Enabling transdisciplinary research: Suggestions for avoiding `road-blocks' based on a case study

In this brief plain language report we introduce a novel diagrammatic way of thinking about interactions in transdisciplinary teams. This representation is designed to provoke debate about how teams which do not share a common world view can make progress, but not necessarily direct progress, towards common goals. We further identify a range of possible problems -- which we refer to as road-blocks -- which can limit progress and reduce the effectiveness of such projects. Finally we make short suggestions about how road-blocks might be lifted. The diagrammatic representation was developed as part of the plain language notes which were kept to document the progress of a work package -- part of the Blue-Action project -- dealing with Arctic Tourism. But the report draws on wider experience of transdisciplinary working in the team and attempts an easily readable summary of some aspects of how such projects do, and do not, work. We propose that interactions between members of a team that have little in common, with respect to experience and expertise, will rarely lead to outputs that meet the goals of the project unless supplementary activities first 'recast' their views towards a common frame of reference.

Hydraulic Characterization of the Full Scale Mock-Up of the DEMO Divertor Outer Vertical Target

In the frame of the pre-conceptual design activities of the DEMO work package DIV-1 “Divertor Cassette Design and Integration” of the EUROfusion program, a mock-up of the divertor outer vertical target (OVT) was built, mainly in order to: (i) demonstrate the technical feasibility of manufacturing procedures; (ii) verify the hydraulic design and its capability to ensure a uniform and proper cooling for the plasma facing units (PFUs) with an acceptable pressure drop; and (iii) experimentally validate the computational fluid-dynamic (CFD) model developed by the University of Palermo. In this context, a research campaign was jointly carried out by the University of Palermo and ENEA to experimentally and theoretically assess the hydraulic performances of the OVT mock-up, paying particular attention to the coolant distribution among the PFUs and the total pressure drop across the inlet and outlet sections of the mock-up. The paper presents the results of the steady-state hydraulic experimental test campaign performed at ENEA Brasimone Research Center as well as the relevant numerical analyses performed at the Department of Engineering at the University of Palermo. The test facility, the experimental apparatus, the test matrix and the experimental results, as well as the theoretical model, its assumptions, and the analyses outcomes are herewith reported and critically discussed.

Pain self-management interventions for community-based patients with advanced cancer: a research programme including the IMPACCT RCT

Background Each year in England and Wales, 150,000 people die from cancer, of whom 110,000 will suffer from cancer pain. Research highlights that cancer pain remains common, severe and undertreated, and may lead to hospital admissions. Objective To develop and evaluate pain self-management interventions for community-based patients with advanced cancer. Design A programme of mixed-methods intervention development work leading to a pragmatic multicentre randomised controlled trial of a multicomponent intervention for pain management compared with usual care, including an assessment of cost-effectiveness. Participants Patients, including those with metastatic solid cancer (histological, cytological or radiological evidence) and/or those receiving anti-cancer therapy with palliative intent, and health professionals involved in the delivery of community-based palliative care. Setting For the randomised controlled trial, patients were recruited from oncology outpatient clinics and were randomly allocated to intervention or control and followed up at home. Interventions The Supported Self-Management intervention comprised an educational component called Tackling Cancer Pain, and an eHealth component for routine pain assessment and monitoring called PainCheck. Main outcome measures The primary outcome was pain severity (measured using the Brief Pain Inventory). The secondary outcomes included pain interference (measured using the Brief Pain Inventory), participants’ pain knowledge and experience, and cost-effectiveness. We estimated costs and health-related quality-of-life outcomes using decision modelling and a separate within-trial economic analysis. We calculated incremental cost-effectiveness ratios per quality-adjusted life-year for the trial period. Results Work package 1 – We found barriers to and variation in the co-ordination of advanced cancer care by oncology and primary care professionals. We identified that the median time between referral to palliative care services and death for 42,758 patients in the UK was 48 days. We identified key components for self-management and developed and tested our Tackling Cancer Pain resource for acceptability. Work package 2 – Patients with advanced cancer and their health professionals recognised the benefits of an electronic system to monitor pain, but had reservations about how such a system might work in practice. We developed and tested a prototype PainCheck system. Work package 3 – We found that strong opioids were prescribed for 48% of patients in the last year of life at a median of 9 weeks before death. We delivered Medicines Use Reviews to patients, in which many medicines-related problems were identified. Work package 4 – A total of 161 oncology outpatients were randomised in our clinical trial, receiving either supported self-management (n = 80) or usual care (n = 81); their median survival from randomisation was 53 weeks. Primary and sensitivity analyses found no significant treatment differences for the primary outcome or for other secondary outcomes of pain severity or health-related quality of life. The literature-based decision modelling indicated that information and feedback interventions similar to the supported self-management intervention could be cost-effective. This model was not used to extrapolate the outcomes of the trial over a longer time horizon because the statistical analysis of the trial data found no difference between the trial arms in terms of the primary outcome measure (pain severity). The within-trial economic evaluation base-case analysis found that supported self-management reduced costs by £587 and yielded marginally higher quality-adjusted life-years (0.0018) than usual care. However, the difference in quality-adjusted life-years between the two trial arms was negligible and this was not in line with the decision model that had been developed. Our process evaluation found low fidelity of the interventions delivered by clinical professionals. Limitations In the randomised controlled trial, the low fidelity of the interventions and the challenge of the study design, which forced the usual-care arm to have earlier access to palliative care services, might explain the lack of observed benefit. Overall, 71% of participants returned outcome data at 6 or 12 weeks and so we used administrative data to estimate costs. Our decision model did not include the negative trial results from our randomised controlled trial and, therefore, may overestimate the likelihood of cost-effectiveness. Conclusions Our programme of research has revealed new insights into how patients with advanced cancer manage their pain and the challenges faced by health professionals in identifying those who need more help. Our clinical trial failed to show an added benefit of our interventions to enhance existing community palliative care support, although both the decision model and the economic evaluation of the trial indicated that supported self-management could result in lower health-care costs. Future work There is a need for further research to (1) understand and facilitate triggers that prompt earlier integration of palliative care and pain management within oncology services; (2) determine the optimal timing of technologies for self-management; and (3) examine prescriber and patient behaviour to achieve the earlier initiation and use of strong opioid treatment. Trial registration Current Controlled Trials ISRCTN18281271. Funding This project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 15. See the NIHR Journals Library website for further project information.

