We test whether genetic influences that explain individual differences in aggression in early life also explain individual differences across the life-course. In two cohorts from The Netherlands (
N
...= 13,471) and Australia (
N
= 5628), polygenic scores (PGSs) were computed based on a genome-wide meta-analysis of childhood/adolescence aggression. In a novel analytic approach, we ran a mixed effects model for each age (Netherlands: 12–70 years, Australia: 16–73 years), with observations at the focus age weighted as 1, and decaying weights for ages further away. We call this approach a ‘rolling weights’ model. In The Netherlands, the estimated effect of the PGS was relatively similar from age 12 to age 41, and decreased from age 41–70. In Australia, there was a peak in the effect of the PGS around age 40 years. These results are a first indication from a molecular genetics perspective that genetic influences on aggressive behavior that are expressed in childhood continue to play a role later in life.
Aims
To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions.
Background
...Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes.
Design
Scoping review.
Data sources
We searched for eligible studies, published between 1980–2019, in six electronic databases.
Review methods
Researchers independently screened the s of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus‐based.
Results
The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care.
Conclusions
The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions.
Impact
Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.
摘要
目的
整理归纳已发布的关于已制定并予以测试的干预措施的研究,避免或减少护理机构中护理服务受限或缺失的比例。
背景
服务受限和缺失的护理已进行过广泛研究,包括其预测因子和对患者和护士影响的相关性。
设计
范围评估。
数据来源
我们在六个电子数据库中查询了1980年至2019年期间所有符合条件的研究。
评估方法
研究员利用纳入和排除标准独立筛选了所检索的研究摘要,并基于共识决定是否包含某项给定研究。
结果
本研究共筛选了1815条研究记录,共纳入13条。其中三项研究报告了结构性干预,即,增加护士人员配置,加强护理团队,这两项措施均大大减少了护理服务受限或缺失的比例。其余10项研究涉及过程干预:其中4项与提醒机制有关(通过技术手段或指定人员),7项研究说明了采取干预措施可以改变甚至优化相关护理过程。全部10项过程干预研究均得出结论,可以极大降低护理缺失的比例。
结论
范围评估的结果说明,特定干预可以对选定护理活动的绩效产生积极影响,例如,预防跌倒。但尚无证据表明这些干预措施可以全面降低护理服务受限和缺失比例。
影响
临床医生、管理人员和研究员可以利用这些结果修改并实施干预,从而减少护理服务受限和缺失的情况。
Purpose
Writing an Advance Directive (AD) is often seen as a part of Advance Care Planning (ACP). ADs may include specific preferences regarding future care and treatment and information that ...provides a context for healthcare professionals and relatives in case they have to make decisions for the patient. The aim of this study was to get insight into the content of ADs as completed by patients with advanced cancer who participated in ACP conversations.
Methods
A mixed methods study involving content analysis and descriptive statistics was used to describe the content of completed My Preferences forms, an AD used in the intervention arm of the ACTION trial, testing the effectiveness of the ACTION Respecting Choices ACP intervention.
Results
In total, 33% of 442 patients who received the ACTION RC ACP intervention completed a My Preferences form. Document completion varied per country: 10.4% (United Kingdom), 20.6% (Denmark), 29.2% (Belgium), 41.7% (the Netherlands), 61.3% (Italy) and 63.9% (Slovenia). Content analysis showed that ‘maintaining normal life’ and ‘experiencing meaningful relationships’ were important for patients to live well. Fears and worries mainly concerned disease progression, pain or becoming dependent. Patients hoped for prolongation of life and to be looked after by healthcare professionals. Most patients preferred to be resuscitated and 44% of the patients expressed maximizing comfort as their goal of future care. Most patients preferred ‘home’ as final place of care.
Conclusions
My Preferences forms provide some insights into patients’ perspectives and preferences. However, understanding the reasoning behind preferences requires conversations with patients.
Nurses are often responsible for the care of many patients at the same time and have to prioritise their daily nursing care activities. Prioritising the different assessed care needs and managing ...consequential conflicting expectations, challenges nurses’ professional and moral values.
To explore and illustrate the key aspects of the ethical elements of the prioritisation of nursing care and its consequences for nurses.
A scoping review was used to analyse existing empirical research on the topics of priority setting, prioritisation and rationing in nursing care, including the related ethical issues. The selection of material was conducted in three stages: research identification using two data bases, CINAHL and MEDLINE. Out of 2024 citations 25 empirical research articles were analysed using inductive content analysis.
Nurses prioritised patient care or participated in the decision-making at the bedside and at unit, organisational and at societal levels. Bedside priority setting, the main concern of nurses, focused on patients’ daily care needs, prioritising work by essential tasks and participating in priority setting for patients’ access to care. Unit level priority setting focused on processes and decisions about bed allocation and fairness. Nurses participated in organisational and societal level priority setting through discussion about the priorities. Studies revealed priorities set by nurses include prioritisation between patient groups, patients having specific diseases, the severity of the patient’s situation, age, and the perceived good that treatment and care brings to patients. The negative consequences of priority setting activity were nurses’ moral distress, missed care, which impacts on both patient outcomes and nursing professional practice and quality of care compromise.
