To survive, all forms of government require popular support, whether voluntary or involuntary. Following the collapse of the Soviet system, Russia's rulers took steps toward democracy, yet under ...Vladimir Putin Russia has become increasingly undemocratic. This book uses a unique source of evidence, eighteen surveys of Russian public opinion from the first month of the new regime in 1992 up to 2009, to track the changing views of Russians. Clearly presented and sophisticated figures and tables show how political support has increased because of a sense of resignation that is even stronger than the unstable benefits of exporting oil and gas. Whilst comparative analyses of surveys on other continents show that Russia's elite is not alone in being able to mobilize popular support for an undemocratic regime, Russia provides an outstanding caution that popular support can grow when governors reject democracy and create an undemocratic regime.
Sleep sex may be a defense for alleged sexual assault. The International Classification of Sleep Disorders (ICSD3) states: “Disorders of arousal should not be diagnosed in the presence of alcohol ...intoxication… The former alcohol blackouts are exponentially more prevalent.” A panel member of ICSD3, quoting ICSD3 asserts: “alcohol intoxication should rule out a sleep‐walking defense”. This implies extremely strong support for a prosecution hypothesis (Hp) over a defense hypothesis (Hd). I use Bayesian methodology to evaluate the evidential probity of alcohol intoxication. The likelihood ratio, LR, measures the amplification of prior odds of guilt,
LR=Posterioroddsofguiltafterconsideringalcoholintoxication/Prioroddsofguiltbeforeconsideringalcoholintoxication
. By Bayes' theorem,
LR=p(alcoholintoxication,givenHp)/p(alcoholintoxication,givenHd)
. I use data from cross‐sectional studies of sexual assault and prevalence of alcohol use, in college students, with data from longitudinal studies, and data from the epidemiology of parasomnias to evaluate LR (alcohol). LR ~1.5 or 5, depending whether alcohol does, or does not, increase the risk of parasomnias. The proposition of extremely strong support for Hp implies a LR ~1,000,000, so the proposition in ICSD3 is not supported by formal analysis. The statistical reasoning in ICSD3 is unclear. There appears to be inversion of the Bayesian conditional (confusing intoxication given assault, and assault given intoxication) and failure to evaluate alcohol intoxication in Hd. Similar statistical errors in R. v Sally Clark are discussed. The American Academy of Sleep Medicine should review the statistical methodology in ICSD3.
Limited medication adherence and persistence with treatment are barriers to successful management of type 2 diabetes (T2D). We searched MEDLINE, EMBASE, the Cochrane Library, the Register of ...Controlled Trials, PsychINFO and CINAHL for observational and interventional studies that compared the adherence or persistence associated with 2 or more glucose‐lowering medications in people with T2D. Where 5 or more studies provided the same comparison, a random‐effects meta‐analysis was performed, reporting mean difference (MD) or odds ratio (OR) for adherence or persistence, depending on the pooled study outcomes. We included a total of 48 studies. Compared with metformin, adherence (%) was better for sulphonylureas (5 studies; MD 10.6%, 95% confidence interval CI 6.5‐14.7) and thiazolidinediones (TZDs; 6 studies; MD 11.3%, 95% CI 2.7%‐20.0%). Adherence to TZDs was marginally better than adherence to sulphonylureas (5 studies; MD 1.5%, 95% CI 0.1‐2.9). Dipeptidyl peptidase‐4 inhibitors had better adherence than sulphonylureas and TZDs. Glucagon‐like peptide‐1 receptor agonists had higher rates of discontinuation than long‐acting analogue insulins (6 studies; OR 1.95; 95% CI 1.17‐3.27). Long‐acting insulin analogues had better persistence than human insulins (5 studies; MD 43.1 days; 95% CI 22.0‐64.2). The methods used to define adherence and persistence were highly variable.
This study was conducted to describe the incidence of diabetes following pancreatic disease, assess how these patients are classified by clinicians, and compare clinical characteristics with type 1 ...and type 2 diabetes.
Primary care records in England (
= 2,360,631) were searched for incident cases of adult-onset diabetes between 1 January 2005 and 31 March 2016. We examined demographics, diabetes classification, glycemic control, and insulin use in those with and without pancreatic disease (subcategorized into acute pancreatitis or chronic pancreatic disease) before diabetes diagnosis. Regression analysis was used to control for baseline potential risk factors for poor glycemic control (HbA
≥7% 53 mmol/mol) and insulin requirement.
We identified 31,789 new diagnoses of adult-onset diabetes. Diabetes following pancreatic disease (2.59 95% CI 2.38-2.81 per 100,000 person-years) was more common than type 1 diabetes (1.64 1.47-1.82;
< 0.001). The 559 cases of diabetes following pancreatic disease were mostly classified by clinicians as type 2 diabetes (87.8%) and uncommonly as diabetes of the exocrine pancreas (2.7%). Diabetes following pancreatic disease was diagnosed at a median age of 59 years and BMI of 29.2 kg/m
. Diabetes following pancreatic disease was associated with poor glycemic control (adjusted odds ratio, 1.7 1.3-2.2;
< 0.001) compared with type 2 diabetes. Insulin use within 5 years was 4.1% (3.8-4.4) with type 2 diabetes, 20.9% (14.6-28.9) with diabetes following acute pancreatitis, and 45.8% (34.2-57.9) with diabetes following chronic pancreatic disease.
Diabetes of the exocrine pancreas is frequently labeled type 2 diabetes but has worse glycemic control and a markedly greater requirement for insulin.
Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this ...imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D.
