Meta-analysis of individual patient data from randomised trials: a review of methods used in practice

Background: Meta-analyses based on individual patient data (IPD) are regarded as the gold standard for systematic reviews. However, the methods used for analysing and presenting results from IPD meta-analyses have received little discussion. Methods We review 44 IPD meta-analyses published during the years 1999–2001. We summarize whether they obtained all the data they sought, what types of approaches were used in the analysis, including assumptions of common or random effects, and how they examined the effects of covariates. Results: Twenty-four out of 44 analyses focused on time-to-event outcomes, and most analyses (28) estimated treatment effects within each trial and then combined the results assuming a common treatment effect across trials. Three analyses failed to stratify by trial, analysing the data is if they came from a single mega-trial. Only nine analyses used random effects methods. Covariate-treatment interactions were generally investigated by subgrouping patients. Seven of the meta-analyses included data from less than 80% of the randomized patients sought, but did not address the resulting potential biases. Conclusions: Although IPD meta-analyses have many advantages in assessing the effects of health care, there are several aspects that could be further developed to make fuller use of the potential of these time-consuming projects. In particular, IPD could be used to more fully investigate the influence of covariates on heterogeneity of treatment effects, both within and between trials. The impact of heterogeneity, or use of random effects, are seldom discussed. There is thus considerable scope for enhancing the methods of analysis and presentation of IPD meta-analysis.

How contractors price risk in bids: theory and practice

Formal and analytical models that contractors can use to assess and price project risk at the tender stage have proliferated in recent years. However, they are rarely used in practice. Introducing more models would, therefore, not necessarily help. A better understanding is needed of how contractors arrive at a bid price in practice, and how, and in what circumstances, risk apportionment actually influences pricing levels. More than 60 proposed risk models for contractors that are published in journals were examined and classified. Then exploratory interviews with five UK contractors and documentary analyses on how contractors price work generally and risk specifically were carried out to help in comparing the propositions from the literature to what contractors actually do. No comprehensive literature on the real bidding processes used in practice was found, and there is no evidence that pricing is systematic. Hence, systematic risk and pricing models for contractors may have no justifiable basis. Contractors process their bids through certain tendering gateways. They acknowledge the risk that they should price. However, the final settlement depends on a set of complex, micro-economic factors. Hence, risk accountability may be smaller than its true cost to the contractor. Risk apportionment occurs at three stages of the whole bid-pricing process. However, analytical approaches tend not to incorporate this, although they could.

Built environment education, research and practice: integrating diverse interests to make an impact

The role of the academic in the built environment seems generally to be not well understood or articulated. While this problem is not unique to our field, there are plenty of examples in a wide range of academic disciplines where the academic role has been fully articulated. But built environment academics have tended not to look beyond their own literature and their own vocational context in trying to give meaning to their academic work. The purpose of this keynote presentation is to explore the context of academic work generally and the connections between education, research and practice in the built environment, specifically. By drawing on ideas from the sociology of the professions, the role of universities, and the fundamentals of social science research, a case is made that helps to explain the kind of problems that routinely obstruct academic progress in our field. This discussion reveals that while there are likely to be great weaknesses in much of what is published and taught in the built environment, it is not too great a stretch to provide a more robust understanding and a good basis for developing our field in a way that would enable us collectively to make a major contribution to theory-building, theory-testing and to make a good stab at tackling some of the problems facing society at large. There is no reason to disregard the fundamental academic disciplines that underpin our knowledge of the built environment. If we contextualise our work in these more fundamental disciplines, there is every reason to think that we can have a much greater impact that we have experienced to date.

Atrocities in theory and practice: An introduction

Classical counterinsurgency theory – written before the 19th century – has generally strongly opposed atrocities, as have theoreticians writing on how to conduct insurgencies. For a variety of reasons – ranging from pragmatic to religious or humanitarian – theoreticians of both groups have particularly argued for the lenient treatment of civilians associated with the enemy camp, although there is a marked pattern of exceptions, for example, where heretics or populations of cities refusing to surrender to besieging armies are concerned. And yet atrocities – defined here as acts of violence against the unarmed (non-combatants, or wounded or imprisoned enemy soldiers), or needlessly painful and/or humiliating treatment of enemy combatants, beyond any action needed to incapacitate or disarm them – occur frequently in small wars. Examples abound where these exhortations have been ignored, both by forces engaged in an insurgency and by forces trying to put down a rebellion. Why have so many atrocities been committed in war if so many arguments have been put forward against them? This is the basic puzzle for which the individual contributions to this special issue are seeking to find tentative answers, drawing on case studies.

