Responding to Young People's Health Risks in Primary Care: A Cluster Randomised Trial of Training Clinicians in Screening and Motivational Interviewing.

OBJECTIVE: To evaluate the effectiveness of a complex intervention implementing best practice guidelines recommending clinicians screen and counsel young people across multiple psychosocial risk factors, on clinicians' detection of health risks and patients' risk taking behaviour, compared to a didactic seminar on young people's health. DESIGN: Pragmatic cluster randomised trial where volunteer general practices were stratified by postcode advantage or disadvantage score and billing type (private, free national health, community health centre), then randomised into either intervention or comparison arms using a computer generated random sequence. Three months post-intervention, patients were recruited from all practices post-consultation for a Computer Assisted Telephone Interview and followed up three and 12 months later. Researchers recruiting, consenting and interviewing patients and patients themselves were masked to allocation status; clinicians were not. SETTING: General practices in metropolitan and rural Victoria, Australia. PARTICIPANTS: General practices with at least one interested clinician (general practitioner or nurse) and their 14-24 year old patients. INTERVENTION: This complex intervention was designed using evidence based practice in learning and change in clinician behaviour and general practice systems, and included best practice approaches to motivating change in adolescent risk taking behaviours. The intervention involved training clinicians (nine hours) in health risk screening, use of a screening tool and motivational interviewing; training all practice staff (receptionists and clinicians) in engaging youth; provision of feedback to clinicians of patients' risk data; and two practice visits to support new screening and referral resources. Comparison clinicians received one didactic educational seminar (three hours) on engaging youth and health risk screening. OUTCOME MEASURES: Primary outcomes were patient report of (1) clinician detection of at least one of six health risk behaviours (tobacco, alcohol and illicit drug use, risks for sexually transmitted infection, STI, unplanned pregnancy, and road risks); and (2) change in one or more of the six health risk behaviours, at three months or at 12 months. Secondary outcomes were likelihood of future visits, trust in the clinician after exit interview, clinician detection of emotional distress and fear and abuse in relationships, and emotional distress at three and 12 months. Patient acceptability of the screening tool was also described for the intervention arm. Analyses were adjusted for practice location and billing type, patients' sex, age, and recruitment method, and past health risks, where appropriate. An intention to treat analysis approach was used, which included multilevel multiple imputation for missing outcome data. RESULTS: 42 practices were randomly allocated to intervention or comparison arms. Two intervention practices withdrew post allocation, prior to training, leaving 19 intervention (53 clinicians, 377 patients) and 21 comparison (79 clinicians, 524 patients) practices. 69% of patients in both intervention (260) and comparison (360) arms completed the 12 month follow-up. Intervention clinicians discussed more health risks per patient (59.7%) than comparison clinicians (52.7%) and thus were more likely to detect a higher proportion of young people with at least one of the six health risk behaviours (38.4% vs 26.7%, risk difference [RD] 11.6%, Confidence Interval [CI] 2.93% to 20.3%; adjusted odds ratio [OR] 1.7, CI 1.1 to 2.5). Patients reported less illicit drug use (RD -6.0, CI -11 to -1.2; OR 0·52, CI 0·28 to 0·96), and less risk for STI (RD -5.4, CI -11 to 0.2; OR 0·66, CI 0·46 to 0·96) at three months in the intervention relative to the comparison arm, and for unplanned pregnancy at 12 months (RD -4.4; CI -8.7 to -0.1; OR 0·40, CI 0·20 to 0·80). No differences were detected between arms on other health risks. There were no differences on secondary outcomes, apart from a greater detection of abuse (OR 13.8, CI 1.71 to 111). There were no reports of harmful events and intervention arm youth had high acceptance of the screening tool. CONCLUSIONS: A complex intervention, compared to a simple educational seminar for practices, improved detection of health risk behaviours in young people. Impact on health outcomes was inconclusive. Technology enabling more efficient, systematic health-risk screening may allow providers to target counselling toward higher risk individuals. Further trials require more power to confirm health benefits. TRIAL REGISTRATION: ISRCTN.com ISRCTN16059206.

