Guidelines on artificial nutrition versus hydration in terminal cancer patients

Whether a terminally ill cancer patient should be actively fed or simply hydrated through subcutaneous or intravenous infusion of isotonic fluids is a matter of ongoing controversy among clinicians involved in the care of these patients. Under the auspices of the European Association for Palliative Care, a committee of experts developed guidelines to help clinicians make a reasonable decision on what type of nutritional support should be provided on a case-by-case basis. It was acknowledged that part of the controversy related to the definition of the terminal cancer patient, since this is a heterogeneous group of patients with different needs, expectations, and potential for a medical intervention. A major difficulty is the prediction of life expectancy and the patient's likely response to vigorous nutritional support. In an attempt to reach a decision on the type of treatment support (artificial nutrition vs. hydration) which would best meet the needs and expectations of the patient, we propose a three-step process: Step I: define the eight key elements necessary to reach a decision: Step II: make the decision; and Step III: reevaluate the patient and the proposed treatment at specified intervals. Step I involves assessing the patient concerning the following: 1) oncological/clinical condition; 2) symptoms; 3) expected length of survival; 4) hydration and nutritional status; 5) spontaneous or voluntary nutrient intake; 6) psychological profile; 7) gut function and potential route of administration; and 8) need for special services based on type of nutritional support prescribed. Step II involves the overall assessment of pros and cons, based on information determined in Step I, in order to reach an appropriate decision based on a well-defined end point (i.e. improvement of quality of life; maintaining patient survival; attaining rehydration). Step III involves the periodic reevaluation of the decision made in Step II based on the proposed goal and the attained result.

Kappa calculus and evidential strength: A note on Åqvist's logical theory of legal evidence

Lennart Åqvist (1992) proposed a logical theory of legal evidence, based on the Bolding-Ekelöf of degrees of evidential strength. This paper reformulates Åqvist's model in terms of the probabilistic version of the kappa calculus. Proving its acceptability in the legal context is beyond the present scope, but the epistemological debate about Bayesian Law isclearly relevant. While the present model is a possible link to that lineof inquiry, we offer some considerations about the broader picture of thepotential of AI & Law in the evidentiary context. Whereas probabilisticreasoning is well-researched in AI, calculations about the threshold ofpersuasion in litigation, whatever their value, are just the tip of theiceberg. The bulk of the modeling desiderata is arguably elsewhere, if one isto ideally make the most of AI's distinctive contribution as envisaged forlegal evidence research.

Assessing the sensitivity of Sabellaria spinulosa to pressures associated with marine activities.

The Joint Nature Conservation Committee (JNCC) commissioned this project to generate an improved understanding of the sensitivities of Sabellaria spinulosa reefs based on the OSPAR habitat definition. This work aimed to provide an evidence base to facilitate and support management advice for Marine Protected Areas, development of UK marine monitoring and assessment, and conservation advice to offshore marine industries. The OSPAR list of threatened and declining species and habitats refers to subtidal S. spinulosa reefs on hard or mixed substratum. S. spinulosa may also occur as thin crusts or individual worms but these are not the focus of conservation. The purpose of this project was to produce sensitivity assessments with supporting evidence for S. spinulosa reefs, clearly documenting the evidence behind the assessments and the confidence in these assessments. Sixteen pressures, falling in five categories - biological, hydrological, physical damage, physical loss, and pollution and other chemical changes - were assessed in this report. To develop each sensitivity assessment, the resistance and resilience of the key elements of the habitat were assessed against the pressure benchmark using the available evidence. The benchmarks were designed to provide a ‘standard’ level of pressure against which to assess sensitivity. The highest sensitivity (‘medium’) was recorded for physical pressures which directly impact the reefs including: • habitat structure changes – removal of substratum; • abrasion and penetration and sub-surface disturbance; • physical loss of habitat and change to habitat; and • siltation rate changes including and smothering. The report found that no evidence for differences in the sensitivity of the three EUNIS S. spinulosa biotopes that comprise the OSPAR definition. However, this evidence review has identified significant information gaps regarding sensitivity, ecological interactions with other species and resilience. No clear difference in resilience was established across the OSPAR S. spinulosa biotopes that were assessed in this report. Using a clearly documented, evidence based approach to create sensitivity assessments allows the assessment and any subsequent decision making or management plans to be readily communicated, transparent and justifiable. The assessments can be replicated and updated where new evidence becomes available ensuring the longevity of the sensitivity assessment tool. Finally, as S. spinulosa habitats may also contribute to ecosystem function and the delivery of ecosystem services, understanding the sensitivity of these biotopes may also support assessment and management in regard to these. Whatever objective measures are applied to data to assess sensitivity, the final sensitivity assessment is indicative. The evidence, the benchmarks, the confidence in the assessments and the limitations of the process, require a sense-check by experienced marine ecologists before the outcome is used in management decisions.

