Guisborough Primary Care Hospital

Osteoarthritis refers to a syndrome of joint pain accompanied by functional limitation and reduced quality of life. It is the most common form of arthritis and one of the leading causes of pain and disability in the United Kingdom. The published evidence for osteoarthritis treatment has many limitations—typically, short duration studies using single drug treatments. However, people with osteoarthritis need to be aware of the treatments that represent core management and of the range of additional treatments available. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the care and management of osteoarthritis in adults.1 NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available, recommendations are based on the guideline development group’s opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Holistic assessment and management of symptomatic osteoarthritis ### Core treatments Provide advice on the following to all people with symptomatic osteoarthritis:

BACKGROUND: There has been no previous incidence survey of children referred to a speech and language therapy service in the UK. Previous studies of prevalence of specific communication difficulties provide contradictory data from which it is difficult to plan speech and language therapy service provision. Reliable data are needed concerning the nature and severity of impairments as well as the age and source of referral and the effects of cultural and socio-economic profiles of the population served. AIMS: To describe referrals received between January 1999 and April 2000 by the paediatric speech and language therapy service of Middlesborough Primary Care Trust, an area of social deprivation. METHODS & PROCEDURES: All referrals were offered an initial assessment appointment within 8 weeks of referral. Standardized tests and quantitative measures of communication difficulties, determined by age, were undertaken. Population and case history information was also gathered. OUTCOMES & RESULTS: The incidence rate of referrals who attended for assessment in a single year was calculated as 16.3% for primary communication disability and 14.6% for speech/language disability. Of the 1100 referrals, 14.9% failed to attend and 9.8% had normal functioning. The distribution of disorder type was dysfluency 5.3%, voice or nasality disruption 2.0%; receptive language difficulties 20.4%, expressive language difficulties 16.9% and speech difficulties 29.1%. A further 0.7% had special educational needs and 0.9% had speech and language impairment but refused consent. The majority of referrals were between 2 and 6 years old, more boys than girls were referred, and socio-economic status matched that of the local population. Both gender and socio-economic status affected diagnosis. CONCLUSIONS: Based on the Middlesborough data, the estimated national incidence rate of referrals who attend for assessment and who have speech and language disability is 85 000-90 000 children per year (14.6% of births). While findings from only one Primary Care Trust must be treated cautiously, they provide paediatric speech and language therapy services managers with information that might guide service planning.

BACKGROUND: Although 75% of skin problems are managed exclusively in primary care, most information on the impact of skin disease on quality of life is hospital based. OBJECTIVES: To examine the ease of use of the Dermatology Life Quality Index (DLQI) in primary care and to measure the handicap levels found, analysed by skin disease, sex and age. METHODS: The handicap levels identified were compared with those published for patients with the same conditions attending hospital clinics. Some conditions that rarely present in secondary care were also studied. RESULT: S The overall mean +/- SD DLQI score was 7.37 +/- 5.71 (women 7.8 +/- 5.8, n = 196; men 6.8 +/- 5.6, n = 145). The scores for separate diseases were similar in ranking and only slightly lower than those in hospital-based studies. The possibility of bias towards surveying an unrepresentative sample of patients is discussed. There was no correlation between age and DLQI score. CONCLUSIONS: The DLQI proved easy to use in general practice. The impact of skin diseases on the quality of life of patients seen in primary care is comparable with that of patients seen in secondary care. This information could be used to inform the planning of services for these patients.

A total of 304 women, for whom operative delivery was considered necessary in the second stage of labour, were randomly assigned to delivery by vacuum extraction or forceps. Of those allocated to forceps a higher proportion of babies were actually delivered with the allocated instrument; however, the caesarean section rate was also higher in this group. Maternal trauma, use of analgesia and blood loss at delivery were significantly less in the group allocated to vacuum extraction. Vacuum extraction did, however, appear to predispose to an increase in mild neonatal jaundice. More serious neonatal morbidity was rare in both groups and the trial was of insufficient size to rule out a clinically important differential effect of the two instruments on these measures of outcome. Another trial is now needed to address this still open question more rigorously.

