Promoting healthy growth: what are the priorities for research and action?

Healthy growth from conception through the first 2 y of life is the foundation for adequate organ formation and function, a strong immune system, physical health, and neurological and cognitive development. Recent studies identified several low-cost interventions to address undernutrition during this age period and noted the lower returns on investment of intervening after this critical period. Although these interventions should be implemented widely, it is recognized that existing nutrition solutions, even if universally applied, would only avert a minority fraction of the estimated death and disability due to undernutrition. This paper reviews some of the knowledge and learning needed to close this "impact gap." Five areas are prioritized for future research: 1) study healthy growth from a lifecycle perspective, because maternal, fetal, and newborn outcomes are connected; 2) understand why growth faltering begins so early in breast-fed infants in the developing world; 3) apply new tools and technologies to study long-recognized problems such as the interaction between nutrition and infection; 4) explore new hypotheses for understanding nutrient assimilation and use to discover and develop intervention leads; and 5) understand the role of the environment in healthy growth and the potential synergistic benefits of multi-sectoral interventions. Policymakers are urged to invest in nutrition-specific and -sensitive interventions to promote healthy growth from conception through the first 2 y of life because of their immediate and long-term health and development benefits.     

NHS values. What are we here for?

Following more than a decade of change, the NHS is keen to explore the values driving its daily life. Consistency between values and behaviour are an important part of building an organisation's identity and confidence. It is likely that pluralistic values inform the NHS more now than was the case in the early years of the welfare state.     

What is the potential for the use of clinical outcome measures to be computerised? Findings from a qualitative research study

Clinical outcome measures are used in clinical audit to monitor the quality of care provided to patients. As information technology (IT) is increasingly being integrated into the delivery of health care, computerising the use of clinical outcome measures has been proposed. However, little is known about the attitudes of health professionals towards this. Aims to understand professionals' views on adapting one clinical outcome measure--the palliative care outcome scale (POS)--for use on hand-held computers. Concludes that these results reinforce existing research on clinical outcome measures and IT in health care; identify special palliative care issues when considering the use of computerised clinical outcome measures with patients; and highlight the need for further research.     

Leveling the playing field? Exploring the merits of the ethics-as-process approach for judging qualitative research proposals

There has been a recent growth in claims that qualitative research proposals are not treated equitably by ethics committees. In response, recent arguments centered on establishing the ethics of qualitative research, in the eyes of ethics committees, have indicated the need for an "ethics-as-process" approach. Accordingly, in this article, the authors illustrate the merits of this approach and provide three examples from the field: the outcomes of participating in qualitative interviews, sensitive handling of ending in qualitative research relationships, and the ongoing establishment of informed consent. The authors hope to increase awareness of the potential benefits of this approach and contribute to the ensuing debate.     

Are potential sources for human exposure to bisphenol-A overlooked?

This review summarizes the numerous applications of bisphenol-A (BPA) and the potential sources for human exposure. The exposure to humans is believed to occur mainly through food contamination from polycarbonate bottles, as well as through food and beverage cans coated with epoxy resins. However, there seems to be a discrepancy between exposure assessments based on biomonitoring data and those based on food/drink concentrations. Several recent studies indicated also the importance of non-food sources. Although the main use of BPA is polymerization to polycarbonate and epoxy resins, it can also be used as an additive, from which it may be easily released. Several studies have already provided scientific evidence for the contribution of sources for dermal BPA absorption, such as thermal paper where BPA is used as an additive. Polymeric applications of BPA require further investigation regarding the amounts of BPA present, as well as the factors affecting its release and potential dermal or non-dermal exposure from these sources. It is clear that not all sources of BPA have been identified. This overview emphasizes the necessity to study also the exposure to these unexpected sources of BPA.     

What makes for successful TQM in the NHS?

A three-year evaluation of total quality management (TQM) at NHS demonstration sites shows there are clear factors which predict successful implementation of TQM. The intention is to raise awareness at both TQM and non-TQM sites of the need to have a structured, pre-planned approach to TQM, based on a thorough understanding of alternative approaches.     

What are the limits of adjuvanticity?

Vaccines developed traditionally following empirical approaches have often limited problems of immunogenicity, probably due to the low level of purity of the active component(s) they contain. The application of new technologies to vaccine development is leading to the production of purer (e.g. recombinant) antigens which, however, tend to have a poorer immunogenicity as compared to vaccines of the previous generation. The search for new vaccine adjuvants involves issues related to their potential limits. Since the introduction of aluminium salts as vaccine adjuvants more than 70 years ago, only one adjuvant has been licensed for human use. The development of some of these new vaccine adjuvants has been hampered by their inacceptable reactogenicity. In addition, some adjuvants work strongly with some antigens but not with others, thus, limiting their potentially widespread use. The need to deliver vaccines via alternative routes of administration (e.g. the mucosal routes) in order to enhance their efficacy and compliance has set new requirements in basic and applied research to evaluate their efficacy and safety. Cholera toxin (CT) and labile enterotoxin (LT) mutants given along with intranasal or oral vaccines are strong candidates as mucosal adjuvants. Their potential reactogenicity is still matter of discussions, although available data support the notion that the effects due to their binding to the cells and those due to the enzymatic activity can be kept separated. Finally, adjuvanticity is more often evaluated in terms of antigen-specific antibody titers induced after parenteral immunization. It is known that, in many instances, antigen-specific antibody titers do not correlate with protection. In addition, very little is known on parameters of cell-mediated immunity which could be considered as surrogates of protection. Tailoring of new adjuvants for the development of vaccines with improved immunogenicity/efficacy and reduced reactogenicity will represent one of the major challenges of the ongoing vaccine-oriented research.     

What are the indications for bariatric surgery?

No studies evaluate the commonly used indications for bariatric surgery. Consensus guidelines suggest that the surgical treatment of obesity should be reserved for patients with a body-mass index (BMI) >40 kg/m(2) or with BMI >35 kg/m(2) and 1 or more significant comorbid conditions, when less invasive methods of weight loss have failed and the patient is at high risk for obesity-associated morbidity and mortality (strength of recommendation: C, based on consensus guidelines).     

Qualitative management research in the NHS. A classic case of counting to one?

This paper examines research that has been undertaken to investigate management in health care and argues that there is no firm "evidence base" to demonstrate its effectiveness. However there is an emerging tradition of qualitative work, which has developed in response to the pace of organisational and structural change in health care, which reveals that the prevalent "ideal type" of rational management is inaccurate. One of the avowed strengths of qualitative research is that it uncovers what the nature of a particular phenomenon is, in essence it aims to "count to one". This need to understand and define health care management, forms the rationale for the studies reviewed and has influenced the research agenda in this area. Evidence is being demanded to demonstrate the efficacy of all clinical procedures, yet in researching managerial practice we are still counting to one.