Global Burden of Disease 2017 estimates for Major Depressive Disorder: a critical appraisal of the epidemiological evidence.

Objectives: To critically appraise the quality of the studies underpinning the Global Burden of Disease (GBD) 2017 estimates for Major Depressive Disorder (MDD) with respect to i) the GBD 2017 inclusion criteria and ii) population coverage. Design: Systematic critical appraisal. Setting: Not applicable. Participants: Not applicable. Main outcome measures: Each study was critically appraised with respect to the four GBD 2017 inclusion criteria: representativeness, study method and sample, diagnostic criteria and publication from 1980 onwards. Population coverage was calculated. Results: Less than half of studies (221/467, 47.3%) were nationally representative. Only 262/467 (56.1%) of studies reported specifically on MDD and more than a third did not use DSM or ICD diagnostic criteria: 94/467 (20.1%) did not specify any diagnostic criteria and 68/467 (14.6%) relied on self-reported depression for diagnosis. Only 62/467 (13.3%) of studies were conducted during the period 2011-2017. Only 107/195 (54.9%) of countries had one or more prevalence studies. Conclusions: GBD 2017 estimates for MDD are based on incomplete country and population coverage. The inclusion of studies with non-representative populations, that do not use diagnostic criteria and the lack of specific data on MDD reduces the reliability of estimates and limits their value for policy making.

Registration of essential medicines in Kenya, Tanzania and Uganda: a retrospective analysis.

OBJECTIVES: To audit national drug registers (NDRs) in Kenya, United Republic of Tanzania and Uganda with respect to national Essential Medicine Lists (EMLs) and to conduct an analysis of highly registered products including a sub-analysis of highly registered antimicrobial products. DESIGN: Retrospective analysis of registration of essential medicines and medicinal products on NDRs as of February 2018. SETTING: Not applicable. PARTICIPANTS: None. MAIN OUTCOME MEASURES: Registration status of essential medicines by country, essential medicine status of registered products by country and medicines with more than 50 registrations across all three countries. RESULTS: A high proportion of essential medicines are not registered: Kenya 28% (175/632), United Republic of Tanzania 50% (400/797) and Uganda 40% (266/663). Of registered products on the NDRs, more than half are not essential: Kenya 71% (4350/6151), United Republic of Tanzania 64% (2278/3590) and Uganda 58% (2268/3896). When the three NDRs were combined, there were 42 medicines with over 50 registered products, accounting for 30% (4153/13637) of products, many of which were non-essential. CONCLUSIONS: Non-registration of essential medicines is a barrier to availability. Over-registration of medicines, particularly non-essential medicines, diverts regulatory resources towards registering non-priority and, sometimes, clinically sub-optimal medicines. The East African Community Medicines Registration Harmonization Project has the potential to improve access to key medicines if registration of essential medicines is prioritised and registration of non-essential medicines is restricted.

Patient choice and private provision decreased public provision and increased inequalities in Scotland: a case study of elective hip arthroplasty.

Background: This is the first research to examine how the policy of patient choice and commercial contracting where NHS funds are given to private providers to tackle waiting times, impacted on direct NHS provision and treatment inequalities. Methods: An ecological study of NHS funded elective primary hip arthroplasties in Scotland using routinely collected inpatient data 1 April 1993-31 March 2013. Results: An increased use of private sector provision by NHS Boards was associated with a significant decrease in direct NHS provision in 2008/09 (P < 0.01) and with widening inequalities by age and socio-economic deprivation. National treatment rate fell from 143.8 (140.3, 147.3) per 100 000 in 2006/07 to 137.8 (134.4, 141.2) per 100 000 in 2007/08. By 2012/13, territorial NHS Boards had not recovered 2006/07 levels of provision; this was most marked for NHS Boards with the greatest use of private sector, namely Fife, Grampian and Lothian. Patients aged 85 years and over or living in the more deprived areas of Scotland appear to have been disadvantaged since the onset of patient choice in 2002. Conclusions: NHS funding of private sector provision for elective hip arthroplasty was associated with a decrease in public provision and may have contributed to an increase in age and socio-economic inequalities in treatment rates.

