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Editorial and opinion pieces speculate (or proclaim) about the foundations of war, the curse of humanity. Here is another perspective, backed by forty years of anthropological research, on origins, causes, variations, and meanings of war, and their contemporary implications.

Background. Tranexamic acid (TXA) is routinely administered intravenously (IV) and intraosseously (IO) in response to exsanguination. Case. This report describes a patient who sustained multiple high-powered rifle gunshot wounds that received battlefield-environment intramuscular (IM) administration of TXA due to inability to obtain IV / IO access. This case represents the unlikely positive outcome in the setting of multiple remarkable obstacles, which may have been ameliorated by novel administration of TXA. Conclusion. Cases of IM TXA administration as a primary intervention are not well represented in the current body of medical literature. This case report highlights a clinical scenario where IM TXA was utilized as part of first-line treatment that led to a positive clinical outcome. Although IM TXA is not yet endorsed by current trauma guidelines, this case suggests that IM route administration of TXA should be further investigated. If indeed IM administration of TXA proves just as efficacious as alternative routes, this would hold considerable advantageous implications for austere situations were sterility and IV / IO placement are impractical. This would also represent another avenue by which to decrease the time-to-TXA for patients, allowing sooner correction of hemorrhage and trauma-associated coagulopathy.

Individuals with Substance Use Disorder (SUD) who do not have empathy toward oneself, or self-compassion, may limit their opportunities for personal growth and overall well-being. Due to scarce empirical studies examining interactions between self-compassion, personal growth and well-being in persons with SUD, the goal of this research was to examine associations among these concepts. A survey was administered to patients in treatment for SUD using validated scales (Sussex-Oxford Compassion for the Self Scale (SSOCS-S), Personal Growth Initiative (PGI) Scale-II, and World Health Organization (WHO)-5 Well-Being Index) and 153 responses were collected. Over two-thirds (69.9%) of the sample were seeking treatment for addiction to prescription opioids; other substances used included heroin (37.3%), methamphetamine (30.7%), benzodiazepines (17%), fentanyl (15.7%), cocaine (9.8%), alcohol (9.8%), and other substances (3.9%). Gender identity, age, and length of treatment did not correlate with personal growth or well-being. Total self-compassion was significantly associated with personal growth initiative (

Why is war so closely associated with men? Is it an expression of male nature or a product of culture? This survey of masculinity and war considers the proposition that men are predisposed to kill ...

Surgery, and especially cardiac surgery, is common, costly, and entails considerable risk. Significant progress has been made in recent years to improve quality, promote patient safety, and increase value and cost-effectiveness in surgical care. Enhanced Recovery After Surgery (ERAS) initiatives are increasing in popularity, improving outcomes, and enriching patient satisfaction. First developed for abdominal surgical cases, ERAS has increasingly established itself across all surgical subspecialities, including cardiac surgery. ERAS focuses on evidence-based initiatives in the preoperative, intraoperative, and postoperative phases of care to promote patient well-being and efficient care. The deliberate, judicious incorporation of technology into surgery and the periprocedural home has tremendous, revolutionary potential in all phases of care and is consistent with ERAS principles. This technology can be harnessed by physicians and the care provider team, the healthcare system, and perhaps most importantly, by patients themselves to lead to a higher level of engagement. We will explore technology's transformational capability by concentrating on cardiac surgery because of its prevalence, costs, risks, and contribution to the healthcare system's bottom line. In addition, the role that ERAS combined with technology can play in a constructive manner will be important. We discuss the disruptive effect that the COVID-19 pandemic offers to accelerate these developments. While the human cost of the pandemic has been staggering, in the post-COVID world, the lessons learned can be vital. Finally, we seek to show that the opportunities technology provides are closely related to what both patients and the physician and provider teams want. As technology inevitably becomes more integrated into healthcare, the ability to harness technology to maximize patient outcomes and well-being while promoting more efficient healthcare delivery will be critical. © Journal of Hospital Management and Health Policy. All rights reserved.

