Repository Of Evidence Research Articles

Global Health Education and Advocacy: Using BMJ Case Reports to Tackle the Social Determinants of Health.

Since 2013, BMJ Case Reports (http://casereports.bmj.com/) has published over 70 global health case reports from five continents, written by doctors, nurses, students, and allied health professionals. These cases, a burgeoning repository of evidence of how real patients are affected by disease, trauma, violence, sexual assault, conflict, migration, adverse living and working conditions, and poor access to health care, discuss, in addition to clinicopathological findings, the global health problems affecting each patient. The global health problem analysis examines the problems of individual patients, critically appraises the literature, and describes actual and potential solutions for the patient, the local community, and patients affected by similar issues across the world. At present global health literature and learning materials lack a patient focus and real-life context in the analysis of global health problems. BMJ Case Reports global health case reports are a unique and important tool to learn about and advocate for change in the social, political, cultural, and financial determinants of health as they affect real patients. This growing evidence base brings together clinicians, local service providers, policy makers, and government and non-governmental institutions to effect real change in patients’ lives toward improving health. Each global health case report is an excellent resource for learning, and together, these case reports provide essential reading for anyone embarking on a career in global health, and writing their own case report. The online course (http://casereports.bmj.com/site/misc/GHMA_Mar_2017.pptx) at BMJ Case Reports uses these cases and is free to access.

Health social workers sources of knowledge for decision making in practice

ABSTRACTThis article presents findings from research examining knowledge social workers in a health network in Victoria, Australia identified as informing their decision-making. Data for 13 patients, and in-depth interviews with six social workers who worked with these patients, were studied. A thematic analysis of interviews revealed that participants identified reliance on past experience and contextual/situational information as underpinning their decisions, demonstrating their commitment to person-in-environment perspectives. However, despite the availability of a repository of empirical evidence, no respondent made use of this. This study provided insight into health practitioners’ sources of knowledge, highlighting gaps and areas for further exploration.

Creation of an Integrated Knowledge Translation Process to Improve Pediatric Emergency Care in Canada

ABSTRACTTREKK (Translating Emergency Knowledge for Kids) was established to address knowledge needs to support care of children in general emergency departments. To achieve this goal, we developed an integrated knowledge translation (KT) process based on identified priorities to create the TREKK Evidence Repository, containing “knowledge pyramids” and Bottom Line Recommendations (summary documents) on the diagnosis and treatment of emergency pediatric conditions. The objective of this article is to describe our methods for developing and disseminating the TREKK Evidence Repository to improve pediatric emergency care in Canada. Our work was guided by the research question: Can an integrated KT process address an information gap in healthcare practice? We utilized a pyramid-shaped framework, built upon the “4S” hierarchy of evidence model, to provide detailed evidence appropriate to stakeholders’ needs. For each priority condition (asthma, bronchiolitis, croup, etc.), clinical advisors and KT experts collaborated to create a Bottom Line Recommendation and to select guidelines, reviews, and key studies for that condition’s topic area in the Evidence Repository on the TREKK website (trekk.ca). Targeted promotion, including a social media campaign, communicated the availability of new topics in the Evidence Repository and available knowledge tools. Feedback from 35 end-users on pilot versions of the Evidence Repository was positive with 91% indicating that they would use the resource in the emergency department. Using an integrated KT process, we responded to end-users’ requests for varying level of information on priority pediatric conditions through the creation of knowledge tools and development of a process to identify and vet high quality evidence-based resources.

Comments on the dilemma in the June issue: Using the evidence

In the dilemma discussed in the June issue of In Practice, you were presented with a lively, 60 kg dog with an obvious anterior cruciate rupture that required surgical repair....

