Optimising a landscape visual quality protocol. A Method for reducing respondent fatigue and obtaining site-specific indicators.

Evaluation of landscape visual quality is crucial for policymaking and planning but is still challenging. A wide range of visual assessment protocols is available, but there is still no consensus on appropriate indicators or approaches. Also, evaluation protocols can encompass many indicators, being exhaustive and complex and making the evaluation lengthy. Furthermore, protocols tend to be catered to a particular type of landscape or site-specific, and it can be tricky to ensure the protocol developed is adequate for the landscape under study. This paper proposes a methodology to optimise the selection of indicators for landscape visual assessments. There are two main goals: i) reduce the evaluation time to avoid respondent fatigue, and ii) make the protocol site-specific, choosing indicators that perform better and avoiding redundant indicators. •The presented method optimises the selection of indicators in expert visual assessments;•Indicators are rated in situ on a 5-point scale and go through a performance and redundancy test;•It helps to adapt complex evaluation protocols to the study landscape and to choose robust indicators in a supported and scientific way.

Consensus on an assessment protocol for children with speech sound disorders in Sri Lanka.

BACKGROUND: Speech sound disorders (SSDs) are the most common form of communication disorders in children. SSD have an impact on children's abilities to make themselves understood to their listeners and can influence a child's social and emotional well-being as well as their academic achievements. Therefore, it is important to identify children with an SSD early, in order to provide appropriate intervention. A wealth of information on best practice in the assessment of children with SSD is available in countries where the speech and language therapy profession is well established. In Sri Lanka, there is a paucity of research evidence supporting assessment practices that are culturally and linguistically appropriate in SSDs. Therefore, clinicians rely on informal assessment methods. There is a need to understand more about how clinicians in Sri Lanka assess this caseload in order to get general agreement regarding comprehensive and consistent procedures for assessment of paediatric SSD in Sri Lanka. This would support speech and language therapists' (SLTs') clinical decision-making in relation to choice of appropriate goals and intervention for this caseload. AIM: To develop and gain consensus on an assessment protocol for Sri Lankan children with SSD that is culturally appropriate and based on existing research. METHOD: A modified Delphi method was utilised to gather data from clinicians currently working in Sri Lanka. The research involved three rounds of data collection, exploring current assessment practices in Sri Lanka, ranking these in order of priority and establishing consensus on a proposed assessment protocol. The proposed assessment protocol was based on the results of the first and second rounds as well as previously published best practice guidelines. OUTCOME AND RESULTS: The proposed assessment protocol achieved consensus in relation to content, format and cultural appropriateness. SLTs affirmed the usefulness of the protocol within the Sri Lankan context. Further research is required to assess the feasibility and effectiveness of this protocol in practice. CONCLUSIONS & IMPLICATIONS: The assessment protocol supports practicing SLTs with a general guide to assessing children with suspected SSDs in Sri Lanka. The application of this protocol built upon consensus enables clinicians to improve their individual practice patterns based on best practice recommendations in the literature and the evidence on culturally and linguistically appropriate practices. This study has identified the need for further research in this area, including the development of culturally and linguistically specific assessment tools that would complement the use of this protocol. WHAT THIS PAPER ADDS: What is already known on the subject The assessment of children with speech sound disorders (SSDs) requires a comprehensive and holistic approach due to their heterogeneous nature. Although there is evidence to support the assessment of paediatric SSDs in many countries where the profession of speech and language therapy is established, there is limited evidence to support the assessment of children with SSDs in Sri Lanka. What this study adds This study provides information about current assessment practices in Sri Lanka and consensus on a proposed culturally appropriate protocol for the assessment of children with SSDs in this country. What are the clinical implications of this work? The proposed assessment protocol provides speech and language therapists in Sri Lanka with a guide for assessment of paediatric SSDs to support more consistent practice in this area. Future evaluation of this preliminary protocol is required; however, the methodology used in this research could be applied to the development of assessment protocols for other range of practice areas in this country.

Feasibility of an online consensus approach for the diagnosis of cognitive impairment and dementia in rural South Africa.