Objectives This study aimed to identify delays of care due to base access security protocols at a stateside military medical treatment facility (MTF) for patients with a time-sensitive medical condition who are seeking emergency medical care at the MTF. Methods We retrospectively analyzed emergency medical services (EMS) run reports from January 1, 2017 to November 12, 2017 to hospital access points to assess patients who were initially denied access to the MTF. Time from EMS activation until patient delivery at the emergency department, number of time-sensitive complaints, number of time-sensitive conditions, and number of unauthorized access attempts are reported. Results During the 11-month period of review, 42 delays of care related to EMS activation by the sentry at hospital access points were identified. Of the 42, 14 were associated with a time-sensitive complaint, 2 with time-sensitive conditions, and none were unauthorized access attempts. Conclusion We identify the potential for patient harm due to delays in care resulting from the security protocols at our MTF. A review of force protection requirements with consideration for their impact on patient safety, especially in cases of time-sensitive conditions, has been conducted.

Healthcare alone cannot improve population health. Laura Webber and colleagues advocate a “health in all policies” approach, with protected funding for preventive interventions

Why do people make war? Is it in human nature? Publication of Napoleon Chagnon’s Noble Savages resurrects old arguments, largely displaced in recent times by study of larger scale political violence, and sidelined by more contemporary theoretical currents. This shift ceded the human nature issue to a variety of biologistic approaches, for which Chagnon’s image of the Orinoco-Mavaca Yanomamo is foundational. Chagnon proposes that war is driven by reproductive competition, with men fighting over women, revenge, and status, among a ‘Stone Age’ people living as they had for countless generations, in a tribal world untouched by larger history or the world system. This paper challenges each of those claims, and offers alternatives that provide a very different view of Yanomami warfare, and why men fight wars.

The Good Practice Guidelines for the Assessment and Treatment of Adults with Gender Dysphoria is a publication of the Intercollegiate Committee of the Royal College of Psychiatrists. The overall goal of the Good Practice Guidelines is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynaecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counselling, psychotherapy), and hormonal and surgical treatments. The Good Practice Guidelines are based on the best available science and expert professional consensus. The Good Practice Guidelines articulate standards of care while acknowledging the role of making informed choices and the value of ...

Summary This paper reviews the evidence for the effectiveness and cost-effectiveness of policies to reduce alcohol-related harm. Policies focus on price, marketing, availability, information and education, the drinking environment, drink-driving, and brief interventions and treatment. Although there is variability in research design and measured outcomes, evidence supports the effectiveness and cost-effectiveness of policies that address affordability and marketing. An adequate reduction in temporal availability, particularly late night on-sale availability, is effective and cost-effective. Individually-directed interventions delivered to at-risk drinkers and enforced legislative measures are also effective. Providing information and education increases awareness, but is not sufficient to produce long-lasting changes in behaviour. At best, interventions enacted in and around the drinking environment lead to small reductions in acute alcohol-related harm. Overall, there is a rich evidence base to support the decisions of policy makers in implementing the most effective and cost-effective policies to reduce alcohol-related harm.

Aims To report on the relationships between age at diagnosis of diabetes, time from registration with the screening programme to first diabetic eye screening and severity of diabetic retinopathy. Methods Data were extracted from four English screening programmes and from the Scottish, Welsh and Northern Irish programmes. Time from diagnosis of diabetes to first screening and age at diagnosis were calculated. Results Time from registration with the screening programme to first screening episode is strongly related to age at registration. Within 18 months of registration 89% of 3958 young people under 18 years of age and 81% of 391 293 people over 35 years of age were seen. In 19 058 people between 18 and 34 years of age, 80% coverage was not reached until 2 years and 9 months. The time from diagnosis of diabetes to first screening is positively associated with severity of disease (P < 0.0001). Conclusions This report is the first that to demonstrate that those in the 18–34 year age group are least likely to attend promptly for screening after registration with a higher risk of referable diabetic retinopathy being present at the time of first screen. Date of diagnosis should be recorded and prodigious efforts made to screen all people promptly after diagnosis. Screening programmes should collect data on those who have not attended within one year of registration., What's new? People in the 18–34 year age group are more likely to have a longer time interval between registration with the screening programme and attendance for screening.People with a longer time interval between registration and attendance for screening are at a greater risk of referable diabetic retinopathy being present at the time of first screen.

