Telemedicine and the sharing economy: the "Uber" for healthcare.

Telehealth platforms, which include both competitors and complements to traditional care delivery, will offer many benefits for both consumers and clinicians, and may promote increased specialization and competition in service delivery. Traditional medical services providers face a challenge similar to that faced by traditional taxicabs after Uber entered the marketplace: how to compete with a connection services platform that threatens to disrupt existing, regulated, and licensed service providers.

The Educational and Employment Aspirations of Adolescents from Areas of High Deprivation in London.

Adolescents from areas of high deprivation are often assumed to have low aspirations for the future. However, recent research has suggested otherwise and there have been calls for more substantial investigation into the relationship between poverty and aspiration. This article reports levels and variation in aspiration from 1214 adolescents (49.5 % male; 50.5 % female) living in areas of high deprivation across 20 London boroughs. A strength of this study is our large and diverse population of low socio-economic status (SES) adolescents, comprising of white British (22 %), black African (21 %), black Caribbean (9 %), Indian/Pakistani/Bangladeshi/Other Asian (24 %), mixed ethnicity (9 %), and 15 % defining themselves as Other. Our measures indicated a high group level of reported aspiration with notable variations. Females reported higher educational (but not occupational) aspirations than males; white British students reported lower educational and occupational aspirations than other ethnic groups; and black African children reported the highest educational aspirations. Perceived parental support for education had the largest positive association with aspirations. In contrast to previous findings from studies carried out in the United States, aspirations were found to be negatively associated with perceptions of school and school peer environment. These measures explored feelings of safety, happiness and belonging within the school environment and school peer group. We discuss possible explanations for this unexpected finding within our population of adolescents from UK state schools and how it might affect future policy interventions. This study makes an important contribution to the literature on adolescent aspirations because of the unique nature of the data sample and the multiple domains of functioning and aspiration measured.

Individual socio-demographic factors and perceptions of the environment as determinants of inequalities in adolescent physical and psychological health: the Olympic Regeneration in East London (ORiEL) study.

BACKGROUND: Populations living in urban areas experience greater health inequalities as well as higher absolute burdens of illness. It is well-established that a range of social and environmental factors determine these differences. Less is known about the relative importance of these factors in determining adolescent health within a super diverse urban context. METHODS: A cross-sectional sample of 3,105 adolescent participants aged 11 to 12 were recruited from 25 schools in the London boroughs of Newham, Tower Hamlets, Hackney and Barking & Dagenham. Participants completed a pseudo-anonymised paper-based questionnaire incorporating: the Warwick-Edinburgh Mental Well-being Scale used for assessing positive mental well-being, the Short Moods and Feelings Questionnaire based on the DSM III-R criteria for assessment of depressive symptoms, the Youth-Physical Activity Questionnaire and a self-assessment of general health and longstanding illness. Prevalence estimates and unadjusted linear models estimate the extent to which positive well-being scores and time spent in physical/sedentary activity vary by socio-demographic and environmental indicators. Logistic regression estimated the unadjusted odds of having fair/(very)poor general health, a long standing illness, or depressive symptoms. Fully adjusted mixed effects models accounted for clustering within schools and for all socio-demographic and environmental indicators. RESULTS: Compared to boys, girls had significantly lower mental well-being and higher rates of depressive symptoms, reported fewer hours physically active and more hours sedentary, and had poorer general health after full adjustment. Positive mental well-being was significantly and positively associated with family affluence but the overall relationship between mental health and socioeconomic factors was weak. Mental health advantage increased as positive perceptions of the neighbourhood safety, aesthetics, walkability and services increased. Prevalence of poor health varied by ethnic group, particularly for depressive symptoms, general health and longstanding illness suggesting differences in the distribution of the determinants of health across ethnic groups. CONCLUSIONS: During adolescence perceptions of the urban physical environment, along with the social and economic characteristics of their household, are important factors in explaining patterns of health inequality.

Health literacy of living kidney donors and kidney transplant recipients.