Reflective practice among MATESOL graduates in the UAE: theoretical construct or ongoing benefit?

Many teacher training programs, including the MATESOL program at the American University of Sharjah (AUS) in United Arab Emirates, encourage their trainees to reflect on their practice. However, whether or not reflection becomes a part of the trainees’ practice once they leave these programs is a thought-provoking question, which formed the core of the current study. The study was qualitative in nature, using interviewing as its method of data collection. The researcher conducted semi-structured interviews with four AUS MATESOL program graduates, and investigated their perceptions of and engagement with reflective practice. The findings of the study indicate that the participants have generally developed an understanding of and appreciation for reflection and reflective practice, are aware of its values, and use different forms of reflection in order to reflect on their practice. However, some of them hold some uncertainties and misconceptions about reflective practice and its different aspects.

Description and process evaluation of pharmacists’ interventions in a pharmacist-led information technology-enabled multicentre cluster randomised controlled trial for reducing medication errors in general practice (PINCER trial)

Objective To undertake a process evaluation of pharmacists' recommendations arising in the context of a complex IT-enabled pharmacist-delivered randomised controlled trial (PINCER trial) to reduce the risk of hazardous medicines management in general practices. Methods PINCER pharmacists manually recorded patients’ demographics, details of interventions recommended, actions undertaken by practice staff and time taken to manage individual cases of hazardous medicines management. Data were coded and double entered into SPSS v15, and then summarised using percentages for categorical data (with 95% CI) and, as appropriate, means (SD) or medians (IQR) for continuous data. Key findings Pharmacists spent a median of 20 minutes (IQR 10, 30) reviewing medical records, recommending interventions and completing actions in each case of hazardous medicines management. Pharmacists judged 72% (95%CI 70, 74) (1463/2026) of cases of hazardous medicines management to be clinically relevant. Pharmacists recommended 2105 interventions in 74% (95%CI 73, 76) (1516/2038) of cases and 1685 actions were taken in 61% (95%CI 59, 63) (1246/2038) of cases; 66% (95%CI 64, 68) (1383/2105) of interventions recommended by pharmacists were completed and 5% (95%CI 4, 6) (104/2105) of recommendations were accepted by general practitioners (GPs), but not completed at the end of the pharmacists’ placement; the remaining recommendations were rejected or considered not relevant by GPs. Conclusions The outcome measures were used to target pharmacist activity in general practice towards patients at risk from hazardous medicines management. Recommendations from trained PINCER pharmacists were found to be broadly acceptable to GPs and led to ameliorative action in the majority of cases. It seems likely that the approach used by the PINCER pharmacists could be employed by other practice pharmacists following appropriate training.

Odd deposits and average practice. A critical history of the concept of structured deposition.

This paper presents a critical history of the concept of ‘structured deposition’. It examines the long-term development of this idea in archaeology, from its origins in the early 1980s through to the present day, looking at how it has been moulded and transformed. On the basis of this historical account, a number of problems are identified with the way that ‘structured deposition’ has generally been conceptualized and applied. It is suggested that the range of deposits described under a single banner as being ‘structured’ is unhelpfully broad, and that archaeologists have been too willing to view material culture patterning as intentionally produced – the result of symbolic or ritual action. It is also argued that the material signatures of ‘everyday’ practice have been undertheorized and all too often ignored. Ultimately, it is suggested that if we are ever to understand fully the archaeological signatures of past practice, it is vital to consider the ‘everyday’ as well as the ‘ritual’ processes which lie behind the patterns we uncover in the ground.