INTRODUCTION: We describe the development and feasibility of using an online consensus approach for diagnosing cognitive impairment and dementia in rural South Africa. METHODS: Cognitive assessments, clinical evaluations, and informant interviews from Cognition and Dementia in the Health and Aging in Africa Longitudinal Study (HAALSI Dementia) were reviewed by an expert panel using a web-based platform to assign a diagnosis of cognitively normal, mild cognitive impairment (MCI), or dementia. RESULTS: Six hundred thirty-five participants were assigned a final diagnostic category, with 298 requiring adjudication conference calls. Overall agreement between each rater's independent diagnosis and final diagnosis (via the portal or consensus conference) was 78.3%. A moderate level of agreement between raters' individual ratings and the final diagnostic outcomes was observed (average κ coefficient = 0.50). DISCUSSION: Findings show initial feasibility in using an online consensus approach for the diagnosis of cognitive impairment and dementia in remote, rural, and low-resource settings.

Antenatal detection of large-for-gestational-age fetuses following implementation of the Growth Assessment Protocol: secondary analysis of a randomised control trial.

OBJECTIVE: To determine whether the Growth Assessment Protocol (GAP) affects the antenatal detection of large for gestational age (LGA) or maternal and perinatal outcomes amongst LGA babies. DESIGN: Secondary analysis of a pragmatic open randomised cluster control trial comparing the GAP with standard care. SETTING: Eleven UK maternity units. POPULATION: Pregnant women and their LGA babies born at ≥36+0  weeks of gestation. METHODS: Clusters were randomly allocated to GAP implementation or standard care. Data were collected from electronic patient records. Trial arms were compared using summary statistics, with unadjusted and adjusted (two-stage cluster summary approach) differences. MAIN OUTCOME MEASURES: Rate of detection of LGA (estimated fetal weight on ultrasound scan above the 90th centile after 34+0  weeks of gestation, defined by either population or customised growth charts), maternal and perinatal outcomes (e.g. mode of birth, postpartum haemorrhage, severe perineal tears, birthweight and gestational age, neonatal unit admission, perinatal mortality, and neonatal morbidity and mortality). RESULTS: A total of 506 LGA babies were exposed to GAP and 618 babies received standard care. There were no significant differences in the rate of LGA detection (GAP 38.0% vs standard care 48.0%; adjusted effect size -4.9%; 95% CI -20.5, 10.7; p = 0.54), nor in any of the maternal or perinatal outcomes. CONCLUSIONS: The use of GAP did not change the rate of antenatal ultrasound detection of LGA when compared with standard care.

Identifying areas of animal welfare concern in different production stages in Danish pig herds using the Danish Animal Welfare Index (DAWIN).

Animal welfare is of increasing public interest, and the pig industry in particular is subject to much attention. The aim of this study was to identify and compare areas of animal welfare concern for commercial pigs in four different production stages: (1) gestating sows and gilts; (2) lactating sows; (3) piglets; and (4) weaner-to-finisher pigs. One welfare assessment protocol was developed for each stage, comprising of between 20 and 29 animal welfare measures including resource-, management- and animal-based ones. Twenty-one Danish farms were visited once between January 2015 and February 2016 in a cross-sectional design. Experts (n = 26; advisors, scientists and animal welfare controllers) assessed the severity of the outcome measures. This was combined with the on-farm prevalence of each measure and the outcome was used to calculate areas of concern, defined as measures where the median of all farms fell below the value defined as 'acceptable welfare.' Between five and seven areas of concern were identified for each production stage. With the exception of carpal lesions in piglets, all areas of concern were resource- and management-based and mainly related to housing, with inadequate available space and the floor type in the resting area being overall concerns across all production stages. This means that animal-based measures were largely unaffected by perceived deficits in resource-based measures. Great variation existed for the majority of measures identified as areas of concern, demonstrating that achieving a high welfare score is possible in the Danish system.

Ackonc-AWA: A multi-species animal welfare assessment protocol for wild animals under human care to overcome the use of generic welfare checklists.

