MYC  activation and to have anti‐inflammatory activity that may impact the risk of Non‐Hodgkin's lymphoma (NHL). We analyzed the relationship between statins and risk of NHL using data from the Women's Health Initiative (WHI). The study population included 161,563 postmenopausal women ages 50–79 years from which 712 cases of NHL were diagnosed after 10.8 years of follow‐up. Information on statin use and other risk factors was collected by self‐ and interviewer‐administered questionnaires. Multivariable‐adjusted HR and 95% CI evaluating the relationship between statin use at baseline, as well as in a time‐dependent manner and risk of NHL, were computed from Cox proportional hazards analyses. A separate analysis was performed for individual NHL subtypes: diffuse large B‐Cell lymphoma (DLBCL) (n = 228), follicular lymphoma (n = 169), and small lymphocytic lymphoma (n = 74). All statistical tests were two‐sided. There was no significant association between use of statins at baseline and risk of NHL . However, in the multivariable‐adjusted time‐dependent models, statin use was associated with a borderline lower risk of NHL . Considering subtypes of NHL, statin use was associated with a lower risk of DLBCL . This effect was driven by lipophilic statins . In the WHI, statins were associated with a lower overall risk of DLBCL, particularly attributable to lipophilic statins. These results may have impact on primary or secondary prevention of NHL, particularly DLBCL.Statins have been shown to induce a phosphoprotein signature that modifies  Statins are the most widely prescribed cholesterol‐lowering drugs in the United States. According to the latest Centers for Disease Control data in the years 2005–2008, the percent of US adults taking statins had increased to 25% Mouse models have demonstrated proapoptotic and antitumor activity of statins against lymphoma Epidemiological studies of the association of statins and risk of lymphoid malignancies have shown mixed results with some studies showing lower risk n = 243) and for whom there was no information on statin use (n = 2) for a final analysis cohort of 161,563.The study population included 161,808 postmenopausal women aged 50 to 79 enrolled in the Women's Health Initiative (WHI) Clinical Trial (CT) and Observational Study (OS) from October 1, 1993 to December 31, 1998. Study implementation details have been published previously Statin use was defined as use of any HMG CoA reductase inhibitor. Statins were classified as lipophilic  or hydrophilic (pravastatin) and by potency as low potency (fluvastatin and lovastatin), medium potency (pravastatin), and high potency (simvastatin and atorvastatin) Information on statin use was collected at baseline in the WHI, and thereafter follow‐up information on statin use was determined at year 3 in the OS participants and years 1, 3, 6, and 9 in the CT participants. At baseline and at each follow‐up visit, participants were asked to bring all of their current prescription medications to the clinic visit (or first interview at baseline). At those visits, interviewers entered each medication name directly from the medication containers into the WHI database, which assigned drug codes using Medispan software . At the time of the visit, women also reported duration of statin use.Self‐report of NHL was locally verified at each clinic by medical record and pathology report review by centrally trained WHI physician adjudicators. Central adjudication and coding of histology were performed at the Clinical Coordinating Center using the Surveillance, Epidemiology, and End Results Program (SEER) coding system. Only NHL cases confirmed by central adjudication were included in the analysis (1091 cases). Information on subtype of NHL was available and included 368 cases of diffuse large B‐Cell lymphoma (DLBCL), 255 cases of follicular lymphoma, 96 cases of small lymphocytic lymphoma (SLL), and the rest were categorized as other lymphoma type. There were two cases where the diagnosis was not adjudicated and were not included in the analysis.Information on all covariates was collected at study entry including sociodemographic characteristics, clinical history as well as factors associated with healthcare utilization which might impact both statin utilization and detection or diagnosis of NHL.The characteristics of statin users at baseline were compared with those of nonusers by chi‐squared tests. Annualized rates of NHL (incidence per person‐year) were calculated according to the use of statins. We performed selected subgroup analyses by information on duration of statin use , statin type, potency, and lipophilic status. Women who reported using two or more statins were included in analyses that compared statin use to none, but were excluded from analyses that examined details of statin use . Hazard ratios (HRs) for NHL among statin users versus nonusers, and 95% confidence intervals (CIs) were computed from Cox proportional hazards analyses. A Cox model that included statin use and the interaction of statin use with follow‐up time and testing for a zero coefficient on the interaction term was used to conduct tests for the proportional hazards assumptions.While only 7.5% of WHI participants used statins at baseline, approximately 25% were using statins at the end of the trial completion. In order to account for increasing statin use during follow‐up, we examined the association of statin use and NHL using time‐dependent analyses. To evaluate the effect of change in statin use overtime, final models were run by entering statin use as a time‐dependent exposure and using updated information on statin use gathered at each follow‐up time point. Cases of NHL as well as noncases were censored if they occurred more than 3 years after last medication update in the OS participants to closely parallel the follow‐up experience of women in the CT. A set of covariates was selected a priori for adjustment of potential confounding based on covariates that are associated with risk of NHL or heathcare utilization. These included age (continuous), history of lupus and rheumatoid arthritis at WHI baseline (yes/no), and current medical care provider . Additionally, all models included strata for age group at WHI enrollment, extension study (yes/no), and study group/trial participation.Additional WHI baseline variables were individually tested as possible confounders: BMI, race/ethnicity, smoking status, education, percent energy from fats, recreational physical activity, waist circumference, aspirin use, history of cardiovascular diseases, and postmenopausal hormone use. We compared results from models that included all of the a priori covariates and each potential confounder to models including the a priori covariates only. Covariates were considered to be confounders if their inclusion in a model resulted in a change in any of the HRs for the statin variables by 10% or more. None of the additional variables met these criteria; therefore, the results presented are those from the models adjusted for the a priori covariates.Separate analyses were conducted for individual subtypes of NHL (diffuse large B‐cell lymphoma (DLBCL), small lymphocytic lymphoma (SLL), marginal zone lymphoma (MZL), and follicular lymphoma).Table Table Table Table Table We analyzed the association of statins and risk of NHL over a long period of follow‐up and showed in a time‐dependent analysis that statin use was associated with a borderline lower risk of NHL. Furthermore, we found that statin use is specifically associated with a statistically significant lower risk of DLBCL. The inverse association with statins was restricted to lipophilic statins, but an association with other statins cannot be ruled out. It is also possible that the results may be due to residual confounding.Table Results from a number of preclinical studies suggest that our current observation is biologically plausible. Statins have been previously shown to have chemopreventive effects for a large number of cancer types based on their downstream molecular effects Statins have also been shown to inhibit the production of FPP and GPPP, two key downstream products involved in posttranslational modification of many proteins including geranylgeranylation of Rho proteins (Rho GTPases) Another mechanism by which statins may impact risk of lymphoma is through inhibition of histone deacetylases (HDACs). It has been recently shown that the carboxylic moiety of lovastatin can bind and chelate the catalytic site of HDAC2, leading to increased p21 expression and inhibition of tumor cell growth Our observation that statins differentially impact lymphoma risk based on their biologic properties is also consistent with the exiting medical literature , 35. StaThe strengths of our analysis include the prospective design, the large diverse population with detailed demographic characterization, adjudicated cancer diagnosis by central review, serial update of statin use, and long follow‐up period. The comprehensive data collection in the WHI also allows for a detailed adjustment for confounding variables. Limitations include the observational nature and the relatively low prevalence of statin use at baseline among WHI subjects. Despite these limitations, we were able to capture updated information on statin use using a time‐dependent analysis. Another limitation is the lack of data documenting medication compliance and HIV status, another risk factor for NHL. It is currently thought that the prevalence of HIV in the WHI cohort of postmenopausal women is low. We also did not have dose information on statins and were not able to analyze relationship of dosing or duration of use in the time‐dependent analysis. Our results suggesting a relationship between lipophilic statins and NHL may be particularly important for high‐risk populations such as those with autoimmune conditions. Our findings showing a specific impact on DLBCL have implications for future studies of the impact of statins on risk of recurrent disease.Statin use may be associated with a lower risk of NHL in women particularly DLBCL. These results should be evaluated in other large datasets, particularly meta‐analyses of trial data, with a particular emphasis on specific type of NHL.None of the authors have any conflicts with regard to this manuscript.


