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While the decision of the House of Lords in Re F in [1990] clarified somewhat the law concerning the treatment of the mentally incapacitated adult, many uncertainties remained. This paper explores proposals discussed in a recent government green paper for reform of the law in an area involving many difficult ethical dilemmas. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this paper is to examine the way in which nurses manage patients who refuse nursing care procedures. Design: This paper reports on a qualitative study which was undertaken to explore the way in which nurses obtain consent prior to nursing care procedures. Focus groups were carried out to obtain background data concerning how consent is obtained. Critical incidents were collected through in depth interviews as a means of focusing on specific incidents in clinical practice. Setting: Two teaching hospitals in England. Participants: Purposive sample of qualified nurses. Results: When a patient refuses nursing care, nurses respond by giving information until the Patient finally accedes to the procedure. Nurses will go to great lengths to achieve patients' agreement to the procedure, but the extent to which the agreement remains voluntary cannot be ascertained by the data collected in this study. If the patient does not eventually agree to a procedure, there is evidence that nurses will administer the care in the absence of consent. Conclusions: Nurses are concerned to obtain the patient's consent prior to the administration of nursing care but if this cannot be achieved do not regard obtaining consent as an absolute requirement. Consent is preferred, but not considered essential. Nurses have some understanding of the principles of informed consent but do not apply them to everyday clinical nursing practice. [ABSTRACT FROM AUTHOR]

Since Bennett, Draper, and Frith published a paper in the Journal of Medical Ethics in 2000 considering the possible criminalization of HIV transmission, an important legal development has taken place. February 2001 saw the first successful United Kingdom prosecution for the sexual transmission of disease for over a century, when Stephen Kelly was convicted in Glasgow of recklessly injuring his former girlfriend by infecting her with HIV. Whether English criminal law (as opposed to Scots law) can apply criminal penalties in such a case, however, still remains uncertain. This paper, in addition to providing some background to the Kelly case, briefly explores the current possibilities for prosecution under English law. It then proceeds to outline and comment on the issues relevant to criminalization, responding in part to points made by Bennett, Draper, and Frith and also by Bird and Leigh Brown in a recent article in the BMJ. [ABSTRACT FROM AUTHOR]

Objective: NHS stop smoking services are expected to play a key part in achieving the infant mortality and life expectancy health inequality targets in England by reducing smoking prevalence in deprived areas. This paper assesses the extent to which services have made a contribution to reducing inequalities in smoking between 2003-4 and 2005-6. Methods: Synthetic estimates of baseline smoking prevalence data were compared with national monitoring data about the numbers of smokers in receipt of services and the proportion who self report quilting at four weeks. The social distribution of service recipients and quitters was compared with estimates of smoking prevalence to assess impact on inequalities. Comparisons were made between officially designated disadvantaged areas (the Spearhead Group) and others. Results: Short-term cessation rates were lower in disadvantaged areas (52.6%) than elsewhere (57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared with 13.4%) (p<0.001). The net effect was that a higher proportion of smokers in the most disadvantaged areas reported success (8.8%) than in more advantaged areas (7.8%) (p<0.001). Using the evidence-based assumption that three-quarters of short-term quitters will relapse within one year, the absolute and relative rate gaps in smoking prevalence between Spearhead areas and others are estimated to fall by small but for Health, University significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to 1.210) between 2003-4 and 2005-6. Conclusion: NHS stop smoking services have probably made a modest contribution to reducing inequalities in smoking prevalence. To achieve government targets, however, requires both the development of more innovative cessation interventions for the most addicted smokers and action to ensure that other aspects of tobacco control policy make a larger contribution to inequality goals. [ABSTRACT FROM AUTHOR]

The Society of Apothecaries examination in Sports Medicine consists of four parts: a multiple-choice question paper; a written paper; a clinical section; and an oral section. The candidates must have experience in sports medicine and have to submit a dissertation and a case history book. The importance of an examination in sports medicine is discussed. [ABSTRACT FROM PUBLISHER]

Announces the holding of a conference for health professionals on ethical issues in health care scheduled for September 21-22, 1994 at the University of Brighton in England. Encouragement of dialogue among health care professionals and educators; Workshops; Contact information.

Following the acquittal of Dr Leonard Arthur in the case of the Down's syndrome infant the co-authors of the first paper in this symposium prepared a draft bill on the treatment of chronically disabled infants which has since been informally commended by the Director of Public Prosecutions. A second contributor, a law student, also argues for legislation as being the most effective way for society to have its standards clarified and observed. In a final paper Dr Havard, Secretary of the British Medical Association, opposes legislation believing it would raise far more problems than it would resolve. The first article was originally published in the Law Society's Gazette. [ABSTRACT FROM PUBLISHER]

The article presents an overview of some of the key topics presented at the British Thoracic Society Winter Meeting held in London, England, from December 5-7, 2001. It states that the winter meeting of the British Thoracic Society covered a wide range of respiratory topics. Over 300 papers were presented and internationally renowned speakers delivered a number of lively symposia. Some of those topics were on asthma, chronic obstructive pulmonary disease and pleural disease. Initial data from the first 150 patients enrolled in the multicentre intrapleural streptokinase versus placebo in empyema trial was presented at the meeting. Emphasis was placed on the importance of obtaining blood cultures for microbiological diagnosis.

