A Systematic Review of the Effectiveness of Interventions to Promote Referral; Adherence; and Uptake of Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Disease.

Background: Pulmonary rehabilitation (PR) is an effective treatment for patients with chronic obstructive pulmonary disease (COPD). However, referral, uptake, and adherence remain low. Objective: To determine effectiveness of interventions to increase patient referral, uptake, and adherence to PR programs for patients with COPD. Methods: Randomized controlled trials (RCTs), non-randomized controlled trials, pre-post studies, and uncontrolled studies were sought from 7 databases and 3 clinical trial registries, to end August 2021. Full articles/conference abstracts were included if a coordinated set of activities was targeted to healthcare professionals (HCPs) caring for COPD patients, adults with COPD or their carers, to increase referral, uptake or adherence to any type of PR program. Two review authors independently screened titles, abstracts and full texts, extracted data and critically appraised studies using standard risk of bias tools. Results: From 11,272 records, 30 studies (23 full-text; 7 abstracts) met inclusion criteria: study interventions and designs were varied and generally low quality, targeting patients (n=13), HCPs (n=14) or both (n=3 studies). A CCT of patient held evidence score cards increased referral by 7.3% compared to 1.3% for usual care (p-0.03). A cluster RCT involving COPD nurse home visits with individualized care plans increased uptake to 31% compared to 10% in usual care (p=0.002). For people with anxiety or depression, one RCT of cognitive behavioral therapy alongside PR increased adherence (mean sessions 14.0 (sd 1.7) compared to 12.4 (sd 2.6)). Conclusion: Although a small number of studies, the weight of evidence suggested that interventions incorporating partnership working between patients and HCPs appeared to increase referral, uptake, and adherence with greater effectiveness than those targeting single populations. Increasing knowledge and empowering HCPs and patients may be important strategies. Concerns about study design and risk of bias suggest clear need for well-designed trials of interventions to report full pathway outcomes.

Non-randomised feasibility study testing a primary care intervention to promote engagement in an online health community for adults with troublesome asthma: protocol.

INTRODUCTION: In the UK, approximately 4.3 million adults have asthma, with one-third experiencing poor asthma control, affecting their quality of life, and increasing their healthcare use. Interventions promoting emotional/behavioural self-management can improve asthma control and reduce comorbidities and mortality. Integration of online peer support into primary care services to foster self-management is a novel strategy. We aim to co-design and evaluate an intervention for primary care clinicians to promote engagement with an asthma online health community (OHC). Our protocol describes a 'survey leading to a trial' design as part of a mixed-methods, non-randomised feasibility study to test the feasibility and acceptability of the intervention. METHODS AND ANALYSIS: Adults on the asthma registers of six London general practices (~3000 patients) will be invited to an online survey, via text messages. The survey will collect data on attitudes towards seeking online peer support, asthma control, anxiety, depression, quality of life, information on the network of people providing support with asthma and demographics. Regression analyses of the survey data will identify correlates/predictors of attitudes/receptiveness towards online peer support. Patients with troublesome asthma, who (in the survey) expressed interest in online peer support, will be invited to receive the intervention, aiming to reach a recruitment target of 50 patients. Intervention will involve a one-off, face-to-face consultation with a practice clinician to introduce online peer support, sign patients up to an established asthma OHC, and encourage OHC engagement. Outcome measures will be collected at baseline and 3 months post intervention and analysed with primary care and OHC engagement data. Recruitment, intervention uptake, retention, collection of outcomes, and OHC engagement will be assessed. Interviews with clinicians and patients will explore experiences of the intervention. ETHICS AND DISSEMINATION: Ethical approval was obtained from a National Health Service Research Ethics Committee (reference: 22/NE/0182). Written consent will be obtained before intervention receipt and interview participation. Findings will be shared via dissemination to general practices, conference presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05829265.

Investigating primary healthcare practitioners' barriers and enablers to referral of patients with COPD to pulmonary rehabilitation: a mixed-methods study using the Theoretical Domains Framework.

