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On World Menopause Day, Dr Anne-Marie Boylan discusses how women deserve better when it comes to options for supporting themselves through menopause.
Educating healthcare students in the Sustainable Development Goals: from translational science to translational humanities.
Healthcare courses typically approach Sustainable Development Goals (SDGs) education from a 'translational science' perspective. Students are taught about 'evidence-based' interventions, which are developed through scientific research (hence, assumed to be politically neutral), implemented with 'fidelity' (ie, in a standardised way in diverse contexts) and then 'rolled out'. Progress is measured using standardised indicators. We argue for a shift to 'translational humanities', in which students are supported to engage critically with the cultural and political dynamics and epistemic uncertainties underpinning the setting of SDG targets, the development and implementation of programmes, and the measurement of success. Translational humanities seeks to surface alternative framings and measures of success, especially by giving voice to marginalised and ignored communities. This radical approach, informed by political philosophy, recognises that conflict among stakeholders and the uncertainty it generates are inevitable and can be a productive force (eg, if surfaced and used to inform multifaceted debate and values-driven action).Whereas a translational science approach to SDG education emphasises objectivity, technical precision and (the pursuit of) certainty, a translational humanities approach seeks to foster human and interpretive qualities such as reflection, critical thinking, commitment to human rights and fairness, appreciation of complexity, epistemic humility and flexibility, willingness to examine problems from multiple angles, the capacity to adapt, and tolerance of uncertainty. In a worked example of how this can be achieved, we introduce the 'critical datathon'-a group exercise in which students engage deeply with case studies of SDGs, examine the assumptions and interests behind conventional solutions, and navigate diverse implementation contexts.
Retrospective analysis of the global antibiotic residues that exceed the predicted no effect concentration for antimicrobial resistance in various environmental matrices.
BackgroundAntimicrobial resistance (AMR) is a growing public health concern. Recent research has suggested that interactions between pathogens and antibiotic residues in various environmental matrices promote the development and spread of AMR in the environment. The levels of antibiotic residues in the aquatic environment have been analysed globally. Recently, Predicted No Effect Environmental Concentration (PNEC) values for many antibiotics have been suggested, based on their estimated minimal selective concentrations for selected bacterial species. The PNEC values can serve as a guide on the maximum levels of antibiotic residues in an environmental matrix, below which resistance is unlikely to develop.AimWe aimed to determine which of the antibiotics, considered as "priority antibiotics" by the World Health Organisation (WHO), most frequently exceeded their PNEC values in the global aquatic environment.MethodsWe obtained data from the German Environment Agency pharmaceutical database on means, medians or single values of 12 antibiotic types in five different environmental matrices [municipal wastewater treatment plant effluent, industrial wastewater effluent, hospital wastewater effluent, surface water, and drinking water] across 47 countries. We compared the mean levels of the 12 antibiotics in each environmental matrix to their suggested PNEC values to determine which antibiotic types exceeded PNEC and were most likely to select for resistance. We also determined which environmental matrices and countries had the highest burden of antibiotic residues.ResultsOur study revealed that 7.9% of all analyses of antibiotic residues performed in the environmental matrices globally exceeded PNEC. Ciprofloxacin and clarithromycin had the greatest proportion (>30%) of residues exceeding PNEC. Hospital wastewater and industrial wastewater had the highest burden of antibiotic residues exceeding PNEC. No antibiotics exceeded PNEC in drinking water.ConclusionWhile most environmental monitoring studies have focused on municipal wastewater treatment plants, the limited number of studies on hospital wastewater and industrial wastewater revealed that a large number of antibiotic residues coming from these sources exceeded their PNEC values. Our study highlights the importance of implementing on-site treatment systems that aim to destroy antibiotics prior to discharging wastewater to surface waters. Attention needs to be focused on the role that environmental matrices, particularly our wastewater sites, play in promoting antibiotic resistance. Novel treatment technologies need to be developed and implemented to increase the removal efficiencies of treatment plants and from antibiotic manufacturing, and decrease the discharge of antibiotic residues into aquatic environments.
