Medical treatment contrary to parents wishes: the illusion of parental autonomy

The NHS Trust v A (a child) & Ors [2007] EWHC 169

Randomised trial of levonorgestrel intrauterine system compared to usual medical treatment for heavy menstrual bleeding:the ECLIPSE Trial

Objective: Heavy menstrual bleeding (menorrhagia) is a common problem, yet evidence is limited to inform therapeutic decisions.We compared the levonorgestrel-releasing intrauterine system(LNG-IUS) to usual medical treatment in a pragmatic randomised trial in primary care. Methods: We randomly assigned 571 women consulting their primary care providers with menorrhagia to LNG-IUS or to usual medical treatment as clinically appropriate (tranexamic acid, mefenamic acid, combined estrogen/progestogen or progestogen only). The primary outcome was a patient-reported measure ofimpact of menorrhagia, the validated Menorrhagia Multi-Attribute Scale (MMAS), assessed over 2 years. Secondary measures included generic quality of life (SF-36), sexual activity and surgical intervention.Results MMAS scores improved from baseline in both the LNG-IUS and usual medical treatment groups by 6 months (mean increases 32.7 points versus 21.4 points, respectively; P < 0.001for both) and were maintained over 2 years, but improvements were significantly greater with LNG-IUS (mean between-group difference 13.4 points, 95%CI, 9.9–16.9; P < 0.001).All domains of MMAS (practical difficulties, social life, family life,work/daily routine, psychological well being and physical health)improved significantly more with LNG-IUS, as were seven of the eight domains of SF-36. More women were still using LNG-IUSthan usual medical treatment at 2 years (64% versus 38%,P < 0.001). There were no significant between-group differences in surgical intervention rates or sexual activity scores. There were no serious adverse events in either group.Conclusions Among women presenting to primary care providers with menorrhagia, LNG-IUS was more effective than usual medical treatment at reducing the impact of this problem on their quality of life. In practice therefore, conventional treatments, such as tranexamic and mefenamic acid, remain helpful choices in women for whom LNG-IUS is considered unsuitable, or due to individual preference. For other women, LNG-IUS can be confidently recommended as an effective initial medical therapy for menorrhagia. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 02/06/02)

Comparison of the effect of pre-treatment and catalysts on liquid quality from fast pyrolysis of biomass

The overall objective of this work was to compare the effect of pre-treatment and catalysts on the quality of liquid products from fast pyrolysis of biomass. This study investigated the upgrading of bio-oil in terms of its quality as a bio-fuel and/or source of chemicals. Bio-oil used directly as a biofuel for heat or power needs to be improved particularly in terms of temperature sensitivity, oxygen content, chemical instability, solid content, and heating values. Chemicals produced from bio-oil need to be able to meet product specifications for market acceptability. There were two main objectives in this research. The first was to examine the influence of pre-treatment of biomass on the fast pyrolysis process and liquid quality. The relationship between the method of pre-treatment of biomass feedstock to fast pyrolysis oil quality was studied. The thermal decomposition behaviour of untreated and pretreated feedstocks was studied by using a TGA (thermogravimetric analysis) and a Py-GC/MS (pyroprobe-gas chromatography/mass spectrometry). Laboratory scale reactors (100g/h, 300g/h, 1kg/h) were used to process untreated and pretreated feedstocks by fast pyrolysis. The second objective was to study the influence of numerous catalysts on fast pyrolysis liquids from wheat straw. The first step applied analytical pyrolysis (Py-GC/MS) to determine which catalysts had an effect on fast pyrolysis liquid, in order to select catalysts for further laboratory fast pyrolysis. The effect of activation, temperature, and biomass pre-treatment on catalysts were also investigated. Laboratory experiments were also conducted using the existing 300g/h fluidised bed reactor system with a secondary catalytic fixed bed reactor. The screening of catalysts showed that CoMo was a highly active catalyst, which particularly reduced the higher molecular weight products of fast pyrolysis. From these screening tests, CoMo catalyst was selected for larger scale laboratory experiments. With reference to the effect of pre-treatment work on fast pyrolysis process, a significant effect occurred on the thermal decomposition of biomass, as well as the pyrolysis products composition, and the proportion of key components in bio-oil. Torrefaction proved to have a mild influence on pyrolysis products, when compared to aquathermolysis and steam pre-treatment.

Detection of bacterial DNA in cardiac vegetations by PCR after the completion of antimicrobial treatment for endorcarditis

PCR with broad-range primers for prokaryotic 16S rRNA genes was used to identify bacterial DNA in tissue from patients undergoing valve replacements following a previous episode of infective endocarditis (IF). Of eight valves investigated, bacterial DNA was detected in three from patients for whom IE had been treated by antibiotic therapy 5, 12 and 18 months previously. The demonstration of bacterial DNA within resected heart valves suggests either recurrence of infection, treatment failure or the persistence of bacterial debris within the cardiac vegetation. There may also be implications for routine use of PCR in the diagnosis of infection. © 2004 Copyright by the European Society of Clinical Microbiology and Infectious Diseases.

