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As the use of simulation has become more established in the delivery of healthcare education and training, there has been a corresponding increase in healthcare simulation research. Simulation-based research can be divided into research about simulation (answers research questions in which the focus is on simulation itself) and research through simulation (simulation as a method/tool for research). However, there are barriers, particularly for smaller less well-resourced simulation centres, that may prohibit participation in research. Therefore, it is suggested that quality improvement (QI) through simulation may be a pragmatic way in which simulation centres of all sizes can contribute to improving patient care beyond education and training. QI is defined as systematic, data-guided activities designed to bring about immediate, positive changes in the delivery of healthcare. Although not the case in healthcare, other industries routinely used simulation to support QI. For example, in aviation simulation is used to inform the design of the working environment, the appropriate use of technology, to exercise emergency procedures and to ‘re-fly’ flights following an adverse event as part of the mishap investigation. Integrating simulation within healthcare QI can support the development of novel interventions as well helping to address heretofore intractable issues.

Misuse of statistics in medical and sports science research is common and may lead to detrimental consequences to healthcare. Many authors, editors and peer reviewers of medical papers will not have expert knowledge of statistics or may be unconvinced about the importance of applying correct statistics in medical research. Although there are guidelines on reporting statistics in medical papers, a checklist on the more general and commonly seen aspects of statistics to assess when peer-reviewing an article is needed. In this article, we propose a CHecklist for statistical Assessment of Medical Papers (CHAMP) comprising 30 items related to the design and conduct, data analysis, reporting and presentation, and interpretation of a research paper. While CHAMP is primarily aimed at editors and peer reviewers during the statistical assessment of a medical paper, we believe it will serve as a useful reference to improve authors’ and readers’ practice in their use of statistics in medical research. We strongly encourage editors and peer reviewers to consult CHAMP when assessing manuscripts for potential publication. Authors also may apply CHAMP to ensure the validity of their statistical approach and reporting of medical research, and readers may consider using CHAMP to enhance their statistical assessment of a paper.

IntroductionCompared with the rest of the UK and Western Europe, England has high rates of the infectious disease tuberculosis (TB). TB is curable, although treatment is for at least 6 months and longer when disease is drug resistant. If patients miss too many doses (non-adherence), they may transmit infection for longer and the infecting bacteria may develop resistance to the standard drugs used for treatment. Non-adherence may therefore risk both their health and that of others. Within England, certain population groups are thought to be at higher risk of non-adherence, but the factors contributing to this have been insufficiently determined, as have the best interventions to promote adherence. The objective of this study was to develop a manualised package of interventions for use as part of routine care within National Health Services to address the social and cultural factors that lead to poor adherence to treatment for TB disease.Methods and analysisThis study uses a mixed-methods approach, with six study components. These are (1) scoping reviews of the literature; (2) qualitative research with patients, carers and healthcare professionals; (3) development of the intervention; (4) a pilot randomised controlled trial of the manualised intervention; (5) a process evaluation to examine clinical utility; and (6) a cost analysis.Ethics and disseminationThis study received ethics approval on 24 December 2018 from Camberwell St. Giles Ethics Committee, UK (REC reference 18/LO/1818). Findings will be published and disseminated through peer-reviewed publications and conference presentations, published in an end of study report to our funder (the National Institute for Health Research, UK) and presented to key stakeholders.Trial registration numberNCT95243114Secondary identifying numbersUniversity College London/University College London Hospitals Joint Research Office 17/0726.National Institute for Health Research, UK 16/88/06.

IntroductionMany patients now turn to the internet as a resource for healthcare information and advice. However, patients’ use of the internet to manage their health has been positioned as a potential source of strain on the doctor–patient relationship in primary care. The current evidence about what happens when internet-derived health information is introduced during consultations has relied on qualitative data derived from interview or questionnaire studies. The ‘Harnessing resources from the internet to maximise outcomes from GP consultations (HaRI)’ study combines questionnaire, interview and video-recorded consultation data to address this issue more fully.Methods and analysisThree data collection methods are employed: preconsultation patient questionnaires, video-recorded consultations between general practitioners (GP) and patients, and semistructured interviews with GPs and patients. We seek to recruit 10 GPs practising in Southeast England. We aim to collect up to 30 patient questionnaires and video-recorded consultations per GP, yielding up to 300. Up to 30 patients (approximately three per participating GP) will be selected for interviews sampled for a wide range of sociodemographic characteristics, and a variety of ways the use of, or information from, the internet was present or absent during their consultation. We will interview all 10 participating GPs about their views of online health information, reflecting on their own usage of online information during consultations and their patients’ references to online health information. Descriptive, conversation and thematic analysis will be used respectively for the patient questionnaires, video-recorded consultations and interviews.Ethics and disseminationEthical approval has been granted by the London–Camden & Kings Cross Research Ethics Committee. Alongside journal publications, dissemination activities include the creation of a toolkit to be shared with patients and doctors, to guide discussions of material from the internet in consultations.

