Testing the limits of the 'joint account' model of genetic information: a legal thought experiment

We examine the likely reception in the courtroom of the 'joint account' model of genetic confidentiality. We conclude that the model, as modified by Gilbar and others, is workable and reflects, better than more conventional legal approaches, both the biological and psychological realities and the obligations owed under Articles 8 and 10 of the European Convention on Human Rights (ECHR).

Improvements in the data quality of a national BMI measuring programme

Variations in data collection between collecting regions can affect the outcome measures. This study examines the impact of improvements in data collection on outcome measures in a national monitoring programme between 2007/2008 and 2010/2011. Multilevel analysis of 2007/2008 and 2010/2011 National Child Measurement Programme (NCMP) data estimated the relationship between body mass index (BMI) z-score and data collection variations within coordinating regions, while adjusting for individual-level and school-level factors. The total sample was 2,013,285 students from 17,279 primary schools in 152 coordinating regions in England. Data collection differences accounted for 31.2% of the regional variation in BMI z-score for Reception (aged 4-5 years) students in 2007/2008; this reduced to 12.6% in 2010/2011. For Year 6 (aged 10-11 years) students, it reduced from 5.3% in 2007/2008 to 2.4% in 2010/2011. Digit preference in the rounding of weight measurements showed the largest decreases, from 27.3 to 4.5% for Reception year pupils and from 4.2 to 1.0% for Year 6 pupils. This demonstrates that improvements in data collection variation between regions in the NCMP have led to improvements in data quality.

WHO'S IN CHARGE? THE RELATIONSHIP BETWEEN MEDICAL LAW, MEDICAL ETHICS, AND MEDICAL MORALITY?

Medical law inevitably involves decision-making, but the types of decisions that need to be made vary in nature, from those that are purely technical to others that contain an inherent ethical content. In this paper we identify the different types of decisions that need to be made, and explore whether the law, the medical profession, or the individual doctor is best placed to make them. We also argue that the law has failed in its duty to create a coherent foundation from which such decision-making might properly be regulated, and this has resulted in a haphazard legal framework that contains no consistency. We continue by examining various medico-legal topics in relation to these issues before ending by considering the risk of demoralisation.

Cancer survivors' self-efficacy to self-manage in the year following primary treatment

PURPOSE

Cancer survivors are increasingly expected to manage the consequences of cancer and its treatment for themselves. There is evidence that self-efficacy is important for successful self-management and that this can be enhanced with support. The purpose of this study was to assess self-efficacy to manage problems in the year following primary treatment.

METHODS

This cross-sectional online survey included cancer survivors who had completed their treatment within the past 12 months. Self-efficacy was assessed and variables expected to be associated with self-efficacy were measured using validated scales including quality of life, well-being, illness perceptions, depression and social support.

RESULTS

One hundred eighty-two respondents (mean age 50; 81% female) completed the survey. They had been treated for a range of cancers; most commonly breast (45%). Self-efficacy scores varied between individuals and according to the illness-related task to be managed. Respondents were least confident in managing fatigue and most confident in accessing information about their cancer. Individuals most likely to report low self-efficacy were women, those experiencing higher levels of pain and/or depression, lower well-being scores, lower socio-economic status, low levels of social support, or a more negative perception of cancer.

CONCLUSIONS

Self-efficacy to self-manage problems faced as a consequence of cancer and its treatment can vary widely in the year following treatment. Fatigue may be particularly difficult to manage.

IMPLICATIONS FOR CANCER SURVIVORS

Variations in self-efficacy highlight the importance of assessing specific problems faced and people's confidence to manage them in order to tailor appropriate self-management support.

