VAT: a precise mechanism to identify drug-food companies.

The impact of drug-foods (tobacco and cane sugar, cocoa and caffeine) and the consequences of their production on the health of both public and planet are wide ranging and increasing from obesity to pressure on water supply. The world's food system is dominated by a small number of global corporations making and promoting drug-foods in myriad forms. The use of sugar-substitute non-sugar sweeteners, and their design of products, are specifically formulated to be 'moreish', to stimulate pleasure responses above and beyond the natural pleasure of eating. In the UK we can identify these foods, and the corporations that make them, since Value Added Tax (VAT) is applied. We suggest that, for food and drink upon which UK VAT is levied, advertising and product placement should be prohibited and controls put on branding and packaging. We further suggest action is taken to: (i) restrain the activities of the companies making these products, (ii) prohibit their sponsorship and/or partnership with government bodies such as schools and NHS, (iii) ensure these corporations pay the full fiscal and environmental costs of drug-foods. Our urgent challenge is to act against the sociopathic power of such corporations, for the public health and that of the planet.

Subclinical thyroid dysfunction symptoms in older adults: cross-sectional study in UK primary care.

BACKGROUND: Subclinical thyroid dysfunction - abnormal serum thyrotrophin (thyroid-stimulating hormone; TSH) concentrations with normal free thyroxine (FT4) is common in older people. It remains unclear whether individuals with subclinical serum status experience an increased symptom profile. AIM: To compare the prevalence of those symptoms typically associated with overt thyroid dysfunction in older individuals with a subclinical and euthyroid serum profile. DESIGN AND SETTING: Cross-sectional study, nested within the Birmingham Elderly Thyroid Study (BETS); from 19 UK general practices. METHOD: Adults living in a community setting (aged ≥65 years), without overt thyroid dysfunction or associated treatment, self-reported the presence or absence of 18 symptoms (while serum result naïve). Serum concentrations of TSH and FT4 were measured to establish thyroid status. RESULTS: A total of 2870 individuals were screened: 2703 (94%) were categorised as euthyroid (normal), 29 (1%) subclinically hyperthyroid, and 138 (5%) subclinically hypothyroid. Symptoms were common in all groups. No significant differences in the prevalence of individual symptoms were observed between the euthyroid and subclinically hypothyroid groups nor in comparison with the subclinically hyperthyroid group. Multivariate logistic regression analysis failed to reveal an association between individual or multiple symptoms and subclinical status. CONCLUSION: Findings suggest that subclinical thyroid dysfunction does not confer a symptom burden in older individuals and support adherence to guidelines in the non-treatment of subclinical thyroid dysfunction. GPs may use the findings to reassure older people presenting with symptoms that subclinical thyroid dysfunction is an unlikely explanation. The presence of persistently abnormal TSH concentrations may be linked to long-term risks of cardiovascular disease, especially atrial fibrillation, but whether this should prompt treatment and whether such treatment alters vascular outcomes is unknown.

What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study.

OBJECTIVES: To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients' experience and outcomes and the organisation of services. DESIGN: Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis. SETTING: Six acute care hospitals in three regions of England in 2016-2017. PARTICIPANTS: 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives. RESULTS: A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams' workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors. CONCLUSIONS: This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.

Stability of thyroid function in older adults: the Birmingham Elderly Thyroid Study.