IntroductionChronic kidney disease (CKD) management in the UK is usually primary care based, with National Institute for Health and Care Excellence (NICE) guidelines defining criteria for referral to secondary care nephrology services. Estimated glomerular filtration rate (eGFR) is commonly used to guide timing of referrals and preparation of patients approaching renal replacement therapy. However, eGFR lacks sensitivity for progression to end-stage renal failure; as a consequence, the international guideline group, Kidney Disease: Improving Global Outcomes has recommended the use of a risk calculator. The validated Kidney Failure Risk Equation may enable increased precision for the management of patients with CKD; however, there is little evidence to date for the implication of its use in routine clinical practice. This study will aim to determine the impact of the Kidney Failure Risk Equation on the redesignation of patients with CKD in the UK for referral to secondary care, compared with NICE CKD guidance.Method and analysisThis is a cross-sectional population-based observational study using The Health Improvement Network database to identify the impact of risk-based designation for referral into secondary care for patients with CKD in the UK. Adult patients registered in primary care and active in the database within the period 1 January 2016 to 31 March 2017 with confirmed CKD will be analysed. The proportion of patients who meet defined risk thresholds will be cross-referenced with the current NICE guideline recommendations for referral into secondary care along with an evaluation of urinary albumin–creatinine ratio monitoring.Ethics and disseminationApproval was granted by The Health Improvement Network Scientific Review Committee (Reference number: 18THIN061). Study outcomes will inform national and international guidelines including the next version of the NICE CKD guideline. Dissemination of findings will also be through publication in a peer-reviewed journal, presentation at conferences and inclusion in the core resources of the Think Kidneys programme.

IntroductionThe occurrence of thyroid cancer is increasing throughout the developed world and since the 1990s has become the fastest increasing malignancy. In 2014, a total of 2693 Australians and 302 New Zealanders were diagnosed with thyroid cancer, with this number projected to rise to 3650 in 2018. The purpose of this protocol is to establish a binational population-based clinical quality registry with the aim of monitoring and improving the quality of care provided to patients diagnosed with thyroid cancer in Australia and New Zealand.Methods and analysisThe Australian and New Zealand Thyroid Cancer Registry (ANZTCR) aims to capture clinical data for all patients over the age of 16 years with thyroid cancer, confirmed by histopathology report, who have been diagnosed, assessed or treated at a contributing hospital. A multidisciplinary steering committee was formed which, with operational support from Monash University, established the ANZTCR in early 2017. The pilot phase of the registry is currently operating in Victoria, New South Wales, Queensland, Western Australia and South Australia, with over 20 sites expected to come on board across Australia in 2018. A modified Delphi process was undertaken to determine the clinical quality indicators to be reported by the registry, and a minimum data set was developed comprising information regarding thyroid cancer diagnosis, pathology, surgery and 90-day follow-up.Future plansThe establishment of the ANZTCR provides the opportunity for Australia and New Zealand to further understand current practice in the treatment of thyroid cancer and identify variation in outcomes. The engagement of endocrine surgeons in supporting this initiative is crucial. While the pilot registry has a focus on early clinical outcomes, it is anticipated that future collection of longer term outcome data particularly for patients with poor prognostic disease will add significant further value to the registry.

