bluuebunny/crossref_metadata_2025 huggingface dataset:
Feasibility of biogas and energy generation from poultry manure in Brazil
Authors: Ribeiro Eruin M , Mambeli Barros Regina , Tiago Filho Geraldo Lúcio , dos Santos Ivan Felipe S , Sampaio Luma C , dos Santos Ticiane V , da Silva Fernando dGB , Silva Ana Paula M , de Freitas João Victor R
Published: February 2018

The aim of the present study is to experimentally measure the volume and composition of biogas produced from the anaerobic biodigestion of laying-hen manure from poultry farms in Itanhandu-MG, Brazil, so that the biogas can be used to generate energy. Two experiments (E1 and E2) were used to characterise the biogas quantities and compositions at room temperature and at a controlled temperature of 36 °C, respectively. The biogas production and calculated net power from the exploitation of biogas energy were compared with the results obtained from methods proposed by the Environmental Company of the State of São Paulo (CETESB, an acronym in Portuguese) using the ‘Biogas: Generation and energy use – effluent and rural waste’ software 1.0, Brasília-DF, Brazil. In addition, after a time equal to the hydraulic retention time subsequent to biodigester loading, the parameters were analysed and correlated with the organic matter content in the substrates. The effluents were subsequently compared with verify the degree of degradability. The biogas volumes were estimated to be 0.143 m3 kg VTS-1 for E1 and 0.283 m3 kg VTS-1 for E2. If the poultry farm considered in this case study uses manure to generate energy, then the estimated energy generation based on the data from experiments E1 and E2 will result in net energy values of 683 MW h y-1 and 27,160 MW h y-1, given 620 MW h y-1 for sludge heating in E2. The energy production values from the simulations of the E1 and E2 experiments did not demonstrate economic viability under the studied conditions.
Modified xonotlite–type calcium silicate hydrate slabs for fire doors
Authors: Levinskas Rimantas , Lukošiūtė Irena , Baltušnikas Arūnas , Kuoga Algirdas , Luobikienė Aldona , Rodriguez José , Cañadas Inmaculada , Brostow Witold
Published: February 2018

Xonotlite-type calcium silicate hydrate slabs were examined under the thermal shock conditions in a solar furnace at the Plataforma Solar de Almeria which can reach a peak of 300 W/cm2. We have studied the original slabs as well as those modified with a mixture of liquid sodium silicate including montmorillonite as thermal insulation materials for fire doors applications. The slabs were kept at 950°C for 1 h. We performed X-ray diffraction, thermogravimetry and differential scanning calorimetry analysis, scanning electron microscopy, Fourier transform infrared spectroscopy, and thermal conductivity measurements and determined N2 adsorption/desorption isotherms. X-ray diffraction shows that during the thermal shock at 950°C xonotlite is converted to wollastonite. Specific surface areas of xonotlite slabs decrease due to release of crystalline water molecules. It is possible to maintain temperatures of the back door not exceeding 70°C while the front door is subjected to 950°C for 1-h time periods. The standard requires no more than 140°C at the back door.
A shipbuilding consultancy is born: The birth, growth and subsequent takeovers of A&P Appledore (International) Limited, and the A&P Group, 1971–2017
Authors: Craggs John , Murphy Hugh , Vaughan Roger
Published: February 2018

There is a distinct lacuna in the historiography of British shipbuilding in that the role of independent consultants within it is largely unknown. This article attempts to rectify this gap by analysing the birth, growth and subsequent denouement of the industry’s most important consulting firm, A&P Appledore (International) Ltd (APA), and setting it in its domestic and international context. Sadly, through its various incarnations, the business records of APA have been lost. However, this article draws upon the recollections and retained correspondence of two senior directors of APA, John Craggs and Roger Vaughan, and other APA consultants. As such, it sheds new light on an under-researched aspect of British and international shipbuilding history.
Dielectric barrier discharge and jet type plasma surface modifications of hybrid polymeric poly (ε-caprolactone)/chitosan scaffolds
Authors: Ozkan Ozan , Turkoglu Sasmazel Hilal
Published: February 2018

In this study, dry air plasma jet and dielectric barrier discharge Ar + O2 or Ar + N2 plasma modifications and their effects on wettability, topography, functionality and biological efficiency of the hybrid polymeric poly (ε-caprolactone)/chitosan scaffolds were reported. The samples treated with Ar + O2 dielectric barrier discharge plasma (80 sccm O2 flow rate, 3-min treatment) or with dry air plasma jet (15-cm nozzle-sample distance, 13-min treatment) had the closest wettability (49.11 ± 1.83 and 53.60 ± 0.95, respectively) to the commercial tissue culture polystyrene used for cell cultivation. Scanning electron microscopy images and X-ray photoelectron spectrometry analysis showed increase in topographical roughness and OH/NH2 functionality, respectively. Increased fluid uptake capacity for the scaffolds treated with Ar + O2 dielectric barrier discharge plasma (73.60% ± 1.78) and dry air plasma jet (72.48% ± 0.75) were also noted. Finally, initial cell attachment as well as seven-day cell viability, growth and proliferation performances were found to be significantly better for both plasma treated scaffolds than for untreated scaffolds.
Predicting Psychosocial Maladjustment in Emerging Adulthood From High School Experiences of Peer Victimization
Authors: Buchanan Carie M. , McDougall Patricia
Published: February 2018