Our series on stopping drugs provides practical advice on why, when and how to withdraw drug therapy. Here the author considers the challenges associated with discontinuing benzodiazepines. Copyright © 2012 Wiley Interface Ltd

Children from disadvantaged backgrounds are more likely to experience unintentional injuries and poor home environments. The aim of this study was to explore the home environment as a potential mediator between socioeconomic circumstances and unintentional injuries, in the UK Millennium Cohort Study (n=14 378).RRs and 95% CIs for being injured in the home between age 9 months and 3 years were estimated according to four measures of socioeconomic circumstances: social class, maternal education, lone parenthood status and tenure. Proxy indicators of housing quality (build type, storey, garden access, rooms per capita, central heating and presence of damp) and safety equipment use (use of fireguards, safety gates, electric socket covers and smoke alarms) were then controlled for in order to observe potential mediation.Children from routine and manual backgrounds were more likely to be injured than those from managerial and professional backgrounds (RR=1.33, 95% CI 1.21 to 1.47), as were children of lone parents (compared with couple families) (RR=1.23, 95% CI 1.12 to 1.36), those whose mothers had no educational qualifications (compared with a degree) (RR=1.42, 95% CI 1.24 to 1.63) and those living in socially rented accommodation (compared with owned/mortgaged homes) (RR=1.35, 95% CI 1.24 to 1.46). However, controlling for the indicators of housing quality and safety equipment use did not alter the elevated risk of injury experienced by children from less advantaged backgrounds.In this contemporary UK cohort, proxy indicators of the home environment did not appear to explain socioeconomic inequalities in injuries. Research exploring alternative explanations for inequalities in injuries could help contribute to the design or adaptation of policies to reduce them.

Recent years have seen an international move towards home treatment of acute mental health difficulties. This has been based upon trial data which do little to develop understanding of how or why this approach is as effective as it seems to be. In order to explore this question the study interviewed patients who had recently used the services of a crisis resolution home treatment (CRHT) team in the English East Midlands. Triangulated parallel qualitative analyses of 33 semi-structured interviews conducted by service users trained in research techniques demonstrated that successful CRHT reflected practitioners' ability to provide clients with a sense of feeling safe, accepted and understood. Unhelpful outcomes followed when participants did not experience such unconditionally supportive relationships. These findings further endorse the primacy of relational factors in mental health practice. They are discussed in relation to the Dodo Bird verdict upon psychological therapies and systemic difficulties acknowledging an inconvenient truth.

This article discusses an unknown restudy of one locale of the People of Puerto Rico Project–my own. From 1980 to 1982 the author did ethnographic fieldwork in Bo. Jauca, Santa Isabel, the research site of Sidney Mintz. Building on Mintz's work, my goal was to take our shared historical materialism further, into a broader analysis of capitalism, colonialism, class, politics, and power. Where Mintz framed his study within production units, such as Colonia Destino and Central Aguirre, my study began with analysis of the oligarchic structure of the United States sugar industry as a whole, and how it shaped colonial policy. Where the People of Puerto Rico Project reconstructed insular class and political patterns as context for local studies, the restudy took islandwide class structure and political positions as a focus of analysis in itself. Where the earlier work chronicled the rise of a plantation system and rural proletariat, the later study explored their decline—why did the Puerto Rican sugar industry c...

Background UK breastfeeding rates are low and socially distributed. Childcare provides a potential setting for breastfeeding promotion. However, little is known about the association between childcare and breastfeeding in different socio-economic groups. Methods Using data from a contemporary UK cohort of infants (n=18 050) the authors calculated RR for breastfeeding for at least 4 months according to informal childcare (care by friends, grandparents, other relatives, etc) and formal childcare (eg, nurseries, creches), both lasting at least 10 h a week and commencing before the age of 4 months, compared to being cared for ‘only by a parent’ (this includes childcare for less than 10 h a week), overall and by socio-economic group. Results Compared to being looked after only by a parent, informal (RR 0.51 (95% CI 0.43 to 0.59)) and formal (0.84 (0.72 to 0.99)) childcare was associated with a reduced likelihood of breastfeeding. For informal childcare, both part-time and full-time care was associated with a reduced risk of breastfeeding, whereas for formal care, only full-time formal childcare was associated with a reduced likelihood of breastfeeding. The reduced likelihood of breastfeeding in informal childcare was similar across all socio-economic groups, whereas for formal childcare the reduced likelihood was only seen for mothers from managerial and professional backgrounds (0.76 (0.62 to 0.94)), those who had a degree (0.71 (0.58 to 0.86)) and couple families (0.79 (0.66 to 0.94)). In contrast, lone mothers were more likely to breastfeed if their infant was cared for in formal childcare (1.65 (1.04 to 2.63)). Conclusions Informal childcare was associated with a reduced likelihood of breastfeeding for all groups of mothers. Formal childcare arrangements were only associated with a reduced likelihood of breastfeeding if used full-time by more advantaged families.