Introduction Inequalities are evident in early childhood caries rates with the socially disadvantaged experiencing greater burden of disease. This study builds on formative qualitative research, conducted in the Moreland/Hume local government areas of Melbourne, Victoria 2006–2009, in response to community concerns for oral health of children from refugee and migrant backgrounds. Development of the community-based intervention described here extends the partnership approach to cogeneration of contemporary evidence with continued and meaningful involvement of investigators, community, cultural and government partners. This trial aims to establish a model for child oral health promotion for culturally diverse communities in Australia. Methods and analysis This is an exploratory trial implementing a community-based child oral health promotion intervention for Australian families from refugee and migrant backgrounds. Families from an Iraqi, Lebanese or Pakistani background with children aged 1–4 years, residing in metropolitan Melbourne, were invited to participate in the trial by peer educators from their respective communities using snowball and purposive sampling techniques. Target sample size was 600. Moreland, a culturally diverse, inner-urban metropolitan area of Melbourne, was chosen as the intervention site. The intervention comprised peer educator led community oral health education sessions and reorienting of dental health and family services through cultural Competency Organisational Review (CORe). Ethics and dissemination Ethics approval for this trial was granted by the University of Melbourne Human Research Ethics Committee and the Department of Education and Early Childhood Development Research Committee. Study progress and output will be disseminated via periodic newsletters, peer-reviewed research papers, reports, community seminars and at National and International conferences. Trial registration number Australian New Zealand Clinical Trials Registry (ACTRN12611000532909).

Both electronic health (eHealth) and mobile health (mHealth) are becoming prominent components of healthcare. In order for healthcare electronic services to be safe and effective and add genuine value to the system, the European Association of Hospital Pharmacists (EAHP) believes that these should be developed in close collaboration with healthcare professionals including hospital pharmacists, and patients. Consequently, the EAHP calls in its position paper upon national governments and health systems across Europe to work towards (1) systematic and European Union-wide achievement of electronic prescribing, administration and use of electronic medical records; (2) ensuring barcoding of medicines to the single units in primary packages to enable more widespread take-up of bedside scanning in European hospitals, thus improving patient safety; (3) appropriate regulatory oversight mechanisms for mHealth applications to ensure that they have a positive impact and adequately protect patient data; (4) provision of appropriate eHealth/mHealth training opportunities to healthcare professionals and promotion of digital health literacy; and (5) involvement of hospital pharmacists in the design, specification of parameters and evaluation of information and communication technology within the medicines processes.

Generally, medical quizzes, multiple-choice questions (MCQs) and other types of mock exams are either created on Microsoft PowerPoint or are paper based. During these sessions, only a few participants are willing to discuss their answers, and it has the risk of becoming a didactic tutorial with minimal interaction, particularilywith larger groups. Kahoot! can be used as a technology-enhanced medium for delivering these types of sessions. It encourages an interactive side to the quiz, promotes fun and competition and thus can get students more motivated in answering questions. Likewise, social learning aspects can be introduced even to bigger groups, so that students can learn from one another by discussing why a particular answer is correct or incorrect. Kahoot! is an application used frequently in primary and secondary schools but less so in adult learning, although it is gaining popularity.1 Presentations are created on the Kahoot! website with the opportunity to upload images. There are options for both private and public quizzes. Participants can then …

EAHP's position paper advocates for the involvement of hospital pharmacists in procurement. The immediate concern of any hospital pharmacist is to ensure that every patient within the hospital receives the medications needed. For this reason, hospital pharmacists have a direct stake in the efficient functioning of the medicines' supply chain. The position touches on pharmaceutical tendering which is a complex process that involves different stakeholders and steps that are regulated at national level leading to diverse solutions in the different European countries. In addition, these processes are guided by publications of other international actors such as the World Health Organisation (WHO) and the Organisation for Economic Co-operation and Development (OECD). The second part focuses on the role of hospital pharmacists in procurement which due to their knowledge and skills are specialists in the field of all medicines' procurement. Hospital pharmacists should lead in all phases of the procurement processes and practices to ensure the continuity of the supply of cost-effective and quality medicines to patients.

Procurement is an important part of drug management and supply for measuring and increasing efficiency at all levels of healthcare institutions. Effective procurement means supplying the right drugs in the right quantities, at the right time, and with recognisable standards of quality. The European Association of Hospital Pharmacists position paper on procurement, released in June 2018,1 states that the knowledge and skills of hospital pharmacists make them specialists in the entire field of medicine procurement. Hospital pharmacists should lead all phases of procurement to ensure continuity of the supply of cost-effective quality medicines to patients. Within the European Union, public procurement …

