their daily activities. In recent years, new rehabilitation techniques have emerged such as constraint-induced therapy, biofeedback therapy and robot-aided therapy. In particular, robotic techniques allow precise recording of movements and application of forces to the affected limb, making it a valuable tool for motor rehabilitation. In addition, robot-aided therapy can utilise visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task such as a game. Visual cues can also be used to control the information sent to the patient about exercise performance and to potentially address psychosomatic variables influencing therapy. This paper overviews the current state-of-the-art on upper limb robot-mediated therapy with a focal point on the technical requirements of robotic therapy devices leading to the development of upper limb rehabilitation techniques that facilitate reach-to-touch, fine motor control, whole-arm movements and promote rehabilitation beyond hospital stay. The reviewed literature suggest that while there is evidence supporting the use of this technology to reduce functional impairment, besides the technological push, the challenge ahead lies on provision of effective assessment of outcome and modalities that have a stronger impact transferring functional gains into functional independence.

Provider diversity in the NHS: impact on quality and innovation

The overall objective of the research project has been to assess the impact of provider diversity on quality and innovation in the NHS. The specific research aims were to identify the differences in performance between non-profit Third Sector organisations, for-profit private enterprises, and incumbent public sector institutions within the NHS as providers of health care services, as well as the factors that affect the entry and growth of new private and Third Sector providers. The study used both qualitative and quantitative methods based on case studies of four Local Health Economies (LHEs). Qualitative methods included documentary analysis and interviews with key informants and managers of both commissioning and provider organisations. To provide a focus to the study, two tracer conditions were followed: orthopaedic surgery and home health care for frail older people. In the case of hospital inpatient care, data on patient characteristics were also collected from the HES database. The analysis of this data provided preliminary estimates of the effects of provider type on quality, controlling for client characteristics and case mix. In addition, a survey of patient experience in diverse provider organisations was analysed to compare the different dimensions of quality of provision of acute services between incumbent NHS organisations and new independent sector treatment centres. The research has shown that, in respect of inpatient hospital services, diverse providers supply health services of at least as good quality as traditional NHS providers, and that there is ample opportunity to expand their scale and scope as providers of services commissioned by the NHS. The research used patient experience survey data to investigate whether hospital ownership affects the quality of services reported by NHS patients in areas other than clinical quality. The raw survey data appear to show that private hospitals provide higher quality services than the public hospitals. However, further empirical analysis leads to a more nuanced understanding of the performance differences. Firstly, the analysis shows that each sector offers greater quality in certain specialties. Secondly, the analysis shows that differences in the quality of patients’ reported experience are mainly attributable to patient characteristics, the selection of patients into each type of hospital, and the characteristics of individual hospitals, rather than to hospital ownership as such. Controlling for such differences, NHS patients are on average likely to experience a similar quality of care in a public or privately-run hospital. Nevertheless, for specific groups of patients and for specific types of treatments, especially the more straightforward ones, the private sector provides an improved patient experience compared to the public sector. Elsewhere, the NHS continues to provide a high quality service and outperforms the private sector in a range of services and for a range of clients.

Development of a wearable assistive soft robotic device for elbow rehabilitation

The loss of motor function at the elbow joint can result as a consequence of stroke. Stroke is a clinical illness resulting in long lasting neurological deficits often affecting somatosensory and motor cortices. More than half of those that recover from a stroke survive with disability in their upper arm and need rehabilitation therapy to help in regaining functions of daily living. In this paper, we demonstrated a prototype of a low-cost, ultra-light and wearable soft robotic assistive device that could aid administration of elbow motion therapies to stroke patients. In order to assist the rotation of the elbow joint, the soft modules which consist of soft wedge-like cellular units was inflated by air to produce torque at the elbow joint. Highly compliant rotation can be naturally realised by the elastic property of soft silicone and pneumatic control of air. Based on the direct visual-actuation control, a higher control loop utilised visual processing to apply positional control, the lower control loop was implemented by an electronic circuit to achieve the desired pressure of the soft modules by Pulse Width Modulation. To examine the functionality of the proposed soft modular system, we used an anatomical model of the upper limb and performed the experiments with healthy participants.

Paddy Hartley: of faces and facades

Paddy Hartley's work is primarily concerned with the ways in which the human face can be repaired, manipulated and recontextualised, and the questions these processes raise about our concepts of beauty and disfigurement. Incorporating surgical and pharmaceutical equipment as well as steel, scrap metal, digital embroidery and textiles, Hartley sets out a critique of how we think about the face today. Taking as a starting point records of facially injured servicemen of the First World War and the pioneering surgery they underwent, Project Facade examines the impact of disfigurement on the human psyche, as well as tracing the development of early facial reconstructive surgery. His Face Corsets, meanwhile, examines attitudes towards cosmetic surgery and the beauty industry, providing a non-surgical means to brutally mimic the results of cosmetic procedures and beyond. The series gained notoriety and success in a wide variety of popular publications both nationally and internationally, and continue to feature in contemporary textiles and fashion publications. Paddy Hartley: Of Faces and Facades brings together these works in book form for the first time, presenting previously unpublished texts from David Houston Jones and Marjorie Gehrhardt, as well as drawings and photographs which document a remarkable creative process and a history that is still insufficiently explored.