Symptoms, comorbidity, and clinical course of depression in immigrants: putting psychopathology in context.

PubMed

Saraga, Michael; Gholam-Rezaee, Mehdi; Preisig, Martin

2013-11-01

Migration is considered a depression risk factor when associated with psychosocial adversity, but its impact on depression's clinical characteristics has not been specifically studied. We compared 85 migrants to 34 controls, examining depression's severity, symptomatology, comorbidity profile and clinical course. A MINI interview modified to assess course characteristics was used to assign DSM-IV axis I diagnoses; medical files were used for Somatoform Disorders. Severity was assessed with the Montgomery-Asberg scale. Wherever possible, we adjusted comparisons for age and gender using logistic and linear regressions. Depression in migrants was characterized by higher comorbidity (mostly somatoform and anxiety disorders), higher severity, and a non-recurrent, chronic course. Our sample comes from a single center, and should be replicated in other health care facilities and other countries. Somatoform disorder diagnoses were solely based on file-content. Depression in migrants presented as a complex, chronic clinical picture. Most of our migrant patients experienced significant psychosocial adversity before and after migration: beyond cultural issues, our results suggest that psychosocial adversity impacts on the clinical expression of depression. Our study also suggests that migration associated with psychosocial adversity might play a specific etiological role, resulting in a distinct clinical picture, questioning the DSM-IV unitarian model of depression. The chronic course might indicate a resistance to standard therapeutic regimen and hints at the necessity of developing specific treatment strategies, adapted to the individual patients and their specific context. © 2013 The Authors. Published by Elsevier B.V. All rights reserved.

Contextual constraints for the design of patient-centered health IT tools.

PubMed

Gonzales, Michael J; O'Connor, Maria Francesca; Riek, Laurel D

2013-01-01

Technologists are constantly working to improve clinical practice by developing new health information technology (Health IT) tools, yet may not always consider the context of how these tools may be used. Patient preferences can vary widely as a result of demographics, health conditions, physical limitations, and personal inclinations, with healthcare providers having to adapt clinical encounters to better suit patient needs. Health IT tools, too, need to be agile across different healthcare contexts, with each stakeholder's specific needs in mind. In this paper, we discuss the challenges and limitations associated with the design and automation of contextually sensitive devices in the healthcare environment. We target the various contexts in which health information is presented in patient-provider encounters, and discuss contextual constraints that may apply to the aforementioned situations. In addition, we present a number of suggestions for informational constraints and the design of informational tools in these settings so that patient and provider informational needs can be better met in clinical communication contexts.

Integrating clinical research with the Healthcare Enterprise: from the RE-USE project to the EHR4CR platform.

PubMed

El Fadly, AbdenNaji; Rance, Bastien; Lucas, Noël; Mead, Charles; Chatellier, Gilles; Lastic, Pierre-Yves; Jaulent, Marie-Christine; Daniel, Christel

2011-12-01

There are different approaches for repurposing clinical data collected in the Electronic Healthcare Record (EHR) for use in clinical research. Semantic integration of "siloed" applications across domain boundaries is the raison d'être of the standards-based profiles developed by the Integrating the Healthcare Enterprise (IHE) initiative - an initiative by healthcare professionals and industry promoting the coordinated use of established standards such as DICOM and HL7 to address specific clinical needs in support of optimal patient care. In particular, the combination of two IHE profiles - the integration profile "Retrieve Form for Data Capture" (RFD), and the IHE content profile "Clinical Research Document" (CRD) - offers a straightforward approach to repurposing EHR data by enabling the pre-population of the case report forms (eCRF) used for clinical research data capture by Clinical Data Management Systems (CDMS) with previously collected EHR data. Implement an alternative solution of the RFD-CRD integration profile centered around two approaches: (i) Use of the EHR as the single-source data-entry and persistence point in order to ensure that all the clinical data for a given patient could be found in a single source irrespective of the data collection context, i.e. patient care or clinical research; and (ii) Maximize the automatic pre-population process through the use of a semantic interoperability services that identify duplicate or semantically-equivalent eCRF/EHR data elements as they were collected in the EHR context. The RE-USE architecture and associated profiles are focused on defining a set of scalable, standards-based, IHE-compliant profiles that can enable single-source data collection/entry and cross-system data reuse through semantic integration. Specifically, data reuse is realized through the semantic mapping of data collection fields in electronic Case Report Forms (eCRFs) to data elements previously defined as part of patient care-centric templates in the EHR context. The approach was evaluated in the context of a multi-center clinical trial conducted in a large, multi-disciplinary hospital with an installed EHR. Data elements of seven eCRFs used in a multi-center clinical trial were mapped to data elements of patient care-centric templates in use in the EHR at the George Pompidou hospital. 13.4% of the data elements of the eCRFs were found to be represented in EHR templates and were therefore candidate for pre-population. During the execution phase of the clinical study, the semantic mapping architecture enabled data persisted in the EHR context as part of clinical care to be used to pre-populate eCRFS for use without secondary data entry. To ensure that the pre-populated data is viable for use in the clinical research context, all pre-populated eCRF data needs to be first approved by a trial investigator prior to being persisted in a research data store within a CDMS. Single-source data entry in the clinical care context for use in the clinical research context - a process enabled through the use of the EHR as single point of data entry, can - if demonstrated to be a viable strategy - not only significantly reduce data collection efforts while simultaneously increasing data collection accuracy secondary to elimination of transcription or double-entry errors between the two contexts but also ensure that all the clinical data for a given patient, irrespective of the data collection context, are available in the EHR for decision support and treatment planning. The RE-USE approach used mapping algorithms to identify semantic coherence between clinical care and clinical research data elements and pre-populate eCRFs. The RE-USE project utilized SNOMED International v.3.5 as its "pivot reference terminology" to support EHR-to-eCRF mapping, a decision that likely enhanced the "recall" of the mapping algorithms. The RE-USE results demonstrate the difficult challenges involved in semantic integration between the clinical care and clinical research contexts. Copyright © 2011 Elsevier Inc. All rights reserved.

Strategies for medical data extraction and presentation part 2: creating a customizable context and user-specific patient reference database.

PubMed

Reiner, Bruce

2015-06-01

One of the greatest challenges facing healthcare professionals is the ability to directly and efficiently access relevant data from the patient's healthcare record at the point of care; specific to both the context of the task being performed and the specific needs and preferences of the individual end-user. In radiology practice, the relative inefficiency of imaging data organization and manual workflow requirements serves as an impediment to historical imaging data review. At the same time, clinical data retrieval is even more problematic due to the quality and quantity of data recorded at the time of order entry, along with the relative lack of information system integration. One approach to address these data deficiencies is to create a multi-disciplinary patient referenceable database which consists of high-priority, actionable data within the cumulative patient healthcare record; in which predefined criteria are used to categorize and classify imaging and clinical data in accordance with anatomy, technology, pathology, and time. The population of this referenceable database can be performed through a combination of manual and automated methods, with an additional step of data verification introduced for data quality control. Once created, these referenceable databases can be filtered at the point of care to provide context and user-specific data specific to the task being performed and individual end-user requirements.

Clinico-Histologic Conferences: Histology and Disease

ERIC Educational Resources Information Center

Shaw, Phyllis A.; Friedman, Erica S.

2012-01-01

Providing a context for learning information and requiring learners to teach specific content has been demonstrated to enhance knowledge retention. To enhance students' appreciation of the role of science and specifically histology in clinical reasoning, disease diagnosis, and treatment, a new teaching format was created to provide clinical…

Impact of Facilitated Asynchronous Distance Education on Clinical Skills Development of International Pharmacy Graduates

ERIC Educational Resources Information Center

Austin, Zubin; Dean, Marie Rocchi

2006-01-01

The use of distance education for clinical skills development in the health professions has not been extensively described, due in part to the intensive nature of the relationship between the patient and practitioner. In the context of pharmacy practice, there are specific needs to develop new vehicles for clinical skills education due to growing…

Education in the workplace for the physician: clinical management states as an organizing framework.

PubMed

Greenes, R A

2000-01-01

Medical educators are interested in approaches to making selected relevant knowledge available in the context of problem-based care. This is of value both during the process of care and as a means of organizing information for offline self-study. Four trends in health information technology are relevant to achieving the goal and can be expected to play a growing role in the future. First, health care enterprises are developing approaches for access to information resources related to the care of a patient, including clinical data and images but also communication tools, referral and other logistic tools, decision support, and educational materials. Second, information for patients and methods for patient-doctor interaction and decision making are becoming available. Third, computer-based methods for representation of practice guidelines are being developed to support applications that can incorporate their logic. Finally, considering patients as being in particular "clinical management states" (or CMSs) for specific problems, approaches are being developed to use guidelines as a kind of "predictive" framework to enable development of interfaces for problem-based clinical encounters. The guidelines for a CMS can be used to identify the kinds of resources specifically needed for clinical encounters of that type. As the above trends converge to produce problem-specific environments, professional specialty organizations and continuing medical education course designers will need to focus energies on organizing and updating medical knowledge to make it available in CMS-specific contexts.

Mental Illness and Firearms: Legal Context and Clinical Approaches.

PubMed

Pinals, Debra A; Anacker, Lisa

2016-12-01

Gun violence and mental illness is a major area of media attention, especially because highly publicized mass shootings seem to have become more commonly reported in the press. Gun access also is undergoing a highly politicized debate in the United States. It is important for mental health practitioners to understand the background and context of laws related to firearms access, and to understand data related to risk of suicide and violence toward others caused by gun violence among persons with mental illness. In addition, clinically driven risk assessments with specific inquiry related to firearms can be important for identifying individuals for whom firearm-focused clinical risk mitigation may be warranted. Copyright © 2016 Elsevier Inc. All rights reserved.

Validation of the Quantitative Diagnostic Thinking Inventory for Athletic Training: A Pilot Study

ERIC Educational Resources Information Center

Kicklighter, Taz; Barnum, Mary; Geisler, Paul R.; Martin, Malissa

2016-01-01

Context: The cognitive process of making a clinical decision lies somewhere on a continuum between novices using hypothetico-deductive reasoning and experts relying more on case pattern recognition. Although several methods exist for measuring facets of clinical reasoning in specific situations, none have been experimentally applied, as of yet, to…

Practice innovation: the need for nimble data platforms to implement precision oncology care.

PubMed

Elfiky, Aymen; Zhang, Dongyang; Krishnan Nair, Hari K

2015-01-01

Given the drive toward personalized, value-based, and coordinated cancer care delivery, modern knowledge-based practice is being shaped within the context of an increasingly technology-driven healthcare landscape. The ultimate promise of 'precision medicine' is predicated on taking advantage of the range of new capabilities for integrating disease- and individual-specific data to define new taxonomies as part of a systems-based knowledge network. Specifically, with cancer being a constantly evolving complex disease process, proper care of an individual will require the ability to seamlessly integrate multi-dimensional 'omic' and clinical data. Importantly, however, the challenges of curating knowledge from multiple dynamic data sources and translating to practice at the point-of-care highlight parallel needs. As patients, caregivers, and their environments become more proactive in clinical care and management, practical success of precision medicine is equally dependent on the development of proper infrastructures for evolving data integration, platforms for knowledge representation in a clinically-relevant context, and implementation within a provider's work-life and workflow.

Effects of exposure in single and multiple contexts on fear renewal: The moderating role of threat-specific and nonspecific emotionality.

PubMed

Olatunji, Bunmi O; Tomarken, Andrew; Wentworth, Brian; Fritzsche, Laura

2017-03-01

The current study examines effects of exposure in multiple contexts on fear reduction and renewal and the moderating effect of baseline threat-specific and nonspecific emotionality. Snake-fearful participants received a negative or neutral emotion induction and were randomized to video exposure to a snake in a single context, multiple context, or a no exposure control group. Anxiety in response to video presentations of a snake was significantly reduced in the two exposure groups compared to the control group, especially among those with heightened baseline threat-specific emotionality as indicated by snake anxiety ratings at baseline. Although the two exposure groups did not differ in responding when confronted with a novel snake, both exposure groups reported significantly lower snake anxiety and arousal than the control group. Subsequent analysis did show that compared to controls, the single context group demonstrated greater increase in anxiety and arousal from post-exposure to exposure to the novel snake among those with heightened snake anxiety at baseline. Furthermore, the multiple context group was less avoidant and less fearful than the single context group on a post-exposure behavioral test. The study used an analogue exposure paradigm with an analogue sample and findings may not be generalizable to a clinical population. These findings suggest that baseline threat-specific emotionality influences fear reduction and renewal. The benefits of exposure in multiple contexts are discussed in relation to a distinct pattern of symptom change that is in line with an inhibitory learning approach. Copyright © 2016 Elsevier Ltd. All rights reserved.

Tissue-specific tumorigenesis – Context matters

PubMed Central

Schneider, Günter; Schmidt-Supprian, Marc; Rad, Roland; Saur, Dieter

2018-01-01

Preface How can we treat cancer more effectively? Traditionally, tumours from the same anatomical site are treated as one tumour entity. This concept has been challenged by recent breakthroughs in cancer genomics and translational research enabling molecular tumour profiling. The identification and validation of cancer drivers, which are shared between different tumour types, spurred the new paradigm to target driver pathways across anatomical sites by off-label drug use, or within so called “basket or umbrella trials”, which are designed to test whether molecular alterations in one tumour entity can be extrapolated to all others. However, recent clinical and preclinical studies suggest that there are tissue- and cell type-specific differences in tumourigenesis and the organization of oncogenic signalling pathways. In this Opinion article, we focus on the molecular, cellular, systemic and environmental determinants of organ-specific tumourigenesis and mechanisms of context-specific oncogenic signalling outputs. Investigation, recognition and in-depth biological understanding of these differences will be vital for the design of next-generation clinical trials and the implementation of molecularly-guided cancer therapies in the future. PMID:28256574

Mothers' autobiographical memory and book narratives with children with specific language impairment.

PubMed

Tompkins, Virginia; Farrar, M Jeffrey

2011-01-01

This study examined the role that mothers' scaffolding plays in the autobiographical memory (AM) and storybook narratives of children with specific language impairment (SLI). Seven 4-5-year-old children and their mothers co-constructed narratives in both contexts. We also compared children's narratives with mothers to their narratives with an experimenter. Narratives were assessed in terms of narrative style (i.e., elaborativeness) and topic control. Mothers' elaborative and repetitive questions during AM and book narratives were related to children's elaborations, whereas mothers' elaborative and repetitive statements were not. Mothers produced more topic-controlling utterances than children in both contexts; however, both mothers and children provided proportionally more information in the book context. Additionally, children were more elaborative with mothers compared to an experimenter. Readers will be able to: (1) understand the importance of mother-child narratives for both typical and clinical populations; (2) understand how mother-child autobiographical memory and storybook narratives may differ between typical and clinical populations; and (3) consider the implications for designing narrative intervention studies for language impaired children. Copyright © 2010 Elsevier Inc. All rights reserved.

Nursing knowledge: hints from the placebo effect.

PubMed

Zanotti, Renzo; Chiffi, Daniele

2017-07-01

Nursing knowledge stems from a dynamic interplay between population-based scientific knowledge (the general) and specific clinical cases (the particular). We compared the 'cascade model of knowledge translation', also known as 'classical biomedical model' in clinical practice (in which knowledge gained at population level may be applied directly to a specific clinical context), with an emergentist model of knowledge translation. The structure and dynamics of nursing knowledge are outlined, adopting the distinction between epistemic and non-epistemic values. Then, a (moderately) emergentist approach to nursing knowledge is proposed, based on the assumption of a two-way flow from the general to the particular and vice versa. The case of the 'placebo effect' is analysed as an example of emergentist knowledge. The placebo effect is usually considered difficult to be explained within the classical biomedical model, and we underscore its importance in shaping nursing knowledge. In fact, nurses are primarily responsible for administering placebo in the clinical setting and have an essential role in promoting the placebo effect and reducing the nocebo effect. The beliefs responsible for the placebo effect are as follows: (1) interactive, because they depend on the relationship between patients and health care professionals; (2) situated, because they occur in a given clinical context related to certain rituals; and (3) grounded on higher order beliefs concerning what an individual thinks about the beliefs of others. It is essential to know the clinical context and to understand other people's beliefs to make sense of the placebo effect. The placebo effect only works when the (higher order) beliefs of doctors, nurses and patients interact in a given setting. Finally, we argue for a close relationship between placebo effect and nursing knowledge. © 2016 John Wiley & Sons Ltd.

The sweet spot of clinical intuitions: Predictors of the effects of context on impressions of conduct disorder symptoms.

PubMed

Marsh, Jessecae K; Burke, Christopher T; De Los Reyes, Andres

2016-02-01

How people interpret a mental disorder symptom has been shown to depend on the contextual life factors surrounding its presentation. Specifically, people are more likely to judge a symptom as clinically relevant if that symptom presents in a high-risk environment (e.g., child associates with deviant peers) relative to a low-risk environment (e.g., child associates with normative peer group). Importantly, not all symptoms are influenced by context to the same extent, and there is low agreement across people as to how this influence manifests. In this paper, we explore what factors predict the extent to which clinicians and laypeople interpret mental disorder symptoms as a function of diagnosis-congruent versus incongruent contextual information. We tested the impact of 2 statistical factors (prevalence and diagnosticity) and 2 more intuitive factors (diagnostic importance and abnormality) on the degree to which a symptom is interpreted differently in different contexts. Clinicians' impressions of the diagnosticity and importance of a symptom evidenced a curvilinear relationship with the use of context, with extremely important and unimportant as well as extremely diagnostic and nondiagnostic symptoms being less influenced by context. Laypeople showed a similar curvilinear relation between diagnosticity judgments and context effects. Additionally, clinicians showed a linear relationship between abnormality judgments and context use, with extremely abnormal symptoms being influenced less by context, whereas laypeople showed a curvilinear relationship between symptom abnormality and context use, with extremely abnormal and normal symptoms being influenced the most by context. We discuss implications of these findings for clinical diagnosis. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Essentials of photometry for clinical electrophysiology of vision.

PubMed

McCulloch, Daphne L; Hamilton, Ruth

2010-08-01

Electrophysiological testing of the visual system requires familiarity with photometry. This technical note outlines the concepts of photometry with a focus on information relevant to clinical ERG and VEP testing. Topics include photometric quantities, consideration of pupil size, specification of brief extended flash stimuli, and the influence of the spectral composition of visual stimuli. Standard units and terms are explained in the context of the ISCEV standards and guidelines for clinical electrophysiology of vision.

Consequences of contextual factors on clinical reasoning in resident physicians.

PubMed

McBee, Elexis; Ratcliffe, Temple; Picho, Katherine; Artino, Anthony R; Schuwirth, Lambert; Kelly, William; Masel, Jennifer; van der Vleuten, Cees; Durning, Steven J

2015-12-01

Context specificity and the impact that contextual factors have on the complex process of clinical reasoning is poorly understood. Using situated cognition as the theoretical framework, our aim was to evaluate the verbalized clinical reasoning processes of resident physicians in order to describe what impact the presence of contextual factors have on their clinical reasoning. Participants viewed three video recorded clinical encounters portraying straightforward diagnoses in internal medicine with select patient contextual factors modified. After watching each video recording, participants completed a think-aloud protocol. Transcripts from the think-aloud protocols were analyzed using a constant comparative approach. After iterative coding, utterances were analyzed for emergent themes with utterances grouped into categories, themes and subthemes. Ten residents participated in the study with saturation reached during analysis. Participants universally acknowledged the presence of contextual factors in the video recordings. Four categories emerged as a consequence of the contextual factors: (1) emotional reactions (2) behavioral inferences (3) optimizing the doctor patient relationship and (4) difficulty with closure of the clinical encounter. The presence of contextual factors may impact clinical reasoning performance in resident physicians. When confronted with the presence of contextual factors in a clinical scenario, residents experienced difficulty with closure of the encounter, exhibited as diagnostic uncertainty. This finding raises important questions about the relationship between contextual factors and clinical reasoning activities and how this relationship might influence the cost effectiveness of care. This study also provides insight into how the phenomena of context specificity may be explained using situated cognition theory.

The Swedish strategy and method for development of a national healthcare information architecture.

PubMed

Rosenälv, Jessica; Lundell, Karl-Henrik

2012-01-01

"We need a precise framework of regulations in order to maintain appropriate and structured health care documentation that ensures that the information maintains a sufficient level of quality to be used in treatment, in research and by the actual patient. The users shall be aided by clearly and uniformly defined terms and concepts, and there should be an information structure that clarifies what to document and how to make the information more useful. Most of all, we need to standardize the information, not just the technical systems." (eHälsa - nytta och näring, Riksdag report 2011/12:RFR5, p. 37). In 2010, the Swedish Government adopted the National e-Health - the national strategy for accessible and secure information in healthcare. The strategy is a revision and extension of the previous strategy from 2006, which was used as input for the most recent efforts to develop a national information structure utilizing business-oriented generic models. A national decision on healthcare informatics standards was made by the Swedish County Councils, which decided to follow and use EN/ISO 13606 as a standard for the development of a universally applicable information structure, including archetypes and templates. The overall aim of the Swedish strategy for development of National Healthcare Information Architecture is to achieve high level semantic interoperability for clinical content and clinical contexts. High level semantic interoperability requires consistently structured clinical data and other types of data with coherent traceability to be mapped to reference clinical models. Archetypes that are formal definitions of the clinical and demographic concepts and some administrative data were developed. Each archetype describes the information structure and content of overarching core clinical concepts. Information that is defined in archetypes should be used for different purposes. Generic clinical process model was made concrete and analyzed. For each decision-making step in the process where information is processed, the amount and type of information and its structure were defined in terms of reference templates. Reference templates manage clinical, administrative and demographic types of information in a specific clinical context. Based on a survey of clinical processes at the reference level, the identification of specific clinical processes such as diabetes and congestive heart failure in adults were made. Process-specific templates were defined by using reference templates and populated with information that was relevant to each health problem in a specific clinical context. Throughout this process, medical data for knowledge management were collected for each health problem. Parallel with the efforts to define archetypes and templates, terminology binding work is on-going. Different strategies are used depending on the terminology binding level.

At-risk studies and clinical antecedents of psychosis, bipolar disorder and depression: a scoping review in the context of clinical staging.

PubMed

Hartmann, Jessica A; Nelson, Barnaby; Ratheesh, Aswin; Treen, Devi; McGorry, Patrick D

2018-06-04

Identifying young people at risk of developing serious mental illness and identifying predictors of onset of illness has been a focus of psychiatric prediction research, particularly in the field of psychosis. Work in this area has facilitated the adoption of the clinical staging model of early clinical phenotypes, ranging from at-risk mental states to chronic and severe mental illness. It has been a topic of debate if these staging models should be conceptualised as disorder-specific or transdiagnostic. In order to inform this debate and facilitate cross-diagnostic discourse, the present scoping review provides a broad overview of the body of literature of (a) longitudinal at-risk approaches and (b) identified antecedents of (homotypic) illness progression across three major mental disorders [psychosis, bipolar disorder (BD) and depression], and places these in the context of clinical staging. Stage 0 at-risk conceptualisations (i.e. familial high-risk approaches) were identified in all three disorders. However, formalised stage 1b conceptualisations (i.e. ultra-high-risk approaches) were only present in psychosis and marginally in BD. The presence of non-specific and overlapping antecedents in the three disorders may support a general staging model, at least in the early stages of severe psychotic or mood disorders.

Community-based medical education: is success a result of meaningful personal learning experiences?

PubMed

Kelly, Len; Walters, Lucie; Rosenthal, David

2014-01-01

Community-based medical education (CBME) is the delivery of medical education in a specific social context. Learners become a part of social and medical communities where their learning occurs. Longitudinal integrated clerkships (LICs) are year-long community-based placements where the curriculum and clinical experience is typically delivered by primary care physicians. These programs have proven to be robust learning environments, where learners develop strong communication skills and excellent clinical reasoning. To date, no learning model has been offered to describe CBME. The characteristics of CBME are explored by the authors who suggest that the social and professional context provided in small communities enhances medical education. The authors postulate that meaningfulness is engendered by the authentic context, which develops over time. These relationships with preceptors, patients and the community provide meaningfulness, which in turn enhances learning. The authors develop a novel learning model. They propose that the context-rich environment of CBME allows for meaningful relationships and experiences for students and that such meaningfulness enhances learning.

Understanding business intelligence in the context of healthcare.

PubMed

Mettler, Tobias; Vimarlund, Vivian

2009-09-01

In today's fast changing healthcare sector, decision makers are facing a growing demand for both clinical and administrative information in order to comply with legal and customer-specific requirements. The use of business intelligence (BI) is seen as a possible solution to this actual challenge. As the existing research about BI is primarily focused on the industrial sector, it is the aim of this contribution to translate and adapt the current findings for the healthcare context. For this purpose, different definitions of BI are examined and condensed in a framework. Furthermore, the sector-specific preconditions for the effective use and future role of BI are discussed.

Contextualisation of patient-centred care: A comparative qualitative study of healthcare professionals' approaches to communicating with seriously ill patients about their dependent children.

PubMed

Dencker, A; Kristiansen, M; Rix, B A; Bøge, P; Tjørnhøj-Thomsen, T

2018-01-01

Patients' family relations play an important part in the provision of patient-centred cancer care, not least when healthcare professionals encounter seriously ill patients with dependent children. Little is known about how children are perceived and dealt with in clinical encounters. In this qualitative comparative study, we explore the influence of medical contexts in three Danish hospital wards, haematology, oncological gynaecology and neuro-intensive care, on communication with patients about their children. In exploring the degree to which the inclusion of children in clinical encounters is dependent on context, we took a comparative approach based on fieldwork in wards either exclusively focusing on cancer treatment or partially involved in critical phases of cancer treatment. We conducted 49 semi-structured, in-depth interviews with doctors and nurses, and 27 days of participant observation. The thematic analysis was based on Bateson's conceptualisation of communication. We found that healthcare professionals' approach to children in clinical encounters and the ways in which children were positioned on each ward were influenced by aspects specific to the ward, including the diagnosis and treatments that related specifically to the patient. Our findings suggest the need to explore further the influence of medical contexts on the inclusion of children in patient communication. © 2017 John Wiley & Sons Ltd.

Approaches for Establishing Clinically Relevant Dissolution Specifications for Immediate Release Solid Oral Dosage Forms.

PubMed

Hermans, Andre; Abend, Andreas M; Kesisoglou, Filippos; Flanagan, Talia; Cohen, Michael J; Diaz, Dorys A; Mao, Y; Zhang, Limin; Webster, Gregory K; Lin, Yiqing; Hahn, David A; Coutant, Carrie A; Grady, Haiyan

2017-11-01

This manuscript represents the perspective of the Dissolution Analytical Working Group of the IQ Consortium. The intent of this manuscript is to highlight the challenges of, and to provide a recommendation on, the development of clinically relevant dissolution specifications (CRS) for immediate release (IR) solid oral dosage forms. A roadmap toward the development of CRS for IR products containing active ingredients with a non-narrow therapeutic window is discussed, within the context of mechanistic dissolution understanding, supported by in-human pharmacokinetic (PK) data. Two case studies present potential outcomes of following the CRS roadmap and setting dissolution specifications. These cases reveal some benefits and challenges of pursuing CRS with additional PK data, in light of current regulatory positions, including that of the US Food and Drug Administration (FDA), who generally favor this approach, but with the understanding that both industry and regulatory agency perspectives are still evolving in this relatively new field. The CRS roadmap discussed in this manuscript also describes a way to develop clinically relevant dissolution specifications based primarily on dissolution data for batches used in pivotal clinical studies, acknowledging that not all IR product development efforts need to be supported by additional PK studies, albeit with the associated risk of potentially unnecessarily tight manufacturing controls. Recommendations are provided on what stages during the life cycle investment into in vivo studies may be valuable. Finally, the opportunities for CRS within the context of post-approval changes, Modeling and Simulation (M&S), and the application of biowaivers, are briefly discussed.

A pragmatic analysis of vulnerability in clinical research.

PubMed

Wendler, David

2017-09-01

Identifying which subjects are vulnerable, and implementing safeguards to protect them, is widely regarded as essential to clinical research. Commentators have endorsed a number of responses to these challenges and have thereby made significant progress in understanding vulnerability in clinical research. At the same time, this literature points to a central contradiction which calls into question its potential to protect vulnerable subjects in practice. Specifically, analysis suggests that all human subjects are vulnerable and vulnerability in clinical research is comparative and context dependent, in the sense that individuals are vulnerable relative to others and in some contexts only. Yet, if everyone is vulnerable, there seems to be no point in citing the vulnerability of some individuals. Moreover, the conclusion that everyone is vulnerable seems inconsistent with the claims that vulnerability is comparative and context dependent, raising concern over whether it will be possible to develop a comprehensive account of vulnerability that is internally consistent. The solution to this dilemma lies in recognition of the fact that the practical significance of claims regarding vulnerability depends on the context in which they are used. The claims that appear to lead to the central contradiction are in fact accurate conclusions that follow from different uses of the term 'vulnerability'. The present manuscript describes this 'pragmatic' approach to vulnerability in clinical research and considers its implications for ensuring that subjects receive appropriate protection. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

Implementation of HIV and Tuberculosis Diagnostics: The Importance of Context

PubMed Central

Dominique, Joyelle K.; Ortiz-Osorno, Alberto A.; Fitzgibbon, Joseph; Gnanashanmugam, Devasena; Gilpin, Christopher; Tucker, Timothy; Peel, Sheila; Peter, Trevor; Kim, Peter; Smith, Steven

2015-01-01

Background. Novel diagnostics have been widely applied across human immunodeficiency virus (HIV) and tuberculosis prevention and treatment programs. To achieve the greatest impact, HIV and tuberculosis diagnostic programs must carefully plan and implement within the context of a specific healthcare system and the laboratory capacity. Methods. A workshop was convened in Cape Town in September 2014. Participants included experts from laboratory and clinical practices, officials from ministries of health, and representatives from industry. Results. The article summarizes best practices, challenges, and lessons learned from implementation experiences across sub-Saharan Africa for (1) building laboratory programs within the context of a healthcare system; (2) utilizing experience of clinicians and healthcare partners in planning and implementing the right diagnostic; and (3) evaluating the effects of new diagnostics on the healthcare system and on patient health outcomes. Conclusions. The successful implementation of HIV and tuberculosis diagnostics in resource-limited settings relies on careful consideration of each specific context. PMID:26409272

Interprofessional supervision in an intercultural context: a qualitative study.

PubMed

Chipchase, Lucy; Allen, Shelley; Eley, Diann; McAllister, Lindy; Strong, Jenny

2012-11-01

Our understanding of the qualities and value of clinical supervision is based on uniprofessional clinical education models. There is little research regarding the role and qualities needed in the supervisor role for supporting interprofessional placements. This paper reports the views and perceptions of medical and allied heath students and supervisors on the characteristics of clinical supervision in an interprofessional, international context. A qualitative case study was used involving semi-structured interviews of eight health professional students and four clinical supervisors before and after an interprofessional, international clinical placement. Our findings suggest that supervision from educators whose profession differs from that of the students can be a beneficial and rewarding experience leading to the use of alternative learning strategies. Although all participants valued interprofessional supervision, there was agreement that profession-specific supervision was required throughout the placement. Further research is required to understand this view as interprofessional education aims to prepare graduates for collaborative practice where they may work in teams supervised by staff whose profession may differ from their own.

Current status of psychology and clinical psychology in India - an appraisal.

PubMed

Virudhagirinathan, Baboo Sankar; Karunanidhi, Subbiah

2014-10-01

This paper provides an overview of the social and cultural context for the emergence and development of psychology in India and also more specifically of the development of clinical psychology. It details the range of universities offering psychology programmes and the various bodies involved in supporting the development of the psychology. The paper also describes the development of clinical psychology in India and the variety of roles undertaken by clinical psychologists. Finally, it raises a number of issues facing the development of Indian psychology into the future.

Reflective learning in community-based dental education.

PubMed

Deogade, Suryakant C; Naitam, Dinesh

2016-01-01

Community-based dental education (CBDE) is the implementation of dental education in a specific social context, which shifts a substantial part of dental clinical education from dental teaching institutional clinics to mainly public health settings. Dental students gain additional value from CBDE when they are guided through a reflective process of learning. We propose some key elements to the existing CBDE program that support meaningful personal learning experiences. Dental rotations of 'externships' in community-based clinical settings (CBCS) are year-long community-based placements and have proven to be strong learning environments where students develop good communication skills and better clinical reasoning and management skills. We look at the characteristics of CBDE and how the social and personal context provided in communities enhances dental education. Meaningfulness is created by the authentic context, which develops over a period of time. Structured reflection assignments and methods are suggested as key elements in the existing CBDE program. Strategies to enrich community-based learning experiences for dental students include: Photographic documentation; written narratives; critical incident reports; and mentored post-experiential small group discussions. A directed process of reflection is suggested as a way to increase the impact of the community learning experiences. We suggest key elements to the existing CBDE module so that the context-rich environment of CBDE allows for meaningful relations and experiences for dental students and enhanced learning.

Evaluating Risks of Insertional Mutagenesis by DNA Transposons in Gene Therapy

PubMed Central

Hackett, Perry B.; Largaespada, David A.; Switzer, Kirsten C.; Cooper, Laurence J.N.

2013-01-01

Investigational therapy can be successfully undertaken using viral- and non-viral-mediated ex vivo gene transfer. Indeed, recent clinical trials have established the potential for genetically modified T cells to improve and restore health. Recently the Sleeping Beauty (SB) transposon/transposase system has been applied in clinical trials to stably insert a chimeric antigen receptor (CAR) to redirect T-cell specificity. We discuss the context in which the SB system can be harnessed for gene therapy and describe the human application of SB-modified CAR+ T cells. We have focused on theoretical issues relating to insertional mutagenesis in the context of human genomes that are naturally subjected to remobilization of transposons and the experimental evidence over the last decade of employing SB transposons for defining genes that induce cancer. These findings are put into the context of the use of SB transposons in the treatment of human disease. PMID:23313630

The use of dreams in the clinical context: convergencies and divergencies: an interdisciplinary proposal.

PubMed

Fischbein, Susana Vinocur

2011-04-01

This paper aims to define some unexpected convergences and foreseeable divergences regarding the conceptualization of dreams and their use as a research tool, specifically in clinical practice with non-neurotic patients. It includes a concise review of different lines of thought on the vicissitudes of dreams throughout the history of psychoanalysis: from their initial conception up to their use to examine transference and relational aspects in the context of a psychoanalytic process. The idea of the merely evacuative function of dreams from patients in certain diagnostic categories is discussed and compared with that of their potential communicative value. Lastly, the essay sets forth an interdisciplinary semiotic-pragmatic approach to the function of dreams and their clinical and technical use in the context of the intersubjective dynamic field. Based on the hypothesis that dreams related in the session are communicative signs, this proposal argues their significance as a symbolic matrix that generates processes of psychic semiosis. To do so, it combines certain lines of psychoanalytic thought with ideas coming from C. S. Peirce's analytic semiotics. Clinical material is included to illustrate this viewpoint. Copyright © 2011 Institute of Psychoanalysis.

A de-identifier for medical discharge summaries.

PubMed

Uzuner, Ozlem; Sibanda, Tawanda C; Luo, Yuan; Szolovits, Peter

2008-01-01

Clinical records contain significant medical information that can be useful to researchers in various disciplines. However, these records also contain personal health information (PHI) whose presence limits the use of the records outside of hospitals. The goal of de-identification is to remove all PHI from clinical records. This is a challenging task because many records contain foreign and misspelled PHI; they also contain PHI that are ambiguous with non-PHI. These complications are compounded by the linguistic characteristics of clinical records. For example, medical discharge summaries, which are studied in this paper, are characterized by fragmented, incomplete utterances and domain-specific language; they cannot be fully processed by tools designed for lay language. In this paper, we show that we can de-identify medical discharge summaries using a de-identifier, Stat De-id, based on support vector machines and local context (F-measure=97% on PHI). Our representation of local context aids de-identification even when PHI include out-of-vocabulary words and even when PHI are ambiguous with non-PHI within the same corpus. Comparison of Stat De-id with a rule-based approach shows that local context contributes more to de-identification than dictionaries combined with hand-tailored heuristics (F-measure=85%). Comparison with two well-known named entity recognition (NER) systems, SNoW (F-measure=94%) and IdentiFinder (F-measure=36%), on five representative corpora show that when the language of documents is fragmented, a system with a relatively thorough representation of local context can be a more effective de-identifier than systems that combine (relatively simpler) local context with global context. Comparison with a Conditional Random Field De-identifier (CRFD), which utilizes global context in addition to the local context of Stat De-id, confirms this finding (F-measure=88%) and establishes that strengthening the representation of local context may be more beneficial for de-identification than complementing local with global context.

A De-identifier for Medical Discharge Summaries1

PubMed Central

Uzuner, Özlem; Sibanda, Tawanda C.; Luo, Yuan; Szolovits, Peter

2008-01-01

Objective Clinical records contain significant medical information that can be useful to researchers in various disciplines. However, these records also contain personal health information (PHI) whose presence limits the use of the records outside of hospitals. The goal of de-identification is to remove all PHI from clinical records. This is a challenging task because many records contain foreign and misspelled PHI; they also contain PHI that are ambiguous with non-PHI. These complications are compounded by the linguistic characteristics of clinical records. For example, medical discharge summaries, which are studied in this paper, are characterized by fragmented, incomplete utterances and domain-specific language; they cannot be fully processed by tools designed for lay language. Methods and Results In this paper, we show that we can de-identify medical discharge summaries using a de-identifier, Stat De-id, based on support vector machines and local context (F-measure = 97% on PHI). Our representation of local context aids de-identification even when PHI include out-of-vocabulary words and even when PHI are ambiguous with non-PHI within the same corpus. Comparison of Stat De-id with a rule-based approach shows that local context contributes more to de-identification than dictionaries combined with hand-tailored heuristics (F-measure = 85%). Comparison with two well-known named entity recognition (NER) systems, SNoW (F-measure = 94%) and IdentiFinder (F-measure = 36%), on five representative corpora show that when the language of documents is fragmented, a system with a relatively thorough representation of local context can be a more effective de-identifier than systems that combine (relatively simpler) local context with global context. Comparison with a Conditional Random Field De-identifier (CRFD), which utilizes global context in addition to the local context of Stat De-id, confirms this finding (F-measure = 88%) and establishes that strengthening the representation of local context may be more beneficial for de-identification than complementing local with global context. PMID:18053696

A clinical decision-making mechanism for context-aware and patient-specific remote monitoring systems using the correlations of multiple vital signs.