Objective Few longitudinal studies have examined the effect of tobacco price increase on both cessation among smokers and relapse among quitters. Our objective was to investigate the differential impact of the tobacco price increase on the changes in smoking status in the total population and various subgroups. Methods We analysed data from a Japanese nationally representative longitudinal study of 30 773 individuals aged 50–59 years (weighted sum of discrete-time number = 215 411) with smoking information, using inverse probability weighting to account for non-response at follow-up. Generalised estimating equation models were used to calculate the odds ratios (ORs) for smoking behavioural changes (cessation among smokers and relapse among quitters), using discrete-time design. Stratified analyses were conducted according to demographic, socioeconomic and health behavioural characteristics. Results From 2005 to 2012, current smoker prevalence among the middle-aged Japanese population decreased from 30.5% to 24.3%. Of all the factors surveyed, only the tobacco price increase in 2010 (up by 37%, the highest increase during the period) was significantly associated with both cessation among smokers (OR 2.14, 95% confidence interval 1.90 to 2.41) and prevention of relapse among quitters (0.60, 0.46 to 0.77). Regarding the subgroup analysis, the tobacco price increase was associated with a significant reduction in relapse in the lowest income, recent quitters and very poor health subgroups. However, different associations were observed for cessation; a significant association between price increase and cessation was observed among all subgroups except for the heavy smoker and recently unemployed subgroups. Conclusions We confirmed that the tobacco price rise was associated with increasing cessation and decreasing relapse concurrently. Furthermore, this price rise was associated with favourable smoking changes in nearly all population subgroups; a large differential impact was not observed across the various subgroups.

Objective To confirm the accuracy of a diagnostic questionnaire for carpal tunnel syndrome (CTS) when presented via a public website rather than on paper. Design Prospective comparison of the probability of CTS as assessed by the web-based questionnaire at http://www.carpal-tunnel.net with the results of nerve conduction studies. Setting Subregional neurophysiology laboratory serving a population of 700 000 in East Kent, UK. Participants 2821 individuals who were able to complete an online diagnostic questionnaire out of 4899 referred for initial diagnostic testing for new presentations with suspected CTS from April 2011 to March 2013. No exclusions were made on grounds of age, gender or coincident pathology. Main outcome measure—nerve conduction results confirming CTS. The severity of median nerve impairment demonstrated was also assessed using a validated neurophysiological scale. Results The web-based questionnaire accurately estimates the probability of CTS being confirmed on nerve conduction studies. Using a website diagnostic score of ≥40% as an example cut-off value the questionnaire achieves 78% sensitivity and 68% specificity in predicting the finding of evidence of CTS on nerve conduction studies. The web-based version of the diagnostic questionnaire was as accurate as the original paper version with an area under the receiver operating characteristic curve of 0.79. There was also a significant correlation between the diagnostic score given by the website and the severity of CTS with higher scores being associated with greater nerve dysfunction (r=0.3, p Conclusions Completion of the symptom questionnaire on the website by patients at home provides a prediction of the likelihood of CTS which is sufficiently accurate to be used in initial planning of investigation and treatment.

Background: Studying stroke rates in a whole community is a rational way to assess the quality of patient care and primary prevention. However, there are few studies of trends in stroke rates worldwide and none in Brazil. Objective: Established study methods were used to define the rates for first ever stroke in a defined population in Brazil compared with similar data obtained and published in 1995. Methods: All stroke cases occurring in the city of Joinville during 2005–2006 were prospectively ascertained. Crude incidence and mortality rates were determined, and age adjusted rates and 30 day case fatality were calculated and compared with the 1995 data. Results: Of the 1323 stroke cases registered, 759 were first ever strokes. The incidence rate per 100 000 was 105.4 (95% CI 98.0 to 113.2), mortality rate was 23.9 (95% CI 20.4 to 27.8) and the 30 day case fatality was 19.1%. Compared with the 1995 data, we found that the incidence had decreased by 27%, mortality decreased by 37% and the 30 day case fatality decreased by 28%. Conclusions: Using defined criteria we showed that in an industrial southern Brazilian city, stroke rates are similar to those from developed countries. A significant decrease in stroke rates over the past decade was also found, suggesting an improvement in primary prevention and inpatient care of stroke patients in Joinville.