In this article, the author focuses on the impact of the British National Health Service (NHS) health care guidelines restraints on clinical commissioning groups (CCGs) in England. He informs that four CCGs have implemented the National Institute for Health and Care Excellence (NICE) guideline for in vitro fertilisation and the general practitioner (GP) referral service management guideline has restricted the flow of patients in CCGs. It states that a white paper released by the NHS in 2010 has revealed that NHS has planned to abolish primary health care trusts. It also mentions that the guidelines have impacted both the budget and responsibilities of CCGs. INSETS: BOX 1: CCGS FAIL TO IMPLEMENT NICE GUIDANCE ON IVF;BOX 2: CLOSING THE GATES¿NEW REFERRAL MANAGEMENT SYSTEMS;COMMISSIONING GROUPS ¿ HOW THEY CAME INTO BEING;BOX 3: FAMILY DOCTOR¿PATIENTS¿ ADVOCATE OR GUARDIAN OF THE PUBLIC

Background In 2008, the Healthy Community Challenge Fund commissioned nine 'healthy towns' in England to implement and evaluate community-based environmental interventions to prevent obesity. This paper examines the role of evidence in informing intervention development, innovation and the potential for programmes to contribute to the evidence base on the effectiveness of interventions that tackle population obesity. Method Twenty qualitative interviews with local programme stakeholders and national policy actors were conducted. Interview transcripts were coded and thematically analysed. Initial analyses were guided by research questions regarding the nature and role of evidence in the development and implementation of the healthy towns programme and the capacity for evidence generation to inform future intervention design, policy and practice. Findings Stakeholders relied on local anecdotal and observational evidence to guide programme development. While the programme was considered an opportunity to trial new and innovative approaches, the requirement to predict likely health impacts and adopt evidence-based practice was viewed contradictory to this aim. Stakeholders believed there were missed opportunities to add to the existing empirical evidence base due to a lack of clarity and planning, particularly around timing, in local and national evaluations. Conclusions A strong emphasis on relying on existing evidence-based practice and producing positive impacts and outcomes may have impeded the opportunity to implement truly innovative programmes because of fear of failure. Building more time for development, implementation and evaluation into future initiatives would maximise the use and generation of robust and relevant evidence for public health policy and practice. [ABSTRACT FROM AUTHOR]

Background Although long-term trends in local labour market conditions are likely to influence health, few studies have assessed whether this is so. This paper examines whether (1) trends in local employment rates have relevance for mortality and morbidity outcomes in England and (2) trends are stronger predictors of these outcomes than employment rates measured at one point in time. Methods Using latent class growth models, local areas were classified into eight groups following distinct trends in employment rates between 1981 and 2008. Areas were also categorised in 'octile' groups by rank of employment rates in 2001. These area groupings were linked to a sample of 207 959 individuals from the Office of National Statistics Longitudinal Study. Associations between area groupings and risk of all-cause mortality and of reporting a limiting long-term illness at the end of the period were measured using logistic regression. Models were adjusted for individuals' socio-demographic characteristics measured in 1981 and for their residential mobility between 1981 and 2001. Results Compared to areas with continuously high employment rates over the period, risk of mortality and morbidity was higher in areas with persistently low or declining employment rates. Findings suggest that longterm trends in local employment rates are useful as predictors of mortality and morbidity differences. These are not so clearly distinguished by only considering employment rates at one point in time. Conclusion Poor health outcomes are associated with long-term economic disadvantage in some areas of England, reflected in employment rates, underlining the importance of efforts to improve health in areas with especially 'deep-seated' deprivation. [ABSTRACT FROM AUTHOR]

Background The WHO International Classification of Functioning, Disability and Health (ICF) is now the dominant model for exploring the social consequences of a health condition. This paper investigates the association of the different ICF disability domains with mortality. Methods Data are from the British Women Heart and Health Study, a large (n=4157) prospectively studied cohort of women randomly selected from 23 towns aged 64-83 years in 2003. Scores were calculated to describe the cumulative load of impairments, limitations and restrictions within each ICF domain. Cox proportional hazards regression was used to calculate mortality HRs per unit score increase within each ICF domain. Adjustments were made for age, town, living status, socioeconomic status, lifestyle behaviours and health conditions. Results Each ICF domain was associated with mortality after controlling for lifestyle factors and health conditions. However, only complex activities (HR=1.09, 95% CI 1.01 to 1.18) and participation (HR=1.10, 95% CI 1.04 to 1.16) were independent predictors of mortality following adjustment for all other disability domains and potential confounders. Conclusions Results suggest that difficulties with complex activities or social participation could be used to identify and target women at high risk of dying. Interventions to facilitate complex activities or improve social participation may help to delay mortality in elderly women. [ABSTRACT FROM AUTHOR]

Background In recent decades, labour market participation has fallen in men, with large amounts of this decline accounted for by increases in permanent sickness. There is speculation that the rising numbers of permanently sick incorporate more people with less severe conditions than was previously the case. This paper examines the relationship between labour market position and subsequent mortality around State Pension Age. Methods Using linked census and death records in the ONS Longitudinal Study, samples of men aged 55-69 and women aged 50-64 were selected from each decennial census, 1971-2001 and their health followed up. Differences between the employed, unemployed and economically inactive in age-specific death rates, Standardised Mortality Ratios and odds of reporting limiting long-term illness were examined. Results Labour market activity in late middle age has changed since 1971. For example, the proportion of men employed at ages 60-64 years has fallen by 39%, and the proportion permanently sick has more than doubled. Despite this change, there has been stability in the RR of mortality between labour market positions. Working people have the lowest risk of premature death, while, relative to working people, the permanently sick continue to have mortalities around three times higher among men and four to five times higher among women. Conclusion The evidence does not support the notion that the permanently sick are becoming less seriously ill. The persistence of the group's raised mortality suggests that measures aimed at encouraging later life employment should ensure provision of work environments suitable for people with chronic illnesses. [ABSTRACT FROM AUTHOR]