OBJECTIVES: Pulmonary rehabilitation (PR) is a highly effective, recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Using behavioural theory within mixed-methods research to understand why referral remains low enables the development of targeted interventions in order to improve future PR referral. DESIGN: A multiphase sequential mixed-methods study. SETTING: United Kingdom (UK). PARTICIPANTS: 252 multiprofessional primary healthcare practitioners (PHCPs). MEASURES: Phase 1: semistructured interviews. Phase 2: a 54-item paper and online questionnaire, based on the Theoretical Domains Framework (TDF). Content and descriptive analysis utilised. Data mixed at two points: instrument design and interpretation. RESULTS: 19 PHCPs took part in interviews and 233 responded to the survey. Integrated results revealed that PHCPs with a post qualifying respiratory qualification (154/241; 63.9%) referred more frequently (91/154; 59.1%) than those without (28/87; 32.2%). There were more barriers than enablers for referral in all 13 TDF domains. Key barriers included: infrequent engagement from PR provider to referrer, concern around patient's physical ability and access to PR (particularly for those in work), assumed poor patient motivation, no clear practice referrer and few referral opportunities. These mapped to domains: belief about capabilities, social influences, environment, optimism, skills and social and professional role. Enablers to referral were observed in knowledge, social influences memory and environment domains. Many PHCPs believed in the physical and psychological value of PR. Helpful enablers were out-of-practice support from respiratory interested colleagues, dedicated referral time (annual review) and on-screen referral prompts. CONCLUSIONS: Referral to PR is complex. Barriers outweighed enablers. Aligning these findings to behaviour change techniques will identify interventions to overcome barriers and strengthen enablers, thereby increasing referral of patients with COPD to PR.

Physical disturbance by recovering sea otter populations increases eelgrass genetic diversity.

Most knowledge regarding the role of predators is ecological in nature. Here, we report how disturbance generated by sea otters (Enhydra lutris) digging for infaunal prey in eelgrass (Zostera marina) meadows increases genetic diversity by promoting conditions for sexual reproduction of plants. Eelgrass allelic richness and genotypic diversity were, respectively, 30 and 6% higher in areas where recovering sea otter populations had been established for 20 to 30 years than in areas where they had been present <10 years or absent >100 years. The influence of sea otter occupancy on the aforementioned measures of genetic diversity was stronger than those of depth, temperature, latitude, or meadow size. Our findings reveal an underappreciated evolutionary process by which megafauna may promote genetic diversity and ecological resilience.

Cascading social-ecological costs and benefits triggered by a recovering keystone predator.

Predator recovery often leads to ecosystem change that can trigger conflicts with more recently established human activities. In the eastern North Pacific, recovering sea otters are transforming coastal systems by reducing populations of benthic invertebrates and releasing kelp forests from grazing pressure. These changes threaten established shellfish fisheries and modify a variety of other ecosystem services. The diverse social and economic consequences of this trophic cascade are unknown, particularly across large regions. We developed and applied a trophic model to predict these impacts on four ecosystem services. Results suggest that sea otter presence yields 37% more total ecosystem biomass annually, increasing the value of finfish [+9.4 million Canadian dollars (CA$)], carbon sequestration (+2.2 million CA$), and ecotourism (+42.0 million CA$). To the extent that these benefits are realized, they will exceed the annual loss to invertebrate fisheries (-$7.3 million CA$). Recovery of keystone predators thus not only restores ecosystems but can also affect a range of social, economic, and ecological benefits for associated communities.

Referral of patients with chronic obstructive pulmonary disease to pulmonary rehabilitation: a qualitative study of barriers and enablers for primary healthcare practitioners.