Objective: To study the prevalence of, and discuss factors contributing to, household second-hand smoke exposure in six counties in China, providing scientific support for the need to establish tobacco control measures in these areas. Methods: A cross-sectional survey was performed. Investigators conducted face-to-face interviews using a standardised questionnaire to collect information on demographics, passive smoking behaviours and knowledge, and attitudes towards tobacco control. The setting was six counties from the three provinces: Mianzhu and Xichong counties in Sichuan Province; Anyi and Hukou counties in Jiangxi Province; and Xinan and Yanshi counties in Henan Province. A total of 8142 non-smokers (aged 18–69) in 2004 were included in the data analysis. Household second-hand smoke exposure rate as defined as the proportion of household passive smokers in the non-smoker population was used as the measure of household second-hand smoke exposure. Results: The analysis of 8142 non-smokers revealed that, in these selected counties, the household second-hand smoke exposure rate was 48.3%. Respondents had positive attitudes towards tobacco control. Of 6972 respondents, 84.4% supported all the three tobacco control policies (banning smoking in public places, banning the selling of cigarettes to minors, banning all cigarette advertisements). In 3165 families with smokers, 87.2% of respondents reported that smokers would smoke in front of them. In 2124 families with smokers and children, 76.5% of respondents reported that smokers would smoke in front of children. As many as 42.1% of non-smokers would offer cigarettes to their guests, and only 46.8% of respondents would ask smokers to smoke outdoors. Only 6.3% of families completely forbade smoking at home. Multivariate logistic regression analysis revealed high second-hand smoke exposure for the following demographic groups: Jiangxi Province inhabitants, females, those with low education level, farmers and married respondents. Conclusions: Household second-hand smoke exposure rates in the selected counties were high. A high percentage of respondents reported that smokers would smoke in front of them and children. The pressure from non-smokers against smoking was relatively low, although offering cigarette was prevalent. Households that were completely smoking-free were rare, Further studies on these correlated factors could help us establish effective measures to reduce household second-hand smoke exposure.

OBJECTIVE White matter lesions are often seen on MR scans of elderly non-demented and demented people. They are attributed to degenerative changes of small vessels and are implicated in the pathogenesis of cognitive decline and dementia. There is evidence that especially periventricular white matter lesions are related to cognitive decline, whereas subcortical white matter lesions may be related to late onset depression. The frequency distribution of subcortical and periventricular white matter lesions according to age and sex reported.METHODS A total of 1077 subjects aged between 60–90 years were randomly sampled from the general population. All subjects underwent 1.5T MR scanning; white matter lesions were rated separately for the subcortical region and the periventricular region.RESULTS Of all subjects 8% were completely free of subcortical white matter lesions, 20% had no periventricular white matter lesions, and 5% had no white matter lesions in either of these locations. The proportion with white matter lesions increased with age, similarly for men and women. Women tended to have more subcortical white matter lesions than men (total volume 1.45 ml v 1.29 ml; p=0.33), mainly caused by marked differences in the frontal white matter lesion volume (0.89 ml v 0.70 ml; p=0.08). Periventricular white matter lesions were also more frequent among women than men (mean grade 2.5 v 2.3; p=0.07). Also severe degrees of subcortical white matter lesions were more common in women than in men (OR 1.1; 95% confidence interval (95% CI) 0.8–1.5) and periventricular white matter lesions (OR 1.2; 95% CI 0.9–1.7), albeit that none of these findings were statistically significant.CONCLUSIONS The prevalence and the degree of cerebral white matter lesions increased with age. Women tended to have a higher degree of white matter lesions than men. This may underlie the finding of a higher incidence of dementia in women than in men, particularly at later age.

Department of Pulmonology, University Hospital, Masstricht, The Netherlands.BACKGROUND: Weight loss is a frequently occurring problem in patients with lung cancer due to an increased resting energy expenditure (REE) and a decreased energy intake. The aim of the present study was to compare the metabolic and inflammatory characteristics of patients with small cell lung carcinoma (SCLC) and non-small cell lung carcinoma (NSCLC). The metabolic parameters of the lung cancer population were compared with those of a healthy control group. METHODS: REE was measured in 66 patients with lung cancer, subdivided according to their histology, and in 33 healthy controls matched for sex, age, and fat free mass (FFM). Inflammatory mediators were measured in the plasma of the patients with lung cancer. RESULTS: An increased REE adjusted for FFM was found in the patients with lung cancer. Those with small cell lung carcinoma (SCLC) had an increased REE adjusted for FFM (mean 1925 kcal/day) compared with those with non-small cell lung carcinoma (NSCLC) (mean 1789 kcal/day, 95% CI for difference 36 to 236). FFM accounted for 69% and 48% of the inter-individual variation in REE in controls and those with NSCLC, respectively, while FFM accounted for only 25% of the variation in REE in patients with SCLC in whom the fat mass (FM) also contributed significantly (28%) to the variation in REE. Increased concentrations of soluble TNF-receptor 75 (sTNF-R75) and cortisol were found in patients with SCLC compared with those with NSCLC. Lipopolyasccharide binding protein (LBP) and sTNF-R55 were related to plasma levels of cortisol. CONCLUSION: An enhanced REE adjusted for FFM occurred in patients with SCLC compared with those with NSCLC.

