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Synthetic cannabinoid receptor agonists (SCRAs), colloquially known as "spice," are commonly used in prisons and enter establishments via the mail in the form of infused papers. Many prisons use benchtop ion mobility spectroscopy (IMS) instruments to screen mail and seized materials for the presence of SCRAs and other controlled substances. The selectivity and sensitivity of Rapiscan Itemiser ® 3E and Itemiser ® 4DN Ion Trap Mobility Spectroscopy™ (ITMS™) systems were evaluated using 21 SCRA reference standards. Some differences in the SCRA reduced mobility (K 0 ) values were observed between this study and those reported previously using IMS detection systems, particularly for cumyl and quinolinyl SCRAs (e.g., 5F-PB-22, Cumyl-4CN-BINACA, and 5F-Cumyl-PEGACLONE), although this was found to have little effect at an operational level. Operational reliability of the systems was evaluated by analyzing 392 paper and card samples with known drug content. ITMS™ system results (e.g., detect or nondetect) were in agreement with gas chromatography-mass spectrometry (GC-MS) analysis in up to 95% of samples tested. Overall, this study found the ITMS™ systems tested to be effective instruments when deployed for the rapid detection of SCRA-infused papers. Used effectively and with up-to-date substance libraries, they will help reduce the supply of SCRAs into prisons and identify emerging threats as they arise. Several emerging SCRAs (5F-MPP-PICA, 5F-EMB-PICA, and 4F-MDMB-BICA) were detected for the first time in Scottish prisons between May and August 2020 as a result of routine monitoring, and all were detected using the ITMS™ systems tested., (© 2021 John Wiley & Sons, Ltd.)

Synthetic cannabinoid receptor agonists (SCRAs) elicit many of their psychoactive effects via type-1 human cannabinoid (CB 1 ) receptors. Enantiomer pairs of eight tert-leucinate or valinate indole- and indazole-3-carboxamide SCRAs were synthesized and their CB 1 potency and efficacy assessed using an in vitro β-arrestin recruitment assay in a HEK239T stable cell system. A chiral high-performance liquid chromatography method with photodiode array and/or quadrupole time-of-flight-mass spectrometry detection (HPLC-PDA and HPLC-PDA-QToF-MS) was applied to 177 SCRA-infused paper samples seized in Scottish prisons between 2018 and 2020. In most samples, SCRAs were almost enantiopure (S)-enantiomer (>98% of total chromatographic peak area), although in some (n = 18), 2% to 16% of the (R)-enantiomer was detected. (S)-enantiomers are consistently more potent than (R)-enantiomers and often more efficacious. The importance of SCRA-CB 1 receptor interactions in the "head" or "linked group" moiety is demonstrated, with the conformation of the "bulky" tert-leucinate group greatly affecting potency (by up to a factor of 374), significantly greater than the difference observed between valinate SCRA enantiomers. (S)-MDMB-4en-PINACA, (S)-4F-MDMB-BINACA, and (S)-5F-MDMB-PICA are currently the most prevalent SCRAs in Scottish prisons, and all have similar high potency (EC 50 , 1-5 nM) and efficacy. Infused paper samples were compared using estimated intrinsic efficacy at the CB 1 receptor (EIE CB1 ) to evaluate samples with variable SCRA content. Given their similar potency and efficacy, any variation in CB 1 receptor-mediated psychoactive effects are likely to derive from variation in dose, mode of use, pharmacokinetic differences, and individual factors affecting the user, rather than differences in the specific SCRA present., (© 2020 John Wiley & Sons, Ltd.)

To assess possible health risks associated with the manufacture of paper, we carried out a retrospective analysis of mortality among 4,242 men and women employed at a Scottish paper mill between 1955 and 1992. During follow-up to 1994, 959 subjects had died giving an SMR of 0.85 (95% CI 0.80-0.90) in comparison with the national population. Mortality from all cancer (SMR 0.77, 95% CI 0.68-0.88) and particularly from lung cancer (SMR 0.64, 95% CI 0.50-0.81) was lower than expected. An excess of lymphatic and hematopoietic cancer (11 deaths, SMR 2.17) was observed in the making department. These findings do not support an occupational hazard of lung cancer as suggested by several earlier studies. The excess of lymphatic and hematopoietic cancer in the making department was unexpected, and may be a chance occurrence.

