Review Panel Research Articles

Clinician consensus on “Inappropriate” presentations to the Emergency Department in the Better Data, Better Planning (BDBP) census: a cross-sectional multi-centre study of emergency department utilisation in Ireland

BackgroundUtilisation of the Emergency Department (ED) for non-urgent care increases demand for services, therefore reducing inappropriate or avoidable attendances is an important area for intervention in prevention of ED crowding. This study aims to develop a consensus between clinicians across care settings about the “appropriateness” of attendances to the ED in Ireland.MethodsThe Better Data, Better Planning study was a multi-centre, cross-sectional study investigating factors influencing ED utilisation in Ireland. Data was compiled in patient summary files which were assessed for measures of appropriateness by an academic General Practitioner (GP) and academic Emergency Medicine Consultant (EMC) National Panel. In cases where consensus was not reached charts were assessed by an Independent Review Panel (IRP). At each site all files were autonomously assessed by local GP-EMC panels.ResultsThe National Panel determined that 11% (GP) to 38% (EMC) of n = 306 lower acuity presentations could be treated by a GP within 24-48 h (k = 0.259; p < 0.001) and that 18% (GP) to 35% (EMC) of attendances could be considered “inappropriate” (k = 0.341; p < 0.001). For attendances deemed “appropriate” the admission rate was 47% compared to 0% for “inappropriate” attendees. There was no consensus on 45% of charts (n = 136). Subset analysis by the IRP determined that consensus for appropriate attendances ranged from 0 to 59% and for inappropriate attendances ranged from 0 to 29%. For the Local Panel review (n = 306) consensus on appropriateness ranged from 40 to 76% across ED sites.ConclusionsMultidisciplinary clinicians agree that “inappropriate” use of the ED in Ireland is an issue. However, obtaining consensus on appropriateness of attendance is challenging and there was a significant cohort of complex heterogenous presentations where agreement could not be reached by clinicians in this study. This research again demonstrates the complexity of ED crowding, the introduction of evidence-based care pathways targeting avoidable presentations may serve to alleviate the problem in our EDs.

A public panel reviews applications and questions applicants: Team member and public contributor discuss a transparent and inclusive approach to data access reviews

ObjectivesWe created a panel with members of the public and longitudinal study participants who review our data access requests. This panel forms an integral part of our data access application process, giving the public a say who can access the data for research.&#x0D; MethodsWe advertised our lay member vacancies using social media, newsletters, word of mouth and the internet. We appointed six people to the public panel. Our panel includes study participants, NHS service users, parents, carers, and people with experience of disability, neurodiversity, and long-term health conditions.&#x0D; The Panel Terms of Reference were created with help from stakeholders and study teams involved in longitudinal studies that involve the public in data access applications. This ensured that the purpose of the panel was clear. The panel reviews lay summaries and makes sure that researchers have adequate public involvement in their project.&#x0D; ResultsPanel members have reviewed 28 applications. Researchers present their research at an online meeting with the panel then answer questions from the panel members. We publish meeting minutes on our website for transparency.&#x0D; A 6-month review was overwhelmingly positive - all panel members indicated they felt valued. They felt able to challenge and question researchers as part of the data access application process. This provides a level of public scrutiny to our work.&#x0D; “I feel there’s a real value in the panel. You get a real sense that this has got such potential to make a contribution.” (panel member)&#x0D; We are further developing the Panel Terms of Reference with panel members. We will consider additional areas of responsibility, for example, public benefit review.&#x0D; ConclusionWe regularly review how to improve public involvement in our work. The panel has proven its value during our application process. Therefore we are exploring with the panel a new approach to assess the public benefit of applications and what is meant by ‘public benefit research’.

