Multidisciplinary strategies for the management of heart failure patients at high risk for admission - A systematic review of randomized trials

OBJECTIVES The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients. BACKGROUND Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients. METHODS Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts. RESULTS Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving. CONCLUSIONS Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations. (C) 2004 by the American College of Cardiology Foundation.

Ecological-economic modeling for biodiversity management: Potential, pitfalls, and prospects

Ecologists and economists both use models to help develop strategies for biodiversity management. The practical use of disciplinary models, however, can be limited because ecological models tend not to address the socioeconomic dimension of biodiversity management, whereas economic models tend to neglect the ecological dimension. Given these shortcomings of disciplinary models, there is a necessity to combine ecological and economic knowledge into ecological-economic models. It is insufficient if scientists work separately in their own disciplines and combine their knowledge only when it comes to formulating management recommendations. Such an approach does not capture feedback loops between the ecological and the socioeconomic systems. Furthermore, each discipline poses the management problem in its own way and comes up with its own most appropriate solution. These disciplinary solutions, however are likely to be so different that a combined solution considering aspects of both disciplines cannot be found. Preconditions for a successful model-based integration of ecology and economics include (1) an in-depth knowledge of the two disciplines, (2) the adequate identification and framing of the problem to be investigated, and (3) a common understanding between economists and ecologists of modeling and scale. To further advance ecological-economic modeling the development of common benchmarks, quality controls, and refereeing standards for ecological-economic models is desirable.

Fast evolution strategies

Evolution strategies are a class of general optimisation algorithms which are applicable to functions that are multimodal, nondifferentiable, or even discontinuous. Although recombination operators have been introduced into evolution strategies, the primary search operator is still mutation. Classical evolution strategies rely on Gaussian mutations. A new mutation operator based on the Cauchy distribution is proposed in this paper. It is shown empirically that the new evolution strategy based on Cauchy mutation outperforms the classical evolution strategy on most of the 23 benchmark problems tested in this paper. The paper also shows empirically that changing the order of mutating the objective variables and mutating the strategy parameters does not alter the previous conclusion significantly, and that Cauchy mutations with different scaling parameters still outperform the Gaussian mutation with self-adaptation. However, the advantage of Cauchy mutations disappears when recombination is used in evolution strategies. It is argued that the search step size plays an important role in determining evolution strategies' performance. The large step size of recombination plays a similar role as Cauchy mutation.

The use of stochastic dynamic programming in optimal landscape reconstruction for metapopulations

A decision theory framework can be a powerful technique to derive optimal management decisions for endangered species. We built a spatially realistic stochastic metapopulation model for the Mount Lofty Ranges Southern Emu-wren (Stipiturus malachurus intermedius), a critically endangered Australian bird. Using diserete-time Markov,chains to describe the dynamics of a metapopulation and stochastic dynamic programming (SDP) to find optimal solutions, we evaluated the following different management decisions: enlarging existing patches, linking patches via corridors, and creating a new patch. This is the first application of SDP to optimal landscape reconstruction and one of the few times that landscape reconstruction dynamics have been integrated with population dynamics. SDP is a powerful tool that has advantages over standard Monte Carlo simulation methods because it can give the exact optimal strategy for every landscape configuration (combination of patch areas and presence of corridors) and pattern of metapopulation occupancy, as well as a trajectory of strategies. It is useful when a sequence of management actions can be performed over a given time horizon, as is the case for many endangered species recovery programs, where only fixed amounts of resources are available in each time step. However, it is generally limited by computational constraints to rather small networks of patches. The model shows that optimal metapopulation, management decisions depend greatly on the current state of the metapopulation,. and there is no strategy that is universally the best. The extinction probability over 30 yr for the optimal state-dependent management actions is 50-80% better than no management, whereas the best fixed state-independent sets of strategies are only 30% better than no management. This highlights the advantages of using a decision theory tool to investigate conservation strategies for metapopulations. It is clear from these results that the sequence of management actions is critical, and this can only be effectively derived from stochastic dynamic programming. The model illustrates the underlying difficulty in determining simple rules of thumb for the sequence of management actions for a metapopulation. This use of a decision theory framework extends the capacity of population viability analysis (PVA) to manage threatened species.

Adjustment to a low-control situation: Reexamining the role of coping responses

The aim of the study was to test a revised conceptualization of the role of coping in adjustment to a low-control stressor-women's adjustment to a failed in vitro fertilization (NF) attempt. Data were collected prior to the IVF treatment (Time I) and twice after the failed NF attempt (1 to 2 weeks after finding out the results, n = 171, and fi weeks later, n = 139). Initial adjustment was assessed at Time I, whereas measures of coping and both self-report and partner ratings of adjustment were obtained at Times ? and 3. As predicted, escapist strategies and problem-management strategies (mainly at Time ?) were associated with poor adjustment, whereas problem-appraisal coping was associated with better adjustment., There was also support for the proposed positive relationship between adjustment and emotional approach coping (on self-report adjustment).