Conclusions and Policy Implications

The work presented in this volume is a compilation of research highlights that represent numerous studies carried out by researchers within the Energy Governance Work Package (WP4) of the Swiss Competence Center for Energy Research, Society and Transition (SCCER CREST). As our Introduction has illustrated in detail, these researchers worked together under common scientific interests in providing recommendations to overcome governance challenges in the course of the energy transition in Switzerland. Despite the variety of disciplines involved in this group, the conscious decision not to over-precise the shared notion of governance has successfully guided this challenging but fruitful four-year collaboration. These findings should help identify basic designs and structural principles of good energy governance, i.e., governance that is more effective, efficient, and transparent. The conclusion chapter summarizes these guiding principles and further challenges that emerged from our research in the context of Swiss energy governance.

Study protocol: evaluation of the addictive potential of e-cigarettes (EVAPE): neurobiological, sociological, and epidemiological perspectives

Background Tobacco use is the largest preventable cause of diseases and deaths; reducing tobacco intake is, therefore, an urgent public health goal. In recent years, e-cigarettes have been marketed as a 'healthier' alternative to tobacco smoking, whilst product features have evolved tremendously in the meantime. A lively scientific debate has developed regarding the potential benefits and risks of e-cigarettes although, surprisingly, there are few studies investigating the addictive potential of nicotine-containing e-cigarettes. The present work comprises three work packages investigating the addictive potential of e-cigarettes from different perspectives: (1) the neurobiological addictive potential of e-cigarettes; (2) the experience and perception of dependence symptoms among users of e-cigarettes in a social context; and (3) the epidemiological perspective regarding factors influencing the potential for dependence. Methods Work package I: the neurobiological study will investigate the key elements of addiction in e-cigarettes compared to tobacco cigarettes using neurobiological and neuropsychological correlates associated with craving, incentive motivation, cue reactivity and attentional bias. Work package II: the sociological study part examines self-reports on the experience and perception of dependence symptoms in a social context, using focus group interviews and the analysis of posts in online discussion forums on e-cigarettes. Work package III: the epidemiological study part focuses on tolerance development and the role of psychosocial and product factors by analyzing longitudinal data from the International Tobacco Control Policy Evaluation Project (ITC). Discussion The present study offers a chosen mix of three methodological approaches, thereby comprehensively examining core symptoms of positive and negative reinforcement in addiction. Whether e-cigarettes are as reinforcing and addictive as combustible tobacco cigarettes is an important public health issue with implications for prevention and treatment programs. Trial registration: Work package I: Registered at clinicaltrials.gov/ct2/show/NCT04772014. Work package II: Registered at OSF Registries: https://osf.io/dxgya (2021, January 14).

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration Current Controlled Trials ISRCTN15568163. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.

Enhanced Subcontractors Allocation for Apartment Construction Project Applying Conceptual 4D Digital Twin Framework

The problem of optimal allocation of resources in limited circumstances to handle assigned tasks has been dealt with in a wide variety of research fields. Various research methodologies have been proposed to address uncertainties such as waiting and waste in construction projects, but they do not take into account the complexity of construction production systems. In this study, a research approach was proposed that simplified the construction production system into a work package to be serviced and a work group to provide services. In addition, a conceptual 4D digital twin framework considering the uncertainty of the construction production system was proposed. This framework includes BIM as an information model and a queuing model as a decision-making model. Through case projects, we have presented how this framework can be used for decision making in several statuses. As a result of the analysis using the performance index of the queuing model, it was possible to monitor the status of the system according to the allocation of resources. In addition, it was possible to confirm the improvement of the performance index according to the additional arrangement of the work group and the activity cycle of the work package. The framework presented in this study helps to quantitatively analyze the state of the system according to the input data based on empirical knowledge, but it has a limitation in that it cannot present an optimized resource allocation solution. Therefore, in future research, it is necessary to consider the grafting of machine learning technology that can provide optimal solutions by solving complex decision-making problems.

