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PubMed2003

How important is sex in later life? The views of older people.

Stereotypes of an asexual old age remain pervasive, shaping not only popular images of older people, but also research and policy agendas. However, older people's own attitudes towards the role and value of sex in later life remain relatively unexplored. This paper draws on both quantitative and qualitative data to examine how sex is prioritised in middle age and later life. Data collection methods involved completion of two quality of life measures (WHOQOL-100 and WHOQOL Importance Scale), followed by semi-structured interviews. In total the sample comprised 69 individuals recruited from the age/sex register of a general practice in Sheffield in the UK. This paper will focus upon the accounts of 21 men and 23 women aged 50-92 years. Ratings of the importance of sex to participants were gathered from the WHOQOL Importance Scale; the in-depth interviews enabled the basis for this prioritisation to be explored. Analysis identified the following key themes. Participants who did not consider sex to be of any importance to them neither had a current sexual partner, nor felt that they would have another sexual partner in their lifetime. Indeed, all participants who had a current sexual partner attributed at least some importance to sex, with many rating sex as 'very' or 'extremely' important. However, experiencing barriers to being sexually active led them to place less importance on sex; this was particularly apparent when health problems and widowhood were experienced. Age was seen as facilitating coping when sex became less frequent, or stopped altogether. This was explained in terms of sexual desire decreasing with age (for some male participants), the cessation of sex being easier to cope with in a relationship of long duration and the expectation that sex will become less possible with 'normal ageing'. The discussion considers the implications of these findings for this developing field.

Adaptation, Psychological↗

PubMed2003

Testing the utility of a geographical profiling approach in three rape series of a single offender: a case study.

The purpose of the study was to test the potential utility of a geographical profiling approach for three separate series of rapes committed by a single offender. Two different mathematical distance-decay functions using either a normal distribution with a mean distance and standard deviation based on previous research or a truncated negative exponential function based on distances between crime sites in the series under investigation were applied to each of the series giving prioritised search areas the accuracy of which was then assessed. The prioritised area that had to be searched before the home base of the offender could be located varied from 7.60 km(2) or 2.15% of the total search area at its best to 15 1.10 km(2) or 42.66% at its worst for the normal distribution based on previous research and from 42.06 km(2) or 11.88% to no improvement when the truncated negative exponential function was used. The functions used showed less predictive ability when the offender was a commuter. Explanations for the variations in the findings as well as suggestions for improvements were outlined in the discussion.

Forecasting↗

PubMed2001

Using a neural network to screen a population for asthma.

PURPOSE: To use a neural network to rank a population according to individual likelihood of asthma based on their responses to a respiratory questionnaire. METHODS: A final diagnosis of asthma can be made only after full clinical assessment but limited resources make it impossible to offer this to complete populations as part of a screening programme. Prioritisation is required so that review can be offered most promptly to those most in need. A stratified random sample of 180 from 6825 respondents to a community survey underwent clinical review. They were categorised according to likelihood of asthma by three independent experts whose opinions were combined into a single probability label for each patient. A neural network was trained to relate questionnaire responses to probability labels. The trained network was applied to the whole community to produce a ranking order based on likelihood of asthma. A screening threshold could then be set to correspond to available resources, and patients above this level with no recorded evidence of asthma diagnosis could be assessed clinically. Using the known probability labels from the training set, it was possible to derive the expected proportion of true asthmatics in any set of patients. RESULTS: If the screening threshold had been set to capture the top 10% of the ranked population (n = 683), then 239 patients above this threshold had no evidence of diagnosis and would need assessment. Of these, it would be expected that 74% would have the diagnosis confirmed. CONCLUSIONS: This approach allows prioritisation of a population where resources for diagnostic examination are limited.

Adolescent↗

PubMed2026

Improving access to antipsychotic medications for schizophrenia in Ethiopia, Nigeria, Rwanda, and South Africa: an evidence-based global consensus.

There are disparities in access to antipsychotics for schizophrenia across different country settings. Improving access to a wider and more equitable range of medications in low-income and middle-income countries is a priority. A multidisciplinary team of international experts, including individuals with lived experience, appraised the most relevant and recent information on antipsychotics in schizophrenia and contextualised it to four African countries (Ethiopia, Nigeria, Rwanda, and South Africa) using a validated consensus methodology. We recommended a list of drugs to prioritise to guide clinical implementation and research, and market shaping. We identified key evidence gaps: little of the existing evidence comes from the countries of interest, trials generally involve highly selected populations, and the complexity of real-world settings is not reflected. However, this methodology highlights a route forward to prioritise the best available evidence on pharmacological treatments for schizophrenia at a global scale, which could also be applied to treatments for other mental health conditions.