Problematising accounting for biodiversity

Purpose – This paper seeks to problematise “accounting for biodiversity” and to provide a framework for analysing and understanding the role of accounting in preserving and enhancing biodiversity on Planet Earth. The paper aims to raise awareness of the urgent need to address biodiversity loss and extinction and the need for corporations to discharge accountability for their part in the current biodiversity crisis by accounting for their biodiversity-related strategies and policies. Such accounting is, it is believed, emancipatory and leads to engendering change in corporate behaviour and attitudes. Design/methodology/approach – The authors reviewed the literature relating to biodiversity across a wide array of disciplines including anthropology, biodiversity, ecology, finance, philosophy, and of course, accounting, in order to build an image of the current state of biodiversity and the role which accounting can and “should” play in the future of biodiversity. Findings – It is found that the problems underlying accounting for biodiversity fall into four broad categories: philosophical and scientific problems, accountability problems, technical accounting problems, and problems of accounting practice. Practical implications – Through establishing a framework problematising biodiversity, a roadmap is laid out for researchers and practitioners to navigate a route for future research and policymaking in biodiversity accounting. It is concluded that an interdisciplinary approach to accounting for biodiversity is crucial to ensuring effective action on biodiversity and for accounting for biodiversity to achieve its emancipatory potential. Originality/value – Although there is a wealth of sustainability reporting research, there is hardly any work exploring the role of accounting in preserving and enhancing biodiversity. There is no research exploring the current state of accounting for biodiversity. This paper summarises the current state of biodiversity using an interdisciplinary approach and introduces a series of papers devoted to the role of accounting in biodiversity accepted for this AAAJ special issue. The paper also provides a framework identifying the diverse problems associated with accounting for biodiversity.

State practice, customary humanitarian law and civilian casualties of armed conflict

The article examines the customary international law credentials of the humanitarian law rules proposed by the International Committee of the Red Cross (ICR) in 2005. It relies on the BIICL/Chatham House analysis as a ‘constructive comment’ on the methodology of the ICRC study and the rules formed as a result of that methodology with respect to the dead and missing as an aid to determination of their customary law status. It shows that most of the rules studied have a customary international lawpedigree which conforms to the conclusions formed on the rules generally in the Wilmshurst and Breau study. However, the rules with respect to return of personal effects, recording location of graves and notification of relatives of access to gravesites do not seem to have even on a majoritarian/deductive approach enough volume of state practice to establish them as customary with respect to civilians.

Theory and practice of industrial policy: evidence from the Latin American experience

Includes bibliography

Die Universalität der Hermeneutik

In dieser Dissertation Die Universalität der Hermeneutik wurde die folgenden zwei Fragen behandelt: Erstens: kann die Psychoanalyse - konkreter gesagt, die Übertragungssituation in dem szenischen Verstehen - eine Ausnahme von der Universalität der Hermeneutik darstellen? Zweitens: ist kritische Reflexion überhaupt moglich?, und konnen die Universalität der Hermeneutik und die kritische Reflexion miteinander in Übereinstimmung gebracht werden? Durch das szenische Verstehen erlautert Habermas den Vorgang, wie die Umgangssprache des Patienten von dem Analytiker analysiert wird. Zumal in der Übertragungssituation ist der Gegenstand des Symptoms des Patienten nichts anderes als der Analytiker selbst, und demzufolge kann der Analytiker selbst dann an dem Symptom seines Patienten teilnehmen. Durch diese Teilnahme kann er die Bedeutung des Symptoms seines Patienten genau erfassen. Aber wenn der Analytiker nicht das Unbewusste, das sein Patient ihm offenbart, umgangssprachlich akzeptiert hätte, oder anders gesagt, wenn das Unbewusste des Patienten sich dem Analytiker nicht als "ein Gesagtes" gezeigt hätte, hätte der Analytiker auf keinem Fall daraus etwas erfassen können. Infolgedessen kann die Psychoanalyse nicht das Gegenbeispiel fur die Universalität der Hermeneutik werden. Damit die kritische Reflexion möglich wäre, müssten vor allem unser Bewusstsein und die Sprache voneinander getrennt werden. Deswegen wurde in dieser Arbeit behauptet, dass sie - obwohl es in der Tat selbstverstandlich unmöglich ist - aber sehr wohl rein begrifflich gesehen voneinander getrennt und unterschieden werden können. In diesem Fall kann das Einflussverhältnis zwischen der Sprache und den außersprachlichen Faktoren in das Einflussverhältnis zwischen der "Arbeit und Herrschaft" und der Sprache und unserem Bewusstsein, unterteilt und differenziert werden: Arbeit und Herrschaft übt auf die Sprache Einfluss aus, und die Sprache übt auf unser Bewusstsein Einfluss aus. Und mit der Tatsache, dass die Praxis des Verstehens verändert wird, kann man beweisen, dass unser Bewusstsein auf die Arbeit und Herrschaft Einfluss ausüben kann. Und das bedeutet, dass unser Bewusstsein, obwohl es nur mittelbar ist, auf jeden Fall auch auf die Sprache Einfluss ausüben kann. Infolgedessen, wenn die Universalität der Hermeneutik gültig ist, kann man auch sagen, dass auf dieselbe Weise, die kritische Reflexion Habermas´ möglich ist. Und diese Einflussverhältnisse sind aber in dauernder Zirkulationsbewegung. Und diese Zirkulationsbewegung an sich ist das Wesen des Menschen, und daraus bildet sich seine Geschichte.