The consequences of burnout syndrome among healthcare professionals in Spain ans Spanish speaking Latin American countrie

Objectives: Identify the frequency and intensity of the perception of adverse professional consequences and their association with burnout syndrome and occupational variables. Methods: Cross-sectional sample of 11,530 healthcare professionals resident in Spain and Latin America. The association of negative work-related consequences on burnout, as measured by the MBI and work-related variables was analysed by multiple logistic regression. Results: The emotional exhaustion was the first variable associated with absenteeism, with intention of giving up profession, personal deterioration, and family deterioration. Depersonalization was most associated with the perception of having made mistakes. Conclusions: The findings indicate a considerable prevalence of adverse work-related consequences

Should Koos I Vestibular Schwannomas Be Treated Early with Gamma Knife Surgery? A Prospective Series of 42 Consecutive Cases

Background: Gamma Knife surgery (GKS) for vestibular schwannomas (VS) has a long-term clinical and scientific track record. After a period of de-escalation of dose prescription, results show a high rate of tumor control with improvement of clinical outcome (less than 1% facial palsy, 50-70% hearing preservation). Currently, there is controversial data about the active early treatment of intracanalicular (Koos I) VS. Methods: We prospectively analyzed 208 VS, focusing on 42 Koos I patients treated with GKS as first intention in Lausanne University Hospital, between July 2010 and February 2015. We concentrated on patient, tumor, and dosimetric characteristics. Special attention was given on the dose to the cochlea and its impact in maintaining serviceable hearing. Results: The mean follow-up period was 1.7 years (range 0.6-4.2). Twenty-six (61.9%) were females and 16 (38.1%) males. Preoperative serviceable hearing was present in 33 (78.57%) patients. The mean maximal diameter was 7.7 (5-10). The median target volume at the moment of GKS was 90 mm3 (range 17-317). The median prescription isodose volume was 118 mm3 (range 37-603). The median marginal dose administrated was 12 Gy (range 11-12). The median number of shots was 2 (range 1-9). The median isodose prescription was 50% (range 45-80%). The median maximal dose received by the cochlea in patients in GR class 1 and 2 was 4.2 Gy (mean 4.4 Gy, range 1.8-7.6). Our preliminary results showed 98% tumor control, with 30% shrinkage on MRI. The actuarial probability of keeping the same audition class for those with functional hearing at GKS was 80% at 3 years; the probability of keeping a functional hearing was more than 90%. A paraclinical evolution (on MRI and/or audiometry) at the time diagnosis, before GKS, was associated with a less good prognosis (p < 0.05). Conclusions: Our preliminary data suggest that Koos I patients should be treated early with GKS, before tumor growth, and/or hearing deterioration, as they have the highest probability of hearing preservation. The results in terms of functional outcome seemed comparable to, or even better than, the other Koos classes (i.e., larger lesions).

WorldSkills - ammattitaitovalmennus osana kone- ja metallialan kilpailukykyä

Nykyaikain ammattitaitovalmennus alkaa olla verrattavissa huippu-urheiluun ja sen sisältämiin valmennusprosesseihin. Tämän tutkimuksen tavoitteena oli kartoittaa ne prosessit, joita käyttämällä ammattitaitovalmennettava saadaan tiedollisesti ja taidollisesti mandollisimman hyvin valmennettua WorldSkills-tason kilpailuihin. Valittuja prosesseja soveltaen ohjeistetaan CAD-suunnittelun valmennus ja kokonaisvaltainen valmistautuminen kilpailuihin. Hyvänä taustapohjana on tutkimuksen tekijän omakohtainen osallistuminen Taitaja-2007 kilpailun järjestämiseen lajivastaavana CAD-suunnittelussa. Tutkimuksessa tehtiin myös kartoitus kilpailutoiminnan vaikuttavuudesta ja sen mandollisista vaikutuksista kone- ja metallialan koulutukseen hakeutuvien nuorten määriin. Tutkimuksen pääkohteina olivat Taitaja-kilpailujen järjestäjinä toimineet paikkakunnat ja koulutuksenjärjestäjät peräkkäisiltä vuosilta eli Turku, Tampere ja Joensuu. Tämän lisäksi Helsingissä järjestetty WorldSkills-2005 kilpailu aiheutti positiivisia vaikutuksia koko ammattitaitovalmennuksen kenttään ja sen esille nostamiseen ammatillisessa koulutuksessa. Näitä tietoja ja prosesseja voidaan käyttää hyväksi ammattitaitovalmennuksen kanssa toimivien oppilaitoksien, työpaikkojen ja valmentajien sekä muiden asiasta kiinnostuneiden tahojen jatkossa tehtävään valmennukseen liittyvään kehitystyöhön.

