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On the nature of the neural abnormality in human amblyopia; neural aberrations and neural sensitivity loss
In this investigation contrast threshold measurements are compared with supra-threshold perception for a group of human amblyopes. The results indicate that human amblyopia involves, in some cases, not only loss of sensitivity but spatial distortion. Thus a new group of amblyopes can now be identified in which only distortion occurs. These results have important physiological implications for both the normal and abnormal visual systems. Neurophysiologists investigating visual loss from deprivation should assess whether similar distortions occur in animals. This question may hold the answer to whether the present animal models are relevant to the human condition. © 1978 Springer-Verlag.
Drug prescription and self-medication in India: An exploratory survey
This paper reports a study of the prescribing and dispensing of drugs in India. The drugs supplied to 2400 patients by the public and private medical sectors and by private pharmacies (over the counter dispensing) were recorded, and were analysed with respect to the patient's presenting complaint and diagnosis. The main findings discussed in this paper are: 1. 1. Large numbers of drugs are prescribed by doctors in the private sector. Combination preparations containing 'hidden' classes of drug are often given. Anti-infectives are widely and often inappropriately used. 2. 2. Potentially dangerous drugs are sold over the counter and prescribed for trivial or bizzare indications. Drugs which have been withdrawn as dangerous in the West remain popular first line drugs in India. 3. 3. Food supplements and tonics of dubious nutritional and pharmacological value make up a high proportion of the total drugs bill. It is concluded that a rational drugs policy and/or an essential drugs list will be useless unless accompanied by intensive efforts to improve the education and updating of doctors and pharmacists and to reduce the commercial pressures on doctors to prescribe unnecessary drugs. © 1987.
Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project.
In 2005 we published draft guidelines for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). We describe the consensus process, which included informal feedback, formal written commentaries, input from publication guideline developers, review of the literature on the epistemology of improvement and on methods for evaluating complex social programs, and a meeting of stakeholders for critical review of the guidelines' content and wording, followed by commentary on sequential versions from an expert consultant group. Finally, we examine major differences between SQUIRE and the initial draft, and consider limitations of and unresolved questions about SQUIRE; we also describe ancillary supporting documents and alternative versions under development, and plans for dissemination, testing, and further development of SQUIRE.
How Do You Modernize a Health Service? A Realist Evaluation of Whole-Scale Transformation in London
Context: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to " modernize" these services with a view to making health care more efficient, effective, and patient centered. Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the context-mechanism-outcome relationship using the guiding question "what works, for whom, under what circumstances?" Findings: In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended). Conclusions: This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers. © 2009 Milbank Memorial Fund.
Publication guidelines for quality improvement studies in health care: evolution of the SQUIRE project.
In 2005 we published draft guidelines for reporting studies of quality improvement, as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as standards for quality improvement reporting excellence (SQUIRE). This narrative progress report summarises the special features of improvement that are reflected in SQUIRE, and describes major differences between SQUIRE and the initial draft guidelines. It also briefly describes the guideline development process; considers the limitations of and unresolved questions about SQUIRE; describes ancillary supporting documents and alternative versions under development; and discusses plans for dissemination, testing, and further development of SQUIRE.
Publication guidelines for improvement studies in health care: evolution of the SQUIRE Project.
In 2005, draft guidelines were published for reporting studies of quality improvement as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as Standards for QUality Improvement Reporting Excellence (SQUIRE). This narrative progress report summarizes the special features of improvement that are reflected in SQUIRE and describes major differences between SQUIRE and the initial draft guidelines. It also explains the development process, which included formulation of responses to informal feedback, written commentaries, and input from publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programs; and a meeting of stakeholders for critical review of the guidelines' content and wording, followed by commentary on sequential versions from an expert consultant group. Finally, the report discusses limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions under development; and plans for dissemination, testing, and further development of SQUIRE.
Getting a Better Grip on Research: The Fate of Those Who Ignore History
Those who ignore history are doomed to repeat it George Santayana American philosopher and poet, 1863–1952 This is the first paper in a series of five describing the use of evidence to support decisions made in clinical practice. The series covers large elements of Statement 2: The general practice consultation, Statement 3.3: Ethics and values based medicine and Statement 3.5: Evidence-based practice of the GP Curriculum.
'We Have Your Medical Record on File': Researching Unpopular Government Policy
The English Department of Health recently introduced the Internet-accessible Summary Care Record (SCR), a summary of personal medical data intended for emergency use and drawn from the GP-held record of NHS patients. The SCR is the most controversial component of the £12 billion NHS IT project. If it goes to plan, around 40 million medical records will be uploaded, and up to a million staff in ten thousand organisations will have access to them. Countless megabytes of sensitive personal data will be available to staff who can claim a ‘legitimaterelationship’ to the patient (and, say critics, to nosey receptionists and hackers).
Getting a Better Grip on Research: The Organizational Dimension
This is the fourth paper in a series of five describing the use of evidence to support decisions made in clinical practice. The series covers large elements of statement 2: The general practice consultation, statement 3.5: Evidence-based practice of the GP curriculum.
Emerging distance degree programs.
The variation in program focus and style is examined in this column, which also identifies resources for evaluation. The integration of Web-based or other distance modality materials to conventional courses, and the expansion of traditional universities to include a virtual campus, should proceed with caution and systematic evaluation. It is an evolution that offers both rewards and pitfalls, but requires more rigorous examination. This article provides information about pedagogical issues and additional distance-education master's degree programs. Some are new, while others are established.
Development of the SQUIRE Publication Guidelines: evolution of the SQUIRE project.
These guidelines address the development and testing of interventions to improve the quality and safety of health care.
Publication guidelines for quality improvement in health care: evolution of the SQUIRE project.
In 2005, draft guidelines were published for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. This article contains the full revised version of the guidelines, which the authors refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). This paper also describes the consensus process, which included informal feedback from authors, editors and peer reviewers who used the guidelines; formal written commentaries; input from a group of publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programmes; a two-day meeting of stakeholders for critical discussion and debate of the guidelines' content and wording; and commentary on sequential versions of the guidelines from an expert consultant group. Finally, the authors consider the major differences between SQUIRE and the initial draft guidelines; limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions that are under development; and plans for dissemination, testing and further development of SQUIRE.