The 1960s cervical screening incident at National Women's Hospital, Auckland, New Zealand: insights for screening research, policy making, and practice.

BACKGROUND AND OBJECTIVES: This article examines a cervical screening incident from the 1960s and draws lessons for screening policy. STUDY DESIGN AND SETTING: Concern about harmful overtreatment of symptomless lesions prompted university gynecologist Herbert Green to study, between 1965 and 1970, a 'special series' of 33 women with carcinoma in situ (CIS) who were managed with only limited punch or wedge biopsy. These women were carefully followed up but not treated unless they showed evidence of progression to invasive cancer. This paper examines source documents and subsequent publications in order to ascertain lessons from this incident. RESULTS: In keeping with the 1964 Helsinki Declaration, written consent was not sought. Green published the outcomes for his patients with CIS including the 'special series.' A Judicial inquiry (the Cartwright Inquiry) in 1987 concluded that some women had suffered harm and some had died, but numbers and evidence were not clearly stated. Medical case review for the Inquiry identified 25 women with only punch or wedge biopsy; in 21 of these, there were reasons why no further treatment was given; two had developed cervical cancer, and none were recorded as having died. The case review found eight patients, not necessarily in the 'special series,' who 'in retrospect and by 1987 standards' might have benefited from earlier conisation or hysterectomy. CONCLUSION: Subsequent claims relating to Green's practice have wrongly stated that as many as one hundred women or more had treatment withheld and over 30 died as a result. These claims are inaccurate.

English lessons: can publishing an atlas of variation stimulate the discussion on appropriateness of care?

NHS England has published series of atlases to highlight variation in costs, outcomes and intervention rates as part of a large scale transformational program to increase value and close the quality gap in health care. The NHS Atlas of Variation series has stimulated the search for unwarranted variation, an important step in the quest to improve quality and reduce harm. This article describes how the series was conceived, shares some of the lessons of preparing and publishing an atlas of variation, and considers how it can stimulate the discussion on appropriate care.

Better value eye care for the 21st century: the population approach.

Health services globally and in the UK face challenges from increasing need and rising expectations to inequalities and financial constraints. The UK government has recently published a Public Health Framework for the first time. This has included preventable sight loss as an outcome measure for the nation's public health reflecting increasing recognition of eye health issues in the broader public health agenda. This presents a real opportunity to improve eye care services at a population level. However, the chief executive of the National Health Service (NHS) has set his own challenge to the NHS to find £20 billion in efficiency savings in the next 3 years in order to maintain services within the available healthcare budget. We have reviewed national routine healthcare data in order to understand the current financial expenditure, activity and outcomes in ophthalmology. Our results have found a wide variation in expenditure in healthcare and activity across the country. We discuss a population based, value-orientated approach to dealing with healthcare issues which will provide a sustainable framework for the future.

Unwarranted variation in health care for children and young people.

The study of geographical variation in healthcare has moved on since J Allison Glover's seminal study in 1938, and its value in highlighting inequity in access, quality and outcomes is well-established. Study of variation in healthcare for children, however, has proven more difficult due to barriers with data and idiosyncrasies in how we measure outcomes for children and families. This paper is a narrative review of unwarranted variations in healthcare for children, and discusses the potential of variation analysis to help researchers and policy makers improve child health services.

Geographical variation in certification rates of blindness and sight impairment in England, 2008-2009.

OBJECTIVES: To examine and interpret the variation in the incidence of blindness and sight impairment in England by PCT, as reported by the Certificate of Vision Impairment (CVI). DESIGN: Analysis of national certification data. SETTING: All Primary Care Trusts, England. PARTICIPANTS: 23 773 CVI certifications issued from 2008 to 2009. MAIN OUTCOME MEASURES: Crude and Age standardised rates of CVI data for blindness and sight loss by PCT. METHODS: The crude and age standardised CVI rates per 100 000 were calculated with Spearman's rank correlation used to assess whether there was any evidence of association between CVI rates with Index of Multiple Deprivation (IMD) and the Programme Spend for Vision. RESULTS: There was high-level variation, almost 11-fold (coefficient of variation 38%) in standardised CVI blindness and sight impairment annual certification rates across PCTs. The mean rate was 43.7 and the SD 16.7. We found little evidence of an association between the rate of blindness and sight impairment with either the IMD or Programme Spend on Vision. CONCLUSIONS: The wide geographical variation we found raises questions about the quality of the data and whether there is genuine unmet need for prevention of sight loss. It is a concern for public health practitioners who will be interpreting these data locally and nationally as the CVI data will form the basis of the public health indicator 'preventable sight loss'. Poor-quality data and inadequate interpretation will only create confusion if not addressed adequately from the outset. There is an urgent need to address the shortcomings of the current data collection system and to educate all public health practitioners.