PubMed

Forkan, Abdur Rahim Mohammad; Khalil, Ibrahim

2017-02-01

In home-based context-aware monitoring patient's real-time data of multiple vital signs (e.g. heart rate, blood pressure) are continuously generated from wearable sensors. The changes in such vital parameters are highly correlated. They are also patient-centric and can be either recurrent or can fluctuate. The objective of this study is to develop an intelligent method for personalized monitoring and clinical decision support through early estimation of patient-specific vital sign values, and prediction of anomalies using the interrelation among multiple vital signs. In this paper, multi-label classification algorithms are applied in classifier design to forecast these values and related abnormalities. We proposed a completely new approach of patient-specific vital sign prediction system using their correlations. The developed technique can guide healthcare professionals to make accurate clinical decisions. Moreover, our model can support many patients with various clinical conditions concurrently by utilizing the power of cloud computing technology. The developed method also reduces the rate of false predictions in remote monitoring centres. In the experimental settings, the statistical features and correlations of six vital signs are formulated as multi-label classification problem. Eight multi-label classification algorithms along with three fundamental machine learning algorithms are used and tested on a public dataset of 85 patients. Different multi-label classification evaluation measures such as Hamming score, F1-micro average, and accuracy are used for interpreting the prediction performance of patient-specific situation classifications. We achieved 90-95% Hamming score values across 24 classifier combinations for 85 different patients used in our experiment. The results are compared with single-label classifiers and without considering the correlations among the vitals. The comparisons show that multi-label method is the best technique for this problem domain. The evaluation results reveal that multi-label classification techniques using the correlations among multiple vitals are effective ways for early estimation of future values of those vitals. In context-aware remote monitoring this process can greatly help the doctors in quick diagnostic decision making. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Murder of the doctor].

PubMed

Lorettu, Liliana; Falchi, Lorenzo; Nivoli, Fabrizia L; Milia, Paolo; Nivoli, Giancarlo; Nivoli, Alessandra M

2015-01-01

To examine possible risk factors for the doctor to be killed by the patient in the clinical practice by examining a series of murders that involved physicians. This aim has been achieved through a retrospective review on clinical cases of doctors killed by patients within the period between 1988 and 2013, in Italy. In this period 18 Italian doctors have been killed in the workplace, with a rate of 0.3/100,000. In 7 cases, the murder resulted in the context of doctor-dissatisfaction; in 7 cases the murder was committed by a psychiatric patient; 1 case in the context of a stalking; 3 cases occurred in a workplace which was not safe enough. Four categories of at-risk contexts have been identified. One category includes a murder in the context of a doctor-dissatisfaction, perceived by patient. The second category concerns murders committed by patients suffering from mental illness. A third category includes homicides in a workplace which is not safe. The last category comprises the murder in the context of stalking. These categories identify specific dangerous situations for physicians, in which are highlighted elements that have played a crucial role in the murder and for which special precautions are suggested preventive.

Social Constructivism and Case-Writing for an Integrated Curriculum

ERIC Educational Resources Information Center

Doubleday, Alison F.; Brown, Blase; Patston, Philip A.; Jurgens-Toepke, Pamela; Strotman, Meaghan Driscoll; Koerber, Anne; Haley, Colin; Briggs, Charlotte; Knight, G. William

2015-01-01

Case-writing within an integrated, systems-based health professions education curriculum presents many unique challenges. Specifically, case-writing in this context must consider integration of multidisciplinary learning objectives and synthesis of biomedical and clinical sciences. Establishing an effective process for content integration and…

Myth and reality: practical test system for the measurement of anti-DNA antibodies in the diagnosis of systemic lupus erythematosus (SLE).

PubMed

McCloskey, Laura J; Christner, Paul; Jacobs-Kosmin, Dana; Jaskowski, Troy D; Hill, Harry R; Lakos, Gabriella; Teodorescu, Marius

2010-01-01

The myth persists that only the labor intensive Farr radioimmunoassay and Crithidia luciliae immunofluorescence (CL-IFA) are systemic lupus erythematosus (SLE)-specific tests. We compared them to ELISA with bacteriophage lambda DNA (EL-dsDNA) and denatured calf thymus DNA (EL-ssDNA). By percentile ranking, the specificity cut-off level was set both out of clinical context (SOCC) on 100 blood bank donors, and in clinical context (SICC) on 100 patients with either rheumatoid arthritis or scleroderma (50/50). Clinical sensitivity was calculated on 100 random SLE patients. At 95% SICC, the sensitivity of Farr, CL-IFA, EL-dsDNA, and EL-ssDNA was similar (95%CI): 76% (66-84), 76% (66-84), 63% (53-72), and 75% (65-83), respectively; 87% of the patients were positive by at least one method and 55%by all methods. At 99% SICC, the sensitivity was also similar (95% CI): 57% (47-67), 47% (37-57), 58% (47-67), and 43% (33-53), respectively. The areas under ROC curve were similar (95% CI) when patients were used as controls for specificity. At 99% SOCC, EL-ssDNA identified 89% positive, 2 negative but positive by another method at 95% SICC, and 9 negative (i.e. 89/2/9), followed by CL-IFA (80/6/14), Farr (76/12/12), and EL-dsDNA (64/23/13). Thus, at relatively low cost and easy automation, under the same conditions of specificity, the two ELISA tests combined were at least as good, if not superior, to CL-IFA or Farr: they showed similar clinical sensitivity and also identified more patients with anti-DNA antibodies. (c) 2010 Wiley-Liss, Inc.

The predictive utility of neuropsychological symptom validity testing as it relates to psychological presentation.

PubMed

Zakzanis, Konstantine K; Gammada, Emnet; Jeffay, Eliyas

2012-01-01

The present study examined the relationship between multiple neuropsychological symptom validity tests (SVTs) and psychological presentation. More formally, we set out to determine if performance on neuropsychological SVTs was related to psychological symptom credibility and which specific neuropsychological SVTs were most associated with noncredible psychological presentation. Archival records from 106 litigating examinees were utilized in this study. Our results illustrate that neuropsychological SVTs are modestly related to psychological symptom credibility and that specific neuropsychological SVTs are variably associated to this end. We conclude that when multiple, but not independent, neuropsychological SVTs are employed within the context of a neuropsychological examination, they do have clinical utility as it relates to credibility of psychological presentation and these constructs do share variance reciprocally in clinically meaningful ways. When independently employed, however, the observed relationship is modest at best. Hence, to place clinical opinion on firmer scientific grounds within the context of a neuropsychological examination, multiple cognitive SVTs, in hand with psychological test instruments that include validity indexes, are essential to derive opinion that is based on science rather than faith in the instance of litigation when an incentive to manifest disability for the sake of an external reward holds probable.

Articular dysfunction patterns in patients with mechanical neck pain: a clinical algorithm to guide specific mobilization and manipulation techniques.

PubMed

Dewitte, Vincent; Beernaert, Axel; Vanthillo, Bart; Barbe, Tom; Danneels, Lieven; Cagnie, Barbara

2014-02-01

In view of a didactical approach for teaching cervical mobilization and manipulation techniques to students as well as their use in daily practice, it is mandatory to acquire sound clinical reasoning to optimally apply advanced technical skills. The aim of this Masterclass is to present a clinical algorithm to guide (novice) therapists in their clinical reasoning to identify patients who are likely to respond to mobilization and/or manipulation. The presented clinical reasoning process is situated within the context of pain mechanisms and is narrowed to and applicable in patients with a dominant input pain mechanism. Based on key features in subjective and clinical examination, patients with mechanical nociceptive pain probably arising from articular structures can be categorized into specific articular dysfunction patterns. Pending on these patterns, specific mobilization and manipulation techniques are warranted. The proposed patterns are illustrated in 3 case studies. This clinical algorithm is the corollary of empirical expertise and is complemented by in-depth discussions and knowledge exchange with international colleagues. Consequently, it is intended that a carefully targeted approach contributes to an increase in specificity and safety in the use of cervical mobilizations and manipulation techniques as valuable adjuncts to other manual therapy modalities. Copyright © 2013 Elsevier Ltd. All rights reserved.

Use of Genetic Testing for Primary Immunodeficiency Patients.

PubMed

Heimall, Jennifer R; Hagin, David; Hajjar, Joud; Henrickson, Sarah E; Hernandez-Trujillo, Hillary S; Tan, Yuval; Kobrynski, Lisa; Paris, Kenneth; Torgerson, Troy R; Verbsky, James W; Wasserman, Richard L; Hsieh, Elena W Y; Blessing, Jack J; Chou, Janet S; Lawrence, Monica G; Marsh, Rebecca A; Rosenzweig, Sergio D; Orange, Jordan S; Abraham, Roshini S

2018-04-01

Genetic testing plays a critical role in diagnosis for many primary immunodeficiency diseases. The goals of this report are to outline some of the challenges that clinical immunologists face routinely in the use of genetic testing for patient care. In addition, we provide a review of the types of genetic testing used in the diagnosis of PID, including their strengths and limitations. We describe the strengths and limitations of different genetic testing approaches for specific clinical contexts that raise concern for specific PID disorders in light of the challenges reported by the clinical immunologist members of the CIS in a recent membership survey. Finally, we delineate the CIS's recommendations for the use of genetic testing in light of these issues.

Is context everything to the definition of clinical depression? A test of the Horwitz and Wakefield postulate.

PubMed

Parker, G; Fletcher, K; Hadzi-Pavlovic, D

2012-02-01

In arguing for the need to distinguish clinical depression from sadness, Horwitz and Wakefield argued for weighting consideration to nuances of life event stressors. Their definition of clinical depression corresponds to the concept of endogenous depression or melancholia, while their model would position reactive (or context specific) non-melancholic depressive disorders more as manifestations of 'sadness' rather than as clinical depression. We test their postulate by examining the extent to which 141 clinically diagnosed melancholic and non-melancholic depressed patients reported episodes as being preceded by a life event stressor or not--and the salience of any life stressor to episode onset and severity. While melancholic patients were more likely than non-melancholic patients to report episodes coming 'out of the blue' and to be more severe than might be expected from the severity of antecedent stressors, differences were more ones of degree and not absolute. Such context variables appeared, however, to differentiate melancholic and non-melancholic patients more consistently than depression symptom variables. As depression severity and impairment levels did not differ across the melancholic and non-melancholic patients, findings were unlikely to be artefacts of such factors. The study finds some support for the Horwitz and Wakefield hypothesis of clinical (or, at least melancholic) depression requiring independence of context or an antecedent stressor, but with precision likely to be compromised by nuances intrinsic to assessment of life event stressors and their contribution to depression onset, difficulties in defining valid 'melancholic' and 'non-melancholic' depressive sub-groups and the parsimony of the hypothesis. Copyright © 2010 Elsevier B.V. All rights reserved.

Context-specific Factors and Contraceptive Use: A Mixed Method Study among Women, Men and Health Providers in a Rural Ghanaian District.

PubMed

Ayanore, Martin Amogre; Pavlova, Milena; Groot, Wim

2017-06-01

Suitable options for improving women's access to effective, safe and context-specific contraceptive methods must be explored to curtail rising unmet needs for contraceptive use in rural Ghana. The study aimed to outline context-specific factors associated with contraceptive use, access on demand and future use intentions among women in one district of Ghana. Using mixed method approach, quantitative data (n=720) was collected among women aged 18-28. Focus group discussions and in-depth interviews were also conducted among women (n=30) aged 18-49 and men (n=10) respectively. IDIs were conducted among 3 midwives. Women who received focused counseling on contraceptive use were twice likely to have ever used (OR=2 95% CI 1.163-3.467) or be current users (OR=2, 95% CI 1.146-4.010) of contraceptives. Male partner support can drive cultural sensitivities towards accepting use of contraception (OR=34.5, CI% 19.01-64.22). Covert use is still preferred by most in the study. Services delivered on good provider-relational grounds and convenient clinic hours encourage contraceptive use among women. Male targeting for improving contraceptive service use must first identify context-specific preferences of the woman, since covert use is highly valued. Ascertaining the prevalence of covert use and how community systems can address this for improved contraceptive uptake is further recommended.

Correlates of hepatitis B virus health-related behaviors of Korean Americans: a situation-specific nursing theory.

PubMed

Lee, Haeok; Fawcett, Jacqueline; Yang, Jin Hyang; Hann, Hie-Won

2012-12-01

The purpose of this article is to explain the evolution of a situation-specific theory developed to enhance understanding of health-related behaviors of Korean Americans (KAs) who have or are at risk for a chronic hepatitis B virus (HBV) infection. The situation-specific theory evolved from an integration of the Network Episode Model, studies of health-related behaviors of people with HBV infection, and our studies of and practice experiences with Asian American individuals with HBV infection. The major concepts of the theory are sociocultural context, social network, individual-level factors, illness experience, and health-related behaviors. The major propositions of the theory are that sociocultural context, social network, and individual-level factors influence the illness experience, and that sociocultural context, social network, individual-level factors, and the illness experience influence health-related behaviors of KAs who have or are at risk for HBV infection. This situation-specific theory represents a translation of abstract concepts into clinical reality. The theory is an explanation of correlates of health-related HBV behaviors of KAs. The next step is to develop and test the effectiveness of a nursing intervention designed to promote behaviors that will enhance the health of KAs who have or are at risk for HBV infection, and that takes into account sociocultural context, social network, individual-level factors, and illness experience. © 2012 Sigma Theta Tau International.

Inhaled phage therapy: a promising and challenging approach to treat bacterial respiratory infections.

PubMed

Bodier-Montagutelli, Elsa; Morello, Eric; L'Hostis, Guillaume; Guillon, Antoine; Dalloneau, Emilie; Respaud, Renaud; Pallaoro, Nikita; Blois, Hélène; Vecellio, Laurent; Gabard, Jérôme; Heuzé-Vourc'h, Nathalie

2017-08-01

Bacterial respiratory tract infections (RTIs) are increasingly difficult to treat due to evolving antibiotic resistance. In this context, bacteriophages (or phages) are part of the foreseen alternatives or combination therapies. Delivering phages through the airways seems more relevant to accumulate these natural antibacterial viruses in proximity to their bacterial host, within the infectious site. Areas covered: This review addresses the potential of phage therapy to treat RTIs and discusses preclinical and clinical results of phages administration in this context. Recent phage formulation and aerosolization attempts are also reviewed, raising technical challenges to achieve efficient pulmonary deposition via inhalation. Expert opinion: Overall, the inhalation of phages as antibacterial treatment seems both clinically relevant and technically feasible. Several crucial points still need to be investigated, such as phage product pharmacokinetics and immunogenicity. Furthermore, given phage-specific features, appropriate regulatory and manufacturing guidelines will need to be defined. Finally, randomized controlled clinical trials should be carried out to establish phage therapy's clinical positioning in the antimicrobial arsenal against RTIs.

[Glycaemic management in type 1 and 2 diabetes patients undergoing interventional cardiology procedures. Heart and Diabetes Working Group. Sociedad Espan˜ola de Cardiologı´a. Sociedad Espan˜ola de Diabetes].

PubMed

Alonso-García, Angeles; Moreno Gómez, Raúl; Miranda Guardiola, Faustino; Artola-Menéndez, Sara; Lisbona-Gil, Arturo

2012-03-03

Despite the growing number of therapeutic alternatives available as well as general reviews and treatment guidelines for the treatment of diabetes, physicians are often left without a clear pathway of therapy to follow in specific clinical contexts such as interventional cardiology. The present document proposes a consensus treatment algorithm, based both on a critical appraisal of evidence from recent clinical trials and on value judgements supported by the authors' collective clinical knowledge and experience, in an attempt to guide practitioners when choosing the most appropriate alternatives in the context of glycemic management in type 1 and 2 diabetic patients scheduled to undergo interventional cardiology procedures in a haemodynamic laboratory. Copyright © 2011 Elsevier España, S.L. All rights reserved.

The use of propofol by gastroenterologists: medico-legal issues.

PubMed

Axon, Andrew E

2010-01-01

The increasing use of non-anesthesiologist-administered propofol for sedation during gastrointestinal endoscopy has both clinical and legal consequences. As medical practices develop, the law of clinical negligence will be applied in the context of such developments. While the law will recognize the desirability of advanced techniques and methods, in circumstances where an injury or adverse outcome occurs, the facts of a particular case will be scrutinized to determine whether or not the duty of care between patient and clinician has been breached. This paper considers a number of specific matters likely to arise in the context of a clinical negligence/malpractice claim resulting from the use of non-anesthesiologist-administered propofol, in particular the role and standard of care expected of gastroenterologist and/or anesthetic provider, the relevance of FDA labeling, the implementation and use of protocols, the importance of patient selection and informed consent. Copyright 2010 S. Karger AG, Basel.

Identification of women at risk of depression in pregnancy: using women's accounts to understand the poor specificity of the Whooley and Arroll case finding questions in clinical practice.

PubMed

Darwin, Zoe; McGowan, Linda; Edozien, Leroy C

2016-02-01

Antenatal mental health assessment is increasingly common in high-income countries. Despite lacking evidence on validation or acceptability, the Whooley questions (modified PHQ-2) and Arroll 'help' question are used in the UK at booking (the first formal antenatal appointment) to identify possible cases of depression. This study investigated validation of the questions and women's views on assessment. Women (n = 191) booking at an inner-city hospital completed the Whooley and Arroll questions as part of their routine clinical care then completed a research questionnaire containing the Edinburgh postnatal depression scale (EPDS). A purposive subsample (n = 22) were subsequently interviewed. The Whooley questions 'missed' half the possible cases identified using the EPDS (EPDS threshold ≥ 10: sensitivity 45.7 %, specificity 92.1 %; ≥ 13: sensitivity 47.8 %, specificity 86.1 %), worsening to nine in ten when adopting the Arroll item (EPDS ≥ 10: sensitivity 9.1 %, specificity 98.2 %; ≥ 13: sensitivity 9.5 %, specificity 97.1 %). Women's accounts indicated that under-disclosure relates to the context of assessment and perceived relevance of depression to maternity services. Depression symptoms are under-identified in current local practice. While validated tools are needed that can be readily applied in routine maternity care, psychometric properties will be influenced by the context of disclosure when implemented in practice.

What every teacher needs to know about clinical reasoning.

PubMed

Eva, Kevin W

2005-01-01

One of the core tasks assigned to clinical teachers is to enable students to sort through a cluster of features presented by a patient and accurately assign a diagnostic label, with the development of an appropriate treatment strategy being the end goal. Over the last 30 years there has been considerable debate within the health sciences education literature regarding the model that best describes how expert clinicians generate diagnostic decisions. The purpose of this essay is to provide a review of the research literature on clinical reasoning for frontline clinical teachers. The strengths and weaknesses of different approaches to clinical reasoning will be examined using one of the core divides between various models (that of analytic (i.e. conscious/controlled) versus non-analytic (i.e. unconscious/automatic) reasoning strategies) as an orienting framework. Recent work suggests that clinical teachers should stress the importance of both forms of reasoning, thereby enabling students to marshal reasoning processes in a flexible and context-specific manner. Specific implications are drawn from this overview for clinical teachers.

Specific entrustable professional activities for undergraduate medical internships: a method compatible with the academic curriculum.

PubMed

Hamui-Sutton, Alicia; Monterrosas-Rojas, Ana María; Ortiz-Montalvo, Armando; Flores-Morones, Felipe; Torruco-García, Uri; Navarrete-Martínez, Andrea; Arrioja-Guerrero, Araceli

2017-08-25

Competency-based education has been considered the most important pedagogical trend in Medicine in the last two decades. In clinical contexts, competencies are implemented through Entrustable Professional Activities (EPAs) which are observable and measurable. The aim of this paper is to describe the methodology used in the design of educational tools to assess students´ competencies in clinical practice during their undergraduate internship (UI). In this paper, we present the construction of specific APROCs (Actividades Profesionales Confiables) in Surgery (S), Gynecology and Obstetrics (GO) and Family Medicine (FM) rotations with three levels of performance. The study considered a mixed method exploratory type design, a qualitative phase followed by a quantitative validation exercise. In the first stage data was obtained from three rotations (FM, GO and S) through focus groups about real and expected activities of medical interns. Triangulation with other sources was made to construct benchmarks. In the second stage, narrative descriptions with the three levels were validated by professors who teach the different subjects using the Delphi technique. The results may be described both curricular and methodological wise. From the curricular point of view, APROCs were identified in three UI rotations within clinical contexts in Mexico City, benchmarks were developed by levels and validated by experts' consensus. In regard to methodological issues, this research contributed to the development of a strategy, following six steps, to build APROCs using mixed methods. Developing benchmarks provides a regular and standardized language that helps to evaluate student's performance and define educational strategies efficiently and accurately. The university academic program was aligned with APROCs in clinical contexts to assure the acquisition of competencies by students.

A point of minimal important difference (MID): a critique of terminology and methods.

PubMed

King, Madeleine T

2011-04-01

The minimal important difference (MID) is a phrase with instant appeal in a field struggling to interpret health-related quality of life and other patient-reported outcomes. The terminology can be confusing, with several terms differing only slightly in definition (e.g., minimal clinically important difference, clinically important difference, minimally detectable difference, the subjectively significant difference), and others that seem similar despite having quite different meanings (minimally detectable difference versus minimum detectable change). Often, nuances of definition are of little consequence in the way that these quantities are estimated and used. Four methods are commonly employed to estimate MIDs: patient rating of change (global transition items); clinical anchors; standard error of measurement; and effect size. These are described and critiqued in this article. There is no universal MID, despite the appeal of the notion. Indeed, for a particular patient-reported outcome instrument or scale, the MID is not an immutable characteristic, but may vary by population and context. At both the group and individual level, the MID may depend on the clinical context and decision at hand, the baseline from which the patient starts, and whether they are improving or deteriorating. Specific estimates of MIDs should therefore not be overinterpreted. For a given health-related quality-of-life scale, all available MID estimates (and their confidence intervals) should be considered, amalgamated into general guidelines and applied judiciously to any particular clinical or research context.

A Scoping Review of Health Game Research: Past, Present, and Future

PubMed Central

Lu, Amy Shirong; Gharghabi, Fardad; Coleman, Whitney

2012-01-01

Abstract Health game research has flourished over the last decade. The number of peer-reviewed scientific publications has surged as the clinical application of health games has diversified. In response to this growth, several past literature reviews have assessed the effectiveness of health games in specific clinical subdomains. The past literature reviews, however, have not provided a general scope of health games independent of clinical context. The present systematic review identified 149 publications. All sources were published before 2011 in a peer-reviewed venue. To be included in this review, publications were required (1) to be an original research, (2) to focus on health, (3) to utilize a sound research design, (4) to report quantitative health outcomes, and (5) to target healthcare receivers. Initial findings showed certain trends in health game publications: Focus on younger male demographics, relatively low number of study participants, increased number of controlled trials, short duration of intervention periods, short duration and frequency of user–game interaction, dominance of exercise and rehab games, lack of underlying theoretical frameworks, and concentration on clinical contexts such as physical activity and nutrition. The review concludes that future research should (1) widen the demographics to include females and elderly, (2) increase the number of participants in controlled trials, (3) lengthen both the intervention period and user–game interaction duration, and (4) expand the application of health games in new clinical contexts. PMID:24416638

Implementation of HIV and Tuberculosis Diagnostics: The Importance of Context.

PubMed

Dominique, Joyelle K; Ortiz-Osorno, Alberto A; Fitzgibbon, Joseph; Gnanashanmugam, Devasena; Gilpin, Christopher; Tucker, Timothy; Peel, Sheila; Peter, Trevor; Kim, Peter; Smith, Steven

2015-10-15

Novel diagnostics have been widely applied across human immunodeficiency virus (HIV) and tuberculosis prevention and treatment programs. To achieve the greatest impact, HIV and tuberculosis diagnostic programs must carefully plan and implement within the context of a specific healthcare system and the laboratory capacity. A workshop was convened in Cape Town in September 2014. Participants included experts from laboratory and clinical practices, officials from ministries of health, and representatives from industry. The article summarizes best practices, challenges, and lessons learned from implementation experiences across sub-Saharan Africa for (1) building laboratory programs within the context of a healthcare system; (2) utilizing experience of clinicians and healthcare partners in planning and implementing the right diagnostic; and (3) evaluating the effects of new diagnostics on the healthcare system and on patient health outcomes. The successful implementation of HIV and tuberculosis diagnostics in resource-limited settings relies on careful consideration of each specific context. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Real-time PCR for type-specific identification of herpes simplex in clinical samples: evaluation of type-specific results in the context of CNS diseases.

PubMed

Meylan, Sylvain; Robert, Daniel; Estrade, Christine; Grimbuehler, Valérie; Péter, Olivier; Meylan, Pascal R; Sahli, Roland

2008-02-01

HSV-1 and HSV-2 cause CNS infections of dissimilar clinico-pathological characteristics with prognostic and therapeutic implications. To validate a type-specific real-time PCR that uses MGB/LNA Taqman probes and to review the virologico-clinical data of 25 eligible patients with non-neonatal CNS infections. This real-time PCR was evaluated against conventional PCR (26 CSF and 20 quality controls), and LightCycler assay (51 mucocutaneous, 8 CSF and 32 quality controls) and culture/immunofluorescence (75 mucocutaneous) to assess typing with independent methods. Taqman real-time PCR detected 240 HSV genomes per ml CSF, a level appropriate for the management of patients, and provided unambiguous typing for the 104 positive (62 HSV-1 and 42 HSV-2) out the 160 independent clinical samples tested. HSV type diagnosed by Taqman real-time PCR predicted final diagnosis (meningitis versus encephalitis/meningoencephalitis, p<0.001) in 24/25 patients at time of presentation, in contrast to clinical evaluation. Our real-time PCR, as a sensitive and specific means for type-specific HSV diagnosis, provided rapid prognostic information for patient management.

Standardized terminology for clinical trial protocols based on top-level ontological categories.

PubMed

Heller, B; Herre, H; Lippoldt, K; Loeffler, M

2004-01-01

This paper describes a new method for the ontologically based standardization of concepts with regard to the quality assurance of clinical trial protocols. We developed a data dictionary for medical and trial-specific terms in which concepts and relations are defined context-dependently. The data dictionary is provided to different medical research networks by means of the software tool Onto-Builder via the internet. The data dictionary is based on domain-specific ontologies and the top-level ontology of GOL. The concepts and relations described in the data dictionary are represented in natural language, semi-formally or formally according to their use.

The relationship between maternal self-efficacy and parenting practices: implications for parent training.

PubMed

Sanders, M R; Woolley, M L

2005-01-01

The present study examined the relationship between maternal self-efficacy, dysfunctional discipline practices and child conduct problems. Specifically, three levels of self-efficacy, global, domain and task-specific self-efficacy, were assessed in mothers of 2- to 8-year-old children with conduct problems (clinic group, n=45) and non-clinic mothers from the community (non-clinic group, n=79). Measures of global, domain and task-specific self-efficacy were completed by mothers. Clinic mothers reported significantly lower self-efficacy than non-clinic mothers for all but one of the parenting tasks assessed. Both groups of mothers reported lowest self-efficacy for similar parenting tasks. In the sample as a whole self-efficacy measures were significant predictors of maternal discipline style after controlling for other parent, child and risk factors. Of the self-efficacy variables behavioural self-efficacy was the best predictor of mothers discipline style. The findings support the importance of developing parenting strategies that enable parents to generalize their parenting skills to a diverse range of diverse parenting contexts both in the home and in the community.

[Validation of a questionnaire to evaluate patient safety in clinical laboratories].

PubMed

Giménez Marín, Ángeles; Rivas-Ruiz, Francisco

2012-01-01

The aim of this study was to prepare, pilot and validate a questionnaire to evaluate patient safety in the specific context of clinical laboratories. A specific questionnaire on patient safety in the laboratory, with 62 items grouped into six areas, was developed, taking into consideration the diverse human and laboratory contextual factors which may contribute to producing errors. A pilot study of 30 interviews was carried out, including validity and reliability analyses using principal components factor analysis and Cronbach's alpha. Subsequently, 240 questionnaires were sent to 21 hospitals, followed by a test-retest of 41 questionnaires with the definitive version. The sample analyzed was composed of 225 questionnaires (an overall response rate of 80%). Of the 62 items initially assessed, 17 were eliminated due to non-compliance with the criteria established before the principal components factor analysis was performed. For the 45 remaining items, 12 components were identified, with an cumulative variance of 69.5%. In seven of the 10 components with two or more items, Cronbach's alpha was higher than 0.7. The questionnaire items assessed in the test-retest were found to be stable. We present the first questionnaire with sufficiently proven validity and reliability for evaluating patient safety in the specific context of clinical laboratories. This questionnaire provides a useful instrument to perform a subsequent macrostudy of hospital clinical laboratories in Spain. The questionnaire can also be used to monitor and promote commitment to patient safety within the search for continuous quality improvement. Copyright © 2011 SESPAS. Published by Elsevier Espana. All rights reserved.

Contributions of acculturation, enculturation, discrimination, and personality traits to social anxiety among Chinese immigrants: A context-specific assessment.

PubMed

Fang, Ke; Friedlander, Myrna; Pieterse, Alex L

2016-01-01

Based on the diathesis-stress model of anxiety, this study examined the contributions of cultural processes, perceived racial discrimination, and personality traits to social anxiety among Chinese immigrants. Further guided by the theory of intergroup anxiety, this study also adopted a context-specific approach to distinguish between participants' experience of social anxiety when interacting with European Americans versus with other Chinese in the United States. This quantitative and ex post facto study used a convenience sample of 140 first-generation Chinese immigrants. Participants were recruited through e-mails from different university and community groups across the United States. The sample includes 55 men and 82 women (3 did not specify) with an average age of 36 years old. Results showed that more social anxiety was reported in the European American context than in the Chinese ethnic context. The full models accounted for almost half the variance in anxiety in each context. Although personality accounted for the most variance, the cultural variables and discrimination contributed 14% of the unique variance in the European American context. Notably, low acculturation, high neuroticism, and low extraversion were unique contributors to social anxiety with European Americans, whereas in the Chinese ethnic context only low extraversion was a unique contributor; more discrimination was uniquely significant in both contexts. The findings suggest a need to contextualize the research and clinical assessment of social anxiety, and have implications for culturally sensitive counseling with immigrants. (c) 2016 APA, all rights reserved).

A concept analysis of social capital within a health context.

PubMed

Hsieh, Ching-Hsing

2008-01-01

This paper aims to clarify the concept of social capital within a health context using Rodgers's (2000) Evolutionary Method. Published literature. The analysis demonstrates that social capital is the intangible assets, including trust, networks, and social norms of reciprocity, possessed by a society within a specific culture. When a unit (individual or a family) increases its sense of community or quality of community participation, this could increase its social capital. The result of this analysis provides a guide for further conceptual and empirical research and clinical practice.

Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis.

PubMed

McMahon, Michelle A; Dluhy, Nancy M

2017-02-01

To analyze the concept of ambiguity in a nursing context. Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP). Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis. Attributes of AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable. Antecedents include (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity. Consequences include ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses. Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.

Automated ancillary cancer history classification for mesothelioma patients from free-text clinical reports

PubMed Central

Wilson, Richard A.; Chapman, Wendy W.; DeFries, Shawn J.; Becich, Michael J.; Chapman, Brian E.

2010-01-01

Background: Clinical records are often unstructured, free-text documents that create information extraction challenges and costs. Healthcare delivery and research organizations, such as the National Mesothelioma Virtual Bank, require the aggregation of both structured and unstructured data types. Natural language processing offers techniques for automatically extracting information from unstructured, free-text documents. Methods: Five hundred and eight history and physical reports from mesothelioma patients were split into development (208) and test sets (300). A reference standard was developed and each report was annotated by experts with regard to the patient’s personal history of ancillary cancer and family history of any cancer. The Hx application was developed to process reports, extract relevant features, perform reference resolution and classify them with regard to cancer history. Two methods, Dynamic-Window and ConText, for extracting information were evaluated. Hx’s classification responses using each of the two methods were measured against the reference standard. The average Cohen’s weighted kappa served as the human benchmark in evaluating the system. Results: Hx had a high overall accuracy, with each method, scoring 96.2%. F-measures using the Dynamic-Window and ConText methods were 91.8% and 91.6%, which were comparable to the human benchmark of 92.8%. For the personal history classification, Dynamic-Window scored highest with 89.2% and for the family history classification, ConText scored highest with 97.6%, in which both methods were comparable to the human benchmark of 88.3% and 97.2%, respectively. Conclusion: We evaluated an automated application’s performance in classifying a mesothelioma patient’s personal and family history of cancer from clinical reports. To do so, the Hx application must process reports, identify cancer concepts, distinguish the known mesothelioma from ancillary cancers, recognize negation, perform reference resolution and determine the experiencer. Results indicated that both information extraction methods tested were dependant on the domain-specific lexicon and negation extraction. We showed that the more general method, ConText, performed as well as our task-specific method. Although Dynamic- Window could be modified to retrieve other concepts, ConText is more robust and performs better on inconclusive concepts. Hx could greatly improve and expedite the process of extracting data from free-text, clinical records for a variety of research or healthcare delivery organizations. PMID:21031012

Pedagogical Tools to Address Clinical Anatomy and Athletic Training Student Learning Styles

ERIC Educational Resources Information Center

Mazerolle, Stephanie; Yeargin, Susan

2010-01-01

Context: A thorough knowledge of anatomy is needed in four of the six domains of athletic training: prevention, injury/condition recognition, immediate care, and treatment/rehabilitation. Students with a solid foundation can achieve competency in these specific domains. Objective: To provide educators with pedagogical tools to promote a deeper…

A mechanistic pan-cancer pathway model informed by multi-omics data interprets stochastic cell fate responses to drugs and mitogens

PubMed Central

Bouhaddou, Mehdi; Koch, Rick J.; DiStefano, Matthew S.; Tan, Annie L.; Mertz, Alex E.

2018-01-01

Most cancer cells harbor multiple drivers whose epistasis and interactions with expression context clouds drug and drug combination sensitivity prediction. We constructed a mechanistic computational model that is context-tailored by omics data to capture regulation of stochastic proliferation and death by pan-cancer driver pathways. Simulations and experiments explore how the coordinated dynamics of RAF/MEK/ERK and PI-3K/AKT kinase activities in response to synergistic mitogen or drug combinations control cell fate in a specific cellular context. In this MCF10A cell context, simulations suggest that synergistic ERK and AKT inhibitor-induced death is likely mediated by BIM rather than BAD, which is supported by prior experimental studies. AKT dynamics explain S-phase entry synergy between EGF and insulin, but simulations suggest that stochastic ERK, and not AKT, dynamics seem to drive cell-to-cell proliferation variability, which in simulations is predictable from pre-stimulus fluctuations in C-Raf/B-Raf levels. Simulations suggest MEK alteration negligibly influences transformation, consistent with clinical data. Tailoring the model to an alternate cell expression and mutation context, a glioma cell line, allows prediction of increased sensitivity of cell death to AKT inhibition. Our model mechanistically interprets context-specific landscapes between driver pathways and cell fates, providing a framework for designing more rational cancer combination therapy. PMID:29579036

Combining skin prick, immediate skin application and specific-IgE testing in the diagnosis of peanut allergy in children.

PubMed

Wainstein, Brynn Kevin; Yee, Anthony; Jelley, Donna; Ziegler, Mary; Ziegler, John B

2007-05-01

Previous studies have suggested various diagnostic cut-offs of allergy tests for the diagnosis of clinical peanut allergy in children. There are few data relating to the use of combinations of these tests in children. We aimed to determine the validity of previously reported diagnostic cut-off levels of peanut allergen skin tests and peanut specific-immunoglobulin (Ig) E, as well as the usefulness of combinations of these, for predicting clinical peanut allergy in our Allergy Clinic. Children attending the Allergy Clinic with a positive peanut skin prick test (SPT; n = 84) were included in the study. Immediate skin application food tests (I-SAFT) using 1 g of peanut butter (positive if any wheals were detected at 15 min), peanut specific-IgE levels and open-label peanut food challenges were performed. Fifty-two of 85 peanut challenges were positive. Skin prick test specificity was 67% at >or=8 mm and 100% at >or=15 mm. The I-SAFT was 82% specific. A peanut specific-IgE level of 0.37 kU/l was 98% sensitive but 33% specific. A level of 10 kU/l was 100% specific. Combinations of a SPT of >or=8 mm with a positive I-SAFT and a peanut specific-IgE >or=0.37 kU/l were 88% specific with a sensitivity of 38%. Using challenge outcomes as the standard, available in vitro and in vivo diagnostic tests for peanut allergy have poor sensitivity and specificity and combining them does not significantly improve their clinical usefulness. Previously described diagnostic cut-off levels do not have general applicability. Allergy practitioners may need to interpret results of allergy tests in the context of their own practices.

Managing Complex Change in Clinical Study Metadata

PubMed Central

Brandt, Cynthia A.; Gadagkar, Rohit; Rodriguez, Cesar; Nadkarni, Prakash M.