BACKGROUND: Health literacy (HL) may be a mediator for known socioeconomic and racial disparities in living kidney donation. METHODS: We evaluated the associations of patient and demographic characteristics with HL in living kidney donors (LD), living donor kidney transplant recipients (LDR), and deceased donor recipients (DDR) in a single-center retrospective review of patients undergoing kidney donation or transplantation from September 2010 to July 2012. HL and demographic data were collected. HL was assessed via the Short Literacy Survey (SLS) comprising three self-reported screening questions scored using the five-point Likert scale (low, moderate, high). Chi-square and logistic regression were used to test factors associated with lower HL. RESULTS: The sample included 360 adults (105 LD, 103 LDR, and 152 DDR; 46±14 years; 70% white; 56% male; 14±3 years of education). HL scores were skewed (49% high, 41% moderate, and 10% low). The distribution of HL categories differed significantly among groups (P=0.019). After controlling for age, race, sex, education, and a race-education interaction term, DDR was more likely to have moderate or low HL than LDR (OR, 1.911; 95% CI, 1.096-3.332; P=0.022). CONCLUSION: Overall, living donors had high HL. The distribution of low, moderate, and high HL differed significantly between LD, DDR, and LDR. DDR had a higher likelihood of having low HL than LDR. Screening kidney transplant candidates and donors for lower HL may identify barriers to living donation. Future interventions addressing HL may be important to increase living donation and reduce disparities.

Laparoscopic versus open peritoneal dialysis catheter insertion cost analysis.

BACKGROUND: Peritoneal dialysis (PD) is a cost-effective alternative to hemodialysis (HD). PD catheters have traditionally been inserted through a small open incision, but insertion using laparoscopic visualization has become increasingly popular and is associated with less catheter malfunction. The aim of this study was to compare costs of laparoscopic and open insertion strategies while taking into account postoperative complications and future salvage procedures. METHODS: A decision analysis model was constructed to simulate 1 y outcomes after PD catheter insertion by either the open or laparoscopic approach. Possible outcomes after PD catheter placement included functional catheter, infection, and catheter malfunction. Ultimately, patients continued with successful PD or switched to HD. Baseline probabilities, costs, and ranges were determined from a critical review of the literature. Sensitivity analyses were performed to determine the model strength over a range of clinically relevant probabilities. RESULTS: The total annual costs, including postoperative management and dialysis treatment, were $69,491 for laparoscopic insertion and $69,960 for open insertion. In case of a catheter malfunction, an initial attempt at salvage by fluoroscopy-guided wire manipulation cost less than a first attempt by laparoscopic repositioning. CONCLUSIONS: When accounting for a year of postoperative management and treatment, laparoscopic insertion can be less costly than open insertion in the hands of an experienced surgeon. Despite higher initial costs, PD catheter insertion under laparoscopic visualization can have lower total costs due to fewer postoperative complications. With increasing emphasis on cost-effective care, laparoscopic insertion is a valuable tool for initiating PD.

Well London Phase-1: results among adults of a cluster-randomised trial of a community engagement approach to improving health behaviours and mental well-being in deprived inner-city neighbourhoods.

BACKGROUND: We report the main results, among adults, of a cluster-randomised-trial of Well London, a community-engagement programme promoting healthy eating, physical activity and mental well-being in deprived neighbourhoods. The hypothesis was that benefits would be neighbourhood-wide, and not restricted to intervention participants. The trial was part of a multicomponent process/outcome evaluation which included non-experimental components (self-reported behaviour change amongst participants, case studies and evaluations of individual projects) which suggested health, well-being and social benefits to participants. METHODS: Twenty matched pairs of neighbourhoods in London were randomised to intervention/control condition. Primary outcomes (five portions fruit/vegetables/day; 5×30 m of moderate intensity physical activity/week, abnormal General Health Questionnaire (GHQ)-12 score and Warwick-Edinburgh Mental Well-being Scale (WEMWBS) score) were measured by postintervention questionnaire survey, among 3986 adults in a random sample of households across neighbourhoods. RESULTS: There was no evidence of impact on primary outcomes: healthy eating (relative risk [RR] 1.04, 95% CI 0.93 to 1.17); physical activity (RR:1.01, 95% CI 0.88 to 1.16); abnormal GHQ12 (RR:1.15, 95% CI 0.84 to 1.61); WEMWBS (mean difference [MD]: -1.52, 95% CI -3.93 to 0.88). There was evidence of impact on some secondary outcomes: reducing unhealthy eating-score (MD: -0.14, 95% CI -0.02 to 0.27) and increased perception that people in the neighbourhood pulled together (RR: 1.92, 95% CI 1.12 to 3.29). CONCLUSIONS: The trial findings do not provide evidence supporting the conclusion of non-experimental components of the evaluation that intervention improved health behaviours, well-being and social outcomes. Low participation rates and population churn likely compromised any impact of the intervention. Imprecise estimation of outcomes and sampling bias may also have influenced findings. There is a need for greater investment in refining such programmes before implementation; new methods to understand, longitudinally different pathways residents take through such interventions and their outcomes, and new theories of change that apply to each pathway.