England was the first European country to pursue a systematic policy to reduce socio-economic inequalities in health. This paper assesses whether this strategy has worked, and what lessons can be learnt. A review of documents was conducted, as well as an analysis of entry-points chosen, specific policies chosen, implementation of these policies, changes in intermediate outcomes, and changes in final health outcomes. Despite some partial successes, the strategy failed to reach its own targets, that is, a 10% reduction in inequalities in life expectancy and infant mortality. This is due to the fact that it did not address the most relevant entry-points, did not use effective policies and was not delivered at a large enough scale for achieving population-wide impacts. Health inequalities can only be reduced substantially if governments have a democratic mandate to make the necessary policy changes, if demonstrably effective policies can be developed, and if these policies are implemented on the scale needed to reach the overall targets. [ABSTRACT FROM AUTHOR]

Objectives To explore similarities and differences in policy content and the political context of the three main English government reports on health inequalities: the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010). Methods Thematic policy and context analysis of the Black Report (1980), the Acheson Enquiry (1998), and the Marmot Review (2010) in terms of: (i) underpinningtheoretical principles; (ii) policy recommendations; (iii) the political contexts in which each was released; and (iv) their actual or potential influence on research and policy. Results There were great similarities and very few differences in terms of both the theoretical principles guiding the recommendations of these reports and the focus of the recommendations themselves. However, there were clear differences in terms of the political contexts of each report, as well as their subsequent impacts on research and policy. Conclusion The paper calls into question the progress of health inequalities research, the use of evidence and of the links between research, politics and policy. [ABSTRACT FROM AUTHOR]

The adult clinical necropsy has been declining for many years and is nearing extinction in many hospitals. In Norwich, to prevent this from occurring, a Pathology Liaison Nurse (PLN) was appointed, resulting in a modest reversal of the trend. In 2005, the number of adult clinical necropsies increased to 58 (clinical necropsy rate = 2.4%) from its nadir of 34 (clinical necropsy rate = 1.4%) in 2003. Moreover, consent is now much more likely to be full and to allow histopathological and other studies. The PLN ensures that consent is properly and fully obtained, in line with current legislation. She also plays an important role in arranging for feedback to be given by clinicians to the families after the examination, and in teaching and training Trust staff about death, bereavement, and related matters. This paper describes how the role of PLN was established and evaluated, and gives details of the current state of the adult clinical necropsy in Norwich. [ABSTRACT FROM AUTHOR]

This paper examines the law relating to healthcare resource allocation in England. The National Health Service (NHS) Act 1977 does not impose an absolute duty to provide specified healthcare services. The courts will only interfere with a resource allocation decision made by an NHS body if that decision is frankly irrational (or where the decision infringes the principle of proportionality when a right under the European Convention on Human Rights (ECHR) is engaged). Such irrationality is very difficult to establish. The ECHR has made no significant contribution to domestic English law in the arena of healthcare provision. The decision of the European Court in the Yvonne Watts case establishes that, in relation to the question of entitlement to seek treatment abroad at the expense of the NHS, a clinical judgment about the urgency of treatment trumps an administrative decision about waiting list targets. That decision goes against the grain of domestic law about healthcare allocation, but is not likely to have wide ramifications in domestic law. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the determinants of self rated health (SRH) in men and women in the British Whitehall II study and the French Gazel cohort study. Methods: The cross sectional analyses reported in this paper use data from wave 1 of the Whitehall II study (1985-88) and wave 2 of the Gazel study (1990). Determinants were either self reported or obtained through medical screening and employer's records. The Whitehall II study is based on 20 civil service departments located in London. The Gazel study is based on employees of France's national gas and electricity company (EDF-GDF). SRH data were available on 6889 men and 3403 women in Whitehall II and 13 008 men and 4688 women in Gazel. Results: Correlation analysis was used to identify determinants of SRH from 35 measures in Whitehall II and 33 in Gazel. Stepwise multiple regressions identified five determinants (symptom score, sickness absence, longstanding illness, minor psychiatric morbidity, number of recurring health problems) in Whitehall II, explaining 34.7% of the variance in SRH. In Gazel, four measures (physical tiredness, number of health problems in the past year, physical mobility, number of prescription drugs used) explained 41.4% of the variance in SRH. Conclusion: Measures of mental and physical health status contribute most to the SRH construct. The part played by age, early life factors, family history, sociodemographic variables, psychosocial factors, and health behaviours in these two occupational cohorts is modest. [ABSTRACT FROM AUTHOR]

It is impossible to be certain, but it is estimated that each year in England and Wales there may be about 30-40 infant deaths from covert homicide, which represents about 10% of the current annual total of sudden unexpected deaths in infancy. This paper reviews the features that have been suggested as possible indicators of covert homicide, describes the difficulties in its identification and the need for better evidence, and emphasizes the importance of thorough medical investigation of all sudden infant deaths. [ABSTRACT FROM AUTHOR]