Background: Teleradiologist interpretation of radiographic studies during after-hours Emergency Department (ED) care has the potential to influence patient management. Study Objectives: We sought to characterize frequencies of discrepancies between teleradiology and in-house radiology interpretations for computed tomography (CT) scans. Methods: We conducted a prospective observational study comparing teleradiologist and in-house radiologist interpretations of CT scans obtained between 7:00 p.m. and 7:00 a.m. from the ED at a Level I trauma center. For each scan, discrepancies were characterized as major, minor, or no discrepancy. Follow-up data were used to characterize major discrepancies. Results: Of 787 studies sent to teleradiology, 550 were scans of the head, cervical spine, chest, or abdomen and pelvis. Major discrepancies were identified in 32 of 550 studies (5.8%; 95% confidence interval 4.1%–8.1%), including 7 of 160 head CT scans, 1 of 29 cervical spine CT scans, 3 of 64 chest CT scans, and 21 of 297 abdominopelvic CT scans. We attributed 8 of the 32 major discrepancies to a teleradiology misinterpretation, with one case leading to an adverse event. Conclusions: We identified major discrepancies due to teleradiologist misinterpretation in 8 of 550 studies, with one patient suffering an adverse event. Our findings support the cautious use of teleradiology interpretations.

Rationale Increasing attention is being given to the evaluation of public health interventions. Methods for the economic evaluation of clinical interventions are well established. In contrast, the economic evaluation of public health interventions raises additional methodological challenges. The paper identifies these challenges and provides suggestions for overcoming them. Methods To identify the methodological challenges, five reviews that explored the economics of public health were consulted. From these, four main methodological challenges for the economic evaluation of public health interventions were identified. A review of empirical studies was conducted to explore how the methodological challenges had been approached in practice and an expert workshop convened to discuss how they could be tackled in the future. Results The empirical review confirmed that the four methodological challenges were important. In all, 154 empirical studies were identified, covering areas as diverse as alcohol, drug use, obesity and physical activity, and smoking. However, the four methodological challenges were handled badly, or ignored in most of the studies reviewed. Discussion The empirical review offered few insights into ways of addressing the methodological challenges. The expert workshop suggested a number of ways forward for overcoming the methodological challenges. Conclusion Although the existing empirical literature offers few insights on how to respond to these challenges, expert opinion suggests a number of ways forward. Much of what is suggested here has not yet been applied in practice, and there is an urgent need both for pilot studies and more methodological research.

Background Provision of universal coverage is essential for achieving equity in healthcare, but inequalities still exist in universal healthcare systems. Between 2004/2005 and 2011/2012, the National Health Service (NHS) in England, which has provided universal coverage since 1948, made sustained efforts to reduce health inequalities by strengthening primary care. We provide the first comprehensive assessment of trends in socioeconomic inequalities of primary care access, quality and outcomes during this period. Methods Whole-population small area longitudinal study based on 32 482 neighbourhoods of approximately 1500 people in England from 2004/2005 to 2011/2012. We measured slope indices of inequality in four indicators: (1) patients per family doctor, (2) primary care quality, (3) preventable emergency hospital admissions and (4) mortality from conditions considered amenable to healthcare. Results Between 2004/2005 and 2011/2012, there were larger absolute improvements on all indicators in more-deprived neighbourhoods. The modelled gap between the most-deprived and least-deprived neighbourhoods in England decreased by: 193 patients per family doctor (95% CI 173 to 213), 3.29 percentage points of primary care quality (3.13 to 3.45), 0.42 preventable hospitalisations per 1000 people (0.29 to 0.55) and 0.23 amenable deaths per 1000 people (0.15 to 0.31). By 2011/2012, inequalities in primary care supply and quality were almost eliminated, but socioeconomic inequality was still associated with 158 396 preventable hospitalisations and 37 983 deaths amenable to healthcare. Conclusions Between 2004/2005 and 2011/2012, the NHS succeeded in substantially reducing socioeconomic inequalities in primary care access and quality, but made only modest reductions in healthcare outcome inequalities.