Analysis of the ethical elements, the causes, concerns and consequences of priority setting, need to be studied further to reveal the underlying causes of priority setting for nursing staff. Prioritising has been reported to be difficult for nurses. Therefore there is a need to study the elements and processes involved in order to determine what type of education and support nurses require to assist them in priority setting.
Objective
Even when medical treatments are limited, supporting patients’ coping strategies could improve their quality of life. Greater understanding of patients’ coping strategies, and influencing ...factors, can aid developing such support. We examined the prevalence of coping strategies and associated variables.
Methods
We used sociodemographic and baseline data from the ACTION trial, including measures of Denial, Acceptance, and Problem‐focused coping (COPE; Brief COPE inventory), of patients with advanced cancer from six European countries. Clinicians provided clinical information. Linear mixed models with clustering at hospital level were used.
Results
Data from 675 patients with stage III/IV lung (342, 51%) or stage IV colorectal (333, 49%) cancer were used; mean age 66 (10 SD) years. Overall, patients scored low on Denial and high on Acceptance and Problem‐focused coping. Older age was associated with higher scores on Denial than younger age (β = 0.05; CI0.023; 0.074), and patients from Italy (β = 1.57 CI0.760; 2.388) and Denmark (β = 1.82 CI0.881; 2.750) scored higher on Denial than patients in other countries.
Conclusions
Patients with advanced cancer predominantly used Acceptance and Problem‐focused coping, and Denial to a lesser extent. Since the studied coping strategies of patients with advanced cancer vary between subpopulations, we recommend taking these factors into account when developing tailored interventions to support patients’ coping strategies.
In oncology, Health Care Professionals often experience conducting Advance Care Planning (ACP) conversations as difficult and are hesitant to start them. A structured approach could help to overcome ...this. In the ACTION trial, a Phase III multi-center cluster-randomized clinical trial in six European countries (Belgium, Denmark, Italy, the Netherlands, Slovenia, United Kingdom), patients with advanced lung or colorectal cancer are invited to have one or two structured ACP conversations with a trained facilitator. It is unclear how trained facilitators experience conducting structured ACP conversations. This study aims to understand how facilitators experience delivering the ACTION Respecting Choices (RC) ACP conversation.
A qualitative study involving focus groups with RC facilitators. Focus group interviews were recorded, transcribed, anonymized, translated into English, and thematically analysed, supported by NVivo 11. The international research team was involved in data analysis from initial coding and discussion towards final themes.
Seven focus groups were conducted, involving 28 of in total 39 trained facilitators, with different professional backgrounds from all participating countries. Alongside some cultural differences, six themes were identified. These reflect that most facilitators welcomed the opportunity to participate in the ACTION trial, seeing it as a means of learning new skills in an important area. The RC script was seen as supportive to ask questions, including those perceived as difficult to ask, but was also experienced as a barrier to a spontaneous conversation. Facilitators noticed that most patients were positive about their ACTION RC ACP conversation, which had prompted them to become aware of their wishes and to share these with others. The facilitators observed that it took patients substantial effort to have these conversations. In response, facilitators took responsibility for enabling patients to experience a conversation from which they could benefit. Facilitators emphasized the need for training, support and advanced communication skills to be able to work with the script.
Facilitators experienced benefits and challenges in conducting scripted ACP conversations. They mentioned the importance of being skilled and experienced in carrying out ACP conversations in order to be able to explore the patients' preferences while staying attuned to patients' needs.
International Standard Randomised Controlled Trial Number registry 63110516 ( ISRCTN63110516 ) per 10/3/2014.
The implementation of core capacities as stated in the International Health Regulations (IHR) is far from complete, and, as the COVID-19 pandemic shows, the spreading of infectious diseases through ...points of entry (POEs) is a serious problem. To guide training and exercises, we performed a training needs assessment on infectious disease management among professionals at European POE.
We disseminated a digital questionnaire to representatives of designated airports, ports, and ground-crossings in Europe. Topics were derived from the IHR core capacities for POEs. Based on the importance (4-point Likert scale) and training needs (4-point Likert scale), we identified the topics with the highest priority for training. These results were put in further perspective using prior experience (training < 3 year, exercise < 5 years, events < 5 years). Also, preferences for training methodologies were assessed.
Fifty questionnaires were included in the analyses, representing 50 POEs from 19 European countries. Importance is high for 26/30 topics, although scores widely vary among respondents. Topics with a high training need (16/30) are amongst others the handling of ill travelers; using and composing the public health emergency contingency plan, and public health measures. Respondents from ports and airports attribute equal importance to most topics, but respondents from ports showed higher training needs on 75% of the topics. POEs are unevenly and generally little experienced. The most preferred training methods were presentations. Simulation is the preferred methodology for training the handling of ill or exposed travelers.
