The Palliative Prognostic (PaP) score; Palliative Prognostic Index (PPI); Feliu Prognostic Nomogram (FPN) and Palliative Performance Scale (PPS) have all been proposed as prognostic tools for ...palliative cancer care. However, clinical judgement remains the principal way by which palliative care professionals determine prognoses and it is important that the performance of prognostic tools is compared against clinical predictions of survival (CPS).
This was a multi-centre, cohort validation study of prognostic tools. Study participants were adults with advanced cancer receiving palliative care, with or without capacity to consent. Key prognostic data were collected at baseline, shortly after referral to palliative care services. CPS were obtained independently from a doctor and a nurse.
Prognostic data were collected on 1833 participants. All prognostic tools showed acceptable discrimination and calibration, but none showed superiority to CPS. Both PaP and CPS were equally able to accurately categorise patients according to their risk of dying within 30 days. There was no difference in performance between CPS and FPN at stratifying patients according to their risk of dying at 15, 30 or 60 days. PPI was significantly (p<0.001) worse than CPS at predicting which patients would survive for 3 or 6 weeks. PPS and CPS were both able to discriminate palliative care patients into multiple iso-prognostic groups.
Although four commonly used prognostic algorithms for palliative care generally showed good discrimination and calibration, none of them demonstrated superiority to CPS. Prognostic tools which are less accurate than CPS are of no clinical use. However, prognostic tools which perform similarly to CPS may have other advantages to recommend them for use in clinical practice (e.g. being more objective, more reproducible, acting as a second opinion or as an educational tool). Future studies should therefore assess the impact of prognostic tools on clinical practice and decision-making.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Prognosis in Palliative care Study (PiPS) models predict survival probabilities in advanced cancer. PiPS-A (clinical observations only) and PiPS-B (additionally requiring blood results) consist of ...14- and 56-day models (PiPS-A14; PiPS-A56; PiPS-B14; PiPS-B56) to create survival risk categories: days, weeks, months. The primary aim was to compare PIPS-B risk categories against agreed multi-professional estimates of survival (AMPES) and to validate PiPS-A and PiPS-B. Secondary aims were to assess acceptability of PiPS to patients, caregivers and health professionals (HPs).
A national, multi-centre, prospective, observational, cohort study with nested qualitative sub-study using interviews with patients, caregivers and HPs. Validation study participants were adults with incurable cancer; with or without capacity; recently referred to community, hospital and hospice palliative care services across England and Wales. Sub-study participants were patients, caregivers and HPs. 1833 participants were recruited. PiPS-B risk categories were as accurate as AMPES PiPS-B accuracy (910/1484; 61%); AMPES (914/1484; 61%); p = 0.851. PiPS-B14 discrimination (C-statistic 0.837) and PiPS-B56 (0.810) were excellent. PiPS-B14 predictions were too high in the 57-74% risk group (Calibration-in-the-large CiL -0.202; Calibration slope CS 0.840). PiPS-B56 was well-calibrated (CiL 0.152; CS 0.914). PiPS-A risk categories were less accurate than AMPES (p<0.001). PiPS-A14 (C-statistic 0.825; CiL -0.037; CS 0.981) and PiPS-A56 (C-statistic 0.776; CiL 0.109; CS 0.946) had excellent or reasonably good discrimination and calibration. Interviewed patients (n = 29) and caregivers (n = 20) wanted prognostic information and considered that PiPS may aid communication. HPs (n = 32) found PiPS user-friendly and considered risk categories potentially helpful for decision-making. The need for a blood test for PiPS-B was considered a limitation.
PiPS-B risk categories are as accurate as AMPES made by experienced doctors and nurses. PiPS-A categories are less accurate. Patients, carers and HPs regard PiPS as potentially helpful in clinical practice.