BACKGROUND: Pulmonary rehabilitation (PR) is a cost-effective, internationally recommended intervention for patients with chronic obstructive pulmonary disease (COPD). Referral is predominately led by primary healthcare practitioners (PHCPs), but referral and patient uptake is poor. AIM: To understand barriers and enablers for PHCPs when considering patient referral to PR, to explore the influence of patient characteristics, and to understand how referral rates may be increased. DESIGN AND SETTING: PHCPs who care for and refer patients with COPD to PR were purposively selected from general practices across Cambridgeshire and Peterborough, and the West Midlands. METHOD: A qualitative study. Semi-structured interviews were undertaken to theme saturation, exploring PR referral. Images depicting patients with varying COPD severity were used to stimulate memory and associative recall. Interviews were recorded, transcribed verbatim, and analysed using rapid qualitative analysis. RESULTS: A total of 19 PHCPs were interviewed. Barriers to PR referral included limited awareness of the clinical benefits, little knowledge of local PR providers, consultation time constraints, and presumed low patient motivation. While practice nurses had the greatest knowledge, they still described difficulty in promoting PR. PHCPs frequently described assessing patient suitability based on presumed accessibility, social, and disease-specific characteristics rather than the clinical benefits of PR. Referrals were facilitated by financial incentives for the practice and positive feedback from patients and providers. CONCLUSION: There were more barriers to PR referral than enablers. Providers must engage better with PHCPs, patients with COPD, and carers, and actively promote PR. Increasing PHCPs' awareness of the benefits of PR, financial incentives, and alternative referral pathways should be considered.

Sex and occupation time influence niche space of a recovering keystone predator.

Predators exert strong effects on ecological communities, particularly when they re-occupy areas after decades of extirpation. Within species, such effects can vary over time and by sex and cascade across trophic levels. We used a space-for-time substitution to make foraging observations of sea otters (Enhydra lutris) across a gradient of reoccupation time (1-30 years), and nonmetric multidimensional scaling (nMDS) analysis to ask whether (a) sea otter niche space varies as a function of occupation time and (b) whether niche space varies by sex. We found that niche space varied among areas of different occupation times. Dietary niches at short occupation times were dominated by urchins (Mesocentrotus and Strongylocentrotus spp; >60% of diets) in open habitats at 10-40 m depths. At longer occupation times, niches were dominated by small clams (Veneroida; >30% diet), mussels (Mytilus spp; >20% diet), and crab (Decapoda; >10% diet) in shallow (<10 m) kelp habitats. Diet diversity was lowest (H' = 1.46) but energy rich (~37 kcal/min) at the earliest occupied area and highest, but energy poor (H' = 2.63, ~9 kcal/min) at the longest occupied area. A similar transition occurred through time at a recently occupied area. We found that niche space also differed between sexes, with bachelor males consuming large clams (>60%), and urchins (~25%) from deep waters (>40 m), and females and territorial males consuming smaller, varied prey from shallow waters (<10 m). Bachelor male diets were less diverse (H' = 2.21) but more energy rich (~27 kcal/min) than territorial males (H' = 2.54, ~13 kcal/min) and females (H' = 2.74, ~11 kcal/min). Given recovering predators require adequate food and space, and the ecological interactions they elicit, we emphasize the importance of investigating niche space over the duration of recovery and considering sex-based differences in these interactions.

The importance of obtaining a sputum sample and how it can aid diagnosis and treatment.

Respiratory disease has a major impact on the NHS and continues to be a growing problem as each year passes. However, through improving diagnosis and management of respiratory disease the problem could be lessened. Taking a sputum sample is common practice within respiratory medicine especially for patients with chronic obstructive pulmonary disease (COPD) and helps to diagnose, confirm infection and offer correct treatment. It is important that the multidisciplinary team are aware of how to appropriately obtain sputum samples and when to request them. It is important as a respiratory health professional to understand the patient's usual sputum history including colour, amount and viscosity. Antibiotic stewardship aims to reduce antibiotic resistance through offering the most appropriate antibiotics for those with a bacterial infection and to discourage antibiotic prescribing for those that have not. This should result in better patient outcomes and lower healthcare costs.

Non-pharmacological management of chronic breathlessness in stable chronic obstructive pulmonary disease.

This paper will review and address the pathological processes in chronic obstructive pulmonary disease (COPD), including the prevalence of comorbidities and the implications of these factors for a common disabling COPD symptom, breathlessness. It will further consider non-pharmacological strategies that community nurses can use to support breathlessness relief in the context of holistic patient care.

Referrals to dietitians/nutritionists: A cross-sectional analysis of Australian GP registrars' clinical practice.