The aim of the present study was to compare recollections of sexual, physical, verbal, social, and cyber peer victimization experienced in high school in terms of depressed affect, self-esteem, and loneliness experienced in university. In all, 247 university students (70 males and 177 females; M = 20.62, SD = 2.54) completed online measures assessing retrospective accounts of their experiences of different forms of peer victimization during high school (i.e., sexual, physical, verbal, social, and cyber) and their current psychosocial adjustment (i.e., self-esteem, depressed affect, and loneliness). Three separate hierarchical multiple regressions were conducted to determine whether different indices of negative psychosocial adjustment are more strongly predicted by experiencing sexual or nonsexual forms of peer victimization. Although many university students recalled experiencing sexual peer victimization in high school at least once at an even higher percentage than verbal and social forms of peer victimization, the results of the present study suggest that social peer victimization in high school predicts higher levels of depressed affect and loneliness in university students than sexual peer victimization experienced in high school. Surprisingly, the young adults reporting higher levels of cyber peer victimization in high school were less lonely in university. Although the hypothesized relationships between each form of peer victimization and specific indices of psychosocial functioning were not consistently supported, these findings suggest that the form of peer victimization matters and may be differentially associated with well-being in emerging adulthood. It is important that future research explores how individual characteristics may further predict varied experiences of peer victimization and the long-term impact of those experiences.
Flexural fatigue performance of hybrid composite laminates based on E-glass and polypropylene fibers
Authors: Abd El-Baky MA , Attia MA
Published: February 2018

An experimental investigation has been conducted to understand the effect of water aging on flexural fatigue performance of unidirectional polypropylene (PP)-glass (G) fiber–reinforced epoxy composites. Test specimens were fabricated using hand lay-up process with a constant total fiber volume fraction. The effects of the reinforcement hybridization, hybrid configuration, and stacking sequences on S–N curves were investigated. Deflection-controlled flexural fatigue tests with a frequency of 25 Hz at zero mean stress have been conducted. A 20% reduction of the initial applied moment was taken as a failure criterion. In the first stage, the flexural fatigue properties of un-aged composite specimens were studied in ambient temperature. In the second stage, flexural fatigue properties were investigated after a preliminary aging step in distilled water for 350 days. The specimen surface temperature rise was measured to ensure that there is no early damage happened in the tested specimens. Results indicated that the hybridization of PP fiber–reinforced composite with G fiber improves its flexural fatigue resistance but increase water uptake. Inter-intraply hybrid laminate with G-fiber layers at the specimen outer faces and PP-fiber layers in the specimen core exhibits the most favorable flexural fatigue behavior, that is, the highest cost ratio and the specific fatigue endurance strength. The water-sorption step induced a significant decrease in fatigue properties of the fabricated specimens. The highest measured temperature rise was observed to be about 9°C for G fiber–reinforced composite.
From employability to ‘complexability’
Authors: Higdon Rachel D.
Published: February 2018

Higher education students and employers in the creative industries dismiss the prevailing skills-focused concept of ‘employability’ as inadequate. Entry into the creative world and subsequent survival require access to contact networks, confidence and the adaptability to cope with uncertainty and with changing contexts for business, partnerships and innovative opportunities. ‘Complexability’, it is suggested, better describes such interactive abilities. In close work with undergraduates, graduates and practitioners in two contrasting disciplines, architecture and dance, a set of interlocking briefs – the ‘creatour’ construct – emerges for the development of the necessary abilities and perspectives. A dance student’s passion for parkour inspired the construct. The article sets out the rationale behind the development of creatour and the methodology through which it was achieved. Its key stages are explained in detail and initial evaluations are reviewed. Although initially developed for the creative arts, unexpectedly creatour has also been seen as applicable to law, business and medicine.
Effect of wheel–rail interface parameters on contact stability in explicit finite element analysis
Authors: Ma Yuewei , Markine Valeri L , Mashal Abdul Ahad , Ren Mingfa
Published: February 2018