Picking the crucial language technologies and how Wikipedia can help: the Welsh experience

When you're making plans to get people using your language as much and as often as possible, there's a list of things related to Wikipedia which can really help. I'll share our experience with the Welsh language. Supporting the Welsh-language Wikipedia community forms Work Package 15 of 27 in the Welsh Government's Welsh Language Technology Action Plan https://gov.wales/sites/default/files/publications/2018-12/welsh-language-technology-and-digital-media-action-plan.pdf. We like supporting Welsh language Wikipedia editing workshops, video workshops and other channels that encourage people to create and publish Welsh-language video, audio, graphic and text content because we're on a mission to try to help double daily use of Welsh by 2050. I'll share developments we're funding in speech, translation and conversational AI. The partners we're giving grants to publish what they develop under open licence. So we can share what we've funded with many companies. We think Microsoft might have used some to make their new synthetic voices in Welsh. We're excited by the potential Wikidata offers. We'll look at its potential in populating Welsh maps this year. We've already used Wikipedia search data as a way of prioritising the training of a Welsh virtual assistant. Welsh may not be spending as much as Icelandic and Estonian do on language technologies, but we'd like to share what we're learning as a smaller language about the important areas to focus on and how Wikipedia can help.

Acute day units in non-residential settings for people in mental health crisis: the AD-CARE mixed-methods study

Background For people in mental health crisis, acute day units provide daily structured sessions and peer support in non-residential settings as an alternative to crisis resolution teams. Objectives To investigate the provision, effectiveness, intervention acceptability and re-admission rates of acute day units. Design Work package 1 – mapping and national questionnaire survey of acute day units. Work package 2.1 – cohort study comparing outcomes during a 6-month period between acute day unit and crisis resolution team participants. Work package 2.2 – qualitative interviews with staff and service users of acute day units. Work package 3 – a cohort study within the Mental Health Minimum Data Set exploring re-admissions to acute care over 6 months. A patient and public involvement group supported the study throughout. Setting and participants Work package 1 – all non-residential acute day units (NHS and voluntary sector) in England. Work packages 2.1 and 2.2 – four NHS trusts with staff, service users and carers in acute day units and crisis resolution teams. Work package 3 – all individuals using mental health NHS trusts in England. Results Work package 1 – we identified 27 acute day units in 17 out of 58 trusts. Acute day units are typically available on weekdays from 10 a.m. to 4 p.m., providing a wide range of interventions and a multidisciplinary team, including clinicians, and having an average attendance of 5 weeks. Work package 2.1 – we recruited 744 participants (acute day units, n = 431; crisis resolution teams, n = 312). In the primary analysis, 21% of acute day unit participants (vs. 23% of crisis resolution team participants) were re-admitted to acute mental health services over 6 months. There was no statistically significant difference in the fully adjusted model (acute day unit hazard ratio 0.78, 95% confidence interval 0.54 to 1.14; p = 0.20), with highly heterogeneous results between trusts. Acute day unit participants had higher satisfaction and well-being scores and lower depression scores than crisis resolution team participants. The health economics analysis found no difference in resource use or cost between the acute day unit and crisis resolution team groups in the fully adjusted analysis. Work package 2.2 – 36 people were interviewed (acute day unit staff, n = 12; service users, n = 21; carers, n = 3). There was an overwhelming consensus that acute day units are highly valued. Service users found the high amount of contact time and staff continuity, peer support and structure provided by acute day units particularly beneficial. Staff also valued providing continuity, building strong therapeutic relationships and providing a variety of flexible, personalised support. Work package 3 – of 231,998 individuals discharged from acute care (crisis resolution team, acute day unit or inpatient ward), 21.4% were re-admitted for acute treatment within 6 months, with women, single people, people of mixed or black ethnicity, those living in more deprived areas and those in the severe psychosis care cluster being more likely to be re-admitted. Little variation in re-admissions was explained at the trust level, or between trusts with and trusts without acute day units (adjusted odds ratio 0.96, 95% confidence interval 0.80 to 1.15). Limitations In work package 1, some of the information is likely to be incomplete as a result of trusts’ self-reporting. There may have been recruitment bias in work packages 2.1 and 2.2. Part of the health economics analysis relied on clinical Health of the Nations Outcome Scale ratings. The Mental Health Minimum Data Set did not contain a variable identifying acute day units, and some covariates had a considerable number of missing data. Conclusions Acute day units are not provided routinely in the NHS but are highly valued by staff and service users, giving better outcomes in terms of satisfaction, well-being and depression than, and no significant differences in risk of re-admission or increased costs from, crisis resolution teams. Future work should investigate wider health and care system structures and the place of acute day units within them; the development of a model of best practice for acute day units; and staff turnover and well-being (including the impacts of these on care). Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 18. See the NIHR Journals Library website for further project information.