ISRCTN13688211.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Disaster associated with natural hazards can lead to important changes—positive or negative—in socio-ecological systems. When disasters occur, much attention is given to the direct disaster impacts ...as well as relief and recovery operations. Although this focus is important, it is noteworthy that there has been little research on the characteristics and progress of change induced by disasters. Change, as distinct from impacts, encompasses formal and informal responses to disaster events and their direct and indirect impacts. While smaller disasters do not often lead to significant changes in societies and organizational structures, major disasters have the potential to change dominant ways of thinking and acting. Against this background, the article presents an analytical framework for distinguishing change from disaster impacts. Drawing from research in Sri Lanka and Indonesia, formal and informal changes after the Indian Ocean Tsunami of 2004 are examined and discussed against the background of the conceptual framework. The changes examined range from the commencement of the peace process in Aceh, Indonesia, to organizational and legal reforms in Sri Lanka. The article concludes that change-making processes after disasters need to be understood more in depth in order to derive important strategic policy and methodological lessons learned for the future, particularly in view of the increasing complexity and uncertainty in decision making due to climate change.
Objectives: To investigate potential interactions between physical and psychosocial risk factors in the workplace that may be associated with symptoms of musculoskeletal disorder of the neck and ...upper limb. Methods: 891 of 1514 manual handlers, delivery drivers, technicians, customer services computer operators, and general office staff reported on physical and psychosocial working conditions and symptoms of neck and upper limb disorders using a self administered questionnaire (59% return rate). Of the 869 valid questionnaire respondents, 564 workers were classified in to one of four exposure groups: high physical and high psychosocial, high physical and low psychosocial, low physical and high psychosocial, and low physical and low psychosocial. Low physical and low psychosocial was used as an internal reference group. The exposure criteria were derived from the existing epidemiological literature and models for physical and psychosocial work factors. The frequency and amplitude of lifting and the duration spent sitting while experiencing vibration were used as physical exposure criteria. Ordinal values of mental demands, job control, and social support with managers and coworkers were used as psychosocial exposure criteria. Results: In the multivariate analyses, the highest and significant increase in risk was found in the high physical and high psychosocial exposure group for symptoms of hand or wrist and upper limb disorders after adjusting for years at the job, age, and sex. A potential interaction effect was found for the symptoms of the hand or wrist and upper limb disorders but not for the neck symptoms. Conclusion: This study showed that workers highly exposed to both physical and psychosocial workplace risk factors were more likely to report symptoms of musculoskeletal disorders than workers highly exposed to one or the other. The results suggest an interaction between physical and psychosocial risk factors in the workplace that increased the risk of reporting symptoms in the upper limbs. Psychosocial risk factors at work were more important when exposure to physical risk factors at work were high than when physical exposure was low. Ergonomic intervention strategies that aim to minimise the risks of work related musculoskeletal disorders of the upper limb should not only focus on physical work factors but also psychosocial work factors.
This paper presents findings from an investigation into the musculoskeletal health of UK cleaners. It focuses on cleaning work organisation and practises, and recommendations for supervisors and ...managers to work with cleaners to reduce health and workplace problems. Questionnaire surveys of 1216 cleaners throughout the UK, 130 assessments of cleaning tasks and interviews with 38 cleaners at 9 workplaces were undertaken to identify potential risk factors for musculoskeletal ill health. Based on the findings of this participative study and previous research e.g. Krüger et al., 1997. Risk Assessment and Preventive Strategies in Cleaning Work. Wirtschaftsverlag NW, Bremerhaven, recommendations were presented to groups of cleaning supervisors, managers, trainers, designers and manufacturers to ensure that advice provided for reducing musculoskeletal ill health was practical for the industry. The recommendations related to work organisational change (i.e. work scheduling and work practises such as teamwork and job extension, communication/social support networks) and organisational strategies (i.e. reporting systems for musculoskeletal ill heath; procedures for risk assessment; training programme design; equipment selection; maintenance procedures; workplace changes). This paper concentrates on only one part of the work system that influences musculoskeletal health; recommendations on musculoskeletal health and cleaning equipment design/use are reported elsewhere Woods and Buckle, 2005. An investigation into the design and use of workplace cleaning equipment. International Journal of Industrial Ergonomics 35, 247–266; Woods et al., 1999. Musculoskeletal Health of Cleaners. HSE Books, Suffolk..