It is widely recognized that the accuracy of explicit finite element simulations is sensitive to the choice of interface parameters (i.e. contact stiffness/damping, mesh generation, etc.) and time step sizes. Yet, the effect of these interface parameters on the explicit finite element based solutions of wheel–rail interaction has not been discussed sufficiently in literature. In this paper, the relation between interface parameters and the accuracy of contact solutions is studied. It shows that the wrong choice of these parameters, such as too high/low contact stiffness, coarse mesh, or wrong combination of them, can negatively affect the solution of wheel–rail interactions which manifest in the amplification of contact forces and/or inaccurate contact responses (here called “contact instability”). The phenomena of “contact (in)stabilities” are studied using an explicit finite element model of a wheel rolling over a rail. The accuracy of contact solutions is assessed by analyzing the area of contact patches and the distribution of normal pressure. Also, the guidelines for selections of optimum interface parameters, which guarantee the contact stability and therefore provide an accurate solution, are proposed. The effectiveness of the selected interface parameters is demonstrated through a series of simulations. The results of these simulations are presented and discussed.
Supporting the future of municipal bonds in sub-Saharan Africa: the centrality of enabling environments and regulatory frameworks
Authors: Gorelick Jeremy
Published: February 2018

This article explores the universal obstacles limiting sub-national governments from using municipal bonds. Specifically, it examines four case studies – Johannesburg, Douala, Dakar and Kampala – to understand their approaches to municipal bond issuance. The chief obstacle to municipal bond issuance for raising funds relates to the constitutional and regulatory systems in each country. This represents a significant departure from the commonly-held understandings that cities in the region are not eligible for long-term debt, lack capacity, or are not viewed as creditworthy by purchasers of municipal bonds.

The success of municipal bond issuance appears contingent on strong interlinkages between central and sub-national governments. This article critically reviews the powers granted to local governments under the countries’ constitutions, specifically the legislation that enables or prohibits municipalities from issuing bonds. Reform for a financially sustainable level of indebtedness for sub-sovereign governments is essential for the future growth of cities in sub-Saharan Africa.
Optimal design and performance analysis of hydraulic ram pump system
Authors: Guo Xinlei , Li Jiazhen , Yang Kailin , Fu Hui , Wang Tao , Guo Yongxin , Xia Qingfu , Huang Wei
Published: February 2018

Hydraulic ram pump is an automatic water-pumping equipment generally used to pump drinking and irrigation water in mountainous and rural areas having short of power. In the past, it has been analyzed and optimized by fabricating various prototypes and conducting experiments and comparisons. This process is time and labor consuming and detailed flow features cannot be determined except efficiency, discharge, and period. In this paper, a method for the optimal design and performance analysis of hydraulic ram pump system with numerical simulation and physical experiment is presented to shorten the number of prototypes and develop high-performance product. The proposed evaluation indexes include head loss coefficient, drag coefficient, eccentric distance of pressure, and velocity distribution uniformity. Two types of structures, named front-enlargement and back-enlargement, were initially designed. According to the numerical simulation, the latter one has lower head loss coefficient and drag coefficient, larger eccentric distance of pressure and higher velocity distribution uniformity and was adopted in the novel hydraulic ram pump. Then, the design theory and method on adjustable and high-head experimental platform have been developed, so that the delivery head can be easily controlled and regulated in laboratory. Experiments were carried out for the delivery heads of 2.0 m and 2.7 m and comparisons were conducted with other products. The results show that, when the delivery head is less than 50 m, the efficiency of the new product ranges from 50% to 70% while the delivery flow is the largest. Its application in Liangshui River, Beijing, indicates that the novel hydraulic ram pump is a practical tool in fountain sight and for irrigation purpose without external power input.
Orthogonal spiral structures for energy harvesting applications: Theoretical and experimental analysis
Authors: Santos Auteliano Antunes Dos , Hobeck Jared D. , Inman Daniel J
Published: February 2018

The capture of energy from vibration of mechanical systems has been extensively studied with the goal of providing power for various microelectromechanical systems. The traditional cantilever beam approach was used as a starting design for more complex, multiple-beam structures like zigzag or spiral geometries. This work presents the orthogonal spiral structure, an alternative compact periodic structure for reduced frequency energy harvesting. The proposed orthogonal spiral structure design is inspired by a combination of zigzag and Archimedean spiral geometries. The orthogonal spiral structure takes advantage of a simple cantilever beam-based design as with the zigzag, but includes the compact concentric-type design of an Archimedean spiral. First, the fundamental frequency is estimated using a lumped parameter model for the substrate beam and the results are compared with experimental results for two different sizes of orthogonal spiral structures. Then, the same model is updated to include a layer of piezoelectric material and used to identify the strain nodes along each beam obtained from the first mode shape. Finally, electromechanical modeling is developed allowing for the evaluation of the energy harvested from base excitations. The results show that the orthogonal spiral structure can be used as an alternative to current energy harvesting systems for micro scale applications.
The Consequences of Legislative Term Limits for Policy Diffusion
Authors: Miller Susan M. , Nicholson-Crotty Jill , Nicholson-Crotty Sean
Published: February 2018

