***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background : The provision of quality end-of-life care is increasingly on the national agenda in many countries . In the United Kingdom , the Gold St and ards Framework for Care Homes programme has been promoted as a national framework for improving end-of-life care . While its implementation is recommended , there are no national guidelines for facilitators to follow to undertake this role . Aim : It was hypothesised that action learning alongside high facilitation when implementing the Gold St and ards Framework for Care Homes programme will result in a reduced proportion of hospital deaths for residents and improvement in the care home staff ability to facilitate good end-of-life care . Design : A cluster r and omised controlled trial where 24 nursing homes received high facilitation to enable them to implement the Gold St and ards Framework for Care Homes programme . The managers of 12 nursing homes additionally took part in action learning sets . A third group ( 14 nursing homes ) received the ‘ st and ard ’ Gold St and ards Framework for Care Homes facilitation available in their locality . Setting / participants : In total , 38 nursing homes providing care for frail older people , their deceased residents and their nurse managers . Results : A greater proportion of residents died in those nursing homes receiving high facilitation and action learning but not significantly so . There was a significant association between the level of facilitation and nursing homes completing the Gold St and ards Framework for Care Homes programme through to accreditation . Year-on-year change occurred across all outcome measures . Conclusion : There is a danger that without national guidelines , facilitation of the Gold St and ards Framework for Care Homes programme will vary and consequently so will its implementation . The nurse manager of a care home must be actively engaged when implementing the Gold St and ards Framework for Care Homes programme Background Supporting 21st century health care and the practice of evidence -based medicine ( EBM ) requires ubiquitous access to clinical information and to knowledge-based re sources to answer clinical questions . Many questions go unanswered , however , due to lack of skills in formulating questions , crafting effective search strategies , and accessing data bases to identify best levels of evidence . Methods This r and omized trial was design ed as a pilot study to measure the relevancy of search results using three different interfaces for the PubMed search system . Two of the search interfaces utilized a specific framework called PICO , which was design ed to focus clinical questions and to prompt for publication type or type of question asked . The third interface was the st and ard PubMed interface readily available on the Web . Study subjects were recruited from interns and residents on an inpatient general medicine rotation at an academic medical center in the US . Thirty-one subjects were r and omized to one of the three interfaces , given 3 clinical questions , and asked to search PubMed for a set of relevant articles that would provide an answer for each question . The success of the search results was determined by a precision score , which compared the number of relevant or gold st and ard articles retrieved in a result set to the total number of articles retrieved in that set . Results Participants using the PICO templates ( Protocol A or Protocol B ) had higher precision scores for each question than the participants who used Protocol C , the st and ard PubMed Web interface . ( Question 1 : A = 35 % , B = 28 % , C = 20 % ; Question 2 : A = 5 % , B = 6 % , C = 4 % ; Question 3 : A = 1 % , B = 0 % , C = 0 % ) 95 % confidence intervals were calculated for the precision for each question using a lower boundary of zero . However , the 95 % confidence limits were overlapping , suggesting no statistical difference between the groups . Conclusion Due to the small number of search es for each arm , this pilot study could not demonstrate a statistically significant difference between the search protocol s. However there was a trend towards higher precision that needs to be investigated in a larger study to determine if PICO can improve the relevancy of search results Background The ' Hawthorne Effect ' may be an important factor affecting the generalisability of clinical research to routine practice , but has been little studied . Hawthorne Effects have been reported in previous clinical trials in dementia but to our knowledge , no attempt has been made to quantify them . Our aim was to compare minimal follow-up to intensive follow-up in participants in a placebo controlled trial of Ginkgo biloba for treating mild-moderate dementia . Methods Participants in a dementia trial were r