Introduction: Maintaining a high level of animal welfare is essential in zoos, sanctuaries and aquaria for ethical, legislative and functional reasons. Therefore, it is necessary to have welfare assessment protocols that can be incorporated into daily management programs. Currently, there are different approaches to assessing animal welfare in zoos. Those that can be applied to multiple species consist of checklists or qualitative assessments, with limitations, especially regarding the lack of guidance in the selection and interpretation of indicators. Validated protocols also exist, but they are for very few wild species. This study aimed to develop, test in the field, and describe an animal welfare assessment protocol for wild animals under human care, that can be applied to multiple species, intended to overcome the use of generic welfare checklists and offer an alternative to challenging and time consuming species-specific tools. Methods: The development process consisted of the elaboration of a protocol, substantiated by published literature on zoo animal welfare and multidisciplinary focus group work, and its on-field feasibility test. This was performed on 14 species of different taxa housed in an Argentinian zoo. The protocol was structured in two forms: an initial form to serve as scan using various animal-based (ABM), resource-based (RBM), and management-based measurements (MBM), and a follow-up form using exclusively ABM. The protocol also included a user's manual with information about preliminary preparation, equipment required, steps from arrival until completion, and details on how to assess each indicator. The scoring method consisted in rating each indicator on a 3-point scale. Results: 23 ABM, 19 RBM, and three MBM were tested and selected to integrate Ackonc-AWA, a multidimensional protocol covering the five animal welfare domains and applicable to multiple species. Discussion: This protocol was entirely developed in Spanish and can be applied noninvasively and at a low cost, which constitute features of high relevance for Latin America. Further applications of the described welfare assessment tool in other species and different institutional contexts will reinforce the validation of the proposed measurements and allow the systematic and routine evaluation of animal welfare in zoos.

Anaerobic recalcitrance in wastewater treatment: A review.

Anaerobic treatment is applied as an alternative to traditional aerobic treatment for recalcitrant compound degradation. This review highlighted the recalcitrant compounds in wastewaters and their pathways under aerobic and anaerobic conditions. Forty-one recalcitrant compounds commonly found in wastewater along with associated anaerobic removal performance were summarized from current research. Anaerobic degradability of wastewater could not be appropriately evaluated by BOD/COD ratio, which should only be suitable for determining aerobic degradability. Recalcitrant wastewaters with a low BOD/COD ratio may be handled by anaerobic treatments after the adaption and provision of sufficient electron donors. Novel indicator characterizing the anaerobic recalcitrance of wastewater is called for, essential for emergent needs to resource recovery from high-strength recalcitrant wastewater for fulfilling appeals of circular bioeconomy of modern societies.

The relation between clinical and objective gait scores in clubfoot patients with and without a relapse.

BACKGROUND: Objective gait analysis that fully captures the multi-segmental foot movement of a clubfoot may help in early identification of a relapse clubfoot. Unfortunately, this type of objective measure is still lacking in a clinical setting and it is unknown how it relates to clinical assessment. RESEARCH QUESTION: The aim of this study was to identify differences in total gait and foot deviations between clubfoot patients with and without a relapse clubfoot and to evaluate their relationship with clinical status. METHODS: In this study, Ponseti-treated idiopathic clubfoot patients were included and divided into clubfoot patients with and without a relapse. Objective gait analysis was done resulting in total gait and foot scores and clinical assessment was performed using the Clubfoot Assessment Protocol (CAP). Additionally, a new clubfoot specific foot score, the clubFoot Deviation Index (cFDI*), was calculated to better capture foot kinematics of clubfoot patients. RESULTS: Clubfoot patients with a relapse show lower total gait quality (GDI*) and lower clinical status defined by the CAP than clubfoot patients without a relapse. Abnormal cFDI* was found in relapse patients, reflected by differences in corresponding variable scores. Moderate relationships were found for the subdomains of the CAP and total gait and foot quality in all clubfoot patients. SIGNIFICANCE: A new total foot score was introduced in this study, which was more relevant for the clubfoot population. The use of this new foot score (cFDI*) besides the GDI*, is recommended to identify gait and foot motion deviations. Along with clinical assessment, this will give an overview of the overall status of the complex, multi-segmental aspects of a (relapsed) clubfoot. The relationships found in this study suggest that clinical assessment might be indicative of a deviation in total gait and foot pattern, therefore hinting towards personalised screening for better treatment decision making.

Improving antenatal detection of small-for-gestational-age fetus: economic evaluation of Growth Assessment Protocol.