Purpose To research the origins of the 2500 g cutoff for low birth weight and the evolution of indicators to identify newborns at high mortality risk. Description Early research concluded “prematurity”, measured mainly through birth weight, was responsible for increased health risks. The World Health Organization’s original prematurity definition was birth weight ≤2500 g. 1960s research clarified the difference between gestational age and birth weight leading to questions of the causal role of birth weight for health outcomes. Focus turned to two etiologies of low birth weight, preterm births and intrauterine growth restriction, which were both causally associated with morbidity and mortality but through different pathways; a standard cutoff based on gestational age or customized cutoff was debated. Assessment While low birth weight can be due to preterm or intrauterine growth restriction (or both), the historic 2500 g cutoff remains the standard by which the majority of policy makers define low birth weight and use it to predict perinatal and infant adverse outcomes. Conclusion Current efforts to refocus research on preterm births and poor intrauterine growth are important to understanding the direct causes of mortality rather than low birth weight as a convenient surrogate. Such distinctions also allow researchers and practitioners to test and target interventions outcomes more effectively. What is already known on this subject? 2500 g is the standard cutoff used to identify low birth weight infants at high mortality risk.What this study adds? This study provides the historical context for this low birthweight standard and more recent trends to link early morbidity and mortality to their etiological causes of birth size.Public health and medical professionals have categorized infants as low birth weight for almost a century. These infants have 20 times greater likelihood of dying compared to infants of normal birth weight  in 1935, summarized the problem as follows:Later in the meeting a standard criterion of prematurity (≤2500 g regardless of period of gestation) to facilitate comparison across studies was proposed. This meeting codified the 2500 g division first proposed by Ylppö in 1919.Subsequent papers began to use definitions in publications with some exceptions. A 1938 review of over 15,000 deliveries focused on the attributes of premature births  emerged  associated with birth weight that also increase mortality risk. Increasing birth weight is a health target for many countries to reduce infant mortality. However, these efforts may be misguided if birth weight is not a causal factor, although it may be a reasonable surrogate measure of a successful policy. More recent work has focused on the epidemiology of preterm and SGA as these are causal factors in neonatal morbidity and mortality (Katz et al. While WHO provides one low birth weight standard for the world it acknowledges “it has also become increasingly evident that the cut-off value of 2500 g may not be appropriate for all settings. Some countries, with high incidence of low birthweight do not necessarily have high mortality rates, as for example in Sri Lanka” Wardlaw . In addiGardosi developed a custom fetal growth weight standard that could be adjusted based on maternal factors and fetal sex (Gardosi et al. Lancet paper described a global reference for fetal-weight and birth weight percentiles (Mikolajczyk et al. Despite evidence against Gardosi’s model its momentum continued with the British Royal College of Obstetricians and Gynaecologists and other professional associations supporting customized birth weight percentiles (Hutcheon et al. INTERGROWTH-21 sought to develop a universal global standard for normal fetal growth (Uauy et al. Low birth weight continues to be an accessible measure of mortality risk in resource limited settings (World Health Organization


Falls are a major socio-economic problem among residential aged care (RAC) populations resulting in high rates of injury including hip fracture. Guidelines recommend that multifactorial prevention strategies are implemented but these require translation into clinical practice. A community of practice (CoP) was selected as a suitable model to support translation of the best available evidence into practice, as it could bring together like-minded people with falls expertise and local clinical knowledge providing a social learning opportunity in the pursuit of a common goal; falls prevention. The aims of this study were to evaluate the impact of a falls prevention CoP on its membership; actions at facility level; and actions at organisation level in translating falls prevention evidence into practice.A convergent, parallel mixed methods evaluation design based on a realist approach using surveys, audits, observations and semi-structured interviews. Participants were 20 interdisciplinary staff nominating as CoP members between Nov 2013-Nov 2015 representing 13 facilities (approximately 780 beds) of a RAC organisation. The impact of the CoP was evaluated at three levels to identify how the CoP influenced the observed outcomes in the varying contexts of its membership (level i.), the RAC facility (level ii.) and RAC organisation (level iii.).p < 0.001) through connecting and sharing. Strategies prioritised and addressed at RAC facility level culminated in an increase in the proportion of residents supplemented with vitamin D (p = 0.002) and development of falls prevention education. At organisation level a falls policy reflecting preventative evidence-based guidelines and a new falls risk assessment procedure with aligned management plans were written, modified and implemented. A key disenabling mechanism identified by CoP members was limited time to engage in translation of evidence into practice whilst enabling mechanisms included proactive behaviours by staff and management.Staff participating as CoP members gained knowledge and awareness in falls prevention  contains supplementary material, which is available to authorized users. Falls are a major socio-economic problem in the residential aged care (RAC) sector; half its population fall annually –3 and 25Therefore the aims of this study were to evaluate the impact of a falls prevention CoP on its: i) membership; ii) actions at facility level; iii) actions at organisation level in translating falls prevention evidence into practice.This study used a convergent, parallel mixed methods evaluation design  based onThe RAC organisation was led by a Chief Executive Officer from a central administrative site. There were approximately 1200 full and part time care staff across 13 geographically diverse facilities providing mainly high level care in a home-like environment for 780 older people with a mean age of 84.01 years (SD = 4.56 years). Facilities were led by a care manager, with direct resident care provided mostly by care assistants supervised by professional nursing and allied health staff. The CoP partnered university researchers with staff across the 13 facilities. As the CoP was an intervention at organisation level and it’s actions interventions at facility level, all RAC facilities operated by the provider organisation were included. CoP membership was open to all RAC facility staff involved in resident care expressing an interest in falls prevention, following invitations delivered at facility and organisational levels. All facilities were represented by at least one CoP member with no more than 20 members at any one time for the duration of the study. Fourteen (65%) allied health professionals five (25%) care/deputy care managers and one (5%) researcher made up the membership. All CoP activities involving RAC staff or residents followed invitations provided at facility and organisation level yielding purposive samples. The study was conducted between November 2013 and November 2015.The impact of the falls prevention CoP was evaluated at three levels; i) membership level (RAC staff who participated), ii) RAC facility level and iii) RAC organisation level on translating falls prevention evidence into practice, as shown in Fig. An online survey questionnaire was administered to CoP members via an email link using software by SurveyMonkey™ on entry into the CoP and following 24 months of CoP operation. Additional open response questions, modified from Ranmuthugala et al. , to deteThe researcher kept a journal to record her observations and reflections regarding CoP member participation and operation. The observations contributed to descriptions and explanations of CoP web based communication, activity and impact. Findings were presented to the CoP members to establish respondent validation or ‘member checking’ , 33.The establishment of a community through connections between its members and knowledge flow through the community was recorded by counting postings on the CoP intranet discussion web page and whom the posting was shared with, in addition to members’ email frequency and attendance at eight face to face meetings. These CoP member interactions were recorded in a Microsoft Excel (2013) spreadsheet .Measurement of the impact of the CoP at facility level prioritised improving the proportion of residents supplemented with vitamin D and development of falls prevention education. These priority areas were determined in the early phase of CoP operation when the CoP conducted an audit of falls prevention activity . One of The proportion of residents at each facility supplemented with vitamin D was calculated from medication charts. Electronic dispensing records from supplying pharmacists were sourced to verify the accuracy of medication chart audits.Surveys of care staff and residents were planned to scope what they knew and thought about falls and falls prevention to inform subsequent education program design.Care staff consenting to participate were surveyed using a self-administered questionnaire distributed in a paper format at facility shift handovers, as computer access was limited. Explanation on completing the questionnaire was provided verbally and in written format by the