Background. Despite clinical guidelines penetrating every aspect of clinical practice and health policy, doubts persist over their ability to improve patient care. We have designed and tested a generic critical appraisal instrument, that assesses whether developers have minimized the biases inherent in creating guidelines, and addressed the requirements for effective implementation. Design. Thirty-seven items describing suggested predictors of guideline quality were grouped into three dimensions covering the rigour of development, clarity of presentation (including the context and content) and implementation issues. The ease of use, reliability and validity of the instrument was tested on a national sample of guidelines for the management of asthma, breast cancer, depression and coronary heart disease, with 120 appraisers. A numerical score was derived to allow comparison of guidelines within and between diseases. Results. The instrument has acceptable reliability (Cronbach’s a coefficient, 0.68‐0.84; intra-class correlation coefficient, 0.82‐0.90). The results provided some evidence of validity (Pearson’s correlation coefficient between appraisers’ dimension scores and their global assessment was 0.49 for dimension one, 0.63 for dimension two and 0.40 for dimension three). The instrument could differentiate between national and local guidelines and was easy to apply. There was variation in the performance of guidelines with most not achieving a majority of criteria in each dimension. Conclusions. Use of this instrument should encourage developers to create guidelines that reflect relevant research evidence more accurately. Potential users or groups adapting guidelines for local use could apply the instrument to help decide which one to follow. The National Health Service Executive is using the instrument to assist in deciding which guidelines to recommend to the UK National Health Service. This methodology forms the basis of a common approach to assessing guideline quality in Europe.

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Development and application of a generic methodology to assess the quality of clinical guidelines.

In the United States alone, >400 000 Americans die annually of coronary artery disease, and >1 000 000 suffer acute coronary events, ie, myocardial infarction and sudden cardiac death.1 Considering the aging of our population and increasing incidence of diabetes mellitus and obesity, the morbidity from coronary artery disease and its associated costs will place an increasing, substantial burden on our society.2 Between 2010 and 2030, total direct medical costs spent in the United States for cardiovascular diseases are projected to triple from $273 billion to $818 billion.2 Although effective treatments are available and considerable efforts are ongoing to identify new strategies for the prevention of coronary events, predicting such events in an individual has been challenging.3 In hopes of improving our ability to determine the risk of coronary events, it is prudent to review our knowledge of factors that lead to acute coronary events.

Coronary atherosclerosis is the underlying condition for coronary events with few exceptions. Events are rarely caused by coronary dissection, arteritis, myocardial bridging, thromboembolism, or coronary vasospasm without obvious coronary artery disease.4 In some of these instances, more sensitive tools for the detection of coronary artery disease revealed its presence after all.5 Coronary atherosclerosis is known to develop in childhood and adolescence, as evident from fatty streaks seen in pathology studies of individuals who died of trauma or other noncardiac causes.6 Depending on the constellation of genetic and environmental factors, coronary artery disease progresses throughout adulthood and is found in most middle-aged individuals in developed nations. Autopsy series in US communities among young adults (mean age, 36±14 years) who died of nonnatural causes revealed coronary atherosclerosis in >80% of the autopsy sample, with ≈8% having obstructive disease.7 Thus, most individuals ≥40 years of age in our society have …

Acute Coronary Events

Emotion and Peace of Mind: From Stoic Agitation to Christian Temptation. RICHARD SORABJI Oxford: Oxford University Press, 2000. Pp. xi, 499.

The Cambridge History of Medieval Philosophy comprises over fifty specially commissioned essays by experts on the philosophy of this period. Starting in the late eighth century, with the renewal of learning some centuries after the fall of the Roman Empire, a sequence of chapters takes the reader through developments in many and varied fields, including logic and language, natural philosophy, ethics, metaphysics, and theology. Close attention is paid to the context of medieval philosophy, with discussions of the rise of the universities and developments in the cultural and linguistic spheres. A striking feature is the continuous coverage of Islamic, Jewish, and Christian material. There are useful biographies of the philosophers, and a comprehensive bibliography. The volumes illuminate a rich and remarkable period in the history of philosophy and will be the authoritative source on medieval philosophy for the next generation of scholars and students alike.

The Cambridge History of Medieval Philosophy

Introduction Hellenistic political philosophy has had a bad press. In lectures published in 1983 the distinguished and influential ancient historian Moses Finley gave it as his view that Plato and Aristotle ‘were the first genuine political theorists of antiquity, and the last’. For only they attempted ‘a complete and coherent account’ of the ideal society ‘grounded in systematic metaphysics, epistemology, psychology and ethics’. Some thirty years earlier, in what remains an eminently serviceable general account of Greek political thought, T. A. Sinclair wrote as follows: Looking back over the political thought of the third century BC one cannot help being struck with its barrenness. This is of course due in part to the decline in the polis and in part to the loss of contemporary writings on the subject. But it is also due to the refusal or inability to relate political thinking to the material conditions in which men lived. Epicurus and Chrysippus did their best to help men to face life cheerfully, but the men whom they helped were the few, who had sufficient education to understand their message and sufficient leisure for lessons in philosophy. Finley and Sinclair are only echoing a long entrenched judgement which finds a classic formulation in the third volume of Zeller's great history of Greek philosophy, first published in 1852. For Zeller the Hellenistic period found the Greeks coping with a deterioration in their external circumstances, and particularly with loss of political self-determination as the monarchies of Alexander's successors eclipsed the city-state, by withdrawing into the inner world of self-consciousness.

Social and political thought

Metaphysics in the Byzantine Tradition: Eustratios of Nicaea on Universals

Medicine as a stochastic art

L'A. etudie la division tripartite du systeme philosophique des Stoiciens a travers la doxographie de Diogene Laerce, qui souleve le probleme de l'unite des disciplines philosophiques a l'interieur du discours philosophique ainsi divise

The Stoic Division of Philosophy

Introduction: The Study of Stoicism: Its Decline and Revival 1. Aristotle and Stoic Logic 2. The Liar Paradox and the Stoics 3. On the Stoic Conception of the Good 4. Rules and Reasoning in Stoic Ethics 5. The Stoic-Platonist Debate on Kathekonta 6. The Stoic Origin of Natural Rights 7. The Stoic Sage in the Cosmic City 8. Chrysippus' Theory of Causes Select Bibliography Index

Topics in stoic philosophy

Introduction 1. Greek-Latin Philosophical Interaction 2. Basil of Caesarea on the Semantics of Proper Names 3. The Justinianic Dialogue On Political Science and its Neoplatonic Sources 4. John of Damascus on Human Action, the Will, and Human Freedom 5. Syllogistic in the Anonymous Heiberg 6. Helenic Philosophy in Byzantium and the Lonely Mission of Michael Psellos 7. Psellis' Paraphrasis on Aristotle's De Interpretatione 8. 'To Every Argument There is a Counter-Argument'. Theodore Metochites' Defence of Scepticism (Semeiosis 61) 9. The Anti-Logical Movement in the 14th Century 10. Byzantine Commentators on the Chaldaean Oracles: Psellos and Plethon 11. Plethon and Scholarios on Aristotle Epilogue: Current Research in Byzantine Philosophy Index Locorum, Index of Names

Katerina Ierodiakonou

Papers

Metaphysics in the Byzantine Tradition: Eustratios of Nicaea on Universals

Medicine as a stochastic art

The Stoic Division of Philosophy

Topics in stoic philosophy

Byzantine philosophy and its ancient sources