2004-01-01

In highly functional metadata-driven software, the interrelationships within the metadata become complex, and maintenance becomes challenging. We describe an approach to metadata management that uses a knowledge-base subschema to store centralized information about metadata dependencies and use cases involving specific types of metadata modification. Our system borrows ideas from production-rule systems in that some of this information is a high-level specification that is interpreted and executed dynamically by a middleware engine. Our approach is implemented in TrialDB, a generic clinical study data management system. We review approaches that have been used for metadata management in other contexts and describe the features, capabilities, and limitations of our system. PMID:15187070

Soluble biomarkers development in osteoarthritis: from discovery to personalized medicine

PubMed Central

Henrotin, Yves; Sanchez, Christelle; Cornet, Anne; Van de Put, Joachim; Douette, Pierre; Gharbi, Myriam

2015-01-01

Abstract Context: Specific soluble biomarkers could be a precious tool for diagnosis, prognosis and personalized management of osteoarthritic (OA) patients. Objective: To describe the path of soluble biomarker development from discovery to clinical qualification and regulatory adoption toward OA-related biomarker qualification. Methods and results: This review summarizes current guidance on the use of biomarkers in OA in clinical trials and their utility at five stages, including preclinical development and phase 1 to phase 4 trials. It also presents all the available regulatory requirements. Conclusions: The path through the adoption of a specific soluble biomarker for OA is steep but is worth the challenge due to the benefit that it can provide. PMID:26954785

Considerations in the development of circulating tumor cell technology for clinical use

PubMed Central

2012-01-01

This manuscript summarizes current thinking on the value and promise of evolving circulating tumor cell (CTC) technologies for cancer patient diagnosis, prognosis, and response to therapy, as well as accelerating oncologic drug development. Moving forward requires the application of the classic steps in biomarker development–analytical and clinical validation and clinical qualification for specific contexts of use. To that end, this review describes methods for interactive comparisons of proprietary new technologies, clinical trial designs, a clinical validation qualification strategy, and an approach for effectively carrying out this work through a public-private partnership that includes test developers, drug developers, clinical trialists, the US Food & Drug Administration (FDA) and the US National Cancer Institute (NCI). PMID:22747748

Implications of the Institute of Medicine Report: Evaluation of Biomarkers and Surrogate Endpoints in Chronic Disease.

PubMed

Wagner, J A; Ball, J R

2015-07-01

The Institute of Medicine (IOM) released a groundbreaking 2010 report, Evaluation of Biomarkers and Surrogate Endpoints in Chronic Disease. Key recommendations included a harmonized scientific process and a general framework for biomarker evaluation with three interrelated steps: (1) Analytical validation -- is the biomarker measurement accurate? (2) Qualification -- is the biomarker associated with the clinical endpoint of concern? (3) Utilization -- what is the specific context of the proposed use? © 2015 American Society for Clinical Pharmacology and Therapeutics.

Clinical research in implant dentistry: evaluation of implant-supported restorations, aesthetic and patient-reported outcomes.

PubMed

Lang, Niklaus P; Zitzmann, Nicola U

2012-02-01

The articles discussed in working group 3 dealt with specific aspects of clinical research. In this context, the literature reporting on survival and complication rates of implant-supported or implant-tooth supported restorations in longitudinal studies of at least 5 years were discussed. The second aspect dealt with the evaluation of aesthetic outcomes in clinical studies and the related index systems available. Finally, the third aspect discussed dealt with patient-reported outcome measures (PROMs). A detailed appraisal of the available methodology was presented. © 2012 John Wiley & Sons A/S.

Year in review 2009: Critical Care--infection.

PubMed

Harbarth, Stephan; Haustein, Thomas

2010-01-01

In 2009 Critical Care provided important and clinically relevant research data for management and prevention of infections in critically ill patients. The present review summarises the results of these observational studies and clinical trials and discusses them in the context of the current relevant scientific and clinical background. In particular, we discuss recent epidemiologic data on nosocomial infections in intensive care units, present new approaches to prevention of ventilator-associated pneumonia, describe recent advances in biomarker-guided antibiotic stewardship and attempt to briefly summarise specific challenges related to the management of infections caused by multidrug-resistant microorganisms and influenza A (H1N1).

Pediatric misophonia with comorbid obsessive-compulsive spectrum disorders.

PubMed

Webber, Troy A; Johnson, Patricia L; Storch, Eric A

2014-01-01

Misophonia is a potentially debilitating condition characterized by increased sensitivity to specific sounds, which cause subsequent behavioral and emotional responses. The nature, clinical phenomenology and etiology of misophonia remain unclear, and misophonic clinical presentations are not currently accounted for by existing psychiatric or audiological disorders. We present a case of pediatric misophonia in the context of comorbid obsessive-compulsive disorder and Tourette's syndrome. Given the interrelationships among obsessive-compulsive spectrum disorders and misophonia, these disorders may share underlying pathophysiology, particularly within the dopaminergic and serotonergic neural systems. Clinical (i.e., treatment) and theoretical implications are discussed. Published by Elsevier Inc.

NCI-FDA Interagency Oncology Task Force Workshop Provides Guidance for Analytical Validation of Protein-based Multiplex Assays | Office of Cancer Clinical Proteomics Research

Cancer.gov

An NCI-FDA Interagency Oncology Task Force (IOTF) Molecular Diagnostics Workshop was held on October 30, 2008 in Cambridge, MA, to discuss requirements for analytical validation of protein-based multiplex technologies in the context of its intended use. This workshop developed through NCI's Clinical Proteomic Technologies for Cancer initiative and the FDA focused on technology-specific analytical validation processes to be addressed prior to use in clinical settings. In making this workshop unique, a case study approach was used to discuss issues related to

mlCAF: Multi-Level Cross-Domain Semantic Context Fusioning for Behavior Identification.

PubMed

Razzaq, Muhammad Asif; Villalonga, Claudia; Lee, Sungyoung; Akhtar, Usman; Ali, Maqbool; Kim, Eun-Soo; Khattak, Asad Masood; Seung, Hyonwoo; Hur, Taeho; Bang, Jaehun; Kim, Dohyeong; Ali Khan, Wajahat

2017-10-24

The emerging research on automatic identification of user's contexts from the cross-domain environment in ubiquitous and pervasive computing systems has proved to be successful. Monitoring the diversified user's contexts and behaviors can help in controlling lifestyle associated to chronic diseases using context-aware applications. However, availability of cross-domain heterogeneous contexts provides a challenging opportunity for their fusion to obtain abstract information for further analysis. This work demonstrates extension of our previous work from a single domain (i.e., physical activity) to multiple domains (physical activity, nutrition and clinical) for context-awareness. We propose multi-level Context-aware Framework (mlCAF), which fuses the multi-level cross-domain contexts in order to arbitrate richer behavioral contexts. This work explicitly focuses on key challenges linked to multi-level context modeling, reasoning and fusioning based on the mlCAF open-source ontology. More specifically, it addresses the interpretation of contexts from three different domains, their fusioning conforming to richer contextual information. This paper contributes in terms of ontology evolution with additional domains, context definitions, rules and inclusion of semantic queries. For the framework evaluation, multi-level cross-domain contexts collected from 20 users were used to ascertain abstract contexts, which served as basis for behavior modeling and lifestyle identification. The experimental results indicate a context recognition average accuracy of around 92.65% for the collected cross-domain contexts.

mlCAF: Multi-Level Cross-Domain Semantic Context Fusioning for Behavior Identification

PubMed Central

Villalonga, Claudia; Lee, Sungyoung; Akhtar, Usman; Ali, Maqbool; Kim, Eun-Soo; Khattak, Asad Masood; Seung, Hyonwoo; Hur, Taeho; Kim, Dohyeong; Ali Khan, Wajahat

2017-01-01

The emerging research on automatic identification of user’s contexts from the cross-domain environment in ubiquitous and pervasive computing systems has proved to be successful. Monitoring the diversified user’s contexts and behaviors can help in controlling lifestyle associated to chronic diseases using context-aware applications. However, availability of cross-domain heterogeneous contexts provides a challenging opportunity for their fusion to obtain abstract information for further analysis. This work demonstrates extension of our previous work from a single domain (i.e., physical activity) to multiple domains (physical activity, nutrition and clinical) for context-awareness. We propose multi-level Context-aware Framework (mlCAF), which fuses the multi-level cross-domain contexts in order to arbitrate richer behavioral contexts. This work explicitly focuses on key challenges linked to multi-level context modeling, reasoning and fusioning based on the mlCAF open-source ontology. More specifically, it addresses the interpretation of contexts from three different domains, their fusioning conforming to richer contextual information. This paper contributes in terms of ontology evolution with additional domains, context definitions, rules and inclusion of semantic queries. For the framework evaluation, multi-level cross-domain contexts collected from 20 users were used to ascertain abstract contexts, which served as basis for behavior modeling and lifestyle identification. The experimental results indicate a context recognition average accuracy of around 92.65% for the collected cross-domain contexts. PMID:29064459

Clinical proteomic biomarkers: relevant issues on study design & technical considerations in biomarker development

PubMed Central

2014-01-01

Biomarker research is continuously expanding in the field of clinical proteomics. A combination of different proteomic–based methodologies can be applied depending on the specific clinical context of use. Moreover, current advancements in proteomic analytical platforms are leading to an expansion of biomarker candidates that can be identified. Specifically, mass spectrometric techniques could provide highly valuable tools for biomarker research. Ideally, these advances could provide with biomarkers that are clinically applicable for disease diagnosis and/ or prognosis. Unfortunately, in general the biomarker candidates fail to be implemented in clinical decision making. To improve on this current situation, a well-defined study design has to be established driven by a clear clinical need, while several checkpoints between the different phases of discovery, verification and validation have to be passed in order to increase the probability of establishing valid biomarkers. In this review, we summarize the technical proteomic platforms that are available along the different stages in the biomarker discovery pipeline, exemplified by clinical applications in the field of bladder cancer biomarker research. PMID:24679154

Context matters when striving to promote active and lifelong learning in medical education.

PubMed

Berkhout, Joris J; Helmich, Esther; Teunissen, Pim W; van der Vleuten, Cees P M; Jaarsma, A Debbie C

2018-01-01

WHERE DO WE STAND NOW?: In the 30 years that have passed since The Edinburgh Declaration on Medical Education, we have made tremendous progress in research on fostering 'self-directed and independent study' as propagated in this declaration, of which one prime example is research carried out on problem-based learning. However, a large portion of medical education happens outside of classrooms, in authentic clinical contexts. Therefore, this article discusses recent developments in research regarding fostering active learning in clinical contexts. Clinical contexts are much more complex and flexible than classrooms, and therefore require a modified approach when fostering active learning. Recent efforts have been increasingly focused on understanding the more complex subject of supporting active learning in clinical contexts. One way of doing this is by using theory regarding self-regulated learning (SRL), as well as situated learning, workplace affordances, self-determination theory and achievement goal theory. Combining these different perspectives provides a holistic view of active learning in clinical contexts. ENTRY TO PRACTICE, VOCATIONAL TRAINING AND CONTINUING PROFESSIONAL DEVELOPMENT: Research on SRL in clinical contexts has mostly focused on the undergraduate setting, showing that active learning in clinical contexts requires not only proficiency in metacognition and SRL, but also in reactive, opportunistic learning. These studies have also made us aware of the large influence one's social environment has on SRL, the importance of professional relationships for learners, and the role of identity development in learning in clinical contexts. Additionally, research regarding postgraduate lifelong learning also highlights the importance of learners interacting about learning in clinical contexts, as well as the difficulties that clinical contexts may pose for lifelong learning. However, stimulating self-regulated learning in undergraduate medical education may also make postgraduate lifelong learning easier for learners in clinical contexts. © 2017 John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Incidental genetic findings in randomized clinical trials: recommendations from the Genomics and Randomized Trials Network (GARNET)

PubMed Central

2013-01-01

Recommendations and guidance on how to handle the return of genetic results to patients have offered limited insight into how to approach incidental genetic findings in the context of clinical trials. This paper provides the Genomics and Randomized Trials Network (GARNET) recommendations on incidental genetic findings in the context of clinical trials, and discusses the ethical and practical issues considered in formulating our recommendations. There are arguments in support of as well as against returning incidental genetic findings in clinical trials. For instance, reporting incidental findings in clinical trials may improve the investigator-participant relationship and the satisfaction of participation, but it may also blur the line between clinical care and research. The issues of whether and how to return incidental genetic findings, including the costs of doing so, should be considered when developing clinical trial protocols. Once decided, plans related to sharing individual results from the aim(s) of the trial, as well as incidental findings, should be discussed explicitly in the consent form. Institutional Review Boards (IRBs) and other study-specific governing bodies should be part of the decision as to if, when, and how to return incidental findings, including when plans in this regard are being reconsidered. PMID:23363732

Do motives matter in male circumcision? 'Conscientious objection' against the circumcision of a Muslim child with a blood disorder.

PubMed

Ahmad, Ayesha

2014-02-01

Whilst there have been serious attempts to locate the practice of male circumcision for religious motives in the context of the (respective) religion's narrative and community, the debate, when referring to a clinical context, is often more nuanced. This article will contribute further to the debate by contextualising the Islamic practice of male circumcision within the clinical setting typical of a contemporary hospital. It specifically develops an additional complication; namely, the child has a pre-existing blood disorder. As an approach to contributing to the circumcision debate further, the ethics of a conscientious objection for secular motives towards a religiously-motivated clinical intervention will be explored. Overall, the discussion will provide relevance for such debates within the value-systems of a multi-cultural society. This article replicates several approaches to deconstructing a request for conscientious refusal of non-therapeutic circumcision by a Clinical Ethics Committee (CEC), bringing to light certain contradictions that occur in normatively categorizing motives for performing the circumcision. © 2013 John Wiley & Sons Ltd.

Clinical context and mechanism of functional tricuspid regurgitation in patients with and without pulmonary hypertension.

PubMed

Topilsky, Yan; Khanna, Amber; Le Tourneau, Thierry; Park, Soon; Michelena, Hector; Suri, Rakesh; Mahoney, Douglas W; Enriquez-Sarano, Maurice

2012-05-01

Functional tricuspid regurgitation (FTR) with structurally normal valve is of poorly defined mechanisms. Prevalence and clinical context of idiopathic FTR (Id-FTR) (without overt TR cause) are unknown. To investigate prevalence, clinical context, and mechanisms specific to FTR types, Id-FTR versus pulmonary hypertension-related (PHTN-FTR, systolic pulmonary pressure ≥50 mm Hg), we analyzed 1161 patients with prospectively quantified TR. Id-FTR (prevalence 12%) was associated with aging and atrial fibrillation. For mechanistic purposes, we measured valvular and right ventricular (RV) remodeling in 141 Id-FTR matched to 140 PHTN-FTR and to 99 controls with trivial TR for age, sex, atrial fibrillation, and ejection fraction. PHTN-FTR and Id-FTR were also matched for TR effective-regurgitant-orifice (ERO). Id-FTR valvular alterations (versus controls) were largest annular area (3.53±0.6 versus 2.74±0.4 cm(2), P<0.0001) and lowest valvular/annular coverage ratio (1.06±0.1 versus 1.45±0.2, P<0.0001) but normal valve tenting height. PHTN-FTR had mild annular enlargement but excessive valve tenting height (0.8±0.3 versus 0.35±0.1 cm, P<0.0001). Valvular changes were linked to specific RV changes, largest basal dilatation, and normal length (RV conical deformation) in Id-FTR versus longest RV with elliptical/spherical deformation in PHTN-FTR. With increasing FTR severity (ERO ≥40 mm(2)), changes specific to each FTR type were accentuated, and RV function (index of myocardial performance) was consistently reduced. Id-FTR is frequent, linked to aging and atrial fibrillation, can be severe, and is of unique mechanism. In Id-FTR, excess annular and RV-basal enlargement exhausts valvular/annular coverage reserve, and RV conical deformation does not cause notable valvular tenting. Conversely, PHTN-FTR is determined by valvular tethering with tenting linked to RV elongation and elliptical/spherical deformation. These specific FTR-mechanisms may be important in considering surgical correction in FTR.

The Design of Clinical Trials in Portal Hypertension.

PubMed

Abraldes, Juan G; Garcia-Tsao, Guadalupe

2017-02-01

Portal hypertension (PH) is the main consequence of cirrhosis and is responsible for the majority of its complications. Gastroesophageal varices and variceal hemorrhage are direct consequences of PH; therefore, most clinical trials in PH have been directed toward treating or preventing variceal hemorrhage. However, varices and variceal hemorrhage are not isolated events; they must be considered in the context of the presence (or absence) of other complications of cirrhosis/PH. Cirrhosis progresses across different stages, each with a different prognosis and pathophysiology and hence different therapeutic targets. In this review, the authors discuss the design of proof-of-concept studies for the assessment of new drugs for the treatment of PH, that are mainly based on the drug's ability to reduce the hepatic venous pressure gradient. They further discuss the design of studies with clinical endpoints in the context of each stage of cirrhosis, specifically targets of therapy, optimal therapies in the control arm, risk stratification, and primary outcome. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Improving the Clinical Pharmacologic Assessment of Abuse Potential: Part 1: Regulatory Context and Risk Management.

PubMed

Sellers, Edward M

2018-02-01

This article brings to the attention of drug developers the Food and Drug Administration's (FDA's) recent final Guidance to Industry on Assessment of Abuse Potential and provides practical suggestions about compliance with the Guidance. The Guidance areas are reviewed, analyzed, and placed in the context of current scientific knowledge and best practices to mitigate regulatory risk. The Guidance provides substantial new detail on what needs to be done at all stages of drug development for central nervous system-active drugs. However, because many psychopharmacologic agents have unique preclinical and clinical features, the plan for each agent needs to be not only carefully prepared but also reviewed and approved by the FDA. Examples are provided where assumptions about interpretation of the Guidance can delay development. If the expertise and experience needed for assessing abuse potential during drug development do not exist within a company, external preclinical and clinical expert should be involved. Consultation with the FDA is encouraged and important because the specific requirements for each drug will vary.

Conceptual framework of knowledge management for ethical decision-making support in neonatal intensive care.

PubMed

Frize, Monique; Yang, Lan; Walker, Robin C; O'Connor, Annette M

2005-06-01

This research is built on the belief that artificial intelligence estimations need to be integrated into clinical social context to create value for health-care decisions. In sophisticated neonatal intensive care units (NICUs), decisions to continue or discontinue aggressive treatment are an integral part of clinical practice. High-quality evidence supports clinical decision-making, and a decision-aid tool based on specific outcome information for individual NICU patients will provide significant support for parents and caregivers in making difficult "ethical" treatment decisions. In our approach, information on a newborn patient's likely outcomes is integrated with the physician's interpretation and parents' perspectives into codified knowledge. Context-sensitive content adaptation delivers personalized and customized information to a variety of users, from physicians to parents. The system provides structuralized knowledge translation and exchange between all participants in the decision, facilitating collaborative decision-making that involves parents at every stage on whether to initiate, continue, limit, or terminate intensive care for their infant.

Speech-language pathologists and the Common Core Standards initiative: an opportunity for leadership and organizational change.

PubMed

Dunkle, Jennifer; Flynn, Perry

2012-05-01

The Common Core State Standards initiative within public school education is designed to provide uniform guidelines for academic standards, including more explicit language targets. Speech-language pathologists (SLPs) are highly qualified language experts who may find new leadership roles within their clinical practice using the Common Core Standards. However, determining its usage by SLPs in clinical practice needs to be examined. This article seeks to discover the social context of organizations and organizational change in relation to clinical practice. Specifically, this article presents the diffusion of innovations theory to explain how initiatives move from ideas to institutionalization and the importance of social context in which these initiatives are introduced. Next, the values of both SLPs and organizations will be discussed. Finally, this article provides information on how to affect organizational change through the value of an affirmative, socially based theoretical perspective and methodology, appreciative inquiry. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

How clinical medical students perceive others to influence their self-regulated learning.

PubMed

Berkhout, Joris J; Helmich, Esther; Teunissen, Pim W; van der Vleuten, Cees P M; Jaarsma, A Debbie C

2017-03-01

Undergraduate medical students are prone to struggle with learning in clinical environments. One of the reasons may be that they are expected to self-regulate their learning, which often turns out to be difficult. Students' self-regulated learning is an interactive process between person and context, making a supportive context imperative. From a socio-cultural perspective, learning takes place in social practice, and therefore teachers and other hospital staff present are vital for students' self-regulated learning in a given context. Therefore, in this study we were interested in how others in a clinical environment influence clinical students' self-regulated learning. We conducted a qualitative study borrowing methods from grounded theory methodology, using semi-structured interviews facilitated by the visual Pictor technique. Fourteen medical students were purposively sampled based on age, gender, experience and current clerkship to ensure maximum variety in the data. The interviews were transcribed verbatim and were, together with the Pictor charts, analysed iteratively, using constant comparison and open, axial and interpretive coding. Others could influence students' self-regulated learning through role clarification, goal setting, learning opportunities, self-reflection and coping with emotions. We found large differences in students' self-regulated learning and their perceptions of the roles of peers, supervisors and other hospital staff. Novice students require others, mainly residents and peers, to actively help them to navigate and understand their new learning environment. Experienced students who feel settled in a clinical environment are less susceptible to the influence of others and are better able to use others to their advantage. Undergraduate medical students' self-regulated learning requires context-specific support. This is especially important for more novice students learning in a clinical environment. Their learning is influenced most heavily by peers and residents. Supporting novice students' self-regulated learning may be improved by better equipping residents and peers for this role. © 2016 The Authors. Medical Education Published by John Wiley & Sons Ltd and The Association for the Study of Medical Education.

Quantitative Analysis of Uncertainty in Medical Reporting: Creating a Standardized and Objective Methodology.

PubMed

Reiner, Bruce I

2018-04-01

Uncertainty in text-based medical reports has long been recognized as problematic, frequently resulting in misunderstanding and miscommunication. One strategy for addressing the negative clinical ramifications of report uncertainty would be the creation of a standardized methodology for characterizing and quantifying uncertainty language, which could provide both the report author and reader with context related to the perceived level of diagnostic confidence and accuracy. A number of computerized strategies could be employed in the creation of this analysis including string search, natural language processing and understanding, histogram analysis, topic modeling, and machine learning. The derived uncertainty data offers the potential to objectively analyze report uncertainty in real time and correlate with outcomes analysis for the purpose of context and user-specific decision support at the point of care, where intervention would have the greatest clinical impact.

Understanding the intersections between metabolism and cancer biology

PubMed Central

Heiden, Matthew G. Vander; DeBerardinis, Ralph J.

2017-01-01

Transformed cells adapt metabolism to support tumor initiation and progression. Specific metabolic activities can participate directly in the process of transformation or support the biological processes that enable tumor growth. Exploiting cancer metabolism for clinical benefit requires defining the pathways that are limiting for cancer progression and understanding the context specificity of metabolic preferences and liabilities in malignant cells. Progress towards answering these questions is providing new insight into cancer biology and can guide the more effective targeting of metabolism to help patients. PMID:28187287

Evidence-based policy-making: the implications of globally-applicable research for context-specific problem-solving in developing countries.

PubMed

Behague, Dominique; Tawiah, Charlotte; Rosato, Mikey; Some, Télésphore; Morrison, Joanna

2009-11-01

In the past 15 or so years, the "evidence-based medicine" (EBM) framework has become increasingly institutionalized, facilitating its transfer across the globe. In the late 1990s, the basic principles of EBM began to have a marked influence in a number of non-clinical public policy arenas. Policy-makers working in these areas are now being urged to move away from developing policies according to political ideologies to a more legitimate approach based on "scientific fact," a process termed "evidence-based policy-making" (EBPM). The conceptual diffusion of EBM to non-clinical arenas has exposed epistemologically destabilizing views regarding the definition of "science," particularly as it relates to the demands of global versus national/sub-national policy-making. Using the maternal and neonatal subfield as an ethnographic case-study, this paper explores the effects of these divergences on EBPM in 5 developing countries (Bangladesh, Burkina Faso, Ghana, Malawi and Nepal). In doing so, our analysis aims to explain why EBPM has thus far had a limited impact in the area of context-specific programmatic policy-development and implementation at the national and sub-national levels. Results highlight that the political contexts in which EBPM is played out promote uniformity of methodological and policy approaches, despite the fact that disciplinary diversity is being called for repeatedly in the public health literature. Even in situations where national EBPM diverges from international priorities, national evidence-based policies are found to hold little weight in countering global policy interests, which some informants claim are themselves legitimated, rather than informed, by evidence. Informants also highlight the way interpretations of research findings are shaped by the broader political context within which donors set priorities and distribute limited resources - contexts that are driven by the need to provide generalisable research recommendations based on scientifically replicable methods. Added to this are clear rifts between senior and junior-level experts within countries that constrain national and sub-national research agendas from serving as tools for empowered knowledge production and problem-solving. We conclude by arguing for diverse forms of research that can more effectively address context-specific problems. While such diversity may render EBPM more conflict-ridden, debate is by no means an undesirable characteristic in any evolving system of knowledge, for it has the potential to foster critical insight and localized change.

Context-based electronic health record: toward patient specific healthcare.

PubMed

Hsu, William; Taira, Ricky K; El-Saden, Suzie; Kangarloo, Hooshang; Bui, Alex A T

2012-03-01

Due to the increasingly data-intensive clinical environment, physicians now have unprecedented access to detailed clinical information from a multitude of sources. However, applying this information to guide medical decisions for a specific patient case remains challenging. One issue is related to presenting information to the practitioner: displaying a large (irrelevant) amount of information often leads to information overload. Next-generation interfaces for the electronic health record (EHR) should not only make patient data easily searchable and accessible, but also synthesize fragments of evidence documented in the entire record to understand the etiology of a disease and its clinical manifestation in individual patients. In this paper, we describe our efforts toward creating a context-based EHR, which employs biomedical ontologies and (graphical) disease models as sources of domain knowledge to identify relevant parts of the record to display. We hypothesize that knowledge (e.g., variables, relationships) from these sources can be used to standardize, annotate, and contextualize information from the patient record, improving access to relevant parts of the record and informing medical decision making. To achieve this goal, we describe a framework that aggregates and extracts findings and attributes from free-text clinical reports, maps findings to concepts in available knowledge sources, and generates a tailored presentation of the record based on the information needs of the user. We have implemented this framework in a system called Adaptive EHR, demonstrating its capabilities to present and synthesize information from neurooncology patients. This paper highlights the challenges and potential applications of leveraging disease models to improve the access, integration, and interpretation of clinical patient data. © 2012 IEEE

Implementation Science Supports Core Clinical Competencies: An Overview and Clinical Example.

PubMed

Kirchner, JoAnn E; Woodward, Eva N; Smith, Jeffrey L; Curran, Geoffrey M; Kilbourne, Amy M; Owen, Richard R; Bauer, Mark S

2016-12-08

Instead of asking clinicians to work faster or longer to improve quality of care, implementation science provides another option. Implementation science is an emerging interdisciplinary field dedicated to studying how evidence-based practice can be adopted into routine clinical care. This article summarizes principles and methods of implementation science, illustrates how they can be applied in a routine clinical setting, and highlights their importance to practicing clinicians as well as clinical trainees. A hypothetical clinical case scenario is presented that explains how implementation science improves clinical practice. The case scenario is also embedded within a real-world implementation study to improve metabolic monitoring for individuals prescribed antipsychotics. Context, recipient, and innovation (ie, the evidence-based practice) factors affected improvement of metabolic monitoring. To address these factors, an external facilitator and a local quality improvement team developed an implementation plan involving a multicomponent implementation strategy that included education, performance reports, and clinician follow-up. The clinic remained compliant with recommended metabolic monitoring at 1-year follow up. Implementation science improves clinical practice by addressing context, recipient, and innovation factors and uses this information to develop and utilize specific strategies that improve clinical practice. It also enriches clinical training, aligning with core competencies by the Accreditation Council for Graduate Medical Education and American Boards of Medical Specialties. By learning how to change clinical practice through implementation strategies, clinicians are more able to adapt in complex systems of practice. © Copyright 2016 Physicians Postgraduate Press, Inc.

Mapping the pathways of resistance to targeted therapies

PubMed Central

Wood, Kris C.

2015-01-01

Resistance substantially limits the depth and duration of clinical responses to targeted anticancer therapies. Through the use of complementary experimental approaches, investigators have revealed that cancer cells can achieve resistance through adaptation or selection driven by specific genetic, epigenetic, or microenvironmental alterations. Ultimately, these diverse alterations often lead to the activation of signaling pathways that, when co-opted, enable cancer cells to survive drug treatments. Recently developed methods enable the direct and scalable identification of the signaling pathways capable of driving resistance in specific contexts. Using these methods, novel pathways of resistance to clinically approved drugs have been identified and validated. By combining systematic resistance pathway mapping methods with studies revealing biomarkers of specific resistance pathways and pharmacological approaches to block these pathways, it may be possible to rationally construct drug combinations that yield more penetrant and lasting responses in patients. PMID:26392071

Contextual factors and clinical reasoning: differences in diagnostic and therapeutic reasoning in board certified versus resident physicians.

PubMed

McBee, Elexis; Ratcliffe, Temple; Picho, Katherine; Schuwirth, Lambert; Artino, Anthony R; Yepes-Rios, Ana Monica; Masel, Jennifer; van der Vleuten, Cees; Durning, Steven J

2017-11-15

The impact of context on the complex process of clinical reasoning is not well understood. Using situated cognition as the theoretical framework and videos to provide the same contextual "stimulus" to all participants, we examined the relationship between specific contextual factors on diagnostic and therapeutic reasoning accuracy in board certified internists versus resident physicians. Each participant viewed three videotaped clinical encounters portraying common diagnoses in internal medicine. We explicitly modified the context to assess its impact on performance (patient and physician contextual factors). Patient contextual factors, including English as a second language and emotional volatility, were portrayed in the videos. Physician participant contextual factors were self-rated sleepiness and burnout.. The accuracy of diagnostic and therapeutic reasoning was compared with covariates using Fisher Exact, Mann-Whitney U tests and Spearman Rho's correlations as appropriate. Fifteen board certified internists and 10 resident physicians participated from 2013 to 2014. Accuracy of diagnostic and therapeutic reasoning did not differ between groups despite residents reporting significantly higher rates of sleepiness (mean rank 20.45 vs 8.03, U = 0.5, p < .001) and burnout (mean rank 20.50 vs 8.00, U = 0.0, p < .001). Accuracy of diagnosis and treatment were uncorrelated (r = 0.17, p = .65). In both groups, the proportion scoring correct responses for treatment was higher than the proportion scoring correct responses for diagnosis. This study underscores that specific contextual factors appear to impact clinical reasoning performance. Further, the processes of diagnostic and therapeutic reasoning, although related, may not be interchangeable. This raises important questions about the impact that contextual factors have on clinical reasoning and provides insight into how clinical reasoning processes in more authentic settings may be explained by situated cognition theory.

Attitudes of academic pediatricians with a specific interest in child abuse toward the spanking of children.

PubMed

Fargason, C A; Chernoff, R G; Socolar, R R

1996-10-01

To evaluate the attitudes of academic child abuse professionals toward spanking, the effect of context and mode of administration on their attitudes toward spanking appropriateness, and what they teach residents about spanking. A survey. Convenience sample of 114 members of the Ambulatory Pediatric Association's Special Interest Group on Child Abuse and Neglect. Respondents were asked if spanking was an appropriate disciplinary option for children 2, 5, and 8 years of age who refused to go to bed, ran into the streets without looking, or hit a playmate. Respondents also rated the appropriateness of spanking in 6 additional scenarios where the setting in which spanking occurred was varied. Respondent's teaching practices relative to spanking observed during a clinic visit were also elicited. The response rate was 70%; 39% thought spanking was appropriate sometimes. The context and mode of spanking affected the acceptance of spanking. All respondents thought that some response was appropriate when spanking was observed during a continuity clinic visit. However, only 29% of respondents taught residents how to handle such situations. Most academic child abuse professionals believe that spanking is inappropriate and their beliefs are influenced by the context in which spanking occurs. Little is taught about how to manage spanking observed in a clinical setting.

Neurophysiology of the pelvic floor in clinical practice: a systematic literature review

PubMed Central

Bianchi, Francesca; Squintani, Giovanna Maddalena; Osio, Maurizio; Morini, Alberto; Bana, Cristina; Ardolino, Gianluca; Barbieri, Sergio; Bertolasi, Laura; Caramelli, Riccardo; Cogiamanian, Filippo; Currà, Antonio; de Scisciolo, Giuseppe; Foresti, Camillo; Frasca, Vittorio; Frasson, Emma; Inghilleri, Maurizio; Maderna, Luca; Motti, Luisa; Onesti, Emanuela; Romano, Marcello Calogero; Del Carro, Ubaldo

2017-01-01

Summary Neurophysiological testing of the pelvic floor is recognized as an essential tool to identify pathophysiological mechanisms of pelvic floor disorders, support clinical diagnosis, and aid in therapeutic decisions. Nevertheless, the diagnostic value of these tests in specific neurological diseases of the pelvic floor is not completely clarified. Seeking to fill this gap, the members of the Neurophysiology of the Pelvic Floor Study Group of the Italian Clinical Neurophysiology Society performed a systematic review of the literature to gather available evidence for and against the utility of neurophysiological tests. Our findings confirm the utility of some tests in specific clinical conditions [e.g. concentric needle electromyography, evaluation of sacral reflexes and of pudendal somatosensory evoked potentials (pSEPs) in cauda equina and conus medullaris lesions, and evaluation of pSEPs and perineal sympathetic skin response in spinal cord lesions], and support their use in clinical practice. Other tests, particularly those not currently supported by high-level evidence, when employed in individual patients, should be evaluated in the overall clinical context, or otherwise used for research purposes.

Understanding clinical work practices for cross-boundary decision support in e-health.

PubMed

Tawfik, Hissam; Anya, Obinna; Nagar, Atulya K

2012-07-01

One of the major concerns of research in integrated healthcare information systems is to enable decision support among clinicians across boundaries of organizations and regional workgroups. A necessary precursor, however, is to facilitate the construction of appropriate awareness of local clinical practices, including a clinician's actual cognitive capabilities, peculiar workplace circumstances, and specific patient-centered needs based on real-world clinical contexts across work settings. In this paper, a user-centered study aimed to investigate clinical practices across three different geographical areas-the U.K., the UAE and Nigeria-is presented. The findings indicate that differences in clinical practices among clinicians are associated with differences in local work contexts across work settings, but are moderated by adherence to best practice guidelines and the need for patient-centered care. The study further reveals that an awareness especially of the ontological, stereotypical, and situated practices plays a crucial role in adapting knowledge for cross-boundary decision support. The paper then outlines a set of design guidelines for the development of enterprise information systems for e-health. Based on the guidelines, the paper proposes the conceptual design of CaDHealth, a practice-centered framework for making sense of clinical practices across work settings for effective cross-boundary e-health decision support.

Human osteopontin splicing isoforms: known roles, potential clinical applications and activated signaling pathways.

PubMed

Gimba, E R; Tilli, T M

2013-04-30

Human osteopontin is subject to alternative splicing, which generates three isoforms, termed OPNa, OPNb and OPNc. These variants show specific expression and roles in different cell contexts. We present an overview of current knowledge of the expression profile of human OPN splicing isoforms (OPN-SIs), their tissue-specific roles, and the pathways mediating their functional properties in different pathophysiological conditions. We also describe their putative application as biomarkers, and their potential use as therapeutic targets by using antibodies, oligonucleotides or siRNA molecules. This synthesis provides new clues for a better understanding of human OPN splice variants, their roles in normal and pathological conditions, and their possible clinical applications. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

From user needs to system specifications: multi-disciplinary thematic seminars as a collaborative design method for development of health information systems.

PubMed

Scandurra, I; Hägglund, M; Koch, S

2008-08-01

This paper presents a new multi-disciplinary method for user needs analysis and requirements specification in the context of health information systems based on established theories from the fields of participatory design and computer supported cooperative work (CSCW). Whereas conventional methods imply a separate, sequential needs analysis for each profession, the "multi-disciplinary thematic seminar" (MdTS) method uses a collaborative design process. Application of the method in elderly homecare resulted in prototypes that were well adapted to the intended user groups. Vital information in the points of intersection between different care professions was elicited and a holistic view of the entire care process was obtained. Health informatics-usability specialists and clinical domain experts are necessary to apply the method. Although user needs acquisition can be time-consuming, MdTS was perceived to efficiently identify in-context user needs, and transformed these directly into requirements specifications. Consequently the method was perceived to expedite the entire ICT implementation process.

Generation of CAR T cells for adoptive therapy in the context of glioblastoma standard of care.

PubMed

Riccione, Katherine; Suryadevara, Carter M; Snyder, David; Cui, Xiuyu; Sampson, John H; Sanchez-Perez, Luis

2015-02-16

Adoptive T cell immunotherapy offers a promising strategy for specifically targeting and eliminating malignant gliomas. T cells can be engineered ex vivo to express chimeric antigen receptors specific for glioma antigens (CAR T cells). The expansion and function of adoptively transferred CAR T cells can be potentiated by the lymphodepletive and tumoricidal effects of standard of care chemotherapy and radiotherapy. We describe a method for generating CAR T cells targeting EGFRvIII, a glioma-specific antigen, and evaluating their efficacy when combined with a murine model of glioblastoma standard of care. T cells are engineered by transduction with a retroviral vector containing the anti-EGFRvIII CAR gene. Tumor-bearing animals are subjected to host conditioning by a course of temozolomide and whole brain irradiation at dose regimens designed to model clinical standard of care. CAR T cells are then delivered intravenously to primed hosts. This method can be used to evaluate the antitumor efficacy of CAR T cells in the context of standard of care.

Year in review 2009: Critical Care - infection

PubMed Central

2010-01-01

In 2009 Critical Care provided important and clinically relevant research data for management and prevention of infections in critically ill patients. The present review summarises the results of these observational studies and clinical trials and discusses them in the context of the current relevant scientific and clinical background. In particular, we discuss recent epidemiologic data on nosocomial infections in intensive care units, present new approaches to prevention of ventilator-associated pneumonia, describe recent advances in biomarker-guided antibiotic stewardship and attempt to briefly summarise specific challenges related to the management of infections caused by multidrug-resistant microorganisms and influenza A (H1N1). PMID:21122168

Regulatory issues with multiplicity in drug approval: Principles and controversies in a changing landscape.

PubMed

Benda, Norbert; Brandt, Andreas

2018-01-01

Recently, new draft guidelines on multiplicity issues in clinical trials have been issued by European Medicine Agency (EMA) and Food and Drug Administration (FDA), respectively. Multiplicity is an issue in clinical trials, if the probability of a false-positive decision is increased by insufficiently accounting for testing multiple hypotheses. We outline the regulatory principles related to multiplicity issues in confirmatory clinical trials intended to support a marketing authorization application in the EU, describe the reasons for an increasing complexity regarding multiple hypotheses testing and discuss the specific multiplicity issues emerging within the regulatory context and being relevant for drug approval.

