A qualitative assessment of the pulmonary rehabilitation decision-making needs of patients living with COPD

Pulmonary rehabilitation (PR) is highly evidenced but underutilised in patients living with chronic obstructive pulmonary disease (COPD). A menu of centre and home-based programmes is available to facilitate uptake but is not routinely offered. An appraisal of the current PR referral approach compared to a menu-based approach was warranted to explore the decision-making needs of patients living with COPD when considering a referral to PR. Face-to-face or telephone, semi-structured interviews were conducted with patients diagnosed with COPD and referred to PR and referring HCPs. Interviews were audio-recorded, transcribed verbatim and analysed using the enhanced critical incident technique. 14 HCPs and 11 patients were interviewed (n = 25). Interview data generated 276 critical incidents which informed 28 categories (30 sub-categories). Five high-level themes captured patients' decision-making needs for PR: Understanding COPD, understanding PR, perceived ability to access PR, a desire to accept PR, and supporting the offer. A menu-based approach would further support patients' PR decision-making, however, insufficient knowledge of the programmes would limit its perceived feasibility and acceptability. The development of shared decision making interventions (e.g., a patient decision aid) to elicit patient-centred, meaningful discussions about the menu is suggested

The TANDEM trial: protocol for the process evaluation of a randomised trial of a complex intervention for anxiety and/or depression in people living with chronic obstructive pulmonary disease (COPD)

Background: TANDEM is a randomised controlled trial of a complex healthcare intervention to improve the psychological and physical health of people living with chronic obstructive pulmonary disease (COPD) and anxiety and/or depression. Based on health psychology theory set out in a logic model, respiratory health professionals were recruited and trained to deliver a cognitive behavioural approach intervention (The TANDEM intervention) under the supervision of senior cognitive behavioural practitioners. Here, we describe the protocol for the process evaluation commissioned alongside the trial. A realist approach that includes attention to describing contexts and mechanisms has been adopted. Methods: We set up a multi-disciplinary team to develop and deliver the process evaluation. The mixed-methods design incorporates quantitative process data; monitoring of intervention fidelity; qualitative interviews with patients, carers, health professionals (facilitators) and clinical supervisors about their perspectives on acceptability of the intervention; and exploration with all stakeholders (including management/policy-makers) on future implementation. Normalisation process theory (NPT) will inform data collection and interpretation with a focus on implementation. Quantitative process data will be analysed descriptively. Qualitative interview data will be analysed before the trial outcomes are known using analytic induction and constant comparison to develop themes. Findings from the different elements will be reported separately and then integrated. Conclusion: Detailed description and analysis of study processes in a research trial such as TANDEM enables research teams to describe study contexts and mechanisms and to examine the relationship with outcomes. In this way, learning from the trial goes beyond the randomised control trial (RCT) model where effectiveness is prioritised and makes it possible to explore issues arising for post-trial study implementation. Trial registration: ISRCTN ISRCTN59537391. Registered on 20 March 2017. Trial protocol version 6.0, 22 April 2018. Process evaluation protocol version 4.0, 1 November 2020

The Problem Distiller Tool: supporting teachers in uncovering why their students have problems understanding Threshold Concepts

In pressThis study explored the use of a web-based tool entitled ‘Problem Distiller’ designed to support teachers in uncovering why their students have problems understanding Threshold Concepts. Data collected involved interviews with two math teachers, invited to experiment the Problem Distiller tool and Think Aloud protocol. Content analysis was used to process and analyse the collected data.. Findings show that teachers found it helpful when the information they entered through the Problem Distiller was fed back as they constructed an online diagnostic quiz. Focusing on the teachers’ understanding of why the students have problems is an effective way of tackling the barriers posed by Threshold Concepts and can be integrated with existing strategies and teaching approaches.CIEC – Research Centre on Child Studies, IE, UMinho (FCT R&D unit 317), PortugalEuropean Community's Seventh Framework ProgrammeThe research leading to these results has received funding from the European Community's Seventh Framework Programme under grant agreement no. 317964 JUXTALEARN. We would like to thank the interviewed teachers for their valuable collaboration

A tailored psychological intervention for anxiety and depression management in people with chronic obstructive pulmonary disease: TANDEM RCT and process evaluation