Study design for development of novel safety biomarkers of drug-induced liver injury by the translational safety biomarker pipeline (TransBioLine) consortium: a study protocol for a nested case–control study

A lack of biomarkers that detect drug-induced liver injury (DILI) accurately continues to hinder early- and late-stage drug development and remains a challenge in clinical practice. The Innovative Medicines Initiative’s TransBioLine consortium comprising academic and industry partners is developing a prospective repository of deeply phenotyped cases and controls with biological samples during liver injury progression to facilitate biomarker discovery, evaluation, validation and qualification.In a nested case–control design, patients who meet one of these criteria, alanine transaminase (ALT) ≥ 5 × the upper limit of normal (ULN), alkaline phosphatase ≥ 2 × ULN or ALT ≥ 3 ULN with total bilirubin > 2 × ULN, are enrolled. After completed clinical investigations, Roussel Uclaf Causality Assessment and expert panel review are used to adjudicate episodes as DILI or alternative liver diseases (acute non-DILI controls). Two blood samples are taken: at recruitment and follow-up. Sample size is as follows: 300 cases of DILI and 130 acute non-DILI controls. Additional cross-sectional cohorts (1 visit) are as follows: Healthy volunteers (n = 120), controls with chronic alcohol-related or non-alcoholic fatty liver disease (n = 100 each) and patients with psoriasis or rheumatoid arthritis (n = 100, 50 treated with methotrexate) are enrolled. Candidate biomarkers prioritised for evaluation include osteopontin, glutamate dehydrogenase, cytokeratin-18 (full length and caspase cleaved), macrophage-colony-stimulating factor 1 receptor and high mobility group protein B1 as well as bile acids, sphingolipids and microRNAs. The TransBioLine project is enabling biomarker discovery and validation that could improve detection, diagnostic accuracy and prognostication of DILI in premarketing clinical trials and for clinical healthcare application.

Epidemiology and Diagnosis of Post-Thrombotic Syndrome: Qualitative Synthesis with a Systematic Review.

Background: Post-thrombotic syndrome (PTS) is a common and debilitating sequela of lower limb deep vein thrombosis (DVT). There is significant heterogeneity in reported PTS incidence due to lack of standardised diagnostic criteria. This review aimed to develop diagnostic criteria for PTS and subsequently refine the reported incidence and severity. Methods: PRISMA principles were followed; however, the review was not registered. The Cochrane CENTRAL database, MEDLINE, Embase, the NHS NICE Healthcare Databases Advanced Search interface, and trial registers including isrctn.com and clinicaltrials.gov were searched for studies addressing areas of interest (PTS definition, epidemiology, assessment). An experienced Clinical Librarian undertook the systematic searches, and two independent reviewers agreed on the relevance of the papers. Conflicts were resolved through panel review. Evidence quality was assessed using a modified Coleman scoring system and weighted according to their relevance to the aforementioned areas of interest. Results: A total of 339 abstracts were retrieved. A total of 33 full-text papers were included in this review. Following qualitative analysis, four criteria were proposed to define PTS: (1) a proven thrombotic event on radiological assessment; (2) a minimum 24-month follow-up period after an index DVT; (3) assessment with a validated score; and (4) evidence of progression of venous insufficiency from baseline. Four papers conformed to our PTS definition criteria, and the incidence of mild to moderate PTS ranged from 7 to 36%. On reviewing the studies which utilised the recommended Villalta scale, PTS incidence narrowed further to 23-36%. Incidence and severity reached a plateau at 24 months. Conclusions: Four diagnostic criteria were developed from qualitative synthesis. When these criteria were applied to the literature, the range of reported PTS incidence narrowed. These four criteria may standardise PTS diagnosis in future studies, facilitating the pooling of data for meta-analysis and synthesis of higher levels of evidence.

The importance of sleep regularity: a consensus statement of the National Sleep Foundation sleep timing and variability panel

ObjectiveTo develop and present consensus findings of the National Sleep Foundation sleep timing and variability panel regarding the impact of sleep timing variability on health and performance. MethodsThe National Sleep Foundation assembled a panel of sleep and circadian experts to evaluate the scientific evidence and conduct a formal consensus and voting procedure. A systematic literature review was conducted using the NIH National Library of Medicine PubMed database, and panelists voted on the appropriateness of 3 questions using a modified Delphi RAND/UCLA Appropriateness Method with 2 rounds of voting. ResultsThe literature search and panel review identified 63 full text publications to inform consensus voting. Panelists achieved consensus on each question: (1) is daily regularity in sleep timing important for (a) health or (b) performance? and (2) when sleep is of insufficient duration during the week (or work days), is catch-up sleep on weekends (or non-work days) important for health? Based on the evidence currently available, panelists agreed to an affirmative response to all 3 questions. ConclusionsConsistency of sleep onset and offset timing is important for health, safety, and performance. Nonetheless, when insufficient sleep is obtained during the week/work days, weekend/non-work day catch-up sleep may be beneficial.

