Cause-specific mortality adjudication in the UPLIFT® COPD trial:findings and recommendations

Mortality is an important endpoint in chronic obstructive pulmonary disease (COPD) trials, although accurately determining cause of death is difficult. In the Understanding the Potential Long-term Impacts on Function with Tiotropium (UPLIFT®) trial, a mortality adjudication committee (MAC) provided systematic, independent and blinded assessment of cause-specific mortality of all 981 reported deaths. Here we describe this process of mortality adjudication and methodological revisions introduced to help standardise the adjudication of two areas recognised to pose particular difficulty; firstly, the classification of fatal COPD exacerbations that occur in the setting of pneumonia and secondly, the categorisation of sudden death. In addition MAC determined cause of death was compared with that reported by site investigators (SIs). MAC-assigned causes of death were: respiratory, 35%; cancer, 25%; cardiovascular, 11%; sudden cardiac death, 4.4%; sudden death, 3.4%; other, 8.8%; unknown, 12.4%. Cancer/cardiac deaths were more common in Global Initiative for Chronic Obstructive Lung Disease stage II, respiratory deaths in stages III and IV. Agreement between MAC and SI regarding cause of death was complete (50.2%), incomplete (18.5%) or none (31.3%). The SI classified deaths as cardiac three-fold more frequently than MAC (incidence rate [IR]/100 patient-years 0.797 vs. 0.257), although IR ratios for cardiac deaths for tiotropium vs. control were similar between SI and MAC. Discrepancies between MAC- and SI-adjudicated causes of death are common, especially increased reporting of cardiac deaths by the SI. Future multicentre COPD trials should plan appropriate infrastructure before study initiation to ensure collection and interpretation of fatal events data.

Compliance with recommendations in a geriatric outreach assessment service

Objectives: to measure the extent to which the recommendations of a geriatric outreach assessment service were being followed, and to determine what patient-related factors were associated with compliance with assessment recommendations. Methods: eighty-one eligible patients or caregivers who had an assessment in a geriatric outreach service participated in a telephone interview. The interview focused on the use of health services and compliance with assessment recomendations. Patient-related variables obtained from charts included demographics, caregiver support and stability, health status and assessment recommendations. Results: overall compliance with recommendations from the geriatric outreach assessment service was 65%. Patients were less likely comply fully with recommendations if they had a high number of recommendations [odds ratio (OR) = 0.23; 95% confidence interval (CI) = 0.12-0.46; P = 0.0001], inadequate caregiver support (OR) = 0.212; 95% CI = 0.04 to 1.02; P = 0.0523), or the ability to transfer themselves independently (OR = 0.12; 95% CI = 0.02-0.63; P = 0.0124). They were more likely to have full compliance if they had normal vision (OR = 6.67; 95% CI = 1.22- 36.46; P = 0.0284). Conclusion: it is important to focus on key issues when developing service recommendations and on the role of the informal caregiver in facilitating compliance with them. Good communication between the patient or caregiver and the family physician and geriatric services can help to identify strategies which might improve acceptance of recommendations.

Responding to desire to die statements from patients with advanced disease:recommendations for health professionals

It is not uncommon for patients with advanced incurable disease to express a desire to hasten their death. Health professionals often have difficulty responding to such statements, and find it challenging to ascertain why these statements are made. Health professionals may struggle to determine whether a 'desire to die' statement (DTDS) is about a request for hastened death, a sign of psychosocial distress, or merely a passing comment that is not intended to be heard literally as a death wish. Given the lack of guidelines to assist health professionals with this issue, we have prepared multidisciplinary recommendations for responding to a DTDS, underpinned by key principles of therapeutic communication and a systematic review of empirical literature. Where the relevant literature was lacking, the recommendations were drafted by the authors (clinicians and/ or academics from the following disciplines: nursing, medicine, psychiatry, psychology, sociology, aged care and theology), based on their expert opinion. Multiple drafts of the recommendations were circulated to the authors for refinement until consensus was reached. Strategies for advancing the evidence base for the maturation of guidelines in this area are offered.

Home-based support for palliative care families:challenges and recommendations

Providing adequate supportive services for the families of palliative care patients is a core principle of palliative care. Caring for a patient with terminal illness at home involves a considerable commitment on the part of family caregivers, and attention must be given to the caregiver's needs as well as those of the patient. Although a home death may be preferred by patients and promoted by healthcare agencies as a cost-effective option, it may be an ideal that is not often realised. Enhanced supportive care strategies can ameliorate the challenges facing families of palliative care patients cared for at home. All health professionals need to improve the standard of family-centred palliative care, and more evidence-based approaches are required.