Jacobite Studies have flourished in recent years in a large part owing to the digitization of manuscript collections. This study examines the impact of the decisions of eighteenth- and nineteenth-century antiquarian collectors on the development of Jacobite Studies through an exploration of the transmission, history, and impact of Robert Forbes's recently digitized "Lyon in Mourning." In this, the work charts the passage of the "Lyon in Mourning" from Forbes's death in 1775 to various antiquarian collectors and on to the National Library of Scotland. In doing so, this study demonstrates the limitations and enduring repercussions of the early fixation with Forbes's papers deemed to be of Jacobite interest, and highlights the value of Forbes's wider writings for the modern studies of Jacobitism. [ABSTRACT FROM AUTHOR]

Examines the stability of photographer Robert Adamson's salted paper prints in Scotland. Adoption of hypo-fixation; Use of photogenic drawing paper; Caveat concerning the nomenclature used for historical photographic processes.

During the half century, which preceded the outbreak of the First World War, the paper industry was one of the most rapidly growing industries in Great Britain. After the repeal of the excise duty on paper in 1861, the annual output of the industry cannot he determined directly, but the growing dependence of paper manufacturers on imported raw materials permits the calculation of reasonably satisfactory estimates of production. These estimates suggest that output increased approximately eleven fold between 1860 and 1914 and although the rate of growth was slower by the 1890s the average annual increase in a decade never fell below four percent. A list of general reasons for the expansion of the British paper industry between 1860 and 1914 may he readily assembled. On the one hands costs were reduced by the introduction of esparto grass in the 1860s and wood pulp in the 1880s to supplement or replace the traditional and more expensive basic raw materials, pulped linen and cotton rags. At the same time chemicals used to treat the raw material tell appreciably in price, whilst the increasing size of plants-not least wider and faster paper-making machines-produced significant economies of scale. The article focuses on Alexander Pine & Sons, one of the leading paper manufacturers in Scotland and discusses the growth of paper industry in the nineteenth century.

This essay describes the Scottish Court of Session Digital Archive Project (SCOS), a multi-institutional collaborative research initiative into Early America and the British Atlantic world. Developed by the digital scholarship team at the University of Virginia Law Library, in partnership with colleagues at the University of Edinburgh, SCOS explores everyday life in the eighteenth and early nineteenth centuries through Session Papers, the printed documents submitted to Scotland's supreme civil court during litigation. The project provides scholars, genealogists, and the public with openaccess digital copies of Session Papers held by the UVA Law Library, the Library of Congress, and other institutional partners. By digitizing these documents, contextualizing them with comprehensive metadata, and providing users with interpretative entry points, SCOS is designed to foster new research on this formative period of Scottish, British, and American history. [ABSTRACT FROM AUTHOR]

Sets out the legislative background to the recycling of waste materials in the United Kingdom. Benefits from recycling; The provision of recycling credits under the 1990 Environmental Protection Act; The draft Economic Community (EC) Packaging Waste Directive; The German DSD scheme; The setting forth of the elements of a cost-benefit analysis of waste paper recycling; Application of that analysis to a recycling scheme in central Scotland; Conclusions.

Objective: The ENT Scotland society (formerly known as the Scottish Otolaryngological Society) has two meetings a year and accepts oral presentations from trainees. This study aimed to identify publication rates from these meetings. Methods: Abstracts of the presentations are published in The Journal of Laryngology and Otology. A structured search on PubMed and Google Scholar was undertaken to identify which presentations from the 2005 to 2014 meetings have been published. Results: Of the 145 abstracts found, 60.7 per cent were presenting clinical research and 44.1 per cent were related to the head and neck subspecialty. Seventy-three abstracts (50.3 per cent) were associated with publication as a peer-reviewed article; otology papers were more likely to be published than those focusing on other subspecialties (64.3 per cent, p = 0.036). No correlation was found between publication and other factors. Conclusion: Presentations at the ENT Scotland meetings undergo unbiased peer review and are as likely to be published as those of other conferences. [ABSTRACT FROM AUTHOR]