We thank Ziemssen et al. (1) for their comments on our recent article (2). The underlying issue is how much evidence is required before screening intervals are changed. Screening is a population-based activity, designed for maximum benefit of the population and the safety of the individual. Using a variable screening interval depending on risk could enable resources to be directed toward patients at the highest risk of visual loss. We agree with Ziemssen et al. that some patients with clinically significant maculopathy will require treatment on referral to the ophthalmology clinic and apologize if we gave the wrong impression. We were trying to indicate that the vast majority of …

OBJECTIVE This study aimed to follow the natural progression of retinal changes in patients with diabetes. Such information should inform decisions with regard to the screening intervals for such patients. RESEARCH DESIGN AND METHODS An observational study was undertaken linking the data from seven diabetes retinal screening programs across the U.K. for retinal grading results between 2005 and 2012. Patients with absent or background retinopathy were followed up for progression to the end points referable retinopathy and treatable retinopathy (proliferative retinopathy). RESULTS In total, 354,549 patients were observed for up to 4 years during which 16,196 patients progressed to referable retinopathy. Of patients with no retinopathy in either eye for two successive screening episodes at least 12 months apart, the conditions of between 0.3% (95% CI 0.3–0.8%) and 1.3% (1.0–1.6%) of patients progressed to referable retinopathy, and rates of treatable eye disease were CONCLUSIONS It may be possible to stratify patients for risk, according to baseline retinal criteria, into groups with low and high risk of their conditions progressing to proliferative retinopathy. Screening intervals for such diverse groups of patients could safely be modified according to their risk.

Objective: In England, primary care organizations (primary care trusts, PCTs) have scope to influence the provision of health care at the margin. However, when faced with difficult commissioning choices, restriction of services potentially leaves them vulnerable to legal challenge. PCTs are developing different approaches to priority setting but there is a need to develop processes that lead to more consistent, accountable and fair decision-making. Our objective was to describe recent local developments on prioritization decision-making. Methods: Rationing policies in PCTs in West Yorkshire and North & East Yorkshire and North Lincolnshire (NEYNL) Strategic Health Authority areas in 2003 were examined. To evaluate priority setting, we compared the descriptive findings with an internationally recognized ethical framework for priority setting, 'accountability for reasonableness' (AFR). Results: PCTs varied as regards the stage of policy development they had reached. Rationing by exclusion was the most common approach to prioritization, but in general PCTs failed to make the rationale for their decisions explicit and accessible. The importance of an appeals process was recognized by the majority of PCTs. Those that had developed a formal process to address difficult commissioning decisions were an exception. Conclusions: Adopting AFR as a prioritization framework can serve to improve the fairness and consistency of the decision-making process, reducing the vulnerability of PCTs to legal challenge. Characteristics of rationing policies already in place fulfil some of the AFR conditions but there remains scope for further improvements in their design and dissemination.

Aims: To estimate the total prevalence of diabetes mellitus (diagnosed and undiagnosed) at national, regional and local level in England to support health-care planning and delivery. Methods: An epidemiological model was constructed by applying age–sex–ethnic-specific reference prevalence rates from epidemiological studies to resident populations (2001 census) of England at national, regional, and local authority/Primary Care Trust levels. Results: Estimated prevalence of total diabetes for all persons in England was 4.41% in 2001, equating to 2 168 000 persons. Type 2 diabetes was estimated to affect 2 002 000 persons (92.3%) and Type 1 diabetes 166 000 persons (7.7%). Diabetes prevalence was estimated to be higher in women (5.17%) than men (3.61%). People from ethnic minority groups had higher crude prevalence than White Europeans (4.29, 5.69, 6.63 and 2.13% among White Europeans, Black African/Caribbeans, South Asians and 'other' groups, respectively). Prevalence increased sharply with age (0.33, 3.37 and 13.92%, respectively, in those aged 0–29, 30–59 and 60+ years). The model allows use of user-defined population denominator estimates to derive numbers and prevalence of people with diabetes for a given local population group, such as at ward or general practice level. Conclusions: Self-reported diabetes prevalence estimates from community surveys underestimate the true burden of diabetes. The model can be used to derive the expected total prevalence of diabetes in health areas that lack reliable data to facilitate the implementation of the National Service Framework for diabetes. It will also allow estimates of future diabetes prevalence to be derived, and can potentially be used for prevalence estimates in all of the UK.