Can donors with high donor risk indices be used cost-effectively in liver transplantation in US Transplant Centers?

In an effort to quantify the impact of donor risk factors on recipient outcomes, the donor risk index (DRI) was developed. A high DRI correlates with poorer post-transplant survival. In this study, high-DRI donors are classified as those having DRIs >2.0, while low-DRI donors have DRIs <2.0. The aim of this study was to evaluate the cost-effectiveness of high-DRI donor use in US Transplant Centers. A Markov-based decision analytic model was created to simulate outcomes for an allocation scheme using only low-DRI donors versus a scheme using both low- and high-DRI donors. Baseline values and ranges were determined from published data and Medicare cost data. Sensitivity analyses were conducted to test model strength and parameter variability. An allocation scheme in which only low-DRI donors were used generated 5.2 quality-adjusted life years (QALYs) at a cost of $83 000/QALY. An allocation scheme using both low- and high-DRI donors generated 5.9 QALYs at a cost of $66 000/QALY. Sensitivity analyses supported the use of an allocation scheme using both low- and high-DRI donors. The overall contribution of high-DRI grafts to the donor pool and the resultant reduction in wait-list mortality make them cost-effective.

Socioeconomic status and functional brain development - associations in early infancy.

Socioeconomic status (SES) impacts on both structural and functional brain development in childhood, but how early its effects can be demonstrated is unknown. In this study we measured resting baseline EEG activity in the gamma frequency range in awake 6-9-month-olds from areas of East London with high socioeconomic deprivation. Between-subject comparisons of infants from low- and high-income families revealed significantly lower frontal gamma power in infants from low-income homes. Similar power differences were found when comparing infants according to maternal occupation, with lower occupational status groups yielding lower power. Infant sleep, maternal education, length of gestation, and birth weight, as well as smoke exposure and bilingualism, did not explain these differences. Our results show that the effects of socioeconomic disparities on brain activity can already be detected in early infancy, potentially pointing to very early risk for language and attention difficulties. This is the first study to reveal region-selective differences in functional brain development associated with early infancy in low-income families.

Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death?

OBJECTIVES: The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD). METHODS: A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS: Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy. CONCLUSIONS: The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.

More donors or more delayed graft function? A cost-effectiveness analysis of DCD kidney transplantation.

Expansion of the donor pool with expanded criteria donors and donation after cardiac death (DCD) donors is essential. DCD grafts result in increased rates of primary non-function (PNF) and delayed graft function (DGF). However, long-term patient and graft survival is similar between donation after brain death (DBD) donors and DCD donors. The aim of this study was to evaluate the cost-effectiveness of the use of DCD donors. A Markov-based decision analytic model was created to simulate outcomes for two wait list strategies: (i) wait list composed of only DBD organs and (ii) wait list combining DBD and DCD organs. Baseline values and ranges were determined from the Scientific Registry of Transplant Recipients (SRTR) database and literature review. Sensitivity analyses were conducted to test model strength and parameter variability. The wait list strategy consisting of DBD donors only provided recipients 5.4 Quality-adjusted life years (QALYs) at $65 000/QALY, whereas a wait list strategy combining DBD + DCD donors provided recipients 6.0 QALYs at a cost of $56 000/QALY. Wait lists with DCD donors provide adequate long-term survival despite more DGF. This equates to an improvement in quality of life and decreased cost when compared to remaining on dialysis for any period of time.

The Olympic Regeneration in East London (ORiEL) study: protocol for a prospective controlled quasi-experiment to evaluate the impact of urban regeneration on young people and their families.