and omised to intensive follow-up ( with comprehensive assessment visits at baseline and two , four and six months post r and omisation ) or minimal follow-up ( with an abbreviated assessment at baseline and a full assessment at six months ) . Our primary outcomes were cognitive functioning ( ADAS-Cog ) and participant and carer-rated quality of life ( QOL-AD ) . Results We recruited 176 participants , mainly through general practice s. The main analysis was based on Intention to treat ( ITT ) , with available data . In the ANCOVA model with baseline score as a co-variate , follow-up group had a significant effect on outcome at six months on the ADAS-Cog score ( n = 140 ; mean difference = -2.018 ; 95%CI -3.914 , -0.121 ; p = 0.037 favouring the intensive follow-up group ) , and on participant-rated quality of life score ( n = 142 ; mean difference = -1.382 ; 95%CI -2.642 , -0.122 ; p = 0.032 favouring minimal follow-up group ) . There was no significant difference on carer quality of life . Conclusion We found that more intensive follow-up of individuals in a placebo-controlled clinical trial of Ginkgo biloba for treating mild-moderate dementia result ed in a better outcome than minimal follow-up , as measured by their cognitive functioning . Trial registration Current controlled trials : IS RCT Objective To determine whether a systematic approach to the treatment of pain can reduce agitation in people with moderate to severe dementia living in nursing homes . Design Cluster r and omised controlled trial . Setting 60 clusters ( single independent nursing home units ) in 18 nursing homes within five municipalities of western Norway . Participants 352 residents with moderate to severe dementia and clinical ly significant behavioural disturbances r and omised to a stepwise protocol for the treatment of pain for eight weeks with additional follow-up four weeks after the end of treatment ( 33 clusters ; n=175 ) or to usual treatment ( control , 27 clusters ; n=177 ) . Intervention Participants in the intervention group received individual daily treatment of pain for eight weeks according to the stepwise protocol , with paracetamol ( acetaminophen ) , morphine , buprenorphine transdermal patch , or pregabaline . The control group received usual treatment and care . Main outcome measures Primary outcome measure was agitation ( scores on Cohen-Mansfield agitation inventory ) . Secondary outcome measures were aggression ( scores on neuropsychiatric inventory-nursing home version ) , pain ( scores on mobilisation-observation-behaviour-intensity-dementia-2 ) , activities of daily living , and cognition ( mini-mental state examination ) . Results Agitation was significantly reduced in the intervention group compared with control group after eight weeks ( repeated measures analysis of covariance adjusting for baseline score , P<0.001 ) : the average reduction in scores for agitation was 17 % ( treatment effect estimate −7.0 , 95 % confidence interval −3.7 to −10.3 ) . Treatment of pain was also significantly beneficial for the overall severity of neuropsychiatric symptoms ( −9.0 , −5.5 to −12.6 ) and pain ( −1.3 , −0.8 to −1.7 ) , but the groups did not differ significantly for activities of daily living or cognition . Conclusion A systematic approach to the management of pain significantly reduced agitation in residents of nursing homes with moderate to severe dementia . Effective management of pain can play an important part in the treatment of agitation and could reduce the number of unnecessary prescriptions for psychotropic drugs in this population . Trial registration Clinical Trials.gov NCT01021696 and Norwegian Medicines Agency EudraCTnr 2008 - 007490 - 20 Background : Despite being widely used , research into the effectiveness of the Liverpool Care of the Dying Pathway ( LCP ) and associated cases of mal practice does not match dissemination . No study exists focusing on concerns voiced by professionals . Aim : To explore the views of professionals who , during the hospital implementation of the Italian version of the Liverpool Care of the Dying Pathway ( LCP-I )  , voiced or showed concerns towards it . Design : A qualitative study nested within the LCP-I r and omized cluster trial , with semi-structured interviews analysed using thematic analysis . Setting and participants : Six nurses and five physicians from six out of the eight hospital wards who completed the LCP-I implementation were interviewed . Eligibility criteria were having taken part in all steps of the LCP-I Programme , voiced or somehow shown concerns , or failed to fully engage with the implementation process . Results : A total of 12 categories were identified , referring to four topics : the Implementation Programme , the LCP-I clinical documentation , the hospital environment and the educational and professional