shift registered nurse and the survey collection box was given prominence at the nurses’ station. Completed questionnaires were collected after two weeks by the researcher.Consenting residents who did not have a diagnosis of cognitive impairment were surveyed face to face by a trained research assistant who read them the questions and recorded their responses.n = 13) were surveyed using an emailed short questionnaire modified from Ranmuthugala et al.  and 24 months post CoP operation ). There was a significant difference between the pre and post scores with post survey scores showing increases in knowledge [p < 0.001]. For example there was awareness of intrinsic risk factors like medication review, P6“it’s improved my personal knowledge of falls management ,” P8“I didn’t know the impact vitamin D and medications can have on falls until I joined the CoP. I bring this up when discussing with residents and staff.”The greatest benefit of CoP membership reported by participants was improved evidence based falls prevention awareness and knowledge, Participating CoP member (P)11“I’ve registered for the local falls conference,” and eight became new contributors to facility falls prevention meetings, P9“I’m part of a regular falls meeting at my facility now.”When member survey responses regarding motivation and confidence to lead falls prevention activities were compared pre CoP and 24 months post CoP operation there were no significant differences  was perceived as a membership benefit. This was reported as particularly relevant for members who were new to the RAC organisation or novice practitioners, P13“It was lovely to have a place where I could ask questions,” P9“I feel I can contribute more to preventing falls and discussions about falls.” Knowledge flow through the CoP and connections amongst members was evident through frequency counts of discussion board participation and post sharing amongst CoP members , promoting vitamin D supplementation (20 member posts), “Ask the CoP?” (21 member posts) and psychotropic medication use (11 member posts). The researcher and facilitator were the most connected across the entire membership providing a link between the research institution and RAC organisation. Six CoP members, who were therapists, became the most connected sharing more than eight postings and additional monthly email contact. Seventeen members shared falls prevention knowledge from the CoP with staff at their facilities, P7 “finding the time with so many other things to do,” Manager 1 “staff got no additional time to support involvement in the CoP, this was a barrier to getting things done.”The key barrier to member participation in the CoP was perceived to be lack of dedicated time due to competing interests P9 The CoP was able to successfully lead and conduct a falls prevention activity audit at all 13 facilities in the organisation. The full procedure and results of the audit are described elsewhere .p = 0.002]  to November 2015 (follow up audit) with the mean increase in the proportion of residents receiving supplementation of 28.23% . Forty residents who did not have a diagnosis of cognitive impairment (response rate 83.3%) across six facilities participated in the resident survey. Education preferences included having a reminder poster for their room [n = 11 (27.5%)]. These findings led to the development and implementation of a pictorial falls prevention poster checklist across all facilities. One CoP member developed the ‘Catch a Falling Star’ program targeting residents assessed as at higher risk of falling and recurrent fallers using a personalised strategy checklist, P16“we have the falling stars program, our residents have personal checklists to remind staff of the strategies to use at all times.” Twenty two (78.6%) care staff participating in the survey from this facility discussed using the program when questioned about their knowledge of falls prevention strategies, Care staff 4“I check and report on the falling star plans every shift,” Care staff 11“falling star plan says to always make sure they (resident) have their call bell in reach.” Following CoP information sharing this program was then implemented by two additional facilities. Feedback from 12 care managers regarding CoP impact at their facility was strongly perceived to be: improved staff falls prevention awareness and actions through education and resources provided by the CoP members, Manager 9 “given staff ideas on how to keep residents from falling, it’s a very precious tool.”To inform development of education, surveys of care staff and residents were undertaken to determine what they knew and thought about falls prevention following piloting at a single facility. Briefly, 147 care staff from eight facilities participated (response rate 37.9%); reminders to carry out falls prevention strategies by displaying posters around the facility were the most popular education preference [n = 3) and falls prevention becoming an agenda item at staff meetings (n = 7), P3 “we prioritised it, we discussed prevention together in team meetings to help them (staff) understand,” P2 “we helped staff realise how important it is by showing them the facts ” and screening resident footwear and clothing (n = 3) P16“we went through the cupboards checking all items that were unsafe so family could remove, if it’s not there staff can’t put it on.” Additional equipment, namely sensor lights for night-time toileting and bed or chair alarms, was introduced at two facilities.Falls prevention practices deemed to be effective at some facilities were shared with others for adoption, these included monthly facility “falls meetings”  as less relevant, then it’s hard to get any impact,” Manager 1“if you’ve got care manager support then it’s front and centre in peoples’ minds.”Barriers identified by CoP members to implementing fall prevention strategies included perceived lack of management support in realising the importance of prioritising falls prevention and member participation“having a culture of wanting to improve is fundamental, acknowledge you are not perfect, have a willingness to change.” A standardised fall definition to assist in clarifying the reporting of falls was adopted, “an unexpected event in which a person comes to rest on the ground or lower level” [“the wording is easier for everyone to understand in this one,” P5“after discussing this and watching the simulation video I realised that some incidences should have been counted as falls at our facility.” The drafting and completion of a falls prevention policy, risk assessment tool and aligned management strategies by the CoP was an iterative extensive process over 11 months, which engaged CoP members with RAC management. This reflected a cultural shift by both CoP members and RAC managers in their approach to falls from one of reactively managing falls to more proactive prevention, Manager 1“there were gaps and I knew we didn’t have a standardised way of addressing falls, now we do all that proactive preventative stuff.” The CoP liaised with clinical and management groups across the organisation through face to face and email discussions regarding content together with IT personnel for adaptation into workable electronic formats, Manager 1“for me the major achievements of the CoP have been the policies and procedures, that was our gap and now I feel like we’re getting there.”CoP auditing of relevant falls related policy and process documents and management meeting minutes identified gaps in governance for targeted attention, Manager 1r level” , P2“the “it’s had a positive impact, I’ve seen it at facilities on coffee tables and noticeboards and heard staff talking about it.” Ten care managers reported the CoP newsletter was distributed at their facilities and 11 thought it was a useful resource. The awareness of the problem of falls and importance of falls prevention raised by the CoP led to CoP reporting becoming an agenda item at the organisation’s Board Care Committees’ meetings, Manager 1“it’s (newsletter) included in reports to the board care committees so they’ve got it as a standing agenda item.”Raising awareness and providing education regarding falls and falls prevention was addressed via a CoP newsletter in electronic and paper formats four monthly across the organisation to all levels of management, clinical working groups and staff, Manager 2“there was a lack of focus , we didn’t give it dedicated time, but there are so many things we are involved in.”Barriers to the CoP translating evidence into practice from an organisational perspective were conflicting priorities and realising commitment in supporting dedicated staff time, Manager 2Results from each of the three levels of evaluation in the form of conjectured CMOs are presented in Table The conjectured CMOs demonstrated how the variability observed in translating evidence into practice was influenced by the RAC context. For example, the level of facility care manager support for CoP member participation and action (context), through realising the need to prioritise falls prevention activities (mechanism), influenced the success of translating evidence into practice (outcome).Overall, interdisciplinary staff perceived that they benefitted from participating in a falls prevention CoP and that the CoP was able to translate falls prevention evidence into practice in the context of their individual facility and the RAC organisation.Our study found that all CoP members benefited from membership by improving their knowledge of RAC falls prevention strategies through association with experts, but translating this knowledge into practice showed varied levels of success. Although possessing the relevant knowledge is a foundation step in the translation process identified by other studies , 18, simMembership of the falls prevention CoP enabled clinicians to gain confidence and credibility, through connections to experts and identify themselves as role models. This motivated members to then step up and contribute to falls prevention change at their facilities, particularly if they were new to