This article discusses pathways to successful partnership working between a significant private archive of a major Scottish landed estate and family, its local community, the wider academic context, and public and charitable agencies. The archives of the Argyll estates and family are housed at their seat, Inveraray Castle, and represent one of the most important private collections in Scotland, encompassing political, social, cultural and economic content over a large geographical area and a long chronology. As such it has obvious academic attractions, which this article explores, but it is also a vital local resource for communities who used to or currently reside on the Argyll estates, as well as genealogists, and family historians. This article uses the Argyll Papers as a case study to explore the ways in which estate archives can animate and illuminate community and heritage priorities in remote and rural areas of great socio-economic fragility. [ABSTRACT FROM AUTHOR]

"Wayfaring Strangers: The Musical Voyage from Scotland and Ulster to Appalachia" is a book by Fiona Ritchie and Doug Orr that explores the cultural pathways of traditional Scottish and Irish folk music as it traveled to Appalachia. The book examines the influences of Welsh, English, German, Dutch, French, African American, and Cherokee cultures on these songs. It is structured into three main sections and includes photographs, maps, and sidebars covering various topics related to folk music. The authors also exchange letters discussing their perspectives on Old and New World music. The book sheds light on the history of American folk music and its connection to immigrant experiences. It includes a contextual timeline, resource centers, a discography, and a bibliography for further exploration. Scholars and music enthusiasts will find this book to be a valuable resource. [Extracted from the article]

This briefing paper discusses how to include historical perspectives to assess the potential success for current and future menstruation legislation. The case of Scotland provides an instructive example of law-making about free period products and period poverty. While commercial products are perceived as a solution, historical research suggests that cultural attitudes, lingering stigma, and regional differences affect opportunities for passing laws. To predict the likelihood that proposed menstrual product legislation might be adopted in other locations, historical factors related to attitudes about menstruation, including stigma, must be considered and understood to effect lasting change. [ABSTRACT FROM AUTHOR]

In the article, the author focuses on the growing popularity of the lists of the greatest, essential or best-loved Scottish books in past years. The author mentions that "The Herald," for one, has asked its readers to nominate their 100 best Scottish novels. The "Scotsman," on the other hand, published in 2005 a list of "20 Scottish Books Everyone Should Read." Also referenced is Rosemary Goring's introduction to "Scotland Bookshelf" to show the tensions inherent in such list-making effort.

Attitudes to sign languages or language policies are often not overtly discussed or recorded but they influence deaf young people's educational opportunities and outcomes. Two qualitative studies from Scotland investigate the provision of British Sign Language as accommodation in public examinations. The first explores the views of deaf pupils and staff about the official system for face‐to‐face interpretation of exam papers. The second investigates a centrally translated digital paper with embedded video questions. Discussion focuses on contrasts between the USA and UK approaches to accommodations, raising issues of standardized technical terms in signed languages, the right to respond in sign, and candidate choice. [ABSTRACT FROM AUTHOR]

This paper reviews natural capital (NC) valuation approaches in the context of woodland, forest, and riparian ecosystems, emphasising the need for participatory methods to take priority over neoclassical economics approaches. Focusing on research carried out in Scotland, the study analyses findings according to a classification of natural capital initiatives that we have developed, building on ideas proposed by the UK ENCA initiative, a guideline proposed to help researchers and practitioners understand NC and take it into account in valuation, decision-making and policy. We have found that landscape-scale initiatives that address the relationships between people and place to inform value and decision-making beyond the economic (monetary) benefits generated by ecosystem services (ES) are becoming popular. For instance, recent methods employed to capture stakeholders' non-utilitarian preferences include the use of participatory GIS mapping, scenario planning, and other participatory methods to identify, explore and quantify less tangible cultural ecosystem services (CES). The review shows that many studies provide information relevant to the formulation of a place-based NC approach, working towards the integration of contextual and relational values into land management decisions to help formulate management strategies that maximise ES delivery. Conversely, we have not found evidence of the integration of shared values arising from an eco-centric perspective of nature valuation into the more classical, instrumental value lens. Such an approach would help inform broader, overarching aspects of woodland and forest management that may foster more effective conservation and help to manage conflicts. [ABSTRACT FROM AUTHOR]

The International Review of Scottish Studies (IRSS) is a leading interdisciplinary journal that focuses on Scottish history and culture. It aims to provide a platform for scholars at all career levels to explore Scotland's past and present. The journal seeks to expand the global reach of Scottish scholarship and connect innovative research from various disciplines to a scholarly audience and the public. The current call for papers is for a special issue on the significance of the ocean in Scotland's culture and history. Submissions are welcome from all humanities and social science disciplines and should be sent to the IRSS Editor by December 16, 2024. [Extracted from the article]