P056: The state of the evidence for emergency medical services (EMS) care of blunt spinal trauma: an analysis of appraised research from the Canadian Prehospital Evidence-based Practice (PEP) Project

Introduction: The Canadian Prehospital Evidence-based Practice (PEP) project is an online, freely accessible, continuously updated EMS evidence repository. The summary of research evidence for EMS interventions used to care for blunt spinal trauma is described. Methods: PubMed was systematically searched. One author reviewed titles and abstracts for relevance. Included studies were scored by trained appraisers on a three-point Level of Evidence (LOE) scale (based on study design and quality) and three-point Direction of Evidence (DOE) scale (supportive, neutral, or opposing results). Second party appraisal was conducted for included studies. Interventions were plotted on a 3x3 table (DOE × LOE) for the spinal injury condition based on appraisal scores. The primary outcome was identified for each study and categorized. Results: Seventy-seven studies were included. Evidence for adult and paediatric blunt spinal trauma interventions was: supportive-high quality (n=1, 7 %), supportive-moderate quality (n=3, 21.4%), supportive-low quality (n=1, 7%), neutral-high quality (n=1, 7%), neutral-moderate quality (n=5, 35.7%), neutral-low quality (n=1, 7%), opposing-high quality (n=0, 0%), opposing-moderate quality (n=0, 0%), opposing-low quality (n=1, 7%). One (7%) intervention had no evidence. Interventions with supportive evidence were: steroids, cervical-spine clearance, scoop stretcher, self-extrication and “leaving helmet in place”. The evidence weakly opposed use of short extrication devices. Leading study primary outcomes were spinal motion, diagnostic accuracy, and pressure/discomfort. Conclusion: EMS blunt spinal trauma interventions are informed by moderate quality supportive and neutral evidence. Future research should focus on high quality studies filling identified evidence gaps using patient-oriented outcomes to best inform EMS care of blunt spinal injury.

Beyond Academic Evidence: Innovative Uses of Technology Within e-Portfolios in a Doctor of Nursing Practice Program.

Portfolios have been used in higher education for the past several years for assessment of student learning and growth and serve as the basis for summative and formative evaluations. While there is some information in the literature on how undergraduate and graduate medical, nursing, and allied health students might use portfolios to showcase acquired knowledge and skills, there is a dearth of information on the use of e-Portfolios with students in doctor of nursing practice programs. There are also limited findings regarding the creative use of technology (that includes infographics and other multimedia tools) to enhance learning outcomes (Stephens & Parr, 2013). This article presents engaging and meaningful ways technology can be used within e-Portfolios. Thus, e-Portfolios become more than a repository for academic evidence; they become unique stories that reflect the breadth and depth of students' learner-centered outcomes.

Supporting the use of research evidence in the Americas through an online "one-stop shop": the EVIPNet VHL.

Since the release of the 'World Report on Knowledge for Better Health' in 2004, a transformation has occurred in the field of health policy and systems research that has brought with it an increased emphasis on supporting the use of research evidence in the policy process. There has been an identified need for comprehensive online "one-stop shops" that facilitate the timely retrieval of research evidence in the policy process. This report highlights the EVIPNet VHL, a recently established project that was developed to meet the need for online repositories of relevant evidence to support knowledge translation efforts in the Americas, which can help contribute to strengthening health systems in the region.

Graftings, Reweavings and Interpretation: The Auchinleck Middle English Breton Lays in Manuscript and Edition

This essay argues that the material textual context provides a framework for reading the Middle English Breton Lays in the Auchinleck MS and in contemporary editions. The lays in the Auchinleck contribute to an understanding of the manuscript as a fulcrum point between English and French/Anglo-Norman cultural productions. The textual environment further supports a nuanced reading of the lays in relation to both literary legacy and historical context. Literary content, linguistic elements, codicological features, and the Auchinleck’s visual program align it with both an Anglo-Norman manuscript tradition as well as with an emerging Middle English vernacular reading audience. Although frequently considered a response to, and encouragement of, an emerging English ‘nation,’ evidence drawn from the large repository of textual and literary evidence suggests that the manuscript and its surviving texts function more as a pivot point, looking back, looking at the present, and looking toward the future in a complex contrapuntal performance. An ‘envoy’ to the argument focused on the manuscript context, considers the contours of three modern editions of the lay material, probing their organizational programs and uncovering ways the presentation of these texts in contemporary editions may shape our interpretive work as readers of the Middle English Breton lays.