Rapport sur le contrôle des pratiques salariales au regard de l'égalité entre femmes et hommes dans les administrations cantonales et communales : résultats de l'enquête EPSACC-2014

L'objectif de cette étude est de faire le point sur les analyses et contrôles des pratiques salariales du point de vue de l'égalité entre les femmes et les hommes dans et par les administrations cantonales et communales en Suisse. La première partie du rapport décrit le niveau et la répartition de l'emploi selon le sexe et le type d'employeur ainsi que le niveau des salaires et les écarts salariaux dans l'administration publique centrale (APC), cantonale et communale, sur la base des données de l'OFS. Ce domaine est encore très peu étudié et les sources y sont rares et difficiles d'accès. La deuxième partie décrit la situation du contrôle des pratiques salariales (CPS) dans les administrations publiques cantonales et communales ainsi que pour les marchés publics et les subventions octroyés par ces institutions. 64 % des administrations cantonales et communales déclarent vérifier leurs pratiques salariales, ou avoir l'intention de le faire dans un avenir proche. En revanche, les contrôles des marchés publics sont plus rares - seules onze administrations (16 %) en réalisent. Or, le principe de l'égalité entre femmes et hommes figure dans l'Accord intercantonal sur les marchés publics et doit également être respecté lors de l'attribution de mandats publics. Sur 26 cantons, 22 ont répondu au sondage en ligne, ainsi que 47 villes de plus de 10 000 habitants sur 137.

Neoadjuvant chemotherapy and extrapleural pneumonectomy of malignant pleural mesothelioma with or without hemithoracic radiotherapy (SAKK 17/04): a randomised, international, multicentre phase 2 trial.

BACKGROUND: Postoperative hemithoracic radiotherapy has been used to treat malignant pleural mesothelioma, but it has not been assessed in a randomised trial. We assessed high-dose hemithoracic radiotherapy after neoadjuvant chemotherapy and extrapleural pneumonectomy in patients with malignant pleural mesothelioma. METHODS: We did this phase 2 trial in two parts at 14 hospitals in Switzerland, Belgium, and Germany. We enrolled patients with pathologically confirmed malignant pleural mesothelioma; resectable TNM stages T1-3 N0-2, M0; WHO performance status 0-1; age 18-70 years. In part 1, patients were given three cycles of neoadjuvant chemotherapy (cisplatin 75 mg/m(2) and pemetrexed 500 mg/m(2) on day 1 given every 3 weeks) and extrapleural pneumonectomy; the primary endpoint was complete macroscopic resection (R0-1). In part 2, participants with complete macroscopic resection were randomly assigned (1:1) to receive high-dose radiotherapy or not. The target volume for radiotherapy encompassed the entire hemithorax, the thoracotomy channel, and mediastinal nodal stations if affected by the disease or violated surgically. A boost was given to areas at high risk for locoregional relapse. The allocation was stratified by centre, histology (sarcomatoid vs epithelioid or mixed), mediastinal lymph node involvement (N0-1 vs N2), and T stage (T1-2 vs T3). The primary endpoint of part 1 was the proportion of patients achieving complete macroscopic resection (R0 and R1). The primary endpoint in part 2 was locoregional relapse-free survival, analysed by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT00334594. FINDINGS: We enrolled patients between Dec 7, 2005, and Oct 17, 2012. Overall, we analysed 151 patients receiving neoadjuvant chemotherapy, of whom 113 (75%) had extrapleural pneumonectomy. Median follow-up was 54·2 months (IQR 32-66). 52 (34%) of 151 patients achieved an objective response. The most common grade 3 or 4 toxic effects were neutropenia (21 [14%] of 151 patients), anaemia (11 [7%]), and nausea or vomiting (eight [5%]). 113 patients had extrapleural pneumonectomy, with complete macroscopic resection achieved in 96 (64%) of 151 patients. We enrolled 54 patients in part 2; 27 in each group. The main reasons for exclusion were patient refusal (n=20) and ineligibility (n=10). 25 of 27 patients completed radiotherapy. Median total radiotherapy dose was 55·9 Gy (IQR 46·8-56·0). Median locoregional relapse-free survival from surgery, was 7·6 months (95% CI 4·5-10·7) in the no radiotherapy group and 9·4 months (6·5-11·9) in the radiotherapy group. The most common grade 3 or higher toxic effects related to radiotherapy were nausea or vomiting (three [11%] of 27 patients), oesophagitis (two [7%]), and pneumonitis (two [7%]). One patient died of pneumonitis. We recorded no toxic effects data for the control group. INTERPRETATION: Our findings do not support the routine use of hemithoracic radiotherapy for malignant pleural mesothelioma after neoadjuvant chemotherapy and extrapleural pneumonectomy. FUNDING: Swiss Group for Clinical Cancer Research, Swiss State Secretariat for Education, Research and Innovation, Eli Lilly.

