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End-of-life care policy has a focus on enabling patients to die in their preferred place; this is believed for most to be home. This review assesses patient preferences for place of death examining: the extent of unreported preferences, the importance of patient factors (place of care and health diagnosis) and who reports preferences. Systematic literature review of 7 electronic databases, grey literature, backwards citations from included studies and Palliative Medicine hand search. Included studies published between 2000-2015, reporting original, quantifiable results of adult UK preferences for place of death. Of 10826 articles reviewed, 61 met the inclusion criteria. Summary charts present preferences for place of death by health diagnosis, where patients were asked and who reported the preference. These charts are recalculated to include 'missing data,' the views of those whose preferences were not asked, expressed or reported or absent in studies. Missing data were common. Across all health conditions when missing data were excluded the majority preference was for home: when missing data were included, it was not known what proportion of patients with cancer, non-cancer or multiple conditions preferred home. Patients, family proxies and public all expressed a majority preference for home when missing data were excluded: when included, it was not known what proportion of patients or family proxies preferred home. Where patients wished to die was related to where they were asked their preference. Missing data calculations are limited to 'reported' data. It is unknown what proportion of patients prefers to die at home or elsewhere. Reported preferences for place of death often exclude the views of those with no preference or not asked: when 'missing data' are included, they supress the proportion of preferences for all locations. Caution should be exercised if asserting that most patients prefer to die at home.

Background In the UK, responsibility for many public health functions was transferred in 2013 from the National Health Service (NHS) to local government; a very different political context and one without the NHS history of policy and practice being informed by evidence-based guidelines. A problem this move presented was whether evidence-based guidelines would be seen as relevant, useful and implementable within local government. This study investigates three aspects of implementing national evidence-based recommendations for public health within a local government context: influences on implementation, how useful guidelines are perceived to be and whether the linear evidence-guidelines-practice model is considered relevant. Methods Thirty-one councillors, public health directors and deputy directors and officers and other local government employees were interviewed about their experiences implementing evidence-based guidelines. Interviews were informed and analysed using a theoretical model of behaviour (COM-B; Capability, Opportunity, Motivation–Behaviour). Results Contextual issues such as budget, capacity and political influence were important influences on implementation. Guidelines were perceived to be of limited use, with concerns expressed about recommendations being presented in the abstract, lacking specificity and not addressing the complexity of situations or local variations. Local evidence was seen as the best starting point, rather than evidence-based guidance produced by the traditional linear ‘evidence–guidelines–practice’ model. Local evidence was used to not only provide context for recommendations but also replace recommendations when they conflicted with local evidence. Conclusions Local government users do not necessarily consider national guidelines to be fit for purpose at local level, with the consequence that local evidence tends to trump evidence-based guidelines. There is thus a tension between the traditional model of guideline development and the needs of public health decision-makers and practitioners working in local government. This tension needs to be addressed to facilitate implementation. One way this might be achieved, and participants supported this approach, would be to reverse or re-engineer the traditional pipeline of guideline development by starting with local need and examples of effective local practice rather than starting with evidence of effectiveness synthesised from the international scientific literature. Alternatively, and perhaps in addition, training about the relevance of research evidence should become a routine for local government staff and councillors.

BackgroundEthical challenges are common in end of life care; the uncertainty of prognosis and the ethically permissible boundaries of treatment create confusion and conflict about the balance between benefits and burdens experienced by patients.ObjectiveWe asked physician trainees in internal medicine how they reacted and responded to ethical challenges arising in the context of perceived futile treatments at the end of life and how these challenges contribute to moral distress.DesignSemi-structured in-depth qualitative interviews.ParticipantsTwenty-two internal medicine residents and fellows across three American academic medical centers.ApproachThis study uses systematic qualitative methods of data gathering, analysis and interpretation.Key ResultsPhysician trainees experienced significant moral distress when they felt obligated to provide treatments at or near the end of life that they believed to be futile. Some trainees developed detached and dehumanizing attitudes towards patients as a coping mechanism, which may contribute to a loss of empathy. Successful coping strategies included formal and informal conversations with colleagues and superiors about the emotional and ethical challenges of providing care at the end of life.ConclusionsMoral distress amongst physician trainees may occur when they feel obligated to provide treatments at the end of life that they believe to be futile or harmful.