Background: People with chronic obstructive pulmonary disease have high levels of anxiety and depression, which is associated with increased morbidity and poor uptake of effective treatments, such as pulmonary rehabilitation. Cognitive-behavioural therapy improves mental health of people with long-term conditions and could potentially increase uptake of pulmonary rehabilitation, enabling synergies that could enhance the mental health of people with chronic obstructive pulmonary disease. Aim: Our aim was to develop and evaluate the clinical effectiveness and cost effectiveness of a tailored cognitive-behavioural approach intervention, which links into, and optimises the benefits of, routine pulmonary rehabilitation. Design: We carried out a pragmatic multicentre randomised controlled trial using a 1.25 : 1 ratio (intervention : control) with a parallel process evaluation, including assessment of fidelity. Setting: Twelve NHS trusts and five Clinical Commissioning Groups in England were recruited into the study. The intervention was delivered in participant\u27s own home or at a local NHS facility, and by telephone. Participants: Between July 2017 and March 2020 we recruited adults with moderate/very severe chronic obstructive pulmonary disease and mild/moderate anxiety and/or depression, meeting eligibility criteria for assessment for pulmonary rehabilitation. Carers of participants were invited to participate. Intervention: The cognitive-behavioural approach intervention (i.e. six to eight 40- to 60-minute sessions plus telephone support throughout pulmonary rehabilitation) was delivered by 31 trained respiratory healthcare professionals to participants prior to commencing pulmonary rehabilitation. Usual care included routine pulmonary rehabilitation referral. Main outcome measures: Co-primary outcomes were Hospital Anxiety and Depression Scale - anxiety and Hospital Anxiety and Depression Scale - depression at 6 months post randomisation. Secondary outcomes at 6 and 12 months included health-related quality of life, smoking status, uptake of pulmonary rehabilitation and healthcare use. Results: We analysed results from 423 randomised participants (intervention, n = 242; control, n = 181). Forty-three carers participated. Follow-up at 6 and 12 months was 93% and 82%, respectively. Despite good fidelity for intervention delivery, mean between-group differences in Hospital Anxiety and Depression Scale at 6 months ruled out clinically important effects (Hospital Anxiety and Depression Scale - anxiety mean difference -0.60, 95% confidence interval -1.40 to 0.21; Hospital Anxiety and Depression Scale - depression mean difference -0.66, 95% confidence interval -1.39 to 0.07), with similar results at 12 months. There were no between-group differences in any of the secondary outcomes. Sensitivity analyses did not alter these conclusions. More adverse events were reported for intervention participants than for control participants, but none related to the trial. The intervention did not generate quality-of-life improvements to justify the additional cost (adjusted mean difference \ua3770.24, 95% confidence interval -\ua327.91 to \ua31568.39) to the NHS. The intervention was well received and many participants described positive affects on their quality of life. Facilitators highlighted the complexity of participants\u27 lives and considered the intervention to be of potential valuable; however, the intervention would be difficult to integrate within routine clinical services. Our well-powered trial delivered a theoretically designed intervention with good fidelity. The respiratory-experienced facilitators were trained to deliver a low-intensity cognitive-behavioural approach intervention, but high-intensity cognitive-behavioural therapy might have been more effective. Our broad inclusion criteria specified objectively assessed anxiety and/or depression, but participants were likely to favour talking therapies. Randomisation was concealed and blinding of outcome assessment was breached in only 15 participants. Conclusions: The tailored cognitive-behavioural approach intervention delivered with fidelity by trained respiratory healthcare professionals to people with chronic obstructive pulmonary disease was neither clinically effective nor cost-effective. Alternative approaches that are integrated with routine long-term condition care are needed to address the unmet, complex clinical and psychosocial needs of this group of patients. Trial registration: This trial is registered as ISRCTN59537391. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 13/146/02) and is published in full in Health Technology Assessment; Vol. 28, No. 1. See the NIHR Funding and Awards website for further award information.People with long-standing lung problems, such as chronic obstructive pulmonary disease, often also have anxiety and depression, which further reduces their quality of life. Two existing treatments could help. Pulmonary rehabilitation (a programme of exercise and education) improves both the physical and mental health of people with chronic obstructive pulmonary disease. Cognitive–behavioural therapy (a talking therapy) may reduce anxiety and depression. The TANDEM [Tailored intervention for Anxiety and Depression Management in chronic obstructive pulmonary disease (COPD)] intervention linked these two treatments by providing talking therapy based on cognitive–behavioural therapy during the waiting time following referral for pulmonary rehabilitation. The TANDEM treatment was delivered by respiratory healthcare professionals (e.g. nurses or physiotherapists) trained to deliver the talking therapy in six to eight weekly sessions. The sessions were conducted in the participant’s home (or another convenient location), with brief telephone support during the pulmonary rehabilitation. Of 423 participants recruited to the study, 242 participants received TANDEM talking therapy and 181 participants received usual care (including a referral to pulmonary rehabilitation). We measured mental health, quality of life, social life, attendance at pulmonary rehabilitation and healthcare use in both groups at 6 and 12 months. Forty-three carers joined the study and we assessed their mental well-being. We interviewed patients, carers and health professionals to find out their views and experience of the TANDEM treatment. We also examined whether or not the TANDEM treatment was good value for money. The TANDEM treatment did not improve the mental or the physical health of people with chronic obstructive pulmonary disease. In addition, the TANDEM treatment cost the NHS an extra \ua3770 per patient, which was not good value for money. The TANDEM treatment was well received, and many participants told us how it had helped them. Heath-care professionals noted how participants did not just have chronic obstructive pulmonary disease, but were coping with many physical, mental and social problems. The TANDEM intervention was not effective and, therefore, other strategies will be needed to help people with chronic obstructive pulmonary disease and mental health problems live with their condition