Policy diffusion scholarship has long sought to understand when lawmakers will imitate innovations adopted by other jurisdictions and when they actually invest the time and resources necessary to learn about potential policies. We develop the theoretical rationale that term limits will reduce the incentive and capacity of state legislatures to gather information about policies available from previous adoptions in other states. We hypothesize that this will decrease the importance of previous adopters when term-limited legislators consider policy innovations. A multilevel analysis of the diffusion of eighty-seven policies between 1960 and 2009 provides support for this expectation. Our findings provide insight into the way in which institutional features shape policy diffusion.
Scandinavian Total Ankle Replacement: 15-Year Follow-up
Authors: Palanca Ariel , Mann Roger A. , Mann Jeffrey A. , Haskell Andrew
Published: February 2018

Background:

Over the past decade, total ankle arthroplasty (TAA) has become a mainstay in the treatment of end-stage ankle arthritis. Currently in its fourth generation, the Scandanavian Total Ankle Replacement (STAR) is the only 3-piece mobile bearing ankle prosthesis available in the United States. Our current study reports implant survivorship at 15 years and patient outcomes for a subset of these survivors available for study.

Methods:

Eighty-four TAAs were performed between 1998 and 2000. Metal component survivorship at 15 years was calculated with a Kaplan-Meier curve. Twenty-four (29%) of 84 patients were available for participation with a minimum 15-year follow-up. Any radiographic changes were documented. All additional procedures and complications were recorded. Clinical findings, self-reported performance and pain evaluations, and AOFAS ankle/hindfoot scores were noted.

Results:

Metal implant survival was 73% at 15 years. Of the 24 patients available for clinical evaluation, 18 of 24 patients (70.7%) had no change in prosthetic alignment from the immediate postoperative radiograph. Only 1 subtalar fusion was required for symptomatic adjacent joint arthritis. Three patients sustained a broken polyethylene component. AOFAS scores improved from an average of 39.6 points preoperatively, to an average of 71.6. More than half (52.4%) of patients with retained implants required an additional surgical procedure; 3 required 2 additional procedures. The average time to subsequent procedure was 10.2 years.

Conclusion:

Our small cohort demonstrated STAR ankles with retention at 9 years were highly likely to survive to 15 years, and patients continued to have significant improvement in pain relief and minimal decrease in function. At 15 years from TAA, metal survivorship was 73%. As with all ankle replacements, supplementary procedures were common.

Level of Evidence:

Level IV, case series.
Crack nucleation in rod-type nuclear fuel pellet
Authors: Mirsalimov Vagif
Published: February 2018

A plane problem of fracture mechanics on crack nucleation in a rod-type nuclear fuel pellet is considered. Nuclear reactor fuel pellets in operation may be damaged in various ways; in particular, crack nucleation. We consider a problem for the case of a heat-releasing fuel pellet with cladding: as the heat release intensity increases, zones of heightened stress are formed in the nuclear fuel pellet. The heightened stress will promote the appearance of prefracture bands that are simulated as zones of weakened interparticle bonds of the material. Interaction of prefracture zone faces is simulated by placing bonds between faces that have a specified deformation pattern. The problem of equilibrium of a fuel pellet with prefracture zones is reduced to the solution of a system of singular integral equations. An analysis of the ultimate state of the zone of weakened interparticle bonds of the material is realized on the basis of the criterion of critical opening of prefracture zone faces.
Genomic Analysis Using Regularized Regression in High-Grade Serous Ovarian Cancer
Authors: Natanzon Yanina , Earp Madalene , Cunningham Julie M , Kalli Kimberly R , Wang Chen , Armasu Sebastian M , Larson Melissa C , Bowtell David DL , Garsed Dale W , Fridley Brooke L , Winham Stacey J , Goode Ellen L
Published: February 2018

High-grade serous ovarian cancer (HGSOC) is a complex disease in which initiation and progression have been associated with copy number alterations, epigenetic processes, and, to a lesser extent, germline variation. We hypothesized that, when summarized at the gene level, tumor methylation and germline genetic variation, alone or in combination, influence tumor gene expression in HGSOC. We used Elastic Net (ENET) penalized regression method to evaluate these associations and adjust for somatic copy number in 3 independent data sets comprising tumors from more than 470 patients. Penalized regression models of germline variation, with or without methylation, did not reveal a role in HGSOC gene expression. However, we observed significant association between regional methylation and expression of 5 genes ( WDPCP, KRT6C, BRCA2, EFCAB13, and ZNF283). CpGs retained in ENET model for BRCA2 and ZNF283 appeared enriched in several regulatory elements, suggesting that regularized regression may provide a novel utility for integrative genomic analysis.
Introducing Sufism to International Relations Theory: A preliminary inquiry into epistemological, ontological, and methodological pathways
Authors: Shahi Deepshikha
Published: February 2018