Paediatric European Network for Treatment of AIDS (PENTA) guidelines for treatment of paediatric HIV-1 infection 2015: optimizing health in preparation for adult life

The 2015 Paediatric European Network for Treatment of AIDS (PENTA) guidelines provide practical recommendations on the management of HIV‐1 infection in children in Europe and are an update to those published in 2009. Aims of treatment have progressed significantly over the last decade, moving far beyond limitation of short‐term morbidity and mortality to optimizing health status for adult life and minimizing the impact of chronic HIV infection on immune system development and health in general. Additionally, there is a greater need for increased awareness and minimization of long‐term drug toxicity. The main updates to the previous guidelines include: an increase in the number of indications for antiretroviral therapy (ART) at all ages (higher CD4 thresholds for consideration of ART initiation and additional clinical indications), revised guidance on first‐ and second‐line ART recommendations, including more recently available drug classes, expanded guidance on management of coinfections (including tuberculosis, hepatitis B and hepatitis C) and additional emphasis on the needs of adolescents as they approach transition to adult services. There is a new section on the current ART ‘pipeline’ of drug development, a comprehensive summary table of currently recommended ART with dosing recommendations. Differences between PENTA and current US and World Health Organization guidelines are highlighted and explained.

Community wide interventions for increasing physical activity

BACKGROUND

Multi-strategic community wide interventions for physical activity are increasingly popular but their ability to achieve population level improvements is unknown.

OBJECTIVES

To evaluate the effects of community wide, multi-strategic interventions upon population levels of physical activity.

SEARCH METHODS

We searched the Cochrane Public Health Group Segment of the Cochrane Register of Studies,The Cochrane Library, MEDLINE, MEDLINE in Process, EMBASE, CINAHL, LILACS, PsycINFO, ASSIA, the British Nursing Index, Chinese CNKI databases, EPPI Centre (DoPHER, TRoPHI), ERIC, HMIC, Sociological Abstracts, SPORT Discus, Transport Database and Web of Science (Science Citation Index, Social Sciences Citation Index, Conference Proceedings Citation Index). We also scanned websites of the EU Platform on Diet, Physical Activity and Health; Health-Evidence.org; the International Union for Health Promotion and Education; the NIHR Coordinating Centre for Health Technology (NCCHTA); the US Centre for Disease Control and Prevention (CDC) and NICE and SIGN guidelines. Reference lists of all relevant systematic reviews, guidelines and primary studies were searched and we contacted experts in the field. The searches were updated to 16 January 2014, unrestricted by language or publication status.

SELECTION CRITERIA

Cluster randomised controlled trials, randomised controlled trials, quasi-experimental designs which used a control population for comparison, interrupted time-series studies, and prospective controlled cohort studies were included. Only studies with a minimum six-month follow up from the start of the intervention to measurement of outcomes were included. Community wide interventions had to comprise at least two broad strategies aimed at physical activity for the whole population. Studies which randomised individuals from the same community were excluded.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted the data and assessed the risk of bias. Each study was assessed for the setting, the number of included components and their intensity. The primary outcome measures were grouped according to whether they were dichotomous (per cent physically active, per cent physically active during leisure time, and per cent physically inactive) or continuous (leisure time physical activity time (time spent)), walking (time spent), energy expenditure (as metabolic equivalents or METS)). For dichotomous measures we calculated the unadjusted and adjusted risk difference, and the unadjusted and adjusted relative risk. For continuous measures we calculated percentage change from baseline, unadjusted and adjusted.