AIM: The present study aimed to describe referral patterns of general practitioner (GP) registrars to dietitians/nutritionists. There is a paucity of research regarding GP referral patterns to dietitians/nutritionists. Limited data show increasing referrals from established GPs to dietitians/nutritionists. There are no data on GP registrar (trainee) referrals. METHODS: This was a cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. ReCEnT is an ongoing, multicentre, prospective cohort study of registrars, which documents 60 consecutive consultations of each registrar in each of the three six-month GP training terms. The outcome factor in this analysis was a problem/diagnosis resulting in dietitian/nutritionist referral (2010-2015). Independent variables were related to registrar, patient, practice and consultation. RESULTS: A total of 1124 registrars contributed data from 145 708 consultations. Of 227 190 problems/diagnoses, 587 (0.26% (confidence interval: 0.23-0.29)) resulted in dietitian/nutritionist referral. The most common problems/diagnoses referred related to overweight/obesity (27.1%) and type 2 diabetes (21.1%). Of referrals to a dietitian/nutritionist, 60.8% were for a chronic disease, and 38.8% were related to a Chronic Disease Management plan. Dietitian/nutritionist referral was significantly associated with a number of independent variables reflecting continuity of care, patient complexity, chronic disease, health equity and registrar engagement. CONCLUSIONS: Established patients with chronic disease and complex care needs are more likely than other patients to be referred by registrars to dietitians/nutritionists. Nutrition behaviours are a major risk factor in chronic disease, and we have found evidence for dietitian/nutritionist referrals representing one facet of engagement by registrars with patients' complex care needs.

Ecosystem features determine seagrass community response to sea otter foraging.

Comparing sea otter recovery in California (CA) and British Columbia (BC) reveals key ecosystem properties that shape top-down effects in seagrass communities. We review potential ecosystem drivers of sea otter foraging in CA and BC seagrass beds, including the role of coastline complexity and environmental stress on sea otter effects. In BC, we find greater species richness across seagrass trophic assemblages. Furthermore, Cancer spp. crabs, an important link in the seagrass trophic cascade observed in CA, are less common. Additionally, the more recent reintroduction of sea otters, more complex coastline, and reduced environmental stress in BC seagrass habitats supports the hypotheses that sea otter foraging pressure is currently reduced there. In order to manage the ecosystem features that lead to regional differences in top predator effects in seagrass communities, we review our findings, their spatial and temporal constraints, and present a social-ecological framework for future research.

Size, growth, and density data for shallow-water sea urchins from Mexico to the Aleutian Islands, Alaska, 1956-2016.

Size, growth, and density have been studied for North American Pacific coast sea urchins Strongylocentrotus purpuratus, S. droebachiensis, S. polyacanthus, Mesocentrotus (Strongylocentrotus) franciscanus, Lytechinus pictus, Centrostephanus coronatus, and Arbacia stellata by various workers at diverse sites and for varying lengths of time from 1956 to present. Numerous peer-reviewed publications have used some of these data but some data have appeared only in graduate theses or the gray literature. There also are data that have never appeared outside original data sheets. Motivation for studies has included fisheries management and environmental monitoring of sewer and power plant outfalls as well as changes associated with disease epidemics. Studies also have focused on kelp restoration, community effects of sea otters, basic sea urchin biology, and monitoring. The data sets presented here are a historical record of size, density, and growth for a common group of marine invertebrates in intertidal and nearshore environments that can be used to test hypotheses concerning future changes associated with fisheries practices, shifts of predator distributions, climate and ecosystem changes, and ocean acidification along the Pacific Coast of North America and islands of the north Pacific. No copyright restrictions apply. Please credit this paper when using the data.

Trends in Food and Beverage Portion Sizes in Australian Children; a Time-Series Analysis Comparing 2007 and 2011-2012 National Data.

In 2011-2012 approximately 26% of Australian children aged between 5-17 years were reported to be overweight or obese. Furthermore, the increase in prevalence of overweight and obesity among US children parallels reported increases in energy intake and portion sizes of common foods, leading to the recognition that availability of larger portion sizes contributes to the rise in overweight and obesity prevalence. Thus, the aim of this time-series analysis was to investigate whether selected food portion sizes in Australian children aged 2-16 years changed between 2007 and 2011-2012. Portion size data from 24-h recalls collected in Australian nutrition surveys were compared between 2007 and 2011-2012. Portion sizes changed significantly in 23% of items with increases in 15% and decreases in 8%. Changes in portion sizes varied by age, sex, and food group. Changes occurred for many meat-based items, energy-dense, nutrient-poor food items, breads, cereals, and some fruits and vegetables. Vegetable and fruit portion sizes were below the respective serving sizes of 75 g and 150 g in the Australian Guide to Healthy Eating, while portion sizes of some energy-dense, nutrient-poor foods have increased. These findings suggest approaches to increasing consumption of nutrient-dense core foods and reducing energy-dense, nutrient-poor food items in children are warranted.