INTRODUCTION: Recent systematic reviews suggest that there is a dearth of evidence on the effectiveness of large-scale urban regeneration programmes in improving health and well-being and alleviating health inequalities. The development of the Olympic Park in Stratford for the London 2012 Olympic and Paralympic Games provides the opportunity to take advantage of a natural experiment to examine the impact of large-scale urban regeneration on the health and well-being of young people and their families. DESIGN AND METHODS: A prospective school-based survey of adolescents (11-12 years) with parent data collected through face-to-face interviews at home. Adolescents will be recruited from six randomly selected schools in an area receiving large-scale urban regeneration (London Borough of Newham) and compared with adolescents in 18 schools in three comparison areas with no equivalent regeneration (London Boroughs of Tower Hamlets, Hackney and Barking & Dagenham). Baseline data will be completed prior to the start of the London Olympics (July 2012) with follow-up at 6 and 18 months postintervention. Primary outcomes are: pre-post change in adolescent and parent mental health and well-being, physical activity and parental employment status. Secondary outcomes include: pre-post change in social cohesion, smoking, alcohol use, diet and body mass index. The study will account for individual and environmental contextual effects in evaluating changes to identified outcomes. A nested longitudinal qualitative study will explore families' experiences of regeneration in order to unpack the process by which regeneration impacts on health and well-being. ETHICS AND DISSEMINATION: The study has approval from Queen Mary University of London Ethics Committee (QMREC2011/40), the Association of Directors of Children's Services (RGE110927) and the London Boroughs Research Governance Framework (CERGF113). Fieldworkers have had advanced Criminal Records Bureau clearance. Findings will be disseminated through peer-reviewed publications, national and international conferences, through participating schools and the study website (http://www.orielproject.co.uk).

The Well London program--a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results.

BACKGROUND: The Well London program used community engagement, complemented by changes to the physical and social neighborhood environment, to improve physical activity levels, healthy eating, and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomized trial (CRT). The baseline survey data are reported here. METHODS: The CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas (LSOAs); ranked in the 11% most deprived LSOAs in London by the English Indices of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information, and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighborhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating, and mental wellbeing were assessed using standardized, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys. RESULTS: There were 4,107 adults and 1,214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighborhoods were broadly similar. There was greater between-cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking, and self-reported anxiety/depression were similar in the Well London adult population and the national Health Survey for England. Levels of physical activity were higher in the Well London adult population but this is likely to be due to the different measurement tools used in the two surveys. CONCLUSIONS: Randomization of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well-balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.

Hemodialysis Reliable Outflow (HeRO) device in end-stage dialysis access: a decision analysis model.

BACKGROUND: The Hemodialysis Reliable Outflow (HeRO) dialysis access device is a permanent tunneled dialysis graft connected to a central venous catheter and is used in patients with end-stage dialysis access (ESDA) issues secondary to central venous stenosis. The safety and effectiveness of the HeRO device has previously been proven, but no study thus far has compared the cost of its use with tunneled dialysis catheters (TDCs) and thigh grafts in patients with ESDA. MATERIALS AND METHODS: A decision analytic model was developed to simulate outcomes for patients with ESDA undergoing placement of a HeRO dialysis access device, TDC, or thigh graft. Outcomes of interest were infection, thrombosis, and ischemic events. Baseline values, ranges, and costs were determined from a systematic review of the literature. Total costs were based on 1 year of post-procedure outcomes. Sensitivity analyses were conducted to test model strength. RESULTS: The HeRO dialysis access device is the least costly dialysis access with an average 1-year cost of $6521. The 1-year cost for a TDC was $8477. A thigh graft accounted for $9567 in a 1-year time period. CONCLUSIONS: The HeRO dialysis access device is the least costly method of ESDA. The primary determinants of cost in this model are infection in TDCs and leg ischemia necessitating amputation in thigh grafts. Further study is necessary to incorporate patient preference and quality of life into the model.

Comparison of open live donor nephrectomy, laparoscopic live donor nephrectomy, and hand-assisted live donor nephrectomy: a cost-minimization analysis.