Humans↗

PubMed2003

A new method for estimating the importance of hydrogen-bonding groups in the binding site of a protein.

We introduce a new method to estimate the importance of hydrogen-bonding sitepoints in the binding site of a protein as part of a structure-based design strategy. Our method identifies hydrogen-bonding sitepoints within a binding pocket and ranks them according to both the accessibility of their hydrogen bonding regions to incoming ligands and their hydrogen-bonding strength. The combination of these components produces a prioritised list of sitepoints that are more likely to be involved in hydrogen bonding with an incoming ligand. A dataset of known protein-ligand interactions was used to compare the prioritisation of sitepoints identified by our method with those observed to be engaged in hydrogen bonding in their crystal structures. Our method was able to remove those sitepoints unable to bind the ligand due to a low accessibility or an unfavourable orientation and to award significantly higher hydrogen-bonding ranking values to those sitepoints observed to form hydrogen bonds. Our method can thus be used to identify hydrogen-bonding sitepoints that should be targeted preferentially in a drug design strategy.

Binding Sites↗

PubMed1998

The role of ophthalmic triage and the nurse practitioner in an eye-dedicated casualty department.

PURPOSE: To evaluate the appropriateness of triage decisions in a busy ophthalmic casualty department and to assess the diagnostic and management skills of eye-dedicated nurse practitioners. METHODS: Three hundred and one consecutive patients attending the Birmingham and Midland Eye Centre (BMEC) accident and emergency (A&E) department over a 2 week period were included in this prospective study. Patients were categorised in terms of urgency in concordance with strict guidelines, and the agreement between the final diagnosis and this system of prioritisation was then investigated. To evaluate nurse practitioner (NP) skills, all patients seen and managed by a NP were also assessed by the most senior doctor in casualty at the time in a masked fashion. Waiting times and a breakdown of waiting times were also calculated. RESULTS: Upon establishment of a diagnosis, triage category allocation was found to be appropriate in all 301 cases. Fifty patients (16.67%) were seen by the NP. Of these the supervising doctor concurred with the NP diagnosis in all cases and with the proposed management in 96% of cases. The mean waiting time (+/- SD) was 83.43 +/- 45.84 min, with a range of 5-335 min. The delay before being attended to was greater for less urgent cases as categorised by the triage system. CONCLUSION: This study confirms the high standard of diagnostic and management skills of the ophthalmic NP and indicates that the triage system of patient prioritisation is accurate. Waiting times in the A&E department remain unacceptable and ways of addressing this include improved ophthalmic training of general practitioners, diverting a greater proportion of non-acute cases to the primary care clinic and expanding the role of the NP.

Adolescent↗

PubMed2004

Facilitators and barriers to improving the quality of referrals for potential oral cancer.

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.

Communication Barriers↗

PubMed2004

The interactive examination: assessing students' self-assessment ability.

BACKGROUND: The ability to self-assess one's competence is a crucial skill for all health professionals. The interactive examination is an assessment model aiming to evaluate not only students' clinical skills and competence, but also their ability to self-assess their proficiency. METHODS: The methodology utilised students' own self-assessment, an answer to a written essay question and a group discussion. Students' self-assessment was matched to the judgement of their instructors. As a final task, students compared their own essay to one written by an "expert". The differences pointed by students in their comparison documents and the accompanying arguments were analysed and categorised. Students received individual feedback on their performance and learning needs. The model was tested on 1 cohort of undergraduate dental students (year 2001, n = 52) in their third semester of studies, replacing an older form of examination in the discipline of clinical periodontology. RESULTS: Students' acceptance of the methodology was very positive. Students tended to overestimate their competence in relation to the judgement of their instructors in diagnostic skills, but not in skills relevant to treatment. No gender differences were observed, although females performed better than males in the examination. Three categories of differences were observed in the students' comparison documents. The accompanying arguments may reveal students' understanding and methods of prioritising. CONCLUSIONS: Students tended to overestimate their competence in diagnostic rather than treatment skills. The interactive examination appeared to be a convenient tool for providing deeper insight into students' ability to prioritise, self-assess and steer their own learning.