Knowledge-based commissioning.

People who pay for health care aim to maximize value in allocating resources between and within patient groups. With limited health care budgets, new high value innovations will replace, not supplement, lower value interventions. Every society and its health care system must consider the issue of value and be aware that the values of payer, provider, clinician, and patient will always be different. Knowledge, while necessary, is never sufficient when commissioning health care. At times, decision maker's subjective values may outweigh objective evidence.

The pipeline and future of drug development in schizophrenia.

While the current antipsychotic medications have profoundly impacted the treatment of schizophrenia over the past 50 years, the newer atypical antipsychotics have not fulfilled initial expectations, and enormous challenges remain in long-term treatment of this debilitating disease. In particular, improved treatment of the negative symptoms and cognitive dysfunction in schizophrenia which greatly impact overall morbidity is needed. In this review we will briefly discuss the current pipeline of drugs for schizophrenia, outlining many of the strategies and targets currently under investigation for the development of new schizophrenia drugs. Many of these compounds have great potential as augmenting agents in the treatment of negative symptoms and cognition. In addition, we will highlight the importance of developing new paradigms for drug discovery in schizophrenia and call for an increased role of academic scientists in discovering and validating novel drug targets. Indeed, recent breakthroughs in genetic studies of schizophrenia are allowing for the development of hypothesis-driven approaches for discovering possible disease-modifying drugs for schizophrenia. Thus, this is an exciting and pivotal time for the development of truly novel approaches to drug development and treatment of complex disorders like schizophrenia.

Better value healthcare--the 21st century agenda.

Health services are faced with increasing cost pressure, and cost-effectiveness is playing a growing role in decision-making in health care. The three elements of decision-making are the evidence available, the values of the population served, and the other needs of the population. There are different types of values: those of patients, clinicians, health service managers, payers of healthcare, and industry. The sharp distinction between traditional functions in healthcare, such as "allocative efficiency" and "technical efficiency", is increasingly being broken down. The effect of this new approach is the rise of programme budgeting, with healthcare resources being allocated to different programmes of care (for example, mental health programmes), making the consequences of moving resources much clearer. Best current evidence about effectiveness and cost-effectiveness is of vital importance in clarifying the opportunities that face people who pay for or manage healthcare.

Duplication 8q22.1-q24.1 associated with bipolar disorder and speech delay.

OBJECTIVE: To report a case of a child with bipolar disorder found to have an unbalanced translocation involving the long arm of chromosome 8, a region that has been previously implicated in genome-wide linkage scans. CASE REPORT: A 7-year-old boy with a complex psychiatric symptom presentation including attention deficits, distractibility, impulsivity, pressured speech, sleep disturbance, aggressive behavior, and hypersexuality diagnosed with bipolar disorder. He also showed evidence of borderline intellectual and adaptive functioning and had mild dysmorphic features with a duplication of distal 8q that arose as an unbalanced chromosomal translocation due to a maternal 15p;8q insertion. CONCLUSION: This finding of an unbalanced translocation provides further evidence to support previous linkage studies of a potential causative gene on 8q for bipolar disorder.

Personality factors correlate with regional cerebral perfusion.

There is an increasing body of evidence pointing to a neurobiological basis of personality. The purpose of this study was to investigate the biological bases of the major dimensions of Eysenck's and Cloninger's models of personality using a noninvasive magnetic resonance perfusion imaging technique in 30 young, healthy subjects. An unbiased voxel-based analysis was used to identify regions where the regional perfusion demonstrated significant correlation with any of the personality dimensions. Highly significant positive correlations emerged between extraversion and perfusion in the basal ganglia, thalamus, inferior frontal gyrus and cerebellum and between novelty seeking and perfusion in the cerebellum, cuneus and thalamus. Strong negative correlations emerged between psychoticism and perfusion in the basal ganglia and thalamus and between harm avoidance and perfusion in the cerebellar vermis, cuneus and inferior frontal gyrus. These observations suggest that personality traits are strongly associated with resting cerebral perfusion in a variety of cortical and subcortical regions and provide further evidence for the hypothesized neurobiological basis of personality. These results may also have important implications for functional neuroimaging studies, which typically rely on the modulation of cerebral hemodynamics for detection of task-induced activation since personality effects may influence the intersubject variability for both task-related activity and resting cerebral perfusion. This technique also offers a novel approach for the exploration of the neurobiological correlates of human personality.