BACKGROUND: Live donor kidney transplantation is the treatment of choice for end-stage renal disease. Open donor nephrectomy (ODN) was the standard until the introduction of the laparoscopic donor nephrectomy (LDN) in 1995. Hand-assisted laparoscopic donor nephrectomy (HALDN) was added shortly thereafter. The laparoscopic techniques are associated with increased operating room times and equipment costs; however, these techniques speed patient return to normal activity. The aim of this study is to evaluate the cost of these techniques. MATERIALS AND METHODS: A decision analysis model was developed to simulate outcomes for donors undergoing ODN, LDN, and HALDN. Outcomes were simulated from both the institutional perspective (IP) and the societal perspective (SP). Baseline values and ranges were determined from a systematic review of the literature. Sensitivity analyses were conducted to test model strength. RESULTS: From the IP, ODN is the least costly strategy with a cost of $11,000, while the cost is $15,200 for HALDN and $15,800 for LDN. From the SP, HALDN is the least costly strategy costing $27,800, while the cost for LDN is $29,000 and for ODN is $41,000. In sensitivity analysis, ODN only became the dominant strategy if the days till return to work exceeded 58 in the HALDN strategy. LDN and HALDN were nearly equivalent as the rate of open conversion of LDN approached zero. CONCLUSIONS: HALDN is the least costly donor nephrectomy strategy, especially from the SP. The primary determinants of cost in this model are conversion to open and days till return to work.

A cost-effectiveness analysis of early vs late reconstruction of iatrogenic bile duct injuries.

BACKGROUND: Controversy exists regarding the optimal timing of repair after iatrogenic bile duct injuries (BDI). Several studies advocate late repair (≥6 weeks after injury) with mandatory drainage and resolution of inflammation. Others indicate that early repair (<6 weeks after injury) produces comparable or superior clinical outcomes. Additionally, although most studies have reported inferior outcomes with primary surgeon repair, this practice continues. With disparate published recommendations and rising health care costs, decision analysis was used to examine the cost-effectiveness of BDI repair. STUDY DESIGN: A Markov model was developed to evaluate primary surgeon repair (PSR), late repair by a hepatobiliary surgeon (LHBS), and early repair by a hepatobiliary surgeon (EHBS). Baseline values and ranges were collected from the literature. Sensitivity analsyses were conducted to test the strength of the model and variability of parameters. RESULTS: The model demonstrated that EHBS was associated with lower costs, earlier return to normal activity, and better quality of life. Specifically, 1 year after repair, PSR yielded 0.53 quality adjusted life years (QALYs) ($120,000/QALY) and LHBS yielded 0.74 QALYs ($74,000/QALY); EHBS yielded 0.82 QALYs ($48,000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. CONCLUSIONS: This cost-effectiveness model demonstrates that early repair by a hepatobiliary surgeon is the superior strategy for the treatment of BDI in properly selected patients. Although there is little clinical difference between early and late repair, there is a great difference in cost and quality of life. Ideally, costs and quality of life should be considered in decisions regarding strategies of repair of injured bile ducts.

Which is more cost-effective under the MELD system: primary liver transplantation, or salvage transplantation after hepatic resection or after loco-regional therapy for hepatocellular carcinoma within Milan criteria?

OBJECTIVE: The optimal strategy for treating hepatocellular carcinoma (HCC), a disease with increasing incidence, in patients with Child-Pugh class A cirrhosis has long been debated. This study evaluated the cost-effectiveness of hepatic resection (HR) or locoregional therapy (LRT) followed by salvage orthotopic liver transplantation (SOLT) vs. that of primary orthotopic liver transplantation (POLT) for HCC within the Milan Criteria. METHODS: A Markov-based decision analytic model simulated outcomes, expressed in costs and quality-adjusted life years (QALYs), for the three treatment strategies. Baseline parameters were determined from a literature review. Sensitivity analyses tested model strength and parameter variability. RESULTS: Both HR and LRT followed by SOLT were associated with earlier recurrence, decreased survival, increased costs and decreased quality of life (QoL), whereas POLT resulted in decreased recurrence, increased survival, decreased costs and increased QoL. Specifically, HR/SOLT yielded 3.1 QALYs (at US$96 000/QALY) and LRT/SOLT yielded 3.9 QALYs (at US$74 000/QALY), whereas POLT yielded 5.5 QALYs (at US$52 000/QALY). Sensitivity analyses supported these findings at clinically meaningful probabilities. CONCLUSIONS: Under the Model for End-stage Liver Disease (MELD) system, in patients with HCC within the Milan Criteria, POLT increases survival and QoL at decreased costs compared with HR or LRT followed by SOLT. Therefore, POLT is the most cost-effective strategy for the treatment of HCC.

The orthodontic-restorative interface: 2. Compensating for variations in tooth number and shape.