Pharmacogenetic and clinical study on adverse effects induced by psychotropic drugs

Second-generation antipsychotics (SGAs) have become the first-line antipsychotic treatment for psychotic disorders due to their better overall tolerance compared to classical antipsychotics. However, metabolic side effects such as weight gain are frequently described during treatment with SGAs and/or other psychotropic drugs including some antidepressants and mood stabilizers, which may also result in poor adherence to treatment. The aim of this work was to investigate different methods to predict common side effects, in particular weight gain during treatment with weight gain inducing psychotropic drugs. Firstly, clinical data were used to determine the potential predictive power of a one month weight gain on weight increase after three and 12 months of treatment (n=351 patients). A fast and strong weight gain of >5% after a period of one month (>5%WG) was found to be the best predictor for an important weight gain at three (>15%) and 12 months (>20%). Similar analyses in an independent cohort of psychiatric adolescents (n=42), showed that a comparable >4% weight gain at one month is the best predictor for an important weight gain at three months (>15%). Secondly, we aimed to determine whether an extensive analysis of genes could be used, in addition to clinical factors, to predict patients at risk for >5%WG or for type 2 diabetes (T2D). Adding genetic markers to clinical variables to predict >5%WG increased significantly the area under the curve (AUC) of the analysis (AUCfinai:0.92, AUCdmicai:0.75, pcO.OOOl, n=248). Conversely, genetic risk scores were found to be associated with T2D (OR: 2.5, p=0.03, n=285) but without a significant increase of AUC'when compared to the prediction based to clinical factors alone. Finally, therapeutic drug monitoring was used to predict extrapyramidal symptoms during risperidone treatment (n=150). Active moiety (sum of risperidone and of its active metabolite 9- hydroxyrisperidone plasma concentrations) of >40 ng/ml should be targeted only in case of insufficient response. These results highlight different approaches for personalizing psychotropic treatments in order to reduce related side effects. Further research is needed, in particular on the identification of genetic markers, to improve the implementation of these results into clinical practice. Résumé Les antipsychotiques atypiques (APA) sont devenus le traitement antipsychotique de première intention pour le traitement des psychoses, grâce à un profil d'effets secondaires plus favorables comparé aux antipsychotiques typiques. Néanmoins, d'autres effets indésirables d'ordre métabolique (ex. prise pondérale) sont observés sous APA, stabilisateurs de l'humeur et/ou certains antidépresseurs, pouvant aussi limiter l'adhérence au traitement. L'objectif de ce travail est d'explorer différentes méthodes permettant de prédire des effets secondaires courants, en particulier la prise de poids durant un traitement avec des psychotropes pouvant induire un tel effet. Dans une première partie, des données cliniques ont été évaluées pour leurs potentiels prédictifs d'une prise de poids à un mois sur une prise de poids à trois et 12 mois de traitement (n=351 patients). Une prise de poids rapide et forte >5% à un mois (PP>5%) s'est avérée être le meilleur prédicteur pour une prise pondérale importante à trois (>15%) et 12 (>20%) mois de traitement. Des analyses similaires dans une cohorte pédiatrique (n=42) ont indiqué une prise de poids >4% à un mois comme le meilleur prédicteur pour une prise pondérale importante (>15%) à trois mois de traitement. Dans une deuxième partie, des marqueurs