Objective: To discover the importance of social sources of tobacco to young people as opposed to commercial sources; to describe the peer market for cigarettes in schools and the consequences for young people of their involvement in it. Study design: Cross sectional questionnaire survey, one-to-one interviews, and focus groups. Setting: Seven schools in Birmingham, UK. Subjects: All students in two randomly selected classes from each school completed the questionnaire, and never smokers, occasional smokers, and regular smokers were interviewed. Results: Two thirds of occasional smokers and one quarter of regular smokers obtained cigarettes socially, mostly for free. A few smokers regularly bought their cigarettes from others. Among friendship groups, both smokers and non-smokers were involved in the exchange of cigarettes, often for money, which is a common activity. A few young people use the selling of cigarettes to fund their own smoking. Some young people, smokers and non-smokers, are involved in semi-commercial selling of cigarettes. All school students ore aware of where to purchase cigarettes from non-friends, which is only used "in emergency" because of the high price. One school had a strong punishment policy for students caught with cigarettes. In this school, more people bought singles from the peer market and the price was higher. Conclusions: The passing and selling of cigarettes in school is a common activity, which from the young persons perspective, ensures that all share cross counter purchases. A few people are prepared to use the peer market for monetary gain and it appears to be responsive to external conditions. The peer market might mean that efforts to control illegal sales of cigarettes are not as effective as hoped. INSET: What this paper adds.. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the association between geographical variations in deprivation, morbidity and mortality in England. The study shows the stronger relations between generic deprivation indices and health outcomes in urban compared to rural areas. It reveals that relation between morbidity and mortality is stronger in urban compared to rural areas, with levels of limiting long term illness (LLTI) seem to be greater in rural areas than projected from mortality rates.

Aim: Acute lymphoblastic leukaemia (ALL) with an L3 morphological FAB type is regarded by some as being synonymous with B cell ALL or ALL with a Burkitt-type chromosomal translocation-t(8;14), t(2;8), t(8;22). This paper describes a series from a population based study of 24 patients with L3 ALL presenting over 17 years. Methods: Clinical data were collected prospectively from all adult patients presenting with acute leukaemia in the Northern region since 1982. Data from all patients diagnosed with FAB type L3 ALL were analysed. Results: Overall, L3 ALL accounts for 8.6% of all adult ALL and it is more common in the elderly than has hitherto been recognised. In addition to classic Burkitt-type translocations (11 of 24 cases), the t(14;18) translocation, which is characteristically found in lower grade lymphomas such as follicular lymphoma, is frequently present (five of 24 cases). Conclusion: The presence of L3 ALL is often associated with non-Burkitt-type translocations and the presence of a t(14;18) translocation may indicate that in some cases a clinically non-apparent lymphoproliferative disorder, such as a low grade follicular lymphoma, has transformed to a more aggressive form and, thus, presents as a de novo acute leukaemia. [ABSTRACT FROM AUTHOR]

Each of the following papers gives an account of a different UK clinical ethics committee. The committees vary in the length of time they have been established, and also in the main focus of their work. The accounts discuss the development of the committees and some of the ethical problems that have been brought to them. The issues raised will be relevant for other National Health Service (NHS) trusts in the UK that wish to set up such a committee. (Journal of Medical Ethics 2001 ;27 suppl I:i9-i17) [ABSTRACT FROM AUTHOR]

Equipoise is widely regarded to be an essential prerequisite for the ethical conduct of a randomised controlled trial There are some circumstances however, under which it is acceptable to conduct a randomised controlled trial (RCT) in the absence of equipoise. Limited access to the preferred intervention is one such circumstance. In this paper we present an example of a randomised trial in which access to the preferred intervention, preschool education, was severely limited by resource constraints. The ethical issues that arise when conducting randomised trials in health care are considered in the context of trials of social interventions. In health, education and social welfare, effective interventions are frequently limited due to budgetary constraints. Explicit acknowledgement of the need to ration interventions, and the use of random allocation to do this even in the absence of equipoise, would facilitate learning more about the effects of these interventions. [ABSTRACT FROM AUTHOR]

Background: To report findings on ventilatory function and estimations of concentrations of personal breathing zone dust in Lancashire textile weavers. Weaving room dust is considered to be less harmful than that encountered in the cardroom or spinning room and weavers are generally thought to have less respiratory disability than carders or spinners. However, this occupational group has not been extensively studied.Methods: Each person was given a respiratory symptom questionnaire (modified Medical Research Council, UK, questionnaire on respiratory diseases). Ventilatory function tests, forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were performed on each person. A representative sample of workers from each occupational group underwent dust sampling in their personal breathing zone. Dust concentrations and ventilatory tests were analysed statistically with the Student's t test, Pearson's correlation coefficient, and forward step regression for relations with symptoms and environmental factors. Significance was p > or = 0.05.Results: The FEV1 and FVC were reduced in workers with respiratory symptoms (non-specific chest tightness, shortness of breath, persistent cough, and wheezing) as well as in preparation room workers, current and former smokers, Asians, those working with predominantly cotton fibre (> 50% cotton) and starch size. Mean total dust concentration (pd1) in the personal breathing zone was 1.98 mg/m3. The corresponding value for total dust with large fibres lifted off the filter paper (pd2) was 1.55 mg/m3. There was a strong correlation (r = 0.94, p < 0.0001) between pd1 and pd2. Non-specific chest tightness was predicted by low dust concentrations and persistent cough by high dust concentrations. On regression analysis, impairment of ventilatory function (FEV1, FVC) was predicted by smoking, male sex, age, not working in the weaving shed, not being white, and personal dust concentrations.Conclusions: The FEV1 and FVC were impaired in smokers and those exposed to high dust concentrations in the personal breathing zone. Symptoms were inconsistently related to dust concentrations in the personal breathing zone. [ABSTRACT FROM AUTHOR]

This paper reviews the work of the sports injury clinic based at the Student Health Centre, University of Manchester during its first eighteen months. A total of 852 patients including 46 Centre of Excellence athletes were treated. The results indicate that the establishment of such a specialised clinic is worthwhile, that the injured sportsmen should be treated by individuals trained and interested in the treatment of injured patients in general and that the commonest injuries are soft tissue injuries to the knee of ankle joint. A record card, designed for future computer analysis, is illustrated. It includes details of the sport, training, mechanism of injury, pathology and treatment. [ABSTRACT FROM AUTHOR]