Do cervical cancer data justify HPV vaccination in India? Epidemiological data sources and comprehensiveness.

The Indian government suspended research in April 2010 on the feasibility and safety of human papillomavirus (HPV) vaccine in two Indian states (Andhra Pradesh and Gujarat) amid public concerns about its safety. This paper describes cervical cancer and cancer surveillance in India and reviews the epidemiological claims made by the Programme for Appropriate Technology in Health (PATH) in support of the vaccine in these two states. National cancer data published by the Indian National Cancer Registry Programme of state registry returns and the International Agency for Research on Cancer cover around seven percent of the population with underrepresentation of rural, northern, eastern and north-eastern areas. There is no cancer registry in the state of Andhra Pradesh and PATH does not cite data from the Gujarat cancer registries. Age-adjusted cervical cancer mortality and incidence rates vary widely across and within states. National trends in age standardized cervical cancer incidence fell from 42.3 to 22.3 per 100,000 between 1982/1983 and 2004/2005 respectively. Incidence studies report low incidence and mortality rates in Gujarat and Andhra Pradesh. Although HPV prevalence is higher in cancer patients (93.3%) than healthy patients (7.0%) and HPV types 16 and 18 are most prevalent in cancer patients, population prevelance data are poor and studies highly variable in their findings. Current data on HPV type and cervical cancer incidence do not support PATH's claim that India has a large burden of cervical cancer or its decision to roll out the vaccine programme. In the absence of comprehensive cancer surveillance, World Health Organization criteria with respect to monitoring effectiveness of the vaccine and knowledge of disease trends cannot be fulfilled.

Waiting list and waiting time statistics in Britain: a critical review.

OBJECTIVES: The measurement of access to health care in the National Health Service is dominated by waiting list and waiting time targets which depend on the collection and publication of a range of government statistics. The aim of this study was to describe the purposes for which waiting statistics are collected, and the different methods of data collection in the countries of Britain, in order to assess the extent to which published data meet their objectives. STUDY DESIGN: Systematic review. METHODS: A systematic evaluation of waiting statistics in England, Scotland and Wales based on official published data collections in each country, plus a review of the relevant literature. RESULTS: Waiting statistics are collected for a number of purposes, but are primarily for performance monitoring against waiting time targets and for local planning. One method of data collection may not best serve all objectives, and there are differences in the practices of the countries of Britain. An important purpose should be to measure access to health care according to individual patient need, and limitations in the statistics were identified in this respect due to methodological issues, omissions and exclusions, hidden waits, the emphasis on achieving targets, and interpretation. CONCLUSIONS: Although there are merits in maintaining the existing series, the use of waiting statistics as the primary method of measuring and monitoring access to services has limitations, not least because statistics do not contain the information required to assess whether time waited is appropriate to need.

An unusual midline swelling--case report of a cutaneous bronchogenic cyst.

Cutaneous bronchogenic cyst remains a very rare cause of a midline swelling in children. The authors report a case of a 14-month-old boy who presented with a sternal sinus and consequent abscess. Histopathological analysis revealed this to be a cutaneous bronchogenic cyst. This is a very rare lesion with only 65 cases reported in the literature. It is caused by an abnormal development in the distal tracheobronchial tree, and diagnosis is confirmed by ciliated and mucin-producing pseudostratified columnar epithelium of respiratory type on histopathological analysis. It is managed by resection of the cyst, as these cysts are often foci for subsequent infections and malignant potential has been reported.

Carrot and sticks? The Community Care Act (2003) and the effect of financial incentives on delays in discharge from hospitals in England.