Farmer perception of suitable conditions for slurry application compared with decision support system recommendations

The application of slurry nutrients to land can be associated with unintended losses to the environment depending on soil and weather conditions. Correct timing of slurry application, however, can increase plant nutrient uptake and reduce losses. A decision support system (DSS), which predicts optimum conditions for slurry spreading based on the Hybrid Soil Moisture Deficit (HSMD) model, was investigated for use as a policy tool. The DSS recommendations were compared to farmer perception of suitable conditions for slurry spreading for three soil drainage classes (well, moderate and poorly drained) to better understand on farm slurry management practices and to identify potential conflict with farmer opinion. Six farmers participated in a survey over two and a half years, during which they completed a daily diary, and their responses were compared to Soil Moisture Deficit (SMD) calculations and weather data recorded by on farm meteorological stations. The perception of land drainage quality differed between farmers and was related to their local knowledge and experience. It was found that the allocation of grass fields to HSMD drainage classes using a visual assessment method aligned farmer perception of drainage at the national scale. Farmer opinion corresponded to the theoretical understanding that slurry should not be applied when the soil is wetter than field capacity, i.e. when drainage can occur. While weather and soil conditions (especially trafficability) were the principal reasons given by farmers not to spread slurry, farm management practices (grazing and silage) and current Nitrates Directive policies (closed winter period for spreading) combined with limited storage capacities were obstacles to utilisation of slurry nutrients. Despite the slightly more restrictive advice of the DSS regarding the number of suitable spreading opportunities, the system has potential to address an information deficit that would help farmers to reduce nutrient losses and optimise plant nutrient uptake by improved slurry management. The DSS advice was in general agreement with the farmers and, therefore, they should not be resistant to adopting the tool for day to day management.

Erythrocytosis in children and adolescents-classification, characterization, and consensus recommendations for the diagnostic approach

During recent years, the increasing knowledge of genetic and physiological changes in polycythemia vera (PV) and of different types of congenital erythrocytosis has led to fundamental changes in recommendations for the diagnostic approach to patients with erythrocytosis. Although widely accepted for adult patients this approach may not be appropriate with regard to children and adolescents affected by erythrocytosis. The "congenital erythrocytosis" working group established within the framework of the MPN&MPNr-EuroNet (COST action BM0902) addressed this question in a consensus finding process and developed a specific algorithm for the diagnosis of erythrocytosis in childhood and adolescence which is presented here. Pediatr Blood Cancer 2013;9999:XX-XX. © 2013 Wiley Periodicals, Inc.

Ecological Impacts of Alien Species: Quantification, Scope, Caveats, and Recommendations

Despite intensive research during the past decade on the effects of alien species, invasion science still lacks the capacity to accurately predict the impacts of those species and, therefore, to provide timely advice to managers on where limited resources should be allocated. This capacity has been limited partly by the context-dependent nature of ecological impacts, research highly skewed toward certain taxa and habitat types, and the lack of standardized methods for detecting and quantifying impacts. We review different strategies, including specific experimental and observational approaches, for detecting and quantifying the ecological impacts of alien species. These include a four-way experimental plot design for comparing impact studies of different organisms. Furthermore, we identify hypothesis-driven parameters that should be measured at invaded sites to maximize insights into the nature of the impact. We also present strategies for recognizing high-impact species. Our recommendations provide a foundation for developing systematic quantitative measurements to allow comparisons of impacts across alien species, sites, and time.

The impact of interventions to promote physical activity in urban green space: A systematic review and recommendations for future research

Evidence is mounting on the association between the built environment and physical activity (PA) with a call for intervention research. A broader approach which recognizes the role of supportive environments that can make healthy choices easier is required. A systematic review was undertaken to assess the effectiveness of interventions to encourage PA in urban green space. Five databases were searched independently by two reviewers using search terms relating to 'physical activity', 'urban green space' and 'intervention' in July 2014. Eligibility criteria included: (i) intervention to encourage PA in urban green space which involved either a physical change to the urban green space or a PA intervention to promote use of urban green space or a combination of both; and (ii) primary outcome of PA. Of the 2405 studies identified, 12 were included. There was some evidence (4/9 studies showed positive effect) to support built environment only interventions for encouraging use and increasing PA in urban green space. There was more promising evidence (3/3 studies showed positive effect) to support PAprograms or PA programs combined with a physical change to the built environment, for increasing urban green space use and PAof users. Recommendations for future research include the need for longer term follow-up post-intervention, adequate control groups, sufficiently powered studies, and consideration of the social environment, which was identified as a significantly under-utilized resource in this area. Interventions that involve the use of PA programs combined with a physical change to the built environment are likely to have a positive effect on PA. Robust evaluations of such interventions are urgently required. The findings provide a platform to inform the design, implementation and evaluation of future urban green space and PAintervention research.