Global patterns of kelp forest change over the past half-century.

Kelp forests (Order Laminariales) form key biogenic habitats in coastal regions of temperate and Arctic seas worldwide, providing ecosystem services valued in the range of billions of dollars annually. Although local evidence suggests that kelp forests are increasingly threatened by a variety of stressors, no comprehensive global analysis of change in kelp abundances currently exists. Here, we build and analyze a global database of kelp time series spanning the past half-century to assess regional and global trends in kelp abundances. We detected a high degree of geographic variation in trends, with regional variability in the direction and magnitude of change far exceeding a small global average decline (instantaneous rate of change = -0.018 y-1). Our analysis identified declines in 38% of ecoregions for which there are data (-0.015 to -0.18 y-1), increases in 27% of ecoregions (0.015 to 0.11 y-1), and no detectable change in 35% of ecoregions. These spatially variable trajectories reflected regional differences in the drivers of change, uncertainty in some regions owing to poor spatial and temporal data coverage, and the dynamic nature of kelp populations. We conclude that although global drivers could be affecting kelp forests at multiple scales, local stressors and regional variation in the effects of these drivers dominate kelp dynamics, in contrast to many other marine and terrestrial foundation species.

How big is a food portion? A pilot study in Australian families.

ISSUES ADDRESSED: It is not known whether individuals can accurately estimate the portion size of foods usually consumed relative to standard serving sizes in national food selection guides. The aim of the present cross-sectional pilot study was to quantify what adults and children deem a typical portion for a variety of foods and compare these with the serving sizes specified in the Australian Guide to Healthy Eating (AGHE). METHODS: Adults and children were independently asked to serve out their typical portion of 10 common foods (rice, pasta, breakfast cereal, chocolate, confectionary, ice cream, meat, vegetables, soft drink and milk). They were also asked to serve what they perceived a small, medium and large portion of each food to be. Each portion was weighed and recorded by an assessor and compared with the standard AGHE serving sizes. RESULTS: Twenty-one individuals (nine mothers, one father, 11 children) participated in the study. There was a large degree of variability in portion sizes measured out by both parents and children, with means exceeding the standard AGHE serving size for all items, except for soft drink and milk, where mean portion sizes were less than the AGHE serving size. The greatest mean overestimations were for pasta (155%; mean 116 g; range 94-139 g) and chocolate (151%; mean 38 g; range 25-50 g), each of which represented approximately 1.5 standard AGHE servings. CONCLUSION: The findings of the present study indicate that there is variability between parents' and children's estimation of typical portion sizes compared with national recommendations. SO WHAT? Dietary interventions to improve individuals' dietary patterns should target education regarding portion size.

The comparative validity and reproducibility of a diet quality index for adults: the Australian Recommended Food Score.

Adult diet quality indices are shown to predict nutritional adequacy of dietary intake as well as all-cause morbidity and mortality. This study describes the reproducibility and validity of a food-based diet quality index, the Australian Recommended Food Score (ARFS). ARFS was developed to reflect alignment with the Australian Dietary Guidelines and is modelled on the US Recommended Food Score. Dietary intakes of 96 adult participants (31 male, 65 female) age 30 to 75 years were assessed in two rounds, five months apart. Diet was assessed using a 120-question semi-quantitative food frequency questionnaire (FFQ). The ARFS diet quality index was derived using a subset of 70 items from the full FFQ. Reproducibility of the ARFS between round one and round two was confirmed by the overall intraclass correlation coefficient of 0.87 (95% CI 0.83, 0.90), which compared favourably to that for the FFQ at 0.85 (95% CI 0.80, 0.89). ARFS was correlated with FFQ nutrient intakes, particularly fiber, vitamin A, beta-carotene and vitamin C (0.53, 95% CI 0.37-0.67), and with mineral intakes, particularly calcium, magnesium and potassium (0.32, 95% CI 0.23-0.40). ARFS is a suitable brief tool to evaluate diet quality in adults and reliably estimates a range of nutrient intakes.