Against Accumulation

Against Accumulation Brian Connolly (bio) We might, with a little work, productively imagine the archive as the historical unconscious, with the evidence therein the near endless series of signifiers. If we were to push this analogy a little further, we might say that the archive is structured like the unconscious (which is structured like language), and if this is the case, then we might be apprehensive about the relationship between the archive, evidence, and “the real,” or reality. The real, we know from the work of Jacques Lacan, is that which is foreclosed, impossible to be symbolized, and thus incapable of being represented in language. It is also undifferentiated, whole—the cut of signification (castration) does not exist there. It is that which we desire, that impossible place without lack. If this is the case, then the archive will never, no matter how much evidence we accumulate, yield reality. Yet, for all of this, recent accumulative trends in digitization of archives (more accessible evidence searched more easily) and extranational scales of analysis (which add geographic spaces in order to challenge the hegemony of the nation) have led to a neo-empiricism that, once again, chases that elusive phantasm of reality. In one sense, this empirical, positivist search for reality is not particularly new. Since at least the nineteenth century, the archive has been figured as the repository of documentary evidence. It was the institutional site where evidence could be found to document the veracity of historical narratives. Of course, this empiricist account of the archive has long been critiqued: think of Jacques Derrida in Archive Fever or Joan Scott in “The Evidence of Experience.” In some instances, the capacity of both evidence and the archive to satisfy our contemporary political desires is called into question, as in Gayatri Spivak’s “Can the Subaltern Speak?”1 For Scott, a critical relation to evidence shifts our work from “a belief in the unmediated relationship between words and things, to one that takes all categories of analysis as contextual, contested, and contingent.”2 In a word, Scott asks historians to acknowledge that we read evidence—we do not discover unmediated accounts of that elusive phantasm, the past “as it actually was.”3 Yet no matter how many critiques, empiricism persists. Recently, a confluence of technology, framework, and new practices of reading have resulted in a newfound fascination with an empirical [End Page 172] orientation toward evidence, one frequently offered as a substitute (or antidote) for now supposedly “tired” hermeneutics. The digitization of archives (and the attendant quasi-disciplinary formation we have come to call digital humanities) and global (and other extranational) studies have engendered an accumulative logic toward evidence and the archive.4 Supposedly, the more evidence we have the better, whether through the multiplication of pieces of evidence or the ability to search keywords across a previously unimaginable number of sources. This move has been accompanied by the emergence of new practices of reading—distant, surface, descriptive—that embrace a certain kind of empiricism—one designed, in part, to move across a large body of evidence, something at which older, tired, and out-of-date critical and hermeneutic practices would be less adept. Yet the digital and the global stand as sentries at the archive, orienting our analyses and capacities for critique. As Derrida wrote of the archons (those who secured the archive and its documents), “They do not only ensure the physical security of what is deposited and of the substrate. They are also accorded the hermeneutic right and competence. They have the power to interpret the archives.”5 The archons of the contemporary scene of historical writing might just be the digital humanities and the spatial turn. While there are certainly critical projects that come out of both domains—indeed, my own work has benefitted greatly from the digitization of archives—there is also a celebratory tone that is primarily about accumulation. Despite its insistent antihermeneutic logic, it is a hermeneutic imperative nonetheless—accumulate more and more, think beyond and against the nation, but always do it in a manner, aided and abetted by digitization, which adds rather than subtracts. The tendency among historians and others to lionize the digital...

Drug Approval and Drug Effectiveness

Data on the efficacy and safety of psychiatric medicines should form the foundation of evidence-based treatment practices. The US Food and Drug Administration (FDA) reviews such data in determining whether to approve new treatments, and the published literature serves as a repository for evidence on treatment benefits and harms. We describe the FDA review of clinical trials, examining the underlying logic and legal guidelines. Several FDA reviews provide evidence that the agency requires only minimal efficacy for psychiatric drugs. Further, in some instances, the FDA has relied on secondary rather than primary outcomes and has discounted the findings of negative studies in its review of antidepressant and antipsychotic medications. The published literature provides another lens into the safety and efficacy of treatments. We describe how treatment efficacy is systematically overstated and treatment-related harms are understated in the scientific literature. Suggestions are provided to improve public access to underlying safety and efficacy data and for the FDA to potentially improve its review process.