I want to congratulate you—and the entire HESTEC organization—on your hard work and dedication to promote math and science literacy to Hispanics around the country. In my mind, the work you’re doing is beyond “important”—it’s critical. It’s critical to the young people … it’s critical to the social and cultural fabric of the nation … and it’s critical to our business infrastructure—both existing and in the future … that your work succeed. I believe, in other words, that it is one of the brightest lights of optimism for helping today’s Hispanic kids get a highly skilled—and highly rewarding—education. The views stated in our Comment section are strictly those of the author and in no way reflect the opinions of the management of Polymer News and Taylor & Francis, Ltd. We will print letters or other comments from our readers which either support or disagree with the above views. This guest editorial is based on an address presented by Mr. Ferguson during Hispanic Engineering, Science &Technology Week (HESTEC...

The Kennedy Report will almost certainly become a defining moment in the history of UK healthcare. On the whole the NHS is poor at learning from history and there is a wealth of important information to be drawn from the report and the whole experience of Bristol. This article distils the essential clinical governance messages that risk being lost. While many of the issues can be viewed from an economic perspective, much of what is required is a change in attitude across whole health economies. The contribution that economics can make is to design appropriate incentive mechanisms to bring about desired behavioural change. It can also continue to promote informed debate on the proper meaning of efficiency and to highlight the features required for an appropriate and effective regulatory framework.

In this paper we argue on the merits of theoretical simulation, a widely used technique in other areas of theoretical economics, to extending the phase diagram analysis of the Grossman's 1972 model of investment in health capital. We argue that theoretical simulations are particularly useful when considering problems with multiple state variables. To illustrate, we perform simulations with varying assumptions of health depreciation rates and conditional survival probabilities and generate time-plots for the evolution of health capital and health investments over individual finite lifetimes.

Azar Gat's argument represents a major advance toward realism in neo-Darwinian theory on war. Consistently reasonable, plausible, with substantial evidence (on some points), his basic argument is that a wide range of reasons for war are all part of an integrated motivational complex, evolved to deal with problems of survival and reproduction in our species past. Some, clashes of material (somatic) or reproductive interests, are "root causes" of conflict. Others are secondary or derived, "second floor" elaborations necessary for coping with more basic competition, including an impulse toward revenge, sensitivity to status, fear of sorcery, quest for power, even predilection toward sadism. His point is that cultural anthropologists have been mistaken in trying to identify one versus another as explaining war, because they all are involved, non-reductionistically, stamped into our species' mind by their complementary contributions to our evolutionary success. In approaching war, he avoids the more dubious evolutionary constructs, such as "instincts to kill" (Ghiglieri 1999: 178), "Darwinian algorithms" for collective aggression (Tooby and Cosmides 1988), and unconscious tracking of reproductive advantages of violence (Chagnon 1979; 1987). I do not know how he categorizes his approach, but in emphasizing material self- interest and behavioral plasticity, along with directed efforts to maximize inclusive fitness, it appears to me as a development of evolutionary ecology. Evolutionary ecology has a great deal of overlap with ecological approaches that do not include reproductive interests. So Gat's view (Part II: 79) of reasons for war on the Pacific Northwest Coast is much like my (Ferguson 1984a) pre-contact model, though he brings in evidence of women capture which, as he notes (I: 28), 1 ignore. And there are major correspondences with the Divale and Harris (1976) model regarding female scarcity and fighting over women, although without the population-regulation element. The primary difference between evolutionary ecology and "regular" ecology is the former posits that human behavior is evolutionarily designed to maximize reproductive success along with material well-being. I have several major disagreements with Gat. First, throughout his arguments runs the assumption that humans practiced war throughout the huntergatherer past. I believe that assumption is unsustainable. The question of the antiquity of war has been raised but clouded by Keeley (1996), whose rhetoric exceeds his evidence in implying war is as old as humanity. The earliest accepted evidence for warfare, Site 117, near Jebel Sahaba, Nubia, is a cemetery dated to 12,000 to 10,000 B.C., in which 24 of 59 well-preserved skeletons are associated with stone artifacts interpreted as projectile microliths (Wendorf 1968: 90-93; Wendorf and Schild 1986: 818-824). Though late Paleolithic in standard periodization, these people had been experimenting with wild crop harvesting thousands of years before the development of agriculture elsewhere. This experiment was brought to a crashing halt by climatic change which would have put extreme pressure on all peoples throughout the region, especially those in favorable locales like Site 117 (Hoffman 1993: 86-90). Northern Australia, a favorite illustration for Gat, is a unique area in terms of the depth and continuity of collective violence among mobile huntergatherers, with rock art images suggesting individual and small group combats from about 8,000 B.C., and larger group confrontations beginning about 4,000 B.C. (Tacon and Chippindale 1994). This was a time of massive ecological crisis, with rising sea levels drowning the rich plain that once connected Australia to New Guinea. Socially, we see signs of increasing complexity and cultural divisions (Jones and Bowler 1980:23; Schrire 1982: 7; Tacon and Chippindale 1994: 217, 224, 227). Why war became such an institutionalized pattern is suggested by historic observations: their reliance on water holes in dry seasons, sources that sometimes disappear in droughts, gave them an extremely concentrated and valuable resource to fight over (Meggitt 1962: 24, 42), as Gat notes (I: 23). …