Benefits from the use of a pimecrolimus-based treatment in the management of atopic dermatitis in clinical practice. Analysis of a Swiss cohort

BACKGROUND: Controlled studies established the efficacy and good tolerability of pimecrolimus cream 1% for the treatment of atopic dermatitis but they may not reflect real-life use. OBJECTIVE: To evaluate the efficacy, tolerability and cosmetic acceptance of a pimecrolimus-based regimen in daily practice in Switzerland. METHODS: This was a 6-month, open-label, multicentre study in 109 patients (55% > or = 18 years) with atopic dermatitis. Pimecrolimus cream 1% was incorporated into patients' standard treatment protocols. RESULTS: The pimecrolimus-based treatment was well tolerated and produced disease improvement in 65.7% of patients. It was particularly effective on the face (improvement rate: 75.0%). Mean pimecrolimus consumption decreased from 6.4 g/day (months 1-3) to 4.0 g/day (months 3-6) as disease improved. Most patients (74.1%) rated their disease control as 'complete' or 'good' and 90% were highly satisfied with the cream formulation. CONCLUSION: The use of a pimecrolimus-based regimen in everyday practice was effective, well tolerated and well accepted by patients.

Accuracy of Preoperative Endoscopic Ultrasound (EUS) to Distinguish Between Early and Locally Advanced Esophageal Cancer in Daily Clinical Practice

Introduction: Preoperative chemoradiotherapy is generally recommended for locally advanced esophageal cancer (clinical stage T3 or T4 or nodal positive disease) but not for early cancer (clinical stage T0 to T2, N0). EUS has been described as the most accurate method to distinguish between early and locally advanced stage in several studies. Recently however, the high accuracy of EUS (90% or higher) was questioned by some investigators. This raises the issue whether the results of studies focused on EUS accuracy may be directly translated into daily clinical practice. Aim & Methods: The aim of this retrospective analysis was to assess the accuracy of preoperative EUS to distinguish between early and locally advanced esophageal cancer in daily clinical practice outside a study setting. EUS was performed by several investigators, including trainees in one university hospital. For this purpose, EUS reports and patient files (medical and surgical) including histological reports of 300 consecutive pts with esophageal tumors were reviewed. In pts with adenocarcinoma or squamous cell cancer and surgical resection without previous radio-/chemotherapy, EUS tumor staging was compared with histological diagnosis. Results: Out of the 300 consecutive pts with esophageal tumor and EUS 102 pts had esophageal surgery after EUS-staging without any radio-/chemotherapy. In 93 pts oesophageal cancer was confirmed, whereas 9 had other tumors. The mean age was 65 years (range 27-89), sex ratio female:male was 1:3.2. To distinguish between early and late tumor stage, the accuracy was 85%. The sensitivity and specificity for early cancer was 59%, and 93%, respectively. The diagnostic accuracy for local tumor spread was 90%, 90%, 68%, 69%, 89% for pT0, pT1, pT2, pT3 and pT4 lesions, respectively. The overall accuracy for T-stage was 74%. For pN-positive staging the accuracy of EUS was 73%. Conclusion: In daily clinical practice, the accuracy of EUS in assessing esophageal tumor staging is lower than in specific studies focusing on EUS accuracy. Mainly early esophageal cancer stages were overstaged. Thus, the implementation of recommendations for diagnostic work-up of esophageal cancer patients resulting from highly specific studies should consider the appropriate clinical setting.

