Differential gains from Business Link support and advice:a treatment effects approach

The provision of advisory support to small firms is almost ubiquitous in OECD countries, although it is organised in different ways and is justified on slightly different grounds. In England publicly supported advisory services are provided through the Business Link (BL) network. Here, we consider two questions: what sort of companies receive advisory support from BL; and, what types of firms benefit most from that support? Our analysis is based on a telephone survey of 2000 firms, around half of which had received intensive assistance from BL between April and October 2003. Probit analysis suggests that the probability of receiving assistance was greater among younger businesses, those with larger numbers of directors in the firm, and those with more gender diversity among the firm's leadership team. Our business-growth models suggest that BL intensive assistance was having a positive effect on employment growth in 2003. BL had a positive but insignificant impact on sales growth over the period. Employment growth effects tend to be larger where firms have a management and organisational structure, which is more conducive to absorbing and making use of external advice. The analysis suggests that BL might increase its impact through targeting these larger, more export-orientated, businesses. Employment growth effects differ little, however, depending on either the ethnic or the gender diversity of the leadership team.

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

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

TRial of an Educational intervention on patients' knowledge of Atrial fibrillation and anticoagulant therapy, INR control, and outcome of Treatment with warfarin (TREAT)

Background Atrial fibrillation (AF) patients with a high risk of stroke are recommended anticoagulation with warfarin. However, the benefit of warfarin is dependent upon time spent within the target therapeutic range (TTR) of their international normalised ratio (INR) (2.0 to 3.0). AF patients possess limited knowledge of their disease and warfarin treatment and this can impact on INR control. Education can improve patients' understanding of warfarin therapy and factors which affect INR control. Methods/Design Randomised controlled trial of an intensive educational intervention will consist of group sessions (between 2-8 patients) containing standardised information about the risks and benefits associated with OAC therapy, lifestyle interactions and the importance of monitoring and control of their International Normalised Ratio (INR). Information will be presented within an 'expert-patient' focussed DVD, revised educational booklet and patient worksheets. 200 warfarin-naïve patients who are eligible for warfarin will be randomised to either the intervention or usual care groups. All patients must have ECG-documented AF and be eligible for warfarin (according to the NICE AF guidelines). Exclusion criteria include: aged < 18 years old, contraindication(s) to warfarin, history of warfarin USE, valvular heart disease, cognitive impairment, are unable to speak/read English and disease likely to cause death within 12 months. Primary endpoint is time spent in TTR. Secondary endpoints include measures of quality of life (AF-QoL-18), anxiety and depression (HADS), knowledge of AF and anticoagulation, beliefs about medication (BMQ) and illness representations (IPQ-R). Clinical outcomes, including bleeding, stroke and interruption to anticoagulation will be recorded. All outcome measures will be assessed at baseline and 1, 2, 6 and 12 months post-intervention. Discussion More data is needed on the clinical benefit of educational intervention with AF patients receiving warfarin. Trial registration ISRCTN93952605

The relationship between Common Language and Length of Treatment in Occupational Therapy

The diversity of ethnic and cultural groups and the effects of language in the therapeutic relationship are timely professional issues of concern to occupational therapy practitioners. The tri-ethnic, tri-cultural South Florida area offers a natural environment where one can study how patient-therapist interactions are influenced by language barriers in a diverse society. This study examines the effects of language on the adequacy of occupational therapy services, specifically how language affects the length of the treatment program. The nature of diagnosis therapists' ethnicity, and how they impact treatment outcomes are also addressed. A sample was drawn from the occupational therapy outpatient department of a large county hospital. Data taken from patients' charts examined race, sex, age, diagnosis, and language. Number of treatment sessions and length of treatment were viewed as proxy measures for adequacy. Findings indicate that the effect of language cannot be understood aside from ethnicity. Implications for occupational therapy practice are discussed.

Intergenerational effects of parental substance-related convictions and adult drug treatment court participation on children's school performance.