Cleaning is important, physically demanding, labour-intensive work, conducted by millions worldwide. Managers and supervisors should work with staff to improve organisation of cleaning to ensure better musculoskeletal health. The importance of organisational changes must be recognised by others in the industry (e.g. employers, contract cleaning managers, training organisations, manufacturers).
Aim: To assess the incidence and risk factors for neck and shoulder pain in nurses. Methods: A longitudinal study of neck and shoulder pain was carried out in female nurses at two hospitals in ...England. Personal and occupational risk factors were assessed at baseline. The self reported incidence of symptoms in the neck and shoulder region was ascertained at three-monthly intervals over two years. A Cox regression model was used to estimate hazard ratios (HRs) for incident neck/shoulder pain during follow up in nurses who had been pain free for at least one month at baseline. Results: The baseline response rate was 56%. Of 903 women who were pain free at baseline, 587 (65%) completed at least one follow up while still in the same job. During an average of 13 months, 34% of these (202 women) reported at least one episode of neck/shoulder pain. The strongest predictor of pain in the neck/shoulder was previous history of the symptom (HRs up to 3.3). For physical exposures at work, the highest risks (HRs up to 1.7) were associated with specific patient handling tasks that involved reaching, pushing, and pulling. Nurses who reported low mood or stress at baseline were more likely to develop neck/shoulder pain later (HR 1.5). Workplace psychosocial factors (including job demands, satisfaction, and control) were not associated with incident neck/shoulder symptoms. Conclusions: Neck/shoulder pain is common among hospital nurses, and patient handling tasks that involve reaching and pulling are the most important target for risk reduction strategies.
•This ESMO Clinical Practice Guideline provides key recommendations for using prognostic estimates in advanced cancer.•The guideline covers recommendations for patients with cancer and an expected ...survival of months or less.•An algorithm for use of clinical predictions, prognostic factors and multivariable risk prediction models is presented.•The author group encompasses a multidisciplinary group of experts from different institutions in Europe, USA and Asia.•Recommendations are based on available scientific data and the authors’ collective expert opinion.
We report magnetotransport measurements of InSb/Al1-xInxSb modulation doped quantum well (QW) structures and the extracted transport ( τ t ) and quantum ( τ q ) lifetime of carriers at low ...temperature ( < 2 K ) . We consider conventional transport lifetimes over a range of samples with different doping levels and carrier densities, and deduce different transport regimes dependent on QW state filling calculated from self-consistent Schrödinger-Poisson modelling. For samples where only the lowest QW subband is occupied at electron densities of 2.13 × 10 11 cm−2 and 2.54 × 10 11 cm−2 quantum lifetimes of τ q 0.107 ps, and τ q 0.103 ps are extracted from Shubnikov-de Haas oscillations below a magnetic field of 0.8 T. The extracted ratios of transport to quantum lifetimes, τ t τ q 17 and τ t τ q 20 are similar to values reported in other binary QW two-dimensional electron gas systems, but are inconsistent with predictions from transport modelling which assumes that remote ionized donors are the dominant scattering mechanism. We find the low τ t τ q ratio and the variation in transport mobility with carrier density cannot be explained by reasonable levels of background impurities or well width fluctuations. Thus, there is at least one additional scattering mechanism unaccounted for, most likely arising from structural defects.
We report the observation of a thermally activated resonant tunnelling feature in the current-voltage characteristics (I(V)) of triple barrier resonant tunnelling structures (TBRTS) due to the ...alignment of the n = 1 confined states of the two quantum wells within the active region. With great renewed interest in tunnelling structures for high frequency (THz) operation, the understanding of device transport and charge accumulation as a function of temperature is critical. With rising sample temperature, the tunnelling current of the observed low voltage resonant feature increases in magnitude showing a small negative differential resistance region which is discernible even at 293 K and is unique to multiple barrier devices. This behaviour is not observed in conventional double barrier resonant tunnelling structures where the transmission coefficient at the Fermi energy is predominantly controlled by an electric field, whereas in TBRTS it is strongly controlled by the 2D to 2D state alignment.
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