This retrospective cohort study was planned to determine whether recommendations to take folic acid have in fact lessened the risk of neural tube defects. Recommendations typically include eating a healthy diet and takingfolic acid supplements when planning pregnancy or throughout the childbearing years. In a few countries, including the United States, flour is fortified so that much of the population will receive at least a small supplemental amount of folic acid. Many governments promote the use of supplements because folic acid is inexpensive, safe, and easy to use. The authors acquired information on more than 13 million births from 13 birth defects registries in Norway that monitored rates of neural tube defects from 1988 to 1998. Cases of anencephaly and spina bifida totaled 8636. Rates of defects were stable during the 10-year monitoring interval in most areas. There were no evident changes in rates of defects after local recommendations were issued. Comparable findings were obtained when analyzing anencephaly and spina bifida separately and combined. Folic acid use in Europe is, in general, low; in Norway, it is approximately 10%. In China, intensive educational efforts and a high rate of planned pregnancies probably are responsible for the effectiveness of a public health campaign to promote the use of folic acid supplements. Rates of folic acid use generally follow economic and educational trends. Fortifying flour with folic acid holds promise for delivering some folic acid to a large part of the population, crossing social and economic barriers. Blood folate levels have increased rapidly where this practice is followed. It is estimated that thousands of neural tube defects occurring since 1992 could have been prevented.

Trunk performance is an important predictor of functional outcome after stroke. However, the percentage of explained variance varies considerably between studies. This may be explained by the stroke population examined, the different scales used to assess trunk performance and the time points used to measure outcome. The aim of this multicentre study was to examine the predictive validity of the Trunk Impairment Scale (TIS) and its subscales when predicting the Barthel Index score at 6 months after stroke.A total of 102 subjects were recruited in three European rehabilitation centres. Participants were assessed on admission (median time since stroke onset 20 days) and 6 months after stroke. Correlation analysis and forward stepwise multiple regression analysis were used to model outcome.The best predictors of the Barthel Index scores at 6 months after stroke were total TIS score (partial R2 = 0.52, p.0001) and static sitting balance subscale score (partial R2 = 0.50, p.0001) on admission. The TIS score on admission and its static sitting balance subscale were stronger predictors of the Barthel Index score at 6 months than the Barthel Index score itself on admission.This study emphasises the importance of trunk performance, especially static sitting balance, when predicting functional outcome after stroke. The TIS is recommended as a prediction instrument in the rehabilitation setting when considering the prognosis of stroke patients. Future studies should address the evolution of trunk performance over time and the evaluation of treatment interventions to improve trunk performance.

Objectives: To investigate why some women prefer caesarean sections and how decisions to medicalise birthing are influenced by patients, doctors, and the sociomedical environment. Design: Population based birth cohort study, using ethnographic and epidemiological methods. Setting: Epidemiological study: women living in the urban area of Pelotas, Brazil who gave birth in hospital during the study. Ethnographic study: subsample of 80 women selected at random from the birth cohort. Nineteen medical staff were interviewed. Participants: 5304 women who gave birth in any of the city9s hospitals in 1993. Main outcome measures: Birth by caesarean section or vaginal delivery. Results: In both samples women from families with higher incomes and higher levels of education had caesarean sections more often than other women. Many lower to middle class women sought caesarean sections to avoid what they considered poor quality care and medical neglect, resulting from social prejudice. These women used medicalised prenatal and birthing health care to increase their chance of acquiring a caesarean section, particularly if they had social power in the home. Both social power and women9s behaviour towards seeking medicalised health care remained significantly associated with type of birth after controlling for family income and maternal education. Conclusions: Fear of substandard care is behind many poor women9s preferences for a caesarean section. Variables pertaining to women9s role in the process of redefining and negotiating medical risks were much stronger correlates of caesarean section rates than income or education. The unequal distribution of medical technology has altered concepts of good and normal birthing. Arguments supporting interventionist birthing for all on the basis of equal access to health care must be reviewed. What is already known on this topic Women9s preferences for caesarean sections are understood to result from lack of knowledge and psychological aptitude to handle vaginal delivery and its consequences Efforts to reduce the demand for caesarean sections have focused on providing consumers with correct information on the relative risks associated with vaginal and operative deliveries What this study adds In Brazil, many women prefer caesarean sections because they consider it good quality care Rich women are more likely to have caesarean sections, supporting the notion that medical intervention represents superior care Poor women may implement a series of medicalised practices that justifies the need for greater medical intervention during birth Interventions for reducing caesarean sections by educating physicians and patients about risk factors associated with birthing procedures are not sufficient