A Sustainable Future in Digital Health: Leveraging Environmentally Friendly Architectural Tactics for Sustainable Data Processing
The rapid growth of big data in healthcare necessitates optimising data processing to reduce its environmental impact. This paper proposes a pilot architectural framework to evaluate the sustainability of a Big Healthcare Data (BHD) system using Microservices Architecture (MSA). The goal is to enhance MSA's architectural tactics by incorporating environmentally friendly metrics into healthcare systems. This is achieved by adopting energy and carbon efficiency models, alongside exploring innovative architectural strategies. The framework, based on recent research, manipulates cloud-native system architecture by using a controller to adjust microservice deployment through real-time monitoring and modelling. This approach demonstrates how sustainability-driven metrics can be applied at different abstraction levels to estimate environmental impact from multiple perspectives.
Sociodemographic Profile of People with Diagnosed Pancreatic Cancer in the UK: Retrospective Sentinel Network Cohort Study
Pancreatic cancer is a devasting disease which is an increasing cause of cancer mortality. The aim of this study was to characterise, using descriptive statistics, the sociodemographic, risk and clinical characteristics of who develops pancreatic cancer. This retrospective cohort study examined data from one of the largest UK primary care databases, from January 1st 2006 to August 31st 2020. A total of 573 primary care practices contributed data. There were 9,267 people diagnosed with pancreatic cancer. The median age at diagnosis was 73 years (IQR 16) and 49.8% (4,616) of people were female. Nearly a third (30.2%, 2,798) of people had diabetes, and 85.8% (2,400) of the people with diabetes received the diabetes diagnosis before pancreatic cancer. For people for whom ethnicity was recorded 94.4% (5,979) were white. Under half of people with BMI recorded (41.9%, 571) were overweight or obese at pancreatic cancer diagnosis and 5.9% (80) were underweight. In addition, 12.6% (1,168) of participants were active smokers and 1.4% (130) exceeded recommended limits of alcohol. Improved characterisation of the sociodemographic, risk and clinical characteristics of who develops pancreatic cancer highlights the opportunity for machine learning and other technologies to flag people at high risk of this cancer.
Healthcare Data Quality Language (HDQL): Streamlining the Translation of Healthcare System Requirements into Software Quality Attributes
Existing software quality definition models often fall short in addressing the dynamic and evolving requirements of Healthcare Information Systems (HIS), particularly the unique regulatory and infrastructural challenges inherent to healthcare environments. This poster introduces the Healthcare Data Quality Language (HDQL), a novel framework designed to bridge the gap between HIS requirements and software quality attributes. HDQL enables healthcare professionals to intuitively define software features tailored to their needs, fostering improved system acceptance, enhanced performance, and system evolution.
Barriers and Opportunities in Developing Health Information System (HIS) Architectures to Support Universal Health Coverage in Resource-Limited Settings
Health Information Systems (HIS) are critical for effective healthcare delivery, especially in resource-limited settings, where access to quality care is challenging. HIS supports Universal Health Coverage (UHC) delivery by managing health data efficiently and aligning national health policies with organisational needs for a more patient-centred approach. This paper explores the barriers and opportunities in developing robust HIS software architectures in such healthcare settings. Key barriers include unreliable infrastructure, insufficient technical support, poor data quality, and financial constraints. However, opportunities for improvement exist, such as adopting interoperable systems, open-source standards, cloud-based solutions, modular upgrades, and capacity-building initiatives. Involving key stakeholders and developing strong policy frameworks are also essential. Future research should focus on improving global interoperability, data quality, sustainability, and scalability to ensure HIS can support UHC goals in resource-limited environments.
General practice characteristics associated with emergency hospital attendances for ambulatory care sensitive conditions
BACKGROUND: Ambulatory care sensitive conditions (ACSC) can be managed in primary care and high-quality care should reduce emergency hospital attendances (EHA) due to ACSC. AIM: To identify general practice characteristics associated with different levels of EHA for ACSC. METHOD: Composite index analysis, including agglomerative hierarchical clustering. Data (2019) from the English general practice workforce minimum data set (wMDS), openly available practice indicators, and hospital-linked routine pseudonymised primary care records. Clustering was performed at practice level. Logistic regression, controlling for patient-level factors, explored if the odds of EHA differed across clusters. RESULTS: Two clusters were identified. Cluster 1, n = 281 practices, 3 175 300 patients - the partnership training model, had: more practices with a GMS contract (70.1% versus 45.4%, P<0.001) and providing GP training (73.0% versus 38.0% P<0.001), partners accounting for a higher proportion of total GP FTE (63.4% versus 29.5%, P<0.001), fewer encounters per patient per year (10 versus 20), higher proportions of patients reporting good experiences (85.9% versus 79.2%, p<0.001). Cluster 2, n = 97 practices, 1 163 030 patients - the multiprofessional urban deprived model had: lower proportions of practice FTE performed by GPs (19.4% versus 23.9%, P<0.001), higher proportions of encounters delivered by other healthcare professionals (15.5% versus 5.7%, P<0.001), more urban practices (90.7% versus 80.0%, P<0.01, greater deprivation (P = 0.02). The odds of EHA in Cluster 1 was 11% lower than Cluster 2 (P<0.0001). CONCLUSION: These findings have implications for policies about the partnership model, and current trends that encourage more encounters with a multiprofessional team.