European Recommendations for Primary Prevention of Congenital Anomalies: A Joined Effort of EUROCAT and EUROPLAN Projects to Facilitate Inclusion of This Topic in the National Rare Disease Plans

Congenital anomalies (CA) are the paradigm example of rare diseases liable to primary prevention actions due to the multifactorial etiology of many of them, involving a number of environmental factors together with genetic predispositions. Yet despite the preventive potential, lack of attention to an integrated preventive strategy has led to the prevalence of CA remaining relatively stable in recent decades. The 2 European projects, EUROCAT and EUROPLAN, have joined efforts to provide the first science-based and comprehensive set of recommendations for the primary prevention of CA in the European Union. The resulting EUROCAT-EUROPLAN 'Recommendations on Policies to Be Considered for the Primary Prevention of Congenital Anomalies in National Plans and Strategies on Rare Diseases' were issued in 2012 and endorsed by EUCERD (European Union Committee of Experts on Rare Diseases) in 2013. The recommendations exploit interdisciplinary expertise encompassing drugs, diet, lifestyles, maternal health status, and the environment. The recommendations include evidence-based actions aimed at reducing risk factors and at increasing protective factors and behaviors at both individual and population level. Moreover, consideration is given to topics specifically related to CA (e.g. folate status, teratogens) as well as of broad public health impact (e.g. obesity, smoking) which call for specific attention to their relevance in the pre- and periconceptional period. The recommendations, reported entirely in this paper, are a comprehensive tool to implement primary prevention into national policies on rare diseases in Europe.

From Boys to Men Overview and Recommendations

The From Boys to Men Project was funded by the Economic and Social Research
Council to explore why some boys become domestic abuse perpetrators when
others do not. In so doing, it sought to establish what more could be done to
reduce the number of young men who become perpetrators. The study
involved three phases of data collection including: Phase 1 - a survey of 1203
school children aged 13-14; Phase 2 - focus groups with 69 young people aged
13-19; and Phase 3 - life history interviews with 30 young men, aged 16-21,
who had experienced domestic abuse as victims, perpetrators or witnesses.
Reports on all stages of the project are freely available on our website
www.boystomenproject.com.
This report provides a brief overview of what we found and what
recommendations follow from the project’s findings.

Decision making in child protection: An international comparative study on maltreatment substantiation, risk assessment and interventions recommendations, and the role of professionals’ child welfare attitudes

Child welfare professionals regularly make crucial decisions that have a significant impact on children and their families. The present study presents the Judgments and Decision Processes in Context model (JUDPIC) and uses it to examine the relationships between three indepndent domains: case characteristic (mother’s wish with regard to removal), practitioner characteristic (child welfare attitudes), and protective system context (four countries: Israel, the Netherlands, Northern Ireland and Spain); and three dependent factors: substantiation of maltreatment, risk assessment, and intervention recommendation.
The sample consisted of 828 practitioners from four countries. Participants were presented with a vignette of a case of alleged child maltreatment and were asked to determine whether maltreatment was substantiated, assess risk and recommend an intervention using structured instruments. Participants’ child welfare attitudes were assessed.
The case characteristic of mother’s wish with regard to removal had no impact on judgments and decisions. In contrast, practitioners’ child welfare attitudes were associated with substantiation, risk assessments and recommendations. There were significant country differences on most measures.
The findings support most of the predictions derived from the JUDPIC model. The significant differences between practitioners from different countries underscore the importance of context in child protection decision making. Training should enhance practitioners’ awareness of the impact that their attitudes and the context in which they are embedded have on their judgments and decisions.

A realistic evaluation of Early Warning Systems and acute care training in Northern Ireland: findings and recommendations

Statement of purpose The purpose of this concurrent session is to present the main findings and recommendations from a five year study evaluating the implementation of Early Warning Systems (EWS) and the Acute Life-threatening Events: Recognition and Treatment (ALERT) course in Northern Ireland. The presentation will provide delegates with an understanding of those factors that enable and constrain successful implementation of EWS and ALERT in practice in order to provide an impetus for change. Methods The research design was a multiple case study approach of four wards in two hospitals in Northern Ireland. It followed the principles of realist evaluation research which allowed empirical data to be gathered to test and refine RRS programme theory [1]. The stages included identifying the programme theories underpinning EWS and ALERT, generating hypotheses, gathering empirical evidence and refining the programme theories. This approach used a variety of mixed methods including individual and focus group interviews, observation and documentary analysis of EWS compliance data and ALERT training records. A within and across case comparison facilitated the development of mid-range theories from the research evidence. Results The official RRS theories developed from the realist synthesis were critically evaluated and compared with the study findings to develop a mid-range theory to explain what works, for whom in what circumstances. The findings of what works suggests that clinical experience, established working relationships, flexible implementation of protocols, ongoing experiential learning, empowerment and pre-emptive management are key to the success of EWS and ALERT implementation. Each concept is presented as ‘context, mechanism and outcome configurations’ to provide an understanding of how the context impacts on individual reasoning or behaviour to produce certain outcomes. Conclusion These findings highlight the combination of factors that can improve the implementation and sustainability of EWS and ALERT and in light of this evidence several recommendations are made to provide policymakers with guidance and direction for future policy development. References: 1. Pawson R and Tilley N. (1997) Realistic Evaluation. Sage Publications; London Type of submission: Concurrent session Source of funding: Sandra Ryan Fellowship funded by the School of Nursing & Midwifery, Queen’s University of Belfast