OBJECTIVES: To investigate the cost effectiveness of cyclo-oxygenase-2 (COX 2) selective inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs), and the addition of proton pump inhibitors to these treatments, for people with osteoarthritis. DESIGN: An economic evaluation using a Markov model and data from a systematic review was conducted. Estimates of cardiovascular and gastrointestinal adverse events were based on data from three large randomised controlled trials, and observational data were used for sensitivity analyses. Efficacy benefits from treatment were estimated from a meta-analysis of trials reporting total Western Ontario and McMaster Universities (WOMAC) osteoarthritis index score. Other model inputs were obtained from the relevant literature. The model was run for a hypothetical population of people with osteoarthritis. Subgroup analyses were conducted for people at high risk of gastrointestinal or cardiovascular adverse events. Comparators Licensed COX 2 selective inhibitors (celecoxib and etoricoxib) and traditional NSAIDs (diclofenac, ibuprofen, and naproxen) for which suitable data were available were compared. Paracetamol was also included, as was the possibility of adding a proton pump inhibitor (omeprazole) to each treatment. MAIN OUTCOME MEASURES: The main outcome measure was cost effectiveness, which was based on quality adjusted life years gained. Quality adjusted life year scores were calculated from pooled estimates of efficacy and major adverse events (that is, dyspepsia; symptomatic ulcer; complicated gastrointestinal perforation, ulcer, or bleed; myocardial infarction; stroke; and heart failure). RESULTS: Addition of a proton pump inhibitor to both COX 2 selective inhibitors and traditional NSAIDs was highly cost effective for all patient groups considered (incremental cost effectiveness ratio less than pound1000 (euro1175, $1650)). This finding was robust across a wide range of effectiveness estimates if the cheapest proton pump inhibitor was used. In our base case analysis, adding a proton pump inhibitor to a COX 2 selective inhibitor (used at the lowest licensed dose) was a cost effective option, even for patients at low risk of gastrointestinal adverse events (incremental cost effectiveness ratio approximately pound10 000). Uncertainties around relative adverse event rates meant relative cost effectiveness for individual COX 2 selective inhibitors and traditional NSAIDs was difficult to determine. CONCLUSIONS: Prescribing a proton pump inhibitor for people with osteoarthritis who are taking a traditional NSAID or COX 2 selective inhibitor is cost effective. The cost effectiveness analysis was sensitive to adverse event data and the specific choice of COX 2 selective inhibitor or NSAID agent should, therefore, take into account individual cardiovascular and gastrointestinal risks.

Seventy severely depressed patients randomly assigned to receive 8 real or sham ECT were further subdivided on the basis of degree of recovery from depression afterwards. In comparison to a non-depressed control group the depressed patients were impaired on a wide range of tests of memory and concentration prior to treatment, but afterwards performance on most of the tests had improved. Real ECT induced impairments of concentration, short-term memory and learning, but significantly facilitated access to remote memories. At 6 months follow-up all differences between real and sham ECT groups had disappeared. On the majority of tests the previously depressed patients now performed at the same level as the control group. There was some evidence that a subgroup of treatment-resistant patients (poor outcome after real ECT) were significantly more likely to complain of memory problems 6 months later.

Although pre-event static stretching (SS) is an accepted practice in most youth programs, pre-event dynamic exercise (DY) is becoming popular. The purpose of this study was to examine the acute effects of pre-event SS, DY, and combined SS and DY (SDY) on vertical jump (VJ), medicine-ball toss (MB), 10-yard sprint (SP), and pro-agility shuttle run (AG) in teenage athletes (15.5 ± 0.9 years). Thirty athletes participated in three testing sessions in random order on three nonconsecutive days. Before testing, participants performed 5 min of walking/jogging followed by one of the following 10 min warm-up protocols: a) five static stretches (2 × 30 s), b) nine moderate-to-high-intensity dynamic movements (2 × 10 yards), or c) five static stretches (1 × 30 s) followed by the same nine dynamic movements (1 × 10 yards). Statistical analysis of the data revealed that performance on the VJ, MB, and SP were significantly ( p < .05) improved after DY and SDY as compared with SS. There were no significant differences in AG after the 3 warm-up treatments. The results of this study indicate that pre-event dynamic exercise or static stretching followed by dynamic exercise might be more beneficial than pre-event static stretching alone in teenage athletes who perform power activities.