the field of falls prevention. Social learning opportunity is a characteristic of CoPs whereby association of novice with expert in a field can lead to professional identity building through sharing and collaborating , 26. HigImprovement in the proportion of residents supplemented with vitamin D varied across the 12 participating facilities, which could have been influenced by the enabling or disenabling actions of the visiting GPs as the main prescribers (of medications). It was perceived by CoP members that GPs who viewed RAC staff as credible peers, regarding providing falls prevention evidence, advocated for vitamin D supplementation, whereas those who didn’t acted as a barrier. Other studies have found that doctor and nurse cooperation can influence the success of intervention implementation: A systematic review of interdisciplinary interventions in nursing home settings reported positive impacts on resident outcomes when the resident’s doctor participated in the intervention . ConversMore falls prevention activities were implemented at RAC facilities that had manager support and when CoP members were motivated and provided meaningful resources. For example the ‘Catch a Falling Star’ program, supported by the facility manager, was one CoP member’s motivational way of sharing falls prevention strategies that made sense to facility staff and resulted in uptake at their facility. Motivational ways of sharing knowledge is recommended for enabling knowledge transfer , 45. EnaCoP members who were given the time to attend face to face CoP meetings and became involved in web-based discussion and collaboration were more successful at implementing falls prevention evidence and practice change at their facility. This action was perceived by CoP members to be triggered when care manager’s realised dedicated time was needed for CoP members to lead falls prevention change and were able to prioritise support for CoP participation. For example, supported CoP members implemented additional multifactorial falls prevention strategies such as tailored resident falls prevention plans, footwear screening and facility committee meetings. Conversely at facilities where CoP members were not supported to participate in CoP meetings and discussions there was limited implementation of evidence based practices. Limited dedicated time for staff to be involved was a common barrier reported in other health implementation studies , 45, 46.The CoP, were able to identify a gap in the falls management policy and procedures. The CoP engaged management using information on the pros and cons of taking preventative action to gain their support in a cultural change to approaching falls. Taking a more proactive cultural approach to falls may lead to better outcomes for residents as RAC culture has been linked to quality outcomes for residents , 47. ProAt an organisational level failure to consistently support opportunity, in terms of dedicated time commitment, for CoP members to learn and engage in falls prevention activity was perceived to limit implementation of falls prevention activities. Whilst CoP members were cognisant of the fact that the organisation had to manage a range of complex issues, they felt this still reflected a lack of realised importance of the need to learn and action falls prevention in the workplace and achieve even better outcomes. Limited time and resources was identified in other studies as a barrier to work place learning and implementing new practices , 48.Regular CoP reporting on their falls prevention actions and outcomes, created a strong feedback loop from frontline care staff to organisational management. Recognition of higher levels of feedback for systems, teams or individuals is a factor linked with successful implementation , 49 and n = 20) but we feel it reflects the authentic number of staff a RAC organisation of this size may assign to participate in a given project. Whilst elements of this study relied on self-report, we have supported validity and credibility of the findings by incorporating quantitative data where possible, triangulating findings using multiple data sources and maintaining an audit trail. Ideally interviews of care staff, facility managers and representatives of the organisation’s Board Committees would have provided further depth to our insights however the pragmatics of such an undertaking were beyond the scope of this study. The intranet software was unable to track members accessing the CoP web site unless they posted comments on the electronic discussion board but future upgrades to the software should have the capacity to track access across all areas.Evaluation and explanation of the impact of operating a falls prevention CoP on falls rates and injurious falls rates was beyond the scope of this study and these findings are reported elsewhere . In thisAn interdisciplinary falls prevention CoP provided connections and knowledge gains amongst its members and was able to facilitate translation of falls prevention evidence into practice in the context of a RAC facility and RAC organisation. Translation worked best at facilities with an active CoP member connected to evidence with management support in a proactive falls prevention culture. Support by RAC management to provide the necessary investment in staff time to better enable change in falls prevention practice is essential for success. Future research should continue to test these conjectured mechanisms of action noting the contextual conditions that produce the desired or undesired outcomes. This may better inform how CoPs impact their membership and the translation of evidence into practice.Additional file 1:CoP member confidence, motivation and opportunity to engage in intranet usage and lead falls prevention activity. (DOCX 15 kb)Additional file 2:Matrix of knowledge flow through CoP and member connections through discussion board participation. (DOCX 21 kb)Additional file 3:Proportion of residents supplemented with vitamin D measured in July 2014 and re-measured November 2015. (JPEG 48 kb)


Determining the geographic connections between breeding and nonbreeding populations, termed migratory connectivity, is critical to advancing our understanding of the ecology and conservation of migratory species. Assignment models based on stable isotopes historically have been an important tool for studying migratory connectivity of small‐bodied species, but the low resolution of these assignments has generated interest into combining isotopes with other sources in information. Abundance is one of the most appealing data sources to include in isotope‐based assignments, but there are currently no statistical methods or guidelines for optimizing the contribution of stable isotopes and abundance for inferring migratory connectivity. Using known‐origin stable‐hydrogen isotope samples of six Neotropical migratory bird species, we rigorously assessed the performance of assignment models that differentially weight the contribution of the isotope and abundance data. For two species with adequate sample sizes, we used Pareto optimality to determine the set of models that simultaneously minimized both assignment error rate and assignment area. We then assessed the ability of the top models from these two species to improve assignments of the remaining four species compared to assignments based on isotopes alone. We show that the increased precision of models that include abundance is often offset by a large increase in assignment error. However, models that optimally weigh the abundance data relative to the isotope data can result in higher precision and, in some cases, lower error than models based on isotopes alone. The top models, however, depended on the distribution of relative breeding abundance, with patchier distributions requiring stronger downweighting of abundance, and we present general guidelines for future studies. These results confirm that breeding abundance can be an important source of information for studies investigating broad‐scale movements of migratory birds and potentially other taxa. Satellite tracking has revolutionized migratory connectivity research for large‐bodied species (>100 g) by enabling remote transmission of individual movements over broad spatial and temporal scales . Because areas differ with regard to relative abundance, it may be reasonable to assume that individuals are more likely to originate from high abundance populations than low abundance populations. Using Bayes rule, the relative abundance can be incorporated into the assignment model as a prior probability. This allows researchers to explicitly model the probability that an individual originated from each population, that is, f(b|y*), and to formally base assignments on both the isotope data (via the likelihood) and breeding abundance (via the prior).The first formal method to include breeding abundance and intrinsic markers in geographic assignments was outlined by Royle and Rubenstein . In thei. This introduces a critical complication that has gone largely unrecognized. The problem arises because most species are patchily distributed across their range, with a few areas of relatively high abundance and extensive areas of lower abundance. When abundance is included as a prior in assignments to continuous surfaces, the low abundance sites may receive low posterior support compared to high abundance locations. Although this outcome is consistent with the logic proposed by Royle and Rubenstein , Northern Parula (Setophaga americana), Prairie Warbler (Setophaga discolor), Black‐and‐White Warbler (Mniotilta varia), American Redstart (Setophaga ruticilla), and Ovenbird (Seiurus aurocapilla). Using stable‐hydrogen isotope data collected at known breeding sites across the breeding range of each species enabled us to assess the performance of different models. Using Pareto optimality, a method for multi‐objective optimization, we show that weighting the isotope and abundance data can increase the performance of assignment models but that the distribution of breeding abundance plays a critical role in