Increasing the efficiency of solute leaching: impacts of flow interruption with drainage of the "preferential flow paths"

Most soils contain preferential flow paths that can impact on solute mobility. Solutes can move rapidly down the preferential flow paths with high pore-water velocities, but can be held in the less permeable region of the soil matrix with low pore-water velocities, thereby reducing the efficiency of leaching. In this study, we conducted leaching experiments with interruption of the flow and drainage of the main flow paths to assess the efficiency of this type of leaching. We compared our experimental results to a simple analytical model, which predicts the influence of the variations in concentration gradients within a single spherical aggregate (SSA) surrounded by preferential flow paths on leaching. We used large (length: 300 mm, diameter: 216 mm) undisturbed field soil cores from two contrasting soil types. To carry out intermittent leaching experiments, the field soil cores were first saturated with tracer solution (CaBr2), and background solution (CaCl2) was applied to mimic a leaching event. The cores were then drained at 25- to 30-cm suction to empty the main flow paths to mimic a dry period during which solutes could redistribute within the undrained region. We also conducted continuous leaching experiments to assess the impact of the dry periods on the efficiency of leaching. The flow interruptions with drainage enhanced leaching by 10-20% for our soils, which was consistent with the model's prediction, given an optimised equivalent aggregate radius for each soil. This parameter quantifies the time scales that characterise diffusion within the undrained region of the soil, and allows us to calculate the duration of the leaching events and interruption periods that would lead to more efficient leaching. Application of these methodologies will aid development of strategies for improving management of chemicals in soils, needed in managing salts in soils, in improving fertiliser efficiency, and in reclaiming contaminated soils. (C) 2000 Elsevier Science B.V. All rights reserved.

Employee group memberships and organisational communication during organisational change

The preset study adopted an intergroup approach to information sharing and communication in three organisational samples during change. In Study 1, employees from a public hospital (N = 142) completed a survey measuring perceptions of organisational communication and strength of identification with the work unit and the organisation as a whole. Consistent with predictions, team members rated communication from double ingroup members (same work unit/same occupational group) more favourably than communication from partial group members (same work unit/different occupational group). Also as predicted, work unit identification was related to favourable ratings of work unit communication across occupational groups, whereas occupational identification was related to favourable ratings of work unit communication within occupational groups. In Study 2, strength of identification with three organisational groups was associated with positive ratings of communication among employees from the same public hospital (N = 189) and a military organisation (N = 2119). Based on these results, intergroup strategies for the management of information sharing and organisational communication during change are discussed.

Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Development of a measure to assess coping for auditory hallucinations

This paper describes the development of an instrument to assess coping strategies for auditory hallucinations. An inventory of coping strategies was obtained by conducting semi-structured interviews with 17 male participants. This inventory was then used to develop a 27-item questionnaire, the Responses to Auditory Hallucinations Questionnaire (RAHQ). The RAHQ was administered to 125 respondents. Measures of symptom severity, appraisal, anxiety, depression and coping dissatisfaction were also administered. Factor Analysis of the RAHQ yielded three coping subscales, Active coping, Passive coping and Suppression coping. The subscales were shown to be empirically distinct and to possess satisfactory internal reliability. For a small subgroup of participants, two of the three subscales demonstrated satisfactory test-retest reliability. Construct validity was assessed within a stress and coping framework. The RAHQ will facilitate the investigation of the efficacy of coping strategies for the management of auditory hallucinations.

Optimal release strategies for biological control agents: an application of stochastic dynamic programming to population management

1. Establishing biological control agents in the field is a major step in any classical biocontrol programme, yet there are few general guidelines to help the practitioner decide what factors might enhance the establishment of such agents. 2. A stochastic dynamic programming (SDP) approach, linked to a metapopulation model, was used to find optimal release strategies (number and size of releases), given constraints on time and the number of biocontrol agents available. By modelling within a decision-making framework we derived rules of thumb that will enable biocontrol workers to choose between management options, depending on the current state of the system. 3. When there are few well-established sites, making a few large releases is the optimal strategy. For other states of the system, the optimal strategy ranges from a few large releases, through a mixed strategy (a variety of release sizes), to many small releases, as the probability of establishment of smaller inocula increases. 4. Given that the probability of establishment is rarely a known entity, we also strongly recommend a mixed strategy in the early stages of a release programme, to accelerate learning and improve the chances of finding the optimal approach.

Change in woolgrower profits from adopting staple strength-enhancing management strategies

Wool tenderness is a significant problem in Australia, especially in areas where sheep graze under highly seasonal conditions. In this study, a profit function model is specified, estimated and simulated to assess the economic impact of staple strength-enhancing research on the profits of Australian woolgrowers. The model is based on a number of fundamental characteristics of the Australian wool industry and the staple-strength enhancing technology being assessed. The model consists of a system of demand and supply equations that are specified in terms of effective, rather than actual, prices. The interrelationships between the inputs and outputs are allowed for in the model in a manner that is consistent with theoretical restrictions. The adoption of the new feed management strategy results in a 4.4% increase in the expected profits of Australian wool producers in the short-run, and a 2.2% increase in expected profits in the long-run.

Strategies of accommodation: Development of a coding system for conversational interaction

This study describes a coding system developed to operationalize the sociolinguistic strategies proposed by communication accommodation theory (CAT) in an academic context. Fifty interactions between two students (of Australian or Chinese ethnic background) or a student and faculty member were videotaped. A turn- and episode-based coding system was developed, focusing on verbal and nonverbal behavior. The development of this system is described in detail, before results are presented. Results indicated that status was the main influence on choice of strategies, particularly the extent and type of discourse management and interpersonal control. Participants' sew and ethnicity also played a role: Male participants made more use of interpretability (largely questions), whereas female participants used discourse management to develop a shared perspective. The results make clear that there is no automatic correspondence between behaviors and the strategies they constitute, and they point to the appropriateness of conceptualizing behavior and strategies separately in CAT.