Translation, cross-cultural adaption, validity and reliability of a composite physical function scale for adults aged 65 + years in a Danish context

BackgroundTo prevent or postpone dependence on help in everyday activities, early identification of adults aged 65 + years at risk of functional decline or with progressing functional decline is essential. The American Composite Physical Function (CPF) scale was developed to detect and prevent this age-conditioned decline. In this study, the aim was to translate and adapt the scale into a Danish version and assess the validity and reliability in Danish adults aged 65 + years.MethodsA forward–backward translation procedure was used, followed by an expert panel review to finalise the Danish version of the CPF scale. In the subsequent pre-test, three-step cognitive interviews and hypotheses testing were performed to evaluate the validity, and a test–retest was done to assess reliability.ResultsIn the pre-test, 47 adults participated in three-step cognitive interviews, and 45 adults answered an online version of the scale. In terms of content validity, the scale was relevant and easy to answer, although many informants skipped the instruction to the questionnaire, which may negatively impact face validity. Construct validity showed a significant difference in CPF scores in adults aged 65 + years by residence and activity level and a decreasing CPF score with increasing age. The reliability test showed an excellent kappa (0.92).ConclusionThe scale covering daily activities helps to identify adults aged 65 + years with reduced physical functions or at risk of loss of independence. Further research is needed to assess the CPF predictive value for adults aged 65 + years at risk of or with a progressing physical decline.

Expert Opinion on Dose Regimen and Therapeutic Drug Monitoring for Long-Term Use of Dalbavancin: Expert Review Panel

BackgroundDalbavancin is a lipoglycopeptide with a long elimination half-life and is currently licensed for the treatment of acute bacterial skin and skin structure infections in adults. Dalbavancin's potential in treating off-label complex Gram-positive infections is promising and real-world experience in treating such infections is growing. However, clear guidance on extended dosing regimens is lacking. ObjectivesThis study aimed to provide clear expert opinion based on recent pharmacokinetic literature and expert and real-world experience in infection areas that require > 2 weeks of treatment. MethodsA single face-to-face meeting was held in September 2022 to collate expert opinion and present safety data of dalbavancin use in these clinical indications. A survey was completed by all authors on their individual experience with dalbavancin, which highlighted the heterogeneity in the regimens that were used. ResultsAfter review of the survey data and recent literature, this study presents expert panel proposals that accommodate different healthcare settings and resource availability, and centre around the length of treatment duration including up to or exceeding 6 weeks. To achieve adequate dalbavancin concentrations for up to 6 weeks, 3000 mg of dalbavancin should be given over 4 weeks for the agreed complex infections requiring > 2 weeks of treatment. Therapeutic drug monitoring (TDM) is advised for longer treatment durations and in cases of renal failure. Specific dosing recommendations for other special populations require further investigation. ConclusionsThese proposals based on expert opinion have been defined to encourage best practice with dalbavancin, to optimise its administration beyond the current approved licenced dose across different healthcare settings.

Psychometric Properties of the Turkish Validity and Reliability of the Parent Diabetes Distress Scale