determining the proper weightings.In this study, we describe a new quantitative method for making geographic assignments to origin that differentially weights stable‐hydrogen isotope and breeding abundance data to maximize assignment area and minimize assignment error. We performed Bayesian assignments of origin for six species of Neotropical‐Nearctic migratory birds: Wood Thrush . The δ2H values reported include only nonexchangeable H as determined by linear regression with the IAEA‐CH‐7, CHS, and KHS keratin standards  was <2‰.Isotope analyses were performed at the Stable Isotope Mass Spectrometry Facility of the Smithsonian Institution in Suitland, MD. Feathers were washed in a 2:1 chloroform:methanol solution to remove surface oils and air‐dried under a fume hood for 48 hr. After transport to the laboratory, feathers were allowed to equilibrate with the local atmosphere for 72 hr. A small sample of each feather (0.30–0.35 mg) was packed into a silver capsule, combusted at 1,350°C in an elemental analyzer (Thermo TC/EA), and introduced online to an isotope ratio mass spectrometer (Thermo Delta V Advantage) via a Conflo IV interface. Four previously calibrated keratin standards were run for every 10 unknowns to account for exchangeable and nonexchangeable H in feather samples  using published corrections for either ground foraging or nonground foraging long‐distance migratory birds  is the likelihood that an individual with δ2Hf=y∗ originated from cell i, μi is the predicted δ2Hf value for cell i, and σ is the standard deviation of δ2Hf values within a single breeding site, which was assumed to be 12 ‰  is the posterior probability that an individual with δ2Hf = y* originated from cell i, f(y*|bi) is the likelihood of assignment to breeding cell i, and f(bi) is the relative abundance  of cell i. Because the abundance data in equation where 2.4−1 to 10, respectively, resulting in 442 assignment models (222 = 441 abundance models + isotope‐only model). Powers >1 sharpen the distribution of values, giving more weight to high values relative to low values. Powers <1, in contrast, flatten the distribution and give more relative weight to low values. For each model, we estimated the assignment error and assignment area as described above.As described above, the combination of isotope data and abundance data described by equation After fitting the models for Wood Thrush and American Redstart, we used a two‐step approach to determine the top‐performing model(s). First, we used an optimization method termed Pareto optimality to eliminate from consideration any model that did not minimize both error rate and assignment area relative to other models. Pareto optimality is widely used in economics and engineering Censor,  but has Although identifying the Pareto frontier allowed us to restrict our attention to models that cannot be strictly improved with regard to both assignment area and assignment error, these models do not necessarily represent acceptable solutions for incorporating abundance into assignments. In particular, some models along the Pareto frontier may have large error rates and are thus inappropriate for assignment of unknown‐origin birds. Therefore, as a second step in determining the top model(s), we compared the assignment area and the error rate of each Pareto optimal model to the area and error rate of the isotope‐only model, under the assumption that any model that includes abundance should at least improve upon the isotope‐only model. Thus, the final model set included only Pareto optimal models that outperformed the isotope‐only model along both axes.2.5One concern with our approach is that the top models for Wood Thrush and American Redstart may be specific to the sampling locations included in our analysis. To test whether our results were sensitive to the specific sampling locations included in the analysis, we iteratively removed all individuals from each site and re‐estimated the top models by comparing the new Pareto optimal models to the isotope‐only model . If the abundance and isotope weights remained constant across these scenarios, we concluded that the top models were robust to any differences in the sampling locations included in the analysis.Species also vary considerably in their geographic distributions and patterns of abundance, and it is possible that these differences may influence the performance of assignment models based on isotopes and abundance. Unfortunately, sample sizes for four of the species included in our analysis  were too small to obtain reliable estimates of top model weights using the Pareto method described above. Instead, we tested whether the top models identified for Wood Thrush and American Redstart outperformed assignments based on the isotope‐only model for the remaining species. For each species, we compared the assignment performance of the top Wood Thrush and American Redstart models to the performance of the respective isotope‐only model. If the top Wood Thrush and American Redstart models outperformed the isotope‐only models for the other species, we concluded that those models provide a general solution for assignments of Neotropical migratory songbirds.3For both Wood Thrush and American Redstart, the majority of the 442 assignment models performed poorly relative to the best models, indicating only a small range of weightings provided reasonable solutions for incorporating abundance into assignments Figure . The isoThe use of Pareto optimality provided an efficient means of eliminating poorly performing models. For Wood Thrush, 405 models (92%) were not Pareto optimal, leaving 37 models along the frontier  and but did not weight the isotope data (Table S8). The isotope weights and the abundance weights were similar across all cross‐validation models for American Redstart  were not Pareto optimal, leaving 47 models along the frontier . Thus, although the naive‐abundance models greatly reduced the assignment area relative to the isotope‐only models (mean decrease in assignment area compared to isotope‐only models = 46%), they performed poorly compared to both the isotope‐only model and the top weighted abundance models for all species Table .The divergent results for Wood Thrush, Ovenbird, Black‐and‐White Warbler, and Northern Parula, on the one hand, and American Redstart and Prairie Warbler, on the other hand, suggest that the performance of abundance models is conditional on the underlying distribution of abundance. To test this hypothesis, we fit a negative exponential distribution to the abundance data for each species and compared the rate parameter across species. Patchy abundance distributions are expected to be characterized by steeply declining distributions and large rate parameters. More even abundance distributions should be less steep and have lower rate parameters. Consistent with our hypothesis, the rate parameters for American Redstart  and Prairie Warbler  are much larger than the parameters for Wood Thrush , Ovenbird , Northern Parula , and Black‐and‐White Warbler .4Given the low resolution of many intrinsic markers, including abundance in assignment models is appealing because it can often greatly increase the precision of assignments. However, in all assignment models that use intrinsic markers, there is an inherent trade‐off between assignment error and precision. Using known‐origin stable‐hydrogen isotope samples of six Neotropical migratory bird species, we show that the increased precision of models that include abundance is often offset by a large increase in assignment error. We demonstrate that proper weighting of the abundance and isotope data can result in models with higher precision and, in some cases, lower error than models based on isotopes alone. These results confirm that breeding abundance can be an important source of information for studies investigating large‐scale movements of migratory birds and potentially other taxa.Although our assignment models involved known‐origin birds, their chief application will be estimating migratory connectivity to breeding areas for adult birds captured in the stationary nonbreeding period or while on migration. We emphasize that combining breeding abundance and stable isotopes in assignment models will yield valid estimates of migratory connectivity for adults but not for immature birds because breeding abundance can be a poor indicator of regional productivity , several models along the Pareto frontier had both lower error and lower assignment area than models based on isotopes alone. Across these four species, models that weighted the isotope data by 10−1 but leaving the isotope data unweighted did provide a slight decrease in assignment area without substantial increase in error rate for these species. Therefore, this combination appears to provide a reasonable solution for these two species.In contrast, including abundance did not provide an unequivocal improvement in assignment performance for the remaining two species (American Redstart and Prairie Warbler). For these species, the isotope‐only model was close to the Pareto frontier. In general, this means that although including abundance in the model will decrease assignment area, it will also increase assignment error. Nevertheless, weighting abundance by 10These results indicate that the distribution of breeding abundance plays a critical role in the performance of assignment models. For species with breeding ranges that are characterized by large areas of very low abundance and a few small centers of high abundance, this patchy distribution likely magnifies the influence of abundance data in the assignment model, overwhelming the information provided by the isotope data and leading to high posterior probabilities for only the high abundance sites .Downweight abundance for species with patchy distributions: Our results for American Redstart and Prairie Warbler, two species characterized by very patchy breeding distributions , suggest that including abundance in assignments provides only a small improvement over the isotope‐only model and only when the abundance data were