James Carson, a Scot, graduated from Edinburgh in 1799. He settled in Liverpool where he became a successful and respected physician and where he also found time to pursue a longstanding interest in physiology and to conduct certain important experiments. He read a series of papers on these experiments and their import before the Literary and Philosophical Society of Liverpool of which the two most important were On the elasticity of the lungs and On lesions of the lungs. In the first he clarified the mechanics of respiration while in the second he suggested that this knowledge might be employed to produce temporary collapse of the lung as a therapeutic measure. Two attempts at a clinical trial were defeated by widespread pleural adhesions but the first recorded attempts at artificial pneumothorax had been made. George Bodington, a Warwickshire man, after serving a surgical apprenticeship studied at St Bartholomew's Hospital and obtained the licence of the Society of Apothecaries in 1825. He later practised near Sutton Coldfield where he was known as an acute observer and a thoughtful and fluent speaker. In 1840 he published an essay on the treatment and cure of pulmonary consumption in which he roundly condemned the current therapy and advocated instead fresh air in abundance, gentle exercise in the open, an adequate and varied diet, and a minimum of medicaments. Violently attacked by the reviewers he became discouraged about tuberculosis and devoted the remainder of his professional life to the care of the mentally ill. [ABSTRACT FROM AUTHOR]

A negative image of community care prevails. This method of care is perceived to be a relatively novel phenomenon and has received mixed media coverage. The negative image of community care has led to the growing belief that this care method has failed. This failure has largely been ascribed to the lack of powers available to control patients in the community and to the method's relative novelty. However, this paper contends that there are two flaws to the above assertion: first, community care is far from new, and second, the inherent problem is not the lack of powers available to control patients in the community, but, essentially, the absence of a secure and stable environment within the community. [ABSTRACT FROM AUTHOR]

This paper addresses ethical concerns emanating from the practice of using patients for health care education. It shows how some of the ways that patients are used in educational strategies to bridge theory-practice gaps can cause harm to patients and patient-practitioner relationships, thus failing to meet acceptable standards of professional practice. This will continue unless there is increased awareness of the need for protection of human rights in teaching situations. Unnecessary exposure of patients, failing to obtain explicit consent, causing harm to vulnerable or disadvantaged groups and inappropriate use of information, though normally regarded as unacceptable professional practices, may go unrecognised in meeting educational needs, widening rather than narrowing theory-practice gaps. [ABSTRACT FROM AUTHOR]

Much of postmodern philosophy questions the assumptions of Modernity, that period in the history of the Western world since the Enlightment. These assumptions are that truth is discoverable through human reason; that certain knowledge is possible; and furthermore, that such knowledge will provide a basis for the ineluctable progress of Mankind. The Enlightenment project is underwritten by the conviction that knowledge gained through the scientific method is secure. In so far as biomedicine inherits these assumptions it becomes fair game for postmodern deconstruction. Today, perhaps more than ever, plural values compete, and contradictory approaches to health, for instance, garner support and acquire supremacy through consumer choice and media manipulation rather than evidence-based science. Many doctors feel a tension between meeting the needs of the patient face to face, and working towards the broader health needs of the public at large. But if the very foundations of medical science are questioned, by patients, or by doctors themselves, wherein lies the value of their work? This paper examines the issues that the anti-foundationalist thrust of postmodernism raises, in the light of a case of mild hypertension. The strict application of medical protocol, derived from a nomothetic, statistical perspective, seems unlikely to furnish value in the treatment of an individual. The anything goes, consumerist approach, however, fares no better. The author argues that whilst value cannot depend on any rationally predetermined parameters, it can be rescued, and emerges from the process of the meeting with the patient. [ABSTRACT FROM AUTHOR]

In 1989, in the wake of the first operations to transplant fetal tissue into the brains of sufferers from Parkinson's Disease, the UK Code of Practice governing the use of the fetus for research was overhauled by an eminent committee under the chairmanship of the Reverend Dr John Polkinghorne. The Polkinghorne Report has, however, attracted remarkably little comment or analysis. This paper is believed to be the first to subject it to sustained ethical and legal scrutiny. The author concludes that, although the committee's recommendations meet the major objections to the Code of Practice, the report is nevertheless vulnerable to criticism in its treatment of at least three issues: the moral status of the fetus; paternal consent to fetal use, and the ethical inter-relation of fetal use and abortion. [ABSTRACT FROM PUBLISHER]

In this paper some of the general issues surrounding recently published guidelines for the practice of research ethics committees are outlined, concentrating in particular on the difficulties raised by research with psychiatric patients. Research is distinguished from ordinary clinical practice by the intention to advance knowledge. So defined, research with psychiatric patients should be governed by the same four principles as research with any other group--knowledge, necessity, benefit and consent. In applying these principles, however, particularly the principle of consent, many acute difficulties are raised by psychiatric patients. A number of proposals for addressing these difficulties are discussed. It is suggested that, notwithstanding the value of published guidelines, and the help that may be available from research ethics committees, the primary responsibility for maintaining high standards of practice in research rests with research workers themselves. [ABSTRACT FROM PUBLISHER]

This paper begins with a discussion of the current legal definition of sex laid down in Corbett v Corbett. The implications of this test for three areas of the law, marriage, birth certificates and employment are then examined. Solutions from the United States of America and West Germany are studied and the suitability of similar solutions being transplanted into British law discussed. [ABSTRACT FROM PUBLISHER]