UNLABELLED: The aim of this second article in this series of two is to outline a variety of methods which may be used to compensate for variations in tooth shape and number using a combination of orthodontic and restorative approaches. It will also provide an overview of other areas of patient care which necessitate a multi-disciplinary orthodontic/restorative approach. The article will highlight the importance of combined planning from the outset and the close relationship between the different specialties, which must be maintained throughout treatment. The methods of compensating for variations in tooth number and shape will often require contributions from both orthodontist and restorative dentist. It is important that both disciplines are involved in the assessment and treatment planning process so that they know what will be expected of them during the patient's care. Treatment planning in isolation may lead to care being delivered which is below the optimum standard which can be achieved. The orthodontist and restorative dentist are likely to liaise with the patient's general dental practitioner so that he/she can provide the restorative treatment in some cases. CLINICAL RELEVANCE: Great improvements in aesthetics and function may be obtained using an interdisciplinary approach for patients who have variations in tooth number and shape.

The orthodontic-restorative interface: 1. Patient assessment.

UNLABELLED: The first article in this series of two aims to outline the assessment of patients for whom a combined orthodontic-restorative approach would be beneficial. In particular, it will concentrate on the assessment of patients who have hypodontia and tooth size discrepancies. The importance of the aesthetic assessment for these cases will be highlighted. Variations in tooth number and tooth size discrepancy often require a combined treatment planning approach from the orthodontist and restorative dentist. The referring general dental practitioner has a key role in recognizing that this approach may be required and highlighting this in the initial patient referral. It is likely in the more straightforward cases that the GDP will be providing the restorative treatment and so an increased understanding of these cases would be beneficial. In the second paper, treatment options will be presented. CLINICAL RELEVANCE: For patients who require a combined orthodontic/restorative approach, it is important that orthodontic and restorative disciplines liaise closely in the assessment and treatment planning process so that optimal care may be planned.

Evaluation of community level interventions to address social and structural determinants of health: a cluster randomised controlled trial.

BACKGROUND: In London and the rest of the UK, diseases associated with poor diet, inadequate physical activity and mental illness account for a large proportion of area based health inequality. There is a lack of evidence on interventions promoting healthier behaviours especially in marginalised populations, at a structural or ecological level and utilising a community development approach.The Well London project financed by the Big Lottery 'Wellbeing' Fund and implemented by a consortium of London based agencies led by the Greater London Authority and the London Health Commission is implementing a set of complex interventions across 20 deprived areas of London. The interventions focus on healthy eating, healthy physical activity and mental health and wellbeing and are designed and executed with community participation complementing existing facilities and services. METHODS/DESIGN: The programme will be evaluated through a cluster randomised controlled trial. Forty areas across London were chosen based on deprivation scores. Areas were characterised by high proportion of Black and Minority Ethnic residents, worklessness, ill-health and poor physical environments. Twenty areas were randomly assigned to the intervention arm of Well London project and twenty 'matched' areas assigned as controls. Measures of physical activity, diet and mental health are collected at start and end of the project and compared to assess impact.The quantitative element will be complemented by a longitudinal qualitative study elucidating pathways of influence between intervention activities and health outcomes. A related element of the study investigates the health-related aspects of the structural and ecological characteristics of the project areas. The project 'process' will also be evaluated. DISCUSSION: The size of the project and the fact that the interventions are 'complex' in the sense that firstly, there are a number of interacting components with a wide range of groups and organisational levels targeted by the intervention, and secondly, a degree of flexibility or tailoring of the intervention, makes this trial potentially very useful in providing evidence of the types of activities that can be used to address chronic health problems in communities suffering from multiple deprivation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68175121.

Ethics consultation to PACT teams: balancing client autonomy and clinical necessity.

The Program for Assertive Community Treatment (PACT) is a community-based treatment program for people with severe and persistent mental illness, who have been underserved by traditional levels of care and are thought to be at high risk for rehospitalization. Within this model can be found a number of nontraditional treatment practices, some of which challenge the balance between client autonomy and paternalism, and can lead to clinical impasses. In this article we present three clinical cases (with discussions) to illustrate the most common ethical dilemmas that our PACT team has faced in assisting clients with their finances, legal terms of probation, and personal safety. We describe our use of professional ethics consultation to help us manage these dilemmas, enhance client informed consent, and promote collaborative care within the PACT model. Such ethics consultation may be useful to other PACT teams struggling to resolve clinical and ethical dilemmas by respecting both the autonomy and best interests of their clients.