Forty-seven patients over the age of 55 years with a displaced fracture of the ankle were entered into a prospective, randomised study in order to compare open reduction and internal fixation with closed treatment in a plaster cast; 36 were reviewed after a mean of 27 months. The outcome was assessed clinically, radiologically and functionally using the Olerud score. The results showed that anatomical reduction was significantly less reliable (p = 0.03) and loss of reduction significantly more common (p = 0.001) in the group with closed treatment. Those managed by open reduction and internal fixation had a significantly higher functional outcome score (p = 0.03) and a significantly better range of movement of the ankle (p = 0.044) at review.

Preface. List of Contributors. 1 Renewable Catalytic Technologies - a Perspective (Rutger A. van Santen). 1.1 Introduction. 1.2 Economic and Societal Background. 1.3 Technology Options. 1.4 Process Options for Biomass Conversion. 1.5 Conclusions. References. 2 Lignocellulose Conversion: An Introduction to Chemistry, Process and Economics (Jean-Paul Lange). 2.1 Overview. 2.2 Introduction. 2.3 Chemistry and Processes. 2.4 Economics. 2.5 Summary and Conclusions. References. 3 Process Options for the Catalytic Conversion of Renewables into Bioproducts (Pierre Gallezot). 3.1 Overview. 3.2 Introduction. 3.3 The Biore.nery Concept. 3.4 Strategies for Biomass Conversion into Bioproducts. 3.5 Concluding Remarks. References. 4 Industrial Development and Application of Biobased Oleochemicals (Karlheinz Hill). 4.1 Overview. 4.2 Raw Material Situation. 4.3 Ecological Compatibility. 4.4 Examples of Products. 4.5 Perspectives. References. 5 Fine Chemicals from Renewables (Herman van Bekkum and Leendert Maat). 5.1 Introduction. 5.2 Vanillin. 5.3 Monoterpenes. 5.4 Alkaloids. 5.5 Steroids. 5.6 Enantioselective Catalysis. 5.7 Artimisinine. 5.8 Tamiflu. 5.9 Final Remarks. References. 6 Options for Catalysis in the Thermochemical Conversion of Biomass into Fuels (Sascha R. A. Kersten, Wim P. M. van Swaaij, Leon Le.erts, and Kulathuiyer Seshan). 6.1 Introduction. 6.2 Biomass as Feedstock for Fuels. 6.3 Composition of Biomass. 6.4 Biore.nery. 6.5 Biomass Pretreatment. 6.6 Thermochemical Conversion of Lignocelluloses. 6.7 Biomass Gasi.cation. 6.8 Liquefaction of Biomass. 6.9 Upgrading Pyrolysis Oil to Fuels. 6.10 Hydrolysis. 6.11 Underlying Approach for Catalyst Design. 6.12 Summary. References. 7 Thermal Biomass Conversion (Simone Albertazzi, Francesco Basile, Giuseppe Fornasari, Ferruccio Trifiro, and Angelo Vaccari). 7.1 Introduction. 7.2 Biomass Resources and Biomass Pre-treatment. 7.3 Biomass Combustion. 7.4 Biomass Gasi.cation. 7.5 Pyrolysis. 7.6 Fuels via Thermal Biomass Conversion. 7.7 Conclusions. References. 8 Thermal Biomass Conversion and NOx Emissions in Grate Furnaces (Rob J.M. Bastiaans, Hans A.J.A. van Kuijk, Bogdan A. Albrecht, Jeroen A. van Oijen and L. Philip H. de Goey). 8.1 Introduction. 8.2 Tunable Diode Laser Measurements of Biomass Kinetics. 8.3 Propagation of Thermal Conversion Fronts. 