heavily downweighted. Therefore, we recommend that researchers first characterize the patchiness of breeding distributions using the exponential curve‐fitting approach described above. For species with patchy distributions (rate parameter > ~15–20), abundance data should only be included if it is heavily downweighted (10−0.6–10−0.8 and abundance data should be unweighted.Moderately downweight isotope data for species with even abundance: For species with more even distributions of breeding abundance (rate parameter < 12), the best models tended to moderately downweight the isotope but not the abundance data. Therefore, we recommend for species with rate parameters < 12, isotope data should be weighted 10Even when researchers follow these guidelines, we recommend comparing the results of the abundance model to the results of assignments based on stable isotopes only. As we show here, the models along the Pareto frontier define the upper bound of assignment performance using abundance and stable‐hydrogen isotopes and, in some cases, the performance of abundance models can be poor compared to the isotope‐only model. As a result, large discrepancies between the two models should be investigated, reported, and carefully interpreted. Ultimately, however, including abundance in assignment models should be viewed as a preliminary step to improving estimates of migratory connectivity for any species. Occupancy probabilities calculated from species distribution models offer a potentially promising alternative to abundance (Fournier et al., Upon acceptance, the data used in this manuscript, along with all necessary code to reproduce the analyses, will be deposited permanently in the Smithsonian Digital Data Repository. Once archived, the data and code will be freely available to users.None declared. Click here for additional data file. Click here for additional data file.


VA) Health‐care System in promoting patient engagement to improve patient care.There is a strong interest in the Veterans Administration  and two VA levels . Rating criteria included desirability, feasibility, patient ability, physician/staff acceptance and impact on patient‐centredness and care quality. Data were analysed using the RAND/UCLA Appropriateness Method for determining consensus.We solicited expert opinion using an online expert panel system with a modified Delphi structure called ExpertLensExperts rated consulting with patients at the local level as the most desirable and feasible patient engagement approach. Engagement at the local level was considered more desirable than engagement at the regional level. Being an equal stakeholder at the local level received the highest ratings on the patient‐centredness and health‐care quality criteria.Our findings illustrate expert opinion about different approaches to patient engagement and highlight the benefits and challenges posed by each. Although experts rated local consultations with patients on an as‐needed basis as most desirable and feasible, they rated being an equal stakeholder at the local level as having the highest potential impact on patient‐centredness and care quality. This result highlights a perceived discrepancy between what is most desirable and what is potentially most effective, but suggests that routine local engagement of patients as equal stakeholders may be a desirable first step for promoting high‐quality, patient‐centred care. The term ‘patient‐centred care’ typically refers to medical care focused on the patient and his/her health‐care needs.Research suggests that patient and stakeholder engagement may increase health‐care research and policy relevance to community needs,n = 48) with experience in patient engagement to rate desirability, feasibility, stakeholder acceptance and potential outcomes of eight scenarios describing four patient engagement roles  and two health‐care system levels .In this paper, we use a conceptual model of patient engagementThe VA is the largest integrated health‐care delivery system in the United States with nearly 1400 sites, organized into 21 Veterans Integrated Service Networks, or VISNs – regional systems of care. Serving 8.3 million Veterans, VA offers a full spectrum of inpatient, outpatient and long‐term care servicesEvery year, VA fields the Survey of Health Experiences of Patients (SHEP) to evaluate patient health‐care experiences, with topics ranging from health‐care access to provider interpersonal skills.Although VA engages patients in a number of ways, there is no consensus on the degree to which patients should be involved in improving the VA health‐care system, nor which health‐care settings or organizational levels are best suited for patient engagement in health system planning. Moreover, despite the availability of patient viewpoints, there is little evidence that Veteran patients or families are systematically involved in routine regional and local decision making around on‐going outpatient care priorities, improvements or policies.et al.'s patient and family engagement framework,Our project is informed by Carman After consulting with VA patient representatives and patient engagement specialists, we modified this framework to better fit the VA context . We found no statistically significant difference between experts participating in Rounds One and Three except for on gender: men were less likely to participate in Round Three.Interested individuals were asked to register for the three‐round panel by providing their demographic information. Of 59 registered experts, 48 (81%), who all reported familiarity with the VA context, participated in at least one rating round of this online panel (see below for round descriptions). Rating results described in the paper are based on analysis of the input collected from those experts who provided their final ratings  participants consider most desirable, regardless of engagement level.Finally, we analysed all qualitative data thematically to identify reasons for high or low scenario ratings. We grouped all explanations of numeric responses based on the numeric rating they referred to and linked all discussion board posts to a patient engagement scenario and rating criterion they described. We then coded all text inductively to identify the most prominent themes and those that span across patient engagement scenarios within the same level of engagement or the same patient role. Coded text was reviewed by two team members to ensure coding consistency; disagreements were discussed until consensus was achieved.Forty‐five of 48 participating experts (94%) provided Round One ratings; 43 (90%) logged into Round Two; and 28 (58%) provided Round Three ratings. On average, participants logged into the discussion round twice, with some accessing the system up to 10 times. Of 43 Round Two participants, 27 (63%) posted at least one discussion comment. Discussion participants posted 145 comments .Participating experts were predominantly female (77%) and had Master's or higher level of education (85%) (see Table Rating data (see Table Experts agreed that consulting with patients at the outpatient facility level (S1) is most desirable (median = 9). This scenario also had the highest median values on three other rating criteria, two of which met our standards for a positive group decision. Panellists agreed that soliciting patients' input on care planning and design decisions on an as‐needed basis at VA outpatient clinics or hospitals, which is how S1 was described to participants, was highly feasible (median = 8) and that patients would have interest and skills necessary for providing their input (median = 7). Although this scenario had the highest median rating on the physician/staff acceptance criterion, the median score of six indicated uncertainty among the experts about physicians’ acceptance. Similarly, panellists were uncertain about the impact of local consultations on health‐care quality (median = 6). Experts, however, agreed that these consultations are likely to improve patient‐centredness of VA care (median = 7).The second most highly rated scenario on the overall desirability criterion described patients as local implementation advisors (S2) (median = 8). This approach had ratings similar to local‐level patient consultation (S1), with two exceptions: its median rating on feasibility was slightly lower (7), and its median rating on patient‐centredness was slightly higher (7.5).Engaging patients as equal stakeholders at the local level (S3) was also considered desirable (median = 7) and received the highest median rating on the patient‐centredness (median = 8) and health‐care quality criteria (median = 7). However, experts were uncertain about its feasibility (median = 6), the interest and ability of patients to provide input (median = 6) and physician/staff acceptance of patients as equal partners (median = 5).Patient leadership at the local level (S4) received uncertain ratings on all criteria, with median ratings ranging from 4 to 6.Similar to S1 , panellists’ ratings indicated that regional consultations (S5) were desirable (median = 7) and likely to improve patient‐centredness (median = 7). While experts agreed that it was feasible for patients to be consultants at the regional level (median = 7), they were uncertain about the impact on health‐care quality (median = 6), as well as patient willingness (median = 6) and physician/staff acceptance (median = 5.5).Experts also agreed that engaging patients as implementation advisors at the regional level (S6) was desirable (median = 7) and likely to have a positive impact on the level of patient‐centredness (median = 7) and health‐care quality (median = 7), but this scenario received uncertain ratings on all other criteria.S7 describing patients as equal stakeholders at the regional level received uncertain ratings on all criteria, with median ratings ranging from 5 to 6.Similar to S4 and S7, S8  received uncertain ratings on all criteria with one notable exception: it received a negative rating on physician/staff acceptance (median = 3).Table Rankings indicate that local‐level patient engagement