Clinical Competence↗

PubMed2005

MODELKEY. Models for assessing and forecasting the impact of environmental key pollutants on freshwater and marine ecosystems and biodiversity.

BACKGROUND: Triggered by the requirement of Water Framework Directive for a good ecological status for European river systems till 2015 and by still existing lacks in tools for cause identification of insufficient ecological status MODELKEY (http:// www.modelkey.org), an Integrated Project with 26 partners from 14 European countries, was started in 2005. MODELKEY is the acronym for 'Models for assessing and forecasting the impact of environmental key pollutants on freshwater and marine ecosystems and biodiversity'. The project is funded by the European Commission within the Sixth Framework Programme. OBJECTIVES: MODELKEY comprises a multidisciplinary approach aiming at developing interlinked tools for an enhanced understanding of cause-effect-relationships between insufficient ecological status and environmental pollution as causative factor and for the assessment and forecasting of the risks of key pollutants on fresh water and marine ecosystems at a river basin and adjacent marine environment scale. New modelling tools for risk assessment including generic exposure assessment models, mechanistic models of toxic effects in simplified food chains, integrated diagnostic effect models based on community patterns, predictive component effect models applying artificial neural networks and GIS-based analysis of integrated risk indexes will be developed and linked to a user-friendly decision support system for the prioritisation of risks, contamination sources and contaminated sites. APPROACH: Modelling will be closely interlinked with extensive laboratory and field investigations. Early warning strategies on the basis of sub-lethal effects in vitro and in vivo are provided and combined with fractionation and analytical tools for effect-directed analysis of key toxicants. Integrated assessment of exposure and effects on biofilms, invertebrate and fish communities linking chemical analysis in water, sediment and biota with in vitro, in vivo and community level effect analysis is designed to provide data and conceptual understanding for risk arising from key toxicants in aquatic ecosystems and will be used for verification of various modelling approaches. CONCLUSION AND PERSPECTIVE: The developed tools will be verified in case studies representing European key areas including Mediterranean, Western and Central European river basins. An end-user-directed decision support system will be provided for cost-effective tool selection and appropriate risk and site prioritisation.

Animals↗

PubMed2002

Intracellular trafficking of micronutrients: from gene regulation to nutrient requirements.

The intracellular distribution of micronutrients, as well as their uptake, is important for cell function. In some cases the distribution of micronutrients or their related proteins is determined by gene expression mechanisms. The 3' untranslated region (3'UTR) of metallothionein-1 mRNA determines localisation of the mRNA, and in turn intracellular trafficking of the protein product. Using transfected cells we have evidence for the trafficking of metallothionein-1 into the nucleus and for its involvement in protection from oxidative stress and DNA damage. When nutritional supply of Se is limited, selenoprotein expression is altered, but not all selenoproteins are affected equally; the available Se is prioritised for synthesis of particular selenoproteins. The prioritisation involves differences in mRNA translation and stability due to 3'UTR sequences. Potentially, genetic variation in these regulatory mechanisms may affect nutrient requirements. Genetic polymorphisms in the 3'UTR from two selenoprotein genes have been observed; one polymorphism affects selenoprotein synthesis. These examples illustrate how molecular approaches can contribute at several levels to an increased understanding of nutrient metabolism and requirements. First, they provide the tools to investigate regulatory features in genes and their products. Second, understanding these processes can provide model systems to investigate nutrient metabolism at the cellular level. Third, once key features have been identified, the availability of human genome sequence information and single nucleotide polymorphism databases present possibilities to define the extent of genetic variation in genes of nutritional relevance. Ultimately, the functionality of any variations can be defined and subgroups of the population with subtly different nutrient requirements identified.

Animals↗

PubMed2006

Metabolic activation of chemicals: in-silico simulation.

The role of metabolism in prioritising chemicals according to their potential adverse health effects is extremely important given the fact that innocuous parents can be transformed into toxic metabolites. Our recent efforts in simulating metabolic activation of chemicals are reviewed in this work. The application of metabolic simulators to predict biodegradation (microbial degradation pathways), bioaccumulation (fish liver metabolism), skin sensitisation (skin metabolism), mutagenicity (rat liver S-9 metabolism) are discussed. The ability of OASIS approach to predict metabolism (toxicokinetics) and toxicity (toxicodynamics) of chemicals resulting from their metabolic activation in a single modelling platform is an important advantage of the method. It allows prioritisation of chemicals due to predicted toxicity of their metabolites.