8.4 Gas-phase CFD Modeling of Grate Furnaces. 8.5 Conclusions. References. 9 Bioethanol: Production and Pathways for Upgrading and Valorization (Stephane Pariente, Nathalie Tanchoux, Francois Fajula, Gabriele Centi, and Siglinda Perathoner). 9.1 Introduction. 9.2 Production, a Short Overview. 9.3 Uses as Biofuel. 9.4 Bioethanol Upgrading and Valorization. 9.5 Conclusions. References. 10 Conversion of Glycerol into Traffic Fuels (Tiia S. Viinikainen, Reetta S. Karinen, and A. Outi I. Krause). 10.1 Introduction. 10.2 Glycerol. 10.3 Etheri.cation of Glycerol with Isobutene. 10.4 Improvements to Biodiesel Process. 10.5 Reforming of Glycerol. 10.6 Future Aspects. References. 11 Catalytic Transformation of Glycerol (Bert Sels, Els D'Hondt, and Pierre Jacobs). 11.1 Introduction and Scope. 11.2 Catalytic Dehydration of Glycerol and Acrolein Formation. 11.3 Etheri.cation of Glycerol via Catalytic Dehydration. 11.4 Catalytic Oxidation of Glycerol. 11.5 Catalytic Hydrogenolysis of Glycerol. 11.6 Glycerol Reforming and Production. 11.7 Miscellaneous Oxidation Reactions. 11.8 Conclusions. References. 12 Catalytic Processes for the Selective Epoxidation of Fatty Acids: More Environmentally Benign Routes (Matteo Guidotti, Rinaldo Psaro, Maila Sgobba, and Nicoletta Ravasio). 12.1 Introduction. 12.2 Non-catalytic Epoxidation Systems. 12.3 Homogeneous Catalytic Systems. 12.4 Chemoenzymatic Epoxidation Systems. 12.5 Heterogeneous Catalytic Systems. 12.6 Epoxidation of FAMEs Over Titanium-based Catalysts: The Skills in Milan. 12.7 Conclusions. References. 13 Integration of Biocatalysis with Chemocatalysis: Cascade Catalysis and Multi-step Conversions in Concert (Tom Kieboom). 13.1 Overview. 13.2 Introduction. 13.3 Types of Cascades. 13.4 Technologies for Cascades. 13.5 Conclusions. References. 14 Production and Fuel Cells as the Bridging Technologies Towards a Sustainable Energy System (Frank A. de Bruijn, Bert Rietveld, and Ruud W. van den Brink). 14.1 Introduction. 14.2 Production from Natural Gas. 14.3 Novel Processes for Production with CO2 Capture. 14.4 Conclusions and Catalytic Challenges. References. 15 Pathways to and Green (Gert J. Kramer, Joep P. P. Huijsmans, and Dave M. Austgen). 15.1 Introduction. 15.2 Energy Resource Availability. 15.3 Modes of Production and Distribution. 15.4 The Cost of Fuel. 15.5 Clean Hydrogen and the Scope for CO2 Reduction. 15.6 Coal and Biomass. 15.7 Conclusions. References. 16 Solar Photocatalysis for Production and CO2 Conversion (Claudio Minero and Valter Maurino). 16.1 Introduction. 16.2 The Photocatalytic Process. 16.3 Photoelectrochemical Cells. 16.4 New Materials. 16.5 Conclusions. References. Conclusions, Perspectives and Roadmap (Gabriele Centi and Rutger A. van Santen). 1 Introduction. 2 Driver for a Biomass Economy. 3 Main Issues and Perspectives on Bioenergy and Biofuels in Relation to Catalysis. 3.1 Biofuels. 3.2 Biore.neries. 3.3 Use of By-products Deriving from Biomass Transformation. 3.4 Biomass as Feedstock for Chemical Production. 3.5 Use of Solar Energy. 4 Conclusions. References. Index.