génétiques, en complément aux données cliniques, ont été analysés pour leur contribution potentielle à la prédiction d'une PP>5% et au dépistage du diabète de type 2 (DT2). L'ajout de variants génétiques aux données cliniques afin de prédire une PP>5% a augmenté significativement l'aire sous la courbe (ASC) de l'analyse (ASCflnai:0.92, ASCC|inique:0.75, p<0.0001, n=248). Concernant le DT2, un score génétique est associé au DT2 (OR: 2.5, p=0.03, n=285), néanmoins aucune augmentation significative de l'ASC n'a été observée par rapport à l'analyse avec les données cliniques seules. Finalement, des mesures de concentrations plasmatiques de médicaments ont été utilisées pour prédire la survenue de symptômes extrapyramidaux sous rispéridone (n=150). Cette analyse nous a permis d'établir qu'une concentration plasmatique de rispéridone associée à son métabolite actif >40 ng/ml ne devrait être recherchée qu'en cas de réponse clinique insuffisante. Ces différents résultats soulignent différentes approches pour personnaliser la prescription de psychotropes afin de réduire la survenue d'effets secondaires. Des études supplémentaires sont néanmoins nécessaires, en particulier sur l'identification de marqueurs génétiques, afin d'améliorer l'implémentation de ces résultats en pratique clinique. Résumé large publique Les antipsychotiques atypiques et autres traitements psychotropes sont couramment utilisés pour traiter les symptômes liés à la schizophrénie et aux troubles de l'humeur. Comme pour tout médicament, des effets secondaires sont observés. L'objectif de ce travail est d'explorer différentes méthodes qui permettraient de prédire la survenue de certains effets indésirables, en particulier une prise de poids et la survenue d'un diabète. Dans une première partie, nous avons évalué l'effet d'une prise de poids précoce sur une prise de poids au long terme sous traitement psychotrope. Les analyses ont mis en évidence dans une population psychiatrique qu'une prise de poids à un mois >5% par rapport au poids initial permettait de prédire une prise pondérale importante après trois (>15%) et 12 (>20%) mois de traitement. Un résultat semblable a. été observé dans un autre groupe de patients exclusivement pédiatriques. Dans une deuxième partie, nous avons évalué la contribution potentielle de marqueurs génétiques à la prédiction d'une prise pondérale de >5% après un mois de traitement ainsi que dans la survenue d'un diabète de type 2. Pour la prise de poids, la combinaison des données génétiques aux données cliniques a permis d'augmenter de 17% la précision de la prédiction, en passant de 70% à 87%. Concernant la survenue d'un diabète, les données génétiques n'ont pas amélioré la prédiction. Finalement, nous avons analysé la relation possible entre les concentrations sanguines d'un antipsychotique atypique couramment utilisé, la rispéridone, et la survenue d'effets secondaires (ici les tremblements). Il est ressorti de cette étude qu'une concentration plasmatique du médicament supérieure à 40 ng/ml ne devrait être dépassée qu'en cas de réponse thérapeutique insuffisante, au risque de voir augmenter la survenue d'effets secondaires du type tremblements. Ces résultats démontrent la possibilité de prédire avec une bonne précision la survenue de certains effets secondaires. Cependant, en particulier dans le domaine de la génétique, d'autres études sont nécessaires afin de confirmer les résultats obtenus dans nos analyses. Une fois cette étape franchie, il serait possible d'utiliser ces outils dans la pratique clinique. A terme, cela pourrait permettre au prescripteur de sélectionner les traitements les mieux adaptés aux profils spécifiques de chaque patient.