One of the most commonly treaded pathways to address the widely recognized Eurocentric biases in International Relations has been the initiation of intellectual efforts toward the incorporation of non-Western world views. However, the greater assimilation of knowledge produced by non-Western scholars from local philosophical-experiential vantage points — that is, the integration of Chinese, Indian, or Brazilian outlooks expressed under the rubric “non-Western International Relations” — cannot make International Relations less Eurocentric or more “Global” if the following slippery grounds are overlooked: (1) if non-Western International Relations theories employ non-Western philosophical resources for generating a derivative discourse of Western/Eurocentric International Relations theories, thereby failing to transcend the conjectural boundaries of Western/Eurocentric International Relations; and (2) if non-Western International Relations theories manufacture an exceptionalist discourse that is specifically applicable to the narrow experiential realities of a native time–space zone, thereby failing to offer an alternative universalist explanation that grants a broad-spectrum relevance to Western/Eurocentric International Relations. In the light of these realizations, the present article aims to explore if “Sufism” — as a non-Western intellectual resource — is capable of offering a fertile ground for crafting a non-derivative and non-exceptionalist Global International Relations theory. In order to do this, the article employs the insights gained from the poetry of a 13th-century Sufi scholar, Jalāl ad-Dīn Muhammad Rūmī. The article draws the conclusion that Sufism, as an established philosophy with a grand temporal-spatial global spread, upholds a “threefold attribute” — namely, epistemological monism, ontological immaterialism, and methodological eclecticism — which gives it a unique foundational status to formulate a non-Eurocentric Global International Relations theory.
Knowledge Based Commissioning: Can a National Clinical Effectiveness Policy Be Compatible with Seeking Local Professional Advice?
Authors: Littlejohns Peter , Dumelow Carol , Griffiths Sian
Published: February 2018

Objectives:

To help develop a means, based on the views of purchasers and providers of health care, of incorporating national research on clinical effectiveness into local professional advisory mechanisms in order to inform health care purchasing and contracting.

Methods:

Three geographically based multidisciplinary workshops attended by National Health Service (NHS) staff drawn from the principal purchaser and provider groups in one English region were organized around the discussion of three health care purchasing case studies: Coronary artery disease, diabetes and management of clinical depression in general practice. The proceedings were transcribed and analyzed using content analysis methods.

Results:

95 people took part. There were major differences between the purchasers' and health care providers' views on the right balance between local and national information and advisory sources for purchasing. In general, providers wanted the provision of advice to purchasers to be local, in which their opinion was sought, either individually or collectively, acted on and the results fed back to them. In contrast, health authority purchasers considered that local professionals were only one source of professional advice, albeit an important one, to be utilized in coming to decisions. General practitioner fundholders as purchasers, however, preferred to rely on their own experiences and contacts with local providers in making purchasing decisions.

Conclusions:

Professional specialist advisory groups are necessary to inform the purchasing of health care, but should extend beyond advising on the placement of individual contracts. Involving health care providers in all short-term contracting is unlikely to be cost-effective given the time commitment required. The emphasis at purchaser/provider meetings should be on education: Providing an opportunity for purchasers and providers to develop closer relationships to discuss political imperatives and financial constraints; increasing communication and understanding of providers' and purchasers' roles; and providing an environment for professionals and purchasers to share their views on purchasing. As currently presented, elements of the national policies in the NHS advocating the use of both national evidence on clinical effectiveness and local professional advice are contradictory and should be clarified.
Structural Change in Hospitals: The Implications for Research
Authors: Harrison Anthony
Published: February 2018

This paper begins by considering briefly the interdependent nature of the health care sector and suggests that most research on structural change in the hospital system has ignored that obvious fact. It then goes on to argue that this failure will become even more significant in the face of the large scale changes that are expected in the way health services are delivered. Its central proposal is that the research horizons should be widened, particularly if change on the scale that appears likely is to be properly evaluated. How that may be done is considered in the final section.
‘Evidence-based’, ‘Cost-Effective’ and ‘Preference-Driven’ Medicine: Decision Analysis Based Medical Decision Making is the Pre-Requisite
Authors: Dowie Jack
Published: February 2018