Attempts to determine the ideal number of consultant neurologists that will be required in the United Kingdom in the future are hampered by a lack of information on a variety of topics, one of which concerns the workload of the average neurologist at the present time. This paper attempts to correct this deficiency by examining the clinical workload of a single handed neurologist practising in the south west of England. Diagnostic information is given on the 3020 new patients seen during 1984-1986 and is compared with similar data on 836 new patients seen in 1975. The pattern of diagnoses on these patients varies little from year to year, indicating a constancy of referral habit of those who seek neurological advice. However, the referral rates for different conditions do not correspond with what would be expected from epidemiological data, for when the incidence of particular conditions in the neurology clinic is compared with the calculated incidence in the community, very wide variations are noted. The implications of these data are discussed and it is suggested that further studies should be performed before detailed predictions are made on how many neurologists will be needed in this country in the future. [ABSTRACT FROM AUTHOR]

Background: The Home Office has recently published estimates which, for the first time, provide a "robust national estimate" of the number of problematic drug users in England. The 2004/05 and 2005/06 estimates are the highest estimates ever produced for England and coincide with the highest ever government annual expenditure on combating illicit drug use. Methods and Results: Review of a range of data sources that indicate a downward trend in problematic drug use in recent years. Conclusions: The validity of the estimates is important for drug policy, and the paper considers the implications of both increasing and decreasing levels of problematic drug use. [ABSTRACT FROM AUTHOR]

In the author's experience most normal healthy adults would like to have the choice of medical help to die if they become incurably ill and find their suffering intolerable. The reasons for this are explored, based on ten years of listening and talking about the subject to a wide variety of people in many countries. The most familiar and common are the avoidance of futile suffering and the desire to retain autonomy. This paper concentrates on the dislike of losing independence and its closely associated wish to continue to behave altruistically. Some reasons for the general lack of recognition of the last two are suggested. [ABSTRACT FROM PUBLISHER]

The article summarizes a study evaluating the relation between high ambient temperatures with the changes in the risk of myocardial infarction on an hourly timescale. Paper-adds including data at an hourly temporal resolution from 11 conurbations in England and Wales showed that higher temperatures were associated with increased risk of myocardial infarction, with reductions in risk at longer lags being consistent with heat, in the six hours after exposure, above a threshold of 20°C.

AimsIt is important to know how far smokers' attempts at using nicotine replacement therapy (NRT) for smoking ‘harm reduction’ (reducing harm from continued smoking) promote or undermine cessation. To contribute to that goal, this study aimed to assess whether smokers' reports of smoking reduction (SR) and the use of NRT for SR and temporary abstinence (TA) predicted subsequent attempts to quit smoking and smoking status in a population sample. It also examined whether use of NRT for SR or TA was associated with reduced cigarette consumption compared with SR without NRT and non-use of NRT for TA.MethodData were collected from 15 539 smokers involved in the Smoking Toolkit Study, a series of monthly household surveys of adults aged 16+; of whom 23% (n=3149) completed a 6-month follow-up questionnaire. At baseline, participants were asked whether they were currently using NRT for SR or TA. They were also asked for demographic information and daily cigarette consumption. At 6-month follow-up, data on attempts to quit smoking and smoking status were collected.ResultsNRT use for SR and TA prospectively predicted attempts to quit smoking (OR 1.61, 95% CI 1.30 to 2.01 and OR 1.94, 95% CI 1.56 to 2.38 for SR and TA respectively) and abstinence (OR 1.51, 95% CI 1.06 to 2.16 and OR 2.09, 95% CI 1.51 to 3.34 for SR and TA respectively) at 6-months follow-up. Use of NRT for SR or TA was associated with a small reduction in cigarette consumption (two cigarettes per day) compared with SR without NRT or non-use of NRT for TA.ConclusionsThe use of NRT for SR or TA appears to be positively associated with subsequent attempts to quit smoking and abstinence among smokers in England, despite very little apparent effect on daily cigarette consumption. With replication, these findings support the potential benefit of using NRT for harm reduction but primarily as a means of promoting cessation. [ABSTRACT FROM AUTHOR]

Background: There appears to be considerable variation between different national jurisdictions and between different sectors of public policy in the use of evidence and particularly the use of randomised controlled trials (RCTs) to evaluate non-healthcare sector programmes. Methods: As part of a wider study attempting to identify RCTs of public policy sector programmes and the reasons for variation between countries and sectors in their use, we carried out a pilot study which interviewed 10 policy makers and researchers in six countries to elicit views on barriers to and facilitators of the use of RCTs for social programmes. Results: While in common with earlier studies, those interviewed expressed a need for unambiguous findings, timely results and significant effect sizes, users could, in fact, be ambivalent about robust methods and robust answers about what works, does not work or makes no difference, particularly where investment or a policy announcement was planned. Different national and policy sector cultures varied in their use of and support for RCTs. Conclusions: In order to maximise the use of robust evaluations of public programmes across the world it would be useful to examine, systematically, cross-national and cross-sectoral variations in the use of different methods including RCTs and barriers to and facilitators of their use. Sound research methods, whatever their scientific value, are no guarantee that findings will be useful or used. 'Stories' have been shown to influence policy; those advocating the use of RCTs may need to provide convincing narratives to avoid repetition about their value. [ABSTRACT FROM AUTHOR]