Testing problem solving in turkey vultures (Cathartes aura) using the string-pulling test.

To examine problem solving in turkey vultures (Cathartes aura), six captive vultures were presented with a string-pulling task, which involved drawing a string up to access food. This test has been used to assess cognition in many bird species. A small piece of meat suspended by a string was attached to a perch. Two birds solved the problem without apparent trial-and-error learning; a third bird solved the problem after observing a successful bird, suggesting that this individual learned from the other vulture. The remaining birds failed to complete the task. The successful birds significantly reduced the time needed to solve the task from early trials compared to late trials, suggesting that they had learned to solve the problem and improved their technique. The successful vultures solved the problem in a novel way: they pulled the string through their beak with their tongue, and may have gathered the string in their crop until the food was in reach. In contrast, ravens, parrots and finches use a stepwise process; they pull the string up, tuck it under foot, and reach down to pull up another length. As scavengers, turkey vultures use their beak for tearing and ripping at carcasses, but possess large, flat, webbed feet that are ill-suited to pulling or grasping. The ability to solve this problem and the novel approach used by the turkey vultures in this study may be a result of the unique evolutionary pressures imposed on this scavenging species.

Validity of the Australian Recommended Food Score as a diet quality index for Pre-schoolers.

BACKGROUND: Diet quality tools provide researchers with brief methods to assess the nutrient adequacy of usual dietary intake. This study describes the development and validation of a pediatric diet quality index, the Australian Recommended Food Scores for Pre-schoolers (ARFS-P), for use with children aged two to five years. METHODS: The ARFS-P was derived from a 120-item food frequency questionnaire, with eight sub-scales, and was scored from zero to 73. Linear regressions were used to estimate the relationship between diet quality score and nutrient intakes, in 142 children (mean age 4 years) in rural localities in New South Wales, Australia. RESULTS: Total ARFS-P and component scores were highly related to dietary intake of the majority of macronutrients and micronutrients including protein, ß-carotene, vitamin C, vitamin A. Total ARFS-P was also positively related to total consumption of nutrient dense foods, such as fruits and vegetables, and negatively related to total consumption of discretionary choices, such as sugar sweetened drinks and packaged snacks. CONCLUSION: ARFS-P is a valid measure that can be used to characterise nutrient intakes for children aged two to five years. Further research could assess the utility of the ARFS-P for monitoring of usual dietary intake over time or as part of clinical management.

Food and beverage portion sizes in Australian children: a secondary analysis of 1995 and 2007 national data.

BACKGROUND: Portion size of foods is reported to contribute to the rise in obesity prevalence. However, evidence of changes in portion size for commonly consumed foods in Australia is lacking. The aim was to evaluate whether Australian child and adolescent portion sizes of selected foods changed from 1995 to 2007. METHODS: Time-series study, comparing dietary data from two national cross-sectional surveys in nationally representative population survey of Australian households. The dietary data was from children aged 2-16 years who participated in the 1995 National Nutrition Survey (n = 2198) and 2007 Australian National Children's Nutrition and Physical Activity Survey (n = 4799). RESULTS: Differences were found across survey years in median portion size of common foods and beverages assessed by 24-hour recalls for age and sex categories. Of the 61 foods items evaluated across the whole population sample, portion size increased in 18 items, decreased in 22, with no change in 20, although the magnitude of change varied by age and sex. Decreases in portion size were detected for most dairy products, breakfast cereal, some packaged snack foods and vegetables, p < 0.0001. Increases were detected for cooked chicken, mixed chicken dishes, bacon and ham (p < 0.0001), cooked meat (p < 0.05), fish (p < 0.01) and pizza (p < 0.0001). No significant changes were detected for many items including white and wholemeal bread, mincemeat, chocolate and soft drink. CONCLUSIONS: Small changes in portion sizes were detected over 12 years in Australian children and adolescents with the degree of change varying by sex, age and food group. Knowledge of usual portion sizes could inform programs targeting appropriate serving sizes selection in children and adolescents.