USING FORMATIVE RESEARCH TO DEVELOP A CONTEXT-SPECIFIC APPROACH TO INFORMED CONSENT FOR CLINICAL TRIALS

PubMed Central

Corneli, Amy L.; Bentley, Margaret E.; Sorenson, James R.; Henderson, Gail E.; van der Horst, Charles; Moses, Agnes; Nkhoma, Jacqueline; Tenthani, Lyson; Ahmed, Yusuf; Heilig, Charles M.; Jamieson, Denise J.

2009-01-01

Participant understanding is of particular concern when obtaining informed consent. Recommendations for improving understanding include disclosing information using culturally appropriate and innovative approaches. To increase the effectiveness of the consent process for a clinical trial in Malawi on interventions to prevent mother-to-child transmission of HIV during breastfeeding, formative research was conducted to explore the community’s understanding of medical research as well as how to explain research through local terms and meanings. Contextual analogies and other approaches were identified to explain consent information. Guided by theory, strategies for developing culturally appropriate interventions, and recommendations from the literature, we demonstrate how the formative data were used to develop culturally appropriate counseling cards specifically for the trial in Malawi. With appropriate contextual modifications, the steps outlined here could be applied in other clinical trials conducted elsewhere, as well as in other types of research. PMID:19385837

From the bench to clinical practice: understanding the challenges and uncertainties in immunogenicity testing for biopharmaceuticals

PubMed Central

Gunn, G. R.; Sealey, D. C. F.; Jamali, F.; Meibohm, B.; Ghosh, S.

2016-01-01

Summary Unlike conventional chemical drugs where immunogenicity typically does not occur, the development of anti‐drug antibodies following treatment with biologics has led to concerns about their impact on clinical safety and efficacy. Hence the elucidation of the immunogenicity of biologics is required for drug approval by health regulatory authorities worldwide. Published ADA ‘incidence’ rates can vary greatly between same‐class products and different patient populations. Such differences are due to disparate bioanalytical methods and interpretation approaches, as well as a plethora of product‐specific and patient‐specific factors that are not fully understood. Therefore, the incidence of ADA and their association with clinical consequences cannot be generalized across products. In this context, the intent of this review article is to discuss the complex nature of ADA and key nuances of the methodologies used for immunogenicity assessments, and to dispel some fallacies and myths. PMID:26597698

Precision Medicine: Functional Advancements.

PubMed

Caskey, Thomas

2018-01-29

Precision medicine was conceptualized on the strength of genomic sequence analysis. High-throughput functional metrics have enhanced sequence interpretation and clinical precision. These technologies include metabolomics, magnetic resonance imaging, and I rhythm (cardiac monitoring), among others. These technologies are discussed and placed in clinical context for the medical specialties of internal medicine, pediatrics, obstetrics, and gynecology. Publications in these fields support the concept of a higher level of precision in identifying disease risk. Precise disease risk identification has the potential to enable intervention with greater specificity, resulting in disease prevention-an important goal of precision medicine.

A quality risk management model approach for cell therapy manufacturing.

PubMed

Lopez, Fabio; Di Bartolo, Chiara; Piazza, Tommaso; Passannanti, Antonino; Gerlach, Jörg C; Gridelli, Bruno; Triolo, Fabio

2010-12-01

International regulatory authorities view risk management as an essential production need for the development of innovative, somatic cell-based therapies in regenerative medicine. The available risk management guidelines, however, provide little guidance on specific risk analysis approaches and procedures applicable in clinical cell therapy manufacturing. This raises a number of problems. Cell manufacturing is a poorly automated process, prone to operator-introduced variations, and affected by heterogeneity of the processed organs/tissues and lot-dependent variability of reagent (e.g., collagenase) efficiency. In this study, the principal challenges faced in a cell-based product manufacturing context (i.e., high dependence on human intervention and absence of reference standards for acceptable risk levels) are identified and addressed, and a risk management model approach applicable to manufacturing of cells for clinical use is described for the first time. The use of the heuristic and pseudo-quantitative failure mode and effect analysis/failure mode and critical effect analysis risk analysis technique associated with direct estimation of severity, occurrence, and detection is, in this specific context, as effective as, but more efficient than, the analytic hierarchy process. Moreover, a severity/occurrence matrix and Pareto analysis can be successfully adopted to identify priority failure modes on which to act to mitigate risks. The application of this approach to clinical cell therapy manufacturing in regenerative medicine is also discussed. © 2010 Society for Risk Analysis.

Oxytocin Treatment, Circuitry, and Autism: A Critical Review of the Literature Placing Oxytocin Into the Autism Context.

PubMed

Guastella, Adam J; Hickie, Ian B

2016-02-01

Observed impairment in reciprocal social interaction is a diagnostic hallmark of autism spectrum disorders. There is no effective medical treatment for these problems. Psychological treatments remain costly, time intensive, and developmentally sensitive for efficacy. In this review, we explore the potential of oxytocin-based therapies for social impairments in autism. Evidence shows that acute oxytocin administration improves numerous markers critical to the social circuitry underlying social deficits in autism. Oxytocin may optimize these circuits and enhance reward, motivation, and learning to improve therapeutic outcomes. Despite this, the current evidence of therapeutic benefit from extended oxytocin treatment remains very limited. We highlight complexity in crossing from the laboratory to the autism clinical setting in evaluation of this therapeutic. We discuss a clinical trial approach that provides optimal opportunity for therapeutic response by using personalized methods that better target specific circuitry to define who will obtain benefit, at what stage of development, and the optimal delivery approach for circuitry manipulation. For the autism field, the therapeutic challenges will be resolved by a range of treatment strategies, including greater focus on specific interventions, such as oxytocin, that have a strong basis in the fundamental neurobiology of social behavior. More sophisticated and targeted clinical trials utilizing such approaches are now required, placing oxytocin into the autism context. Copyright © 2016 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.

Clinical professional governance for detailed clinical models.

PubMed

Goossen, William; Goossen-Baremans, Anneke

2013-01-01

This chapter describes the need for Detailed Clinical Models for contemporary Electronic Health Systems, data exchange and data reuse. It starts with an explanation of the components related to Detailed Clinical Models with a brief summary of knowledge representation, including terminologies representing clinic relevant "things" in the real world, and information models that abstract these in order to let computers process data about these things. Next, Detailed Clinical Models are defined and their purpose is described. It builds on existing developments around the world and accumulates in current work to create a technical specification at the level of the International Standards Organization. The core components of properly expressed Detailed Clinical Models are illustrated, including clinical knowledge and context, data element specification, code bindings to terminologies and meta-information about authors, versioning among others. Detailed Clinical Models to date are heavily based on user requirements and specify the conceptual and logical levels of modelling. It is not precise enough for specific implementations, which requires an additional step. However, this allows Detailed Clinical Models to serve as specifications for many different kinds of implementations. Examples of Detailed Clinical Models are presented both in text and in Unified Modelling Language. Detailed Clinical Models can be positioned in health information architectures, where they serve at the most detailed granular level. The chapter ends with examples of projects that create and deploy Detailed Clinical Models. All have in common that they can often reuse materials from earlier projects, and that strict governance of these models is essential to use them safely in health care information and communication technology. Clinical validation is one point of such governance, and model testing another. The Plan Do Check Act cycle can be applied for governance of Detailed Clinical Models. Finally, collections of clinical models do require a repository in which they can be stored, searched, and maintained. Governance of Detailed Clinical Models is required at local, national, and international levels.

Chimeric Antigen Receptor (CAR)-Specific Monoclonal Antibody to Detect CD19-Specific T Cells in Clinical Trials

PubMed Central

Jena, Bipulendu; Maiti, Sourindra; Huls, Helen; Singh, Harjeet; Lee, Dean A.; Champlin, Richard E.; Cooper, Laurence J. N.

2013-01-01

Clinical trials targeting CD19 on B-cell malignancies are underway with encouraging anti-tumor responses. Most infuse T cells genetically modified to express a chimeric antigen receptor (CAR) with specificity derived from the scFv region of a CD19-specific mouse monoclonal antibody (mAb, clone FMC63). We describe a novel anti-idiotype monoclonal antibody (mAb) to detect CD19-specific CAR+ T cells before and after their adoptive transfer. This mouse mAb was generated by immunizing with a cellular vaccine expressing the antigen-recognition domain of FMC63. The specificity of the mAb (clone no. 136.20.1) was confined to the scFv region of the CAR as validated by inhibiting CAR-dependent lysis of CD19+ tumor targets. This clone can be used to detect CD19-specific CAR+ T cells in peripheral blood mononuclear cells at a sensitivity of 1∶1,000. In clinical settings the mAb is used to inform on the immunophenotype and persistence of administered CD19-specific T cells. Thus, our CD19-specific CAR mAb (clone no. 136.20.1) will be useful to investigators implementing CD19-specific CAR+ T cells to treat B-lineage malignancies. The methodology described to develop a CAR-specific anti-idiotypic mAb could be extended to other gene therapy trials targeting different tumor associated antigens in the context of CAR-based adoptive T-cell therapy. PMID:23469246

A Comparative Discourse Study of Simulated Clinical Roleplays in Two Assessment Contexts: Validating a Specific-Purpose Language Test

ERIC Educational Resources Information Center

Woodward-Kron, Robyn; Elder, Catherine

2016-01-01

The aim of this paper is to investigate from a discourse analytic perspective task authenticity in the speaking component of the Occupational English Test (OET), an English language screening test for clinicians designed to reflect the language demands of health professional-patient communication. The study compares the OET speaking sub-test…

Developing prehospital clinical practice guidelines for resource limited settings: why re-invent the wheel?

PubMed

McCaul, Michael; de Waal, Ben; Hodkinson, Peter; Pigoga, Jennifer L; Young, Taryn; Wallis, Lee A

2018-02-05

Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, the volume of literature is not matched by research into alternative methods of CPG development using existing CPG documents-a specific issue for guideline development groups in low- and middle-income countries. We report on how we developed a context specific prehospital CPG using an alternative guideline development method. Difficulties experienced and lessons learnt in applying existing global guidelines' recommendations to a national context are highlighted. The project produced the first emergency care CPG for prehospital providers in Africa. It included > 270 CPGs and produced over 1000 recommendations for prehospital emergency care. We encountered various difficulties, including (1) applicability issues: few pre-hospital CPGs applicable to Africa, (2) evidence synthesis: heterogeneous levels of evidence classifications and (3) guideline quality. Learning points included (1) focusing on key CPGs and evidence mapping, (2) searching other resources for CPGs, (3) broad representation on CPG advisory boards and (4) transparency and knowledge translation. Re-inventing the wheel to produce CPGs is not always feasible. We hope this paper will encourage further projects to use existing CPGs in developing guidance to improve patient care in resource-limited settings.

Characteristics, correlates, and outcomes of childhood and adolescent depressive disorders

PubMed Central

Rao, Uma; Chen, Li-Ann

2009-01-01

Depressive illness beginning early in life can have serious developmental and functional consequences. Therefore, understanding the disorder during this developmental stage is critical for determining its etiology and course, as well as for deveiopinq effective intervention straieqies. This paper summarizes current knoviedqe reqardinq the etiology, phenomenoiogy, correlates, natural course, and consequences of unipolar depression in children and adolescents. Using adult depression as a framevork, the unique aspects of childhood and adolescence are considered in order to better understand depression within a developmental context. The data suggest that the clinical presentation, correlates, and natural course of depression are remarkably similar across the lifespan. There are, however, important developmental differences. Specifically, the familial and psychological context in which depression develops in youngsters is associated with variability in the frequency and nature of depressive symptoms and comorbid conditions among children and adolescents. Maturational differences have also been identified in the neurobiological correlates of depression. These developmental differences may be associated with the observed variability in clinical response to treatment and longitudinal course. Characterization of the developmental differences will be helpful in developing more specific and effective interventions for youngsters, thereby allowing them to reach their full potential as adults. PMID:19432387

The Counseling Center Assessment of Psychological Symptoms (CCAPS-62): Acceptance, feasibility, and initial psychometric properties in a UK student population.

PubMed

Broglia, Emma; Millings, Abigail; Barkham, Michael

2017-09-01

The burden and severity of student mental health continue to increase in parallel with increasing financial pressures on students and services alike. There is a need for a student-specific measure of distress that acknowledges their unique context. This study examined the feasibility, acceptance, and initial psychometric properties of a US measure, the Counseling Center Assessment of Psychological Symptoms (CCAPS), in a UK student sample. A sample of 294 UK help-seeking students from two universities completed the CCAPS-62 and Clinical Outcomes in Routine Evaluation (CORE-10) as a comparator. The factor solution and reliability of the CCAPS-62 were examined. Correlations and clinical boundaries were determined between the CCAPS-62 subscales and CORE-10, and comparisons were made with US published norms. The CCAPS-62 demonstrated a strong factor solution that matched the intended subscales. All subscales had good reliability and correlated significantly with the CORE-10. The agreement on caseness between the two measures was 92.8% with 86.3% reaching clinical threshold on both the CCAPS-62 and CORE-10. Severity was most noticeable for academic distress, depression, anxiety, and social anxiety. Compared to US data, UK students showed higher clinical severity for all psychological symptoms. The CCAPS-62 is a reliable and psychometrically valid assessment measure to use with UK students without revision. The overall distress indicated is similar to that of the CORE-10, but the individual subscales are more informative of specific student concerns including academic distress, social anxiety, and substance abuse. Potential benefits of administering a student-focused assessment measure in student counselling services are discussed. University students attending counselling in the UK demonstrate clinical severity for academic distress, depression, anxiety, and social anxiety. Compared to university students in the US, UK students present with higher clinical severity on all contextual measures of student psychological distress. It is advantageous for university counselling services to administer a student-specific clinical measure over measures intended for the general clinical population. CCAPS-62 is an acceptable, feasible, and psychometrically valid measure of student psychological distress that can be used in the UK without revision. It is important for university counselling services to continue to provide support from therapists that are trained and experienced in the university context over services intended for the general clinical population. Copyright © 2017 John Wiley & Sons, Ltd.

Utility of HLA Antibody Testing in Kidney Transplantation

PubMed Central

Konvalinka, Ana

2015-01-01

HLA antigens are polymorphic proteins expressed on donor kidney allograft endothelium and are critical targets for recipient immune recognition. HLA antibodies are risk factors for acute and chronic rejection and allograft loss. Solid-phase immunoassays for HLA antibody detection represent a major advance in sensitivity and specificity over cell-based methods and are widely used in organ allocation and pretransplant risk assessment. Post-transplant, development of de novo donor–specific HLA antibodies and/or increase in donor-specific antibodies from pretransplant levels are associated with adverse outcomes. Although single antigen bead assays have allowed sensitive detection of recipient HLA antibodies and their specificities, a number of interpretive considerations must be appreciated to understand test results in clinical and research contexts. This review, which is especially relevant for clinicians caring for transplant patients, discusses the technical aspects of single antigen bead assays, emphasizes their quantitative limitations, and explores the utility of HLA antibody testing in identifying and managing important pre- and post-transplant clinical outcomes. PMID:25804279

A conceptual framework of clinical nursing care in intensive care.

PubMed

da Silva, Rafael Celestino; Ferreira, Márcia de Assunção; Apostolidis, Thémistoklis; Brandão, Marcos Antônio Gomes

2015-01-01

to propose a conceptual framework for clinical nursing care in intensive care. descriptive and qualitative field research, carried out with 21 nurses from an intensive care unit of a federal public hospital. We conducted semi-structured interviews and thematic and lexical content analysis, supported by Alceste software. the characteristics of clinical intensive care emerge from the specialized knowledge of the interaction, the work context, types of patients and nurses characteristic of the intensive care and care frameworks. the conceptual framework of the clinic's intensive care articulates elements characteristic of the dynamics of this scenario: objective elements regarding technology and attention to equipment and subjective elements related to human interaction, specific of nursing care, countering criticism based on dehumanization.

Students' approaches to learning in a clinical practicum: A psychometric evaluation based on item response theory.

PubMed

Zhao, Yue; Kuan, Hoi Kei; Chung, Joyce O K; Chan, Cecilia K Y; Li, William H C

2018-07-01

The investigation of learning approaches in the clinical workplace context has remained an under-researched area. Despite the validation of learning approach instruments and their applications in various clinical contexts, little is known about the extent to which an individual item, that reflects a specific learning strategy and motive, effectively contributes to characterizing students' learning approaches. This study aimed to measure nursing students' approaches to learning in a clinical practicum using the Approaches to Learning at Work Questionnaire (ALWQ). Survey research design was used in the study. A sample of year 3 nursing students (n = 208) who undertook a 6-week clinical practicum course participated in the study. Factor analyses were conducted, followed by an item response theory analysis, including model assumption evaluation (unidimensionality and local independence), item calibration and goodness-of-fit assessment. Two subscales, deep and surface, were derived. Findings suggested that: (a) items measuring the deep motive from intrinsic interest and deep strategies of relating new ideas to similar situations, and that of concept mapping served as the strongest discriminating indicators; (b) the surface strategy of memorizing facts and details without an overall picture exhibited the highest discriminating power among all surface items; and, (c) both subscales appeared to be informative in assessing a broad range of the corresponding latent trait. The 21-item ALWQ derived from this study presented an efficient, internally consistent and precise measure. Findings provided a useful psychometric evaluation of the ALWQ in the clinical practicum context, added evidence to the utility of the ALWQ for nursing education practice and research, and echoed the discussions from previous studies on the role of the contextual factors in influencing student choices of different learning strategies. They provided insights for clinical educators to measure nursing students' approaches to learning and facilitate their learning in the clinical practicum setting. Copyright © 2018. Published by Elsevier Ltd.

Women, weight, poverty and menopause: understanding health practices in a context of chronic disease prevention.

PubMed

Audet, Mélisa; Dumas, Alex; Binette, Rachelle; Dionne, Isabelle J

2017-11-01

Socioeconomic inequalities in health persist despite major investments in illness prevention campaigns and universal healthcare systems. In this context, the increased risks of chronic diseases of specific sub-groups of vulnerable populations should be further investigated. The objective of this qualitative study is to examine the interaction between socioeconomic status (SES) and body weight in order to understand underprivileged women's increased vulnerability to chronic diseases after menopause. By drawing specifically on Pierre Bourdieu's sociocultural theory of practice, 20 semi-structured interviews were conducted from May to December of 2013 to investigate the health practices of clinically overweight, postmenopausal women living an underprivileged life in Canada. Findings emphasise that poor life conditions undermine personal investment in preventive health and weight loss, showing the importance for policy makers to bring stronger consideration on upstream determinants of health. © 2017 Foundation for the Sociology of Health & Illness.

Alcohol Biomarkers in Clinical and Forensic Contexts.

PubMed

Andresen-Streichert, Hilke; Müller, Alexander; Glahn, Alexander; Skopp, Gisela; Sterneck, Martina

2018-05-04

Biomarkers of alcohol consumption are important not only in forensic contexts, e.g., in child custody proceedings or as documentation of alcohol abstinence after temporary confiscation of a driver's license. They are increasingly being used in clinical medicine as well for verification of abstinence or to rule out the harmful use of alcohol. This review is based on pertinent publications that were retrieved by a selective literature search in PubMed concerning the direct and indirect alcohol markers discussed here, as well as on the authors' experience in laboratory analysis and clinical medicine. Alongside the direct demonstration of ethanol, the available markers of alcohol consumption include the classic indirect markers carbohydrate-deficient transferrin (CDT), gamma-glutamyltransferase (GGT), and mean corpuscular volume (MCV) as well as direct alcohol markers such as ethyl glucuronide (EtG) and ethyl sulfate (EtS) in serum and urine and EtG and fatty acid ethyl esters (FAEE) in hair. Phosphatidylethanol (PEth) is a promising parameter that com - plements the existing spectrum of tests with high specificity (48-89%) and sensi - tivity (88-100%). In routine clinical practice, the demonstration of positive alcohol markers often leads patients to admit previously denied alcohol use. This makes it possible to motivate the patient to undergo treatment for alcoholism. The available alcohol biomarkers vary in sensitivity and specificity with respect to the time period over which they indicate alcohol use and the minimum extent of alcohol use that they can detect. The appropriate marker or combination of markers should be chosen in each case according to the particular question that is to be answered by laboratory analysis.

Barriers and benefits associated with nurses information seeking related to patient education needs on clinical nursing units.

PubMed

Jones, Josette; Schilling, Katherine; Pesut, Daniel

2011-01-01

The purpose of this study was to answer the following two questions: What are clinical nurses' rationales for their approaches to finding patient educational materials on the web? What are perceived barriers and benefits associated with the use of web-based information resources for patient education in the context of nursing clinical practice?Over 179 individual data units were analyzed to understand clinical nurses' rationales for their approaches to find patient educational materials on the web. Rationales were defined as those underlying catalysts or activators leading to an information need. Analyses found that the primary reasons why clinical nurses conducted web-based information searches included direct patient requests ( 9 requests), colleague requests (6 requests), building patient materials collections (4), patients' family requests (3), routine teaching (1), personal development (1), or staff development (1). From these data, four broad themes emerged: professional reasons, personal reasons, technology reasons, and organization reasons for selecting information resources. Content analysis identified 306 individual data units representing either 'benefits' (178 units) or 'barriers' (128) to the nurses' use of web resources for on-unit patient care. Inter-rater reliability was assessed and found to be excellent (r = 0.943 to 0.961). The primary themes that emerged as barriers to the used of web-based resources included: 1) time requirements to perform a search, 2) nurses' experience and knowledge about the resources or required technology, 3) specific characteristics of individuals electronic information resources, and 4) organizational procedures and policies. Three primary themes that represented the benefits of using web-based resources were also identified: 1) past experiences and knowledge of a specific resource or the required technologies, 2) availability and accessibility on the unit, and 3) specific characteristics of individual information tool. In many cases, nurses commented on specific characteristics or features of favorite information resources. Favorite sites included a variety or reputable health care organizations that displayed context in text, audio, and/or video. In addition such sites were described as easy-to read and provided content related to patient-focused information or specific content such as toll free telephone contact numbers.Information searching is the interaction between and among information users and computer-based information systems. Information seeking is becoming an important part of the knowledge work of nurses. Information seeking and searching intersects with the field of human computer interaction (HCI), which focuses on all aspects of human, and computer interactions. Users of an information system are understood as "actors" in situations, with a set of skills and shared practices based on work experiences with others. Designing better tools and developing information searching strategies that support, extend, and transform practices, begins by asking: Who are the users? What are the tasks? What is the interplay between the technology and the organization of the task? This study contributes fundamental data and information about the rationales nurses use in information seeking tasks. In addition it provides empirical evidences regarding barriers and benefits of information seeking in the context of patient education needs in inpatient clinical settings.

BSACI guideline for the diagnosis and management of peanut and tree nut allergy.

PubMed

Stiefel, G; Anagnostou, K; Boyle, R J; Brathwaite, N; Ewan, P; Fox, A T; Huber, P; Luyt, D; Till, S J; Venter, C; Clark, A T

2017-06-01

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required. © 2017 John Wiley & Sons Ltd.

Treating childhood pneumonia in hard-to-reach areas: a model-based comparison of mobile clinics and community-based care.

PubMed

Pitt, Catherine; Roberts, Bayard; Checchi, Francesco

2012-01-10

Where hard-to-access populations (such as those living in insecure areas) lack access to basic health services, relief agencies, donors, and ministries of health face a dilemma in selecting the most effective intervention strategy. This paper uses a decision mathematical model to estimate the relative effectiveness of two alternative strategies, mobile clinics and fixed community-based health services, for antibiotic treatment of childhood pneumonia, the world's leading cause of child mortality. A "Markov cycle tree" cohort model was developed in Excel with Visual Basic to compare the number of deaths from pneumonia in children aged 1 to 59 months expected under three scenarios: 1) No curative services available, 2) Curative services provided by a highly-skilled but intermittent mobile clinic, and 3) Curative services provided by a low-skilled community health post. Parameter values were informed by literature and expert interviews. Probabilistic sensitivity analyses were conducted for several plausible scenarios. We estimated median pneumonia-specific under-5 mortality rates of 0.51 (95% credible interval: 0.49 to 0.541) deaths per 10,000 child-days without treatment, 0.45 (95% CI: 0.43 to 0.48) with weekly mobile clinics, and 0.31 (95% CI: 0.29 to 0.32) with CHWs in fixed health posts. Sensitivity analyses found the fixed strategy superior, except when mobile clinics visited communities daily, where rates of care-seeking were substantially higher at mobile clinics than fixed posts, or where several variables simultaneously differed substantially from our baseline assumptions. Current evidence does not support the hypothesis that mobile clinics are more effective than CHWs. A CHW strategy therefore warrants consideration in high-mortality, hard-to-access areas. Uncertainty remains, and parameter values may vary across contexts, but the model allows preliminary findings to be updated as new or context-specific evidence becomes available. Decision analytic modelling can guide needed field-based research efforts in hard-to-access areas and offer evidence-based insights for decision-makers.

Explaining parent-child (dis)agreement in generic and short stature-specific health-related quality of life reports: do family and social relationships matter?

PubMed

Quitmann, Julia; Rohenkohl, Anja; Sommer, Rachel; Bullinger, Monika; Silva, Neuza

2016-10-21

In the context of health-related quality of life (HrQoL) assessment in pediatric short stature, the present study aimed to examine the levels of agreement/disagreement between parents' and children's reports of generic and condition-specific HrQoL, and to identify socio-demographic, clinical and psychosocial variables associated with the extent and direction of parent-child discrepancies. This study was part of the retest phase of the QoLISSY project, which was a multicenter study conducted simultaneously in France, Germany, Spain, Sweden and UK. The sample comprised 137 dyads of children/adolescents between 8 and 18 years of age, diagnosed with growth hormone deficiency (GHD) or idiopathic short stature (ISS), and one of their parents. The participants completed child- and parent-reported questionnaires on generic (KIDSCREEN-10 Index) and condition-specific HrQoL (QoLISSY Core Module). Children/adolescents also reported on social support (Oslo 3-items Social Support Scale) and parents assessed the parent-child relationships (Parental Role subscale of the Social Adjustment Scale) and burden of short stature on parents (QoLISSY- additional module). The parent-child agreement on reported HrQoL was strong (intraclass correlation coefficients between .59 and .80). The rates of parent-child discrepancies were 61.5 % for generic and 35.2 % for condition-specific HrQoL, with the parents being more prone to report lower generic (42.3 %) and condition-specific HrQoL (23.7 %) than their children. The extent of discrepancies was better explained by family and social relationships than by clinical and socio-demographic variables: poorer parent-child relationships and better children's social support were associated with larger discrepancies in generic HrQoL, while more parental burden was associated with larger discrepancies in condition-specific HrQoL reports. Regarding the direction of discrepancies, higher parental burden was significantly associated with parents' underrating, and better children's social support was significantly associated with parents' overrating of condition-specific HrQoL. Routine assessment of pediatric HrQoL in healthcare and research contexts should include child- and parent-reported data as complementary sources of information, and also consider the family and social context.

Biomarkers and surrogate endpoints in clinical trials.

PubMed

Fleming, Thomas R; Powers, John H

2012-11-10

One of the most important considerations in designing clinical trials is the choice of outcome measures. These outcome measures could be clinically meaningful endpoints that are direct measures of how patients feel, function, and survive. Alternatively, indirect measures, such as biomarkers that include physical signs of disease, laboratory measures, and radiological tests, often are considered as replacement endpoints or 'surrogates' for clinically meaningful endpoints. We discuss the definitions of clinically meaningful endpoints and surrogate endpoints, and provide examples from recent clinical trials. We provide insight into why indirect measures such as biomarkers may fail to provide reliable evidence about the benefit-to-risk profile of interventions. We also discuss the nature of evidence that is important in assessing whether treatment effects on a biomarker reliably predict effects on a clinically meaningful endpoint, and provide insights into why this reliability is specific to the context of use of the biomarker. Copyright © 2012 John Wiley & Sons, Ltd.

Biomarkers and Surrogate Endpoints In Clinical Trials

PubMed Central

Fleming, Thomas R.; Powers, John H

2012-01-01

One of the most important considerations in designing clinical trials is the choice of outcome measures. These outcome measures could be clinically meaningful endpoints that are direct measures of how patients feel, function and survive. Alternatively, indirect measures, such as biomarkers that include physical signs of disease, laboratory measures and radiological tests, often are considered as replacement endpoints or “surrogates” for clinically meaningful endpoints. We discuss the definitions of clinically meaningful endpoints and surrogate endpoints, and provide examples from recent clinical trials. We provide insight into why indirect measures such as biomarkers may fail to provide reliable evidence about the benefit-to-risk profile of interventions. We also discuss the nature of evidence that is important in assessing whether treatment effects on a biomarker reliably predict effects on a clinically meaningful endpoint, and provide insights into why this reliability is specific to the context of use of the biomarker. . PMID:22711298

Reproductive tourism in Argentina: clinic accreditation and its implications for consumers, health professionals and policy makers.

PubMed

Smith, Elise; Behrmann, Jason; Martin, Carolina; Williams-Jones, Bryn

2010-08-01

A subcategory of medical tourism, reproductive tourism has been the subject of much public and policy debate in recent years. Specific concerns include: the exploitation of individuals and communities, access to needed health care services, fair allocation of limited resources, and the quality and safety of services provided by private clinics. To date, the focus of attention has been on the thriving medical and reproductive tourism sectors in Asia and Eastern Europe; there has been much less consideration given to more recent 'players' in Latin America, notably fertility clinics in Chile, Brazil, Mexico and Argentina. In this paper, we examine the context-specific ethical and policy implications of private Argentinean fertility clinics that market reproductive services via the internet. Whether or not one agrees that reproductive services should be made available as consumer goods, the fact is that they are provided as such by private clinics around the world. We argue that basic national regulatory mechanisms are required in countries such as Argentina that are marketing fertility services to local and international publics. Specifically, regular oversight of all fertility clinics is essential to ensure that consumer information is accurate and that marketed services are safe and effective. It is in the best interests of consumers, health professionals and policy makers that the reproductive tourism industry adopts safe and responsible medical practices.

Context-specific adjustment of cognitive control: Transfer of adaptive control sets.

PubMed

Surrey, Caroline; Dreisbach, Gesine; Fischer, Rico

2017-11-01

Cognitive control protects processing of relevant information from interference by irrelevant information. The level of this processing selectivity can be flexibly adjusted to different control demands (e.g., frequency of conflict) associated with a certain context, leading to the formation of specific context-control associations. In the present study we investigated the robustness and transferability of the acquired context-control demands to new situations. In three experiments, we used a version of the context-specific proportion congruence (CSPC) paradigm, in which each context (e.g., location) is associated with a specific conflict frequency, determining high and low control demands. In a learning phase, associations between context and control demands were established. In a subsequent transfer block, stimulus-response mappings, whole task sets, or context-control demands changed. Results showed an impressive robustness of context-control associations, as context-specific adjustments of control from the learning phase were virtually unaffected by new stimuli and tasks in the transfer block. Only a change of the context-control demand eliminated the context-specific adjustment of control. These findings suggest that context-control associations that have proven to be adaptive in the past are continuously applied despite major changes in the task structure as long as the context-control associations remain the same.

From Clinic to Classroom: A Case Study of a Literacy Specialist Examining Teacher Learning and Instructional Decision Making

ERIC Educational Resources Information Center

Pontrello, Camille Marie

2011-01-01

The purpose of this case study was to explore how the specific content knowledge developed in a newly certified literacy specialist's practicum experiences are taken up in her practice as she supports the learning of her struggling literacy learners in the situated context of the middle school. Focused on her perspective, the present study…

Reporting results from whole-genome and whole-exome sequencing in clinical practice: a proposal for Canada?

PubMed

Zawati, Ma'n H; Parry, David; Thorogood, Adrian; Nguyen, Minh Thu; Boycott, Kym M; Rosenblatt, David; Knoppers, Bartha Maria

2014-01-01

This article proposes recommendations for the use of whole-genome and whole-exome (WGS/WES) sequencing in clinical practice, endorsed by the board of directors of the Canadian College of Medical Geneticists. The publication of statements and recommendations by several international and national organisations on clinical WGS/WES has prompted a need for Canadian-specific guidance. A multi-disciplinary group consisting of lawyers, ethicists, genetic researchers, and clinical geneticists was assembled to review existing guidelines on WGS/WES and identify provisions relevant to the Canadian context. Definitions were provided to orient the recommendations and to minimize confusion with other recommendations. Recommendations include the following: WGS/WES should be used in a judicious and cost-efficient manner; WGS/WES should be used to answer a clinical question; and physicians need to explain to adult patients the nature of the results that could arise, so as to allow them to make informed choices over whether to take the test and which results they wish to receive. Recommendations are also provided for WGS/WES in the pediatric context, and for when results implicate patients' family members. These recommendations are only a proposal to be developed into comprehensive Canadian-based guidelines. They aim to promote discussion about the reporting of WGS/WES results, and to encourage the ethical implementation of these new technologies in the clinical setting.

A JAVA-based multimedia tool for clinical practice guidelines.

PubMed

Maojo, V; Herrero, C; Valenzuela, F; Crespo, J; Lazaro, P; Pazos, A

1997-01-01

We have developed a specific language for the representation of Clinical Practice Guidelines (CPGs) and Windows C++ and platform independent JAVA applications for multimedia presentation and edition of electronically stored CPGs. This approach facilitates translation of guidelines and protocols from paper to computer-based flowchart representations. Users can navigate through the algorithm with a friendly user interface and access related multimedia information within the context of each clinical problem. CPGs can be stored in a computer server and distributed over the World Wide Web, facilitating dissemination, local adaptation, and use as a reference element in medical care. We have chosen the Agency for Health Care and Policy Research's heart failure guideline to demonstrate the capabilities of our tool.

Digital Platforms in the Assessment and Monitoring of Patients with Bipolar Disorder

PubMed Central

Rajagopalan, Arvind; Shah, Pooja; Zhang, Melvyn W.; Ho, Roger C.

2017-01-01

This paper aims to review the application of digital platforms in the assessment and monitoring of patients with Bipolar Disorder (BPD). We will detail the current clinical criteria for the diagnosis of BPD and the tools available for patient assessment in the clinic setting. We will go on to highlight the difficulties in the assessment and monitoring of BPD patients in the clinical context. Finally, we will elaborate upon the impact that diital platforms have made, and have the potential to make, on healthcare, mental health, and specifically the management of BPD, before going on to evaluate the benefits and drawbacks of the use of such technology. PMID:29137156

Healthcare provider education to support integration of pharmacogenomics in practice: the eMERGE Network experience

PubMed Central

Rohrer Vitek, Carolyn R; Abul-Husn, Noura S; Connolly, John J; Hartzler, Andrea L; Kitchner, Terrie; Peterson, Josh F; Rasmussen, Luke V; Smith, Maureen E; Stallings, Sarah; Williams, Marc S; Wolf, Wendy A; Prows, Cynthia A

2017-01-01

Ten organizations within the Electronic Medical Records and Genomics Network developed programs to implement pharmacogenomic sequencing and clinical decision support into clinical settings. Recognizing the importance of informed prescribers, a variety of strategies were used to incorporate provider education to support implementation. Education experiences with pharmacogenomics are described within the context of each organization's prior involvement, including the scope and scale of implementation specific to their Electronic Medical Records and Genomics projects. We describe common and distinct education strategies, provide exemplars and share challenges. Lessons learned inform future perspectives. Future pharmacogenomics clinical implementation initiatives need to include funding toward implementing provider education and evaluating outcomes. PMID:28639489

Ligand-independent TLR signals generated by ectopic overexpression of MyD88 generate local and systemic anti-tumor immunity

PubMed Central

Hartman, Zachary C.; Osada, Takuya; Glass, Oliver; Yang, Xiao Y.; Lei, Gang-jun; Lyerly, H. Kim; Clay, Timothy M.

2010-01-01

Although critical for initiating and regulating immune responses, the therapeutic use of individual cytokines as anti-cancer immunotherapeutic agents has achieved only modest clinical success. Consequently, many current strategies have focused on the use of specific immunotherapeutic agonists that engage individual receptors of innate immune networks, such as the Toll Like-Receptor (TLR) system, each resulting in specific patterns of gene expression, cytokine production and inflammatory outcome. However, these immunotherapeutics are constrained by variable cellular TLR expression and responsiveness to particular TLR agonists, as well as the specific cellular context of different tumors. We hypothesized that overexpression of MyD88, a pivotal regulator of multiple TLR signaling pathways, could circumvent these constraints and mimic coordinated TLR signaling across all cell types in a ligand independent fashion. To explore this hypothesis, we generated an adenoviral vector expressing MyD88 and demonstrate that Ad-MyD88 infection elicits extensive Th1-specific transcriptional and secreted cytokine signatures in all murine and human cell types tested in vitro and in vivo. Importantly, in vivo intratumoral injection of Ad-MyD88 into established tumor masses enhanced adaptive immune responses and inhibited local tumor immunosuppression, resulting in significantly inhibited local and systemic growth of multiple tumor types. Finally, Ad-MyD88 infection of primary human dendritic cells, tumor associated fibroblasts, and colorectal carcinoma cells elicited significant Th1-type cytokine responses, resulting in enhanced tumor cell lysis and expansion of human tumor antigen-specific T-cells. Thus, Ad-MyD88 initiated robust anti-tumor activity in established murine tumor microenvironments and in human contexts, suggesting its potential effectiveness as a clinical immunotherapeutic strategy. PMID:20823152

Chronic homework in emerging borderlands of healthcare.