This paper challenges the simplified binary division of suppliers of goods and services into market or state categories and identifies the continued relevance of household, community, and third-sector provision in rural areas. We explain the emergence, survival, and development of place-based and collaborative action using a three-fold typology, reflecting differences in the motivations and rationales for providing goods and services in these ways. In a place-based context, some communities have acted collectively using collaborative agency. Many observers of rural community development have suggested that place-based communitarian action may be unable to break free from class-based controls, but this is contested by some compelling examples. Where supported by effective public policy, place-based communitarianism can offer an alternative mode of provision for a wide range of services. Using Scotland as an example, this paper explores the dynamics of interactions between community and policy actors in land acquisition and management, renewable energy, and social care. [ABSTRACT FROM AUTHOR]

This paper explores the interconnections and relative importance of seven determinants implicit in the development of sustainable tourism indicators. These determinants provide a framework for understanding the process of indicator selection for sustainable tourism. This research has suggested that some of the implicit determinants may be interconnected and some may be more important than others. The paper reports findings from twelve stakeholder groups in two Scottish National Parks which are engaged in developing sustainable tourism indicators. It is important for park authorities to be aware of the different views of stakeholder groups on the issues surrounding indicator selection and development and this research provided an opportunity for such groups to be consulted. The paper will examine the relative importance each group placed on the implicit determinants and consider possible reasons for between-group differences. Analysis will also focus on the existence of linkages between individual implicit determinants. The paper concludes that different typologies of stakeholder groups exist, affecting both the interpretation of, and importance attributed to, the determinants and that the framework as a whole serves to be more than the sum of its parts. [ABSTRACT FROM AUTHOR]

Advocates of STV claim it provides strong incentives to undertake constituency service. However, international experience indicates that candidate evaluations do not necessarily significantly influence how people complete a STV ballot. This paper analyses how voters in Scotland completed their ballot papers in the 2007 local elections, at which STV was used for the first time. Candidate evaluations mattered less than they do in Ireland, but mattered sufficiently to suggest there will be an incentive to provide constituency service. [ABSTRACT FROM AUTHOR]

The article examines the periodical's evolving focus across centuries, indicating a quantitative shift from earlier pre-Reformation studies towards biographical accounts and an inclination toward Presbyterian history. It also highlights the society's historical emphasis, noting a waning attention to certain periods and denominations, while seeing a surge in interest in others, such as the Highland and Island regions.

Presents a case study of the human resource management approach of the Finnish-owned Caledonian Paper company at Irvine New Town in Scotland. Background of the company; Essence of the corporate culture or management style of Caledonian Paper; Provisions of the employment policy of the company; Relationship between the nature of the organization's competitive strategy and the need for workforce flexibility.

Analyzes the chemical processes in photography used by photographers John and Robert Adamson in Scotland. Salted paper prints; Calotype negatives; Photographic image and paper.

Provides a guide to supplement the guide to the Scottish papers submitted to the British cabinet during 1917 to 1945 and 1945 to 1966. Responsibilities of the Scottish secretary and his relationship with the British cabinet and its decision-making process; Sections of the guide covering papers presented to cabinet, committees on health and home affairs, economic affairs, and papers presented to the legislative committee.

Presents a guide to records held at the Public Record Office and National Archives of Scotland pertaining to Scottish papers submitted to the Cabinet from 1945-1966. Aim of the guide; Economic matters covered by the papers; General classification of Cabinet papers and memoranda.

The article focuses on a study in Scotland, United Kingdom of prioritizing protection of children from secondhand smoke exposure (SHSE) in a private space where smoke-free public places are enforced. It discusses the difficulty of political acceptability in enforcing the issue and the intervention over parental autonomy to smoke in their own home. The article also reports on the findings based on the study used called Reducing Families' Exposure to Secondhand Smoke (REFRESH) project.

In this article the author discusses aspects of ballots and voting practices in elections held in Scotland. At issue is a form of proportional representation called the mixed-member or additional member system, which requires the use of two separate paper ballots. In answer to protests that this system led to confusion and resulted in a higher number of spoiled and invalid ballots, a government board of inquiry was convened. The author endorses the finding of the commission which recommended changing the name of the voting system.