background of hospital healthcare staff . Issues raised by participants concerned both ‘ real ’ characteristics of the LCP-I and a misinterpretation of the LCP-I approach and clinical documentation . Furthermore , difficulties were reported which were not linked to the Programme but rather to end-of-life care . Conclusion : This study provides insights into the experience of professionals with negative opinions of or concerns with the LCP-I. A more comprehensive approach to professional training in palliative care is needed and may envisage the development of new interventions aim ed at improving the quality of care throughout the illness trajectory OBJECTIVES To investigate whether it is possible to determine signs of imminent dying and change in pain and symptom intensity during pharmacological treatment in nursing home patients , from day perceived as dying and to day of death . DESIGN Prospect i ve , longitudinal trajectory trial . SETTING Forty-seven nursing homes within 35 municipalities of Norway . PARTICIPANTS A total of 691 nursing home patients were followed during the first year after admission and 152 were assessed carefully in their last days of life . MEASUREMENTS Time between admission and day of death , and symptom severity by  Edmonton symptom assessment system ( ESAS ) ,  pain  ( mobilization-observation-behavior-intensity-dementia-2 ) , level of dementia ( clinical dementia rating scale ) , physical function ( Karnofsky performance scale ) , and activities of daily living ( physical self-maintenance scale ) . RESULTS Twenty-five percent died during the first year after admission . Increased fatigue ( logistic regression , odds ratio [ OR ] 1.8 , P = .009 ) and poor appetite ( OR 1.2 , P = .005 ) were significantly associated with being able to identify the day a person was imminently dying , which was possible in 61 % of the dying ( n = 82 ) . On that day , the administration of  opioids , midazolam , and anticholinergics  increased significantly ( P < .001 ) , and was associated with amelioration of symptoms , such as pain ( mixed-models linear regression , 60 % vs 46 % , P < .001 ) , anxiety ( 44 % vs 31 % , P < .001 ) , and depression ( 33 % vs 15 % , P < .001 ) . However , most symptoms were still prevalent at day of death , and moderate to severe dyspnea and death rattle increased from 44 % to 53 % ( P = .040 ) and 8 % to 19 % ( P < .001 ) , respectively . Respiratory symptoms were not associated with opioids or anticholinergics . CONCLUSION Pharmacological treatment ameliorated distressing symptoms in dying nursing home patients ; however , most symptoms , including pain and dyspnea , were still common at day of death . Results emphasize critical needs for better implementation of guidelines and staff education . TRIAL REGISTRATION Clinical Trials.govNCT01920100 Around half a million older people aged 65 or over live in care homes across the UK and substantial numbers end their lives in these care setting s. The Liverpool Care Pathway for the dying patient ( LCP ) was developed to transfer the hospice model of care into other care setting s. This paper describes a pilot project to introduce the LCP into care homes local to the Queen Mary 's Sidcup NHS Trust with a view to reducing the number of very ill elderly patients who are transferred to the acute trust from care homes and then die in BACKGROUND  Neuropsychiatric symptoms ( NPS ) are prevalent in nursing-home ( NH ) patients with dementia , but little is known about the long-term course of these symptoms . METHODS In this study , 931 NH patients with dementia took part in a prospect i ve cohort study with four assessment s over a 53-month follow-up period . NPS and level of dementia  were assessed with the  Neuropsychiatric Inventory scale and the Clinical Dementia Rating scale  , respectively . RESULTS Mild , moderate , and severe dementia was present in 25 % , 33 % , and 42 % , respectively . There was an increase in the severity of the dementia from the first to the fourth assessment . Agitation , irritability , disinhibition , and apathy were the most prevalent and persistent symptoms during the study period . The affective subsyndrome ( depression and anxiety ) became less severe , whereas the agitation subsyndrome ( agitation/aggression , disinhibition , and irritability ) and apathy increased in severity during the follow-up period . More severe dementia was associated with more severe agitation , psychosis , and apathy , but not more severe affective symptoms . Mild dementia was associated with an increase in the severity of psychosis , whereas moderate or severe dementia was associated with decreasing severity of psychosis over the follow-up period . CONCLUSION Nearly all the patients 
    Output:
    
Conclusion LCP has not been adapted to nursing home patients and people with dementia .