We previously reported high mortality and high incidence of cancer in second generation Irish people (children of Irish migrants) living in England and Wales. 1 2 In this study we examine the mortality of third generation Irish people (grandchildren of Irish migrants) living in England and Wales. The longitudinal study by the Office for National Statistics is a record linkage study of a 1% representative sample of the population of England and Wales. The sample was first extracted from the 1971 census and is updated with new births and immigrants. Information from censuses and registrations of vital events is linked to the records of study members.3 First generation Irish classified by country of birth covered those people born in Northern Ireland and the Irish Republic. For second and third generations, only those people with parents and grandparents born in the Republic of Ireland could be identified because parents born …

Objectives: To assess the effects of taking an intercalated degree (BSc) on the study habits and learning styles of medical students and on their interest in a career in medical research.\ud \ud Design: Longitudinal questionnaire study of medical students at application to medical school and in their final year.\ud \ud Setting: All UK medical schools.\ud \ud Participants: 6901 medical school applicants for admission in 1991 were studied in the autumn of 1990. 3333 entered medical school in 1991 or 1992 and 2695 who were due to qualify in 1996 or 1997 were studied 3 months before the end of their clinical course. Response rates were 92% for applicants and 56% for final year students.\ud \ud Main outcome measures: Study habits (surface, deep, and strategic learning style) and interest in different medical careers, including medical research. Identical questions were used at time of application and in final year.\ud \ud Results: Students who had taken an intercalated degree had higher deep and strategic learning scores than at application to medical school Those with highest degree classes had higher strategic and deep learning scores and lower surface learning scores. Students taking intercalated degrees showed greater interest in careers in medical research and laboratory medicine and less interest in general practice than their peers. The effects of the course on interest in medical research and learning styles were independent. The effect of the intercalated degree was greatest in schools where relatively few students took intercalated degrees.\ud \ud Conclusions: Intercalated degrees result in a greater interest in research careers and higher deep and strategic learning scores. However, the effects are much reduced in schools where most students intercalate a degree Introduction of intercalated degrees for all medical students without sufficient resources may not therefore achieve its expected effects.\ud \ud Key messages\ud \ud - Although intercalated degrees are well established, little is known about their effect on medical students.\ud \ud - In this longitudinal study final year students who had taken intercalated degree were more interested in medical research, and had higher deep and strategic learning style scores than other students.\ud \ud - The effects of the intercalated degree were dose dependent, being greatest in those gaining a first class degree.\ud \ud - The effects of the intercalated degree were greatest in medical schools where a relatively small proportion of medical students took the degree.\ud \ud - Differences between medical schools are most easily explained by resource dilution.

The proportions of X and Y chromosome bearing sperms in human semen are equal, but more boys than girls are born. Male embryos and fetuses have a greater risk of attrition in utero than their female counterparts, and therefore male excess is likely to be still larger at the time of conception. It remains unexplained, however, what is responsible, presumably at some point between insemination and conception, for the greater probability of Y bearing sperms fusing with the ovum. One hypothesis relates to experiments showing that Y bearing sperms swim faster than X bearing sperms in viscous fluids.1 For natural conception, human sperms have to penetrate cervical mucus, the viscosity of which varies among and within women.2 Since mucal viscosity also influences the probability of conception,2 we expected that natural conceptions that take longer to achieve are more likely to be male than quick conceptions. We tested our prediction by assessing the relation between time to pregnancy and sex of the offspring. We …

The National Institute for Health and Care Excellence (NICE), the UK’s main healthcare priority-setting body, recently reaffirmed a longstanding claim that in recommending technologies to the National Health Service it cannot apply the ‘rule of rescue’. This paper explores this claim by identifying key characteristics of the rule and establishing to what extent these are also features of NICE’s approach to evaluating ultra-orphan drugs through its highly specialised technologies (HST) programme. It argues that although NICE in all likelihood does not act because of the rule in prioritising these drugs, its actions in relation to HSTs are nevertheless in accordance with the rule and are not explained by the full articulation of any alternative set of rationales. That is, though NICE implies that its approach to HSTs is not motivated by the rule of rescue, it is not explicit about what else might justify this approach given NICE’s general concern with overall population need and value for money. As such, given NICE’s reliance on notions of procedural justice and its commitment to making the reasons for its priority-setting decisions public, the paper concludes that NICE’s claim to reject the rule is unhelpful and that NICE does not currently meet its own definition of a fair and transparent decision-maker.