OBJECTIVE: To determine whether the Growth Assessment Protocol (GAP), as implemented in the DESiGN trial, is cost-effective in terms of antenatal detection of small-for-gestational-age (SGA) neonate, when compared with standard care. METHODS: This was an incremental cost-effectiveness analysis undertaken from the perspective of a UK National Health Service hospital provider. Thirteen maternity units from England, UK, were recruited to the DESiGN (DEtection of Small for GestatioNal age fetus) trial, a cluster randomized controlled trial. Singleton, non-anomalous pregnancies which delivered after 24 + 0 gestational weeks between November 2015 and February 2019 were analyzed. Probabilistic decision modeling using clinical trial data was undertaken. The main outcomes of the study were the expected incremental cost, the additional number of SGA neonates identified antenatally and the incremental cost-effectiveness ratio (ICER) (cost per additional SGA neonate identified) of implementing GAP. Secondary analysis focused on the ICER per infant quality-adjusted life year (QALY) gained. RESULTS: The expected incremental cost (including hospital care and implementation costs) of GAP over standard care was £34 559 per 1000 births, with a 68% probability that implementation of GAP would be associated with increased costs to sustain program delivery. GAP identified an additional 1.77 SGA neonates per 1000 births (55% probability of it being more clinically effective). The ICER for GAP was £19 525 per additional SGA neonate identified, with a 44% probability that GAP would both increase cost and identify more SGA neonates compared with standard care. The probability of GAP being the dominant clinical strategy was low (11%). The expected incremental cost per infant QALY gained ranged from £68 242 to £545 940, depending on assumptions regarding the QALY value of detection of SGA. CONCLUSION: The economic case for replacing standard care with GAP is weak based on the analysis reported in our study. However, this conclusion should be viewed taking into account that cost-effectiveness analyses are always limited by the assumptions made. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Impact of introduction of the growth assessment protocol in a South Indian tertiary hospital on SGA detection, stillbirth rate and neonatal outcome.

OBJECTIVES: India has a high rate of stillbirths, and many deaths are due to fetal growth restriction and potentially preventable. Screening and identification of the small for gestational age (SGA) fetus during the antenatal period has been shown to reduce stillbirths. We set out to evaluate the impact of implementing the Growth Assessment Protocol (GAP), a programme designed for screening for SGA. METHODS: Observational study comparing two-time epochs; before (years 2011-2014) and after (years 2015-2018) introduction of GAP. The programme includes identification of risk factors, risk categorization, serial fundal height measurement, customised fetal growth charts and appropriate referral protocols. Fetal growth charts and birth centiles were generated based on the hospital database of normal outcome pregnancies, customised to women's ethnicity, parity, height, and weight. The protocol was introduced following training of obstetric and midwifery care providers. We evaluated SGA detection rates, stillbirth rates (from 28 weeks) and neonatal morbidity at term. RESULTS: There were 26,199 and 31,498 births, with 115 and 108 stillbirths in the pre and post-GAP implementation periods, respectively. SGA detection rates increased from 51.1 to 67.1%, representing a 31% improvement (p<0.001). Overall stillbirth rates declined from 4.4 to 3.4 per 1000 births (RR 0.78 CI 95% 0.60-1.02) and at term from 1.5 to 0.6 (RR 0.37 CI 95% 0.20-0.66). Neonatal intensive care admission and neonatal encephalopathy in term neonates also decreased significantly. CONCLUSIONS: Introduction of the GAP programme in an Indian tertiary maternity service was associated with improved antenatal detection of SGA and reduced stillbirth rates and neonatal morbidity.

Evaluating the Growth Assessment Protocol for stillbirth prevention: progress and challenges.

Many stillbirths are associated with fetal growth restriction, and are hence potentially avoidable. The Growth Assessment Protocol (GAP) is a multidisciplinary program with an evidence based care pathway, training in risk assessment, fetal growth surveillance with customised charts and rolling audit. Antenatal detection of small for gestational age (SGA) has become an indicator of quality of care. Evaluation is essential to understand the impact of such a prevention program. Randomised trials will not be effective if they cannot ensure proper implementation before assessment. Observational studies have allowed realistic evaluation in practice, with other factors excluded that may have influenced the outcome. An award winning 10 year study of stillbirth data in England has been able to assess the effect of GAP in isolation, and found a strong, causal association with improved antenatal detection of SGA babies, and the sustained decline in national stillbirth rates. The challenge now is to apply this program more widely in low and middle income settings where the main global burden of stillbirth is, and to adapt it to local needs and resources.