The aim of this study was to evaluate the validity and reliability of the Turkish translation of the Parent Diabetes Distress Scale (PDDS). The PDDS is a 5-point Likert-type scale with 20 items. After obtaining permission from the scale developers, the study commenced. First, a systematic adaptation of the scale into the Turkish language was performed including translation, expert panel review, back translation, and pilot study. Test-retest was applied to 35 participants. After these procedures, data collection was undertaken using the adapted PDDS and a demographic data collection form. The collected data were analyzed for reliability, including stability of the scale with test-retest and internal consistency of the scale (Cronbach’s α), and validity including construct validity of the scale with confirmatory factor analysis (CFA). The parents of 210 teenagers, aged >11 and <18 years, who had been diagnosed with type 1 diabetes mellitus for at least one year were included. Of these parents, 71.9% (n=151) were mothers and 53.3% (n=112) of the children were girls. The Cronbach’s α value was 0.906. The results of the CFA were χ2/df=4.406, p<0.001, comparative fit test 0.704, and goodness of fit tests 0.749. The mean total PDDS score was 2.2±0.7. These results indicate that scores of 1.6 points or less was evaluated as “little or no distress” 1.7-2.4 as “moderate distress,” and >2.4 points as “high distress”. This showed that the majority of the parents in the study experienced moderate or severe diabetes-related distress. The Turkish version of the PDDS fulfilled the validity and reliability tests at an acceptable level.

Distrust in grant peer review—reasons and remedies

Abstract With the increasing reliance on competitive grants to fund research, we see a review system under pressure. While peer review has long been perceived as the cornerstone of self-governance in science, researchers have expressed distrust in the peer review procedures of funding agencies. This paper draws on literature pointing out ability, benevolence, and integrity as important for trustworthiness and explores the conditions under which researchers have confidence in grant review. Based on rich survey material, we find that researchers trust grant reviewers far less than they trust journal peer reviewers or their colleagues’ ability to assess their research. Yet, scholars who have success with grant proposals or serve on grant review panels appear to have more trust in grant reviewers. We conclude that transparency and reviewers with field competencies are crucial for trust in grant review and discuss how this can be ensured.

Time is of the Essence: Why Goals-of-Care Conversations and Prognosis Documentation Matters in Advanced Cancer Patients in an Integrated Health System.

Background: Advanced cancer patients benefit less from aggressive therapies and more from goal-directed palliative management. Early and clearly documented goals-of-care discussions, including end-of-life decision making, are essential in this patient population. Integrated healthcare systems are comprehensive care models associated with improved quality of care and lower mortality compared to other healthcare models. The role of advance care planning within our system is understudied. Methods: Patients 18years and older with a diagnosis of advanced-stage cancer were identified over a 6-month period. Expert panel review was performed to evaluate medical appropriateness of the selected diagnostic workup and management. The role and extent of care planning was reviewed in association with the clinical context. Results: In a cohort of 82 patients, evidence-based and individualized appropriateness of medical management was found to be consistent for all patients. Eighty-two percent of patients elected for oncologic-based treatment, 5% pursued active surveillance, and 11% did not receive treatment. Seventy-three percent of patients were referred to palliative care. Fifty-six percent of patients had a full goals-of-care conversation documented; yet only 9% of goals-of-care conversations were documented by an oncologist. Prognosis was documented fully for only 22% of patients. At the end of the study period, 43 patients were deceased (52%), further indicating the critical importance of documentation. Conclusions: Within our integrated health system, we found consistent guideline- and patient-directed diagnosis and management, along with frequent integration of palliative care services. Goals-of-care conversation and prognosis documentation, especially by the oncologist, remains an area of needed improvement.

Strategy for Generating Blinded Evidence for Single-Arm Trials with External Controls Using Expert Review of Home Video

IntroductionNeurodegenerative diseases cause developmental delays and loss of milestones in infants and children. However, scalable outcome measures that quantify features meaningful to parents/caregivers (P/CGs) and have regulatory precedence are lacking for assessing the effectiveness of treatments in clinical trials of neurodegenerative disorders. To address this gap, we developed an innovative, blinded strategy for single-arm trials with external controls using expert panel review of home video.MethodWe identified meaningful, observable, and objective developmental milestones from iterative interviews with P/CGs and clinical experts. Subsequently, we standardized video recording procedures and instructions to ensure consistency in how P/CGs solicited each activity. In practice, videos would be graded by an expert panel blinded to treatment. To ensure blinding and quality control, video recordings from interim time points would be randomly interspersed. We conducted a pilot study and a pretest of grading to test feasibility and improve the final strategy.ResultsThe five P/CGs participating in the pilot study found the instructions clear, selected activities important and reflective of their children’s abilities, and recordings at-home preferrable to in-clinic assessments. The three grading experts found the videos easy to grade and the milestones clinically meaningful.ConclusionOur standardized strategy enables expert panel grading of developmental milestone achievements using at-home recordings, blinded to treatment and post-baseline time points. This rigorous and objective scoring system has broad applicability in various disease contexts, with or without external controls. Moreover, our strategy facilitates flexible, continued data collection and the videos can be archived for future analyses.