OBJECTIVE: To provide clear guidelines for the safe and effective performance of endometrial ablation. DATA SOURCES: Representatives of American, Australian, British, and Canadian hysteroscopists were brought together to produce a consensus document of good practice in endometrial ablation. METHODS OF STUDY SELECTION: The guidelines were produced after researching the literature, combining the extensive experience of the group, and debating the relevant issues. CONCLUSIONS: Endometrial ablation is a new procedure. Correct patient selection is essential in producing good results. Patients must be counseled carefully about the advantages, disadvantages, and potential complications of this approach to the management of menstrual disorders. The main indication for endometrial ablation is heavy menstrual loss in the absence of organic disease. Excessive uterine size, the presence of active pelvic infection, and evidence of malignant and premalignant endometrium are absolute contraindications. Ablation can be produced by electrosurgical resection, rollerball or rollerbarrel ablation and Nd-YAG laser ablation. Severe complications can occur, and techniques should be adopted to avoid uterine perforation, hemorrhage, and excessive fluid absorption. In skilled hands, endometrial ablation can be a safe and effective treatment for menorrhagia.

We compared the referral diagnoses of TIAs and minor strokes made by non-specialists with those of two consultant neurologists, in 565 consecutive cerebrovascular clinic patients, of whom 508 (90%) were referred with a diagnosis of any TIA or stroke. In 373 (73%), the neurologists felt the diagnosis of a cerebrovascular event to be correct. Agreement with the vascular syndrome (CVA vs. TIA) was significantly higher for patients with a referral diagnosis of stroke (136/176) (77%) than it was for patients with a referral diagnosis of TIA (200/332) (60%) (difference in proportions 17%, 95% CI 9-25). In 37 patients (7%) the neurologists confirmed the diagnosis of cerebrovascular disease but not the specific TIA/stroke diagnosis. Vascular surgeons were more likely to be correct in their referral diagnosis of carotid territory cerebrovascular disease (88% correct) than all other sources combined (63% correct) (difference in proportions 25%, 95% CI 11-39), but there was no significant variation in diagnostic accuracy between other individual groups. In 135/508 patients (27%) referred as any TIA or stroke, the diagnosis of cerebrovascular disease was undone. Alternative diagnoses included migraine (3%), epilepsy (1%), hyperventilation (1%), multiple sclerosis (1%) and a case of idiopathic Parkinson's disease, but many symptoms (8%) were unclassifiable. A strict comparison of diagnostic accuracy would have required assessment of patients not referred for specialist opinion, to estimate false-negative as well as false-positive diagnoses. However, in this patient group (which reflects current local practice) TIAs and strokes seem overdiagnosed.

Prolactin, cortisol, growth hormone and TSH serum levels (before and 15 minutes after treatment) were measured in 62 patients with endogenous depression randomly allocated to real or pseudo-ECT. Prolactin increased significantly more in those receiving real ECT than in those receiving pseudo-ECT, but the size of this effect had diminished by the time of the last (8th) treatment in the trial. Cortisol secretion was also significantly increased following the first treatment by real ECT, but this increase was of significantly smaller size in patients with delusions. Tolerance to the effects of ECT on cortisol secretion was not observed. No effects of ECT on growth hormone or TSH secretion were detected, and no clear evidence was obtained that endocrine responses can be used as a predictor of response to ECT.