PubMed

Mattingly, Cheryl; Grøn, Lone; Meinert, Lotte

2011-09-01

The task of caring for those with chronic illnesses has gained a new centrality in health care at a global level. We introduce the concept of "chronic homework" to offer a critical reflection on the treatment of chronic illnesses in three quite different national and local contexts: Uganda, Denmark, and the United States. A major challenge for clinicians, patients, and family caregivers is how to navigate the task of moving health care from clinic to home. By "chronic homework," we refer to the work patients and families are expected to carry out in their home contexts as part of the treatment of chronic conditions. Families and patients spend time receiving training by clinical experts in the various tasks they are to do at home. While this "colonization" of the popular domain could easily be understood from a Foucauldian perspective as yet another emerging mode of governmentality, this a conceptualization can oversimplify the way specific practices of homework are re-imagined and redirected by patients and significant others in their home surroundings. In light of this re-invention of homework in local home contexts, we foreground another conceptual trope, describing chronic homework as a borderland practice.

Electrophysiological correlates of oxytocin-induced enhancement of social performance monitoring.

PubMed

de Bruijn, Ellen R A; Ruissen, Margit I; Radke, Sina

2017-10-01

Altered performance monitoring has been demonstrated after administration of different pharmacological compounds and in various clinical populations, such as excessive neurophysiological responses to mistakes in anxiety disorders. Here, a novel social pharmacological approach was applied to investigate whether oxytocin administration (24 IU) enhances performance monitoring for errors that have negative consequences for another individual, so-called social mistakes. Healthy male volunteers (N = 24) participated in a placebo-controlled crossover design. EEG measures were obtained while pairs of participants performed a speeded choice reaction-time task in an individual and social context. Following oxytocin administration, error-related negativity amplitudes were increased for social compared with individual mistakes. This increase was not found in the placebo condition. No effects of oxytocin were present in the individual context. The current study shows that oxytocin enhances performance monitoring specifically for social mistakes. This outcome is in line with a presumed role for oxytocin in salience attribution to social cues and underlines its context-dependency. Combining these processes may thus open up new research avenues and advance our understanding of individual differences in performance monitoring and oxytocin responses from a social neurocognitive, pharmacological and clinical perspective. © The Author (2017). Published by Oxford University Press.

Assessment of first-year veterinary students' communication skills using an objective structured clinical examination: the importance of context.

PubMed

Hecker, Kent G; Adams, Cindy L; Coe, Jason B

2012-01-01

Communication skills are considered to be a core clinical skill in veterinary medicine and essential for practice success, including outcomes of care for patients and clients. While veterinary schools include communication skills training in their programs, there is minimal knowledge on how best to assess communication competence throughout the undergraduate program. The purpose of this study was to further our understanding of the reliability, utility, and suitability of a communication skills Objective Structured Clinical Examination (OSCE). Specifically we wanted to (1) identify the greatest source of variability (student, rater, station, and track) within a first-year, four station OSCE using exam scores and scores from videotape review by two trained raters, and (2) determine the effect of different stations on students' communication skills performance. Reliability of the scores from both the exam data and the two expert raters was 0.50 and 0.46 respectively, with the greatest amount of variance attributable to student by station. The percentage of variance due to raters in the exam data was 16.35%, whereas the percentage of variance for the two expert raters was 0%. These results have three important implications. First, the results reinforce the need for communication educators to emphasize that use of communication skills is moderated by the context of the clinical interaction. Second, by increasing rater training the amount of error in the scores due to raters can be reduced and inter-rater reliability increases. Third, the communication assessment method (in this case the OSCE checklist) should be built purposefully, taking into consideration the context of the case.

Eating disorders in the context of preconception care: fertility specialists' knowledge, attitudes, and clinical practices.

PubMed

Rodino, Iolanda S; Byrne, Susan M; Sanders, Katherine A

2017-02-01

To gauge fertility specialists' knowledge, clinical practices, and training needs in regard to eating disorders. Cross-sectional study. Fertility clinics. Eighty Australian and New Zealand fertility specialists who were members of the Fertility Society of Australia. None. Responses to an anonymously completed online questionnaire. Approximately 54% of doctors correctly identified the body mass index relevant to anorexia nervosa, and 30% identified menstrual disturbances for anorexia, while 63.8% of doctors incorrectly nominated maladaptive weight control behaviors as a characteristic of binge eating disorder. While clinicians (83.7%) agreed it was important to screen for eating disorders during preconception assessments, 35% routinely screened for eating disorders and 8.8% indicated that their clinics had clinical practice guidelines for management of eating disorders. A minority of participants (13.8%) felt satisfied with their level of university training in eating disorders, 37.5% of doctors felt confident in their ability to recognize symptoms of an eating disorder, and 96.2% indicated a need for further education and clinical guidelines. On most items examined, knowledge and clinical practices regarding eating disorders did not differ according to doctor gender or years of clinical experience working as a fertility specialist. Knowledge about eating disorders in the context of fertility treatment is important. This study highlights the uncertainty among fertility specialists in detecting features of eating disorders. The findings point to the importance of further education and training, including the development of clinical guidelines specific to fertility health care providers. Copyright © 2016 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Extinction learning is slower, weaker and less context specific after alcohol

PubMed Central

Bisby, James A.; King, John A.; Sulpizio, Valentina; Degeilh, Fanny; Valerie Curran, H.; Burgess, Neil

2015-01-01

Alcohol is frequently involved in psychological trauma and often used by individuals to reduce fear and anxiety. We examined the effects of alcohol on fear acquisition and extinction within a virtual environment. Healthy volunteers were administered alcohol (0.4 g/kg) or placebo and underwent acquisition and extinction from different viewpoints of a virtual courtyard, in which the conditioned stimulus, paired with a mild electric shock, was centrally located. Participants returned the following day to test fear recall from both viewpoints of the courtyard. Skin conductance responses were recorded as an index of conditioned fear. Successful fear acquisition under alcohol contrasted with impaired extinction learning evidenced by persistent conditioned responses (Experiment 1). Participants’ impairments in extinction under alcohol correlated with impairments in remembering object-locations in the courtyard seen from one viewpoint when tested from the other viewpoint. Alcohol-induced extinction impairments were overcome by increasing the number of extinction trials (Experiment 2). However, a test of fear recall the next day showed persistent fear in the alcohol group across both viewpoints. Thus, alcohol impaired extinction rather than acquisition of fear, suggesting that extinction is more dependent than acquisition on alcohol-sensitive representations of spatial context. Overall, extinction learning under alcohol was slower, weaker and less context-specific, resulting in persistent fear at test that generalized to the extinction viewpoint. The selective effect on extinction suggests an effect of alcohol on prefrontal involvement, while the reduced context-specificity implicates the hippocampus. These findings have important implications for the use of alcohol by individuals with clinical anxiety disorders. PMID:26234587

An online study combining the constructs from the theory of planned behaviour and protection motivation theory in predicting intention to test for chlamydia in two testing contexts.

PubMed

Powell, Rachael; Pattison, Helen M; Francis, Jill J

2016-01-01

Chlamydia is a common sexually transmitted infection that has potentially serious consequences unless detected and treated early. The health service in the UK offers clinic-based testing for chlamydia but uptake is low. Identifying the predictors of testing behaviours may inform interventions to increase uptake. Self-tests for chlamydia may facilitate testing and treatment in people who avoid clinic-based testing. Self-testing and being tested by a health care professional (HCP) involve two contrasting contexts that may influence testing behaviour. However, little is known about how predictors of behaviour differ as a function of context. In this study, theoretical models of behaviour were used to assess factors that may predict intention to test in two different contexts: self-testing and being tested by a HCP. Individuals searching for or reading about chlamydia testing online were recruited using Google Adwords. Participants completed an online questionnaire that addressed previous testing behaviour and measured constructs of the Theory of Planned Behaviour and Protection Motivation Theory, which propose a total of eight possible predictors of intention. The questionnaire was completed by 310 participants. Sufficient data for multiple regression were provided by 102 and 118 respondents for self-testing and testing by a HCP respectively. Intention to self-test was predicted by vulnerability and self-efficacy, with a trend-level effect for response efficacy. Intention to be tested by a HCP was predicted by vulnerability, attitude and subjective norm. Thus, intentions to carry out two testing behaviours with very similar goals can have different predictors depending on test context. We conclude that interventions to increase self-testing should be based on evidence specifically related to test context.

An Ontology for Telemedicine Systems Resiliency to Technological Context Variations in Pervasive Healthcare

PubMed Central

Bults, Richard G. A.; Van Sinderen, Marten J.; Widya, Ing; Hermens, Hermie J.

2015-01-01

Clinical data are crucial for any medical case to study and understand a patient’s condition and to give the patient the best possible treatment. Pervasive healthcare systems apply information and communication technology to enable the usage of ubiquitous clinical data by authorized medical persons. However, quality of clinical data in these applications is, to a large extent, determined by the technological context of the patient. A technological context is characterized by potential technological disruptions that affect optimal functioning of technological resources. The clinical data based on input from these technological resources can therefore have quality degradations. If these degradations are not noticed, the use of this clinical data can lead to wrong treatment decisions, which potentially puts the patient’s safety at risk. This paper presents an ontology that specifies the relation among technological context, quality of clinical data, and patient treatment. The presented ontology provides a formal way to represent the knowledge to specify the effect of technological context variations in the clinical data quality and the impact of the clinical data quality on a patient’s treatment. Accordingly, this ontology is the foundation for a quality of data framework that enables the development of telemedicine systems that are capable of adapting the treatment when the quality of the clinical data degrades, and thus guaranteeing patients’ safety even when technological context varies. PMID:27170903

Can corneal pannus with trachomatous inflammation--follicular be used in combination as an improved specific clinical sign for current ocular Chlamydia trachomatis infection?

PubMed

Derrick, Tamsyn; Holland, Martin J; Cassama, Eunice; Markham-David, Rod; Nabicassa, Meno; Marks, Michael; Bailey, Robin L; Last, Anna R

2016-01-27

Trachoma is a blinding disease caused by conjunctival infection with Chlamydia trachomatis (Ct). Mass drug administration (MDA) for trachoma control is administered based on the population prevalence of the clinical sign of trachomatis inflammation - follicular (TF). However, the prevalence of TF is often much higher than the prevalence of Ct infection. The addition of a clinical sign specific for current ocular Ct infection to TF could save resources by preventing unnecessary additional rounds of MDA. Study participants were aged between 1-9 years and resided on 7 islands of the Bijagos Archipelago, Guinea Bissau. Clinical grades for trachoma and corneal pannus and ocular swab samples were taken from 80 children with TF and from 81 matched controls without clinical evidence of trachoma. Ct infection testing was performed using droplet digital PCR. New pannus was significantly associated with Ct infection after adjustment for TF (P = 0.009, OR = 3.65 (1.4-9.8)). Amongst individuals with TF, individuals with new pannus had significantly more Ct infection than individuals with none or old pannus (75.0% vs 45.5%, Chi(2) P = 0.01). TF and new pannus together provide a highly specific (91.7%), but a poorly sensitive (51.9%) clinical diagnostic test for Ct infection. As we move towards trachoma elimination it may be desirable to use a combined clinical sign (new pannus in addition to TF) that is highly specific for current ocular Ct infection. This would allow national health systems to obtain a more accurate estimate of Ct population prevalence to inform further need for MDA without the expense of Ct molecular diagnostics, which are currently unaffordable in programmatic contexts.

Auditory Verbal Hallucinations in Persons With and Without a Need for Care

PubMed Central

Johns, Louise C.; Kompus, Kristiina; Connell, Melissa; Humpston, Clara; Lincoln, Tania M.; Longden, Eleanor; Preti, Antonio; Alderson-Day, Ben; Badcock, Johanna C.; Cella, Matteo; Fernyhough, Charles; McCarthy-Jones, Simon; Peters, Emmanuelle; Raballo, Andrea; Scott, James; Siddi, Sara; Sommer, Iris E.; Larøi, Frank

2014-01-01

Auditory verbal hallucinations (AVH) are complex experiences that occur in the context of various clinical disorders. AVH also occur in individuals from the general population who have no identifiable psychiatric or neurological diagnoses. This article reviews research on AVH in nonclinical individuals and provides a cross-disciplinary view of the clinical relevance of these experiences in defining the risk of mental illness and need for care. Prevalence rates of AVH vary according to measurement tool and indicate a continuum of experience in the general population. Cross-sectional comparisons of individuals with AVH with and without need for care reveal similarities in phenomenology and some underlying mechanisms but also highlight key differences in emotional valence of AVH, appraisals, and behavioral response. Longitudinal studies suggest that AVH are an antecedent of clinical disorders when combined with negative emotional states, specific cognitive difficulties and poor coping, plus family history of psychosis, and environmental exposures such as childhood adversity. However, their predictive value for specific psychiatric disorders is not entirely clear. The theoretical and clinical implications of the reviewed findings are discussed, together with directions for future research. PMID:24936085

Family predictors of disease management over one year in Latino and European American patients with type 2 diabetes.

PubMed

Chesla, Catherine A; Fisher, Lawrence; Skaff, Marilyn M; Mullan, Joseph T; Gilliss, Catherine L; Kanter, Richard

2003-01-01

Family context is thought to influence chronic disease management but few studies have longitudinally examined these relationships. Research on families and chronic illness has focused almost exclusively on European American families. In this prospective study we tested a multidimensional model of family influence on disease management in type 2 diabetes in a bi-ethnic sample of European Americans and Latinos. Specifically, we tested how baseline family characteristics (structure, world view, and emotion management) predicted change in disease management over one year in 104 European American and 57 Latino patients with type 2 diabetes. We found that emotion management predicted change in disease management in both groups of patients as hypothesized, while family world view predicted change in both ethnic groups but in the predicted direction only for European Americans. Examining family context within ethnic groups is required to elucidate unique cultural patterns. Attending to culturally unique interpretations of constructs and measures is warranted. The import of family emotion management, specifically conflict resolution, in disease management deserves further study to support clinical intervention development. Examining multiple domains of family life and multidimensional health outcomes strengthens our capacity to develop theory about family contexts and individual health.

[Drug-facilitated crime and sexual abuse: a pediatric observation].

PubMed

Rey-Salmon, C; Pépin, G

2007-11-01

Drug-facilitated crime in sexual assault situations remains insufficiently recognized by physicians. In the possible context of an assault and in front of recent neuropsychicological disturbances in a child, such an issue has to be considered. The quality of sampling, the use of ultra-sensitive and specific toxicologic methods and a clinical-biological collaboration allow to recognize this form of delinquency whose consequences are both medical and legal.

Protecting retinal ganglion cells.

PubMed

Khatib, T Z; Martin, K R

2017-02-01

Retinal ganglion cell degeneration underlies several conditions which give rise to significant visual compromise, including glaucoma, hereditary optic neuropathies, ischaemic optic neuropathies, and demyelinating disease. In this review, we discuss the emerging strategies for neuroprotection specifically in the context of glaucoma, including pharmacological neuroprotection, mesenchymal stem cells, and gene therapy approaches. We highlight potential pitfalls that need to be considered when developing these strategies and outline future directions, including the prospects for clinical trials.

Developing nursing care plans.

PubMed

Ballantyne, Helen

2016-02-24

This article aims to enhance nurses' understanding of nursing care plans, reflecting on the past, present and future use of care planning. This involves consideration of the central theories of nursing and discussion of nursing models and the nursing process. An explanation is provided of how theories of nursing may be applied to care planning, in combination with clinical assessment tools, to ensure that care plans are context specific and patient centred.

Research and developing countries: hopes and hypes.

PubMed

Moazam, Farhat

2006-01-01

The paper outlines the universal problem of ensuring ethical practices in human subject research, and focuses on specific difficulties faced in the developing world with particular reference to Pakistan. It discusses the influence of traditional and hierarchical social norms of physician-patient relationships in heightening these problems. Two emerging issues of specific concern in Pakistan are described: an exponential rise in multinational clinical drug trials, and commercial ventures offering unproven stem cell "therapy" for all kinds of diseases. The importance of introducing ethical practices in research within the context of local cultural and socioeconomic realities is highlighted.

Manufacture of tumor- and virus-specific T lymphocytes for adoptive cell therapies

PubMed Central

Wang, X; Rivière, I

2015-01-01

Adoptive transfer of tumor-infiltrating lymphocytes (TILs) and genetically engineered T lymphocytes expressing chimeric antigen receptors (CARs) or conventional alpha/beta T-cell receptors (TCRs), collectively termed adoptive cell therapy (ACT), is an emerging novel strategy to treat cancer patients. Application of ACT has been constrained by the ability to isolate and expand functional tumor-reactive T cells. The transition of ACT from a promising experimental regimen to an established standard of care treatment relies largely on the establishment of safe, efficient, robust and cost-effective cell manufacturing protocols. The manufacture of cellular products under current good manufacturing practices (cGMPs) has a critical role in the process. Herein, we review current manufacturing methods for the large-scale production of clinical-grade TILs, virus-specific and genetically modified CAR or TCR transduced T cells in the context of phase I/II clinical trials as well as the regulatory pathway to get these complex personalized cellular products to the clinic. PMID:25721207

Manufacture of tumor- and virus-specific T lymphocytes for adoptive cell therapies.

PubMed

Wang, X; Rivière, I

2015-03-01

Adoptive transfer of tumor-infiltrating lymphocytes (TILs) and genetically engineered T lymphocytes expressing chimeric antigen receptors (CARs) or conventional alpha/beta T-cell receptors (TCRs), collectively termed adoptive cell therapy (ACT), is an emerging novel strategy to treat cancer patients. Application of ACT has been constrained by the ability to isolate and expand functional tumor-reactive T cells. The transition of ACT from a promising experimental regimen to an established standard of care treatment relies largely on the establishment of safe, efficient, robust and cost-effective cell manufacturing protocols. The manufacture of cellular products under current good manufacturing practices (cGMPs) has a critical role in the process. Herein, we review current manufacturing methods for the large-scale production of clinical-grade TILs, virus-specific and genetically modified CAR or TCR transduced T cells in the context of phase I/II clinical trials as well as the regulatory pathway to get these complex personalized cellular products to the clinic.

[The MMPI-2 test in the evaluation of the mobbing syndrome].

PubMed

Pappone, P; Santalucia, L; Del Castello, E; De Maino, V; Garofalo, E; Cappelluccio, R; Feola, D; Ruberto, M; Liotti, F

2007-01-01

MMPI-2 test is widely used in psychodiagnostic evaluation as well as in the evaluation of psychic pathologies related to psychosocial adversative events in working activities. A more efficacious use of MMPI-2 test in the working context can be achieved by the individuation of indexes able to facilitate the evaluation of mobbing syndrome. This work is based on the analysis of 150 cases (39.7% women and 60.7% men, 30 to 60 years of age), evaluated through an accurate examination of working history and a series of clinic conversations, followed by psychodiagnostic evaluation. The average of T-scores on the clinical scale, the content scale, the PK addition scale and the validation scale were calculated from tests. Pathologic high T-scores on the scales Hs, D. Hy e Pa were found in subjects having positive mobbing anamnesis. These results strongly indicate the presence of clinical specificities in workers exposed to working harassments, and that these specificities can be efficaciously evidenced by the MMPI-2 test.

College drinking problems and social anxiety: The importance of drinking context.

PubMed

Terlecki, Meredith A; Ecker, Anthony H; Buckner, Julia D

2014-06-01

Social anxiety more than quadruples the risk of developing an alcohol use disorder, yet it is inconsistently linked to heavy alcohol use. Elucidation of the relation between social anxiety and alcohol use is an important next step in treating and preventing risky drinking. College students routinely face potentially anxiety-provoking social situations (e.g., meeting new people) and socially anxious undergraduates are especially vulnerable to alcohol-related impairment. Drinking to cope with social anxiety is thought to reinforce alcohol use, yet research on coping-motivated drinking among socially anxious students has yielded inconsistent findings. Further, undergraduate drinking varies by drinking context, yet the role of context in drinking behaviors among socially anxious individuals remains unclear. The current study sought to examine the relationship of social anxiety and drinking quantity in specific drinking contexts among undergraduates (N = 611). We also evaluated whether relevant drinking contexts mediated the relationship between social anxiety and alcohol-related problems. Clinically elevated social anxiety was related to heavier consumption in negative emotion (e.g., feeling sad or angry) and personal/intimate (e.g., before sexual intercourse) contexts, but not social/convivial contexts (e.g., parties, bars). Quantity of alcohol consumed in negative emotion and personal/intimate contexts mediated the relationship between social anxiety and drinking problem severity. Drinking in personal/intimate contexts demonstrated a unique mediational role. Findings suggest that heavy drinking in particular contexts (especially personal/intimate and negative emotion) may play an important role in drinking problems among socially anxious individuals.

Making reasonable decisions: a qualitative study of medical decision making in the care of patients with a clinically significant haemoglobin disorder.

PubMed

Crowther, Helen J; Kerridge, Ian

2015-10-01

Therapies utilized in patients with clinically significant haemoglobin disorders appear to vary between clinicians and units. This study aimed to investigate the processes of evidence implementation and medical decision making in the care of such patients in NSW, Australia. Using semi-structured interviews, 11 haematologists discussed their medical decision-making processes with particular attention paid to the use of published evidence. Transcripts were thematically analysed by a single investigator on a line-by-line basis. Decision making surrounding the care of patients with significant haemoglobin disorders varied and was deeply contextual. Three main determinants of clinical decision making were identified - factors relating to the patient and to their illness, factors specific to the clinician and the institution in which they were practising and factors related to the notion of evidence and to utility and role of evidence-based medicine in clinical practice. Clinicians pay considerable attention to medical decision making and evidence incorporation and attempt to tailor these to particular patient contexts. However, the patient context is often inferred and when discordant with the clinician's own contexture can lead to discomfort with decision recommendations. Clinicians strive to improve comfort through the use of experience and trustworthy evidence. © 2015 John Wiley & Sons, Ltd.

[Posttraumatic stress disorder endophenotypes: several clinical dimensions for specific treatments].

PubMed

Auxéméry, Y

2012-01-01

Posttraumatic stress disorder is a syndrome with a very complex clinical that it is useful to describe according to a multidimensional approach. Following a critical review of the international literature, we have been able to highlight the genetic supports of posttraumatic stress disorder in the perspective of returning to the source of the clinical of this syndrome in order to steer its treatment better. We consider in succession the neuromodulation pathways involving dopamine, serotonine and noradrenaline to describe the hyperdomaminergic, hyposerotoninergic and hypernoradrenergic endophenotypes of posttraumatic stress disorder. Neurogenetic studies have affirmed two essential proposals. On the one hand, the pharmacological treatment of psychotraumatic disorders can be very closely adjusted to the different endophenotypes. On the other hand, the psychotherapeutic approach retains all its importance in the sense that it is the subjective implication that generated the trauma, subjectivity interacting with a genetic heritage and environmental factors integrating a social context. The changing definition of posttraumatic stress disorder over time comes from scientific exploration in part determined by a sociocultural context and, reciprocally, the psychic trauma is caused by the collapse of reassuring social values which were considered as immutable. The clinical is not developed according to fixed references: the evolution of neurogenetic techniques changes our perception of psychic traumas and the therapeutic possibilities.

The phenomenology of the first panic attack in clinical and community-based samples.

PubMed

Pané-Farré, Christiane A; Stender, Jan P; Fenske, Kristin; Deckert, Jürgen; Reif, Andreas; John, Ulrich; Schmidt, Carsten Oliver; Schulz, Andrea; Lang, Thomas; Alpers, Georg W; Kircher, Tilo; Vossbeck-Elsebusch, Anna N; Grabe, Hans J; Hamm, Alfons O

2014-08-01

The purpose of the study was to contrast first panic attacks (PAs) of patients with panic disorder (PD) with vs. without agoraphobia and to explore differences between first PAs leading to the development of PD and those that remain isolated. Data were drawn from a community survey (N=2259 including 88 isolated PAs and 75 PD cases). An additional sample of 234 PD patients was recruited in a clinical setting. A standardized interview assessed the symptoms of the first PA, context of its occurrence and subsequent coping attempts. Persons who developed PD reported more severe first PAs, more medical service utilization and exposure-limiting coping attempts than those with isolated PAs. The context of the first PA did not differ between PD and isolated PAs. PD with agoraphobia was specifically associated with greater symptom severity and occurrence of first attacks in public. Future research should validate these findings using a longitudinal approach. Copyright © 2014 Elsevier Ltd. All rights reserved.

Evidence-based medicine for every day, everyone, and every therapeutic study.

PubMed

Govindarajan, Raghav; Narayanaswami, Pushpa

2018-04-17

The rapid growth in published medical literature makes it difficult for clinicians to keep up with advances in their fields. This may result in a cursory scan of the abstract and conclusion of a study without critically evaluating study quality. The application of evidence-based medicine (EBM) is the process of converting the abstract task of reading the literature into a practical method of using the literature to inform care in a specific clinical context while simultaneously expanding one's knowledge. EBM involves 4 steps: (1) stating the clinical problem in a defined question; (2) searching the literature for the evidence; (3) critically appraising the evidence for its validity; and (4) applying the evidence in the context of the patient's situation, preferences, and values. In this review, we use the recently published trial of thymectomy in myasthenia gravis as an example and systematically go through the steps of assessing internal validity, precision, and external validity. Muscle Nerve, 2018. © 2018 Wiley Periodicals, Inc.

Disease Specific Productivity of American Cancer Hospitals

PubMed Central

Goldstein, Jeffery A.; Prasad, Vinay

2015-01-01

Context Research-oriented cancer hospitals in the United States treat and study patients with a range of diseases. Measures of disease specific research productivity, and comparison to overall productivity, are currently lacking. Hypothesis Different institutions are specialized in research of particular diseases. Objective To report disease specific productivity of American cancer hospitals, and propose a summary measure. Method We conducted a retrospective observational survey of the 50 highest ranked cancer hospitals in the 2013 US News and World Report rankings. We performed an automated search of PubMed and Clinicaltrials.gov for published reports and registrations of clinical trials (respectively) addressing specific cancers between 2008 and 2013. We calculated the summed impact factor for the publications. We generated a summary measure of productivity based on the number of Phase II clinical trials registered and the impact factor of Phase II clinical trials published for each institution and disease pair. We generated rankings based on this summary measure. Results We identified 6076 registered trials and 6516 published trials with a combined impact factor of 44280.4, involving 32 different diseases over the 50 institutions. Using a summary measure based on registered and published clinical trails, we ranked institutions in specific diseases. As expected, different institutions were highly ranked in disease-specific productivity for different diseases. 43 institutions appeared in the top 10 ranks for at least 1 disease (vs 10 in the overall list), while 6 different institutions were ranked number 1 in at least 1 disease (vs 1 in the overall list). Conclusion Research productivity varies considerably among the sample. Overall cancer productivity conceals great variation between diseases. Disease specific rankings identify sites of high academic productivity, which may be of interest to physicians, patients and researchers. PMID:25781329

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis.

PubMed

Jacobson, Jon A; Roberts, Catherine C; Bencardino, Jenny T; Appel, Marc; Arnold, Erin; Baccei, Steven J; Cassidy, R Carter; Chang, Eric Y; Fox, Michael G; Greenspan, Bennett S; Gyftopoulos, Soterios; Hochman, Mary G; Mintz, Douglas N; Newman, Joel S; Rosenberg, Zehava S; Shah, Nehal A; Small, Kirstin M; Weissman, Barbara N

2017-05-01

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Modeling Heterogeneity in Momentary Interpersonal and Affective Dynamic Processes in Borderline Personality Disorder

PubMed Central

Wright, Aidan G. C.; Hallquist, Michael N.; Stepp, Stephanie D.; Scott, Lori N.; Beeney, Joseph E.; Lazarus, Sophie A.; Pilkonis, Paul A.

2016-01-01

Borderline personality disorder (BPD) is a diagnosis defined by impairments in several dynamic processes (e.g., interpersonal relating, affect regulation, behavioral control). Theories of BPD emphasize that these impairments appear in specific contexts, and emerging results confirm this view. At the same time, BPD is a complex construct that encompasses individuals with heterogeneous pathology. These features—dynamic processes, situational specificity, and individual heterogeneity—pose significant assessment challenges. In the current study, we demonstrate assessment and analytic methods that capture both between-person differences and within-person changes over time. Twenty-five participants diagnosed with BPD completed event-contingent, ambulatory assessment protocols over 21 days. We used p-technique factor analyses to identify person-specific psychological structures consistent with clinical theories of personality. Five exemplar cases are selected and presented in detail to showcase the potential utility of these methods. The presented cases' factor structures reflect not only heterogeneity but also suggest points of convergence. The factors also demonstrated significant associations with important clinical targets (self-harm, interpersonal violence). PMID:27317561

How Can We Improve Outcomes for Patients and Families Under Palliative Care? Implementing Clinical Audit for Quality Improvement in Resource Limited Settings

PubMed Central

Selman, Lucy; Harding, Richard

2010-01-01

Palliative care in India has made enormous advances in providing better care for patients and families living with progressive disease, and many clinical services are well placed to begin quality improvement initiatives, including clinical audit. Clinical audit is recognized globally to be essential in all healthcare, as a way of monitoring and improving quality of care. However, it is not common in developing country settings, including India. Clinical audit is a cyclical activity involving: identification of areas of care in need of improvement, through data collection and analysis utilizing an appropriate questionnaire; setting measurable quality of care targets in specific areas; designing and implementing service improvement strategies; and then re-evaluating quality of care to assess progress towards meeting the targets. Outcome measurement is an important component of clinical audit that has additional advantages; for example, establishing an evidence base for the effectiveness of services. In resource limited contexts, outcome measurement in clinical audit is particularly important as it enables service development to be evidence-based and ensures resources are allocated effectively. Key success factors in conducting clinical audit are identified (shared ownership, training, managerial support, inclusion of all members of staff and a positive approach). The choice of outcome measurement tool is discussed, including the need for a culturally appropriate and validated measure which is brief and simple enough to incorporate into clinical practice and reflects the holistic nature of palliative care. Support for clinical audit is needed at a national level, and development and validation of an outcome measurement tool in the Indian context is a crucial next step. PMID:20859465

'Trust my doctor, trust my pancreas': trust as an emergent quality of social practice.

PubMed

Cohn, Simon

2015-06-11

Growing attention is being paid to the importance of trust, and its corollaries such as mistrust and distrust, in health service and the central place they have in assessments of quality of care. Although initially focussing on doctor-patient relationships, more recent literature has broadened its remit to include trust held in more abstract entities, such as organisations and institutions. There has consequently been growing interest to develop rigorous and universal measures of trust. Drawing on illustrative ethnographic material from observational research in a UK diabetes clinic, this paper supports an approach that foregrounds social practice and resists conceiving trust as solely a psychological state that can be divorced from its context. Beyond exploring the less-than-conscious nature of trust, the interpretations attend to the extent to which trust practices are distributed across a range of actors. Data from clinical encounters reveal the extent to which matters of trust can emerge from the relationships between people, and sometimes people and things, as a result of a wide range of pragmatic concerns, and hence can usefully be conceived of as an extended property of a situation rather than a person. Trust is rarely explicitly articulated, but remains a subtle feature of experience that is frequently ineffable. A practice approach highlights some of the problems with adopting a general psychological or intellectualist conception of trust. In particular, assuming it is a sufficiently stable internal state that can be stored or measured not only transforms a diffuse and often ephemeral quality into a durable thing, but ultimately presents it as a generic state that has meaning independent of the specific relationships and context that achieve it. Emphasising the context-specific nature of trust practices does not dismiss the potential of matters of trust, when they emerge, to be transposed to other contexts. But it does highlight how, on each occasion, trust as a relational quality is ways 'done' or 'achieved' anew.

Molecular allergy diagnostics using IgE singleplex determinations: methodological and practical considerations for use in clinical routine: Part 18 of the Series Molecular Allergology.

PubMed

Kleine-Tebbe, Jörg; Jakob, Thilo

Allergen molecules (synonyms: single allergens, allergen components) open up new horizons for the targeted allergen-specific diagnostics of immunoglobulin E (IgE) in singleplex determination. The following rationales support the targeted use of allergen molecules and, more importantly, improve test properties: (1) increased test sensitivity ("analytical sensitivity"), particularly when important allergens are under-represented or lacking in the extract; (2) improved test selectivity (analytical specificity), particularly when the selected IgE repertoire against an allergen yields additional information on: (a) potential risk, (b) possible cross-reactivity, or (c) primary (species-specific) sensitization. However, the appropriate indication for the use of single allergens can only be established on a case-by-case basis (depending on the clinical context and previous history) and in an allergen-specific manner (depending on the allergen source and the single allergens available), rather than in a standardized way. Numerous investigations on suspected food allergy, insect venom allergy, or sensitization to respiratory allergens have meanwhile demonstrated the successful use of defined molecules for allergen-specific singleplex IgE diagnosis. Specific IgE to single allergens is limited in its suitability to predict the clinical relevance of sensitivity on an individual basis. In food allergies, one can at best identify the relative risk of a clinical reaction on the basis of an IgE profile, but no absolutely reliable prediction on (future) tolerance can be made. Ultimately, the clinical relevance of all IgE findings depends on the presence of corresponding symptoms and can only be assessed on an individual basis (previous history, symptom log, and provocation testing with the relevant allergen source where appropriate). Thus, also in molecular allergology, the treating physician and not the test result should determine the clinical relevance of diagnostic findings. Supplementary material is available for this article at 10.1007/s40629-015-0067-z and is accessible for authorized users.

Child Abuse and Neglect: Screening for Risks During the Perinatal Period

PubMed Central

Besier, T.; Pillhofer, M.; Botzenhart, S.; Ziegenhain, U.; Kindler, H.; Spangler, G.; Bovenschen, I.; Gabler, S.; Künster, A. K.

2012-01-01

Purpose: Currently, there is a claim for earlier interventions for families in order to prevent child maltreatment. Here, a screening instrument to assess risk indicators for child abuse and neglect already in the context of maternity clinics is introduced. The present study is the first report on the psychometric properties of this instrument, the “short questionnaire for risk indices around birth” (RIAB). Material and Methods: Data were collected in the context of three different studies conducted at Ulm University Hospital. To examine interrater reliability eight case vignettes were rated by n = 90 study participants (50 students and 40 experts working at a maternity clinic). Criterion validity was examined in two studies applying the German version of the child abuse potential inventory CAPI (n = 96 families at risk and n = 160 additional families). Results: Both laymen and experts were able to understand and use the screening instrument correctly, leading to a high agreement with the sample solutions given. A high concordance was found between parentsʼ and expertsʼ ratings: In case of no reported risk factors applying the screening instrument RIAB, parents themselves reported significantly less stressors and burdens, compared to those parents with an indication for a thorough examination as pointed out in the RIAB. Conclusion: In the context of maternity clinics the RIAB is a useful, broadly applicable instrument, screening for existing risk factors at the earliest and thus allowing for the initiation of specific interventions when needed. PMID:25298543

The sensitivity and specificity of clinical measures of sport concussion: three tests are better than one

PubMed Central

Resch, Jacob E; Brown, Cathleen N; Schmidt, Julianne; Macciocchi, Stephen N; Blueitt, Damond; Cullum, C Munro; Ferrara, Michael S

2016-01-01

Context A battery of clinical measures of neurocognition, balance and symptoms has been recommended for the management of sport concussion (SC) but is based on variable evidence. Objective To examine the sensitivity and specificity of a battery of tests to assess SC in college athletes. Design Cross-sectional. Setting Research laboratory. Patients or other participants Division 1 athletes diagnosed with a SC (n=40) who were 20.2±1.60 years of age and 180.5±11.12 cm tall and healthy athletes (n=40) who were 19.0±0.93 years of age and 179.1±11.39 cm tall were enrolled. Intervention(s) Participants were administered Immediate Postconcussion Assessment and Cognitive Test (ImPACT), the Sensory Organization Test (SOT) and the Revised Head Injury Scale (HIS-r) prior to and up to 24 h following injury between the 2004 and 2014 sport seasons. Sensitivity and specificity were calculated using predictive discriminant analyses (PDA) and clinical interpretation guidelines. Main outcome measures Outcome measures included baseline and postinjury ImPACT, SOT and HIS-r composite scores. Results Using PDA, each clinical measure's sensitivity ranged from 55.0% to 77.5% and specificity ranged from 52.5% to 100%. The test battery possessed a sensitivity and specificity of 80.0% and 100%, respectively. Using clinical interpretation guidelines, sensitivity ranged from 55% to 97.5% individually, and 100% when combined. Conclusions Our results support a multidimensional approach to assess SC in college athletes which correctly identified 80–100% of concussed participants as injured. When each test was evaluated separately, up to 47.5% of our sample was misclassified. Caution is warranted when using singular measures to manage SC. PMID:27900145

Social impact evaluation : Some implications of the specific decisional context approach for anticipatory project assessment with special reference to available alternatives and to techniques of evaluating the social impacts of the anticipated effects of such alternatives

NASA Technical Reports Server (NTRS)

Mayo, L. H.

1972-01-01

The implications are explored of the specific decision context approach to anticipatory project assessment. More specifically, it is hypothesized that with respect to any given effect of a proposed project or action (mobility, job opportunities, air pollution, population distribution, etc.) such effect will likely differ in probability and/or magnitude from one decisional context to another; that the social desirability or undesirability of a given effect is a function (will differ with) each specific decisional context; that therefore the social impact of such effect will in all likelihood differ with each specific decisional context; and that the social significance of even the dame social impact of a given effect will vary from one decisional context to another when such social impact interacts with (competes with or reinforces) the social impacts of other effects. It also follows from this analysis that the respective roles of scientific method (demonstrable data) and adversarial system will not only differ with each specific decisional context but with each alternative course of action available to the decisional entity in each specific context.

Is it the time to rethink clinical decision-making strategies? From a single clinical outcome evaluation to a Clinical Multi-criteria Decision Assessment (CMDA).