EComment. Paradigm shift in surgery for massive pulmonary embolism: If not now then when?

This retrospective study by Zarrabi et al. adds to the growing repository of contemporary evidence regarding the safety and efficacy of surgical embolectomy for massive and submassive pulmonary embolism [1]. The authors highlight the potential for chronic thromboembolic pulmonary hypertension, an important but often overlooked sequelae of suboptimal therapy which may result following anticoagulation only, or catheter directed thrombolysis due to incomplete recanalization. The significant consistent reduction in pulmonary arterial systolic pressures reported on serial studies immediately before and after surgery and on follow-up is most encouraging. Despite improved outcomes, a surgical embolectomy largely remains a second line or last resort alternative therapy, perhaps burdened by historical outcomes. However, with the increased availability of cardiopulmonary bypass support and more detailed imaging (computed tomography and transoesophageal echocardiography), a surgical embolectomy should feature early in the treatment algorithm of any patient with a large volume central thrombus burden in the main pulmonary artery or proximal branch pulmonary arteries. Surgery should also be considered for the haemodynamically stable patient who may have features of impending right ventricular dysfunction, a known prognosticator for an embolism-related early (in-hospital or 30 day) death [2]. In carefully selected patients, an early surgical embolectomy may offer the best opportunity to rapidly and completely reperfuse the pulmonary arterial vasculature, thereby avoiding potential future complications such as chronic thromboembolic pulmonary hypertension. Conflict of Interest: None declared

Meeting the Challenge of Evidence-Based Medicine in the Family Medicine Clerkship: Closing the Loop from Academics to Office

An EBM Seminar and POEM® project was developed to teach evidence-based medicine in a family medicine clerkship. The seminar focused on the application of preclinical coursework in biostatistics and epidemiology to the clinical third year. POEM projects involved answering clinical questions, derived from patient cases in the family medicine offices, with best available evidence. These questions and answers were archived in a wiki which was made available to the institution's family medicine physicians. Selected POEMs were also published in the in-house family medicine newsletter. The POEM projects evolved from an educational exercise for medical students to a valuable repository of evidence for clinicians.

Introduction to the Academy for Healthcare Improvement conference on advancing the methods for healthcare quality improvement research