A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate eGFR), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population (n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m2. The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio OR 0.86, 95% CI 0.79-0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58-0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31-0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39-0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35-0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79-0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70-0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01-1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00-1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79-0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80-0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation.
Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.
New forms of evidence are needed to complement evidence generated from randomised controlled trials (RCTs). Real-World Evidence (RWE) is a potential new form of evidence, but remains undefined. This ...paper sets to fill that gap by defining RWE as the output from a rigorous research process which: (1) includes a clear a priori statement of a hypothesis to be tested or research question to be answered; (2) defines the data sources that will be used and critically appraises their strengths and weaknesses; and (3) applies appropriate methods, including advanced analytics. These elements should be set out in advance of the study commencing, ideally in a published protocol.The strengths of RWE studies are that they are more inclusive than RCTs and can enable an evidence base to be developed around real-world effectiveness and to start to address the complications of managing other real-world problems such as multimorbidity. Computerised medical record systems and big data provide a rich source of data for RWE studies. However, guidance is needed to help assess the rigour of RWE studies so that the strength of recommendations based on their output can be determined. Additionally, RWE advanced analytics methods need better categorisation and validation.We predict that the core role of RCTs will shift towards assessing safety and achieving regulatory compliance. RWE studies, notwithstanding their limitations, may become established as the best vehicle to assess efficacy.
Russia Transformed Rose, Richard; Mishler, William; Munro, Neil
11/2006
eBook
Since the fall of communism Russia has undergone a treble transformation of its political, social and economic system. The government is an autocracy in which the Kremlin manages elections and ...administers the law to suit its own ends. It does not provide the democracy that most citizens desire. Given a contradiction between what Russians want and what they get, do they support their government and, if so, why? Using the New Russia Barometer - a unique set of public opinion surveys from 1992 to 2005 - this book shows that it is the passage of time that has been most important in developing support for the new regime. Although there remains great dissatisfaction with the regime's corruption, it has become accepted as a lesser evil to alternatives. The government appears stable today, but will be challenged by constitutional term limits forcing President Putin to leave office in 2008.
Even in countries with sophisticated primary care systems where generalists and specialists have similar earnings, only about a quarter of recent graduates profess an initial interest in general ...practice. 2 The failure to fully recruit to UK general practice training this year after an unprecedented third round of selection suggests serious problems with the career itself. 3 In countries like the US, where more than three quarters of doctors specialise, efforts have been targeted at selecting school leavers intent on a career in general practice.
Sodium-glucose co-transporter-2 inhibitors (SGLT-2is) are licenced for initiation for glucose lowering in people with type 2 diabetes (T2DM) with an estimated glomerular filtration rate (eGFR) ≥ ...60 mL/min/1.73m
). However, recent trial data have shown that these medications have renal and cardio-protective effects, even for impaired kidney function. The extent to which trial evidence and updated guidelines have influenced real-world prescribing of SGLT-2is is not known, particularly with co-administration of diuretics.
We performed a cross-sectional analysis of people with T2DM registered with practices in the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) database on the 31st July 2019. We calculated the percentage of people prescribed SGLT-2is according to eGFR categories (< 45, 45-59, and ≥ 60 mL/min/1.73m
), with a heart failure diagnosis and stratified by body mass index categories (underweight, normal weight, overweight, obese), and with concomitant prescription of a diuretic. Multilevel logistic regression analysis was performed to determine whether heart failure diagnosis and renal function were associated with SGLT-2i prescribing.
From a population of 242,624 people with T2DM across 419 practices, 11.0% (n = 26,700) had been prescribed SGLT-2is. The majority of people initiated SGLT-2is had an eGFR ≥ 60 mL/min/1.73m
(93.2%), and 4.3% had a heart failure diagnosis. 9,226 (3.8%) people were prescribed SGLT-2is as an add-on to their diuretic prescription. People in the highest eGFR category (≥ 60 mL/min/1.73m
) were more likely to be prescribed SGLT-2is than those in eGFR lower categories. Overweight (OR 2.05, 95% CI 1.841-2.274) and obese people (OR 3.84, 95% CI 3.472-4.250) were also more likely to be prescribed these medications, whilst use of diuretics (OR 0.74, 95% CI 0.682-0.804) and heart failure (OR 0.81, 95% CI 0.653-0.998) were associated with lower odds of being prescribed SGLT-2is.
Prescribing patterns of SGLT-2is for glucose lowering in T2DM in primary care generally concur with licenced indications according to recommended renal thresholds. A small percentage of people with heart failure were prescribed SGLT-2is for T2DM. An updated analysis is merited should UK National Institute for Health Care and Excellence prescribing guidelines for T2DM be revised to incorporate new data on the benefits for those with reduced renal function or with heart failure.
As quantitative or spatially distributed studies of environmental change over truly long-term periods of more than 100 years are extremely rare, we re-photographed 361 landscapes that appear on ...historical photographs (1868-1994) within a 40,000 km(2) study area in northern Ethiopia. Visible evidence of environmental changes apparent from the paired photographs was analyzed using an expert rating system. The conditions of the woody vegetation, soil and water conservation structures and land management were worse in the earlier periods compared to their present conditions. The cover by indigenous trees is a notable exception: it peaked in the 1930s, declined afterwards and then achieved a second peak in the early 21st century. Particularly in areas with greater population densities, there has been a significant increase in woody vegetation and soil and water conservation structures over the course of the study period. We conclude that except for an apparent upward movement of the upper tree limit, the direct human impacts on the environment are overriding the effects of climate change in the north Ethiopian highlands and that the northern Ethiopian highlands are currently greener than at any other time in the last 145 years.
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