MAIN RESULTS

After the selection process had been completed, 33 studies were included. A total of 267 communities were included in the review (populations between 500 and 1.9 million). Of the included studies, 25 were set in high income countries and eight were in low income countries. The interventions varied by the number of strategies included and their intensity. Almost all of the interventions included a component of building partnerships with local governments or non-governmental organisations (NGOs) (29 studies). None of the studies provided results by socio-economic disadvantage or other markers of equity. However, of those included studies undertaken in high income countries, 14 studies were described as being provided to deprived, disadvantaged or low socio-economic communities. Nineteen studies were identified as having a high risk of bias, 10 studies were unclear, and four studies had a low risk of bias. Selection bias was a major concern with these studies, with only five studies using randomisation to allocate communities. Four studies were judged as being at low risk of selection bias although 19 studies were considered to have an unclear risk of bias. Twelve studies had a high risk of detection bias, 13 an unclear risk and four a low risk of bias. Generally, the better designed studies showed no improvement in the primary outcome measure of physical activity at a population level.All four of the newly included, and judged to be at low risk of bias, studies (conducted in Japan, United Kingdom and USA) used randomisation to allocate the intervention to the communities. Three studies used a cluster randomised design and one study used a stepped wedge design. The approach to measuring the primary outcome of physical activity was better in these four studies than in many of the earlier studies. One study obtained objective population representative measurements of physical activity by accelerometers, while the remaining three low-risk studies used validated self-reported measures. The study using accelerometry, conducted in low income, high crime communities of USA, emphasised social marketing, partnership with police and environmental improvements. No change in the seven-day average daily minutes of moderate to vigorous physical activity was observed during the two years of operation. Some program level effect was observed with more people walking in the intervention community, however this result was not evident in the whole community. Similarly, the two studies conducted in the United Kingdom (one in rural villages and the other in urban London; both using communication, partnership and environmental strategies) found no improvement in the mean levels of energy expenditure per person per week, measured from one to four years from baseline. None of the three low risk studies reporting a dichotomous outcome of physical activity found improvements associated with the intervention.Overall, there was a noticeable absence of reporting of benefit in physical activity for community wide interventions in the included studies. However, as a group, the interventions undertaken in China appeared to have the greatest possibility of success with high participation rates reported. Reporting bias was evident with two studies failing to report physical activity measured at follow up. No adverse events were reported.The data pertaining to cost and sustainability of the interventions were limited and varied.

AUTHORS' CONCLUSIONS

Although numerous studies have been undertaken, there is a noticeable inconsistency of the findings in the available studies and this is confounded by serious methodological issues within the included studies. The body of evidence in this review does not support the hypothesis that the multi-component community wide interventions studied effectively increased physical activity for the population, although some studies with environmental components observed more people walking.

Function and viability of human islets encapsulated in alginate sheets: in vitro and in vivo culture

Islet encapsulation offers an immune system barrier for islet transplantation, and encapsulation within an alginate sheetlike structure offers the ability to be retrievable after transplanted. This study aims to show that human islets encapsulated into islet sheets remain functional and viable after 8 weeks in culture or when transplanted into the subcutaneous space of rats. Human islets were isolated from cadaveric organs. Dissociation and purification were done using enzymatic digestion and a continuous Ficoll-UWD gradient. Purified human islets were encapsulated in alginate sheets. Human Islet sheets were either kept in culture, at 37°C and 5% CO(2), or transplanted subcutaneously into Lewis rats. After 1, 2, 4, and 8 weeks, the human islet sheets were retrieved from the rats and assessed. The viability of the sheets was measured using fluorescein diacetate (FDA)/propidium iodide (PI), and function was measured through glucose-stimulated insulin release, in which the sheets were incubated for an hour in low-glucose concentration (2.8 mmol/L) and then high (28 mmol/L), then high (28 mmol/L) plus 3-isobutyl-1-methylxanthine (50 μm). Human islet sheets remained both viable, above 70%, and functional, with a stimulation index (insulin secretion in high glucose divided by insulin secretion in low glucose) above 1.5, over 8 weeks of culture or subcutaneous transplantation. Islet transplantation continues to make advances in the treatment of type 1 diabetes. These preliminary results suggest that encapsulated islets sheets can survive and maintain islet viability and function in vivo, within the subcutaneous region.

A systematic review of the influence of the retail food environment around schools on obesity-related outcomes

The high prevalence of childhood obesity has led to questions about the influence of 'obesogenic' environments on children's health. Public health interventions targeting the retail food environment around schools have been proposed, but it is unclear if they are evidence based. This systematic review investigates associations between food outlets near schools and children's food purchases, consumption and body weight. We conducted a keyword search in 10 databases. Inclusion criteria required papers to be peer reviewed, to measure retailing around schools and to measure obesity-related outcomes among schoolchildren. Thirty papers were included. This review found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption, but some evidence of an effect on body weight. Given the general lack of evidence for association with the mediating variables of food purchases and consumption, and the observational nature of the included studies, it is possible that the effect on body weight is a result of residual confounding. Most of the included studies did not consider individual children's journeys through the food environment, suggesting that predominant exposure measures may not account for what individual children actually experience. These findings suggest that future interventions targeting the food environment around schools need careful evaluation.