Background Behaviour change is key to addressing both the challenges facing human health and wellbeing and to promoting the uptake of research findings in health policy and practice. We need to make better use of the vast amount of accumulating evidence from behaviour change intervention (BCI) evaluations and promote the uptake of that evidence into a wide range of contexts. The scale and complexity of the task of synthesising and interpreting this evidence, and increasing evidence timeliness and accessibility, will require increased computer support. The Human Behaviour-Change Project (HBCP) will use Artificial Intelligence and Machine Learning to (i) develop and evaluate a ‘Knowledge System’ that automatically extracts, synthesises and interprets findings from BCI evaluation reports to generate new insights about behaviour change and improve prediction of intervention effectiveness and (ii) allow users, such as practitioners, policy makers and researchers, to easily and efficiently query the system to get answers to variants of the question ‘ What works, compared with what, how well, with what exposure, with what behaviours (for how long), for whom, in what settings and why?’ . Methods The HBCP will: a) develop an ontology of BCI evaluations and their reports linking effect sizes for given target behaviours with intervention content and delivery and mechanisms of action, as moderated by exposure, populations and settings; b) develop and train an automated feature extraction system to annotate BCI evaluation reports using this ontology; c) develop and train machine learning and reasoning algorithms to use the annotated BCI evaluation reports to predict effect sizes for particular combinations of behaviours, interventions, populations and settings; d) build user and machine interfaces for interrogating and updating the knowledge base; and e) evaluate all the above in terms of performance and utility. Discussion The HBCP aims to revolutionise our ability to synthesise, interpret and deliver evidence on behaviour change interventions that is up-to-date and tailored to user need and context. This will enhance the usefulness, and support the implementation of, that evidence.

Recent case reports and series have identified a subgroup of atypical femoral-shaft fractures associated with bisphosphonate use. This study analyzed data from three large, randomized bisphosphonate trials. Subtrochanteric or diaphyseal femur fractures were very rare, even among women who had been treated with bisphosphonates for as long as 10 years. In patients with osteoporosis, proven benefits for fracture reduction appear to outweigh the possible risk of femoral-shaft fractures. This study analyzed data from three large, randomized bisphosphonate trials. Subtrochanteric or diaphyseal femur fractures were very rare, even among women who had been treated with bisphosphonates for as long as 10 years. Several case series have described cases of “atypical” subtrochanteric and diaphyseal fractures of the femoral shaft and have suggested that the risk may be increased in long-term users of bisphosphonates. 1 – 13 Descriptions of associated atypical characteristics vary but have been described as a simple transverse or oblique (<30 degrees) fracture with cortical beaking and diffuse cortical thickening. 2 Clinical associations that have been mentioned in some reports include low-level trauma, prodromal pain or evidence of a previous stress fracture, contralateral changes, and the use of specific concomitant drugs (including corticosteroids), 9 , 10 antiresorptive drugs (including hormone-replacement therapy), 10 and proton-pump inhibitors. 13 However, these . . .

Background Bedtime routines has shown important associations with areas associated with child wellbeing and development. Research into bedtime routines is limited with studies mainly focusing on quality of sleep. The objectives of the present study were to examine the relationship between bedtime routines and a variety of factors associated with child wellbeing and to examine possible determinants of bedtime routines. Methods A total of 50 families with children between 3 and 5 years old took part in the study. Data on bedtime routines, parenting styles, school readiness, children’s dental health, and executive function were collected. Results Children in families with optimal bedtime routines showed better performance in terms of executive function, specifically working memory (t (44)= − 8.51, p  ≤ .001), inhibition and attention (t (48)= − 9.70, p  ≤ .001) and cognitive flexibility (t (48)= − 13.1, p  ≤ .001). Also, children in households with optimal bedtime routines scored higher in their readiness for school (t (48)= 6.92, p  ≤ .001) and had better dental health (U = 85.5, p  = .011). Parents in households with suboptimal bedtime routines showed worse performance on all measures of executive function including working memory (t (48)= − 10.47, p  ≤ .001), inhibition-attention (t (48)= − 10.50, p  ≤ .001) and cognitive flexibility (t (48)= − 13.6, p  ≤ .001). Finally, parents with optimal bedtime routines for their children deployed a more positive parenting style in general (i.e. authoritative parenting) compared to those with suboptimal bedtime routines (t (48)= − 6.45, p  ≤ .001). Conclusion The results of the present study highlight the potentially important role of bedtime routines in a variety of areas associated with child wellbeing and the need for further research.

Background Innovative approaches are required to move beyond individual approaches to behaviour change and develop more appropriate insights for the complex challenge of increasing population levels of activity. Recent research has drawn on social practice theory to describe the recursive and relational character of active living but to date most evidence is limited to small-scale qualitative research studies. To ‘upscale’ insights from individual contexts, we pooled data from five qualitative studies and used machine learning software to explore gendered patterns in the context of active travel. Methods We drew on 280 transcripts from five research projects conducted in the UK, including studies of a range of populations, travel modes and settings, to conduct unsupervised ‘topic modelling analysis’. Text analytics software, Leximancer, was used in the first phase of the analysis to produce inter-topic distance maps to illustrate inter-related ‘concepts’. The outputs from this first phase guided a second researcher-led interpretive analysis of text excerpts to infer meaning from the computer-generated outputs. Results Guided by social practice theory, we identified ‘interrelated’ and ‘relating’ practices across the pooled datasets. For this study we particularly focused on respondents’ commutes, travelling to and from work, and on differentiated experiences by gender. Women largely described their commute as multifunctional journeys that included the school run or shopping, whereas men described relatively linear journeys from A to B but highlighted ‘relating’ practices resulting from or due to their choice of commute mode or journey such as showering or relaxing. Secondly, we identify a difference in discourses about practices across the included datasets. Women spoke more about ‘subjective’, internal feelings of safety (‘I feel unsafe’), whereas men spoke more about external conditions (‘it is a dangerous road’). Conclusion This rare application of machine learning to qualitative social science research has helped to identify potentially important differences in co-occurrence of practices and discourses about practice between men’s and women’s accounts of travel across diverse contexts. These findings can inform future research and policy decisions for promoting travel-related social practices associated with increased physical activity that are appropriate across genders.