Three broad movements are seeking to change the world of medicine. The proponents of ‘evidence-based medicine’ are mainly concerned with ensuring that strategies of proven clinical effectiveness are adopted. Health economists are mainly concerned to establish that ‘cost-effectiveness’ and not ‘clinical effectiveness’ is the criterion used in determining option selection. A variety of patient support and public interest groups, including many health economists, are mainly concerned with ensuring that patient and public preferences drive clinical and policy decisions. This paper argues that decision analysis based medical decision making (DABMDM) constitutes the pre-requisite for the widespread introduction of the main principles embodied in evidence-based medicine, cost-effective medicine and preference-driven medicine; that, in the light of current modes of practice, seeking to promote these principles without a prior or simultaneous move to DABMDM is equivalent to asking the cart to move without the horse; and that in fact DABMDM subsumes and enjoins the valuable aspects of all three. Particular attention is paid to differentiating between DABMDM and EBM, by way of analysis of various expositions of EBM and examination of two recent empirical studies. EBM, as so far expounded, reflects a problem-solving attitude that results in a heavy concentration on RCTs and meta-analyses, rather than a broad decision making focus that concentrates on meeting all the requirements of a good clinical decision. The latter include: Ensuring that inferences from RCTs and meta-analyses to individual patients (or patient groups) are made explicitly; paying equally serious attention to evidence on values and costs as to clinical evidence; and accepting the inadequacy of ‘taking into account and bearing in mind’ as a way of integrating the multiple and distinct elements of a decision.
Why Should Health Services Be Primary Care-Led?
Authors: Coulter Angela
Published: February 2018

A primary care-led health service is the latest fashion in health policy, yet there is no consensus on what this means. One manifestation of this policy is the attempt to shift the balance of resources from secondary to primary care, with the goal of improving the cost-effectiveness of health care. This has been taken furhtest in the UK, where GP fundholders have been given resources to purchase a significant proportion of their patients' health care. The scheme provides incentives to shift the location of care out of hospitals, but there is very little evidence that this will result in better quality patient care at lower cost.
Inequalities in Health: What Health Systems Can and Cannot Do
Authors: Foster Peggy
Published: February 2018

Health promotion activities are actively encouraged in most countries, including the UK. Meanwhile many health care providers and health experts are becoming increasingly concerned about the growing evidence of significant health inequalities between social groups in the UK, and in particular the strong association between relative deprivation and poor health. In 1995, a report for the British government entitled ‘Variations in health: What can the Department of Health and the NHS do?’, identified the need for the Department of Health and the NHS to play a key role in coordinating and implementing public health programmes intended to reduce inequalities in health. Examination of existing evidence on the effectiveness of health promotion and prevention programmes designed to improve the health status of the most vulnerable groups in society reveals very little evidence to support current enthusiasm for adopting public health strategies in order to reduce variations in health status between the affluent and the poor. Alternative and potentially more effective health care responses to inequalities in health status need to be considered.
Economics, Public Health and Health Care Purchasing: The Tayside Experience of Programme Budgeting and Marginal Analysis
Authors: Ruta Danny A. , Donaldson Cam , Gilray Ingrid
Published: February 2018

In this paper it is shown how the economics framework of programme budgeting and marginal analysis (PBMA) can be used to help formulate a purchasing strategy in health care; in this case, for child health services. The basic premise of PBMA is that to have more of some services it is necessary to have less of others. Therefore, it is important to know how resources are currently spent, what changes can be made, and what are the possible costs and benefits of such changes. Despite a lack of evidence on the effectiveness of services, PBMA provides a pragmatic purchasing framework. This framework permits consideration of national policy, local epidemiology, current spending, and the views both of parents and professionals as to how such spending can be changed.
Patient Preferences in Randomised Trials: Threat or Opportunity?
Authors: Torgerson David J. , Klaber-Moffett Jennifer , Russell Ian T.
Published: February 2018

Objectives:

To assess whether it is feasible to elicit patients’ preferences for treatments and then to proceed with randomisation which may allocate those with preferences to their less preferred treatment; and to describe which prognostic variables were associated with such preferences within the context of a randomised trial of an exercise programme for back pain.

Methods:

The first 97 patients enrolled in a randomised controlled trial (RCT) for the treatment of back pain were asked about their preferences, health characteristics and other prognostic variables.

Results:

Fifty-eight (60%) patients preferred to be allocated to the exercise programme whilst 38 (39%) were indifferent; one patient preferred conventional general practitioner (GP) management. No patient refused randomisation. Comparing patients preferring the exercise programme with indifferent patients showed that the former had a higher belief in the effectiveness of the new treatment ( P > 0.01), tended to have worse back pain ( P = 0.09), had back pain for a shorter duration ( P = 0.04), and tended to have had more GP home visits ( P = 0.06).