PubMed

Migliore, Alberto; Integlia, Davide; Bizzi, Emanuele; Piaggio, Tomaso

2015-10-01

There are plenty of different clinical, organizational and economic parameters to consider in order having a complete assessment of the total impact of a pharmaceutical treatment. In the attempt to follow, a holistic approach aimed to provide an evaluation embracing all clinical parameters in order to choose the best treatments, it is necessary to compare and weight multiple criteria. Therefore, a change is required: we need to move from a decision-making context based on the assessment of one single criteria towards a transparent and systematic framework enabling decision makers to assess all relevant parameters simultaneously in order to choose the best treatment to use. In order to apply the MCDA methodology to clinical decision making the best pharmaceutical treatment (or medical devices) to use to treat a specific pathology, we suggest a specific application of the Multiple Criteria Decision Analysis for the purpose, like a Clinical Multi-criteria Decision Assessment CMDA. In CMDA, results from both meta-analysis and observational studies are used by a clinical consensus after attributing weights to specific domains and related parameters. The decision will result from a related comparison of all consequences (i.e., efficacy, safety, adherence, administration route) existing behind the choice to use a specific pharmacological treatment. The match will yield a score (in absolute value) that link each parameter with a specific intervention, and then a final score for each treatment. The higher is the final score; the most appropriate is the intervention to treat disease considering all criteria (domain an parameters). The results will allow the physician to evaluate the best clinical treatment for his patients considering at the same time all relevant criteria such as clinical effectiveness for all parameters and administration route. The use of CMDA model will yield a clear and complete indication of the best pharmaceutical treatment to use for patients, helping physicians to choose drugs with a complete set of information, imputed in the model. Copyright © 2015 Elsevier Ltd. All rights reserved.

Challenging clinical learning environments: experiences of undergraduate nursing students.

PubMed

O'Mara, Linda; McDonald, Jane; Gillespie, Mary; Brown, Helen; Miles, Lynn

2014-03-01

Clinical learning is an essential component of becoming a nurse. However at times, students report experiencing challenging clinical learning environments (CCLE), raising questions regarding the nature of a challenging clinical learning environment, its impact on students' learning and how students might respond within a CCLE. Using an Interpretive Descriptive study design, researchers held focus groups with 54 students from two Canadian sites, who self-identified as having experienced a CCLE. Students defined a CCLE as affected by relationships in the clinical area and by the context of their learning experiences. CCLE decreased students' learning opportunities and impacted on them as persons. As students determined which relationships were challenging, they tapped other resources and they used strategies to rebuilt, reframe, redirect and/or retreat relative to the specific challenge. Relationships also acted as buffers to unsupportive practice cultures. Implications for practice and research are addressed. Copyright © 2013 Elsevier Ltd. All rights reserved.

Creating learning momentum through overt teaching interactions during real acute care episodes.

PubMed

Piquette, Dominique; Moulton, Carol-Anne; LeBlanc, Vicki R

2015-10-01

Clinical supervisors fulfill a dual responsibility towards patient care and learning during clinical activities. Assuming such roles in today's clinical environments may be challenging. Acute care environments present unique learning opportunities for medical trainees, as well as specific challenges. The goal of this paper was to better understand the specific contexts in which overt teaching interactions occurred in acute care environments. We conducted a naturalistic observational study based on constructivist grounded theory methodology. Using participant observation, we collected data on the teaching interactions occurring between clinical supervisors and medical trainees during 74 acute care episodes in the critical care unit of two academic centers, in Toronto, Canada. Three themes contributed to a better understanding of the conditions in which overt teaching interactions among trainees and clinical supervisors occurred during acute care episodes: seizing emergent learning opportunities, coming up against challenging conditions, and creating learning momentum. Our findings illustrate how overt learning opportunities emerged from certain clinical situations and how clinical supervisors and trainees could purposefully modify unfavorable learning conditions. None of the acute care episodes encountered in the critical care environment represented ideal conditions for learning. Yet, clinical supervisors and trainees succeeded in engaging in overt teaching interactions during many episodes. The educational value of these overt teaching interactions should be further explored, as well as the impact of interventions aimed at increasing their use in acute care environments.

Preferred information sources for clinical decision making: critical care nurses' perceptions of information accessibility and usefulness.

PubMed

Marshall, Andrea P; West, Sandra H; Aitken, Leanne M

2011-12-01

Variability in clinical practice may result from the use of diverse information sources to guide clinical decisions. In routine clinical practice, nurses privilege information from colleagues over more formal information sources. It is not clear whether similar information-seeking behaviour is exhibited when critical care nurses make decisions about a specific clinical practice, where extensive practice variability exists alongside a developing research base. This study explored the preferred sources of information intensive care nurses used and their perceptions of the accessibility and usefulness of this information for making decisions in clinically uncertain situations specific to enteral feeding practice. An instrumental case study design, incorporating concurrent verbal protocols, Q methodology and focus groups, was used to determine intensive care nurses' perspectives of information use in the resolution of clinical uncertainty. A preference for information from colleagues to support clinical decisions was observed. People as information sources were considered most useful and most accessible in the clinical setting. Text and electronic information sources were seen as less accessible, mainly because of the time required to access the information within the documents. When faced with clinical uncertainty, obtaining information from colleagues allows information to be quickly accessed and applied within the context of a specific clinical presentation. Seeking information from others also provides opportunities for shared decision-making and potential validation of clinical judgment, although differing views may exacerbate clinical uncertainty. The social exchange of clinical information may meet the needs of nurses working in a complex, time-pressured environment but the extent of the evidence base for information passed through verbal communication is unclear. The perceived usefulness and accessibility of information is premised on the ease of use and access and thus the variability in information may be contributing to clinical uncertainty. Copyright ©2011 Sigma Theta Tau International.

Clinical and no-clinical setting specificities in first session short-term psychotherapy psychodrama group.

PubMed

Drakulić, Aleksandra Mindoljević

2011-03-01

Modern history of short-term group psychotherapy dates back to the late 1950-ies. From then to present day, this psychotherapeutic method has been used in various forms, from dynamic-oriented to cognitive behavioural psychotherapies. Although it has always been considered rather controversial, due its cost-effectiveness, it has been capturing more and more popularity. This paper presents the specificities of first session short-term psychotherapy psychodrama group through session work with two examined groups: a group of 20 adult women who suffer from mild or moderate forms of unipolar depression and a group of 20 students of the School of Medicine in Zagreb without any psychiatric symptomatology. The results indicate the high importance of having structure in first psychodrama session, of relating it with the previously thoroughly conducted, initial, clinical, interviews, and of the clarity and focus in terms of determining the goals of therapy, especially in a clinical context. This study also confirmed assumptions regarding the need for different approaches of warming-up in psychodrama, both in the clinical and in non-clinical samples. A psychodrama psychotherapist should have good time managing skills and capability to convert the time available into an opportunity for directly boosting the group energy and work on therapeutic alliance.

Protecting retinal ganglion cells

PubMed Central

Khatib, T Z; Martin, K R

2017-01-01

Retinal ganglion cell degeneration underlies several conditions which give rise to significant visual compromise, including glaucoma, hereditary optic neuropathies, ischaemic optic neuropathies, and demyelinating disease. In this review, we discuss the emerging strategies for neuroprotection specifically in the context of glaucoma, including pharmacological neuroprotection, mesenchymal stem cells, and gene therapy approaches. We highlight potential pitfalls that need to be considered when developing these strategies and outline future directions, including the prospects for clinical trials. PMID:28085136

Supporting nursing students' critical thinking with a mobile web learning environment.

PubMed

Lai, Chin-Yuan; Wu, Cheng-Chih

2012-01-01

The use of mobile technology has the potential of revolutionizing and transforming the way clinical practicums are conducted in nursing training. Our Web-based implementation suggested that incorporating technology, specifically with Internet and mobile devices, to promote nursing students’ critical thinking is feasible and showed dramatic results. As our environment was tailored for the psychiatric nursing practicum, future studies should delineate the context in which they are to be delivered.

Current Role of Blood and Urine Biomarkers in the Clinical Care of Adults with Congenital Heart Disease.

PubMed

Rajpal, Saurabh; Alshawabkeh, Laith; Opotowsky, Alexander R

2017-06-01

There is an increasing number of adult patients with congenital heart disease (CHD). While several biomarkers have been validated and integrated into general cardiology clinical practice, these tests are often applied to adults with CHD in the absence of disease-specific validation. Although these patients are often grouped into a single population, there is heterogeneous pathophysiology, variable disease chronicity, extensive multisystem involvement, and a low event rate relative to acquired heart disease. These stand as challenges to systematic investigation and clinical application of biomarkers for adults with CHD. This paper reviews recent studies investigating the use of biomarkers in this population, with emphasis on biomarkers applied in clinical adult CHD care. A handful of biomarkers have been integrated into adult CHD practice, such as iron studies in cyanotic heart disease and stool alpha-1 antitrypsin for diagnosis of protein losing enteropathy in the Fontan circulation. Use of kidney and liver tests has been studied in prognostication of adult CHD patients. A few other biomarkers like natriuretic peptides and troponins seem likely to provide useful information in other ACHD situations based on limited disease-specific data and extrapolation from acquired heart disease. More research is needed to support the robust validity of most existing clinical biomarkers in adult congenital cardiology practice. Until data from larger, prospectively enrolled cohorts are available, clinical use of biomarkers in these patients will require careful interpretation with attention to underlying pathophysiology, as well as detailed understanding of potential pitfalls of specific assays and clinical contexts.

Foundations of Pharmacotherapy for Heart Failure With Reduced Ejection Fraction: Evidence Meets Practice, Part II.

PubMed

McIlvennan, Colleen K; Page, Robert L

Pharmacologic treatment for systolic heart failure, otherwise known as heart failure with reduced ejection fraction, has been established through clinical trials and is formulated into guidelines to standardize the diagnosis and treatment. Since the introduction of angiotensin-converting enzyme inhibitors and vasodilators in the 1980s, many guideline-recommended therapies have emerged over the past 20 years targeting specific neurohormones, aldosterone, and catecholamines to treat heart failure. Part 2 of this series will describe β-blockers, digoxin, and aldosterone antagonists in the context of the mechanism of action in heart failure, investigational trials that showed beneficial effects, and the practical applications for clinical use.

Context Processing and the Neurobiology of Post-Traumatic Stress Disorder

PubMed Central

Liberzon, Israel; Abelson, James L.

2016-01-01

Summary Progress in clinical and affective neuroscience is redefining psychiatric illness as symptomatic expression of cellular/molecular dysfunctions in specific brain circuits. Post-traumatic stress disorder (PTSD) has been an exemplar of this progress, with improved understanding of neurobiological systems subserving fear learning, salience detection, and emotion regulation explaining much of its phenomenology and neurobiology. However, many features remain unexplained and a parsimonious model that more fully accounts for symptoms and the core neurobiology remains elusive. Contextual processing is a key modulatory function of hippocampal-prefrontal-thalamic circuitry, allowing organisms to disambiguate cues and derive situation-specific meaning from the world. We propose that dysregulation within this context-processing circuit is at the core of PTSD pathophysiology, accounting for much of its phenomenology and most of its biological findings. Understanding core mechanisms like this, and their underlying neural circuits, will sharpen diagnostic precision and understanding of risk factors, enhancing our ability to develop preventive and “personalized” interventions. PMID:27710783

Returning findings within longitudinal cohort studies: the 1958 birth cohort as an exemplar.

PubMed

Wallace, Susan E; Walker, Neil M; Elliott, Jane

2014-01-01

Population-based, prospective longitudinal cohort studies are considering the issues surrounding returning findings to individuals as a result of genomic and other medical research studies. While guidance is being developed for clinical settings, the process is less clear for those conducting longitudinal research. This paper discusses work conducted on behalf of The UK Cohort and Longitudinal Study Enhancement Resource programme (CLOSER) to examine consent requirements, process considerations and specific examples of potential findings in the context of the 1958 British Birth cohort. Beyond deciding which findings to return, there are questions of whether re-consent is needed and the possible impact on the study, how the feedback process will be managed, and what resources are needed to support that process. Recommendations are made for actions a cohort study should consider taking when making vital decisions regarding returning findings. Any decisions need to be context-specific, arrived at transparently, communicated clearly, and in the best interests of both the participants and the study.

Clinical caring science as a scientific discipline.

PubMed

Rehnsfeldt, Arne; Arman, Maria; Lindström, Unni Å

2017-09-01

Clinical caring science will be described from a theory of science perspective. The aim of this theoretical article to give a comprehensive overview of clinical caring science as a human science-based discipline grounded in a theory of science argumentation. Clinical caring science seeks idiographic or specific variations of the ontology, concepts and theories, formulated by caring science. The rationale is the insight that the research questions do not change when they are addressed in different contexts. The academic subject contains a concept order with ethos concepts, core and basic concepts and practice concepts that unites systematic caring science with clinical caring science. In accordance with a hermeneutic tradition, the idea of the caring act is based on the degree to which the theory base is hermeneutically appropriated by the caregiver. The better the ethos, essential concepts and theories are understood, the better the caring act can be understood. In order to understand the concept order related to clinical caring science, an example is given from an ongoing project in a disaster context. The concept order is an appropriate way of making sense of the essence of clinical caring science. The idea of the concept order is that concepts on all levels need to be united with each other. A research project in clinical caring science can start anywhere on the concept order, either in ethos, core concepts, basic concepts, practice concepts or in concrete clinical phenomena, as long as no parts are locked out of the concept order as an entity. If, for example, research on patient participation as a phenomenon is not related to core and basic concepts, there is a risqué that the research becomes meaningless. © 2016 Nordic College of Caring Science.

Online Mental Health Resources in Rural Australia: Clinician Perceptions of Acceptability

PubMed Central

Holloway, Kristi; Riley, Geoffrey; Auret, Kirsten

2013-01-01

Background Online mental health resources have been proposed as an innovative means of overcoming barriers to accessing rural mental health services. However, clinicians tend to express lower satisfaction with online mental health resources than do clients. Objective To understand rural clinicians’ attitudes towards the acceptability of online mental health resources as a treatment option in the rural context. Methods In-depth interviews were conducted with 21 rural clinicians (general practitioners, psychologists, psychiatrists, and clinical social workers). Interviews were supplemented with rural-specific vignettes, which described clinical scenarios in which referral to online mental health resources might be considered. Symbolic interactionism was used as the theoretical framework for the study, and interview transcripts were thematically analyzed using a constant comparative method. Results Clinicians were optimistic about the use of online mental health resources into the future, showing a preference for integration alongside existing services, and use as an adjunct rather than an alternative to traditional approaches. Key themes identified included perceptions of resources, clinician factors, client factors, and the rural and remote context. Clinicians favored resources that were user-friendly and could be integrated into their clinical practice. Barriers to use included a lack of time to explore resources, difficulty accessing training in the rural environment, and concerns about the lack of feedback from clients. Social pressure exerted within professional clinical networks contributed to a cautious approach to referring clients to online resources. Conclusions Successful implementation of online mental health resources in the rural context requires attention to clinician perceptions of acceptability. Promotion of online mental health resources to rural clinicians should include information about resource effectiveness, enable integration with existing services, and provide opportunities for renegotiating the socially defined role of the clinician in the eHealth era. PMID:24007949

Online mental health resources in rural Australia: clinician perceptions of acceptability.

PubMed

Sinclair, Craig; Holloway, Kristi; Riley, Geoffrey; Auret, Kirsten

2013-09-05

Online mental health resources have been proposed as an innovative means of overcoming barriers to accessing rural mental health services. However, clinicians tend to express lower satisfaction with online mental health resources than do clients. To understand rural clinicians' attitudes towards the acceptability of online mental health resources as a treatment option in the rural context. In-depth interviews were conducted with 21 rural clinicians (general practitioners, psychologists, psychiatrists, and clinical social workers). Interviews were supplemented with rural-specific vignettes, which described clinical scenarios in which referral to online mental health resources might be considered. Symbolic interactionism was used as the theoretical framework for the study, and interview transcripts were thematically analyzed using a constant comparative method. Clinicians were optimistic about the use of online mental health resources into the future, showing a preference for integration alongside existing services, and use as an adjunct rather than an alternative to traditional approaches. Key themes identified included perceptions of resources, clinician factors, client factors, and the rural and remote context. Clinicians favored resources that were user-friendly and could be integrated into their clinical practice. Barriers to use included a lack of time to explore resources, difficulty accessing training in the rural environment, and concerns about the lack of feedback from clients. Social pressure exerted within professional clinical networks contributed to a cautious approach to referring clients to online resources. Successful implementation of online mental health resources in the rural context requires attention to clinician perceptions of acceptability. Promotion of online mental health resources to rural clinicians should include information about resource effectiveness, enable integration with existing services, and provide opportunities for renegotiating the socially defined role of the clinician in the eHealth era.

A Knowledge Base for Teaching Biology Situated in the Context of Genetic Testing

NASA Astrophysics Data System (ADS)

van der Zande, Paul; Waarlo, Arend Jan; Brekelmans, Mieke; Akkerman, Sanne F.; Vermunt, Jan D.

2011-10-01

Recent developments in the field of genomics will impact the daily practice of biology teachers who teach genetics in secondary education. This study reports on the first results of a research project aimed at enhancing biology teacher knowledge for teaching genetics in the context of genetic testing. The increasing body of scientific knowledge concerning genetic testing and the related consequences for decision-making indicate the societal relevance of such a situated learning approach. What content knowledge do biology teachers need for teaching genetics in the personal health context of genetic testing? This study describes the required content knowledge by exploring the educational practice and clinical genetic practices. Nine experienced teachers and 12 respondents representing the clinical genetic practices (clients, medical professionals, and medical ethicists) were interviewed about the biological concepts and ethical, legal, and social aspects (ELSA) of testing they considered relevant to empowering students as future health care clients. The ELSA suggested by the respondents were complemented by suggestions found in the literature on genetic counselling. The findings revealed that the required teacher knowledge consists of multiple layers that are embedded in specific genetic test situations: on the one hand, the knowledge of concepts represented by the curricular framework and some additional concepts (e.g. multifactorial and polygenic disorder) and, on the other hand, more knowledge of ELSA and generic characteristics of genetic test practice (uncertainty, complexity, probability, and morality). Suggestions regarding how to translate these characteristics, concepts, and ELSA into context-based genetics education are discussed.

Psychobiologic correlates of treatment response in schizophrenia.

PubMed

Lieberman, J A; Alvir, J M; Koreen, A; Geisler, S; Chakos, M; Sheitman, B; Woerner, M

1996-03-01

In studies conducted on largely treatment naive patients in their first episode of psychosis, we have found that treatment outcome is quite good and that most patients recover or at least achieve a substantial degree of symptom remission. However, over the course of their illness and in the context of subsequent psychotic episodes, they may experience some decrease in their treatment response from illness progression. In addition, the heterogeneity of treatment outcome is associated with specific clinical (gender, primary negative symptoms of the deficit state, duration of psychosis) and biological variables (pHVA, ventricular volume). It is unclear whether these variables represent aspects of discrete subtypes of schizophrenia or dimensional measures of pathology within the broad context of a unitary disease entity.

The clinical application of genome-wide sequencing for monogenic diseases in Canada: Position Statement of the Canadian College of Medical Geneticists

PubMed Central

Boycott, Kym; Hartley, Taila; Adam, Shelin; Bernier, Francois; Chong, Karen; Fernandez, Bridget A; Friedman, Jan M; Geraghty, Michael T; Hume, Stacey; Knoppers, Bartha M; Laberge, Anne-Marie; Majewski, Jacek; Mendoza-Londono, Roberto; Meyn, M Stephen; Michaud, Jacques L; Nelson, Tanya N; Richer, Julie; Sadikovic, Bekim; Skidmore, David L; Stockley, Tracy; Taylor, Sherry; van Karnebeek, Clara; Zawati, Ma'n H; Lauzon, Julie; Armour, Christine M

2015-01-01

Purpose and scope The aim of this Position Statement is to provide recommendations for Canadian medical geneticists, clinical laboratory geneticists, genetic counsellors and other physicians regarding the use of genome-wide sequencing of germline DNA in the context of clinical genetic diagnosis. This statement has been developed to facilitate the clinical translation and development of best practices for clinical genome-wide sequencing for genetic diagnosis of monogenic diseases in Canada; it does not address the clinical application of this technology in other fields such as molecular investigation of cancer or for population screening of healthy individuals. Methods of statement development Two multidisciplinary groups consisting of medical geneticists, clinical laboratory geneticists, genetic counsellors, ethicists, lawyers and genetic researchers were assembled to review existing literature and guidelines on genome-wide sequencing for clinical genetic diagnosis in the context of monogenic diseases, and to make recommendations relevant to the Canadian context. The statement was circulated for comment to the Canadian College of Medical Geneticists (CCMG) membership-at-large and, following incorporation of feedback, approved by the CCMG Board of Directors. The CCMG is a Canadian organisation responsible for certifying medical geneticists and clinical laboratory geneticists, and for establishing professional and ethical standards for clinical genetics services in Canada. Results and conclusions Recommendations include (1) clinical genome-wide sequencing is an appropriate approach in the diagnostic assessment of a patient for whom there is suspicion of a significant monogenic disease that is associated with a high degree of genetic heterogeneity, or where specific genetic tests have failed to provide a diagnosis; (2) until the benefits of reporting incidental findings are established, we do not endorse the intentional clinical analysis of disease-associated genes other than those linked to the primary indication; and (3) clinicians should provide genetic counselling and obtain informed consent prior to undertaking clinical genome-wide sequencing. Counselling should include discussion of the limitations of testing, likelihood and implications of diagnosis and incidental findings, and the potential need for further analysis to facilitate clinical interpretation, including studies performed in a research setting. These recommendations will be routinely re-evaluated as knowledge of diagnostic and clinical utility of clinical genome-wide sequencing improves. While the document was developed to direct practice in Canada, the applicability of the statement is broader and will be of interest to clinicians and health jurisdictions internationally. PMID:25951830

The clinical application of genome-wide sequencing for monogenic diseases in Canada: Position Statement of the Canadian College of Medical Geneticists.

PubMed

Boycott, Kym; Hartley, Taila; Adam, Shelin; Bernier, Francois; Chong, Karen; Fernandez, Bridget A; Friedman, Jan M; Geraghty, Michael T; Hume, Stacey; Knoppers, Bartha M; Laberge, Anne-Marie; Majewski, Jacek; Mendoza-Londono, Roberto; Meyn, M Stephen; Michaud, Jacques L; Nelson, Tanya N; Richer, Julie; Sadikovic, Bekim; Skidmore, David L; Stockley, Tracy; Taylor, Sherry; van Karnebeek, Clara; Zawati, Ma'n H; Lauzon, Julie; Armour, Christine M

2015-07-01

The aim of this Position Statement is to provide recommendations for Canadian medical geneticists, clinical laboratory geneticists, genetic counsellors and other physicians regarding the use of genome-wide sequencing of germline DNA in the context of clinical genetic diagnosis. This statement has been developed to facilitate the clinical translation and development of best practices for clinical genome-wide sequencing for genetic diagnosis of monogenic diseases in Canada; it does not address the clinical application of this technology in other fields such as molecular investigation of cancer or for population screening of healthy individuals. Two multidisciplinary groups consisting of medical geneticists, clinical laboratory geneticists, genetic counsellors, ethicists, lawyers and genetic researchers were assembled to review existing literature and guidelines on genome-wide sequencing for clinical genetic diagnosis in the context of monogenic diseases, and to make recommendations relevant to the Canadian context. The statement was circulated for comment to the Canadian College of Medical Geneticists (CCMG) membership-at-large and, following incorporation of feedback, approved by the CCMG Board of Directors. The CCMG is a Canadian organisation responsible for certifying medical geneticists and clinical laboratory geneticists, and for establishing professional and ethical standards for clinical genetics services in Canada. Recommendations include (1) clinical genome-wide sequencing is an appropriate approach in the diagnostic assessment of a patient for whom there is suspicion of a significant monogenic disease that is associated with a high degree of genetic heterogeneity, or where specific genetic tests have failed to provide a diagnosis; (2) until the benefits of reporting incidental findings are established, we do not endorse the intentional clinical analysis of disease-associated genes other than those linked to the primary indication; and (3) clinicians should provide genetic counselling and obtain informed consent prior to undertaking clinical genome-wide sequencing. Counselling should include discussion of the limitations of testing, likelihood and implications of diagnosis and incidental findings, and the potential need for further analysis to facilitate clinical interpretation, including studies performed in a research setting. These recommendations will be routinely re-evaluated as knowledge of diagnostic and clinical utility of clinical genome-wide sequencing improves. While the document was developed to direct practice in Canada, the applicability of the statement is broader and will be of interest to clinicians and health jurisdictions internationally. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Complex contexts and relationships affect clinical decisions in group therapy.

PubMed

Tasca, Giorgio A; Mcquaid, Nancy; Balfour, Louise

2016-09-01

Clinical errors tend to be underreported even though examining them can provide important training and professional development opportunities. The group therapy context may be prone to clinician errors because of the added complexity within which therapists work and patients receive treatment. We discuss clinical errors that occurred within a group therapy in which a patient for whom group was not appropriate was admitted to the treatment and then was not removed by the clinicians. This was countertherapeutic for both patient and group. Two clinicians were involved: a clinical supervisor who initially assessed and admitted the patient to the group, and a group therapist. To complicate matters, the group therapy occurred within the context of a clinical research trial. The errors, possible solutions, and recommendations are discussed within Reason's Organizational Accident Model (Reason, 2000). In particular, we discuss clinician errors in the context of countertransference and clinician heuristics, group therapy as a local work condition that complicates clinical decision-making, and the impact of the research context as a latent organizational factor. We also present clinical vignettes from the pregroup preparation, group therapy, and supervision. Group therapists are more likely to avoid errors in clinical decisions if they engage in reflective practice about their internal experiences and about the impact of the context in which they work. Therapists must keep in mind the various levels of group functioning, especially related to the group-as-a-whole (i.e., group composition, cohesion, group climate, and safety) when making complex clinical decisions in order to optimize patient outcomes. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Identifying the domains of context important to implementation science: a study protocol.

PubMed

Squires, Janet E; Graham, Ian D; Hutchinson, Alison M; Michie, Susan; Francis, Jill J; Sales, Anne; Brehaut, Jamie; Curran, Janet; Ivers, Noah; Lavis, John; Linklater, Stefanie; Fenton, Shannon; Noseworthy, Thomas; Vine, Jocelyn; Grimshaw, Jeremy M

2015-09-28

There is growing recognition that "context" can and does modify the effects of implementation interventions aimed at increasing healthcare professionals' use of research evidence in clinical practice. However, conceptual clarity about what exactly comprises "context" is lacking. The purpose of this research program is to develop, refine, and validate a framework that identifies the key domains of context (and their features) that can facilitate or hinder (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. A multi-phased investigation of context using mixed methods will be conducted. The first phase is a concept analysis of context using the Walker and Avant method to distinguish between the defining and irrelevant attributes of context. This phase will result in a preliminary framework for context that identifies its important domains and their features according to the published literature. The second phase is a secondary analysis of qualitative data from 13 studies of interviews with 312 healthcare professionals on the perceived barriers and enablers to their application of research evidence in clinical practice. These data will be analyzed inductively using constant comparative analysis. For the third phase, we will conduct semi-structured interviews with key health system stakeholders and change agents to elicit their knowledge and beliefs about the contextual features that influence the effectiveness of implementation interventions and healthcare professionals' use of evidence in clinical practice. Results from all three phases will be synthesized using a triangulation protocol to refine the context framework drawn from the concept analysis. The framework will then be assessed for content validity using an iterative Delphi approach with international experts (researchers and health system stakeholders/change agents). This research program will result in a framework that identifies the domains of context and their features that can facilitate or hinder: (1) healthcare professionals' use of evidence in clinical practice and (2) the effectiveness of implementation interventions. The framework will increase the conceptual clarity of the term "context" for advancing implementation science, improving healthcare professionals' use of evidence in clinical practice, and providing greater understanding of what interventions are likely to be effective in which contexts.

Short Stature—Physiology and Pathology

PubMed Central

Rimoin, David L.; Borochowitz, Zvi; Horton, William A.

1986-01-01

Stature, the quantitative measure of height, varies widely within each ethnic group with a fairly normal distribution. Of the numerous patients whom physicians encounter because of short stature, relatively few are pathologically small in the context of family and ethnic background. Physicians must be able to differentiate pathologic short stature from the lower end of the normal curve before embarking on a complex diagnostic evaluation. There are literally hundreds of different causes of short stature, and the clinical evaluation requires a wide variety of clinical, radiographic, pathologic and biochemical tools. Although specific treatment to promote growth is available only in persons with the endocrinopathies and the acquired nutritional, emotional and chronic disease states, diagnosis of the specific form of short stature can have great importance in being able to prevent complications and to offer accurate prognostic information and genetic counseling. ImagesFigure 2.Figure 3. PMID:2873688

Linking guidelines to Electronic Health Record design for improved chronic disease management.

PubMed

Barretto, Sistine A; Warren, Jim; Goodchild, Andrew; Bird, Linda; Heard, Sam; Stumptner, Markus

2003-01-01

The promise of electronic decision support to promote evidence based practice remains elusive in the context of chronic disease management. We examine the problem of achieving a close relationship of Electronic Health Record (EHR) content to other components of a clinical information system (guidelines, decision support and workflow), particularly linking the decisions made by providers back to the guidelines. We use the openEHR architecture, which allows extension of a core Reference Model via Archetypes to refine the detailed information recording options for specific classes of encounter. We illustrate the use of openEHR for tracking the relationship of a series of clinical encounters to a guideline via a case study of guideline-compliant treatment of hypertension in diabetes. This case study shows the contribution guideline content can have on problem-specific EHR structure and demonstrates the potential for a constructive interaction of electronic decision support and the EHR.

Linking Guidelines to Electronic Health Record Design for Improved Chronic Disease Management

PubMed Central

Barretto, Sistine A.; Warren, Jim; Goodchild, Andrew; Bird, Linda; Heard, Sam; Stumptner, Markus

2003-01-01

The promise of electronic decision support to promote evidence based practice remains elusive in the context of chronic disease management. We examine the problem of achieving a close relationship of Electronic Health Record (EHR) content to other components of a clinical information system (guidelines, decision support and work-flow), particularly linking the decisions made by providers back to the guidelines. We use the openEHR architecture, which allows extension of a core Reference Model via Archetypes to refine the detailed information recording options for specific classes of encounter. We illustrate the use of openEHR for tracking the relationship of a series of clinical encounters to a guideline via a case study of guideline-compliant treatment of hypertension in diabetes. This case study shows the contribution guideline content can have on problem-specific EHR structure and demonstrates the potential for a constructive interaction of electronic decision support and the EHR. PMID:14728135

Antithrombotic treatment in elderly patients with atrial fibrillation.

PubMed

Suárez Fernández, C; Camafort, M; Cepeda Rodrigo, J M; Díez-Manglano, J; Formiga, F; Pose Reino, A; Tiberio, G; Mostaza, J M

2015-04-01

Atrial fibrillation (AF) in the elderly is a complex condition due to the high number of frequently associated comorbidities, such as cardiovascular and kidney disease, cognitive disorders, falls and polypharmacy. Except when contraindicated, anticoagulation is necessary for preventing thromboembolic events in this population. Both vitamin K antagonists and direct oral anticoagulants (dabigatran, rivaroxaban and apixaban) are indicated in this context. Renal function should be closely monitored for this age group when these drugs are used. In recent years, various clinical practice guidelines have been published on patients with AF. The majority of these guidelines make specific recommendations on the clinical characteristics and treatment of elderly patients. In this update, we review the specific comments on the recommendations concerning antithrombotic treatment in elderly patients with nonvalvular AF. Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.

An SPR based immunoassay for the sensitive detection of the soluble epithelial marker E-cadherin.

PubMed

Vergara, Daniele; Bianco, Monica; Pagano, Rosanna; Priore, Paola; Lunetti, Paola; Guerra, Flora; Bettini, Simona; Carallo, Sonia; Zizzari, Alessandra; Pitotti, Elena; Giotta, Livia; Capobianco, Loredana; Bucci, Cecilia; Valli, Ludovico; Maffia, Michele; Arima, Valentina; Gaballo, Antonio

2018-06-11

Protein biomarkers are important diagnostic tools for cancer and several other diseases. To be validated in a clinical context, a biomarker should satisfy some requirements including the ability to provide reliable information on a pathological state by measuring its expression levels. In parallel, the development of an approach capable of detecting biomarkers with high sensitivity and specificity would be ideally suited for clinical applications. Here, we performed an immune-based label free assay using Surface Plasmon Resonance (SPR)-based detection of the soluble form of E-cadherin, a cell-cell contact protein that is involved in the maintaining of tissue integrity. With this approach, we obtained a specific and quantitative detection of E-cadherin from a few hundred μl of serum of breast cancer patients by obtaining a 10-fold enhancement in the detection limit over a traditional colorimetric ELISA. Copyright © 2018 Elsevier Inc. All rights reserved.

Renewal after the punishment of free operant behavior.

PubMed

Bouton, Mark E; Schepers, Scott T

2015-01-01

Three experiments examined the role of context in punishment learning. In Experiment 1, rats were trained to lever press for food in Context A and then punished for responding in Context B (by presenting response-contingent footshock). Punishment led to complete suppression of the response. However, when responding was tested (in extinction) in Contexts A and B, a strong renewal of responding occurred in Context A. In Experiment 2, renewal also occurred when initial reinforcement occurred in Context A, punishment occurred in Context B, and testing occurred in a new context (Context C). In both experiments, behavioral suppression and renewal were not observed in groups that received noncontingent (yoked) footshocks in Context B. In Experiment 3, 2 responses (lever press and chain pull) were separately reinforced in Contexts A and B and then punished in the opposite context. Although the procedure equated the contexts on their association with reinforcement and punishment, renewal of each response was observed when it was tested in its nonpunished context. The contexts also influenced response choice. Overall, the results suggest that punishment is specific to the context in which it is learned, and establish that its context-specificity does not depend on a simple association between the context and shock. Like extinction, punishment may involve learning to inhibit a specific response in a specific context. Implications for theories of punishment and for understanding the cessation of problematic operant behavior (e.g., drug abuse) are discussed. PsycINFO Database Record (c) 2015 APA, all rights reserved.

Reliability associated with the Roter Interaction Analysis System (RIAS) adapted for the telemedicine context.

PubMed

Nelson, Eve-Lynn; Miller, Edward Alan; Larson, Kiley A

2010-01-01

This study's purpose was to adapt the Roter Interaction Analysis System (RIAS) for telemedicine clinics and to investigate the adapted measure's reliability. The study also sought to better understand the volume of technology-related utterance in established telemedicine clinics and the feasibility of using the measure within the telemedicine setting. This initial evaluation is a first step before broadly using the adapted measure across technologies and raters. An expert panel adapted the RIAS for the telemedicine context. This involved accounting for all consultation participants (patient, provider, presenter, family) and adding technology-specific subcategories. Ten new and 36 follow-up telemedicine encounters were videotaped and double coded using the adapted RIAS. These consisted primarily of follow-up visits (78.0%) involving patients, providers, presenters, and other parties. Reliability was calculated for those categories with 15 or more utterances. Traditional RIAS categories related to socioemotional and task-focused clusters had fair to excellent levels of reliability in the telemedicine setting. Although there were too few utterances to calculate the reliability of the specific technology-related subcategories, the summary technology-related category proved reliable for patients, providers, and presenters. Overall patterns seen in traditional patient-provider interactions were observed, with the number of provider utterances far exceeding patient, presenter, and family utterances, and few technology-specific utterances. The traditional RIAS is reliable when applied across multiple participants in the telemedicine context. Reliability of technology-related subcategories could not be evaluated; however, the aggregate technology-related cluster was found to be reliable and may be especially relevant in understanding communication patterns with patients new to the telemedicine setting. Use of the RIAS instrument is encouraged to facilitate comparison between traditional, face-to-face clinics and telemedicine; among diverse consultation mediums and technologies; and across different specialties. Future research is necessary to further investigate the reliability and validity of adding technology-related subcategories to the RIAS. The limited number of technology-related utterances, however, implies a certain degree of comfort with two-way interactive video consultation among study participants. Telemedicine continues to increase access to healthcare. The technology-related categories of the adapted RIAS were reliable when aggregated, thereby providing a tool to better understand how telemedicine affects provider-patient communication and outcomes.

An ontologically founded architecture for information systems in clinical and epidemiological research.

PubMed

Uciteli, Alexandr; Groß, Silvia; Kireyev, Sergej; Herre, Heinrich

2011-08-09

This paper presents an ontologically founded basic architecture for information systems, which are intended to capture, represent, and maintain metadata for various domains of clinical and epidemiological research. Clinical trials exhibit an important basis for clinical research, and the accurate specification of metadata and their documentation and application in clinical and epidemiological study projects represents a significant expense in the project preparation and has a relevant impact on the value and quality of these studies.An ontological foundation of an information system provides a semantic framework for the precise specification of those entities which are presented in this system. This semantic framework should be grounded, according to our approach, on a suitable top-level ontology. Such an ontological foundation leads to a deeper understanding of the entities of the domain under consideration, and provides a common unifying semantic basis, which supports the integration of data and the interoperability between different information systems.The intended information systems will be applied to the field of clinical and epidemiological research and will provide, depending on the application context, a variety of functionalities. In the present paper, we focus on a basic architecture which might be common to all such information systems. The research, set forth in this paper, is included in a broader framework of clinical research and continues the work of the IMISE on these topics.

The context dependency of extinction negates the effectiveness of cognitive enhancement to reduce cocaine-primed reinstatement.

PubMed

Hammond, Sherri; Wagner, John J

2013-09-01

With respect to the treatment of addiction, the objective of extinction training is to decrease drug-seeking behavior by repeatedly exposing the patient to cues in the absence of unconditioned reinforcement. Such exposure therapy typically takes place in a novel (clinical) environment. This is potentially problematic, as the effects of extinction training include a context dependent component and therefore diminished efficacy is expected upon the patient's return to former drug-seeking/taking environments. We have reported that treatment with the NMDAR coagonist d-serine is effective in facilitating the effects of extinction to reduce cocaine-primed reinstatement. The present study assesses d-serine's effectiveness in reducing drug-primed reinstatement under conditions in which extinction training occurs in a novel environment. After 22 days of cocaine self-administration (0.5 mg/kg) in context "A", animals underwent 5 extinction training sessions in context "B". Immediately after each extinction session in "B", animals received either saline or d-serine (60 mg/kg) treatment. Our results indicate that d-serine treatment following extinction in "B" had no effect on either IV or IP cocaine-primed reinstatement conducted in "A". These results stand in contrast to our previous findings where extinction occurred in "A", indicating that d-serine's effectiveness in facilitating extinction training to reduce drug-primed reinstatement is not transferable to a novel extinction environment. This inability of d-serine treatment to reduce the context specificity of extinction training may explain the inconsistent effects observed in clinical studies published to date in which adjunctive cognitive enhancement treatment has been combined with behavioral therapy without significant benefit. Copyright © 2013 Elsevier B.V. All rights reserved.