This study examined the intergenerational effects of parental conviction of a substance-related charge on children's academic performance and, conditional on a conviction, whether completion of an adult drug treatment court (DTC) program was associated with improved school performance. State administrative data from North Carolina courts, birth records, and school records were linked for 2005-2012. Math and reading end-of-grade test scores and absenteeism were examined for 5 groups of children, those with parents who: were not convicted on any criminal charge, were convicted on a substance-related charge and not referred by a court to a DTC, were referred to a DTC but did not enroll, enrolled in a DTC but did not complete, and completed a DTC program. Accounting for demographic and socioeconomic factors, the school performance of children whose parents were convicted of a substance-related offense was worse than that of children whose parents were not convicted on any charge. These differences were statistically significant but substantially reduced after controlling for socioeconomic characteristics; for example, mother's educational attainment. We found no evidence that parent participation in an adult DTC program led to improved school performance of their children. While the children of convicted parents fared worse on average, much--but not all--of this difference was attributed to socioeconomic factors, with the result that parental conviction remained a risk factor for poorer school performance. Even though adult DTCs have been shown to have other benefits, we could detect no intergenerational benefit in improved school performance of their children.

Step-count accuracy of three motion sensors for older and frail medical inpatients

Objectives: To measure the step-count accuracy of an ankle-worn accelerometer, a thigh-worn accelerometer and one pedometer in older and frail inpatients. Design: Cross-sectional design study. Setting: Research room within a hospital. Participants: Convenience sample of inpatients aged ≥65 years, able to walk 20 metres unassisted, with or without a walking-aid. Intervention: Patients completed a 40-minute programme of predetermined tasks while wearing the three motion sensors simultaneously. Video-recording of the procedure provided the criterion measurement of step-count. Main Outcome Measures: Mean percentage (%) errors were calculated for all tasks, slow versus fast walkers, independent versus walking-aid-users, and over shorter versus longer distances. The Intra-class Correlation was calculated and accuracy was visually displayed by Bland-Altman plots. Results: Thirty-two patients (78.1 ±7.8 years) completed the study. Fifteen were female and 17 used walking-aids. Their median speed was 0.46 m/sec (interquartile range, IQR 0.36-0.66). The ankle-worn accelerometer overestimated steps (median 1% error, IQR -3 to 13). The other motion sensors underestimated steps (40% error (IQR -51 to -35) and 38% (IQR -93 to -27), respectively). The ankle-worn accelerometer proved more accurate over longer distances (3% error, IQR 0 to 9), than shorter distances (10%, IQR -23 to 9). Conclusions: The ankle-worn accelerometer gave the most accurate step-count measurement and was most accurate over longer distances. Neither of the other motion sensors had acceptable margins of error.

Effectiveness of early lens extraction for the treatment of primary angle-closure glaucoma (EAGLE): a randomised controlled trial

Background
Primary angle-closure glaucoma is a leading cause of irreversible blindness worldwide. In early-stage disease, intraocular pressure is raised without visual loss. Because the crystalline lens has a major mechanistic role, lens extraction might be a useful initial treatment.

Methods
From Jan 8, 2009, to Dec 28, 2011, we enrolled patients from 30 hospital eye services in five countries. Randomisation was done by a web-based application. Patients were assigned to undergo clear-lens extraction or receive standard care with laser peripheral iridotomy and topical medical treatment. Eligible patients were aged 50 years or older, did not have cataracts, and had newly diagnosed primary angle closure with intraocular pressure 30 mm Hg or greater or primary angle-closure glaucoma. The co-primary endpoints were patient-reported health status, intraocular pressure, and incremental cost-effectiveness ratio per quality-adjusted life-year gained 36 months after treatment. Analysis was by intention to treat. This study is registered, number ISRCTN44464607.

Findings
Of 419 participants enrolled, 155 had primary angle closure and 263 primary angle-closure glaucoma. 208 were assigned to clear-lens extraction and 211 to standard care, of whom 351 (84%) had complete data on health status and 366 (87%) on intraocular pressure. The mean health status score (0·87 [SD 0·12]), assessed with the European Quality of Life-5 Dimensions questionnaire, was 0·052 higher (95% CI 0·015–0·088, p=0·005) and mean intraocular pressure (16·6 [SD 3·5] mm Hg) 1·18 mm Hg lower (95% CI –1·99 to –0·38, p=0·004) after clear-lens extraction than after standard care. The incremental cost-effectiveness ratio was £14 284 for initial lens extraction versus standard care. Irreversible loss of vision occurred in one participant who underwent clear-lens extraction and three who received standard care. No patients had serious adverse events.

Interpretation
Clear-lens extraction showed greater efficacy and was more cost-effective than laser peripheral iridotomy, and should be considered as an option for first-line treatment.