Assessment of Skin and Mucosa at the Equine Oral Commissures to Assess Pathology from Bit Wear: The Oral Commissure Assessment Protocol (OCA) for Analysis and Categorisation of Oral Commissures.

This study addresses the presence and location of natural pigmentation, potentially pathological changes in pigment, interruptions of the natural lining (scars), roughness, and erosions/contusion (bruising) in and around the corners of the lips of 206 horses presented to a veterinarian for routine preventative dental treatment. After sedation, photographs were taken and later evaluated for the presence of lesions. During the photographic analysis, the Oral Commissure Assessment (OCA) protocol was developed to map precisely the areas of skin and mucosa around the corners of the lips, and the presence of lesions was recorded for each area. Potentially pathological pigment changes occurred more frequently in horses with a higher level of training (p = 0.04) and in light-coloured horses (p = 0.0004), but there was no association with the current use of a bit or the discipline that the horse participated in (p = 0.20). Scars occurred more frequently in horses competing at a higher level. Only two horses had contusions or erosions, five had ulcers, and none showed bleeding; these numbers were too low for statistical analysis. Using the OCA protocol provides a detailed method for categorizing and recording lesions in and around the corners of the lips, including natural vs. potential and/or definite pathological character.

Future Directions for the HRS Harmonized Cognitive Assessment Protocol.

In the absence of effective pharmacological treatment to halt or reverse the course of Alzheimer's disease and related dementias (ADRDs), population-level research on the modifiable determinants of dementia risk and outcomes for those living with ADRD is critical. The Harmonized Cognitive Assessment Protocol (HCAP), fielded in 2016 as part of the U.S. Health and Retirement Study (HRS) and multiple international counterparts, has the potential to play an important role in such efforts. The stated goals of the HCAP are to improve our ability to understand the determinants, prevalence, costs, and consequences of cognitive impairment and dementia in the U.S. and to support cross-national comparisons. The first wave of the HCAP demonstrated the feasibility and value of the more detailed cognitive assessments in the HCAP compared to the brief cognitive assessments in the core HRS interviews. To achieve its full potential, we provide eight recommendations for improving future iterations of the HCAP. Our highest priority recommendation is to increase the representation of historically marginalized racial/ethnic groups disproportionately affected by ADRDs. Additional recommendations relate to the timing of the HCAP assessments; clinical and biomarker validation data, including to improve cross-national comparisons; dropping lower performing items; enhanced documentation; and the addition of measures related to caregiver impact. We believe that the capacity of the HCAP to achieve its stated goals will be greatly enhanced by considering these changes and additions.

MusicCohort: Pilot feasibility of a protocol to assess students' physical and mental health in a Canadian post-secondary school of music.

OBJECTIVE: Music-related physical and mental health conditions are common among post-secondary music students, with many studies reporting a prevalence greater than 70%. However, there is currently no consensus on appropriate, validated assessments for this population. The aim of this pilot study was to test the feasibility of an assessment protocol developed for a German longitudinal study with Canadian post-secondary music students, and to compare the health of music students to non-music students. Using a cross-sectional design, first-semester music and non-music control students were recruited at two campuses at the same university. Both groups completed questionnaires and physical testing, including range of motion, core strength, and pressure pain threshold. Nineteen music students and 50 non-music student controls participated in this study. RESULTS: The German protocol is feasible in a Canadian post-secondary setting. Canadian music students demonstrated similar health outcomes to those in the parent study. All participants demonstrated poorer mental and physical quality of life than the Canadian norms, though this was not statistically significant. The results of this study should be confirmed in a larger study. Future studies with larger sample sizes can provide further insight into the health of Canadian music students, providing a basis for prevention and intervention.

Strategies for the implementation of an electronic fracture risk assessment tool in long term care: a qualitative study.