Global Stillbirth Policy Review - Outcomes And Implications Ahead of the 2030 Sustainable Development Goal Agenda.

Globally, data on stillbirth is limited. A call to action has been issued to governments to address the data gap by strengthening national policies and strategies to drive urgent action on stillbirth reduction. This study aims to understand the policy environment for stillbirths to advance stillbirth recording and reporting in data systems. A systematic three-step process (survey tool examination, identifying relevant study questions, and reviewing country responses to the survey and national documents) was taken to review country responses to the global 2018-2019 World Health Organization (WHO) Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy Survey. Policy Survey responses were reviewed to identify if and how stillbirths were included in national documents. This paper uses descriptive analyses to identify and describe the relationship between multiple variables. Responses from 155 countries to the survey were analysed, and over 800 national policy documents submitted by countries in English reviewed. Fewer than one-fifth of countries have an established stillbirth rate (SBR) target, with higher percentages reported for under-5 (71.0%) and neonatal mortality (68.5%). Two-thirds (65.8%) of countries reported a national maternal death review panel. Less than half (43.9%) of countries have a national policy that requires stillbirths to be reviewed. Two-thirds of countries have a national policy requiring review of neonatal deaths. WHO websites and national health statistics reports are the common data sources for stillbirth estimates. Countries that are signatories to global initiatives on stillbirth reduction have established national targets. Globally, nearly all countries (94.8%) have a national policy that requires every death to be registered. However, 45.5% of reviewed national policy documents made mention of registering stillbirths. Only 5 countries had national policy documents recommending training of health workers in filling out death certificates using the International Classification of Diseases (ICD)-10 for stillbirths. The current policy environment in countries is not supportive for identifying stillbirths and recording causes of death. This is likely to contribute to slow progress in stillbirth reduction. The paper proposes policy recommendations to make every baby count.

Mi Vida Saludable: Content Validity and Reliability of The Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW) for Cancer Survivors.

The purpose of this study is to conduct validity and reliability testing of a new instrument, the Preferences and Self-Efficacy of Diet and Physical Activity Behaviors Questionnaire for Latina Women (PSEDPALW), which is for women who identify as Latina and are breast cancer survivors. PSEDPALW measures preferences and self-efficacy for four behaviors: physical activity (PA), fruit and vegetable (FV) intake, dietary fat (DF) intake, and added sugar (AS) intake (eight scales in total). Validity testing was conducted through an expert panel review and a cognitive interviewing focus group (n = 4). Reliability was tested via internal consistency reliability (n = 118) and test-retest reliability (n = 30). Validity testing was used to refine PSEDPALW. Reliability testing was conducted on three versions with 104, 47, and 41 items. PA scales had acceptable Cronbach's α (>0.70) but low ICC (NS). FV and DF scales had acceptable Cronbach's α (>0.70), with preferences for the shorter (47- and 41-item) versions (Cronbach's α < 0.70), and all scales had moderate ICC (p < 0.05, except the FV scale on the 104-item version (p = 0.07)). The AS preferences scale had Cronbach's α < 0.70, with self-efficacy > 0.70 for all versions and ICC moderate for all versions (p ≤ 0.01). PSEDPALW may be useful to assess diet and physical activity preferences and self-efficacy in theory-based diet and physical activity interventions in women who identify as Latina and are breast cancer survivors.