Knowledge of the patients regarding leprosy and adherence to treatment

Leprosy is a chronic infectious disease caused by Mycobacterium leprae. It is known for its great disfiguring capacity and is considered an extremely serious disease to public health worldwide. The state of Ceará ranks 13th in number of cases of leprosy in Brazil, and fourth in Northeastern region, with an average of 2,149 new cases diagnosed every year. This study aimed to evaluate the knowledge of leprosy patients regarding treatment, and to assess the level of treatment adherence and its possible barriers. The study was conducted in the reference center for dermatology, from September 2010 to October 2010, in Fortaleza, Ceará. The study data were collected by means of a structured interview, along with the Morisky-Green test, in order to assess treatment adherence and barriers to adherence. A total of 70 patients were interviewed, out of whom 66 were new cases. The majority of patients were between 42 and 50 years old, and 37 (52.9%) were male. Most patients were clinically classified as presentingmultibacillary leprosy (80%), and 78.6% of them were from Fortaleza, Brazil. The Morisky-Green test indicated that 62.9% of patients presented a low level of adherence (p < 0.005), despite claiming to aware of the disease risks. However, it was observed that 57.1% of the patients had no difficulty adhering to treatment, while 38.6% reported little difficulty. This study shows that despite the patients claiming to be familiar with leprosy and its treatment, the Morisky-Green test clearly demonstrated that they actually were not aware of the principles of therapy, which is evidenced by the low degree of treatment adherence

BAP Guidelines on the Management of Weight Gain, Metabolic Disturbances and Cardiovascular Risk Associated With Psychosis and Antipsychotic Drug Treatment

Excess deaths from cardiovascular disease are a major contributor to the significant reduction in life expectancy experienced by people with schizophrenia. Important risk factors in this are smoking, alcohol misuse, excessive weight gain and diabetes. Weight gain also reinforces service users’ negative views of themselves and is a factor in poor adherence with treatment. Monitoring of relevant physical health risk factors is frequently inadequate, as is provision of interventions to modify these. These guidelines review issues surrounding monitoring of physical health risk factors and make recommendations about an appropriate approach. Overweight and obesity, partly driven by antipsychotic drug treatment, are important factors contributing to the development of diabetes and cardiovascular disease in people with schizophrenia. There have been clinical trials of many interventions for people experiencing weight gain when taking antipsychotic medications but there is a lack of clear consensus regarding which may be appropriate in usual clinical practice. These guidelines review these trials and make recommendations regarding appropriate interventions. Interventions for smoking and alcohol misuse are reviewed, but more briefly as these are similar to those recommended for the general population. The management of impaired fasting glycaemia and impaired glucose tolerance (‘pre-diabetes’), diabetes and other cardiovascular risks, such as dyslipidaemia, are also reviewed with respect to other currently available guidelines. These guidelines were compiled following a consensus meeting of experts involved in various aspects of these problems. They reviewed key areas of evidence and their clinical implications. Wider issues relating to primary care/secondary care interfaces are discussed but cannot be resolved within guidelines such as these.

Finnish Preclinical and Clinical Medical Students as Strategic L2 English Learners: Language Learning Strategies and Communicating with Patients

This thesis focused on medical students’ language learning strategies for patient encounters. The research questions concerned the types of learning strategies that medical students use and the differences between the preclinical students and the clinical students, two groups who have had varying amounts of experience with patients. Additionally, strategy use was examined through activity systems to gain information on the context of language learning strategy use in order to learn language for patient encounters. In total, 130 first-year medical students (preclinical) and 39 fifth-year medical students (clinical) participated in the study by filling in a questionnaire on language learning strategies. In addition, two students were interviewed in order to create activity systems for the medical students at different stages of their studies. The study utilised both quantitative and qualitative research methods; the analysis of the results relies on Oxford’s Strategic Self-Regulation Model in the quantitative part and on activity theory in the qualitative part. The theoretical sections of the study introduced earlier research and theories regarding English for specific purposes, language learning strategies and activity theory. The results indicated that the medical students use affective, sociocultural-interactive and metasociocultural-interactive strategies often and avoid using negative strategies, which hinder language learning or cease communication altogether. Slight differences between the preclinical and clinical students were found, as clinical students appear to use affective and metasociocultural-interactive strategies more frequently compared to the preclinical students. The activity systems of the two students interviewed were rather similar. The students were at different stages of their studies, but their opinions were very similar. Both reported the object of learning to be mutual understanding between the patient and the doctor, which in part explains the preference for strategies that support communication and interaction. The results indicate that the nature of patient encounters affects the strategy use of the medical students at least to some extent.