BACKGROUND: Thyroid function tests (TFTs) are among the most requested tests internationally. However, testing practice is inconsistent, and potentially suboptimal and overly costly. The natural history of thyroid function remains poorly understood. AIM: To establish the stability of thyroid function over time, and identify predictors of development of overt thyroid dysfunction. DESIGN AND SETTING: Longitudinal follow-up in 19 general practices in the UK. METHOD: A total of 2936 participants from the Birmingham Elderly Thyroid Study (BETS 1) with a baseline TFT result indicating euthyroid or subclinical state were re-tested after approximately 5 years. Change in thyroid-stimulating hormone (TSH), free thyroxine (FT4), and thyroid status between baseline and follow-up was determined. Predictors of progression to overt dysfunction were modelled. RESULTS: Participants contributed 12 919 person-years; 17 cases of overt thyroid dysfunction were identified, 13 having been classified at baseline as euthyroid and four as having subclinical thyroid dysfunction. Individuals with subclinical results at baseline were 10- and 16-fold more likely to develop overt hypothyroidism and hyperthyroidism, respectively, compared with euthyroid individuals. TSH and FT4 demonstrated significant stability over time, with 61% of participants having a repeat TSH concentration within 0.5 mIU/L of their original result. Predictors of overt hypothyroidism included new treatment with amiodarone (odds ratio [OR] 92.1), a new diagnosis of atrial fibrillation (OR 7.4), or renal disease (OR 4.8). CONCLUSION: High stability of thyroid function demonstrated over the 5-year interval period should discourage repeat testing, especially when a euthyroid result is in the recent clinical record. Reduced repeat TFTs in older individuals is possible without conferring risk, and could result in significant cost savings.

Clinical teaching associates in medical education: the benefits of certification.

BACKGROUND: Clinical teaching associates (CTAs) are human simulators who use themselves (i.e. their bodies and psyches) as an integral part of the teaching and assessing process. Increasingly, various CTAs are used in clinical education, for instance as stand-ins for clinical tutors or for high-stakes assessments. CONTEXT: Four groups of people have a stake in the competence of CTAs: patients (as they are at risk, both currently, in the clinical situation, and in the future if learners develop inappropriate behaviours that they later exhibit in their clinical work); learners (as their interaction with CTAs may be in a high-stakes assessment); CTAs themselves (as they may wish to evidence their professional competence to new employers); and the organisations using them (as the reputation of the organisation depends on the competence of its faculty staff and graduates). INNOVATION: We argue that the professionalisation and certification of CTAs becomes more important as the total risk rises, using a three-dimensional matrix of risk (for patients), stakes (for learners) and responsibility (for CTAs). IMPLICATIONS: We suggest that the time is right for a colloquium to endeavour to agree standards for the certification of CTAs. This would be to the advantage of all stakeholders and would facilitate the use of CTAs in high-risk, high-stakes learning and assessment.

Is subclinical thyroid dysfunction in the elderly associated with depression or cognitive dysfunction?

BACKGROUND: Widespread use of automated sensitive assays for thyroid hormones and thyroid-stimulating hormone (TSH) has increased identification of mild thyroid dysfunction, especially in elderly patients. The clinical significance of this dysfunction, however, remains uncertain, and associations with cognitive impairment, depression, and anxiety are unconfirmed. OBJECTIVE: To determine the association between mild thyroid dysfunction and cognition, depression, and anxiety in elderly persons. DESIGN: Cross-sectional study. Associations were explored through mixed-model analyses. SETTING: Primary care practices in central England. PATIENTS: 5865 patients 65 years of age or older with no known thyroid disease who were recruited from primary care registers. MEASUREMENTS: Serum TSH and free thyroxine (T4) were measured. Depression and anxiety were assessed by using the Hospital Anxiety and Depression Scale (HADS), and cognitive functioning was established by using the Middlesex Elderly Assessment of Mental State and the Folstein Mini-Mental State Examination. Comorbid conditions, medication use, and sociodemographic profiles were recorded. RESULTS: 295 patients met the criteria for subclinical thyroid dysfunction (127 were hyperthyroid, and 168 were hypothyroid). After confounding variables were controlled for, statistically significant associations were seen between anxiety (HADS score) and TSH level (P = 0.013) and between cognition and both TSH and free T4 levels. The magnitude of these associations lacked clinical relevance: A 50-mIU/L increase in the TSH level was associated with a 1-point reduction in the HADS anxiety score, and a 1-point increase in the Mini-Mental State Examination score was associated with an increase of 50 mIU/L in the TSH level or 25 pmol/L in the free T4 level. LIMITATIONS: Because of the low participation rate, low prevalence of subclinical thyroid dysfunction, and other unidentified recruitment biases, participants may not be representative of the elderly population. CONCLUSIONS: After the confounding effects of comorbid conditions and use of medication were controlled for, subclinical thyroid dysfunction was not associated with depression, anxiety, or cognition.