Neuropsychological investigation of anterior and posterior cortical function in early-stage probable Alzheimer's disease

In vivo neuroimaging studies have generally indicated a greater involvement of posterior cortical areas in early-stage dementia of the Alzheimer type (DAT) relative to frontal involvement. By contrast, some recent neuropsychological studies have shown that DAT patients perform poorly in frontal lobe tasks even in the early stages of the disease, although there is disagreement as to whether this necessarily implicates frontal pathology. The main aim of this study was to examine the hypothesis prompted by both neuroimaging studies and the traditional clinical conception of the disease, that, compared with the functioning of posterior association cortex, executive functions (thought to depend on frontal lobe integrity) are relatively spared in the early stages of DAT. A group of patients with a diagnosis of early-stage, probable DAT (n = 17) was compared with age- and IQ-matched controls (n = 17) across a range of neuropsychological tasks presumed to exercise frontal or temporoparietal functions. A profile of strengths and weaknesses was observed across 'anterior' and 'posterior' cognitive tests, including dissociations among some tests of temporoparietal function, in particular visual object perception (impaired) and spatial analysis skills (intact). Thus there was little support for the notion that the disease progresses cortically in a posterior-to-anterior direction. Possible reasons for the discrepancy between neurophysiological and neuropsychological observations are discussed, including the possibility that neuropsychological tests do not provide a valid indication of regional brain function when used in the context of DAT. Caution is urged in the clinical application of 'frontal lobe tests' for the differential diagnosis of DAT.

From informed consent to informed request: strengthening shared decisionmaking

Obtaining valid consent is regarded as essential before there can be an ethically or legally appropriate medical intervention. The justification is, simply, that patient autonomy should be respected. The patient's body is hers, and she has a right to do with it what she chooses. In order for that choice to be real, it has to be a choice made by a patient who is competent to make it. That competence has two elements. First, the patient must have the cognitive hardware and software necessary to receive, retain and process the information, weighing the benefits and the burdens of the proposed treatment against each other. Second, the inputs must be the relevant ones: the information to be processed must be (i) accurate and (ii) sufficient.

Dignity and the use of body parts

This paper contends that the conventional ethical and legal ways of analysing the wrong involved in the misuse of human body parts are inadequate, and should be replaced with an analysis based on human dignity. It examines the various ways in which dignity has been understood, outlines many of the criticisms made of those ways (agreeing with many of the criticisms), and proposes a new way of seeing dignity which is exegetically consonant with the way in which dignity has been historically understood, and yet avoids the pitfalls which have led to dignity being dismissed by many as hopelessly amorphous or incurably theological. The account of dignity proposed is broadly Aristotelian. It defines dignity in terms of human thriving, and presupposes that it is possible, at least in principle, to determine empirically what makes humans thrive. It contends that humans are quintessentially relational animals, and that it is not possible (and certainly not ethically desirable) to define humans as atomistic entities. One important corollary of this is that when using dignity/thriving as a criterion for determining the ethical acceptability of a proposed action or inaction, one should ask not merely how the dignity interests of the patient (for instance) would be affected, but how the dignity interests of all stakeholders would be affected. The business of ethics is then the business of auditing all those interests, and determining the course of action which would maximise the amount of thriving in the world.

Autonomy in the medico-legal courtroom: a principle fit for purpose?

This article examines the way that the principle of autonomy is handled in (mostly English) law. The law pays loud lip-service to autonomy, saying that it is the governing principle in many areas. This is particularly true for cases involving bioethics. The courts are rarely philosophically explicit about which account of autonomy is favoured, but three accounts (Millian self-determination, Kantian deontology, and relational autonomy-in which the social nexus of the subject is explicitly recognised) can be identified. Despite the law's traditional rhetorical insistence that autonomy rules absolutely, that rule is, in practice, unworkable. Other principles, such as beneficence and dignity, have to be drafted in to help. Much of the philosophical work that autonomy should do in the law is delegated to the notion of capacity, but that notion too is insufficiently examined by the courts, and is problematic.