In order to evaluate patients with necrobiosis lipoidica diabeticorum and to compare them with age, sex, and duration of diabetes matched controls, 15 patients with necrobiosis were each matched with 5 control subjects with diabetes mellitus. Complications of diabetes, glycaemic control, and proteinuria were measured. Patients with necrobiosis (mean age 40, range 18-74 years) had a mean duration of diabetes of 14 (range 3-36) years; 8 patients were male, and 7 were female. For necrobiosis versus controls, background retinopathy (67% vs 27%, p = 0.009), proteinuria (53% vs 17%, p = 0.006), and smoking (60% vs 20%, p = 0.003) were all more common with necrobiosis. There were no significant differences between patients with necrobiosis and control patients in the prevalence of vascular disease and neuropathy. Glycosylated haemoglobin concentrations were higher in patients with necrobiosis (p = 0.02). Blood pressure measurements were similar in both groups. We conclude that smoking, proteinuria, and retinopathy were more prevalent in diabetic patients with necrobiosis; the skin lesion may therefore share common aetiological factors which affect the microvascular circulation, leading to damage to basement membranes and vascular endothelial cells.

The aim of this study was to determine the prevalence of deep venous thrombosis (DVT) following lower limb arthroplasty and to assess whether this adversely affected satisfaction, relief from pain, or the level of mobility as perceived by patients. Six hundred and ten consecutive recipients of primary total hip replacement (THR) or total knee replacement (TKR) underwent routine post-operative venography. The functional outcome had already been assessed at one year by using the Regional Arthroplasty Database questionnaire, the results of which were correlated to venographic records. The combined prevalence of DVT after THR and TKR in the patients, who did not receive chemical thromboprophylaxis, was 46.4%. Thrombus was identified in 57.6% of those with a TKR and in 33.5% of patients with a THR. Proximal thrombus was found in 11.0% of TKRs and in 14.8% of THRs. One year after surgery, patients who had a DVT established by venography did not report higher levels of immobility (p = 0.07), discomfort (p = 0.12) or dissatisfaction (p = 0.23) when compared to those with patent venous systems. This suggests that the prevalence of DVT following TKR/THR without chemical thromboprophylaxis is high and these findings are consistent with the literature. However, patients did not perceive thrombosis to compromise their overall outcome. This challenges the belief that DVT is associated with morbidity and calls for further comprehensive research in this area. The low morbidity of the lower limb associated with DVT in these patients does not support the use of chemical thromboprophylaxis.

The hypothesis that the prevalence of cardiovascular risk factors in people with diabetes is inversely related to socio-economic status was tested. Demographic and biochemical data were collected on 1246 patients, aged 20-69 years, attending a hospital diabetes clinic. This is estimated to represent between 71% and 78% of all people of this age with a diagnosis of diabetes in the health authority. In total, 296 people were classified as Type 1 (insulin-dependent) diabetic patients (age of onset < 31, now on insulin). Using data from the 1991 census a deprivation score was ascribed to each individual according to their area (enumeration district) of residence. The total study population was ranked by deprivation score and divided into quintiles. The relationships between means and quintiles of deprivation were assessed by ANOVA for linear trend, and between proportions and quintiles of deprivation by the chi-squared test for trend. In Type 1 diabetes increasing quintiles of deprivation were significantly related to mean serum cholesterol (p < 0.01) and proportion smoking (p < 0.01), and in Type 2 (non-insulin-dependent) diabetes to mean body mass index (p < 0.001), proportion smoking (p < 0.001), and proportion with proteinuria (p < 0.05). The need for health measures to prevent cardiovascular disease in people with diabetes is greatest in deprived areas.

The aim of this study was to determine the prevalence of deep venous thrombosis (DVT) following lower limb arthroplasty and to assess whether this adversely affected satisfaction, relief from pain, or the level of mobility as perceived by patients. Six hundred and ten consecutive recipients of primary total hip replacement (THR) or total knee replacement (TKR) underwent routine post-operative venography. The functional outcome had already been assessed at one year by using the Regional Arthroplasty Database questionnaire, the results of which were correlated to venographic records. The combined prevalence of DVT after THR and TKR in the patients, who did not receive chemical thromboprophylaxis, was 46.4%. Thrombus was identified in 57.6% of those with a TKR and in 33.5% of patients with a THR. Proximal thrombus was found in 11.0% of TKRs and in 14.8% of THRs. One year after surgery, patients who had a DVT established by venography did not report higher levels of immobility (p = 0.07), discomfort (p = 0.12) or dissatisfaction (p = 0.23) when compared to those with patent venous systems. This suggests that the prevalence of DVT following TKR/THR without chemical thromboprophylaxis is high and these findings are consistent with the literature. However, patients did not perceive thrombosis to compromise their overall outcome. This challenges the belief that DVT is associated with morbidity and calls for further comprehensive research in this area. The low morbidity of the lower limb associated with DVT in these patients does not support the use of chemical thromboprophylaxis.