Conclusions:

For many randomised trials preference may be an important prognostic variable. In such circumstances, preference should be taken into account in the final analysis. This study demonstrates it is sometimes feasible to randomise patients to their less preferred treatment, thus allowing more robust statistical comparisons between randomised groups. This modification may make RCTs more rigorous and improve their external validity.
Simulation Models in the Planning of Health Care Facilities: An Application in the Case of Neonatal Extracorporeal Membrane Oxygenation
Authors: Michel Bowine C. , van Staveren Rob J. E. , Geven Wil B. , van Hout Ben A.
Published: February 2018

Objectives:

To investigate whether modelling techniques can be used in the planning of health care facilities for patients requiring neonatal extracorporeal membrane oxygenation (ECMO).

Methods:

In a micro-simulation model the number of patients that will have to be referred to facilities abroad is estimated for any number of neonatal ECMO patients presenting annually for treatment in The Netherlands, and any number of ECMO facilities. The inputs to the model consist of the number of ECMO facilities, the number of patients presenting annually, the duration of treatment and the date on which patients present for ECMO treatment. The model is estimated on data from The Netherlands for 1992, during which 29 patients were treated in three facilities. Several future scenarios are modelled, principally one in which a potential increase to 56 patients per year is foreseen.

Results:

The model indicates that, if such an increase takes place, no additional ECMO facilities will be necessary in The Netherlands if between three and four referrals annually to centres outside the region (or abroad) are considered acceptable and feasible. In that situation, it is expected that on 22 occasions each year two patients will be treated simultaneously, for a total of 81 days. On ten occasions, all three facilities will be occupied at the same time, for 21 days in total. On 199 days, at least one of the facilities will be occupied.

Conclusion:

The current study shows that the acceptability and feasibility of patient referrals to ECMO centres abroad is an important issue which health care planners will have to consider. The study also shows that modelling techniques can provide information that is useful to policy-makers in the planning of health care facilities.
The Cost-Effectiveness of Condoms in the Prevention of HIV Infection in England and Wales: Should Condoms Be Available on Prescription?
Authors: Hughes David , Morris Stephen
Published: February 2018

Objectives:

HIV and AIDS represent a considerable challenge to the British National Health Service, and the resources devoted to treatment and prevention of HIV/AIDS are significant and likely to increase. The focus of recent campaigns promoting safer sexual practices to prevent the spread of HIV have focused on the use of condoms, since condom use reduces the probability of infection. Furthermore, it has also been suggested that condoms should Be provided routinely on prescription by general practitioners (GPs). The objective of this study was to evaluate the cost-effectiveness of GP-provision of condoms in the prevention of HIV infection. Since risk factors for HIV infection differ across population groups, cost-effectiveness ratios for three at-risk groups were considered.

Methods:

Estimates of the cost per infection prevented and the cost per life year gained were made for female heterosexuals, male heterosexuals, and male homosexuals in England and Wales. Sensitivity analysis was conducted on a number of key parameters.

Results:

The costs per infection prevented were £2 327 744 for female heterosexuals, £9 709 987 for male heterosexuals and £1315 for male homosexuals. The corresponding costs per life year gained were £56 774, £269 722 and £37. When savings from the costs of care were taken into account the use of condoms resulted in cost savings of nearly £50 000 for homosexual males.

Conclusions:

The provision of GP-prescribed condoms is highly cost-effective for male homosexuals. Such provision is much less cost-effective for heterosexuals, primarily due to the relatively low prevalence of HIV in the heterosexual population and the low infectivity parameter. This suggests that routine GP-provision of condoms would be inappropriate for all at-risk groups, and should target high-risk groups, specifically male homosexuals.
The Problem of ‘Noise’ in Monitoring Patient-Based Outcomes: Generic, Disease-Specific and Site-Specific Instruments for Total Hip Replacement
Authors: Dawson Jill , Fitzpatrick Ray , Murray David , Carr Andrew
Published: February 2018

Objectives:

To compare the performance of three types of patient-based health status instrument — generic, disease-specific and site-specific — in assessing changes resulting from total hip replacement (THR).

Methods:

A two-stage prospective study of patients undergoing surgery for THR involving an assessment at a pre-surgical clinic and a follow-up clinic at 6 months. 173 patients with a diagnosis of arthritis and being admitted for unilateral THR were recruited in the outpatient departments of a specialist orthopaedic hospital and peripheral clinics within Oxfordshire. Patients’ health status was assessed using the 12-item Oxford Hip Score, the Arthritis Impact Measurement Scales (AIMS) and SF-36 general health questionnaire together with their surgeons’ assessment using Charnley hip score obtained before and 6 months after surgery.