In this paper, the author introduces the work of one of France's most important architects of the Renaissance period and suggests briefly how many of his published designs - in particular his sketches for country houses - could have been familiar to Scottish architects and builders. [ABSTRACT FROM AUTHOR]

Focuses on the collections of the Scottish Architects' Papers Preservation Project. Buchanan Campbell; Carr and Matthew; J. and J.A. Carrick; Dick Peddie and McKay.

Focuses on the preservation and conservation of architects' papers in Scotland. Cataloguing of materials; Use and promotion of archive collections; Architectural heritage.

STV is often extolled because it allows voters to express a nuanced choice, but is criticised for being too confusing. In practice the system is little used, but evidence from where it is indicates much depends on how voters choose to use it. STV was used for the first time in Scottish local elections in 2007, providing valuable new evidence on how voters respond to the system. We use survey data to examine the incidence of various indicators of apparent failure by Scottish voters to exploit STV, and compare both the levels and patterns of incidence with equivalent data for Ireland. We find little sign of confusion in either country, but significant evidence of ballot order effects in Scotland. [Copyright &y& Elsevier]

Presents a guide to papers submitted to the Cabinet by Scottish ministers and departments between 1917 and 1945, and held at the Public Record Office and National Archives of Scotland. Cabinet Memoranda, 1917-39; Papers submitted to the Home Affairs Committee between 1926 and 1939; Papers submitted to the Ad Hoc Committees between 1919 and 1939; War Cabinet Memoranda, 1939-1945.

Purpose - Many learners with disabilities and special educational needs have difficulty reading or accessing traditional paper examinations at school. The most common method of accommodating these candidates, in Scotland, is the use of reader and scribe. This paper aims to define a specification for digital examination papers for candidates with disabilities, identify a suitable electronic format, and report on trials of these digital assessments. Design/methodology/approach - The support needs of candidates with disabilities were investigated through interviews with teaching staff and students, analysis of the type of requests made for accommodations, and the reasons for the requests. Findings from this exercise, together with consideration of the requirements of the examination context, were used to construct a specification for digital examination papers. Pilot trials using digital papers were then undertaken. Findings - Adobe portable document format (PDF) was judged to match the specification most closely Successful pilot trials in 2005, 2006 and 2007 led to the introduction of digital papers by the Scottish Qualifications Authority in 2008. Research limitations/implications - There is some evidence that digital papers provide a more independent and less costly alternative to reader/scribes; this requires further research. Practical implications - Between 2008 and 2011, the number of requests for digital papers increased fivefold, indicating that digital question papers in PDF offer a practical and cost effective method of accommodation in examinations. Originality/value - This research is of interest to examination boards, assessment designers, educators and learners. It demonstrates that candidates with disabilities can successfully access assessments in digital format. [ABSTRACT FROM AUTHOR]

Background: Universal health visiting has been a cornerstone of preventative healthcare for children in the United Kingdom (UK) for over 100 years. In 2016, Scotland introduced a new Universal Health Visiting Pathway (UHVP), involving a greater number of contacts with a particular emphasis on the first year, visits within the home setting, and rigorous developmental assessment conducted by a qualified Health Visitor. To evaluate the UHVP, an outcome indicator framework was developed using routine administrative data. This paper sets out the development of these indicators. Methods: A logic model was produced with stakeholders to define the group of outcomes, before further refining and aligning of the measures through discussions with stakeholders and inspection of data. Power calculations were carried out and initial data described for the chosen indicators. Results: Eighteen indicators were selected across eight outcome areas: parental smoking, breastfeeding, immunisations, dental health, developmental concerns, obesity, accidents and injuries, and child protection interventions. Data quality was mixed. Coverage of reviews was high; over 90% of children received key reviews. Individual item completion was more variable: 92.2% had breastfeeding data at 6–8 weeks, whilst 63.2% had BMI recorded at 27–30 months. Prevalence also varied greatly, from 1.3% of children's names being on the Child Protection register for over six months by age three, to 93.6% having received all immunisations by age two. Conclusions: Home visiting services play a key role in ensuring children and families have the right support to enable the best start in life. As these programmes evolve, it is crucial to understand whether changes lead to improvements in child outcomes. This paper describes a set of indicators using routinely-collected data, lessening additional burden on participants, and reducing response bias which may be apparent in other forms of evaluation. Further research is needed to explore the transferability of this indicator framework to other settings. [ABSTRACT FROM AUTHOR]

The publication in the 1980s of The Christian Watt Papers brought to public attention the life of a previously unknown, long-term inmate of the Aberdeen Royal Asylum. Christian Watt's story inspired a play and a television documentary. This paper examines what the historical records reveal about Watt's life and how this compares with her own account.

