What are the main methodological problems in the estimation of placebo effects?

Researchers disagree whether placebo effects are clinically important. The controversy is partly due to conceptual and methodological problems. The objective of this paper is to analyze the main methodological problems in the estimation of placebo effects. Variations in the meaning of the concept of placebo effect are described, and the main methodological problems are analyzed. The notion of placebo effect has at least two main meanings: effect of placebo intervention, and effect of patient-provider interaction. When the terms are defined pragmatically, effects of placebo can be estimated as the difference between placebo and no-treatment in randomized trials. The effect of patient-provider interaction can similarly be assessed by comparing manipulation of the patient-provider interaction with no manipulation. In both cases bias due to lack of double-blinding is a potential problem.     

What sort of networks are public health networks?

BACKGROUND: Re-organization of the English National Health Service (NHS) has fragmented the public health workforce, relocating teams from about 100 health authorities into over 300 primary care trusts (PCTs). The UK Government announced the setting up of public health networks (PHNs) as a solution to the problems created by fragmentation. METHODS: Fifty-seven semi-structured telephone interviews were held with key players in PHNs in all strategic health authority areas in England in early 2003. RESULTS: PHNs appeared to be primarily networks of public health professionals rather than of organizations. Informants were unsure about PCTs' commitment to public health. Predominantly, members were those NHS personnel with a clear and explicit public health role. Most PHNs intended to include others later (e.g. health visitors, environmental health officers), although a few thought that inclusivity was essential from the start. Continuing professional development for public health personnel dominated the work being undertaken, with some collaborative work across PCTs. PHNs were seen as a compulsory reconfiguration of existing networks, and informants doubted that they were appropriate for the many levels of networking that public health work requires. CONCLUSION: The formation of PHNs does not appear to have been either necessary or sufficient. However, the public health community has a well-established tradition of networking, and therefore has the skills to use PHNs advantageously.     

What are the effects of anti‐discriminatory legislation on socioeconomic inequalities in the employment consequences of ill health and disability?

OBJECTIVE: To investigate how anti-discrimination legislation in the form of the UK Disability Discrimination Act (DDA) affected socioeconomic disparities in the employment rates of people with a limiting long-term illness (LLTI) or disability. DESIGN: National cross-sectional data on employment rates for people with and without an LLTI or disability were obtained from the General Household Survey (GHS) for a 14-year period (1990-2003; 12 surveys). Representative population samples were analysed. The sample size for the GHS over the study period ranged from 19,193 to 24,657 and the average response rate ranged from 72% to 82%. MAIN OUTCOME MEASURE: Age-standardised employment rates for individuals with and without an LLTI or disability, analysed by sex and socioeconomic status. RESULTS: Analysis of covariance identified that the DDA had had a negative effect on employment rates for individuals with an LLTI or disability during the study period. This negative effect was found to be differential according to social class ranging from no effect in social classes I and II (-2.86%, 95% CI -8.7% to 2.99%), increasing with social class group, to a highly significant effect in social classes IV and V (-10.7%, 95% CI -6.16% to -15.24%). No differential effect was identified by sex. CONCLUSIONS: Anti-discriminatory legislation is not an effective way of overcoming the employment consequences of ill health and disability, nor is it a useful public policy tool in terms of reducing inequalities.     

What are the limits of adjuvanticity?

Vaccines developed traditionally following empirical approaches have often limited problems of immunogenicity, probably due to the low level of purity of the active component(s) they contain. The application of new technologies to vaccine development is leading to the production of purer (e.g. recombinant) antigens which, however, tend to have a poorer immunogenicity as compared to vaccines of the previous generation. The search for new vaccine adjuvants involves issues related to their potential limits. Since the introduction of aluminium salts as vaccine adjuvants more than 70 years ago, only one adjuvant has been licensed for human use. The development of some of these new vaccine adjuvants has been hampered by their inacceptable reactogenicity. In addition, some adjuvants work strongly with some antigens but not with others, thus, limiting their potentially widespread use. The need to deliver vaccines via alternative routes of administration (e.g. the mucosal routes) in order to enhance their efficacy and compliance has set new requirements in basic and applied research to evaluate their efficacy and safety. Cholera toxin (CT) and labile enterotoxin (LT) mutants given along with intranasal or oral vaccines are strong candidates as mucosal adjuvants. Their potential reactogenicity is still matter of discussions, although available data support the notion that the effects due to their binding to the cells and those due to the enzymatic activity can be kept separated. Finally, adjuvanticity is more often evaluated in terms of antigen-specific antibody titers induced after parenteral immunization. It is known that, in many instances, antigen-specific antibody titers do not correlate with protection. In addition, very little is known on parameters of cell-mediated immunity which could be considered as surrogates of protection. Tailoring of new adjuvants for the development of vaccines with improved immunogenicity/efficacy and reduced reactogenicity will represent one of the major challenges of the ongoing vaccine-oriented research.     

What are the essentials of system integration?

In summary, the Luke article is a solid starting point for understanding the relationships between existing hospital systems, developing regional systems, and ultimate benefits to patients, their employers, and their communities. We clearly have a long way to go though, and the attention should turn to some of the key functional features of integrated systems.     

What are the prospects for enduring comprehensive health care reform?

Enduring reform must cover the uninsured, reduce inefficiency in funding and delivery of care, improve quality, and tame but not destroy the development of new medical technologies. Obstacles to reform include "special interests," especially as they exploit the U.S. political system; Machiavelli's Law of Reform, which favors the status quo; and the inability of reformers to agree on a common approach. Short-term prospects for enduring comprehensive reform are virtually nil. Over five to ten years, prospects are fifty-fifty unless there were a major economic, political, social, or public health crisis. In the long run, major reform is inevitable.     

What are the effects of tobacco policies on vulnerable populations? A better practices review

BACKGROUND: While comprehensive tobacco policies have reduced the prevalence of smoking in Canada, some groups remain vulnerable to tobacco use and display high rates of smoking. This article reviews three types of tobacco policies--tax and price, smoking location restrictions and sales restrictions--and examines the consequences for Aboriginal people, youth and low-income people. METHODS: A better practices review model was used to assess the strength of studies published between 1990 and 2004 that examined the effects of these tobacco policies on the three vulnerable populations of interest. A total of 72 studies were assessed and 42 judged medium or high strength. A gender-based and diversity analysis was applied to assess the differential impacts on females and males and/or diverse characteristics within these populations. Intended and unintended consequences were examined. FINDINGS: Few studies assessed the potential or differential effects of tobacco policies on the three selected populations. In these, it was difficult to disentangle the effects of each policy in a comprehensive tobacco control environment, and there is need for improved indicators and greater attention to sex and gender analysis. CONCLUSIONS: Research is required to measure the intended and unintended impacts of tobacco policies on populations vulnerable to tobacco use. There are problems in assessing these studies that could be resolved with more precise indicator development. An equity-based framework for assessing the effects of tobacco policies is needed that is conceptually linked to health determinants and inequities. The article concludes with a set of recommendations for research, evaluation, policy and ethics arising from this review.     

What are the Read Codes?

The Read Codes were initially developed by a general practitioner, Dr James Read from Loughborough, in the early 1980s and rapidly gained acceptance by general practitioners as a popular and useful mechanism for storing structured information about patients in individual, patient-based records, which were beginning to become popular in a few general practices at the time. This short article aims to explain the past and future development of the coding system in the National Health Service as a whole.