Controversies in the management of advanced prostate cancer

For advanced prostate cancer, the main hormone treatment against which other treatments are assessed is surgical castration. It is simple, safe and effective, however it is not acceptable to all patients. Medical castration by means of luteinizing hormone-releasing hormone (LH-RH) analogues such as goserelin acetate provides an alternative to surgical castration. Diethylstilboestrol, previously the only non-surgical alternative to orchidectomy, is no longer routinely used. Castration reduces serum testosterone by around 90%, but does not affect androgen biosynthesis in the adrenal glands. Addition of an anti-androgen to medical or surgical castration blocks the effect of remaining testosterone on prostate cells and is termed combined androgen blockade (CAB). CAB has now been compared with castration alone (medical and surgical) in numerous clinical trials. Some trials show advantage of CAB over castration, whereas others report no significant difference. The author favours the view that CAB has an advantage over castration. No study has reported that CAB is less effective than castration. Of the anti-androgens which are available for use in CAB, bicalutamide may be associated with a lower incidence of side-effects compared with the other non-steroidal anti-androgens and, in common with nilutamide, has the advantage of once-daily dosing. Only one study has compared anti-androgens within CAB: bicalutamide plus LH-RH analogue and flutamide plus LH-RH analogue. At 160-week follow-up, the groups were equivalent in terms of survival and time to progression. However, bicalutamide caused significantly less diarrhoea than flutamide. Withdrawal and intermittent therapy with anti-androgens extend the range of treatment options. © 1999 Cancer Research Campaig

Feasibility of a shared decision-making intervention for individuals with COPD considering Pulmonary Rehabilitation

Introduction: Our intervention was developed to support patients with Chronic Obstructive Pulmonary Disease (COPD) make informed and values-based decisions about PR with healthcare professionals (PRhp) The shared decision making intervention (SDMi) components are a patient decision aid, decision coaching training, and a consultation prompt. Aim: To evaluate the feasibility of the SDMi. Methods: Convenience sampling was used to recruit patients with COPD referred to a UK PR service between Dec 2021 and Sep 2022. PRhp attended decision coaching training, patients received the decision aid at PR referral, and the PRhp used the consultation prompt during consultations. Outcomes included recruitment capability, data completeness, and intervention fidelity. Questionnaires assessed patient activation and decisional conflict at baseline and at completion/drop out of PR. Consultations were audio recorded and assessed using the Observer OPTION-5 scale (scores range from 0-100 with higher scores indicating greater adoption of SDM). Results: Recruitment rates for patients were 13% (n=31, 32% female) and for PRhp were 100% (n=9, 78% female). Patients had a mean(SD) age 71.2(7.5) and median(IQR) MRC dyspnoea 3.11(1.05)). At follow up, 81% (n=25) patients completed the patient activation and decisional conflict outcomes. SDM elements were present in all consultations; standardised scores ranged from 10.00 to 82.50 (mean(SD)=36.97(21.40). Conclusions: The results indicate the study processes and SDMi is feasible for patients with COPD and PRhp and can be delivered with fidelity. The next step is to assess impact in a fully powered randomised controlled trial

Pedagogical and organizational concerns for the deployment of interactive public displays at schools

This paper is a pre-print of an accepted paperThe integration of digital technology into schools is facing substantial challenges. In this study, we address the roles that public displays in communal spaces at the school can play as an additional vehicle for learning practices and, particularly, as a medium for sharing educational videos created by students themselves. Using a participatory design methodology, three hands- on workshops were conducted with teachers of a secondary school from the north of Portugal in order to elicit expectations towards the system design and its integration into school practices. Based on recorded video, direct observations, paper prototypes and open ended questionnaires created during the workshops, we conducted a systematic content analysis of teachers’ concerns associated with the deployment of public displays at schools. Findings suggest that teachers are receptive to the technology and were able to generate scenarios that take advantage of the possibilities offered by digital public displays to stimulate learning processes. However, to accommodate the constraints of learning practices and organizational realities, the design of the system needs to take into account a broad range of sensitivities.CIEC – Research Centre on Child Studies, UM (FCT R&D 317)European Community's Seventh Framework Programme (FP7/2007-2013)Centro Algoritm

Computing Teachers' Perspectives on Threshold Concepts: Functions and Procedural Abstraction

With the introduction of the new computing curriculum in England, teachers are facing many challenges, among them the teaching of computer programming. Literature suggests that the conceptual understanding of this subject contributes to its difficulty and that threshold concepts, as a source of troublesome knowledge, have a significant role in this. This paper explores computing teachers' perspectives on the Threshold Concept framework and suggests potential threshold concepts in the area of Functions and, more generally, in Procedural Abstraction. A study was conducted, using the Delphi method, including both computing teachers with experience teaching at upper secondary/high school and computing teachers with experience practicing programming in a professional environment for more than 7 years. The results indicate that the majority of the participants support that the Threshold Concept framework can explain students' difficulties in programming and agreed on 11 potential threshold concepts in the area of Functions and Procedural Abstraction. The participants focused more on the troublesome characteristic of threshold concepts and less on the transformative and integrative. Most of the participants also specified that they would change the way they teach a concept if they knew that this is a threshold one. Finally, the paper discusses the findings and how these will shape our future research