BACKGROUND: The belief that many delays in discharge from hospital were caused by social service departments (SSDs) led to the Community Care Act 2003 giving NHS hospitals in England the power to charge SSDs. METHODS: We surveyed 150 SSDs in England about the implementation of the Act and used routine data to analyse trends in the number of delayed discharge patients; the number and cause of delayed discharge bed days by sector; and the proportion of inpatient bed days that consisted of delayed discharges. FINDINGS: Most hospitals opted not to charge SSDs for delays. Almost two thirds of SSDs (62%) made no payment of any kind to an acute hospital in 2004/05 and 2005/06, preferring to work collaboratively. The fall in number of 'delayed discharge patients' is a long term trend which precedes the implementation of the 2003 Act. Delayed discharge bed days accounted for 1.58% of all inpatient bed days in 2004/05. Contrary to popular opinion, the NHS accounted for two thirds (67%) of bed day delays, lack of suitable alternative NHS provision and services is a key factor. Patients are being discharged in greater numbers and earlier in their post-acute recovery phase. There are however questions about the quality and safety of early discharge. For example, emergency hospital readmissions rates have risen from 5.4% in 2002/03 to 6.7% in 2005/06, and patient dissatisfaction is significant. CONCLUSION: Although delays in discharge from acute hospital beds have fallen, the quality of discharge and the capacity of Primary Care Trusts (PCTs) and SSDs to ensure appropriate and adequate post-discharge care is not as it should be. Contrary to popular perception, social services delays are of less significance than delays attributable to the NHS. There is no evidence to support government policy of charging SSDs for delay. Other factors, including NHS provision, are important, and a comprehensive overview of health and social care is vital.

The reform of UK research ethics committees: throwing the baby out with the bath water?

On 1 May 2004 research ethics committees became legally accountable to a new government body, the United Kingdom Ethics Committee Authority. This marks the end of the self regulation of research ethics. This paper describes how this change in research ethics committee status has come about and explores the implications for research subjects, researchers, institutions, and for regulation of research.

Urachal adenocarcinoma in situ with pseudomyxoma peritonei: a case report.

A 54 year old man presented with a six month history of abdominal pain. A computerised tomography scan showed a well defined intra-abdominal unilocular mass with a calcified wall just superior to the bladder. At laparotomy, pseudomyxoma peritonei was discovered, together with a midline abdominal mass adherent to the anterior abdominal wall originating from the fundus of the bladder. The specimen consisted of a cystic mass measuring 14 x 9.5 x 7 cm overall, which contained mucoid material. Histological examination revealed that the cyst was lined by mucinous epithelium, which in areas varied from having bland morphology to showing pronounced nuclear and architectural atypia. There was abundant extracellular mucin. The specimen was extensively sampled but there was no evidence of invasion. This tumour has many unusual features, namely: the absence of destructive invasion, association with pseudomyxoma peritonei, areas of dysplasia and cystadenoma, and stromal osseous metaplasia within the wall.

Cytokeratin 7: a useful adjunct in the diagnosis of chromophobe renal cell carcinoma.

AIMS: The histopathological diagnosis of chromophobe renal cell carcinoma can present a diagnostic challenge, as these tumours can resemble either conventional renal cell carcinoma or oncocytoma. The aim of this study was to determine whether cytokeratin 7 expression is of practical use in the distinction of these three entities. METHODS AND RESULTS: A total of 40 cases previously diagnosed as either chromophobe renal cell carcinoma, conventional renal cell carcinoma or oncocytoma were identified. A representative section of each was stained with H&E and cytokeratin 7. Following independent review of the cases by three pathologists, a consensus diagnosis for each case was reached and the pattern of cytokeratin 7 staining was assessed. There were 12 cases of chromophobe renal cell carcinoma in the study, all of which showed a characteristic peripheral membrane pattern of staining for cytokeratin 7. Seventeen of the 18 cases of conventional renal cell carcinoma studied were negative for cytokeratin 7, while one case showed weak focal staining of <5% of the cells. The 10 cases of oncocytoma showed patchy weak to moderate cytoplasmic expression of cytokeratin 7, without the characteristic peripheral membrane accentuation seen in the chromophobe carcinomas. CONCLUSIONS: Immunohistochemical staining for cytokeratin 7 appears to be a useful adjunct in the diagnosis of chromophobe renal cell carcinoma, and in distinguishing this tumour from both oncocytoma and conventional renal cell carcinoma.