Parent education and home-based behaviour analytic intervention: an examination of parents' perceptions of outcome

There is convincing evidence that applied behaviour analysis (ABA) offers a highly effective form of intervention for children with autistic spectrum disorder (ASD). There is less evidence, however, about how parents perceive and evaluate ABA programmes. In this paper an examination of parents’ perceptions of outcome is reported. Twenty-two questionnaires were completed by two groups of parents. The first group had just completed an introductory course in ABA and were in the early stages of implementing ABA programmes with their children. The second group had been involved in ABA education for more than 2 years. Overall, both groups of parents reported a positive impact of ABA on the lives of their children, their family life, and themselves. The long- term group reported that they had achieved complex goals with their children, whilst the short-term group reported an immediate positive impact on child and family functioning and parental self-esteem. Conclusions are drawn in the context of evidence-based practice.

Generic, disease-specific and individualised approaches to measuring health-related quality of life among people with heart disease - a comparative analysis.

Increasing emphasis is being placed on the evaluation of health-related quality of life. However, there is no consensus on the definition of this concept and as a result there are a plethora of existing measurement instruments. Head-to-head comparisons of the psychometric properties of existing instruments are necessary to facilitate evidence-based decisions about which instrument should be chosen for routine use. Therefore, an individualised instrument (the modified Patient Generated Index), a generic instrument (the Short Form 36) and a disease-specific instrument (the Quality of Life after Myocardial Infarction questionnaire) were administered to patients with ischaemic heart disease (n=117) and the evidence for the validity, reliability and sensitivity of each instrument was examined and compared. The modified Patient Generated Index compared favourably with the other instruments but none of the instruments examined provided sound evidence for sensitivity to change. Therefore, any recommendation for the use of the individualised approach in the routine collection of health-related quality of life data in clinical practice must be conditional upon the submission of further evidence to support the sensitivity of such instruments.

Development of a Complex Intervention for Secondary Prevention of Coronary Heart Disease in Primary Care Using the UK Medical Research Council Framework

Objective: To apply the UK Medical Research Council (MRC) framework for development and evaluation of trials of complex interventions to a primary healthcare intervention to promote secondary prevention of coronary heart disease. Study Design: Case report of intervention development. Methods: First, literature relating to secondary prevention and lifestyle change was reviewed. Second, a preliminary intervention was modeled, based on literature findings and focus group interviews with patients (n = 23) and staff (n = 29) from 4 general practices. Participants’ experiences of and attitudes toward key intervention components were explored. Third, the preliminary intervention was pilot-tested in 4 general practices. After delivery of the pilot intervention, practitioners evaluated the training sessions, and qualitative data relating to experiences of the intervention were collected using semistructured interviews with staff (n = 10) and patient focus groups (n = 17). Results: Literature review identified 3 intervention components: a structured recall system, practitioner training, and patient information. Initial qualitative data identified variations in recall system design, training requirements (medication prescribing, facilitating behavior change), and information appropriate to the prospective study participants. Identifying detailed structures within intervention components clarified how the intervention could be tailored to individual practice, practitioner, and patient needs while preserving the theoretical functions of the components. Findings from the pilot phase informed further modeling of the intervention, reducing administrative time, increasing practical content of training, and omitting unhelpful patient information. Conclusion: Application of the MRC framework helped to determine the feasibility and development of a complex intervention for primary care research.

Revisión sistemática de la producción española sobre rendimiento académico entre 1980 y 2011

El bajo rendimiento académico sigue siendo un problema de investigación de gran impacto social. Sin embargo, los resultados científicos no están teniendo repercusión en la mejora, ni en las políticas educativas. En este trabajo nos propusimos identificar, ordenar, analizar y extraer conclusiones sobre la producción española sobre rendimiento académico, con el fin de visualizarla y derivar problemas futuros objeto de investigación. Para ello se llevó a cabo un estudio de revisión en seis etapas, en el que se combinaron procedimientos metodológicos de investigación de síntesis y de investigación bibliométrica. Se identificaron las publicaciones en cuatro bases de datos españolas; posteriormente se analizaron y codificaron los datos extraídos alrededor de nueve indicadores: título, año, tipo de documento, editorial, autor, número autores, institución, comunidad autónoma y tema. Los resultados muestran una producción constante y creciente (1595 referencias), pero dispersa, tanto por el inmenso número de autores que publican, la mayoría con un solo trabajo, como por los lugares donde publican. Las temáticas más tratadas se refieren en primer lugar a modelos explicativos, diagnóstico y tratamiento; en segundo lugar se abordan los factores y variables determinantes del bajo y alto rendimiento académico; en tercer lugar se desarrollan estudios sobre legislación y de otras variables psicológicas y educativas en relación con el rendimiento. Este estudio supone una aproximación sintetizada de la producción sobre rendimiento académico en España, y un primer paso para investigaciones de síntesis posteriores, que nos permitan identificar buenas prácticas para el ejercicio de “prácticas basadas en la evidencia”, y otros problemas de investigación.