Prevalence of subclinical thyroid dysfunction and its relation to socioeconomic deprivation in the elderly: a community-based cross-sectional survey.

CONTEXT: Population-based screening has been advocated for subclinical thyroid dysfunction in the elderly because the disorder is perceived to be common, and health benefits may be accrued by detection and treatment. OBJECTIVE: The objective of the study was to determine the prevalence of subclinical thyroid dysfunction and unidentified overt thyroid dysfunction in an elderly population. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional survey of a community sample of participants aged 65 yr and older registered with 20 family practices in the United Kingdom. EXCLUSIONS: Exclusions included current therapy for thyroid disease, thyroid surgery, or treatment within 12 months. OUTCOME MEASURE: Tests of thyroid function (TSH concentration and free T4 concentration in all, with measurement of free T3 in those with low TSH) were conducted. EXPLANATORY VARIABLES: These included all current medical diagnoses and drug therapies, age, gender, and socioeconomic deprivation (Index of Multiple Deprivation, 2004). ANALYSIS: Standardized prevalence rates were analyzed. Logistic regression modeling was used to determine factors associated with the presence of subclinical thyroid dysfunction. RESULTS: A total of 5960 attended for screening. Using biochemical definitions, 94.2% [95% confidence interval (CI) 93.8-94.6%] were euthyroid. Unidentified overt hyper- and hypothyroidism were uncommon (0.3, 0.4%, respectively). Subclinical hyperthyroidism and hypothyroidism were identified with similar frequency (2.1%, 95% CI 1.8-2.3%; 2.9%, 95% CI 2.6-3.1%, respectively). Subclinical thyroid dysfunction was more common in females (P < 0.001) and with increasing age (P < 0.001). After allowing for comorbidities, concurrent drug therapies, age, and gender, an association between subclinical hyperthyroidism and a composite measure of socioeconomic deprivation remained. CONCLUSIONS: Undiagnosed overt thyroid dysfunction is uncommon. The prevalence of subclinical thyroid dysfunction is 5%. We have, for the first time, identified an independent association between the prevalence of subclinical thyroid dysfunction and deprivation that cannot be explained solely by the greater burden of chronic disease and/or consequent drug therapies in the deprived population.

Perceptions of the learning environment in higher specialist training of doctors: implications for recruitment and retention.

INTRODUCTION: Career choice, sense of professional identity and career behaviour are influenced, subject to change and capable of development through interaction with the learning environment. In this paper workplace learning discourses are used to frame ongoing concerns associated with higher specialist training. Data from the first stage of a multimethods investigation into recruitment into and retention in specialties in the West Midlands is used to consider some possible effects of the specialist learning environment on recruitment and retention. METHODS: The aim of the study was to identify issues, through interviews with 6 consultants and questionnaires completed by specialist registrars from specialties representing a range of recruitment levels. These would inform subsequent study of attributes and dispositions relevant to specialist practice and recruitment. The data were analysed using NVivo software for qualitative data management. RESULTS: Participants' perceptions are presented as bipolar dimensions, associated with: curriculum structure, learning relationships, assessment of learning, and learning climate. They demonstrate ongoing struggle between different models of workplace learning. CONCLUSION: Changes in the postgraduate education of doctors seem set to continue well into the future. How these are reflected in the balance between workplace learning models, and how they influence doctors' sense of identity as specialists suggests a useful basis for examination of career satisfaction and recruitment to specialties.