A study was carried out to examine the economic and qualitative aspects of nurse prescribing for patients, carers, nurses and other health care professionals. The design was a case study, without controls or randomisation, and involved patients, nurses, general practitioners and other health care professionals in GP fundholding practices, one in each region of England, that were designated by the Department of Health as demonstration sites for nurse prescribing. This paper reports the data from the economic analysis. The main outcome measures were changes in the frequency and cost of prescribing compared with a range of scenarios, and the impact on health professionals' time. There was no evidence to suggest that prescribing costs in the eight demonstration sites increased more than they would have done in the absence of nurse prescribing. It is relatively safe to conclude that the impact on prescribing costs in those sites was neutral. The range of uncertainty around the first-year costs in the demonstration sites is nevertheless high, in the order of £240,000. Further work is required to identify the economic impact of nurse prescribing with a larger sample of practices, to assess whether prescribing costs will be contained (preferably in relation to a control sample) and whether notional time savings are cash-releasing. Research is also needed to shed light on questions of appropriateness and effectiveness of prescribing.

This paper describes one part of a feasibility study carried out in England which examined the costs, quality and effectiveness of continence services in areas with different approaches to provision. It involved the design of instruments to collect the views and perceptions of patients and an investigation of ways to develop a methodology to implement comparative studies. It is the design and piloting of the questionnaires and the way patients responded that forms the focus of this paper. The main sample group recruited for the study were women who had recently sought formal help with urinary incontinence and were likely to receive conservative treatment or management in the community. They were interviewed and asked to complete four questionnaires at two points in time. A smaller sub-group of disabled women, interviewed only once, were included to compare cost profiles for different client groups. The questionnaires which were developed address the impact of urinary incontinence (using a standard scale), the effectiveness of service provision in terms of patients' clinical history, expectations and hoped-for outcomes, service receipt and its cost, and patients' satisfaction with several aspects of service provision. In total 118 women were interviewed, including 28 disabled women. The study generated a set of survey instruments which might be used for a variety of purposes including audit and future research and which could inform purchaser and provider decisions by using patients' perspectives of quality of life outcomes to enhance service development.

As part of the evaluation of nurse prescribing in eight demonstration sites, interviews were conducted with a sample of the prescribing nurses' patients (n=148). Information obtained related to the number and range of medicinal items bought over-thecounter (OTC) in a one month period, as well as the reasons why patients chose particular products. Patient views regarding when items should be bought OTC and when obtained on a prescription were also explored. A number of similarities with other literature on self medication were observed and are discussed.