Aims —To describe the clinical and histopathological features of a rare variant of naevoid melanoma, small cell melanoma, and discuss the histological differential diagnoses. Methods —The clinical and histological features of cases of malignant melanoma with the histological features of small (non-Merkel like) melanoma were reviewed and documented. In addition, five cases had available material for immunohistochemistry and this was performed using antibodies to the S100 protein and melan-A, and the HMB-45 antibody. Results —There were 15 cases of small cell melanoma from 14 (10 female, four male) patients, aged between 30 and 77 (mean, 48.6) years. The trunk was the most common location. In more than half the cases, the provisional diagnosis was melanoma/borderline lesion. All shared similar histological appearances of an intraepidermal component of in situ melanoma and a dermal component of nests of cells with hyperchromatic nuclei and scanty cytoplasm, usually in tightly packed nests. All components (junctional and intradermal) of the lesions investigated by immunohistochemistry were positive both for S100 protein and melan-A. All junctional components were positive with HMB-45, but with variable staining of the dermal components with this antibody. Conclusions —Small cell malignant melanoma is postulated to be a distinct histopathological entity and a rare variant of naevoid melanoma. Such lesions can be difficult to interpret and easily missed at scanning magnification because the cells of the dermal component mimic benign naevus cells.

This review covers advances in the analysis of advanced materials, metals, fuels and lubricants, nanostructures, ceramics, refractories, organic and inorganic chemicals, catalysts and nuclear materials by a range of techniques including X-ray, ICP, LIBS, mass spectrometry, synchrotron-based techniques, plus non-destructive and ablation surface techniques.

This review covers advances in the analysis of advanced materials, metals, fuels and lubricants, nano structures, ceramics, refractories, organic and inorganic chemicals, catalysts and nuclear materials by a range of techniques including X-ray, ICP, LIBS, mass spectrometry, synchrotron-based techniques, plus non-destructive and ablation surface techniques.

RATIONALE, AIMS AND OBJECTIVES: Clinical practice guidelines often grade the 'strength' of their recommendations according to the robustness of the supporting research evidence. The existing methodology does not allow the strength of recommendation (SOR) to be upgraded for recommendations for which randomized controlled trials are impractical or unethical. The purpose of this study was to develop a new method of determining SOR, incorporating both research evidence and expert opinion. METHODS: A Delphi technique was employed to produce 10 recommendations for the role of exercise therapy in the management of osteoarthritis of the hip or knee. The SOR for each recommendation was determined by the traditional method, closely linked to the category of research evidence found on a systematic literature search, and on a visual analogue scale (VAS). Recommendations were grouped A-D according to the traditional SOR allocated and the mean VAS calculated. Difference across the groups was assessed by one-way ANOVA variance analysis. RESULTS: Mean VAS scores for the traditional SOR groups A-D and one proposition which was 'not recommended' showed significant linearity on one-way ANOVA. However, certain recommendations which, for practical reasons, could not assessed in randomized controlled trials and therefore could not be recommended strongly by the traditional methodology, were allocated a strong recommendation by VAS. CONCLUSIONS: This new system of grading strength of SOR is less constrained than the traditional methodology and offers the advantage of allowing SOR for procedures which cannot be assessed in RCTs for practical or ethical reasons to be upgraded according to expert opinion.