BackgroundThere are few examples of the practical application of the concepts of social accountability, as defined by the World Bank and WHO, to health system change. This paper describes a robust approach led by First Nations Health Authority and the Rural Coordination Centre of British Columbia. This was achieved using partnerships in British Columbia, Canada, where the health system features inequities in service and outcomes for rural and Indigenous populations. Social accountability is achieved when all stakeholders come together simultaneously as partners and agree on a path forward. This approach has enabled socially accountable healthcare, effecting change in the healthcare system by addressing the needs of the population.InnovationOur innovative approach uses social accountability engagement to counteract persistent health inequities. This involves an adaptation of the Boelen Health Partnership model (policymakers, health administrators, health professionals, academics and community members) extended by addition of linked sectors (eg, industry and not-for-profits) to the ‘Partnership Pentagram Plus’. We used appreciative inquiry and deliberative dialogue focused on the rural scale and integrating Indigenous ways of knowing along with western scientific traditions (‘two-eyed seeing’). Using this approach, partners are brought together to identify common interests and direction as a learning community. Equitable engagement and provision of space as ‘peers’ and ‘partners’ were key to this process. Groups with varying perspectives came together to create solutions, building on existing strengths and new collaborative approaches to address specific issues in the community and health services delivery. A resulting provincial table reflecting the Pentagram Plus model has fostered policies and practices over the last 3 years that have resulted in meaningful collaborations for health service change.ConclusionThis paper presents the application of the ‘Partnership Pentagram Plus’ approach and uses appreciative inquiry and deliberative dialogue to bring about practical and positive change to rural and Indigenous communities.

IntroductionBreaking bad news and dealing with difficult patient encounters is a skill that medical residents must learn during their curriculum. Many different tools are available to measure communication quality, but their development and validation processes are often missing. In this paper, we present the protocol of a systematic review aiming to identify the validated tools for measuring communication skills or communication effectiveness with parents in a paediatrics setting in general, including for difficult patient encounters.Methods and analysisWe will conduct our systematic review in accordance with the methodology suggested by COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and will report this paper following the guidelines of the Preferred Reporting Items for Systematic reviews and Meta-Analyses. We will include the studies in which authors developed and/or validated tools for assessing the quality of communication with families by residents and/or physicians during patient encounters in paediatric settings. Studies assessing communication in telemedicine and studies that use the tool to measure a different outcome than its validation will be excluded. Our search strategy will be developed by a scientific librarian and validated using the Peer Review of Electronic Search Strategy (PRESS) tool. Two reviewers will independently screen the studies for selection, extract data of the ones included and assess their level of risk of bias using the COSMIN Risk of Bias checklist. We will perform a narrative synthesis on the study selection process, the characteristics of studies and study population, the characteristics of tools identified, their process of development and/or validation and their psychometric properties. If sufficient data are available, we will do quantitative analyses for each psychometric property.Ethics and disseminationApproval from an ethics committee is not required, as there is no primary data collection. Our findings will be disseminated through a peer-reviewed publication and at local, national and international conferences.PROSPERO registration numberCRD42020151642.

BackgroundChildren undergoing surgery, and their parents, are at risk of developing post-traumatic stress reactions. We systematically reviewed the literature to understand the prevalence of this issue, as well as potential risk factors.MethodsWe conducted a systematic review and meta-analysis, using PubMed, PsycInfo, Web of Science and Google Scholar, with searches conducted in February 2021. Papers were included if they measured post-traumatic stress in children and/or parents following paediatric surgery, and were excluded if they did not use a validated measure of post-traumatic stress. Data was extracted from published reports.FindingsOur search yielded a total of 1,672 papers, of which 16 of met our inclusion criteria. In meta-analysis, pooled studies of children estimated an overall prevalence of 16% meeting criteria for post-traumatic stress disorder post-surgery (N= 187, 95% CI : 5-31%, I2= 80%). After pooling studies of parents, overall prevalence was estimated at 23% (N= 1444, 95% CI 16-31%, I2= 91%). Risk factors reported within studies included length of stay, level of social support and parental mental health.InterpretationThere is consistent evidence of traumatic stress following surgery in childhood which warrants further investigation. Those delivering surgical care to children would benefit from a raised awareness of the potential for post-traumatic stress in their patients and their families, including offering screening and support.FundingWe did not seek or receive any funding for this study.