Animals↗

PubMed2006

A combined QSAR and partial order ranking approach to risk assessment.

QSAR generated data appear as an attractive alternative to experimental data as foreseen in the proposed new chemicals legislation REACH. A preliminary risk assessment for the aquatic environment can be based on few factors, i.e. the octanol-water partition coefficient (Kow), the vapour pressure (VP) and the potential biodegradability of the compound in combination with the predicted no-effect concentration (PNEC) and the actual tonnage in which the substance is produced. Application of partial order ranking, allowing simultaneous inclusion of several parameters leads to a mutual prioritisation of the investigated substances, the prioritisation possibly being further analysed through the concept of linear extensions and average ranks. The ranking uses endpoint values (log Kow and log VP) derived from strictly linear 'noise-deficient' QSAR models as input parameters. Biodegradation estimates were adopted from the BioWin module of the EPI Suite. The population growth impairment of Tetrahymena pyriformis was used as a surrogate for fish lethality.

1-Octanol↗

PubMed2003

The use of a modified Delphi procedure for the determination of 26 prognostic factors in the sub-acute stage of stroke.

The aim of this study was to reach consensus about the prognostic factors when deciding the discharge destination from a hospital stroke unit, and to construct a prognostic conceptual framework. To realise an optimal integration of knowledge from research findings and from clinical experience by expert opinions we used a 'modified Delphi Technique', which is the most commonly used method for the production of clinical guidelines. The process yielded 26 prognostic factors, which were arranged in clinical and social sub-domains. The sub-domains and the factors within each sub-domain were prioritised according to their assumed predictive value for the decision process. The order of importance of the prognostic factors in the clinical domain was: (1) disabilities, (2) pre-morbid disabilities, (3) impairments and (4) disease/biology; and the order of importance of the factors in the social domain was: (1) home front, (2) social situation and (3) residence. The Delphi procedure is an excellent instrument to determine and prioritise prognostic factors. With this procedure research-based and consensus-based knowledge can be combined. For a valid procedure it is mandatory to state explicitly in advance how the scores will be judged, and to explain the scientific level of the evidence during the whole procedure.

Activities of Daily Living↗

PubMed1998

Consequentialism, reasons, value and justice.

Over the past 10 years, John Harris has made important contributions to thinking about distributive justice in health care. In his latest work, Harris controversially argues that clinicians should stop prioritising patients according to prognosis. He argues that the good or benefit of health care is providing each individual with an opportunity to live the best and longest life possible for him or her. I call this thesis, opportunism. For the purpose of distribution of resources in health care, Harris rejects welfarism (the thesis that the good of health care is well-being) and argues that utilitarianism in general may lead to de facto discrimination against groups of people needing health care. I argue that well-being is a superior theory of the good of health care to Harris' opportunism. Harris' concerns about utilitarianism can be better addressed by: (i) relating justice more closely to reasons for action; (ii) by conceptualising the relationship between reasons for action and the value of the consequences of those actions as a plateau rather than scalar relationship. Justice can be understood as satisfying as many equally rational claims on resources as possible. The rationality of a person's claim on health resources turns on the strength of that person's reasons to promote certain health-related states of affairs. I argue that the strength of that reason does not track the expected value of that state of affairs in a fully scalar fashion. Rather a person can have most reason to promote some state of affairs, even though he or she could promote other more valuable states of affairs. Thus there can be equal reason for a distributor of public resources to save either of two people, even though one will have a better and more valuable life. This approach, while addressing many of Harris' concerns about utilitarianism, does not imply that doctors should give up prioritising patients according to prognosis altogether, but it does allow that patients with lower but reasonable prognosis should have a share of public resources.

Age Factors↗

PubMed1999

Justice and equal opportunities in health care.

The principle that each individual is entitled to an equal opportunity to benefit from any public health care system, and that this entitlement is proportionate neither to the size of their chance of benefitting, nor to the quality of the benefit, nor to the length of lifetime remaining in which that benefit may be enjoyed, runs counter to most current thinking about the allocation of resources for health care. It is my contention that any system of prioritisation of the resources available for healthcare or of rationing such resources must be governed by this principle. This can have apparently paradoxical conclusions in that it can seem wasteful to give someone with a very slim chance of a lifesaving treatment the same priority as someone with a much better chance. In an important and thoughtful recent paper, Julian Savulescu has concentrated on this apparent weakness and has argued for a particular conception of the good or benefit to be achieved by a healthcare system which purports to demonstrate the inadequacies of an equal opportunities approach to prioritisation and to replace it with an altogether better account. This paper will show that a rational 'reasons based consequentialism' is more in line with the equal opportunities approach, which I defended some time ago in these pages, than with that of Savulescu. I shall then examine more closely the conception of equal opportunities in health care and show that if we give weight to an individual's reasons, and what is expected to be good for them, we will opt for exactly the equality based account of distributive justice that I have recommended.