The effect of thermochemical treatment on the fatigue properties of alloy steels

The effect of thermochemical treatment namely carburising on the fatigue behaviour of one carbon and two alloy steels has been studied in rotating and unidirectional bending. The effect of carbon profile on the unidirect¬ional bending fatigue strength of 63SA14 was assessed, and it was found that single stage carburising with a surface carbon content of 0.8% has resulted in a higher fatigue strength than other types of carbon profiles. Residual stresses and other metallurgical variables arising from different carbon profiles, were also considered. The highest compressive stresses h~e resulted from boost-diffuse-carburising. On the other hand surface decarburisation was associated with tensile residual stresses and a reduced fatigue strength. Retained austenite was found to be detrimental in unidirectional bending fatigue; however its presence in carburised 83SAIS did not seem to influence the rotating bending fatigue strength. Carbide particles in globular and/or intergranular form were detrimental to compressive residual stresses; the unidirectional bending fatigue strength is markedly lowered. The highest fatigue strength was accomplished by vacuum carburising. The absence of internal oxidation was the key factor in the increased fatigue strength; the presence of uniformly distributed fine carbide particles did not upset the superior fatigue strength of vacuum carburised pieces. The effect of mean stress on the fatigue strength of carburised 63SA14 was studied. Increasing the mean stress as would be expected resulted in a decreased fatigue strength. Carburisation showed its advantages at low mean stress, but at high mean stress it offers little advantage over the uncarburised hardened conditions. Notch effect was also studied in unidirectional bending of carburised 080MlS. The general trend showed that the fatigue strength decreases with increasing the stress concentration factor. But different carburising conditions have different effect on notch sensitivity.

The effect of heat treatment on mechanical properties of pulsed Nd:YAG welded thin Ti6Al4V

Pulsed Nd:YAG has been adopted successfully in welding process of thin (0.7 mm) Ti6Al4V. Laser welding of such thin sheet requires a small focal spot, good laser beam quality and fast travel speed, since too much heat generation can cause distortion for thin sheet weld. The microstructures of Ti6Al4V were complex and strongly affected the mechanical properties. These structures include: a´ martensite, metastable ß, Widmanstätten, bimodal, lamellar and equiaxed microstructure. Bimodal and Widmanstätten structures exhibit a good-balance between strength and ductility. The microstructure of pulsed Nd:YAG welded Ti6Al4V was primarily a´ martensite, which showed the lowest ductility but not significantly high strength. A heat treatment at 950 followed by furnace cooling can transform the microstructure in the weld from a´ martensite structure into Widmanstätten structure.

The effect of the environment on the mechanical properties of medical grade silicones

Silicone spacers have been in use as replacement joints in the human hand for over 30 years. Since they were first used there has been a number of designs all of which have had problems with fracture. This may be due to a defect in the material caused during implantation, or by bony intrusions within the arthritic hand after implantation. The aim of this research was to investigate the effect of the environment on the mechanical properties of medical grade silicones used for human implantation. The materials were subjected to static tensile testing after various forms of ageing. The environmental conditions included temperatures of 37 and 80°C and the environments of Ringer's solution, distilled water, and air. The environmental conditions employed resulted in reduced mechanical strength with ageing time of the silicones. This research supports the view that failure of silicone implants in the hand could be partly attributed to the effects of environmental ageing of the material.

Crack-growth of medical-grade silicone using pure shear tests

Silicone elastomers are commonly used in the manufacture of single-piece joint replacement implants for the finger joints. However, the survivorship of these implants can be poor, with failure typically occurring from fracture of the stems. The aim of this paper was to investigate the crack growth of medical-grade silicone using pure shear tests. Two medical-grade silicones (C6-180 and Med82-5010-80) were tested. Each sample had a 20 mm crack introduced and was subjected to a sinusoidally varying tensile strain, with a minimum of 0 per cent and a maximum in the range 10 to 77 per cent. Testing was undertaken at a frequency of 10 Hz. At various times during testing, the testing machine was stopped, the number of cycles completed was noted, and the crack length measured. Graphs of crack length against number of cycles were plotted, as well as the crack growth rate against tearing energy. The results show that Med82-5010-80 is more crack resistant than C6-180. Graphs of crack growth rate against tearing energy can be used to predict the failure of these medical-grade elastomers.

Spillover effects of service failures in coalition loyalty programs:the buffering effect of special treatment benefits

Coalition loyalty programs are on the rise, yet few studies investigate the impact of service failures in such programs. Using data from a retail context, the authors show that a program partner deemed responsible for a service failure suffers negative customer responses. However, customers' perceptions of the benefits of the coalition loyalty program buffer these consequences. Perhaps most importantly, when customers perceive the program's special treatment benefits as low, direct and indirect spillover effects occur, such that a service failure by one program partner has a negative effect on customer loyalty toward the program itself. © 2013 New York University.

Modelling of wastewater treatment plants:how far shall we go with sophisticated modelling tools?