Objective To examine the impact of the ban on smoking in enclosed public places implemented in England in July 2007 on children's exposure to secondhand tobacco smoke. Design Repeated cross-sectional surveys of the general population in England. Setting The Health Survey for England. Participants Confirmed non-smoking children aged 4-15 with measured saliva cotinine participating in surveys from 1998 to 2008, a total of 10 825 children across years. Main outcome measures The proportion of children living in homes reported to be smoke-free; the proportion of children with undetectable concentrations of cotinine; geometric mean cotinine as an objective indicator of overall exposure. Results Significantly more children with smoking parents lived in smoke-free homes in 2008 (48.1%, 95% CI 43.0% to 53.1%) than in either 2006 (35.5%, 95% CI 29.7% to 41.7%) or the first 6 months of 2007, immediately before the ban came into effect (30.5%, 95% CI 19.7% to 43.9%). A total of 41.1% (95% CI 38.9% to 43.4%) of children had undetectable cotinine in 2008, up from 34.0% (95% CI 30.8% to 37.3%) in 2006. Geometric mean cotinine in all children combined was 0.21 ng/ml (95% CI 0.20 to 0.23) in 2008, slightly lower than in 2006, 0.24 ng/ml (95% CI 0.21 to 0.26). Conclusions Predictions that the 2007 legislative ban on smoking in enclosed public places would adversely affect children's exposure to tobacco smoke were not confirmed. While overall exposure in children has not been greatly affected by the ban, the trend towards the adoption of smoke-free homes by parents who themselves smoke has received fresh impetus. [ABSTRACT FROM AUTHOR]

Background Disturbed sleep is common throughout the community and is associated with an increase in daytime sleepiness, both of which, in turn are associated with an increased risk of ischaemic vascular disease. The hypothesis that sleep disturbances are predictive of dementia, and in particular vascular dementia was tested in a large community-based cohort of older men. Methods A questionnaire on sleep disturbances was administered to 1986 men aged 55-69 years in the Caerphilly Cohort Study and 10 years later the men were examined clinically for evidence of dementia or cognitive impairment with no dementia (CIND). Findings Approximately 20% of the men reported disturbed sleep and 30% reported 'severe' daytime sleepiness. Ten years later 1225 men (75% of the surviving men in the cohort) were tested and 268 (22%) were found to be cognitively impaired with 93 (7.6%) showing clear evidence of dementia and the remaining 175 (14.3%) showing evidence of CIND. After adjustment for possible confounding, including cognitive function and the taking of sleeping tablets at baseline, sleep disturbances appeared to be predictive of dementia and CIND of vascular origin, while there was no suggestion of prediction of non-vascular cognitive impairment by sleep. Prediction of vascular dementia appeared to be particularly strong for daytime sleepiness, with an adjusted OR of 4.44 (95% CI 2.05 to 9.61). Further adjustments for psychological distress at baseline reduced the size of the relationships, but the ORs remain large, consistent with a direct positive effect of sleep disturbance on vascular dementia. Interpretation Sleep disturbances, and in particular severe daytime sleepiness, appear to be strongly predictive of vascular dementia, but have no predictive power for non vascular dementia. [ABSTRACT FROM AUTHOR]

Objectives To investigate parental smoking behaviours between England and Scotland after the smoke-free legislation in Scotland came into effect in 2006 and examine inequalities in maternal smoking behaviours between countries. Methods 5954 white mothers and 3757 fathers resident in England and 1522 white mothers and 904 fathers resident in Scotland who participated in the Millennium Cohort Study (a prospective nationally representative cohort study) when the cohort child was age 9 months (before legislation) and 5 years (after legislation in Scotland but not in England). The main outcome measures were smoking at 9 months and 5 years, quitting smoking by 5 years, starting smoking by 5 years. Results In England and Scotland approximately 30% of parents reported smoking at 9 months with only a slight decrease in smoking at 5 years. There were no differences between countries in parental smoking after the smoke-free legislation in Scotland came into effect, taking into account prior smoking levels. Light smokers (1-9 cigarettes/day) from Scotland were less likely to quit by 5 years than those from England, but there were no differences between countries among heavy smokers (10+ cigarettes/day). Non-smoking mothers from Scotland (6.2%) were less likely to start smoking by 5 years than mothers from England (7.3%). Mothers from more disadvantaged circumstances in both countries were more likely to report that they smoked or started smoking. In England quitting was also socially patterned, but in Scotland, after the legislation was introduced, the gradients in quitting smoking were flatter across social groups. Conclusions Smoking behaviours among parents with young children remained relatively stable, highlighting the need for additional tobacco control efforts to support smoking cessation. However, the smoke-free legislation does not appear to widen health inequalities and may even help reduce them by encouraging quitting across socioeconomic groups. [ABSTRACT FROM AUTHOR]

