Communication of scientific uncertainty: International case studies on the development of folate and vitamin D Dietary Reference Values

Objective Transparent evidence-based decision making has been promoted worldwide to engender trust in science and policy making. Yet, little attention has been given to transparency implementation. The degree of transparency (focused on how uncertain evidence was handled) during the development of folate and vitamin D Dietary Reference Values was explored in three a priori defined areas: (i) value request; (ii) evidence evaluation; and (iii) final values. Design Qualitative case studies (semi-structured interviews and desk research). A common protocol was used for data collection, interview thematic analysis and reporting. Results were coordinated via cross-case synthesis. Setting Australia and New Zealand, Netherlands, Nordic countries, Poland, Spain and UK. Subjects Twenty-one interviews were conducted in six case studies. Results Transparency of process was not universally observed across countries or areas of the recommendation setting process. Transparency practices were most commonly seen surrounding the request to develop reference values (e.g. access to risk manager/assessor problem formulation discussions) and evidence evaluation (e.g. disclosure of risk assessor data sourcing/evaluation protocols). Fewer transparency practices were observed to assist with handling uncertainty in the evidence base during the development of quantitative reference values. Conclusions Implementation of transparency policies may be limited by a lack of dedicated resources and best practice procedures, particularly to assist with the latter stages of reference value development. Challenges remain regarding the best practice for transparently communicating the influence of uncertain evidence on the final reference values. Resolving this issue may assist the evolution of nutrition risk assessment and better inform the recommendation setting process.

Evaluation of three field monitoring-density estimation protocols and their relevance to Komodo dragon conservation

Finding practical ways to robustly estimate abundance or density trends in threatened species is a key facet for effective conservation management. Further identifying less expensive monitoring methods that provide adequate data for robust population density estimates can facilitate increased investment into other conservation initiatives needed for species recovery. Here we evaluated and compared inference-and cost-effectiveness criteria for three field monitoring-density estimation protocols to improve conservation activities for the threatened Komodo dragon (Varanus komodoensis). We undertook line-transect counts, cage trapping and camera monitoring surveys for Komodo dragons at 11 sites within protected areas in Eastern Indonesia to collect data to estimate density using distance sampling methods or the Royle-Nichols abundance induced heterogeneity model. Distance sampling estimates were considered poor due to large confidence intervals, a high coefficient of variation and that false absences were obtained in 45 % of sites where other monitoring methods detected lizards present. The Royle-Nichols model using presence/absence data obtained from cage trapping and camera monitoring produced highly correlated density estimates, obtained similar measures of precision and recorded no false absences in data collation. However because costs associated with camera monitoring were considerably less than cage trapping methods, albeit marginally more expensive than distance sampling, better inference from this method is advocated for ongoing population monitoring of Komodo dragons. Further the cost-savings achieved by adopting this field monitoring method could facilitate increased expenditure on alternative management strategies that could help address current declines in two Komodo dragon populations.

The delivery of a telephone coaching programme to people with type 2 diabetes by practice nurses in Victoria, Australia : a qualitative evaluation

Aim.  To evaluate telephone coaching undertaken by practice nurses in a randomised controlled trial of self-management support for people with type 2 diabetes.

Background.  Qualitative evaluation of the processes that take place in randomised controlled trials has the advantage of providing information on those variables that contribute to the success or failure of the randomised controlled trial. This additional information can be used to improve or modify chronic disease management programme designs.

Methods.  Grounded theory was used to analyse transcriptions of telephone coaching sessions between practice nurses and patient participants in the randomised controlled trial.

Findings.   Analysis of transcriptions found that patient participants had complex multiple medical conditions to manage, as well as maintaining their daily lives. Two approaches to working with this complexity by practice nurses emerged. We characterised one as ‘treat to target’ and the other as ‘personalised care’. While each approach shapes identities available to patients within the relationship with the practice nurse, the impact or effectiveness of these approaches on outcomes has yet to be reported.

Conclusions.  Telephone coaching takes place in complex social contexts as well as complex medical conditions. People with type 2 diabetes must manage their diabetes care and their care of other conditions within their social contexts. This means a constant negotiation of priorities.

Relevance to clinical practice.  Awareness of how health professional support for patients’ self-management becomes a relationship and element of the negotiated identity of patients is important in adapting clinical guideline-based protocols to achieving targets in the management of chronic illness.