It is very likely that digital resources will be the primary source materials of the historians of the future. After 550 years, printing on paper is no longer the only means of information transfer. This paper summarises some of the new ways of digitally disseminating medical information before using the example of a Scottish professional society to show the importance of that extraordinarily successful method of information transfer - printing on paper using movable types. The paper aims to show how a seemingly simple, comparatively low technology, process has driven a lot of the decisions of the Royal College of Physicians of Edinburgh and provided a reliable means to document those decisions for over 300 years.

Against a background of rising debt levels, this article examines the range of solutions available to a debtor in financial difficulty in Scots law and the recent proposals for reform of bankruptcy law in Scotland brought forward by the Scottish Executive as part of its new approach to debt management and enforcement in Scotland and considers the extent to which they may accord an over-burdened debtor the opportunity for a fresh start. It concludes that while the emphasis on providing appropriate solutions for over-burdened debtors with a view to enabling them to make a fresh start evidenced by these proposals is to be welcomed, they may not yet have struck quite the right balance in this respect. Copyright © 2004 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Reports on developments about geological studies as of September 2003. Recovery of Fossil Nessie, a plesiosaur from the waters of Loch Ness, Scotland. Plan of the Tuvalu government to evacuate its 9,300 inhabitants because of the rise in sea levels in the Island of Tuvalu in the Pacific; Threat of the loss of peat Ireland due to the demand for peat by British gardeners.

The article provides information on Artists' Papers Register, a finding list of archival documents that is related to artists, engravers, wood-engravers and lithographers. The author reveals that in 1987, the Artists' Papers Register has begun with a pilot project at Glasgow University Library and funded by the Getty Grant Program. The Artist' Papers Register is devoted to investigate the holdings of artists' documents that are stored in west of Scotland institutions. The database of the Register can be searched by the names of artists and by several categories. Moreover, it further points out that it is planned that the said Register should be regularly updated so that there will be opportunities to extend its usefulness.

Drug checking services (DCS) enable individuals to voluntarily submit a small amount of a substance for analysis, providing information about the content of the substance along with tailored harm reduction support and advice. There is some evidence suggesting that DCS may lead to behaviour and system change, with impacts for people who use drugs, staff and services, and public health structures. The evidence base is still relatively nascent, however, and several evidence gaps persist. This paper reports on qualitative interviews with forty-three participants across three Scottish cities where the implementation of community-based DCS is being planned. Participants were drawn from three groups: professional participants; people with experience of drug use; and affected family members. Findings focus on perceived harm reduction impacts of DCS delivery in Scotland, with participants highlighting the potential for drug checking to impact a number of key groups including: individual service users; harm reduction services and staff; drug market monitoring structures and networks; and wider groups of people who use and sell drugs, in shaping their interactions with the drug market. Whilst continued evaluation of individual health behaviour outcomes is crucial to building the evidence base for DCS, the findings highlight the importance of extending evaluation beyond these outcomes. This would include evaluation of processes such as: information sharing across a range of parties; engagement with harm reduction and treatment services; knowledge building; and increased drug literacy. These broader dynamics may be particularly important for evaluations of community-based DCS serving individuals at higher-risk, given the complex relationship between information provision and health behaviour change which may be mediated by mental and physical health, stigma, criminalisation and the risk environment. This paper is of international relevance and adds to existing literature on the potential impact of DCS on individuals, organisations, and public health structures. [ABSTRACT FROM AUTHOR]

This paper examines some of the issues in the grading and use of evidence, and suggests that the (US) Agency for Health Care Policy and Research (AHCPR) system used by the Scottish Intercollegiate Guidelines Network (SIGN) and others is useful, but that it needs development to take account not only of type of study, but also of quality. It also considers the need to complement evidence of efficacy from randomised controlled trials, which may involve selected patients in selected centres, with evidence of "real-life" effectiveness. Furthermore, there are occasions where randomised controlled trials are not necessary. A grading system to take account of these issues is proposed for discussion.