Objective To explore social and behavioural impacts of English smoke-free legislation (SFL) in different ethnic groups. Design A longitudinal, qualitative panel study of smokers using in-depth interviews conducted before and after introduction of SFL. Participants A purposive sample of 32 smokers selected from three ethnic groups in deprived London neighbourhoods with approximately equal numbers of younger and older, male and female respondents. Results SFL has had positive impacts with half smoking less and three quitting. Although there were no apparent differences in smoking and quitting behaviours between groups, there were notable differences in the social impacts of SFL. The greatest negative impacts were in smokers over 60 years, potentially increasing their social isolation, and on young Somali women whose smoking was driven more underground. In contrast, most other young adult smokers felt relatively unaffected by SFL, describing unexpected social benefits. Although there was high compliance, reports of illegal smoking were more frequent among young, ethnic minority smokers, with descriptions of venues involved suggesting they are ethnically distinct and well hidden. Half of respondents reported stopping smoking in their own homes after SFL, but almost all were Somali or Turkish. White respondents tended to report increases in home smoking. Discussion Although our study suggests that SFL can lead to reductions in tobacco consumption, it also shows that impacts vary by ethnicity, age and sex. This study highlights the importance of understanding the meaning of smoking in different social contexts so future tobacco control interventions can be developed to reduce health and social inequalities. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tobacco displays at the point of sale (PoS) are an important means for the tobacco industry to communicate with consumers. With regulations prohibiting PoS displays recently having come into force in Ireland, passed into law in England, Wales and Northern Ireland and some Australian states, and being considered in New Zealand, Finland and Brazil, this is an increasingly important issue. This study explores the nature of displays, the extent to which they are tobacco industry funded, and the relation between the tobacco companies and retailers. METHODS: Three areas were chosen to gain a snapshot of PoS displays in England. Over 100 retailers were visited, with interviews taking place on site. Information was gathered on the type and size of tobacco display, who was paying for the display, requirements and incentives, and visits by industry representatives. RESULTS: The majority of retailers had gantries provided by tobacco companies. A minority of these were fitted with automated dispensers called retail vending machines. Attractive lighting and colour were often used to highlight particular products. Most retailers were being visited by industry representatives who checked displays. Some retailers also reported incentives offered to them for displaying products. CONCLUSIONS: The results suggest that the tobacco industry presence and control in the retail environment is significant. Tobacco companies overwhelmingly provided tobacco gantries in the shops surveyed and influenced displays through a combination of requirements and incentives. The extensive involvement of tobacco companies in providing and monitoring retail displays suggests the importance of implementing policies to end this form of advertising. [ABSTRACT FROM AUTHOR]

The article presents a study on the level of support for a total sales ban on tobacco products in England. The study found that a total ban was supported by more women than men, by more non-smokers and former smokers than smokers, and by those in the lower socioeconomic group. A decrease in prevalence and social acceptance is deemed likely. The possibility of the creation of a policy banning tobacco sales is suggested.

The article presents a study on the influence of the July 1, 2007 smoke-free legislation in England which banned smoking in public areas and workplaces. According to the article, attempts among smokers to quit smoking temporarily increased after the ban was introduced. The ban was also found to influence quitting behavior across social grades and prompted intentions to quit among those ages under 45 years old.

This article focuses on the evaluation of National Congenial Anomaly System (NCAS) in England and Wales. The problems with NCAS are well described in the papers--very poor ascertainment, and no data on antenatally diagnosed cases, except when fed data by the regional congenital anomaly registers; massively incomplete data fields; and consequently a severely limited capacity to fulfill the role for which it was set up in the wake of the thalidomide disaster. Yet congenital anomaly remains a leading cause of death and disability, perinatally and in infancy. It continues to pose challenges to public health, neonatal medicine and surgery.

OBJECTIVE: To examine the prevalence of smoke-free homes in England between 1996 and 2007 and their impact on children’s exposure to second-hand smoke via a series of annual cross-sectional surveys: the Health Survey for England. These comprised nationally representative samples of non-smoking children aged 4–15 (n = 13 365) and their parents interviewed in the home. Main outcome measures were cotinine measured in saliva, smoke-free homes defined by "no" response to "Does anyone smoke inside this house/flat on most days?", self-reported smoking status of parents and self-reported and cotinine validated smoking status in children. RESULTS: The proportion of homes where one parent was a smoker that were smoke free increased from 21% in 1996 to 37% in 2007, and where both parents were smokers from 6% to 21%. The overwhelming majority of homes with non-smoking parents were smoke free (95% in 1996; 99% in 2007). For children with non-smoking parents and living in a smoke-free home the geometric mean cotinine across all years was 0.22 ng/ml. For children with one smoking parent geometric mean cotinine levels were 0.37 ng/ml when the home was smoke free and 1.67 ng/ml when there was smoking in the home; and for those with two smoking parents, 0.71 ng/ml and 2.46 ng/ml. There were strong trends across years for declines in cotinine concentrations in children in smoke-free homes for the children of smokers and non-smokers. CONCLUSIONS: There has been a marked secular trend towards smoke-free homes, even when parents themselves are smokers. Living in a smoke-free home offers children a considerable, but not complete, degree of protection against exposure to parental smoking. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Smokers from more deprived socioeconomic groups are less likely to become ex-smokers. This study examined how far this is attributable in England to a social gradient in quit attempts, use of aids to cessation and/or the success of quit attempts. DESIGN: Cross-sectional household survey. SETTING: England. PARTICIPANTS: 6950 respondents aged 16+ who had smoked in the past year, of whom 2983 had tried to stop in the past year and 469 reported having stopped at the time of the survey. MAIN OUTCOME MEASURES: Reported attempts to stop smoking in the past year; the use of stop-smoking medications (nicotine replacement therapy, bupropion or varenicline); use of behavioural support offered by the National Health Service Stop Smoking Services; current smoking status. RESULTS: There was a large difference in success rates of quit attempts: 20.4% in social grade AB versus 11.4% in social grade E of those who made attempts were still not smoking by the time of the survey (p<0.001). However, there was no difference across social grades in the rate of attempts to stop (42.7% in social grade AB to 41.3% in E), use of medications to aid cessation (46.7% of those making quit attempts in AB to 50.9% in E) or use of NHS Stop Smoking Services (7.0% of those making quit attempts in AB to 4.8% in E). CONCLUSIONS: Smokers in more deprived socioeconomic groups are just as likely as those in higher groups to try to stop and use aids to cessation but there is a strong gradient across socioeconomic groups in success, with those in the lowest group being half as likely to succeed compared with the highest. Determining the cause of, and counteracting, this gradient is paramount in reducing health inequalities. [ABSTRACT FROM AUTHOR]