Nearly two decades ago, the International Scientific Symposium on Improving the Quality and Value of Health Care was created to foster the mission of building a scholarly foundation for quality improvement education and research. The program of presentations at the inaugural symposium was comprised almost entirely of non-experimental, before-after studies that are subject to significant problems with reliability and validity. The passing years have seen an evolving trend toward robust study designs with more rigorous statistical methods such as process control and interrupted time-series analyses. The foundation for quality improvement established over the past twenty years has created a repository of evidence. Quality improvement has a proliferation of publications appearing in peer-reviewed journals. Discipline specific outlets have emerged such as the British Medical Journal of Quality and Safety in Health Care, Implementation Science, Joint Commission Journal on Quality and Patient Safety, Journal for Healthcare Quality, and Journal of Nursing Care Quality. However, the methodology in quality improvement and implementation science must become on par with the methods in health economics and related areas of health services research if quality improvement research is to materialize into evidence-based health care and contribute to health care reform. Practitioners and researchers in the field of quality improvement recognize the need to elevate the relevance and value of their research. The potential contribution of implementation science as a strategic approach for obtaining safe, efficient, and effective health care is too easily overlooked without a solid record of publication in the scientific literature. The need to generate the best evidence for systematic quality improvement was the driving factor for a conference on Advancing the Methods for Healthcare Quality Improvement Research, held on May 7-8, 2012 in Arlington, Virginia. The aims of the conference were 1) to reflect on the past two decades of quality improvement and quality improvement research and appreciate the emergence of methods and techniques in the literature today, and 2) to define quality improvement research, characterize its strengths, and propose future directions for quality improvement research and implementation science. This conference set out to further the goal of elevating quality improvement research to a higher level of validity and value. The conference presented information on the conduct of quality improvement research, including study design, data registries, comparative effectiveness, and the issue of health care disparities. In addition, there were several talks on sophisticated methods including robust quasi-experimental designs, hybrid research designs, and risk-adjusted statistical process control. By the use of key speakers, a call for abstracts for podium and poster presentations, and case-based learning using examples of best methods in the literature, this conference was a forum on the current state and future needs of quality improvement research and its methodological and technical issues. The proceedings of this conference are presented in this supplement to provide a series of concise papers that describe the key messages of the presentations and a commentary about the contribution to advancing the field of quality improvement and implementation science. Session one was a set of three talks on the architecture of study design for doing quality improvement research presented by Dr. Duncan Neuhauser, Dr. Mark Bauer, and Dr. Peter Margolis. Session two comprised two talks on the implementation of a practice-based learning registry for quality improvement (Dr. Richard Colletti) and advanced statistical process control methods for reporting findings from quality surveillance registries (Dr. Michael Matheny). Sessions three and four introduced new frontiers for quality improvement research in comparative effectiveness (Dr. David Atkins) disparities research (Dr. Donald Goldmann), implementation science (Dr. John Ovretveit), and the contribution to government contract initiatives (Dr. Joanne Lynn). In session five, Dr. Brian Mittman delivered an eloquent presentation on what the future holds for quality improvement research. Sessions six and seven concluded the conference with audience roundtable discussions on evaluating strengths and weaknesses of quality improvement research using two examples of best practices and making recommendations for the future direction of quality improvement and research. Our objective for this program was to formulate the types of questions relevant to advancing quality improvement and implementation science and their appropriate study designs. Our overall goal is to bring about more effective application of quality improvement science in health care delivery and to learn new areas for application of quality improvement research. With this conference proceeding, we disseminate the highlights. Voice-over recordings of the full presentations are available at the Academy for Healthcare Improvement web site (http://www.A4HI.org) as well as a listing of recommended readings. By sharing the knowledge gained from this conference, we hope to inspire the spirit of initiative, innovation, motivation, and thinking that fuels the passion for improving health and delivery of health care.

The economy of memory: Archive-driven documentaries in the digital age

ABSTRACTIn the world of the historical documentary, the archive footage arms of large media corporations control our access to images from the past. This article explores whether archive-driven historical films are possible on low budgets, discussing the strategies used to research, clear and license footage for my recent archive-driven feature documentary Children of the Revolution (2010). I note the critical misalignment between the cost of licensing archive footage and the production budgets and prices paid for creative documentaries by broadcasters.On a broader level, I examine public policy towards these repositories of historical evidence and analyse the hypothesis of the recent Hargreaves report (2011), that ‘Copyright licensing [in the audiovisual archive sector] is not fit for purpose for the digital age’ (Hooper 2012: 21). I also consider alternative models for archive-driven historical films that stretch the form while skirting the clearance complications and expense of the standard industry model.

Putting health policy and systems research on the map

Putting health policy and systems research on the map

A spatially disaggregated time-series analysis of the short-term effects of particulate matter exposure on mortality in Chennai, India