Several levels of complexity are available for modelling of wastewater treatment plants. Modelling local effects rely on computational fluid dynamics (CFD) approaches whereas activated sludge models (ASM) represent the global methodology. By applying both modelling approaches to pilot plant and full scale systems, this paper evaluates the value of each method and especially their potential combination. Model structure identification for ASM is discussed based on a full-scale closed loop oxidation ditch modelling. It is illustrated how and for what circumstances information obtained via CFD (computational fluid dynamics) analysis, residence time distribution (RTD) and other experimental means can be used. Furthermore, CFD analysis of the multiphase flow mechanisms is employed to obtain a correct description of the oxygenation capacity of the system studied, including an easy implementation of this information in the classical ASM modelling (e.g. oxygen transfer). The combination of CFD and activated sludge modelling of wastewater treatment processes is applied to three reactor configurations, a perfectly mixed reactor, a pilot scale activated sludge basin (ASB) and a real scale ASB. The application of the biological models to the CFD model is validated against experimentation for the pilot scale ASB and against a classical global ASM model response. A first step in the evaluation of the potential of the combined CFD-ASM model is performed using a full scale oxidation ditch system as testing scenario.

Fatigue behaviour of C-Mn-B steels:effects of heat treatment prestrain and residual stress

The fatigue-crack propagation and threshold behaviour of a C-Mn steel containing boron has been investigated at a range of strength levels suitable for mining chain applications. The heat-treatment variables examined include two austenitizing temperatures (900 degree C and 1250 degree C) and a range of tempering treatments from the as-quenched condition to tempering at 400 degree C. In mining applications the haulage chains undergo a 'calibration' process which has the effect of imposing a tensile prestrain on the chain links before they go into service. Prestrain is shown to reduce threshold values in these steels and this behaviour is related to its effects on the residual stress distribution in the test specimens.

Medical error:a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error

Introduction: There is a growing public perception that serious medical error is commonplace and largely tolerated by the medical profession. The Government and medical establishment's response to this perceived epidemic of error has included tighter controls over practising doctors and individual stick-and-carrot reforms of medical practice. Discussion: This paper critically reviews the literature on medical error, professional socialization and medical student education, and suggests that common themes such as uncertainty, necessary fallibility, exclusivity of professional judgement and extensive use of medical networks find their genesis, in part, in aspects of medical education and socialization into medicine. The nature and comparative failure of recent reforms of medical practice and the tension between the individualistic nature of the reforms and the collegiate nature of the medical profession are discussed. Conclusion: A more theoretically informed and longitudinal approach to decreasing medical error might be to address the genesis of medical thinking about error through reforms to the aspects of medical education and professional socialization that help to create and perpetuate the existence of avoidable error, and reinforce medical collusion concerning error. Further changes in the curriculum to emphasize team working, communication skills, evidence-based practice and strategies for managing uncertainty are therefore potentially key components in helping tomorrow's doctors to discuss, cope with and commit fewer medical errors.

Ranibizumab 0.5 mg for diabetic macular edema with bimonthly monitoring after a phase of initial treatment:18-month, multicenter, phase IIIB RELIGHT study

Abstract PURPOSE: To evaluate ranibizumab 0.5 mg using bimonthly monitoring and individualized re-treatment after monthly follow-up for 6 months in patients with visual impairment due to diabetic macular edema (DME). DESIGN: A phase IIIb, 18-month, prospective, open-label, multicenter, single-arm study in the United Kingdom. PARTICIPANTS: Participants (N = 109) with visual impairment due to DME. METHODS: Participants received 3 initial monthly ranibizumab 0.5 mg injections (day 0 to month 2), followed by individualized best-corrected visual acuity (BCVA) and optical coherence tomography-guided re-treatment with monthly (months 3-5) and subsequent bimonthly follow-up (months 6-18). Laser was allowed after month 6. MAIN OUTCOME MEASURES: Mean change in BCVA from baseline to month 12 (primary end point), mean change in BCVA and central retinal thickness (CRT) from baseline to month 18, gain of ≥10 and ≥15 letters, treatment exposure, and incidence of adverse events over 18 months. RESULTS: Of 109 participants, 100 (91.7%) and 99 (90.8%) completed the 12 and 18 months of the study, respectively. The mean age was 63.7 years, the mean duration of DME was 40 months, and 77.1% of the participants had received prior laser treatment (study eye). At baseline, mean BCVA was 62.9 letters, 20% of patients had a baseline BCVA of >73 letters, and mean baseline CRT was 418.1 μm, with 32% of patients having a baseline CRT <300 μm. The mean change in BCVA from baseline to month 6 was +6.6 letters (95% confidence interval [CI], 4.9-8.3), and after institution of bimonthly treatment the mean change in BCVA at month 12 was +4.8 letters (95% CI, 2.9-6.7; P < 0.001) and +6.5 letters (95% CI, 4.2-8.8) at month 18. The proportion of participants gaining ≥10 and ≥15 letters was 24.8% and 13.8% at month 12 and 34.9% and 19.3% at month 18, respectively. Participants received a mean of 6.8 and 8.5 injections over 12 and 18 months, respectively. No new ocular or nonocular safety findings were observed during the study. CONCLUSIONS: The BCVA gain achieved in the initial 6-month treatment period was maintained with an additional 12 months of bimonthly ranibizumab PRN treatment.