Physicians' Perceptions of Clinical Teaching: A Qualitative Analysis in the Context of Change

ERIC Educational Resources Information Center

Knight, Lynn V.; Bligh, John

2006-01-01

Background: Change is ubiquitous. Current trends in both educational and clinical settings bring new challenges to clinicians and have the potential to threaten the quality of clinical teaching. Objective: To investigate hospital specialists' perceptions of clinical teaching in the context of change. Design: Qualitative study using in-depth…

Reflective Practice: A Comparative Dimensional Analysis of the Concept in Nursing and Education Studies.

PubMed

Goulet, Marie-Hélène; Larue, Caroline; Alderson, Marie

2016-04-01

This paper reports on an analysis of the concept of reflective practice. Reflective practice, a concept borrowed from the field of education, is widely used in nursing. However, to date, no study has explored whether this appropriation has resulted in a definition of the concept specific to the nursing discipline. A sample comprised of 42 articles in the field of nursing drawn from the CINAHL database and 35 articles in education from the ERIC database (1989-2013) was analyzed. A concept analysis using the method proposed by Bowers and Schatzman was conducted to explore the differing meanings of reflective practice in nursing and education. In nursing, the dimensions of the concept differ depending on context. In the clinical context, the dimensions may be summarized as theory-practice gap, development, and caring; in training, as learning, guided process, and development; and in research, as knowledge, method, and social change. In education, the concept is also used in the contexts of training (the dimensions being development, deliberate review, emotions, and evaluation) and research (knowledge, temporal distance, and method). The humanist dimension in nursing thus reflects a use of the concept more specific to the discipline. The concept analysis helped clarify the meaning of reflective practice in nursing and its specific use in the discipline. This observation leads to a consideration of how the concept has developed since its appropriation by nursing; the adoption of a terminology particular to nursing may well be worth contemplating. © 2015 Wiley Periodicals, Inc.

Technical aspects of CT imaging of the spine.

PubMed

Tins, Bernhard

2010-11-01

This review article discusses technical aspects of computed tomography (CT) imaging of the spine. Patient positioning, and its influence on image quality and movement artefact, is discussed. Particular emphasis is placed on the choice of scan parameters and their relation to image quality and radiation burden to the patient. Strategies to reduce radiation burden and artefact from metal implants are outlined. Data acquisition, processing, image display and steps to reduce artefact are reviewed. CT imaging of the spine is put into context with other imaging modalities for specific clinical indications or problems. This review aims to review underlying principles for image acquisition and to provide a rough guide for clinical problems without being prescriptive. Individual practice will always vary and reflect differences in local experience, technical provisions and clinical requirements.

Urokinase-receptor (u-PAR): an essential player in multiple games of cancer: a review on its role in tumor progression, invasion, metastasis, proliferation/dormancy, clinical outcome and minimal residual disease.

PubMed

Laufs, Stephanie; Schumacher, Jens; Allgayer, Heike

2006-08-01

The relevance of the u-PA system in mediating tumor-associated proteolysis, invasion and metastasis, amongst other phenomena associated with tumor progression, has been clearly demonstrated in diverse cancer entities. This review will update on the biological and clinical relevance of the urokinase-receptor (u-PAR). Specifically, the article focuses on the potential importance of u-PAR for the development of minimal residual disease in solid cancer, and in this context reviews the biological relevance of the u-PAR for tumor cell dormancy. Furthermore, transcriptional mechanisms regulating u-PAR in vitro and in vivo, and their potential clinical and therapeutic relevance in gastrointestinal cancers, are elucidated.

Entorhinal Cortical Ocean Cells Encode Specific Contexts and Drive Context-Specific Fear Memory

PubMed Central

Kitamura, Takashi; Sun, Chen; Martin, Jared; Kitch, Lacey J; Schnitzer, Mark J; Tonegawa, Susumu

2016-01-01

Summary Forming distinct representations and memories of multiple contexts and episodes is thought to be a crucial function of the hippocampal-entorhinal cortical network. The hippocampal dentate gyrus (DG) and CA3 are known to contribute to these functions but the role of the entorhinal cortex (EC) is poorly understood. Here, we show that Ocean cells, excitatory stellate neurons in the medial EC layer II projecting into DG and CA3, rapidly form a distinct representation of a novel context and drive context-specific activation of downstream CA3 cells as well as context-specific fear memory. In contrast, Island cells, excitatory pyramidal neurons in the medial EC layer II projecting into CA1, are indifferent to context-specific encoding or memory. On the other hand, Ocean cells are dispensable for temporal association learning, for which Island cells are crucial. Together, the two excitatory medial EC layer II inputs to the hippocampus have complementary roles in episodic memory. PMID:26402611

PROGRESS IN ACUTE MYELOID LEUKEMIA

PubMed Central

Kadia, Tapan M.; Ravandi, Farhad; O’Brien, Susan; Cortes, Jorge; Kantarjian, Hagop M.

2014-01-01

Significant progress has been made in the treatment of acute myeloid leukemia (AML). Steady gains in clinical research and a renaissance of genomics in leukemia have led to improved outcomes. The recognition of tremendous heterogeneity in AML has allowed individualized treatments of specific disease entities within the context of patient age, cytogenetics, and mutational analysis. The following is a comprehensive review of the current state of AML therapy and a roadmap of our approach to these distinct disease entities. PMID:25441110

Treatment of elderly ovarian cancer patients in the context of controlled clinical trials: a joint analysis of the AGO Germany experience.

PubMed

Hilpert, Felix; Wimberger, Pauline; du Bois, Andreas; Pfisterer, Jacobus; Harter, Philipp

2012-01-01

Age remains a negative prognostic factor in ovarian cancer (OC). 3 separate analyses by the AGO (Arbeitsgemeinschaft Gynaekologische Onkologie) give insight into the treatment of elderly patients (EPs) in the context of controlled clinical trials (CCTs). 1 retrospective study evaluated the reasons for non-enrolment into CCTs of patients with advanced OC in AGO centers. 2 other exploratory age-specific analyses of a phase III trial in advanced OC treated with platinum/ paclitaxel evaluated (1) feasibility, toxicity and quality of life (QoL) and (2) the clinical outcome. Non-study patients were significantly older (66.7 vs. 57.2 years). Reasons for non-enrolment were predominantly predefined exclusion criteria, numeric age, and the patient's decision. The phase III trial confirmed an under-representation of EPs. Cycle delivery was significantly lower and discontinuation more frequent in EPs than in younger patients (YPs), although QoL, toxicity, cycle delays, and dose reductions were comparable. Delivery of cycles was prognostically significant in EPs but not YPs. The survival advantage of YPs remained significant even in completely debulked patients. There is some kind of investigator reservation for the treatment of EPs, which not only applies for the enrolment into clinical trials but also for the treatment, even under CCT conditions, with impact on outcome. Copyright © 2012 S. Karger AG, Basel.

Developing a leadership pipeline: the Cleveland Clinic experience.

PubMed

Hess, Caryl A; Barss, Christina; Stoller, James K

2014-11-01

The complexity of health care requires excellent leadership to address the challenges of access, quality, and cost of care. Because competencies to lead differ from clinical or research skills, there is a compelling need to develop leaders and create a talent pipeline, perhaps especially in physician-led organizations like Cleveland Clinic. In this context, we previously reported on a cohort-based physician leadership development course called Leading in Health Care and, in the current report, detail an expanded health care leadership development programme called the Cleveland Clinic Academy (CCA). CCA consists of a broad suite of offerings, including cohort-based learning and 'a la carte' half- or full-day courses addressing specific competencies to manage and to lead. Academy attendance is optional and is available to all physicians, nurses, and administrators with the requisite experience. Course selection is guided by competency matrices which map leadership competencies to specific courses. As of December 2012, a total of 285 course sessions have been offered to 6,050 attendees with uniformly high ratings of course quality and impact. During the past 10 years, Cleveland Clinic's leadership and management curriculum has successfully created a pipeline of health care leaders to fill executive positions, search committees, board openings, and various other organizational leadership positions. Health care leadership can be taught and learned.

Partial and specific source memory for faces associated to other- and self-relevant negative contexts.

PubMed

Bell, Raoul; Giang, Trang; Buchner, Axel

2012-01-01

Previous research has shown a source memory advantage for faces presented in negative contexts. As yet it remains unclear whether participants remember the specific type of context in which the faces were presented or whether they can only remember that the face was associated with negative valence. In the present study, participants saw faces together with descriptions of two different types of negative behaviour and neutral behaviour. In Experiment 1, we examined whether the participants were able to discriminate between two types of other-relevant negative context information (cheating and disgusting behaviour) in a source memory test. In Experiment 2, we assessed source memory for other-relevant negative (threatening) context information (other-aggressive behaviour) and self-relevant negative context information (self-aggressive behaviour). A multinomial source memory model was used to separately assess partial source memory for the negative valence of the behaviour and specific source memory for the particular type of negative context the face was associated with. In Experiment 1, source memory was specific for the particular type of negative context presented (i.e., cheating or disgusting behaviour). Experiment 2 showed that source memory for other-relevant negative information was more specific than source memory for self-relevant information. Thus, emotional source memory may vary in specificity depending on the degree to which the negative emotional context is perceived as threatening.

It is time to revise the international Good Clinical Practices guidelines: recommendations from non-commercial North-South collaborative trials.

PubMed

Ravinetto, Raffaella; Tinto, Halidou; Diro, Ermias; Okebe, Joseph; Mahendradhata, Yodi; Rijal, Suman; Gotuzzo, Eduardo; Lutumba, Pascal; Nahum, Alain; De Nys, Katelijne; Casteels, Minne; Boelaert, Marleen

2016-01-01

The Good Clinical Practices (GCP) codes of the WHO and the International Conference of Harmonization set international standards for clinical research. But critics argue that they were written without consideration for the challenges faced in low and middle income countries (LMICs). Based on our field experience in LMICs, we developed a non-exhaustive set of recommendations for the improvement of GCP. These cover 3 domains: ethical, legal and operational, and 8 specific issues: the double ethical review of 'externally sponsored' trials; the informed consent procedure in minors and in illiterate people; post-trial access to newly-developed products for the trial communities; the role of communities as key research actors; the definition of sponsor; and the guidance for contractual agreements, laboratory quality management systems, and quality assurance of investigational medicinal products. Issues not covered in our analysis include among others biobanking, standard of care, and study designs. The international GCP codes de facto guide national legislators and funding agencies, so the current shortcomings may weaken the regulatory oversight of international research. In addition, activities neglected by GCP are less likely to be implemented or funded. If GCP are meant to serve the interests of global society, a comprehensive revision is needed. The revised guidelines should be strongly rooted in ethics, sensitive to different sociocultural perspectives, and allow consideration for trial-specific and context-specific challenges. This can be only achieved if all stakeholders, including researchers, sponsors, regulators, ethical reviewers and patients' representatives from LMICs, as well as non-commercial researchers and sponsors from affluent countries, are transparently involved in the revision process. We hope that our limited analysis would foster advocacy for a broad and inclusive revision of the international GCP codes, to make them at the same time 'global', 'context centred' and 'patient centred'.

Framing moving and handling as a complex healthcare intervention within the acute care of older people with osteoporosis: a qualitative study.

PubMed

Smith, Margaret Coulter; O'May, Fiona; Tropea, Savina; Berg, Jackie

2016-10-01

To investigate healthcare staff's views and experiences of caring for older hospitalised adults (aged 60+) with osteoporosis focusing on moving and handling. Specific objectives were to explore the composition of manual handling risk assessments and interventions in osteoporosis. Osteoporosis is a skeletal disease that reduces bone density and causes increased fracture risk. Incidence rises with age and osteoporotic fractures cause increased morbidity and mortality. It is a major global health problem. In the UK older hospitalised adults are normally screened for falls risk but not necessarily for osteoporosis. As presentation of osteoporosis is normally silent until fractures are evident, it is frequently undiagnosed. Healthcare staff's knowledge of osteoporosis is often suboptimal and specific manual handling implications are under-researched. An exploratory qualitative content analysis research design informed by critical realism. The purposive sample comprised 26 nursing and allied health professionals. Semi-structured interviews addressed topics including knowledge of osteoporosis, implications for acute care, moving and handling and clinical guidelines. Qualitative content data analysis was used. Awareness of osteoporosis prevalence in older populations varies and implications for nursing are indistinct to nonspecialists. In-hospital fractures potentially linked to suboptimal moving and handling seemed rare, but prospective studies are needed. Categories of 'Understanding moving and handling as routine care or as a healthcare intervention', with further categories 'healthcare practitioners' capacities and capabilities for dealing with people with osteoporosis' and 'the structural and organisational context for moving and handling' are reported alongside safety, frailty and dependency dimensions. This study informs moving and handling in higher risk groups such as osteoporosis. Clinical knowledge/expertise is required when adapting generic manual handling guidelines to specific patients/contexts. Patients' experiences of moving and handling have received limited attention. Increased focus on musculoskeletal conditions and moving and handling implications is required. © 2016 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd.

Tissue slide-based microRNA characterization of tumors: how detailed could diagnosis become for cancer medicine?

PubMed Central

Sempere, Lorenzo F

2014-01-01

miRNAs are short, non-coding, regulatory RNAs that exert cell type-dependent, context-dependent, transcriptome-wide gene expression control under physiological and pathological conditions. Tissue slide-based assays provide qualitative (tumor compartment) and semi-quantitative (expression levels) information about altered miRNA expression at single-cell resolution in clinical tumor specimens. Reviewed here are key technological advances in the last 5 years that have led to implementation of fully automated, robust and reproducible tissue slide-based assays for in situ miRNA detection on US FDA-approved instruments; recent tissue slide-based discovery studies that suggest potential clinical applications of specific miRNAs in cancer medicine are highlighted; and the challenges in bringing tissue slide-based miRNA assays into the clinic are discussed, including clinical validation, biomarker performance, biomarker space and integration with other biomarkers. PMID:25090088

Individual-level outcomes from a national clinical leadership development programme.

PubMed

Patton, Declan; Fealy, Gerard; McNamara, Martin; Casey, Mary; Connor, Tom O; Doyle, Louise; Quinlan, Christina

2013-08-01

A national clinical leadership development programme was instituted for Irish nurses and midwives in 2010. Incorporating a development framework and leadership pathway and a range of bespoke interventions for leadership development, including workshops, action-learning sets, mentoring and coaching, the programme was introduced at seven pilot sites in the second half of 2011. The programme pilot was evaluated with reference to structure, process and outcomes elements, including individual-level programme outcomes. Evaluation data were generated through focus groups and group interviews, individual interviews and written submissions. The data provided evidence of nurses' and midwives' clinical leadership development through self and observer-reported behaviours and dispositions including accounts of how the programme participants developed and displayed particular clinical leadership competencies. A key strength of the new programme was that it involved interventions that focussed on specific leadership competencies to be developed within the practice context.

Informed consent for clinical trials of deep brain stimulation in psychiatric disease: challenges and implications for trial design.

PubMed

Lipsman, Nir; Giacobbe, Peter; Bernstein, Mark; Lozano, Andres M

2012-02-01

Advances in neuromodulation and an improved understanding of the anatomy and circuitry of psychopathology have led to a resurgence of interest in surgery for psychiatric disease. Clinical trials exploring deep brain stimulation (DBS), a focally targeted, adjustable and reversible form of neurosurgery, are being developed to address the use of this technology in highly selected patient populations. Psychiatric patients deemed eligible for surgical intervention, such as DBS, typically meet stringent inclusion criteria, including demonstrated severity, chronicity and a failure of conventional therapy. Although a humanitarian device exemption by the US Food and Drug Administration exists for its use in obsessive-compulsive disorder, DBS remains a largely experimental treatment in the psychiatric context, with its use currently limited to clinical trials and investigative studies. The combination of a patient population at the limits of conventional therapy and a novel technology in a new indication poses interesting challenges to the informed consent process as it relates to clinical trial enrollment. These challenges can be divided into those that relate to the patient, their disease and the technology, with each illustrating how traditional conceptualisations of research consent may be inadequate in the surgical psychiatry context. With specific reference to risk analysis, patient autonomy, voluntariness and the duty of the clinician-researcher, this paper will discuss the unique challenges that clinical trials of surgery for refractory psychiatric disease present to the consent process. Recommendations are also made for an ethical approach to clinical trial consent acquisition in this unique patient population.

Utilisation of the healthcare system for authentic early experience placements.

PubMed

Hays, Richard B

2013-01-01

Authentic early experience in clinical contexts adds interest and relevance to basic medical education, and is regarded positively by both learners and teachers. However, with the recent expansion of medical education, the healthcare system appears close to reaching its capacity for student supervision. This study explores the utilisation of the healthcare system for early clinical placements. A secondary analysis was conducted of data from the Medical Schools Outcomes Database, collected from the 2010 annual questionnaire, focusing on the timing, duration and location of clinical placements during 2009 within the first half of basic medical education programs in Australia. Data was received for 67% of Australian medical students, reporting a total of 16 812 early clinical placements that occupied 97 319 days of supervised time in a wide variety of hospital, general practice and Indigenous health contexts, both urban and rural, across the Australian healthcare system. These early placements occupied about 16% of total clinical placement time for all students in all training years during 2009. The majority of these placements were for only a few hours or days; exceptions were longitudinal placements in regional and rural communities at a minority of schools. Early clinical placements may pose significant resource costs for placement providers, particularly supervision time and expertise. As medical education expands and the teaching capacity of the Australian healthcare system appears to reach its limits, it may be necessary to allocate placements according to their specific learning outcomes, prioritise more acute settings for more senior students, and increase capacity in less acute health and social care settings.

Instruments to identify prescription medication misuse, abuse, and related events in clinical trials: an ACTTION systematic review

PubMed Central

Smith, Shannon M.; Paillard, Florence; McKeown, Andrew; Burke, Laurie B.; Edwards, Robert R.; Katz, Nathaniel P.; Papadopoulos, Elektra J.; Rappaport, Bob A.; Slagle, Ashley; Strain, Eric C.; Wasan, Ajay D.; Turk, Dennis C.; Dworkin, Robert H.

2017-01-01

Measurement of inappropriate medication use events (e.g., abuse, misuse) in clinical trials is important in characterizing a medication’s abuse potential. However, no “gold standard” assessment of inappropriate use events in clinical trials has been identified. In this systematic review, we examine the measurement properties (i.e., content validity, cross-sectional reliability and construct validity, longitudinal construct validity, ability to detect change, and responder definitions) of instruments assessing inappropriate use of opioid and non-opioid prescription medications to identify any that meet U.S. and European regulatory agencies’ rigorous standards for outcome measures in clinical trials. Sixteen published instruments were identified, most of which were not designed for the selected concept of interest and context of use. For this reason, many instruments were found to lack adequate content validity (or documentation of content validity) to evaluate current inappropriate medication use events; for example, evaluating inappropriate use across the lifespan rather than current use, including items that did not directly assess inappropriate use (e.g., questions about anger), or failing to capture information pertinent to inappropriate use events (e.g., intention, route of administration). In addition, the psychometric data across all instruments were generally limited in scope. A further limitation is the heterogeneous, non-standardized use of inappropriate medication use terminology. These observations suggest that available instruments are not well suited for assessing current inappropriate medication use within the specific context of clinical trials. Further effort is needed to develop reliable and valid instruments to measure current inappropriate medication use events in clinical trials. PMID:25660826

Measuring attitudes towards the dying process: A systematic review of tools.

PubMed

Groebe, Bernadette; Strupp, Julia; Eisenmann, Yvonne; Schmidt, Holger; Schlomann, Anna; Rietz, Christian; Voltz, Raymond

2018-04-01

At the end of life, anxious attitudes concerning the dying process are common in patients in Palliative Care. Measurement tools can identify vulnerabilities, resources and the need for subsequent treatment to relieve suffering and support well-being. To systematically review available tools measuring attitudes towards dying, their operationalization, the method of measurement and the methodological quality including generalizability to different contexts. Systematic review according to the PRISMA Statement. Methodological quality of tools assessed by standardized review criteria. MEDLINE, PsycINFO, PsyndexTests and the Health and Psychosocial Instruments were searched from their inception to April 2017. A total of 94 identified studies reported the development and/or validation of 44 tools. Of these, 37 were questionnaires and 7 alternative measurement methods (e.g. projective measures). In 34 of 37 questionnaires, the emotional evaluation (e.g. anxiety) towards dying is measured. Dying is operationalized in general items ( n = 20), in several specific aspects of dying ( n = 34) and as dying of others ( n = 14). Methodological quality of tools was reported inconsistently. Nine tools reported good internal consistency. Of 37 tools, 4 were validated in a clinical sample (e.g. terminal cancer; Huntington disease), indicating questionable generalizability to clinical contexts for most tools. Many tools exist to measure attitudes towards the dying process using different endpoints. This overview can serve as decision framework on which tool to apply in which contexts. For clinical application, only few tools were available. Further validation of existing tools and potential alternative methods in various populations is needed.

Discrete Circuits Support Generalized versus Context-Specific Vocal Learning in the Songbird.

PubMed

Tian, Lucas Y; Brainard, Michael S

2017-12-06

Motor skills depend on the reuse of individual gestures in multiple sequential contexts (e.g., a single phoneme in different words). Yet optimal performance requires that a given gesture be modified appropriately depending on the sequence in which it occurs. To investigate the neural architecture underlying such context-dependent modifications, we studied Bengalese finch song, which, like speech, consists of variable sequences of "syllables." We found that when birds are instructed to modify a syllable in one sequential context, learning generalizes across contexts; however, if unique instruction is provided in different contexts, learning is specific for each context. Using localized inactivation of a cortical-basal ganglia circuit specialized for song, we show that this balance between generalization and specificity reflects a hierarchical organization of neural substrates. Primary motor circuitry encodes a core syllable representation that contributes to generalization, while top-down input from cortical-basal ganglia circuitry biases this representation to enable context-specific learning. Copyright © 2017 Elsevier Inc. All rights reserved.

The MG Composite

PubMed Central

Burns, Ted M.; Conaway, Mark; Sanders, Donald B.

2010-01-01

Objective: To study the concurrent and construct validity and test-retest reliability in the practice setting of an outcome measure for myasthenia gravis (MG). Methods: Eleven centers participated in the validation study of the Myasthenia Gravis Composite (MGC) scale. Patients with MG were evaluated at 2 consecutive visits. Concurrent and construct validities of the MGC were assessed by evaluating MGC scores in the context of other MG-specific outcome measures. We used numerous potential indicators of clinical improvement to assess the sensitivity and specificity of the MGC for detecting clinical improvement. Test-retest reliability was performed on patients at the University of Virginia. Results: A total of 175 patients with MG were enrolled at 11 sites from July 1, 2008, to January 31, 2009. A total of 151 patients were seen in follow-up. Total MGC scores showed excellent concurrent validity with other MG-specific scales. Analyses of sensitivities and specificities of the MGC revealed that a 3-point improvement in total MGC score was optimal for signifying clinical improvement. A 3-point improvement in the MGC also appears to represent a meaningful improvement to most patients, as indicated by improved 15-item myasthenia gravis quality of life scale (MG-QOL15) scores. The psychometric properties were no better for an individualized subscore made up of the 2 functional domains that the patient identified as most important to treat. The test-retest reliability coefficient of the MGC was 98%, with a lower 95% confidence interval of 97%, indicating excellent test-retest reliability. Conclusions: The Myasthenia Gravis Composite is a reliable and valid instrument for measuring clinical status of patients with myasthenia gravis in the practice setting and in clinical trials. PMID:20439845

Bringing prosocial values to translational, disease-specific stem cell research.

PubMed

Sass, Reuben G

2014-02-27

Disease-specific stem cell therapies, created from induced pluripotent stem cell lines containing the genetic defects responsible for a particular disease, have the potential to revolutionize the treatment of refractory chronic diseases. Given their capacity to differentiate into any human cell type, these cell lines might be reprogrammed to correct a disease-causing genetic defect in any tissue or organ, in addition to offering a more clinically realistic model for testing new drugs and studying disease mechanisms. Clinical translation of these therapies provides an opportunity to design a more systematic, accessible and patient-influenced model for the delivery of medically innovative treatments to chronically ill patients. I focus on disease-specific cell therapies because the types of patients who would benefit from them have congenital, severe, high-maintenance chronic conditions. They accordingly have a very strong claim for medical need and therapeutic intervention, must interact regularly with health providers, and so have the greatest stake in influencing, at a systemic level, the way their care is delivered. Given such patients' shared, aggregate needs for societal support and access to medical innovation, they constitute "patient communities". To reify the relevance of patient communities within a clinical context, I propose competitive grants or "prizes" to spur innovation in delivery of care, promoting "prosocial" values of transparency, equity, patient empowerment, and patient-provider and inter-institutional collaboration. As facilitators of participant-driven advocacy for health and quality of life-improving measures, patient communities may be synergistic with the broad-based, geo-culturally embedded public health networks typically referred to as "communities" in the public health literature. Prosocial values acquire a strong ethical justification based on shared need, and can be clearly defined as grant criteria, when applied to patients such as those who will benefit from disease-specific stem cell treatments. Within this context, prosociality aims not just to expand patients' treatment choices, but also their opportunities to take a more active role in the management of their own care and contribute towards shared goals through better-informed advocacy. Accordingly, prosociality promotes relational autonomy as well as other basic bioethical principles, including beneficence and a holistic, relational conception of human dignity.

Development and pilot testing of an interprofessional patient-centered team training programme in medical rehabilitation clinics in Germany: a process evaluation.

PubMed

Becker, Sonja; Körner, Mirjam; Müller, Christian; Lippenberger, Corinna; Rundel, Manfred; Zimmermann, Linda

2017-07-14

Interprofessional teamwork is considered to be a key component of patient-centred treatment in healthcare, and especially in the rehabilitation sector. To date, however, no interventions exist for improving teamwork in rehabilitation clinics in Germany. A team training programme was therefore designed that is individualised in content but standardised regarding methods and process. It is clinic specific, task related, solution focused and context oriented. The aim of the study was to implement and evaluate this training for interprofessional teams in rehabilitation clinics in Germany. The measure consists of a training of a varying number of sessions with rehabilitation teams that consists of four distinct phases. Those are undergone chronologically, each with clinic-specific contents. It was implemented between 2013 and 2014 in five rehabilitation clinics in Germany and evaluated by the participants via questionnaire (n = 52). Staff in three clinics evaluated the programme as helpful, in particular rating moderation, discussions and communication during the training positively. Staff in the remaining two clinics rated it as not very or not helpful and mentioned long-term structural problems or a lack of need for team training as a reason for this. The team training is applicable and accepted by staff. It should, however, be tested in a greater sample and compared with a control group. Processes should be studied in more detail in order to determine what differentiates successful from non-successful interventions and the different requirements each of these might have.

Cued Reacquisition Trials during Extinction Weaken Contextual Renewal in Human Predictive Learning

ERIC Educational Resources Information Center

Effting, Marieke; Vervliet, Bram; Beckers, Tom; Kindt, Merel

2013-01-01

Extinction is generally more context specific than acquisition, as illustrated by the renewal effect. While most strategies to counteract renewal focus on decreasing the context specificity of extinction, the present work aimed at increasing the context specificity of acquisition learning. Two experiments examined whether presenting cued…

Safe Genetic Modification of Cardiac Stem Cells Using a Site-Specific Integration Technique

PubMed Central

Lan, Feng; Liu, Junwei; Narsinh, Kazim H.; Hu, Shijun; Han, Leng; Lee, Andrew S.; Karow, Marisa; Nguyen, Patricia K.; Nag, Divya; Calos, Michele P.; Robbins, Robert C.; Wu, Joseph C.

2012-01-01

Background Human cardiac progenitor cells (hCPCs) are a promising cell source for regenerative repair after myocardial infarction. Exploitation of their full therapeutic potential may require stable genetic modification of the cells ex vivo. Safe genetic engineering of stem cells, using facile methods for site-specific integration of transgenes into known genomic contexts, would significantly enhance the overall safety and efficacy of cellular therapy in a variety of clinical contexts. Methods and Results We employed the phiC31 site-specific recombinase to achieve targeted integration of a triple fusion reporter gene into a known chromosomal context in hCPCs and human endothelial cells (hECs). Stable expression of the reporter gene from its unique chromosomal integration site resulted in no discernible genomic instability or adverse changes in cell phenotype. Namely, phiC31-modified hCPCs were unchanged in their differentiation propensity, cellular proliferative rate, and global gene expression profile when compared to unaltered control hCPCs. Expression of the triple fusion reporter gene enabled multimodal assessment of cell fate in vitro and in vivo using fluorescence microscopy, bioluminescence imaging (BLI), and positron emission tomography (PET). Intramyocardial transplantation of genetically modified hCPCs resulted in significant improvement in myocardial function two weeks after cell delivery, as assessed by echocardiography (P = 0.002) and magnetic resonance imaging (P = 0.001). We also demonstrated the feasibility and therapeutic efficacy of genetically modifying differentiated hECs, which enhanced hindlimb perfusion (P<0.05 at day 7 and 14 after transplantation) on laser Doppler imaging. Conclusions The phiC31 integrase genomic modification system is a safe, efficient tool to enable site-specific integration of reporter transgenes in progenitor and differentiated cell types. PMID:22965984

Safe genetic modification of cardiac stem cells using a site-specific integration technique.

PubMed

Lan, Feng; Liu, Junwei; Narsinh, Kazim H; Hu, Shijun; Han, Leng; Lee, Andrew S; Karow, Marisa; Nguyen, Patricia K; Nag, Divya; Calos, Michele P; Robbins, Robert C; Wu, Joseph C

2012-09-11

Human cardiac progenitor cells (hCPCs) are a promising cell source for regenerative repair after myocardial infarction. Exploitation of their full therapeutic potential may require stable genetic modification of the cells ex vivo. Safe genetic engineering of stem cells, using facile methods for site-specific integration of transgenes into known genomic contexts, would significantly enhance the overall safety and efficacy of cellular therapy in a variety of clinical contexts. We used the phiC31 site-specific recombinase to achieve targeted integration of a triple fusion reporter gene into a known chromosomal context in hCPCs and human endothelial cells. Stable expression of the reporter gene from its unique chromosomal integration site resulted in no discernible genomic instability or adverse changes in cell phenotype. Namely, phiC31-modified hCPCs were unchanged in their differentiation propensity, cellular proliferative rate, and global gene expression profile when compared with unaltered control hCPCs. Expression of the triple fusion reporter gene enabled multimodal assessment of cell fate in vitro and in vivo using fluorescence microscopy, bioluminescence imaging, and positron emission tomography. Intramyocardial transplantation of genetically modified hCPCs resulted in significant improvement in myocardial function 2 weeks after cell delivery, as assessed by echocardiography (P=0.002) and MRI (P=0.001). We also demonstrated the feasibility and therapeutic efficacy of genetically modifying differentiated human endothelial cells, which enhanced hind limb perfusion (P<0.05 at day 7 and 14 after transplantation) on laser Doppler imaging. The phiC31 integrase genomic modification system is a safe, efficient tool to enable site-specific integration of reporter transgenes in progenitor and differentiated cell types.

Identifying specific cues and contexts related to bingeing behavior for the development of effective virtual environments.

PubMed

Pla-Sanjuanelo, Joana; Ferrer-García, Marta; Gutiérrez-Maldonado, José; Riva, Giuseppe; Andreu-Gracia, Alexis; Dakanalis, Antonios; Fernandez-Aranda, Fernando; Forcano, Laura; Ribas-Sabaté, Joan; Riesco, Nadine; Rus-Calafell, Mar; Sánchez, Isabel; Sanchez-Planell, Luís

2015-04-01

Binge eating behavior constitutes a central feature of both bulimia nervosa (BN) and binge eating disorder (BED). Cue exposure therapy (CET) has been proposed as an effective intervention. To determine which situations and specific cues trigger higher levels of binge craving and to use the results in the development of virtual reality scenarios in which CET could be applied with BN and BED patients. Participants were 101 outpatients, 50 with BED and 51 with BN, according to DSM-5 criteria, and 63 healthy undergraduate students who completed a self-administered questionnaire to assess binge craving. The likelihood of binge craving in the clinical group was greater when alone at home, during the afternoon/early evening and in the late evening/at night, at weekends, and at dinner time or between meals. Higher levels of craving were produced in the kitchen, bedroom, dining room, and bakery situations. With regard to the specific cues reported, the presence of and access to high calorie food and snacks was the most commonly reported cue. Although some gender differences regarding triggering factors were obtained, no statistical differences were observed between ED subtypes. BN and BED patients showed significantly higher levels of binge craving than controls in all the contexts except when feeling positive affect; in this situation, levels of craving were low in both groups. This information regarding trigger contexts and specific cues can be used to create valid and reliable virtual environments for CET. Indeed, the data from this study may serve to develop a wide range of situations with different levels of binge craving, in which the therapeutic aim is to extinguish conditioned responses and facilitate the generalization of craving extinction. Copyright © 2014 Elsevier Ltd. All rights reserved.

The importance of semen analysis in the context of azoospermia.

PubMed

Aziz, Nabil

2013-01-01

Azoospermia is a descriptive term referring to ejaculates that lack spermatozoa without implying a specific underlying cause. The traditional definition of azoospermia is ambiguous, which has ramifications on the diagnostic criteria. This issue is further compounded by the apparent overlap between the definitions of oligospermia and azoospermia. The reliable diagnosis of the absence of spermatozoa in a semen sample is an important criterion not only for diagnosing male infertility but also for ascertaining the success of a vasectomy and for determining the efficacy of hormonal contraception. There appears to be different levels of rigor in diagnosing azoospermia in different clinical situations, which highlights the conflict between scientific research and clinical practice in defining azoospermia.

[Conceptual foundation of the operational diagnostic approach in psychiatry].

PubMed

Jäger, M; Strauss, A; Frasch, K; Becker, T

2007-08-01

Based on the pioneering work of Emil Kraepelin, Karl Jaspers, Kurt Schneider and representatives of logical empiricism, the basic principles of the operational diagnostic approach in psychiatry are described. Operational diagnostic systems like ICD-10 and DSM-IV aimed at a standardisation of psychiatric language which can be accepted by different schools in psychiatry. However, ICD-10 and DSM-IV should not be misinterpreted as "nosology" because they do not reflect a specific model of psychiatric diseases. The advantages of operational diagnostic systems as instruments for communication in a clinical and scientific context are limited by the fact that they disregard the subjective psychopathology. This dimension, however, deserves attention in clinic and research.

Validity of the construct of post-traumatic stress disorder in a low-income country: interview study of women in Gujarat, India.

PubMed

Mehta, Khyati; Vankar, Ganpat; Patel, Vikram

2005-12-01

The validity of the clinical construct of post-traumatic stress disorder (PTSD) has been questioned in non-Western cultures. This report describes in-depth interviews exploring the experiences of women who were traumatised by the communal riots in Ahmedabad, India, in March 2002. Three specific narratives are presented which describe experiences that closely resemble re-experiencing, avoidance and hyperarousal. Thus, symptoms described as characteristic features of PTSD in biomedical classifications are clearly expressed by the women in our study, and are attributed by them to trauma and grief. We conclude that PTSD may be a relevant clinical construct in the Indian context.

HIV Genetic Diversity and Drug Resistance.

PubMed

Santos, André F; Soares, Marcelo A

2010-02-01

Most of the current knowledge on antiretroviral (ARV) drug development and resistance is based on the study of subtype B of HIV-1, which only accounts for 10% of the worldwide HIV infections. Cumulative evidence has emerged that different HIV types, groups and subtypes harbor distinct biological properties, including the response and susceptibility to ARV. Recent laboratory and clinical data highlighting such disparities are summarized in this review. Variations in drug susceptibility, in the emergence and selection of specific drug resistance mutations, in viral replicative capacity and in the dynamics of resistance acquisition under ARV selective pressure are discussed. Clinical responses to ARV therapy and associated confounding factors are also analyzed in the context of infections by distinct HIV genetic variants.

Cognitive deficits are a matter of emotional context: inflexible strategy use mediates context-specific learning impairments in OCD.

PubMed

Zetsche, Ulrike; Rief, Winfried; Westermann, Stefan; Exner, Cornelia

2015-01-01

The present study examines the interplay between cognitive deficits and emotional context in obsessive-compulsive disorder (OCD) and social phobia (SP). Specifically, this study examines whether the inflexible use of efficient learning strategies in an emotional context underlies impairments in probabilistic classification learning (PCL) in OCD, and whether PCL impairments are specific to OCD. Twenty-three participants with OCD, 30 participants with SP and 30 healthy controls completed a neutral and an OCD-specific PCL task. OCD participants failed to adopt efficient learning strategies and showed fewer beneficial strategy switches than controls only in an OCD-specific context, but not in a neutral context. Additionally, OCD participants did not show any explicit memory impairments. Number of beneficial strategy switches in the OCD-specific task mediated the difference in PCL performance between OCD and control participants. Individuals with SP were impaired in both PCL tasks. In contrast to neuropsychological models postulating general cognitive impairments in OCD, the present findings suggest that it is the interaction between cognition and emotion that is impaired in OCD. Specifically, activated disorder-specific fears may impair the flexible adoption of efficient learning strategies and compromise otherwise unimpaired PCL. Impairments in PCL are not specific to OCD.

Risk-adjusted sequential probability ratio tests: applications to Bristol, Shipman and adult cardiac surgery.