was more desirable than regional‐level patient engagement . They also show that less‐engaged patient roles were rated as more desirable. Nonetheless, although the role of a consultant received the most favourable rank (mean rank of 3.2), participants believed that the roles of implementation advisor and equal partner  would have the highest impact on health‐care quality (data not shown).In general, participants' comments showed that they had very positive opinions about patient engagement in the design and planning of VA outpatient care. They felt that soliciting patients' input is ‘essential to the survival of the system’. As one expert put it, ‘if you want our Veterans to stay, they MUST [sic] participate. They MUST [sic] feel it is their system. And that way they will be loyal and continue to be a partner in the process of improvement planning’. Several participants noted that ‘patients are the customers’, ‘they are the ones we want to please’ and they are the ones who can identify ‘where glitches in the delivery of care exist’. ‘Without patient input’, noted another expert, ‘care planning becomes one‐sided’.Although generally positive about patient engagement, discussion comments provided insight into experts’ ratings regarding specific patient engagement approaches. Experts voiced concerns about the feasibility and physician/staff support of even the least intensive approaches to patient engagement (e.g. S1), given the existing organizational structure and culture of VA. As one expert summarized his/her perspective to patients as consultants, ‘there is a potential for feasibility, but currently there are too many barriers for this to happen. The situation is also different depending on the degree of culture transformation at each facility’. Leadership support and resources available for patient engagement were noted as important facilitators.While some experts felt that it was impossible for patients to be equal partners, others believed that Veteran patients' input should be valued equally to that of other stakeholders. Some indicated that facility or VISN leadership may not be oriented towards patient engagement and argued for a paradigm shift in the organizational culture of VA to consider patients as equal partners in outpatient care planning and design decision making. Similarly, panellists were concerned about physician/staff acceptance of patients as equal partners, citing ‘the level of cynicism directed towards patients'. Some experts argued that patients' input could be as influential as that of other stakeholders only if top leadership insisted on it and if providers and staff were exposed to a collaborative approach to making decisions.Likewise, experts expressed doubts about patients having a more influential voice than other stakeholders in outpatient care planning and design decisions. Indeed, this role received either uncertain or negative ratings on all criteria at the local and regional levels (see Table Discussion comments also provided further insight into the desirability and potential impact of engagement at the local vs. regional levels. As one expert explained, ‘patients may more readily provide input on ways to improve practices at the local level because they have a concrete point of reference that has immediate relevance to them; by contrast, asking for input at the VISN level may feel abstract and less compelling’. The rating data also revealed that three of the five desirable patient engagement scenarios described engagement at the local level. While participants felt that local‐level engagement is desirable, some commented that engagement at the regional level is likely to have a greater impact because ‘more systems are involved [at the VISN level] and [there are] greater implications for action or inaction’. Other experts defended the importance of local engagement, suggesting that engaging patients in local clinics is a building block for engagement at the regional level. ‘Local input is always important and can be channeled to VISN level’, said one expert. ‘Utilizing the local VSOs [Veteran Service Organizations] is always a win’, stated another. ‘This is truly LOCAL [sic] input affecting the LOCAL VHA [sic]. Do this in each VISN supervised hospital to gather consensus info for VISN level action. Win/win’. One strategy of bridging the local–regional divide suggested by experts was to ‘gather [patient] input at the source of care, but topics should include those that will impact VISN policy decisions’.Our project was designed to explore expert opinion about the desirability, feasibility, stakeholder acceptance and potential outcomes of different roles and levels of engaging VA patients in outpatient care design decision making. Our findings show that experts agreed that soliciting patient input as consultants on care planning and design decisions on an as‐needed basis, including through surveys, focus groups and advisory councils, is currently the most desirable approach to promoting patient influence on VA outpatient care. They also agreed that this approach is feasible, that patients have the interests and skills to contribute as consultants at the local level and that engaging patients this way will have a positive impact on patient‐centredness of VA care.Our finding about the overall perceived desirability of engaging patients as consultants is consistent with the findings of a recent study on public involvement in health‐care decision making, suggesting that the public generally favours the role of a consultant who provides input, but is not responsible for making the ultimate decision or its consequences.While deemed desirable, the role of a consultant at the local level received uncertain ratings on physician/staff acceptance and health‐care quality. Research conducted in other settings suggests that despite declaring their interest in patient satisfaction surveys, health‐care staff often do not sufficiently discuss survey results, which limits their use in practice and their potential impact on initiating organizational change.Experts also agreed that equal partnership between patients and providers at the local level is most likely to affect the level of patient‐centredness and quality of VA care. Although local equal partnerships did not receive the highest rating on the overall desirability criterion, the positive ratings this approach received on patient‐centredness and care quality suggest that building equal partnerships with patients might be an aspirational goal for VA and other health‐care systems in their attempts to improve patient care. This finding is consistent with a recent recommendation for designing patient engagement approaches that value and give equal weight to contributions of every stakeholder.Our results also illustrate a contradiction between perceived effectiveness and feasibility of more active patient engagement. Although participating experts generally felt that higher levels of engagement may be more effective, more engaged patient roles were considered to be less feasible. Experts’ uncertainty about the feasibility, patient willingness/interest and physician/staff acceptance of patients as equal stakeholders suggests that health‐care systems interested in patient engagement may need to build patients' capacity and educate physician/staff on how to work in partnership with patients. Recent experimental research on community representation also suggests that it is important to develop on‐going, collaborative and constructive relationships among patients and providers that can change providers’ attitudes towards patient engagement.In general, patient engagement at the local level received higher desirability and feasibility ratings than patient engagement at the regional level. This finding seems consistent with the result of a UK‐based study showing higher perceived value for engaging patients in practical, operational issues that are likely to generate results in the short term, compared to engaging them in larger‐scale strategic decision making.Experts’ ratings of patients as local consultants on all criteria were very similar to their ratings of patients as local implementation advisors. However, the latter was rated slightly less feasible and slightly more patient‐centred than the former. The endorsement of more than one patient engagement approach suggests that patients and health‐care systems can choose an approach that they are most comfortable withAlthough innovative and timely, this exploratory project has important limitations. First, as is typical for expert panels,Based on our interpretation of expert opinion collected in this panel, we suggest five lessons learned about patient engagement.Experts agreed that engaging patients as consultants and implementation advisors is relatively feasible, particularly at the local level, and highly desirable. Therefore, VA leaders may want to develop approaches for routinely soliciting patient input on care planning and design decisions.Engaging patients at the local level may be a crucial step towards broader engagement at the regional level because patients are better able to imagine the possible impact and see the actual outcomes of their engagement in their local facility.VA leaders may want to encourage equal partnerships between patients and providers in the process of making care planning and design decisions if the ultimate goal is to improve patient‐centredness and quality of VA care. However, doing so may currently not be feasible, in part because it may require substantial cultural change among physicians and staff.Building patient engagement capacity will require continued effort. Given the engagement barriers, it may be important to educate patients, providers and staff on the benefits of patient engagement; develop best practices and engagement toolkits; and learn how to reward engagement efforts.Health‐care systems may need to provide multiple engagement opportunities so that patients could choose the one that best fits their interests, skills and preferences.Table S1. IPR and IPRAS Values.Click here for additional data file.