Developmental Insights from Modelling the Digital Maturity of the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC)
The Oxford-RCGP Research and Surveillance Centre (RSC) is one of the largest health surveillance systems in Europe, using real-world primary care data to inform public health policy and clinical practice. As UK general practice has evolved digitally and the demand for strong information governance (IG) has increased, the RSC has expanded its technological capabilities. This paper applies a Digital Maturity Model (DMM) to assess the RSC's progress across five dimensions and ten key informatics and IG elements. The analysis highlights the RSC's strengths in meeting public health needs and identifies areas for improvement. This review identifies predictive analytics, cloud-based services, multi-dimensional modelling, and advanced visualisations as areas for future development.
Randomized trial of inhaled fluticasone propionate in chronic stable pulmonary sarcoidosis: A pilot study
Pulmonary sarcoidosis is a disease in which the pathological processes are distributed along lymphatic pathways, particularly those around the broncho-vascular bundles. Delivery of disease-modulating drugs by the inhaled route is therefore an attractive option. The aim of this study was to determine the efficacy of inhaled fluticasone propionate 2 mg·day-1 in adults with stable pulmonary sarcoidosis. Forty-four adult patients (22 from each centre) were enrolled from outpatient clinics in two London teaching hospitals in a two centre, double-blind, randomized, placebo-controlled trial. Primary end points were home recordings of peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), and forced vital capacity (FVC). Secondary end points were symptom scores, use of rescue bronchodilator medication, and clinic values for PEFR, FEV1, FVC, forced mid-expiratory flow (FEF25-75%), diffusion capacity of the lung for carbon monoxide (DL,CO), and total lung capacity (TLC). Symptom scores of cough, breathlessness and wheeze were lower in the active treatment group, but this did not reach statistical significance, and a general health perception assessment (Short Form (SF)-36) showed a difference between active and placebo treatment. No significant differences were found between the two groups in any physiological outcome measure. No new adverse reactions were detected. The results of this pilot study do not show an objective benefit of inhaled fluticasone propionate in pulmonary sarcoidosis where the disease is stable and is controlled without the use of inhaled corticosteroids.
Collecting stories: Is it research? Is it good research? Preliminary guidance based on a Delphi study
Context: The use of narratives (stories) in research, education, audit and evaluation is increasingly common, but there is no consensus on when research ethics committee approval is necessary for such studies or what counts as 'good narrative research'. Objective: This study aimed to produce preliminary guidance for researchers, reviewers and ethics committees on what to classify as narrative research in health care and how to evaluate it. Methods: We carried out a 3-round Delphi study on a volunteer sample of 20 academic researchers, practitioners and service users who were active in narrative health research and its application. After reading academic papers on narrative theory and method, and via extensive online discussion, participants generated a set of preliminary statements. Each participant ranked these on a 9-point Likert scale for relevance and validity (round 1), and then received feedback on his or her scorings compared with the group median and range for each item. This cycle of group discussion, revision of statements, individual rankings and aggregation of scores was repeated twice. Results: The study produced a definition of narrative research which allows such work to be distinguished from the non-research use of stories in health care, and preliminary quality standards for evaluating narrative research. Most participants on this heterogeneous panel felt able to sign up to the final guidance. Residual disagreements were generally attributable to incommensurabilities in philosophical positions. Conclusions: Research ethics committees and scientific reviewers may find the guiding principles in this paper a useful starting point for further reflection and discussion about narrative research studies. © Blackwell Publishing Ltd 2008.