Results:

Effect sizes, used to compare change scores, revealed that pain and function domains changed most following THR on both the AIMS and the SF-36. 71 patients (41%) were assessed as having symptoms or problems currently affecting lower limb joints other than the hip recently replaced. Change scores were compared between these patients and all other patients who reported no current problems with other joints. The Oxford Hip Score found no significant difference between change scores for these two groups of patients while both AIMS and SF-36 physical and pain dimensions recorded significant differences of similar magnitude (physical P < 0.01, pain P < 0.05). Likely reasons for this were apparent on closer inspection of the item content of each instrument.

Conclusions:

Assessment of outcomes in THR is necessarily long-term. Within studies of this kind, a hip-specific instrument (Oxford Hip Score) is likely to be more able to distinguish between symptoms and functional impairment produced by the index joint, as compared with other joints and conditions, than either a disease-specific instrument (AIMS) or a generic health status measure (SF-36). This is important given the high probability of existing and subsequent co-morbidity affecting such populations of patients. This consideration is likely to be relevant to any long-term assessment programme following treatment for a condition which threatens bilateral expression over time.
Development Standards for Health Measures
Authors: McDowell Ian , Jenkinson Crispin
Published: February 2018

The growing demand for subjective measurements of health in clinical studies has encouraged the rapid creation of many new scales, leading to compromises in the quality of some instruments. Quality control standards are desirable to guide the development of measures and subsequent data interpretation. The limitations in existing measures may be classified under three broad topic areas: 1) shortcomings in the design of the instrument, 2) methodological limitations in the process of its development, and 3) shortcomings in the way that the instrument is described following its initial development. We outline examples of common problems in these areas and propose guidelines for the design, development and presentation of health measurement methods. The guidelines represent a preliminary step in formalizing a discipline of health measurement.
Factors Influencing the Attendance Rate at Accident and Emergency Departments in East London: The Contributions of Practice Organization, Population Characteristics and Distance
Authors: Hull Sally A. , Jones Ian Rees , Moser Kath
Published: February 2018

Objectives:

To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments.

Design:

Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census.

Setting:

East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London.

Main outcome measure:

Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994.

Results:

Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8–18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied ( R = 0.55, P < 0.001) and pensioners living alone ( R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity ( R = −0.31, P = 0.002) and residents lacking amenities ( R = −0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance ( R = −0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: Percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value.

Conclusions:

Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.
Defining Core Services: New Zealand Experiences
Authors: Cumming Jacqueline
Published: February 2018

A key aspect of the New Zealand health reforms was the proposed development of an explicit core of services to which all New Zealanders would have access. A range of approaches has been taken by the government, its advisers, purchasers and providers to describe sets of services to which New Zealanders are to have access. The development of an explicit core aims to promote equity of access to services, to ensure that those services available are those that are the most cost-effective and the services New Zealanders feel to be the most important, and to clarify entitlements to publicly funded health care. This paper describes the current approaches that are being used to define core services in New Zealand, discusses the reasons behind some of the choices made and notes some key issues for further policy debate.
Advice-giving in Community Pharmacies in the UK
Authors: Tully Mary P. , Hassell Karen , Noyce Peter R.
Published: February 2018

Objectives:

To review (1) the published evidence on the information provided with prescribed and purchased medicines by pharmacists and pharmacy assistants, (2) clients' expectations of advice about medicines from community pharmacies and their experience and use of it, and (3) appropriateness and rigour of study methods used.

Methods:

Papers, published between 1980 and 1995 inclusively, were identified based on searches of on-line databases, a published literature index, key pharmacy practice journals and cited references in the bibliographies of published papers. Those papers selected reported research findings on any aspect of medicines-related communications and the provision of advice about medicines to members of the public who visited pharmacies in the UK. The comparatively small volume of work and lack of design consistency meant that a subjective assessment, rather than a criteria-based objective review, was deemed appropriate.

Results:

Forty-two suitable studies were identified and are reviewed. No common definition of ‘advice’ has emerged. Most studies reported were quantitative, concentrating on the frequency of advice-giving in community pharmacies and only one study considered the impact of advice on outcome. The quality of advice given was judged highly variable, although pharmacists' referrals, where made, were considered appropriate. Given that pharmacy assistants appear to make most of the medicine sales, remarkably few studies addressed their contribution to advicegiving. The review can provide little insight into what determines when advice is provided, but it does illuminate the disparity between the advice that clients say they want and what they actually seek.

Conclusions:

Where there appears to be a consensus that advice-giving in community pharmacies is wanted, this review reveals a lack of shared understanding between consumer bodies and the pharmacy profession about who needs advice and when and how it should be given. The need for unsolicited advice-giving associated with the sale of medicines is particularly contentious. With the current programme of deregulation of medicines, this is an increasingly important issue to resolve. The authors suggest a need for a consensus-building forum to generate guidelines that meet shared expectations between clients, community pharmacists, government and the pharmaceutical industry.