Development and Validation of an Automated Classification System for Osteonecrosis of the Femoral Head Using Deep Learning Approach: A Multicenter Study

BackgroundAccurate classification can facilitate the selection of appropriate interventions to delay the progression of osteonecrosis of the femoral head (ONFH). This study aimed to perform the classification of ONFH through a deep learning approach. MethodsWe retrospectively sampled 1,806 midcoronal magnetic resonance images (MRIs) of 1,337 hips from 4 institutions. Of these, 1,472 midcoronal MRIs of 1,155 hips were divided into training, validation, and test datasets with a ratio of 7:1:2 to develop a convolutional neural network model (CNN). An additional 334 midcoronal MRIs of 182 hips were used to perform external validation. The predictive performance of the CNN and the review panel was also compared. ResultsA multiclass CNN model was successfully developed. In internal validation, the overall accuracy of the CNN for predicting the severity of ONFH based on the Japanese Investigation Committee classification was 87.8%. The macroaverage values of area under the curve (AUC), precision, recall, and F-value were 0.90, 84.8, 84.8, and 84.6%, respectively. In external validation, the overall accuracy of the CNN was 83.8%. The macroaverage values of area under the curve, precision, recall, and F-value were 0.87, 79.5, 80.5, and 79.9%, respectively. In a human–machine comparison study, the CNN outperformed or was comparable to that of the deputy chief orthopaedic surgeons. ConclusionThe CNN is feasible and robust for classifying ONFH and correctly locating the necrotic area. These findings suggest that classifying ONFH using deep learning with high accuracy and generalizability may aid in predicting femoral head collapse and clinical decision-making.

Cross-Cultural Adaptation, Reliability, and Convergent Validity of Occupational Self-Assessment for Brazilian Portuguese.

The Occupational Self-Assessment version 2.2 (OSA) is a self-assessment of the client's occupational competence and values. To describe the process of cross-cultural adaptation of OSA into Brazilian Portuguese (OSA-Brazil) and examine its reliability and validity for use with the Brazilian population. Assessment translation was guided by two international guidelines for cross-cultural adaptation of standardized instruments. Face validity was tested with 24 participants. Internal consistency, test-retest reliability, and convergent validity were tested with a convenience sample of 40 participants. The cross-cultural adaptation process concluded with a consensus among the expert panel review (r > 80%) and evidence of strong face validity. The OSA-Brazil demonstrated appropriate test-retest reliability (r > 0.70) and convergent validity with the 36-Item Short-Form Health Survey (SF-36) (p < .05). The OSA-Brazil has good face validity, test-retest reliability, and convergent validity. The assessment can be used by the Brazilian occupational therapists to assess client's occupational competence.

The Role of the Urban Design Review Panel in a Master-Planned Community Development: A Case Study of Hobsonville Point, New Zealand

Design guidelines and design review panel (DRPs) are crucial components in ensuring consistent and high-quality design within masterplan sites. This study focuses on New Zealand, examining the challenges faced by industry partners in adapting to master-planned design guidelines. The case study centres on Hobsonville Point, the largest government-led masterplan community in New Zealand, which promotes sustainable and higher-density living—an uncommon concept in the country. We conducted interviews with 18 key stakeholders involved in the development of Hobsonville Point. The results show that the DRP provides flexible judgments and insightful information that better accommodate individual development characteristics than the strict numerical standards specified in design guidelines. This study underscores the importance of the DRP in producing good design outcomes, especially when they are involved at the very beginning of the design process. Additionally, we took note of stakeholder concerns about DRP members’ expertise and the possible effects of high turnover rates on the design process. To strive for continual improvement, future empirical studies on the DRP process are encouraged to enhance proficiency and dependability. Design guidance should be prioritised to ensure that climate-related design is implemented to promote sustainable urban development.

Management of the Difficult Airway: An Appraisal of Clinical Practice Guidelines.