The global burden of disease due to air pollution is concentrated in the rapidly developing counties of Asia, but a recent meta-analysis found that relatively few studies on short-term exposure to air pollution and mortality have been performed in these countries, including India. Local evidence on the effects of short-term exposures to air pollutants on mortality and cardio-respiratory morbidity in Asia would reduce the uncertainties in current impact estimations and facilitate effective public policy responses to a deteriorating air pollution situation in South Asia. Here, we report the results from one of the first of such studies in metropolitan Chennai, India, conducted as part of a co-ordinated multi-city time-series initiative in India aimed at estimating the effect of short-term exposure to particulate matter ≤10 μm in aerodynamic diameter (PM10) on all-cause mortality. The studies in Indian cities (Chennai, Delhi and Ludhiana) were part of a larger multi-city effort in Asia, co-ordinated by The Health Effects Institute (Boston, MA, USA) under their program for Public health and Air Pollution in Asia (PAPA). An important study output included the development of methodological refinements to overcome the limitations of routinely collected data in terms of missing measurements, small footprints of air pollution monitors and incomplete address information on death records. We used data on ambient air quality and all-cause mortality collected over the period 2002–2004. Exposures and health outcomes were disaggregated at the level of individual city zones and subsequently used in quasi-Poisson generalized additive models with smooth functions of time, temperature and relative humidity. Our model estimated a 0.44% (95% confidence interval 0.17–0.71) increase in mortality per 10 μg/m3 increase in daily average concentrations of PM10, which is comparable to estimates from other PAPA cities and previous studies in North America and Europe. The results from PAPA studies in India, while preliminary, serve to strengthen the local evidence base for air pollution-related health effects that is imminently needed for better air quality management, while adding valuable information from India to the global repository of evidence.

Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?

Abstract I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to assess (1) whether research was published in the practice area of rehabilitation, disability, and participation and (2) the evidence being produced in an underdeveloped subcategory of this practice area: cognitive rehabilitation after stroke. The review revealed one intervention effectiveness study that addressed cognitive rehabilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive intervention approaches in use have been shown to have little or no effect on improving everyday life activity. Occupational therapy has a key research and practice role with the poststroke population, and occupational therapists should be at the forefront in developing the science to support the effectiveness of their services.

Automatic indexing and retrieval of encounter-specific evidence for point-of-care support

Evidence-based medicine relies on repositories of empirical research evidence that can be used to support clinical decision making for improved patient care. However, retrieving evidence from such repositories at local sites presents many challenges. This paper describes a methodological framework for automatically indexing and retrieving empirical research evidence in the form of the systematic reviews and associated studies from The Cochrane Library, where retrieved documents are specific to a patient–physician encounter and thus can be used to support evidence-based decision making at the point of care. Such an encounter is defined by three pertinent groups of concepts – diagnosis, treatment, and patient, and the framework relies on these three groups to steer indexing and retrieval of reviews and associated studies. An evaluation of the indexing and retrieval components of the proposed framework was performed using documents relevant for the pediatric asthma domain. Precision and recall values for automatic indexing of systematic reviews and associated studies were 0.93 and 0.87, and 0.81 and 0.56, respectively. Moreover, precision and recall for the retrieval of relevant systematic reviews and associated studies were 0.89 and 0.81, and 0.92 and 0.89, respectively. With minor modifications, the proposed methodological framework can be customized for other evidence repositories.

Late Quaternary aeolian and fluvial interactions on the Cooper Creek Fan and the association between linear and source-bordering dunes, Strzelecki Desert, Australia

The Innamincka Dome and associated low-gradient fan in the Strzelecki Desert is the product of Cenozoic crustal warping that has aided formation of an extensive array of palaeochannels, source-bordering transverse dunes and superimposed linear dunes. These dunes have impeded the course of Cooper Creek and provided a repository of evidence for Quaternary climate change as well as the interactive processes between transverse and linear dune formation. At Turra, Gidgealpa and sites nearby are extensive fluvial and aeolian sand bodies that date from marine isotope stages (MIS) 8–3 and the Last Glacial Maximum (LGM) and are now surrounded or buried by overbank mud. The sandy alluvium was deposited on the downstream slope of the dome by large channels transporting abundant bedload, subsequently blown northward to form transverse dunes from what were probably seasonally-exposed bars in a palaeo-Cooper system. Thermoluminescence (TL) and optically stimulated luminescence (OSL) ages demonstrate that the base of the dune complex is at least MIS 7 in age (∼250 ka) but that it has been subsequently reworked by wind with additional sand blown from the river. Source-bordering dunes formed during a period of enhanced river flow and sand supply from ∼120 to 100 ka, with another short episode of the same at ∼85–80 ka and from ∼68 to 53. The LGM was associated with enhanced flows and the supply of dune sediment, from 28 to 18 ka. Pronounced river flow and dune activity occurred in the early to mid Holocene, but there is no evidence of dunes being supplied from Cooper Creek since the LGM. The dunes forming the oldest basal sand units appear to be largely transverse in form and are aligned roughly parallel to adjacent east–west trending palaeochannels. Linear dunes have formed from and over these, and yield basal ages ranging from MIS 5 or MIS 4 but continuing to accrete and rework through to the Holocene. The study results in one of the few detailed chronological investigations of the interaction between transverse and linear dunes. It is apparent that long-distance sand transport has played no significant role in dune formation here for the linear dunes show no significant downwind decline in ages. Linear dunes appear to have accreted vertically from underlying transverse dunes. A wind-rift vertical accretion model with only minor lengthwise extension is the dominant mode of linear dune formation in this section of the Strzelecki Desert, the bulk of dune sediment being sourced from adjacent swales since the LGM.