Delivery of Health Care↗

PubMed2004

A survey of the attitudes of infertile and parous women towards the availability of assisted reproductive technology.

OBJECTIVE: The aim of the study was to assess differences in attitudes towards aspects of assisted reproduction technology between infertile and parous women. DESIGN: Case-control study. SETTING: University-based tertiary care clinic. POPULATION/SAMPLE: Three hundred and ninety-two women with fertility problems and 200 parous controls. METHODS: A questionnaire was sent out to 392 the members of Childless Support Association and 200 parous women who had at least three infants and had given birth at Kuopio University Hospital. The questionnaire consisted of 46 questions: demographic information, fertility history, different aspects of assisted reproduction technology and prioritisation issues. MAIN OUTCOME MEASURES: Attitudes towards assisted reproduction technology. RESULTS: The overall response rate was 46%. Infertile women were highly educated (P < 0.01) and had lower parity (mean 0.83 vs 4.76, P < 0.01) than parous women. We recorded four major differences in attitudes between the two groups (OR >2 or <0.5) including provision of infertility treatment to lesbian (46.9% vs 16.7%) and homosexual couples (28.4% vs 11.4%), the opportunity for homosexual couples to use surrogate mothers (30.6% vs 15.2%) and limitations in the number of infertility treatment cycles (28.4% vs 61.4%). For 11 questions, we recorded minor, but statistically significant, differences. In the prioritisation questions, the women set the order according to their own interests, probably because the women were at fertile age and they had or would like to have a child. Maternity services and screening for cancer in women (Papanicolaou's test and mammography) were at the top of the list. CONCLUSION: These results reflect a split attitude that was influenced by the wish of infertile women to help childless couples and to be able to recruit suitable sperm/oocyte donors. Parous women were motivated by their concern for children's rights.

Adult↗

PubMed2006

How we do it: analysing GP referral priorities: the unforeseen effect of 'Choose and Book'.

The introduction of Choose and Book may have a significant effect on the proportion of urgent referrals seen by ENT surgeons. Much of the responsibility for prioritisation will be transferred to the GP. Patients who are considered urgent by the ENT surgeon will be added to those considered urgent by the GP. Our results show that there was little agreement between GPs and ENT surgeon on what constitutes an urgent referral. The combined effect of joint prioritisation and the removal of the 'soon' category resulted in a 270% increase in 'urgent' referrals in our sample. This potentially unforeseen consequence of the Choose and Book system should be taken into consideration by ENT departments to allow for an expansion of the 'urgent' category.

Appointments and Schedules↗

PubMed2006

Artificial neural network is superior to MELD in predicting mortality of patients with end-stage liver disease.

BACKGROUND: Despite its accuracy, the model for end-stage liver disease (MELD), currently adopted to determine the prognosis of patients with liver cirrhosis, guide referral to transplant programmes and prioritise the allocation of donor organs, fails to predict mortality in a considerable proportion of patients. AIMS: To evaluate the possibility to better predict 3-month liver disease-related mortality of patients awaiting liver transplantation using an artificial neural network (ANN). PATIENTS AND METHODS: The ANN was constructed using data from 251 consecutive people with cirrhosis listed for liver transplantation at the Liver Transplant Unit, Bologna, Italy. The ANN was trained to predict 3-month survival on 188 patients, tested on the remaining 63 (internal validation group) unknown by the system and finally on 137 patients listed for liver transplantation at the King's College Hospital, London, UK (external cohort). Predictions of survival obtained with ANN and MELD on the same datasets were compared using areas under receiver-operating characteristic (ROC) curves (AUC). RESULTS: The ANN performed significantly better than MELD both in the internal validation group (AUC = 0.95 v 0.85; p = 0.032) and in the external cohort (AUC = 0.96 v 0.86; p = 0.044). CONCLUSIONS: The ANN measured the mortality risk of patients with cirrhosis more accurately than MELD and could better prioritise liver transplant candidates, thus reducing mortality in the waiting list.

Area Under Curve↗