Uncertainty and anxiety in the cancer of unknown primary patient journey: a multiperspective qualitative study

BACKGROUND

Patients with cancer of unknown primary (CUP) have metastatic malignant disease without an identifiable primary site; it is the fourth most common cause of cancer death.

OBJECTIVES

To explore patients' informal and professional carers' experiences of CUP to inform development of evidence-based, patient-centred care.

METHODS

Qualitative study involving development of multiple exploratory case studies, each comprising a patient and nominated informal and professional carers, with contextual data extracted from medical records.

RESULTS

17 CUP patients, 14 informal and 13 professional carers participated in the study. Two inter-related themes distinct to CUP emerged: uncertainty and continuity of care. In the absence of a primary diagnosis, patients and informal carers experienced uncertainty regarding prognosis, possible recurrence and the primary's hereditary potential. Professional carers experienced difficulty communicating uncertainty to patients, ambiguity in deciding optimal treatment plans in the absence of trial data and a test or treat dilemma: when to discontinue seeking the primary and start treatment. Common problems with care continuity were amplified for CUP patients relating to coordination, accountability and timeliness of care. The remit of multidisciplinary teams (MDTs) often excluded CUP, leading to "MDT tennis" where patients were "bounced" between MDTs.

CONCLUSIONS

The experience of those with CUP is distinctive and it can serve to amplify some of the issues encountered by people with cancer. The clinical uncertainties related to CUP compound existing shortcomings in continuity of care, increasing the likelihood of a disrupted patient journey. However, while little can be done to overcome uncertainty, more could be done to address issues regarding continuity of care.

Remote and web 2.0 interventions for promoting physical activity

BACKGROUND

Remote and web 2.0 interventions for promoting physical activity (PA) are becoming increasingly popular but their ability to achieve long term changes are unknown.

OBJECTIVES

To compare the effectiveness of remote and web 2.0 interventions for PA promotion in community dwelling adults (aged 16 years and above) with a control group exposed to placebo or no or minimal intervention.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and some other databases (from earliest dates available to October 2012). Reference lists of relevant articles were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared remote and web 2.0 PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using remote or web 2.0 technologies (for example the internet, smart phones) or more traditional methods (for example telephone, mail-outs), or both. To assess behavioural change over time, the included studies had a minimum of 12 months follow-up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow-up if they did not apply an intention-to-treat analysis.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the quality of each study and extracted the data. Non-English language papers were reviewed with the assistance of an interpreter who was an epidemiologist. Study authors were contacted for additional information where necessary. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for the continuous measures of self-reported PA and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios and 95% CIs were calculated.

MAIN RESULTS

A total of 11 studies recruiting 5862 apparently healthy adults met the inclusion criteria. All of the studies took place in high-income countries. The effect of the interventions on cardiovascular fitness at one year (two studies; 444 participants) was positive and moderate with significant heterogeneity of the observed effects (SMD 0.40; 95% CI 0.04 to 0.76; high quality evidence). The effect of the interventions on self-reported PA at one year (nine studies; 4547 participants) was positive and moderate (SMD 0.20; 95% CI 0.11 to 0.28; moderate quality evidence) with heterogeneity (I² = 37%) in the observed effects. One study reported positive results at two years (SMD 0.20; 95% CI 0.08 to 0.32; moderate quality evidence). When studies were stratified by risk of bias, the studies at low risk of bias (eight studies; 3403 participants) had an increased effect (SMD 0.28; 95% CI 0.16 to 0.40; moderate quality evidence). The most effective interventions applied a tailored approach to the type of PA and used telephone contact to provide feedback and to support changes in PA levels. There was no evidence of an increased risk of adverse events (seven studies; 2892 participants). Risk of bias was assessed as low (eight studies; 3060 participants) or moderate (three studies; 2677 participants). There were no differences in effectiveness between studies using different types of professionals delivering the intervention (for example health professional, exercise specialist). There was no difference in pooled estimates between studies that generated the prescribed PA using an automated computer programme versus a human, nor between studies that used pedometers as part of their intervention compared to studies that did not.