Background The prevalence of childhood obesity has been increasing but the causes are not fully understood. Recent public health interventions and guidance aiming to reduce childhood obesity have focused on the whole family, as opposed to just the child but there remains a lack of empirical evidence examining this relationship. Methods Using data from the longitudinal Millennium Cohort Study (MCS), we investigate the dynamic relationship between underlying family lifestyle and childhood obesity during early childhood. The MCS interviewed parents shortly after the birth of their child and follow up interviews were carried out when the child was 3, 5 and 7 years. We use a dynamic latent factor model, an approach that allows us to identify family lifestyle, its evolution over time (in this case between birth and 7 years) and its influence on childhood obesity and other observable outcomes. Results We find that family lifestyle is persistent, 87.43% of families which were above the 95th percentile on the lifestyle distribution, remained above the 95th percentile when the child was 7 years old. Family lifestyle has a significant influence on all outcomes in the study, including diet, exercise and parental weight status; family lifestyle accounts for 11.3% of the variation in child weight by age 7 years. Conclusion The analysis suggests that interventions should therefore be prolonged and persuasive and target the underlying lifestyle of a family as early as possible during childhood in order to have the greatest cumulative influence. Our results suggest that children from advantaged backgrounds are more likely to be exposed to healthier lifestyles and that this leads to inequalities in the prevalence of obesity. To reduce inequalities in childhood obesity, policy makers should target disadvantaged families and design interventions specifically for these families.

PurposePrevious studies on adults with degenerative scoliosis (ADS) have been fixed the threshold of PI-LL mismatch less than 10° for achieving good clinical outcomes. Recent studies discussed that PI-LL mismatch should consider individual pelvic incidence (PI) and should be set first in a normal population. The purpose of this study is to assess the variability of PI-LL mismatch according to PI in an asymptomatic population.MethodsFull-body low dose stereoradiographic evaluation was done in a multi-ethnic cohort of 468 asymptomatic adult volunteers. Patients were clustered in three groups depending on individual PI values: PI < 45°, 45° < PI < 60° and PI > 60°. 3D measurements were performed using a commercially available 2D/3D modeling software to establish a correlation of PI with other spinopelvic parameters. ANOVA and Tukey’s HSD for post-hoc analysis were used to determine the differences between the three groups.ResultsIn our asymptomatic population, the mean value of PI-LL mismatch is − 5.4° ± 10.7°. Clusterization of the population reveals significant differences in the distribution of L1S1 lordosis, pelvic tilt and PI-LL with positive linear correlation according to PI values. As an interestingly result, PI-LL mismatch is equal to 0° when PI is around 64°.ConclusionsThe present study demonstrated that PI-LL mismatch is negative in an asymptomatic population (− 5.4° ± 10.7°) and the value should be customized to each patient to be able to restore the appropriate lordosis in ADS. The PI-LL mismatch is given by the formula PI-LL = − 28.5 + 0.44 × PI.

Purpose This study aims to psychometrically validate the Psychache Scale (PAS) and investigate its prognostic value in predicting postoperative outcomes. Methods This is a prospective single-center study. Adults undergoing lumbar or thoracolumbar surgery were recruited. Participants completed PAS preoperatively and patient-reported outcome measures evaluating mental health, pain, physical function, and disability preoperatively and at one and six months postoperatively. PAS internal consistency was evaluated by Cronbach’s alpha coefficient, and factor structure was evaluated using confirmatory factor analysis. Construct validity was assessed by examining correlations between PAS and measures of mental and physical health. PAS prognostic utility was evaluated by assessing its association with short- and longer-term surgical outcomes. Results We included 166 patients. Mean (SD) age was 59.7 (12) years, with 55% females. PAS reliability was high (Cronbach’s alpha = 0.95), and factor analysis confirmed the hypothesized one-factor structure. PAS showed strong correlations with PHQ-9 ( r  = 0.64), PROMIS anxiety ( r  = 0.64), pain catastrophizing scale (PCS) ( r  = 0.7), and its helplessness ( r  = 0.72), magnification ( r  = 0.59), and rumination ( r  = 0.59) subscales. However, it shows weak to moderate correlations with non-mental health-related metrics (0.07 <  r  < 0.44). Preoperative PAS was moderately correlated with one-month pain interference, and six-month PHQ-9 and PROMIS anxiety scores. In predicting outcomes, the addition of PAS to models including baseline values improved the prediction of all outcomes except for PROMIS physical function. Conclusions Our study suggests PAS may be a valuable tool for assessing psychological distress in this patient population. Further research is needed to understand its relevance in spine surgery practice. Level of Evidence II.