George Goring (1608–1657): Caroline Courtier and Royalist General (review)

Reviewed by: George Goring (1608–1657): Caroline Courtier and Royalist General Mark Charles Fissel George Goring (1608–1657): Caroline Courtier and Royalist General. By Florene S. Memegalos. Burlington, Vt: Ashgate, 2007. ISBN 978-0-7546-5299-1. Maps. Illustrations. Notes. Select bibliography. Index. Pp. x, 392. $99.95. Florene Memegalos’s biography of Colonel George Goring is old-fashioned English military history at its most enjoyable. Employing the traditional narrative, she recites Goring’s adventures, particularly those during the reign of Charles I. The colonel fought on the Continent in the 1630s, in the English civil wars in the 1640s, and concluded a fairly distinguished career as a commissioned officer in the Spanish Army of Flanders in the 1650s. Although the events she recounts are familiar, Memegalos unearths new details (p. 225) in her treatment of a complicated and controversial warrior. Goring’s military reputation has been besmirched by allegations of debauchery and unprincipled behavior. Yet, his consistent [End Page 1277] employment, not to mention the trust placed in him by his king, queen, comrades, and several foreign governments, substantiates his dependability and talent. The author perused manuscripts in county record offices, the Bodleian Library, the British Library, and overseas archives. The main repository for evidence concerning English military history is the National Archives (formerly the Public Record Office), now located in the London suburb of Kew. Whilst the author’s investigation of auxiliary archives is superlative, she chose not to explore the National Archives, relying instead on the dated, incomplete, and occasionally inaccurate Calendar of State Papers, Domestic. A goodly amount of uncalendared material bearing directly on English warfare survives in the Exchequer class of documents (E 101, E 351, E 407, etc.), the War Office (WO 49, WO 50, etc.), and the Privy Council Registers (PC 2, available in printed facsimile in many cases). The veritable gold mine for the English civil war, however, is State Papers 28, comprised of scores of boxes of military documentation that lacks a published calendar. Goring’s name (and likely his signature) would doubtless turn up in these darker corners of the National Archives, and Memegalos possesses the skill to have a good trawl through this material. The colonel’s biography might have been described as definitive if she had perhaps another year or so to cull through these intriguing classifications. This book illuminates the royalist, rather than the parliamentary, officer corps. In the last decade a relatively complex historiography of the cavaliers has developed, and Goring’s royalism is a promising line of inquiry. His military identity and experiences may have been the determinants of those actions described by some as “deplorable”. As a veteran of the Low Countries’ Wars, Goring’s use of violence fits the continental model, and the latitude he granted his troops in plundering England’s West Country was more a matter of expediency than terror. His “unprincipled” political actions, such as divulging details of the Army Plot to Parliament, were based on a pragmatism and realpolitik that civilian royalists rarely fathomed, blinded as they were by ideology and family connection. Little wonder that some royalist courtiers, ministers, and politicians regarded Goring with disdain. In that sense, the book might appeal to a broader audience interested in how professional soldiers make their way through the political world. Mark Charles Fissel The Augusta Arsenal Augusta, Georgia Copyright © 2008 Society for Military History