Social structures of science and approaches to outcomes-based medical research

Recently, two seemingly divergent approaches have emerged in outcomes-based medical research. Proponents of evidence-based medicine (EBM) argue that the most effective treatments will be found by adopting a hierarchical approach that gives pre-eminence to randomized controlled clinical trials, where these are available. Proponents of participatory medical research argue that research undertaken with consumers and other partners in the community will produce the best outcomes. While one approach marginalizes consumer experience the other approach draws consumers into it. EBM assumes a high level of consensus in a scientific community, while participatory medical research relies on co-opting consumer experience. This paper indicates that each approach involves a particular view of social structure in science. The paper uses theories of social relations among scientists for the purpose of critically assessing EBM and the participatory model.

Iraq and the Arab revolutions : protesting the failure to democratise governance

As the Arab Revolutions swept across the Middle East and North Africa in late 2010 and into 2011, Iraqis were confronted with the failures of their own democracy to deliver on the many promises made to them since 2003. This led to weeks of scattered protests across Iraq, culminating in the “Day of Rage” (February 25, 2011) in which thousands of protestors took to the streets in at least 17 separate demonstrations across the country following Friday prayers. On the surface, these protests shared much in common with others across the region: the use of Facebook and other social media to promote the protests, and the focus on corruption, unemployment and poor public infrastructure. Also similar was the reaction of key Iraqi political figures such as Maliki and Barzani who met Iraqi protests with a mixture of brutal suppression and modest political and economic concessions. However, as this paper will demonstrate, upon closer inspection the Iraqi protests are in fact very different to others across the MENA and are therefore among the most significant for the future of democracy in the region. The Iraqi people were not protesting against an autocratic regime or an entrenched monarchy that had held power for decades, but a relatively new – and supposedly ‘democratic’ - political elite who had been brought to power in the wake of the US invasion. Indeed, while protestors across the region called for more democracy in the form of a written constitution, free and fair elections, a robust media sphere and the rule of law, Iraqis were protesting against the failures of the Iraqi government to democratise such mechanisms of governance (all of which they more or less have). They felt routinely disenfranchised by a state that has manipulated the very institutions and discourses of democracy to retain, rather than diffuse, power.

Implications for Australian anaesthetists and proceduralists of a recent court decision regarding informed consent and patient positioning

 This article discusses the medicolegal implications of a recent judgment in relation to a patient who suffered significant morbidity as a result of patient positioning during an operative procedure. The patient developed an unexpected serious complication following surgery, in the context of a preoperative consent that did not cover every potential complication or contingency. The court held that the failure to warn of a particular risk that would have prevented the patient from undergoing a procedure but did not occur will not necessarily result in a finding of negligence in relation to another risk where the harm did occur. This finding is well aligned to current clinical practice and at the same time does not abrogate the practitioner's duty to provide a comprehensive list of possible complications during the consent process for any proceduralist. In the context of a procedure requiring anaesthesia, the importance of communication and understanding between the anaesthetist and proceduralist as to which aspects of the consent process are undertaken by whom, and to ensure the process is done comprehensively, is of great importance and is indirectly highlighted by this recent judgment.

Gender-specific barriers and facilitators to heart failure self-care: a mixed methods study

Necking and failure at low strains in a coarse-grained wrought Mg alloy

Tensile testing of rolled AZ31 alloy with a mean grain size of 80 μm reveals localization and failure prior to diffuse necking. Optical microscopy reveals that failure is caused by voids that have formed within twins. A simple localization criterion is proposed that captures the role of grain size in the effect. Such early failure is only predicted for coarse grain sizes, in line with observation.

Professional carers' knowledge and response to depression among their aged-care clients : the care recipients' perspective

Depression is an under-diagnosed disorder among the elderly, even in those who are in receipt of aged-care services. One factor associated with this under diagnosis has been identified as a reluctance amongst the elderly to discuss their mood and emotions with their medical practitioners. The current study focused on why depression is not recognised and acted on by those providing residential or home-based care to older people. We interviewed 15 elderly people residing in high-level or low-level aged-care facilities, and three elderly people who were receiving personal care in their homes. All participants had been identified by their care agencies as depressed. Participants reported their perceptions of their personal carers' knowledge and practices in managing the residents' depression. Although the participants described their carers in positive terms, they were critical of their knowledge and skills in recognising depression, and indicated that the communication between personal carers and care recipients about depressive symptomatology was seriously flawed. Training for personal carers in these areas, and efforts to change organisational culture are recommended.

Dyslipidaemia in rural Australia : prevalence, awareness, and adherence to treatment guidelines in the Greater Green Triangle risk factor study

Objectives: To determine population lipid profiles, awareness of hyperlipidaemia and adherence to Australian lipid management guidelines.
Design and setting: Population survey in rural south-eastern Australia, 2004–2006.
Participants: Stratified random sample from the electoral roll. Data from 1274 participants (40%) aged 25–74 years were analysed.
Main outcome measures: Population mean total, low-density lipoprotein and high-density lipoprotein cholesterol (TC, LDL-C and HDL-C) and triglyceride (TG) concentrations, prevalence of dyslipidaemia, and treatment according to 2001 and 2005 Australian guideline target levels.
Results: Population-adjusted mean TC, TG, LDL-C and HDL-C concentrations were 5.38 mmol/L (95% CI, 5.30–5.45), 1.50 mmol/L (95% CI, 1.43–1.56), 3.23 mmol/L (95% CI, 3.16–3.30) and 1.46 mmol/L (95% CI, 1.44–1.49), respectively. Prevalence of hypercholesterolaemia (TC > 5.5 mmol/L or on treatment) was 48%. Lipid-lowering medication use was reported by 12%. Seventy-seven of 183 participants with established cardiovascular disease (CVD) or diabetes were untreated, and of the 106 treated, 59% reached the target LDL-C. Of those without CVD or diabetes already treated, 38% reached target LDL-C, and 397 participants at high absolute risk did not receive primary prevention. Ninety-five per cent of treated individuals with CVD or diabetes and 86% of others treated had cholesterol measured in the previous year. Sixty-nine per cent of individuals at low risk aged over 45 years had their cholesterol measured within the previous 5 years.
Conclusions: A comprehensive national strategy for lowering mean population cholesterol is required, as is better implementation of absolute risk management guidelines — particularly in rural populations.

Medical error and decision making : learning from the past and present in intensive care

Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

Purpose : The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.