BACKGROUND: Older adults in long-term care (LTC) homes experience high rates of fractures, which are detrimental to their quality of life. The purpose of this study is to identify and make recommendations on strategies to implementing an evidence-based Fracture Risk Clinical Assessment Protocol (CAP) in LTC. METHODS: Following the Behaviour Change Wheel framework, we conducted six focus group interviews with a total of 32 LTC stakeholders (e.g. LTC physicians) to identify barriers and facilitators, suggest implementation strategies, and discuss whether the identified strategies were affordable, practicable, effective, acceptable, safe, and if they promote equity (APEASE). The interviews were transcribed verbatim and analyzed using thematic content analysis. RESULTS: Themes of implementation strategies that met the APEASE criteria were minimizing any increase in workload, training on CAP usage, education for residents and families, and persuasion through stories. Other strategy themes identified were culture change, resident-centred care, physical restructuring, software features, modeling in training, education for staff, social rewards, material rewards, public benchmarking, and regulations. CONCLUSIONS: To implement the Fracture Risk CAP in LTC, we recommend using implementation strategies centred around minimizing any increase in workload, training on CAP usage, providing education for residents and families, and persuading through stories. Through improving implementation of the fracture risk CAP, results from this work will improve identification and management of LTC residents at high fracture risk and could inform the implementation of guidelines for other conditions in LTC homes.

A case report on using biofeedback for psychological assessment.

A psychological assessment using biofeedback was performed for an adjustment disorder inpatient who showed less verbal and non-verbal expressions, and experienced difficulty in receiving favorable results from treatment. The assessment revealed hidden problems behind the symptoms. She was subsequently discharged, after which no clinical intervention was required, including medication.

Overuse-Related Injuries of the Musculoskeletal System: Systematic Review and Quantitative Synthesis of Injuries, Locations, Risk Factors and Assessment Techniques.

Overuse-related musculoskeletal injuries mostly affect athletes, especially if involved in preseason conditioning, and military populations; they may also occur, however, when pathological or biological conditions render the musculoskeletal system inadequate to cope with a mechanical load, even if moderate. Within the MOVIDA (Motor function and Vitamin D: toolkit for risk Assessment and prediction) Project, funded by the Italian Ministry of Defence, a systematic review of the literature was conducted to support the development of a transportable toolkit (instrumentation, protocols and reference/risk thresholds) to help characterize the risk of overuse-related musculoskeletal injury. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) approach was used to analyze Review papers indexed in PubMed and published in the period 2010 to 2020. The search focused on stress (overuse) fracture or injuries, and muscle fatigue in the lower limbs in association with functional (biomechanical) or biological biomarkers. A total of 225 Review papers were retrieved: 115 were found eligible for full text analysis and led to another 141 research papers derived from a second-level search. A total of 183 papers were finally chosen for analysis: 74 were classified as introductory to the topics, 109 were analyzed in depth. Qualitative and, wherever possible, quantitative syntheses were carried out with respect to the literature review process and quality, injury epidemiology (type and location of injuries, and investigated populations), risk factors, assessment techniques and assessment protocols.

The impact of a standard pain assessment protocol on pain levels and consumption of analgesia among postoperative orthopaedic patients.

BACKGROUND: Pain is a leading concern in post-surgical orthopaedic settings; andeffective pain assessment tools are important aspects of pain management. OBJECTIVE: This study assessed the effect of using standard pain assessment protocols (SPAP) on pain levels, pain management, and analgesia consumption among patients in the first 24 h following orthopaedic surgery. METHODS: In total, 101 patients were recruited and assigned to the comparison group (n = 50) and experimental group (n = 51). SPAP was used in the experimental group while the comparison group received routine care. Pain levels at rest and during movement and analgesic consumption were compared between the two groups. FINDINGS: There were significant differences in pain levels between the comparison and experimental groups. The experimental group consumed significantly less pain medication at 8-11 h of opioid medications and 12-15 h of non-opioid medications (P < .001). The use of non-pharmacological modalities was significantly higher in the experimental group compared to the comparison group (P < .001). CONCLUSIONS: Regular pain assessment and management using SPAP can promote pain management and reduce pain levels as well as reduce analgesia administration and promote the use of non-pharmacologic approaches. These outcomes can result in fewer side effects for patients. IMPLICATIONS: The findings suggest that using SPAP can result in improved outcomes as well as the use of non-pharmacologic approaches to pain management. This approach can result in better outcomes and increased communication between the nurse and the patient.