Management of the difficult airway can be a challenging process, which necessitates actionable recommendations from well-established guidelines. Herein, clinical practice guideline (CPG) quality is evaluated using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. A systematic literature search was performed using Scopus, EMBASE, and MEDLINE via PubMed. Literature database. Data were abstracted from relevant guidelines and appraised by 4 expert reviewers in the 6 domains of quality defined by AGREE II. Intraclass correlation coefficients (ICC) were calculated across domains to quantify interrater reliability. Twelve guidelines met the inclusion criteria. With a mean quality score of 83.1%, the highest quality guideline was authored by the American Society of Anesthesiologists (ASA). Low-quality content was observed in CPGs authored by the Japanese Society of Anesthesiologists (JSA) and the Chinese Collaboration Group for Emergency Airway Management (CCGEAM). Overall, deficits were most pronounced in domains describing the involvement of stakeholders, developmental rigor, and editorial independence. These findings were consistent among the panel of independent reviewers, with high ICC inter-rater reliability scores of 58.0% to 70.0% for the referenced domains. By providing a comprehensive appraisal of guidelines, this report may serve as a reference for clinicians seeking to understand and improve upon the developmental quality of difficult airway management resources. According to AGREE II criteria for the quality of the guideline creation process, the 2022 ASA guideline outperforms its predecessors.

Complexity Theory and Child Protection and Welfare: A Tool of Hindsight and/or a Tool to Assist Improved Decision Making in Child Protection and Welfare Work

Abstract Child abuse and neglect is a ‘wicked problem’ (Devaney, J. and Spratt, T. (2009) ‘Child abuse as a complex and wicked problem: Reflecting on policy developments in the United Kingdom in working with children and families with multiple problems’, Children and Youth Services Review, 31(6), pp. 635–41.). Child Protection and Welfare (CPW) systems are open systems in which a wide variety of practitioners and families themselves contribute to outcomes. Small interacting changes in one part of a CPW system can lead to unpredictable and systemic effects so linear, technocratic solutions are not sufficient in addressing this complexity. Whilst CPW systems may aim to make clear roles and responsibilities, steered by legislation and regulatory guidance, complex systems do not behave as system designers expect. Recent literature has demonstrated a turn to complexity theory and systems theory concepts for understanding and working in the world of child protection. This article suggests a practice framework based on complexity theory concepts of self-organisation/emergence/adaptation, path-dependency and bifurcation. The utility of the framework is tested by its application to a fictionalised case study built on a thematic analysis of five National Review Panel published case reviews in the Irish child protection context (2019–2020). We argue that complexity theory may be a useful tool for both post hoc analytics as well as providing a proactive tool for application to practice to assist decision making in CPW systems, services and organisations.

Development and validation of assessment tools for food allergy-related knowledge and management confidence.

Given the life-threatening nature of food allergy (FA), it is important to assess the level of knowledge among families with food-allergic patients and their ability to cope with anaphylaxis. This study constructed a FA knowledge questionnaire (FAKQ) and confidence in FA management skills (CIFAMS) questionnaire to assess understanding and attitudes toward FA management in food-allergic families. Items from literature review and expert panel showing ≥80% content validity index and semantic equivalence were selected for translation into Chinese. These questionnaires underwent feasibility pilot testing followed by cross-sectional validation to assess their psychometric properties of internal consistency, test-retest reliability, and construct validity with a FA quality-of-life questionnaire and discriminant validity. Exploratory factor analysis was performed to confirm their factor structure. A total of 155 subjects (104 patients and 51 parents) completed a 20-item FAKQ and 10-item CIFAMS. Both tools showed acceptable internal consistency in baseline and retest groups. FAKQ and CIFAMS correlated for all subjects (P=.002) and for adults (P= .002), and similarly between CIFAMS and parent-reported FA independent measure (P=.005). Total score of FAKQ was sensitive to within-group differences of patients hospitalized for FA (P< .001). FAKQ and CIFAMS items were factored into 4 and 2 domains, respectively. Subjects scored the lowest on FAKQ items about signs of allergic reaction and CIFAMS items on epinephrine autoinjector use. FAKQ and CIFAMS developed by our group are valid and reliable in assessing knowledge and confidence in FA management in patients and parents. These tools are crucial for formulating education programs and advocacy campaigns for FA.

Protocol for a multicentre cross-sectional, longitudinal ambulatory clinical trial in rheumatoid arthritis and Parkinson’s disease patients analysing the relation between the gut microbiome, fasting and immune status in Germany (ExpoBiome)

IntroductionChronic inflammatory diseases like rheumatoid arthritis (RA) and neurodegenerative disorders like Parkinson’s disease (PD) have recently been associated with a decreased diversity in the gut microbiome, emerging as key driver...