Testosterone Replacement Therapy (TRT) was – during the last 7 to 8 decades - associated with triggering or worsening of a prostate cancer. A meta-analysis in 2005 of 19 randomized controlled trials showed no statistically significant difference in the diagnosis of prostate cancer in men using TRT or placebo  in symptomatic hypogonadal men with no impact in the oncologic outcomes. We conducted a Medline search to find publications on TRT after RP and we summarized what we have found in literature.Early in 2004, Kaufman and Graydon  reportedIn 2005, Agarwal and Oefelein  treated In 2008, Nabulsi et al.  reportedAlso in 2008, Davila et al.  reportedIn 2009, Khera et al.  presenteIn 2010, Isbarn et al.  reportedAlso in 2010, Sathyamoorthy et al.  presenteIn 2012, Matsushita et al.  reportedIn 2013, Pastuzak et al.  reviewedIn 2016, Ory et al.  reportedThe analysis of all these data raises two questions:Do we have good evidence to conclude that testosterone hormone therapy after radical prostatectomy is safe ?Is there any evidence that it is safe to initiate TRT one year after radical prostatectomy?These data are very reassuring that we can use TRT in selected men submitted to RP, since biochemical recurrence of prostate cancer is very low: only 1.19%! In the study with a control untreated group, the incidence of BCR was higher than in the treated group . It is aThe data also tell us that the time to initiate TRT after RP is very unpredictable among studies. We have series initiating TRT after 2.5, 3, 6, 12 and 24 months after TRT. But in the study that showed the higher incidence of biochemical recurrence, TRT was initiated 12.3 months after surgery!Some groups of experts and also some scientific societies have issued opinions on the subject:Buvat et al.  stated: Khera et al.  affirmedThe European Association of Urology (EAU) guidelines on Male Hypogonadism  says: “OKaplan et al.  said thahttp://clinicaltrials.gov/ct2/show/NCT00848497).There is a current Clinical Trial, randomized placebo controlled, FDA approved for TRT in hypogonadal men starting three months after radical prostatectomy: NCT00848497 (In conclusion: “Do we have enough evidences to safely treat a man with hypogonadism one year after radical prostatectomy for prostate cancer ?” YES !!This revision reassures us that selected hypogonadal symptomatic men after curative treatment for prostate cancer with radical prostatectomy can safely receive testosterone replacement therapy, since biochemical recurrence rate of the tumor is very low.“Do we have enough evidences to safely treat a man with hypogonadism one year after radical prostatectomy for prostate cancer ? YES !The data above showed us that it is also safe to offer TRT earlier – just three months after surgery ! And the inclusion criteria for the FDA approved Clinical Trial on TRT after RP is three months after surgery with two undetectable PSAs. So why one year after treatment would not be safe ?But we are at the moment – despite with very reassuring data – with still a small number of patients submitted to radical prostatectomy under TRT: longer follow-up studies and larger sample sizes are needed to stablish the real safety of TRT after RP and to also standardize the time after radical prostatectomy we should initiate TRT.But just a final personal input: if we consider that administration of testosterone to a symptomatic hypogonadal man with a history of treated prostate cancer to turn him into an eugonadal man would increase the risk of prostate cancer recurrence, why don’t we turn all our eugonadal post radical prostatectomy patients into an hypogonadal status in order to prevent an eventual prostate cancer progression ?


BML) is a very rare condition and is characterized by the presence of benign smooth muscle tumours in organs distant from the uterus, most commonly the lung. It generally affects women of reproductive age and prognostic is usually excellent. However, the course of the disease is unpredictable. We report here the case of a 76‐year‐old woman with a previous medical history of uterine benign leiomyomas in whom BML was acutely revealed by a respiratory distress due to voluminous pulmonary and pleural leiomyomas requiring surgical extraction. Clinical evolution was remarkable by resistance to medical treatment and development of rare bone localization.Benign metastasizing leiomyoma (BML is a contradictory entity characterized by benign histological features but with metastatic potential. Pulmonologists as well as oncologists in charge of patients with multiple pulmonary nodules and a history of uterine leiomyoma should be aware of this potential diagnosis in order to implement appropriate diagnostic procedures for this benign tumour. Benign metastasizing leiomyoma (BML), characterized by the presence of benign smooth muscle tumours in organs distant from the uterus, most commonly the lung, is a very rare condition (<200 cases reported in the literature). It generally affects women of reproductive age with a history of benign uterine leiomyoma resection We report here the case of a 76‐year‐old woman in whom BML was acutely revealed by a respiratory distress and whose evolutive pattern was remarkable by resistance to medical treatment and development of a rare bone BML localization.A 76‐year‐old woman was admitted in intensive care for acute respiratory distress. She complained of an increasing and isolated dyspnoea developed over the previous months. Her medical history included heavy smoking habits , ischaemic coronaropathy, and a total hysterectomy 4 years previously for postmenopausal metrorrhagia. It had revealed multiple subserosal uterine benign leiomyomas with no evidence of extrauterine involvement at that time.On admission, she was severely hypoxemic with a saturation of 91% when breathing 6 L/mn of oxygen. Chest X‐ray showed a right, unilateral massive pleural effusion associated with bilateral parenchymal nodules. Biology was unremarkable. A pleural chest tube was rapidly inserted disclosing an exudate (49 g/L of proteins) with 80% lymphocytes. Clinical improvement was dramatic and chest high‐resolution computed tomography (HRCT) confirmed the presence of bilateral, well‐defined lung nodules with one of them reaching 15 cm in diameter . Surgical biopsy is therefore the most frequent approach to histopathological confirmation of BML. Various immunohistochemical markers such as desmin, muscle‐specific actin, and caldesmon confirm smooth muscle differentiation. Presence of oestrogen and progesterone receptors suggests a female genital tract origin and a hormone‐dependent growth. The usually low expression of Ki 67 and absence of cytological atypia argues for their benign nature In several other aspects, our patient was quite atypical. First, her age was higher than usually reported in the literature. Second, clinical presentation was unusually acute due to a massive pleural effusion and large pleural and pulmonary nodules mimicking a metastatic lung cancer in this ex‐heavy smoker. Third, bone localization with lytic femoral BML lesion has to the best of our knowledge not been reported before.Treatment options for BML include surgical removal in the first place, potentially iterative in case of recurring symptomatic lung nodules BML is a contradictory entity characterized by benign histological features but a highly metastatic potential. Pneumologists as well as oncologists in charge of patients with multiple pulmonary nodules and a history of uterine leiomyoma should be aware of this potential diagnosis in order to implement appropriate diagnostic procedures for this benign tumour.No conflict of interest declared.Appropriate written informed consent was obtained for publication of this case report and accompanying images.