Reduction of stillbirths in England from 2008 to 2017 according to uptake of the Growth Assessment Protocol: 10-year population-based cohort study.

OBJECTIVE: Antenatal detection of small-for-gestational age (SGA) can reduce significantly the risk of stillbirth. The Growth Assessment Protocol (GAP) was developed to address the problem that most SGA fetuses are missed antenatally. We set out to analyze the effect that the GAP program has had on stillbirth rates in England. METHODS: We analyzed data from 2008 (the year before roll-out of the GAP program) to 2017 (latest available Office for National Statistics (ONS) unit-based data). The program consists of five elements: training, evidence-based guidelines for risk assessment and surveillance of fetal growth, customized charts, recording of process and outcome indicators, and audit of missed SGA cases. All maternity units in England were categorized into one of three groups according to their GAP status in 2017: (1) not in the GAP program; (2) GAP implemented partially (incomplete adoption of protocol, no monitoring and audit); and (3) GAP implemented completely. A subset of the complete-implementation group comprised the 20 units with the highest SGA detection rates. Unit-level live-birth and stillbirth data were obtained from the ONS for each of these groups. RESULTS: Stillbirth rates declined across all groups from 2008 to 2017, and significantly more in units in which GAP was implemented completely than in the non-GAP units (P < 0.05). The steepest decline in stillbirth rate was observed in the 20 units with the highest SGA detection rates, which had a 24% lower stillbirth rate compared with the units not using GAP (P < 0.01) in 2017. This difference remained significant after mixed-effects logistic regression analysis of potential confounding, including social deprivation (odds ratio, 0.76 (95% CI, 0.64-0.90)). Assessment of the nine Bradford Hill causality criteria and associated characteristics suggested that the association between implementation of the GAP program and reduction in stillbirth rate was causal. CONCLUSIONS: There has been an overall reduction in stillbirth rates in England that is likely to be a result of increased awareness of the importance of antenatal detection of SGA as a key risk factor for stillbirth. The decline in stillbirth rates was significantly greater in maternity units that had fully implemented the GAP program, and was most pronounced in the units with the highest antenatal SGA detection rates. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Developing a Fracture Risk Clinical Assessment Protocol for Long-Term Care: A Modified Delphi Consensus Process.

OBJECTIVES: To develop a fracture risk Clinical Assessment Protocol (CAP) based on long-term care (LTC) fracture prevention recommendations and an embedded fracture risk assessment tool. DESIGN: A modified Delphi consensus approach including 2 survey rounds and a face-to-face meeting was implemented to reach consensus on matching of LTC fracture prevention guideline statements to Fracture Risk Scale (FRS) risk levels. SETTING AND PARTICIPANTS: A national panel of recognized experts in osteoporosis, fractures, and long-term care, including an LTC resident and family members. METHODS: Round 1 survey respondents (n = 24) were provided the LTC fracture prevention guidelines matched to FRS risk levels and were asked whether they agreed the guideline was appropriate for the risk level (yes, no, I don't know, I agree with some but not all of it) and to provide comments. In round 2, guideline statements that did not achieve consensus (≥80% agreement) were revised consistent with comments provided in round 1 and respondents were asked again if they agreed with the guideline statement. Statements that did not achieve consensus were to be discussed and resolved in an in-person meeting (n = 17). RESULTS: In round 1 (75% response rate), consensus was achieved in 7/14 guideline statements. In round 2 (56% response rate), 5 statements were revised based on round 1 feedback and for 2 statements additional information was provided. Consensus was achieved in all but one statement related to the inappropriateness of pharmacologic therapy for residents with life expectancy less than 1 year. Following facilitated meeting discussions, consensus was obtained to revise the guideline statement to reflect that life expectancy was but one of several criteria that should be used to inform medication decisions. CONCLUSIONS AND IMPLICATIONS: An evidence-based fracture risk CAP was developed that will be embedded in international routine clinical assessment tools to guide fracture prevention in LTC.