Sweat testing practice in Swiss hospitals

AIMS: To determine whether the current practice of sweat testing in Swiss hospitals is consistent with the current international guidelines. METHODS: A questionnaire was mailed to all children's hospitals (n = 8), regional paediatric sections of general hospitals (n = 28), and all adult pulmonology centres (n = 8) in Switzerland which care for patients with cystic fibrosis (CF). The results were compared with published "guidelines 2000" of the American National Committee for Clinical Laboratory Standards (NCCLS) and the UK guidelines of 2003. RESULTS: The response rate was 89%. All 8 children's hospitals and 18 out of 23 answering paediatric sections performed sweat tests but none of the adult pulmonology centres. In total, 1560 sweat tests (range: 5-200 tests/centre/year, median 40) per year were done. 88% (23/26) were using Wescor systems, 73% (19/26) the Macroduct system for collecting sweat and 31% (8/26) the Nanoduct system. Sweat chloride was determined by only 62% (16/26) of all centres; of these, only 63% (10/16) indicated to use the recommended diagnostic chloride-CF-reference value of >60 mmol/l. Osmolality was measured in 35%, sodium in 42% and conductivity in 62% of the hospitals. Sweat was collected for maximal 30-120 (median 55) minutes; only three centres used the maximal 30 minutes sample time recommended by the international guidelines. CONCLUSIONS: Sweat testing practice in Swiss hospitals was inconsistent and seldom followed the current international guidelines for sweat collection, analyzing method and reference values. Only 62% were used the chloride concentration as a diagnostic reference, the only accepted diagnostic measurement by the NCCLS or UK guidelines.

Osteoporosis case finding in the general practice: phalangeal radiographic absorptiometry with and without risk factors for osteoporosis to select postmenopausal women eligible for lumbar spine and hip densitometry

Mass screening for osteoporosis using DXA measurements at the spine and hip is presently not recommended by health authorities. Instead, risk factor questionnaires and peripheral bone measurements may facilitate the selection of women eligible for axial bone densitometry. The aim of this study was to validate a case finding strategy for postmenopausal women who would benefit most from subsequent DXA measurement by using phalangeal radiographic absorptiometry (RA) alone or in combination with risk factors in a general practice setting. The sensitivity and specificity of this strategy in detecting osteoporosis (T-score < or =2.5 SD at the spine and/or the hip) were compared with those of the current reimbursement criteria for DXA measurements in Switzerland. Four hundred and twenty-three postmenopausal women with one or more risk factors for osteoporosis were recruited by 90 primary care physicians who also performed the phalangeal RA measurements. All women underwent subsequent DXA measurement of the spine and the hip at the Osteoporosis Policlinic of the University Hospital of Berne. They were allocated to one of two groups depending on whether they matched with the Swiss reimbursement conditions for DXA measurement or not. Logistic regression models were used to predict the likelihood of osteoporosis versus "no osteoporosis" and to derive ROC curves for the various strategies. Differences in the areas under the ROC curves (AUC) were tested for significance. In women lacking reimbursement criteria, RA achieved a significantly larger AUC (0.81; 95% CI 0.72-0.89) than the risk factors associated with patients' age, height and weight (0.71; 95% C.I. 0.62-0.80). Furthermore, in this study, RA provided a better sensitivity and specificity in identifying women with underlying osteoporosis than the currently accepted criteria for reimbursement of DXA measurement. In the Swiss environment, RA is a valid case finding tool for patients with risk factors for osteoporosis, especially for those who do not qualify for DXA reimbursement.