AUTHORS' CONCLUSIONS

We found consistent evidence to support the effectiveness of remote and web 2.0 interventions for promoting PA. These interventions have positive, moderate sized effects on increasing self-reported PA and measured cardio-respiratory fitness, at least at 12 months. The effectiveness of these interventions was supported by moderate and high quality studies. However, there continues to be a paucity of cost effectiveness data and studies that include participants from varying socioeconomic or ethnic groups. To better understand the independent effect of individual programme components, longer term studies, with at least one year follow-up, are required.

Face-to-face interventions for promoting physical activity

BACKGROUND

Face-to-face interventions for promoting physical activity (PA) are continuing to be popular but their ability to achieve long term changes are unknown.

OBJECTIVES

To compare the effectiveness of face-to-face interventions for PA promotion in community dwelling adults (aged 16 years and above) with a control exposed to placebo or no or minimal intervention.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and some other databases (from earliest dates available to October 2012). Reference lists of relevant articles were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared face-to-face PA interventions for community dwelling adults with a placebo or no or minimal intervention control group. We included studies if the principal component of the intervention was delivered using face-to-face methods. To assess behavioural change over time the included studies had a minimum of 12 months follow-up from the start of the intervention to the final results. We excluded studies that had more than a 20% loss to follow-up if they did not apply an intention-to-treat analysis.

DATA COLLECTION AND ANALYSIS

At least two authors independently assessed the quality of each study and extracted data. Non-English language papers were reviewed with the assistance of an interpreter who was an epidemiologist. Study authors were contacted for additional information where necessary. Standardised mean differences (SMDs) and 95% confidence intervals (CIs) were calculated for continuous measures of self-reported PA and cardio-respiratory fitness. For studies with dichotomous outcomes, odds ratios (ORs) and 95% CIs were calculated.

MAIN RESULTS

A total of 10 studies recruiting 6292 apparently healthy adults met the inclusion criteria. All of the studies took place in high-income countries. The effect of interventions on self-reported PA at one year (eight studies; 6725 participants) was positive and moderate with significant heterogeneity (I² = 74%) (SMD 0.19; 95% CI 0.06 to 0.31; moderate quality evidence) but not sustained in three studies at 24 months (4235 participants) (SMD 0.18; 95% CI -0.10 to 0.46). The effect of interventions on cardiovascular fitness at one year (two studies; 349 participants) was positive and moderate with no significant heterogeneity in the observed effects (SMD 0.50; 95% CI 0.28 to 0.71; moderate quality evidence). Three studies (3277 participants) reported a positive effect on increasing PA levels when assessed as a dichotomous measure at 12 months, but this was not statistically significant (OR 1.52; 95% CI 0.88 to 2.61; high quality evidence). Although there were limited data, there was no evidence of an increased risk of adverse events (one study; 149 participants). Risk of bias was assessed as low (four studies; 4822 participants) or moderate (six studies; 1543 participants). Any conclusions drawn from this review require some caution given the significant heterogeneity in the observed effects. Despite this, there was some indication that the most effective interventions were those that offered both individual and group support for changing PA levels using a tailored approach. The long term impact, cost effectiveness and rates of adverse events for these interventions was not established because the majority of studies stopped after 12 months.

AUTHORS' CONCLUSIONS

Although we found evidence to support the effectiveness of face-to-face interventions for promoting PA, at least at 12 months, the effectiveness of these interventions was not supported by high quality studies. Due to the clinical and statistical heterogeneity of the studies, only limited conclusions can be drawn about the effectiveness of individual components of the interventions. Future studies should provide greater detail of the components of interventions, and assess impact on quality of life, adverse events and economic data.