Assessment in CLIL

The aim of this talk is to explore assessment in higher education and support for learners during their academic education. It investigates the assessment methods that provide success for universities and learners. Universities which implement CLIL should assess learners who would like to attend a programme in English without taking account of their English language qualifications. This assessment should be done in writing, listening and comprehension, speaking and reading and comprehension. In the literature, formative and summative assessments are considered. Formative assessment is ongoing, 'more complex as its intention is to be directly diagnostics with a view to immediately impacting on learner's next steps' (Coyle et al, 2010). Summative assessment occurs at the end of the term or course. McKay, 2006 divides assessment into three phases: design, operationalization and administration phase. If these three phases can't be embedded in the classroom as they are, they can be introduced as a set of questions; why?, how? and what?

Aplicación de un programa integral de actividad física en niños y niñas entre 6 y 12 años con sobrepeso y obesidad

El propósito de este estudio longitudinal prospectivo es abordar un plan integral de actividad física en niños y niñas entre 6 y 12 años que padezcan sobrepeso y obesidad. El programa se llevará a cabo en el Hospital de San Juan de Dios de Barcelona, donde se utilizarán una serie de variables de medida y tests que serán valorados antes, durante y después de este plan integral. Participarán dos profesionales de la salud, un fisioterapeuta y un nutricionista, quienes intervendrán en 20 niños y niñas con sobrepeso y obesidad. La finalidad de este estudio es disminuir el índice de masa corporal (IMC), así como el porcentaje de grasa corporal total (GCT) en los niños y niñas con sobrepeso y obesidad. También se pretende introducir y fomentar hábitos de vida saludables en relación a la actividad física y la alimentación en los niños y niñas y en su entorno familiar.

Communication skills in diagnostic pathology.

Communication is an essential element of good medical practice also in pathology. In contrast to technical or diagnostic skills, communication skills are not easy to define, teach, or assess. Rules almost do not exist. In this paper, which has a rather personal character and cannot be taken as a set of guidelines, important aspects of communication in pathology are explored. This includes what should be communicated to the pathologist on the pathology request form, communication between pathologists during internal (interpathologist) consultation, communication around frozen section diagnoses, modalities of communication of a final diagnosis, with whom and how critical and unexpected findings should be communicated, (in-)adequate routes of communication for pathology diagnoses, who will (or might) receive pathology reports, and what should be communicated and how in case of an error or a technical problem. An earlier more formal description of what the responsibilities are of a pathologist as communicator and as collaborator in a medical team is added in separate tables. The intention of the paper is to stimulate reflection and discussion rather than to formulate strict rules.

“L’Emozione di conoscere e il desiderio di esistere”: Què és i com afecta la seva pràctica en el desenvolupament de l'autonomia de l'infant

El treball que es presenta a continuació pretén fer un aprofundiment en la metodologia pedagògica “Emozione di conoscere e desiderio di esistere”, nascuda a Itàlia i usada com a referent en l’Educació Especial, amb la intensió de poder valorar de quina manera afecta la seva pràctica en el desenvolupament de l’autonomia de l’infant. Per fer-ho, s’ha fet un recull dels estudis més rellevants relacionats amb el mètode “Emozione di conocscere” i amb el concepte d’autonomia. Seguidament, s’ha fet una observació acurada per poder descriure la posada en pràctica d’un projecte basat en aquesta metodologia i analitzar com aquest intervé en desenvolupar dita competència en els alumnes. Tot això, emmarcat dins l’escenari de la “Scuola Elementare Pirazzini”, situada al centre – nord d’Itàlia.

Anàlisi del funcionament i el grau d'inclusió de dues unitats de suport a l'educació especial (USEE)

L’estudi que es detalla a continuació consisteix en un anàlisi sobre el funcionament i grau d’inclusió de les USEE (Unitat de Suport a l’Educació Especial). Per dur-lo a terme s’han analitzat les pràctiques de les USEE de dues escoles a través de quatre entrevistes, tres observacions i dos registres a cada centre. La recerca respon als dos objectius generals basats en avançar en el coneixement de les USEE actuals en termes d’organització, funcionament i de les pràctiques que actualment s’hi desenvolupen i en analitzar si treballen de forma inclusiva o no des del punt de vista de l’Índex d’Inclusió (Booth i Ainscow, 2000). En general, s’observa la intenció inclusiva de la mesura, no obstant, es detecten obstacles que en dificulten el procés i que en termes generals evidencien que encara és necessari un treball de sensibilització social i de revisió sobre els principis i les pràctiques educatives envers la inclusió.

Voting advice applications : impact on voting decisions in the 2011 Swiss national elections

In most democracies voting Advice Applications (VAAs) advising citizens which candidate or party they should vote for become more and more popular. It is therefore crucial to know more about the functioning and the effects of such tools. After some general remarks about the spread of these tools and their possible effects gathered so far in various studies, this paper presents the latest results from a research conducted in the course of the 2011 Swiss national elections. They confirm that VAAs can lead to better informed voters and are likely to have a positive impact on electoral turnout. Additionally it can be shown that the Swiss VAA smartvote made voters change their voting intention and that they voted for a different party. This was particularly advantageous for the Green Liberal Party. At the moment, only a minority of voters rely on the voting recommendation by smartvote. This might change dramatically with the introduction of e-voting. Once people can vote electronically, there are hardly any possibilities to prevent voters from transferring their selection of candidates based on the recommendation given by a VAA into the official electronic ballot paper. If this is possible, e-voting will become more popular than postal voting.