Recognizing rhetoric in health care policy analysis
Critiques of the 'naïve rationalist' model of policy-making abound in the sociological and political science literature. Yet academic debate on health care policy-making continues to be couched in the dominant discourse of evidence-based medicine, whose underlying assumptions - that policies are driven by facts rather than values and these can be clearly separated; that 'evidence' is context-free, can be objectively weighed up and placed unproblematically in a 'hierarchy'; and that policy-making is essentially an exercise in decision science - have constrained both thinking and practice. In this paper, drawing on theoretical work from political science and philosophy, and innovative empirical work in the health care sector, we argue that health care is well overdue for a re-defining of what policy-making is. Policy-making is the formal struggle over ideas and values, played out by the rhetorical use of language and the enactment of social situations. While the selection, evaluation and implementation of research evidence are important in the policy-making process, they do not equate to that process. The study of argument in the construction of policy has the potential to illuminate dimensions of the process that are systematically occluded when policy-making is studied through a naïve rationalist lens. In particular, a rhetorical perspective highlights the struggle over ideas, the 'naming and framing' of policy problems, the centrality of audience and the rhetorical use of language in discussion to increase the audience's adherence to particular framings and proposals. Rhetorical theory requires us to redefine what counts as 'rationality' - which must extend from what is provably true (by logic) and probably true (by Bayesian reasoning) to embrace, in addition, that which is plausibly true (i.e. can convince a reasonable audience). Future research into health care policy-making needs to move beyond the study of 'getting evidence into practice' and address the language, arguments and discourse through which policy is constructed and enacted. © The Royal Society of Medicine Press Ltd 2008.
Reframing evidence synthesis as rhetorical action in the policy making drama.
This paper presents a novel conceptualization of policy making as social drama. The selection and presentation of evidence for policy making, including the choice of which questions to ask, which evidence to compile in a synthesis and which syntheses to bring to the policy making table, should be considered as moves in a rhetorical argumentation game and not as the harvesting of objective facts to be fed into a logical decision-making sequence. Viewing policy making as argument does not mean it is beyond rationality--merely that we must redefine rationality to include not only logical inference and probabilistic reasoning, but also the consideration of plausibility by a reasonable audience. We need better evidence, but we also urgently need better awareness by policy makers of the language games on which their work depends.
Diabetes in British South Asians: Nature, nurture, and culture
Diabetes mellitus and its complications account for a high proportion of avoidable morbidity and premature mortality in people of South Asian origin living in the UK. This review examines available evidence as to why this might be and what can be done to address the problems. The sources for data were a Medline search by MeSH terms, free text and key authors by name, and relevant references, searched by hand, from all review articles in the AIM journals, up to April 1996. Most trials identified were epidemiological surveys. The high instance of diabetes and some of its complications do not have a single explanation. The early incidence of diabetes and its link with coronary heart disease may be partially explained by the central adiposity-insulin resistance syndrome. Predisposition to this is probably largely genetic but exacerbated by other factors such as diet, immune inflammatory changes, and physical activity levels. There is less evidence to support conventional dietary risk factors and some for potentially deleterious effects of traditional Western dietary advice in this population. The impact of the genetic and environmental influences is exacerbated by suboptimal use of health services. The contribution of economic deprivation to the poor outcome of diabetes in these patients may be substantial. There is a considerable impact of psychosocial stress on morbidity, supporting the view that a narrow biomedical model will neither fully explain the problem nor provide solutions. To be successful, strategies for the secondary prevention of diabetes complications in British South Asians need to incorporate a number of paradigms: genetic, physiological, psychological, anthropological, and sociological. Recommendations for a multidimensional approach to this important clinical issue are proposed.
Narrative based medicine: Narrative based medicine in an evidence based world
Even 'evidence based' clinicians uphold the importance of clinical expertise and judgement. Clinical method is an interpretive act which draws on narrative skills to integrate the overlapping stories told by patients, clinicians, and test results. The art of selecting the most appropriate medical maxim for a particularly clinical decision is acquired largely through the accumulation of 'case expertise' (the stories or 'illness scripts' of patients and clinical anecdotes). The dissonance we experience when trying to apply research findings to the clinical encounter often occurs when we abandon the narrative-interpretive paradigm and try to get by on 'evidence' alone.