The British Labour government's reform of the National Health Service.

The recent general election in Britain saw healthcare as the dominant issue amongst voters. The victorious Labour Party responded to this concern with a set of reforms designed to introduce greater private-sector involvement in the delivery of healthcare. These reforms are ill-thought-out. The standard of care in British private hospitals is below that found in public hospitals, whilst new contracting arrangements are likely to increase the administration costs within the system. Faith in private-sector management techniques is misplaced at a time when the real problem facing the NHS is that of capacity. The Labour Party is also committed to redefining some aspects of healthcare as a personal responsibility and not a right, moving Britain towards a more market-based healthcare system.

The use of acute hospital services by elderly residents of nursing and residential care homes.

The objective of this study was to compare hospitalisation rates by cause of admission, hospital death rates and length of stay for residents from nursing and residential care homes with those in the community. This is a retrospective study of acute hospital emergency admissions in one health district, Merton, Sutton and Wandsworth between April 1996 and March 1997. Data linkage and manual look up were used to derive emergency hospital admissions for residents of care homes aged 65 and over. Admission rates were calculated for cause, length of stay and hospital death for residents of care homes and in the community with relative risks. The relative risk of emergency admission from a care home compared with the community was 1.39 for all diagnoses, 2.68 for all injuries, and 3.96 for fracture of neck of femur. The relative risk of dying in hospital for care home residents was 2.58 overall, and 3.64 in the first 48 hours of a hospital stay (all P-values <0.0001). Admission rates were higher from residential than from nursing homes. There was some increase in admissions from homes during holiday periods and over Christmas. In conclusion, there are major difficulties in monitoring admissions from nursing and residential care homes due to poor quality recording and inaccuracies in NHS coding. This was compounded by an absence of data on the age and sex profile and healthcare needs of the resident population in care homes. Prospective studies are required to ascertain when admission is avoidable and when it is appropriate. The information strategy needs to ensure that routine data sources are capable of monitoring the use of hospital services by residents of care homes.

Absent voices compromise the effectiveness of nursing home regulation: a critique of regulatory reform in the UK nursing home industry.

Over the last decade there has been consistent pressure for the healthcare services in the UK to become more accountable to users. Now over half the healthcare beds in England are in the privatised nursing home sector, and regulation of the sector is under reform. Yet requirements for user accountability have not been reflected in these reforms. In other sectors, consumer involvement in regulatory agencies and processes is seen as important to the success of the regulatory enterprise. But in the care sector neither users nor their representatives have been given legal rights of involvement in the National Care Standards Commission or in regulatory processes. This paper argues that failure to involve users not only places the regulation enterprise at risk of capture by the industry, but will also weaken the legitimacy of the new Commission.

Rewriting the regulations: how the World Trade Organisation could accelerate privatisation in health-care systems.

The World Trade Organisation (WTO) is drawing up regulatory proposals which could force governments to open up their public services to foreign Investors and markets. As part of the General Agreement on Trade in Services (GATS) negotiations, the WTO working party on reform of domestic regulation is developing a regulatory reform agenda which could mark a new era of compulsion in international trade law. Article VI.4 of the GATS is being strengthened with the aim of requiring member states to show that they are employing least trade-restrictive policies. The legal tests under consideration would outlaw the use of non-market mechanisms such as cross-subsidisation, universal risk pooling, solidarity, and public accountability in the design, funding, and delivery of public services as being anti-competitive and restrictive to trade. The domestic policies of national governments will be subject to WTO rules, and if declared illegal, could lead to trade sanctions under the WTO disputes panel process. The USA and European Union, with the backing of their own multinational corporations, believe that these new powers will advantage their own economies. Health-care professionals and public-health activists must ensure that this secretive regulatory reform process is opened up for public debate.