The European workforce at designated ports, airports and ground-crossings has a different level of experience and perceives varying importance of the topics assessed in our study. We identified the topics on which training is required. We call for European collaboration between POEs to agree upon the importance of infectious disease management, and to jointly build a trained and prepared workforce that is ready to face the next crisis.
Aims/hypothesis
It is important to differentiate the two major phenotypes of adult-onset diabetes, autoimmune type 1 diabetes and non-autoimmune type 2 diabetes, especially as type 1 diabetes ...presents in adulthood. Serum GAD65 autoantibodies (GADA) are the most sensitive biomarker for adult-onset autoimmune type 1 diabetes, but the clinical value of GADA by current standard radiobinding assays (RBA) remains questionable. The present study focused on the clinical utility of GADA differentiated by a new electrochemiluminescence (ECL) assay in patients with adult-onset diabetes.
Methods
Two cohorts were analysed including 771 diabetic participants, 30–70 years old, from the Action LADA study (
n
= 6156), and 2063 diabetic participants, 20–45 years old, from the Diabetes in Young Adults (DiYA) study. Clinical characteristics of participants, including requirement of early insulin treatment, BMI and development of multiple islet autoantibodies, were analysed according to the status of RBA-GADA and ECL-GADA, respectively, and compared between these two assays.
Results
GADA was the most prevalent and predominant autoantibody, >90% in both cohorts. GADA positivity by either RBA or ECL assay significantly discriminated clinical type 1 from type 2 diabetes. However, in both cohorts, participants with ECL-GADA positivity were more likely to require early insulin treatment, have multiple islet autoantibodies, and be less overweight (for all
p
< 0.0001). However, clinical phenotype, age at diagnosis and BMI independently improved positive predictive value (PPV) for the requirement of insulin treatment, even augmenting ECL-GADA. Participants with GADA detectable by RBA, but not confirmed by ECL, had a phenotype more similar to type 2 diabetes. These RBA-GADA positive individuals had lower affinity GADA compared with participants in which GADA was confirmed by ECL assay.
Conclusions/interpretation
Detection of GADA by ECL assay, given technical advantages over RBA-GADA, identified adult-onset diabetes patients at higher risk of requiring early insulin treatment, as did clinical phenotype, together allowing for more accurate clinical diagnosis and management.
Graphical abstract
The ACTION trial evaluated the effect of a modified version of the Respecting Choices' advance care planning programme in patients with advanced cancer in six European countries. For this purpose, an ...advance directive acceptable for all six ACTION countries to be used for documenting the wishes and preferences of patients and as a communication tool between patients, their caregivers and healthcare staff, was needed. To describe the development of a multinational cancer specific advance directive, the 'My Preferences form', which was first based on the 2005 Wisconsin 'Physician Orders of Life Sustaining Treatment' Form, to be used within the ACTION trial. Framework analysis of all textual data produced by members of the international project team during the development of the ACTION advance directives (e.g. drafts, emails, meeting minutes...). ACTION consortium members (N = 28) with input from clinicians from participating hospitals (N = 13) and 'facilitators' (N = 8) who were going to deliver the intervention. Ten versions of the ACTION advance directive, the 'My Preferences form', were developed and circulated within the ACTION consortium. Extensive modifications took place; removal, addition, modification of themes and modification of clinical to lay terminology. The result was a thematically comprehensive advance directive to be used as a communication tool across the six European countries within the ACTION trial. This article shows the complex task of developing an advance directive suitable for cancer patients from six European countries; a process which required the resolution of several cross cultural differences in law, ethics, philosophy and practice. Our hope is that this paper can contribute to a deeper conceptual understanding of advance directives, their role in supporting decision making among patients approaching the end of life and be an inspiration to others wishing to develop a disease-specific advance directive or a standardised multinational advance directive.
Missing data are common in end-of-life care studies, but there is still relatively little exploration of which is the best method to deal with them, and, in particular, if the missing at random (MAR) ...assumption is valid or missing not at random (MNAR) mechanisms should be assumed. In this paper we investigated this issue through a sensitivity analysis within the ACTION study, a multicenter cluster randomized controlled trial testing advance care planning in patients with advanced lung or colorectal cancer.
Multiple imputation procedures under MAR and MNAR assumptions were implemented. Possible violation of the MAR assumption was addressed with reference to variables measuring quality of life and symptoms. The MNAR model assumed that patients with worse health were more likely to have missing questionnaires, making a distinction between single missing items, which were assumed to satisfy the MAR assumption, and missing values due to completely missing questionnaire for which a MNAR mechanism was hypothesized. We explored the sensitivity to possible departures from MAR on gender differences between key indicators and on simple correlations.
Up to 39% of follow-up data were missing. Results under MAR reflected that missingness was related to poorer health status. Correlations between variables, although very small, changed according to the imputation method, as well as the differences in scores by gender, indicating a certain sensitivity of the results to the violation of the MAR assumption.
The findings confirmed the importance of undertaking this kind of analysis in end-of-life care studies.
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