Disease burden evaluation of fall-related events in the elderly due to hypoglycemia and other diabetic complications: a clinical review

A hypoglycemia-induced fall is common in older persons with diabetes. The etiology of falls in this population is usually multifactorial, and includes microvascular and macrovascular complications and age-related comorbidities, with hypoglycemia being one of the major precipitating causes. In this review, we systematically searched the literature that was available up to March 31, 2014 from MEDLINE/PubMed, Embase, and Google Scholar using the following terms: hypoglycemia; insulin; diabetic complications; and falls in elderly. Hypoglycemia, defined as blood glucose <4.0 mmol/L (70 mg/dL) requiring external assistance, occurs in one-third of elderly diabetics on glucose-lowering therapies. It represents a major barrier to the treatment of diabetes, particularly in the elderly population. Patients who experience hypoglycemia are at a high risk for adverse outcomes, including falls leading to bone fracture, seizures, cognitive dysfunction, and prolonged hospital stays. An increase in mortality has been observed in patients who experience any one of these events. Paradoxically, rational insulin therapy, dosed according to a patient's clinical status and the results of home blood glucose monitoring, so as to achieve and maintain recommended glycemic goals, can be an effective method for the prevention of hypoglycemia and falls in the elderly. Contingencies, such as clinician-directed hypoglycemia treatment protocols that guide the immediate treatment of hypoglycemia, help to limit both the duration and severity of the event. Older diabetic patients with or without underlying renal insufficiency or other severe illnesses represent groups that are at high risk for hypoglycemia-induced falls and, therefore, require lower insulin dosages. In this review, the risk factors of falls associated with hypoglycemia in elderly diabetics were highlighted and management plans were suggested. A target hemoglobin A1c level between 7% and 8% seems to be more appropriate for this population. In addition, the first-choice drugs should have good safety profiles and have the lowest probability of causing hypoglycemia - such as metformin (in the absence of significant renal impairment) and incretin enhancers - while other therapies that may cause more frequent hypoglycemia should be avoided.

Energy-efficiency analysis of cluster-based routing protocols in wireless sensor network

This paper extends the conditions of the cluster-based routing protocols in terms of general algorithm complexity of data fusion, general compressing ratio of data fusion, and network area with long distance. Corresponding three general evaluation methods to evaluate the energy efficiency of the cluster-based routing protocols such as LEACH, PEGASIS, and BCDCP are provided. Moreover, three facts are found in them: (1) High-level software energy macro model is used to compute the energy dissipation of general data fusion software and make the constant value of energy dissipation of 1-bit data fusion an especial instance. (2) Multi-hop energy efficiency is related to the radio hardware parameters and the dynamic topology of network and the above protocols do not exploit the best use of the energy efficiency of multi-hop scheme. (3) High-energy dissipation non-cluster-head nodes, whose number changes with the density of the sensor nodes in clusters, worsen the death of nodes. The numerical results of experiments reprove these discoveries. Furthermore, they provide helpful guide for improving the above routing protocols to extent their application ranges.

Evaluating impact of clinical guidelines using a realist evaluation framework

RATIONALE, AIMS AND OBJECTIVES: The Remote Primary Health Care Manuals (RPHCM) project team manages the development and publication of clinical protocols and procedures for primary care clinicians practicing in remote Australia. The Central Australian Rural Practitioners Association Standard Treatment Manual, the flagship manual of the RPHCM suite, has been evaluated for accessibility and acceptability in remote clinics three times in its 20-year history. These evaluations did not consider a theory-based framework or a programme theory, resulting in some limitations with the evaluation findings. With the RPHCM having an aim of enabling evidence-based practice in remote clinics and anecdotally reported to do so, testing this empirically for the full suite is vital for both stakeholders and future editions of the RPHCM. METHODS: The project team utilized a realist evaluation framework to assess how, why and for what the RPHCM were being used by remote practitioners. A theory regarding the circumstances in which the manuals have and have not enabled evidence-based practice in the remote clinical context was tested. The project assessed this theory for all the manuals in the RPHCM suite, across government and aboriginal community-controlled clinics, in three regions of Australia. CONCLUSION: Implementing a realist evaluation framework to generate robust findings in this context has required innovation in the evaluation design and adaptation by researchers. This article captures the RPHCM team's experience in designing this evaluation.