PubMed

Spiegelhalter, David; Grigg, Olivia; Kinsman, Robin; Treasure, Tom

2003-02-01

To investigate the use of the risk-adjusted sequential probability ratio test in monitoring the cumulative occurrence of adverse clinical outcomes. Retrospective analysis of three longitudinal datasets. Patients aged 65 years and over under the care of Harold Shipman between 1979 and 1997, patients under 1 year of age undergoing paediatric heart surgery in Bristol Royal Infirmary between 1984 and 1995, adult patients receiving cardiac surgery from a team of cardiac surgeons in London,UK. Annual and 30-day mortality rates. Using reasonable boundaries, the procedure could have indicated an 'alarm' in Bristol after publication of the 1991 Cardiac Surgical Register, and in 1985 or 1997 for Harold Shipman depending on the data source and the comparator. The cardiac surgeons showed no significant deviation from expected performance. The risk-adjusted sequential probability test is simple to implement, can be applied in a variety of contexts, and might have been useful to detect specific instances of past divergent performance. The use of this and related techniques deserves further attention in the context of prospectively monitoring adverse clinical outcomes.

Assessment of complex dissociative disorder patients and simulated dissociation in forensic contexts.

PubMed

Brand, Bethany L; Webermann, Aliya R; Frankel, A Steven

Few assessors receive training in assessing dissociation and complex dissociative disorders (DDs). Potential differential diagnoses include anxiety, mood, psychotic, substance use, and personality disorders, as well as exaggeration and malingering. Individuals with DDs typically elevate on many clinical and validity scales on psychological tests, yet research indicates that they can be distinguished from DD simulators. Becoming informed about the testing profiles of DD individuals and DD simulators can improve the accuracy of differential diagnoses in forensic settings. In this paper, we first review the testing profiles of individuals with complex DDs and contrast them with DD simulators on assessment measures used in forensic contexts, including the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Personality Assessment Inventory (PAI), and the Structured Inventory of Reported Symptoms (SIRS), as well as dissociation-specific measures such as the Dissociative Experiences Scale (DES) and Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D-R). We then provide recommendations for assessing complex trauma and dissociation through the aforementioned assessments. Copyright © 2016 Elsevier Ltd. All rights reserved.

The neuroscience of placebo effects: connecting context, learning and health

PubMed Central

Wager, Tor D.; Atlas, Lauren Y.

2018-01-01

Placebo effects are beneficial effects that are attributable to the brain–mind responses to the context in which a treatment is delivered rather than to the specific actions of the drug. They are mediated by diverse processes — including learning, expectations and social cognition — and can influence various clinical and physiological outcomes related to health. Emerging neuroscience evidence implicates multiple brain systems and neurochemical mediators, including opioids and dopamine. We present an empirical review of the brain systems that are involved in placebo effects, focusing on placebo analgesia, and a conceptual framework linking these findings to the mind–brain processes that mediate them. This framework suggests that the neuropsychological processes that mediate placebo effects may be crucial for a wide array of therapeutic approaches, including many drugs. PMID:26087681

The infra-value of human rights in the context of assisted regulation in México.

PubMed

Esparza-Pérez, Rosa Verónica

Infertility represents a problem in the context of reproductive health; to treat it were developed the techniques of assisted human reproduction, despite medical advances, the practice of techniques is subject to medical, legal and ethical dysfunctions. In Mexico, since the late 1980s assisted reproduction clinics were set up in public and private sector hospitals; however, they do not yet have a legal framework to regulate them in a specific way, which causes human rights violations that could be avoided with adequate regulation. This article advances the need to provide Mexico with such regulation as a means of guaranteeing both human rights and the rights of physicians and other health workers involved in these techniques. Copyright: © 2017 SecretarÍa de Salud.

An Argument for Fewer Clinical Trials.

PubMed

Borgerson, Kirstin

2016-11-01

The volume of clinical research is increasing exponentially-far beyond our ability to process and absorb the results. Given this situation, it may be beneficial to consider reducing the flow at its source. In what follows, I will motivate and critically evaluate the following proposal: researchers should conduct fewer clinical trials. More specifically, I c onsider whether researchers should be permitted to conduct only clinical research of very high quality and, in turn, whether research ethics committees (RECs) should prohibit all other, lower-quality research, even when it might appear to meet some minimal ethical standard. Following a close analysis of the social-value requirement of ethical clinical research, I argue that this proposal is defensible. The problem identified in this paper has two parts, quantity and quality, and some clarification is needed about the latter because "quality" is a highly contested term in the medical literature. When some scholars advocate for high-quality trials, they mean large-scale, simple, explanatory randomized controlled trials. Others, including myself, have defended a different characterization of high-quality research that tends more toward pragmatic trial design and the use of methods other than RCTs. Pragmatic trials aim to provide evidence that directly supports clinical decision-making in "usual" care settings. Unlike explanatory trials, which aim to abstract away from particular settings and patients, in the hopes of creating ideal conditions for the success of an intervention, pragmatic trials deliberately pursue knowledge of high applicability, through the use of representative subjects, clinically important questions, flexible treatment protocols, patient-oriented outcome measures, and so on. I see applicability as a marker of high-quality research. The context in which research is meant to be applied should be the context in which new interventions are evaluated. © 2016 The Hastings Center.

Instruments to Identify Prescription Medication Misuse, Abuse, and Related Events in Clinical Trials: An ACTTION Systematic Review.

PubMed

Smith, Shannon M; Paillard, Florence; McKeown, Andrew; Burke, Laurie B; Edwards, Robert R; Katz, Nathaniel P; Papadopoulos, Elektra J; Rappaport, Bob A; Slagle, Ashley; Strain, Eric C; Wasan, Ajay D; Turk, Dennis C; Dworkin, Robert H

2015-05-01

Measurement of inappropriate medication use events (eg, abuse or misuse) in clinical trials is important in characterizing a medication's abuse potential. However, no gold standard assessment of inappropriate use events in clinical trials has been identified. In this systematic review, we examine the measurement properties (ie, content validity, cross-sectional reliability and construct validity, longitudinal construct validity, ability to detect change, and responder definitions) of instruments assessing inappropriate use of opioid and nonopioid prescription medications to identify any that meet U.S. and European regulatory agencies' rigorous standards for outcome measures in clinical trials. Sixteen published instruments were identified, most of which were not designed for the selected concept of interest and context of use. For this reason, many instruments were found to lack adequate content validity (or documentation of content validity) to evaluate current inappropriate medication use events; for example, evaluating inappropriate use across the life span rather than current use, including items that did not directly assess inappropriate use (eg, questions about anger), or failing to capture information pertinent to inappropriate use events (eg, intention and route of administration). In addition, the psychometric data across all instruments were generally limited in scope. A further limitation is the heterogeneous, nonstandardized use of inappropriate medication use terminology. These observations suggest that available instruments are not well suited for assessing current inappropriate medication use within the specific context of clinical trials. Further effort is needed to develop reliable and valid instruments to measure current inappropriate medication use events in clinical trials. This systematic review evaluates the measurement properties of inappropriate medication use (eg, abuse or misuse) instruments to determine whether any meet regulatory standards for clinical trial outcome measures to assess abuse potential. Copyright © 2015 American Pain Society. All rights reserved.

Implementation of Pediatric Early Warning Score; Adherence to Guidelines and Influence of Context.

PubMed

Almblad, Ann-Charlotte; Siltberg, Petra; Engvall, Gunn; Målqvist, Mats

To describe data of Pediatric Early Warning Score (PEWS) registrations and to evaluate the implementation of PEWS by examining adherence to clinical guidelines based on measured PEWS, and to relate findings to work context. PEWS, as a part of a concept called Early Detection and Treatment-Children (EDT-C) was implemented at three wards at a Children's Hospital in Sweden. Data were collected from the Electronic Patient Record (EPR) retrospectively to assess adherence to guidelines. The Alberta Context Tool (ACT) was used to assess work context among healthcare professionals (n=109) before implementation of EDT-C. The majority of PEWS registrations in EPR were low whereas 10% were moderate to high. Adherences to ward-specific guidelines at admission and for saturation in respiratory distress were high whereas adherence to pain assessment was low. There were significant differences in documented recommended actions between wards. Some differences in leadership and evaluation between wards were identified. Evaluation of PEWS implementation indicated frequent use of the tool despite most scores being low. High scores (5-9) occurred 28 times, which may indicate that patients with a high risk of clinical deterioration were identified. Documentation of the consequent recommended actions was however incomplete and there was a large variation in adherence to guidelines. Contextual factors may have an impact on adherence. EDT-C can lead to increased knowledge about early detection of deterioration, strengthen nurses as professionals, optimize treatment and teamwork and thereby increase patient safety for children treated in hospitals. Copyright © 2017 Elsevier Inc. All rights reserved.

A business rules design framework for a pharmaceutical validation and alert system.

PubMed

Boussadi, A; Bousquet, C; Sabatier, B; Caruba, T; Durieux, P; Degoulet, P

2011-01-01

Several alert systems have been developed to improve the patient safety aspects of clinical information systems (CIS). Most studies have focused on the evaluation of these systems, with little information provided about the methodology leading to system implementation. We propose here an 'agile' business rule design framework (BRDF) supporting both the design of alerts for the validation of drug prescriptions and the incorporation of the end user into the design process. We analyzed the unified process (UP) design life cycle and defined the activities, subactivities, actors and UML artifacts that could be used to enhance the agility of the proposed framework. We then applied the proposed framework to two different sets of data in the context of the Georges Pompidou University Hospital (HEGP) CIS. We introduced two new subactivities into UP: business rule specification and business rule instantiation activity. The pharmacist made an effective contribution to five of the eight BRDF design activities. Validation of the two new subactivities was effected in the context of drug dosage adaption to the patients' clinical and biological contexts. Pilot experiment shows that business rules modeled with BRDF and implemented as an alert system triggered an alert for 5824 of the 71,413 prescriptions considered (8.16%). A business rule design framework approach meets one of the strategic objectives for decision support design by taking into account three important criteria posing a particular challenge to system designers: 1) business processes, 2) knowledge modeling of the context of application, and 3) the agility of the various design steps.

Context-specific modulation of cocaine-induced locomotor sensitization and ERK and CREB phosphorylation in rat nucleus accumbens

PubMed Central

Marin, Marcelo T.; Berkow, Alexander; Golden, Sam A.; Koya, Eisuke; Planeta, Cleopatra S.; Hope, Bruce T.

2009-01-01

Learned associations are hypothesized to develop between drug effects and contextual stimuli during repeated drug administration to produce context-specific sensitization that is expressed only in the drug-associated environment and not in a non-drug paired environment. Neuroadaptations that mediate such context-specific behavior are largely unknown. We investigated context-specific modulation of CREB phosphorylation and four upstream kinases in nucleus accumbens that phosphorylate CREB, including ERK, PKA, CaMKII and IV. Rats received seven once daily injections of cocaine or saline in one of two distinct environments outside their home cages. Seven days later, test injections of cocaine or saline were administered in either the Paired or the Non-paired environment. CREB and ERK phosphorylation were assessed with immunohistochemistry while phosphorylation of the remaining kinases, as well as CREB and ERK, were assessed by Western blotting. Repeated cocaine administration produced context-specific sensitized locomotor responses accompanied by context-specific enhancement of the number of cocaine-induced phosphoCREB and phosphoERK immunoreactive nuclei in a minority of neurons. In contrast, CREB and CaMKIV phosphorylation in nucleus accumbens homogenates were decreased by cocaine test injections. We have recently shown that a small number of cocaine-activated accumbens neurons mediate the learned association between cocaine effects and the drug administration environment to produce context-specific sensitization. The corresponding cocaine and context-specific phosphorylation of ERK and CREB in cocaine-activated accumbens neurons in the present study suggests that this signal transduction pathway is also selectively activated in the same set of accumbens neurons. PMID:19912338

Impulsive responding in threat and reward contexts as a function of PTSD symptoms and trait disinhibition.

PubMed

Sadeh, Naomi; Spielberg, Jeffrey M; Hayes, Jasmeet P

2018-01-01

We examined current posttraumatic stress disorder (PTSD) symptoms, trait disinhibition, and affective context as contributors to impulsive and self-destructive behavior in 94 trauma-exposed Veterans. Participants completed an affective Go/No-Go task (GNG) with different emotional contexts (threat, reward, and a multidimensional threat/reward condition) and current PTSD, trait disinhibition, and risky/self-destructive behavior measures. PTSD interacted with trait disinhibition to explain recent engagement in risky/self-destructive behavior, with Veterans scoring high on trait disinhibition and current PTSD symptoms reporting the highest levels of these behaviors. On the GNG task, commission errors were also associated with the interaction of PTSD symptoms and trait disinhibition. Specifically, PTSD symptoms were associated with greater commission errors in threat vs. reward contexts for individuals who were low on trait disinhibition. In contrast, veterans high on PTSD and trait disinhibition exhibited the greatest number of commission errors in the multidimensional affective context that involved both threat and reward processing. Results highlight the interactive effects of PTSD and disinhibited personality traits, as well as threat and reward systems, as risk factors for impulsive and self-destructive behavior in trauma-exposed groups. Findings have clinical implications for understanding heterogeneity in the expression of PTSD and its association with disinhibited behavior. Copyright © 2017 Elsevier Ltd. All rights reserved.

Using Generic and Context-Specific Scaffolding to Support Authentic Science Inquiry

ERIC Educational Resources Information Center

Belland, Brian R.; Gu, Jiangyue; Armbrust, Sara; Cook, Brant

2013-01-01

In this conceptual paper, we propose an heuristic to balance context-specific and generic scaffolding, as well as computer-based and teacher scaffolding, during instruction centered on authentic, scientific problems. This paper is novel in that many researchers ask a dichotomous question of whether generic or context-specific scaffolding is best,…

Specificity of jumping to conclusions and attributional biases: a comparison between patients with schizophrenia, depression, and anorexia nervosa.

PubMed

Wittorf, Andreas; Giel, Katrin E; Hautzinger, Martin; Rapp, Alexander; Schönenberg, Michael; Wolkenstein, Larissa; Zipfel, Stephan; Mehl, Stephanie; Fallgatter, Andreas J; Klingberg, Stefan

2012-05-01

The knowledge of the specificity of cognitive biases in psychiatric disorders is important in order to develop disorder-specific cognitive models and therapies. This cross-sectional study aimed to investigate the specificity of jumping to conclusions (JTC) and attributional biases (AB) for patients with schizophrenia. Twenty patients with paranoid schizophrenia were compared with patients with depression (n=20) and with anorexia nervosa (n=15) and nonclinical controls (n=55). All participants were administered a modified version of the beads task (JTC), a revised German version of the Internal, Personal, and Situational Attributions Questionnaire (AB), and several symptom and neurocognitive measures. The proportion of patients with JTC bias in the schizophrenia group was, at the descriptive level, higher than in the depression and the anorexia groups. Regarding AB, the schizophrenia group showed a significantly stronger externalising but not personalising bias than the clinical control groups. Neither JTC nor attributional biases were significantly associated with delusions in general or persecutory delusion. We found evidence for the specificity of an externalising bias for paranoid schizophrenia. Concerning JTC bias the evidence was less clear. Whether the modification of those biases through psychological interventions would have an effect on psychopathology should be investigated in the context of clinical trials.

Activation of context-specific attentional control sets by exogenous allocation of visual attention to the context?

PubMed

Gottschalk, Caroline; Fischer, Rico

2017-03-01

Different contexts with high versus low conflict frequencies require a specific attentional control involvement, i.e., strong attentional control for high conflict contexts and less attentional control for low conflict contexts. While it is assumed that the corresponding control set can be activated upon stimulus presentation at the respective context (e.g., upper versus lower location), the actual features that trigger control set activation are to date not described. Here, we ask whether the perceptual priming of the location context by an abrupt onset of irrelevant stimuli is sufficient in activating the context-specific attentional control set. For example, the mere onset of a stimulus might disambiguate the relevant location context and thus, serve as a low-level perceptual trigger mechanism that activates the context-specific attentional control set. In Experiment 1 and 2, the onsets of task-relevant and task-irrelevant (distracter) stimuli were manipulated at each context location to compete for triggering the activation of the appropriate control set. In Experiment 3, a prior training session enabled distracter stimuli to establish contextual control associations of their own before entering the test session. Results consistently showed that the mere onset of a task-irrelevant stimulus (with or without a context-control association) is not sufficient to activate the context-associated attentional control set by disambiguating the relevant context location. Instead, we argue that the identification of the relevant stimulus at the respective context is a precondition to trigger the activation of the context-associated attentional control set.

Cervical VEMP threshold response curve in the identification of Ménière's disease.

PubMed

Zhu, Yi; McPherson, James; Beatty, Charles; Driscoll, Colin; Neff, Brian; Eggers, Scott; Shepard, Neil T

2014-03-01

To investigate the sensitivity/specificity of a shift upward in the most sensitive frequency of the cervical vestibular evoked myogenic potential (cVEMP) threshold-response curve in the identification of Ménière's disease (MD). A secondary purpose was to investigate the clinical characteristics that had an impact on the sensitivity/specificity and to adjust the criteria for a positive shift upward in the cVEMP curve to maximize performance of the test. A retrospective review of patients diagnosed with MD and those without MD. Two hundred ninety-four patients met the inclusion criteria of symptom complaints of spontaneous events of vertigo and a full vestibular and balance evaluation with cVEMP threshold-response curve testing. Two hundred six of these patients were diagnosed with MD, and 88 patients were determined to be non-MD. Review of the patients' medical records was used to extract data on the results of the cVEMP curve, age, gender, duration from time of onset of spontaneous events, pure tone average from hearing test, and water caloric asymmetry. Student's t-test, χ² test, receiver operating characteristic (ROC) curve with area under the curve (AUC), Pearson correlation coefficient, and sensitivity/specificity from 2 × 2 tables were all used in the analysis. Basic sensitivity/specificity for a shift upward in the most sensitive frequency to 1000 Hz in the cVEMP threshold-response curve was 0.47/0.64 respectively. Clinical characteristics that were found to have a significant impact on the sensitivity/specificity were age equal to or above 60 yr and a caloric asymmetry ≥25%. Various combinations of age and caloric with the requirement of a shift upward in the cVEMP curve most sensitive frequency to 1000 Hz resulted in significant but modest improvements in sensitivity/specificity. However, the overall performance was not shown acceptable for routine clinical use with maximum sensitivity at 0.73. Therefore, placing an emphasis on specificity over sensitivity results showed specificity of 0.95 for those under 60 yr and 0.90 for those 60 yr of age or older with sensitivity at 0.20, but only in the context of a ≥25% caloric asymmetry. We recommend the use of the shift upward to 1000 Hz with a caloric asymmetry as the clinical protocol to maximize the use of the cVEMP threshold-response curve for assistance in the identification of MD, in the context of a ≥25% caloric asymmetry. This implies that if the test is negative no interpretation of identification of MD can be made. If the test is positive the results can be used to increase the argument for MD since the probability of the result being a false positive is only 5-10%. American Academy of Audiology.

Absence of verbal recall or memory for symptom acquisition in fear and trauma exposure: a conceptual case for fear conditioning and learned nonuse in assessment and treatment.

PubMed

Seifert, A Ronald

2012-01-01

Absence of memory or verbal recall for symptom acquisition in fear and trauma exposure, as well as absence of successful coping behavior for life events, is associated with a number of diagnoses, including traumatic brain injury, posttraumatic stress disorder, pain, and anxiety. The difficulty with diagnosis and treatment planning based on the absence of recall, memory, and successful coping behavior is threefold: (1) these assessments do not distinguish between disruption of behavior and lack of capacity, (2) the absence of verbal recall and memory complicates cognitive-based treatment, and (3) a confounding issue is the same absent behavior can be observed at different times and contexts. While memory of the specific details of the initial traumatic event(s) may not be available to verbal report, the existence of time- and context-dependent relationships for the initial as well as subsequent experiences is arguable. The absence of memory or lack of verbal recall does not rule out measurable physiological bodily responses for the initial trauma(s), nor does it help to establish the effects of subsequent experiences for symptom expression. Also, the absence of memory must include the prospect of fear-based learning that does not require or involve the cortex. It is posited that the literatures of fear conditioning and learned nonuse provide complementary illustrations of how the time and context of the initial trauma(s) and subsequent experiences affect behavior, which is not dependent on the effected individual being able to provide a memory-based verbal report. The replicated clinical application demonstrates that, without scientific demonstration, neither neuroanatomy nor verbal report can be assumed sufficient to predict overt behavior or physiologic responses. For example, while commonly assumed to be predictively so, autonomic nervous system innervation is insufficient to define the unique stimulus- and context-dependent physiological responses of an individual. By recording simultaneous physiological responses to the controlled presentation of a context-dependent stimulus, the unique relationships of physiology and overt behaviors for the individual can be demonstrated. Using this process also allows more complex virtual reality or other in vivo stimulus assessments to be incorporated for the development of individually tailored assessments and therapeutic plans. Thus, with or without memory or verbal recall, the use of multiple time- and context-specific simultaneous physiological measures and overt behavior can guide clinical effort as well as serve to objectively assess the ongoing treatment and its outcome.

The effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine: an exploratory study.

PubMed

Tichelaar, Jelle; van Kan, Coen; van Unen, Robert J; Schneider, Anton J; van Agtmael, Michiel A; de Vries, Theo P G M; Richir, Milan C

2015-02-01

The aim of this study is to evaluate the effect of different levels of realism of context learning on the prescribing competencies of medical students during the clinical clerkship in internal medicine. Between 2001 and 2007, 164 medical students took part in the prospective explorative study during their clinical clerkship in internal medicine at the VU University Medical Center, Amsterdam, The Netherlands. In a fixed order, each student had to formulate a treatment plan for a real patient in three situations of increasing realism: a minimal level (studying a patient record), medium level (preparing for a therapeutic consultation), and optimal level (preparing for and performing a therapeutic consultation with the patient). In comparison to studying a patient record (minimal context level), preparing a therapeutic consultation (medium context) improved four of the six steps of the WHO six-step plan. Preparing and performing a therapeutic consultation with a real patient (optimal context) further improved three essential prescribing competencies, namely checking for contraindications and interactions, prescription writing, and instructions to the patient. The results of this first explorative study suggest that enrichment of the learning context (responsibility for patient care) might be an important factor to improve the training of rational prescribing skills of medical students during their clinical clerkship in internal medicine. Clinical (pharmacology) teachers should be aware that seemingly small adaptations in the learning context of prescribing training during clinical clerkships (i.e., with or without involvement with and responsibility for patient care) may have relatively large impact on the development of prescribing competencies of our future doctors.

Time-Dependent Effects of Prazosin on the Development of Methamphetamine Conditioned Hyperactivity and Context-Specific Sensitization in Mice

PubMed Central

White, André O.; Rauhut, Anthony S.

2014-01-01

The present experiments examined the effects of prazosin, a selective α1-adrenergic receptor antagonist, on the development of methamphetamine conditioned hyperactivity and context-specific sensitization. Mice received an injection of vehicle (distilled water) or prazosin (0.5, 1.0 or 2.0 mg/kg) 30 minutes prior to a second injection of vehicle (saline) or methamphetamine (1.0 mg/kg) during the conditioning sessions (Experiment 1). Following the conditioning sessions, mice were tested for conditioned hyperactivity and then tested for context-specific sensitization. In subsequent experiments, mice received an injection of vehicle (distilled water) or prazosin (2.0 mg/kg) immediately (Experiment 2) or 24 hours (Experiment 3) after the conditioning sessions and then tested for conditioned hyperactivity and context-specific sensitization. Prazosin dose-dependently blocked the development of methamphetamine conditioned hyperactivity and context-specific sensitization when administered prior to the methamphetamine during the conditioning phase; however nonspecific motor impairments also were observed (Experiment 1). Immediate (Experiment 2), but not the 24-hour delay (Experiment 3), post-session administration of prazosin attenuated the development of methamphetamine conditioned hyperactivity and context-specific sensitization. Nonspecific motor impairments were not observed in these latter experiments. Collectively, these results suggest that the α1-adrenergic receptor mediates the development of methamphetamine-conditioned hyperactivity and context-specific sensitization, perhaps by altering memory consolidation and/or reconsolidation processes. PMID:24487011

Observable phenomena that reveal medical students' clinical reasoning ability during expert assessment of their history taking: a qualitative study.

PubMed

Haring, Catharina M; Cools, Bernadette M; van Gurp, Petra J M; van der Meer, Jos W M; Postma, Cornelis T

2017-08-29

During their clerkships, medical students are meant to expand their clinical reasoning skills during their patient encounters. Observation of these encounters could reveal important information on the students' clinical reasoning abilities, especially during history taking. A grounded theory approach was used to analyze what expert physicians apply as indicators in their assessment of medical students' diagnostic reasoning abilities during history taking. Twelve randomly selected clinical encounter recordings of students at the end of the internal medicine clerkships were observed by six expert assessors, who were prompted to formulate their assessment criteria in a think-aloud procedure. These formulations were then analyzed to identify the common denominators and leading principles. The main indicators of clinical reasoning ability were abstracted from students' observable acts during history taking in the encounter. These were: taking control, recognizing and responding to relevant information, specifying symptoms, asking specific questions that point to pathophysiological thinking, placing questions in a logical order, checking agreement with patients, summarizing and body language. In addition, patients' acts and the course, result and efficiency of the conversation were identified as indicators of clinical reasoning, whereas context, using self as a reference, and emotion/feelings were identified by the clinicians as variables in their assessment of clinical reasoning. In observing and assessing clinical reasoning during history taking by medical students, general and specific phenomena to be used as indicators for this process could be identified. These phenomena can be traced back to theories on the development and the process of clinical reasoning.

How the provenance of electronic health record data matters for research: a case example using system mapping.

PubMed

Johnson, Karin E; Kamineni, Aruna; Fuller, Sharon; Olmstead, Danielle; Wernli, Karen J

2014-01-01

The use of electronic health records (EHRs) for research is proceeding rapidly, driven by computational power, analytical techniques, and policy. However, EHR-based research is limited by the complexity of EHR data and a lack of understanding about data provenance, meaning the context under which the data were collected. This paper presents system flow mapping as a method to help researchers more fully understand the provenance of their EHR data as it relates to local workflow. We provide two specific examples of how this method can improve data identification, documentation, and processing. EHRs store clinical and administrative data, often in unstructured fields. Each clinical system has a unique and dynamic workflow, as well as an EHR customized for local use. The EHR customization may be influenced by a broader context such as documentation required for billing. We present a case study with two examples of using system flow mapping to characterize EHR data for a local colorectal cancer screening process. System flow mapping demonstrated that information entered into the EHR during clinical practice required interpretation and transformation before it could be accurately applied to research. We illustrate how system flow mapping shaped our knowledge of the quality and completeness of data in two examples: (1) determining colonoscopy indication as recorded in the EHR, and (2) discovering a specific EHR form that captured family history. Researchers who do not consider data provenance risk compiling data that are systematically incomplete or incorrect. For example, researchers who are not familiar with the clinical workflow under which data were entered might miss or misunderstand patient information or procedure and diagnostic codes. Data provenance is a fundamental characteristic of research data from EHRs. Given the diversity of EHR platforms and system workflows, researchers need tools for evaluating and reporting data availability, quality, and transformations. Our case study illustrates how system mapping can inform researchers about the provenance of their data as it pertains to local workflows.

Personalised fluid resuscitation in the ICU: still a fluid concept?

PubMed

van Haren, Frank

2017-12-28

The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used.Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient's context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid.The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.

Practicing Handoffs Early: Applying a Clinical Framework in the Anatomy Laboratory

ERIC Educational Resources Information Center

Lazarus, Michelle D.; Dos Santos, Jason A.; Haidet, Paul M.; Whitcomb, Tiffany L.

2016-01-01

The anatomy laboratory provides an ideal environment for the integration of clinical contexts as the willed-donor is often regarded as a student's "first patient." This study evaluated an innovative approach to peer teaching in the anatomy laboratory using a clinical handoff context. The authors introduced the "Situation,…

Self-organizing biopsychosocial dynamics and the patient-healer relationship.

PubMed

Pincus, David

2012-01-01

The patient-healer relationship has an increasing area of interest for complementary and alternative medicine (CAM) researchers. This focus on the interpersonal context of treatment is not surprising as dismantling studies, clinical trials and other linear research designs continually point toward the critical role of context and the broadband biopsychosocial nature of therapeutic responses to CAM. Unfortunately, the same traditional research models and methods that fail to find simple and specific treatment-outcome relations are similarly failing to find simple and specific mechanisms to explain how interpersonal processes influence patient outcomes. This paper presents an overview of some of the key models and methods from nonlinear dynamical systems that are better equipped for empirical testing of CAM outcomes on broadband biopsychosocial processes. Suggestions are made for CAM researchers to assist in modeling the interactions among key process dynamics interacting across biopsychosocial scales: empathy, intra-psychic conflict, physiological arousal, and leukocyte telomerase activity. Finally, some speculations are made regarding the possibility for deeper cross-scale information exchange involving quantum temporal nonlocality. Copyright © 2012 S. Karger AG, Basel.

Axl as a mediator of cellular growth and survival.

PubMed

Axelrod, Haley; Pienta, Kenneth J

2014-10-15

The control of cellular growth and proliferation is key to the maintenance of homeostasis. Survival, proliferation, and arrest are regulated, in part, by Growth Arrest Specific 6 (Gas6) through binding to members of the TAM receptor tyrosine kinase family. Activation of the TAM receptors leads to downstream signaling through common kinases, but the exact mechanism within each cellular context varies and remains to be completely elucidated. Deregulation of the TAM family, due to its central role in mediating cellular proliferation, has been implicated in multiple diseases. Axl was cloned as the first TAM receptor in a search for genes involved in the progression of chronic to acute-phase leukemia, and has since been established as playing a critical role in the progression of cancer. The oncogenic nature of Axl is demonstrated through its activation of signaling pathways involved in proliferation, migration, inhibition of apoptosis, and therapeutic resistance. Despite its recent discovery, significant progress has been made in the development of effective clinical therapeutics targeting Axl. In order to accurately define the role of Axl in normal and diseased processes, it must be analyzed in a cell type-specific context.

Context-specific control and the Stroop negative priming effect.

PubMed

Milliken, Bruce; Thomson, David R; Bleile, Karmen; MacLellan, Ellen; Giammarco, Maria

2012-01-01

The present study highlights the utility of context-specific learning for different probe types in accounting for the commonly observed dependence of negative priming on probe selection. Using a Stroop priming procedure, Experiments 1a and 1b offered a demonstration that Stroop priming effects can differ qualitatively for selection and no-selection probes when probe selection is manipulated between subjects, but not when it is manipulated randomly from trial to trial within subject (see also Moore, 1994). In Experiments 2 and 3, selection and no-selection probes served as two contexts that varied randomly from trial to trial, but for which proportion repeated was manipulated separately. A context-specific proportion repeated effect was observed in Experiment 2, characterized by modest quantitative shifts in the repetition effects as a function of the context-specific proportion repeated manipulation. However, with a longer intertrial interval in Experiment 3, a context-specific proportion repeated manipulation that focused on the no-selection probes changed the repetition effect qualitatively, from negative priming when the proportion repeated was .25 to positive priming when the proportion repeated was .75. The results are discussed with reference to the role of rapid, context-specific learning processes in the integration of prior experiences with current perception and action.

What Purposes, Specifically? Re-Thinking Purposes and Specificity in the Context of the "New Vocationalism"

ERIC Educational Resources Information Center

Dovey, Teresa

2006-01-01

Discipline-specific approaches to English for Academic Purposes (EAP) tend to overlook the purposes of the disciplines themselves and the issue of transferability from academic to professional contexts. This becomes problematic in the context of the "new knowledge economy" and emergent pedagogies in higher education, which are increasingly focused…

Diagnostic Performance of Electronic Syndromic Surveillance Systems in Acute Care

PubMed Central

Kashiouris, M.; O’Horo, J.C.; Pickering, B.W.; Herasevich, V.

2013-01-01

Context Healthcare Electronic Syndromic Surveillance (ESS) is the systematic collection, analysis and interpretation of ongoing clinical data with subsequent dissemination of results, which aid clinical decision-making. Objective To evaluate, classify and analyze the diagnostic performance, strengths and limitations of existing acute care ESS systems. Data Sources All available to us studies in Ovid MEDLINE, Ovid EMBASE, CINAHL and Scopus databases, from as early as January 1972 through the first week of September 2012. Study Selection: Prospective and retrospective trials, examining the diagnostic performance of inpatient ESS and providing objective diagnostic data including sensitivity, specificity, positive and negative predictive values. Data Extraction Two independent reviewers extracted diagnostic performance data on ESS systems, including clinical area, number of decision points, sensitivity and specificity. Positive and negative likelihood ratios were calculated for each healthcare ESS system. A likelihood matrix summarizing the various ESS systems performance was created. Results The described search strategy yielded 1639 articles. Of these, 1497 were excluded on abstract information. After full text review, abstraction and arbitration with a third reviewer, 33 studies met inclusion criteria, reporting 102,611 ESS decision points. The yielded I2 was high (98.8%), precluding meta-analysis. Performance was variable, with sensitivities ranging from 21% –100% and specificities ranging from 5%-100%. Conclusions There is significant heterogeneity in the diagnostic performance of the available ESS implements in acute care, stemming from the wide spectrum of different clinical entities and ESS systems. Based on the results, we introduce a conceptual framework using a likelihood ratio matrix for evaluation and meaningful application of future, frontline clinical decision support systems. PMID:23874359

Clinical relevance of retrieval cues for attenuating context renewal of fear.

PubMed

Culver, Najwa C; Stoyanova, Milena; Craske, Michelle G

2011-03-01

The present studies investigated if retrieval cues (reminder objects) can attenuate context renewal of fear. In Study 1, 32 participants completed exposure in one of two contexts; 1-week follow-up testing occurred in a novel or the same context. Results indicated significant renewal of fear for those tested in a novel context. In Study 2, 40 participants completed exposure in one of these contexts; half were presented with cues. One week later, all were tested in a novel context with or without cues. Results indicated weak attenuation of context renewal for participants re-presented with cues. In Study 3, 18 participants completed exposure in one of two maximally distinct contexts; all with cues. One week later, participants were tested in a novel context with or without cues. Results indicated no group differences. These findings suggest that clinical relevance of this set of cues for attenuating context renewal may be limited. Copyright © 2010 Elsevier Ltd. All rights reserved.

Surgeon Design Interface for Patient-Specific Concentric Tube Robots

PubMed Central

Morimoto, Tania K.; Greer, Joseph D.; Hsieh, Michael H.; Okamura, Allison M.

2017-01-01

Concentric tube robots have potential for use in a wide variety of surgical procedures due to their small size, dexterity, and ability to move in highly curved paths. Unlike most existing clinical robots, the design of these robots can be developed and manufactured on a patient- and procedure-specific basis. The design of concentric tube robots typically requires significant computation and optimization, and it remains unclear how the surgeon should be involved. We propose to use a virtual reality-based design environment for surgeons to easily and intuitively visualize and design a set of concentric tube robots for a specific patient and procedure. In this paper, we describe a novel patient-specific design process in the context of the virtual reality interface. We also show a resulting concentric tube robot design, created by a pediatric urologist to access a kidney stone in a pediatric patient. PMID:28656124

Surgeon Design Interface for Patient-Specific Concentric Tube Robots.

PubMed

Morimoto, Tania K; Greer, Joseph D; Hsieh, Michael H; Okamura, Allison M

2016-06-01

Concentric tube robots have potential for use in a wide variety of surgical procedures due to their small size, dexterity, and ability to move in highly curved paths. Unlike most existing clinical robots, the design of these robots can be developed and manufactured on a patient- and procedure-specific basis. The design of concentric tube robots typically requires significant computation and optimization, and it remains unclear how the surgeon should be involved. We propose to use a virtual reality-based design environment for surgeons to easily and intuitively visualize and design a set of concentric tube robots for a specific patient and procedure. In this paper, we describe a novel patient-specific design process in the context of the virtual reality interface. We also show a resulting concentric tube robot design, created by a pediatric urologist to access a kidney stone in a pediatric patient.

Context-specific control and context selection in conflict tasks.

PubMed

Schouppe, Nathalie; Ridderinkhof, K Richard; Verguts, Tom; Notebaert, Wim

2014-02-01

This study investigated whether participants prefer contexts with relatively little cognitive conflict and whether this preference is related to context-specific control. A conflict selection task was administered in which participants had to choose between two categories that contained different levels of conflict. One category was associated with 80% congruent Stroop trials and 20% incongruent Stroop trials, while the other category was associated with only 20% congruent Stroop trials and 80% incongruent Stroop trials. As predicted, participants selected the low-conflict category more frequently, indicating that participants avoid contexts with high-conflict likelihood. Furthermore, we predicted a correlation between this preference for the low-conflict category and the control implementation associated with the categories (i.e., context-specific proportion congruency effect, CSPC effect). Results however did not show such a correlation, thereby failing to support a relationship between context control and context selection. Copyright © 2013 Elsevier B.V. All rights reserved.

Using Competency-Based Digital Open Learning Activities to Facilitate and Promote Health Professions Education (OLAmeD): A Proposal

PubMed Central

Barman, Linda

2016-01-01

Background Traditional learning in medical education has been transformed with the advent of information technology. We have recently seen global initiatives to produce online activities in an effort to scale up learning opportunities through learning management systems and massive open online courses for both undergraduate and continued professional education. Despite the positive impact of such efforts, factors such as cost, time, resources, and the specificity of educational contexts restrict the design and exchange of online medical educational activities. Objective The goal is to address the stated issues within the health professions education context while promoting learning by proposing the Online Learning Activities for Medical Education (OLAmeD) concept which builds on unified competency frameworks and generic technical standards for education. Methods We outline how frameworks used to describe a set of competencies for a specific topic in medical education across medical schools in the United States and Europe can be compared to identify commonalities that could result in a unified set of competencies representing both contexts adequately. Further, we examine how technical standards could be used to allow standardization, seamless sharing, and reusability of educational content. Results The entire process of developing and sharing OLAmeD is structured and presented in a set of steps using as example Urology as a part of clinical surgery specialization. Conclusions Beyond supporting the development, sharing, and repurposing of educational content, we expect OLAmeD to work as a tool that promotes learning and sets a base for a community of medical educational content developers across different educational contexts. PMID:27390226

Using Competency-Based Digital Open Learning Activities to Facilitate and Promote Health Professions Education (OLAmeD): A Proposal.

PubMed

Vaitsis, Christos; Stathakarou, Natalia; Barman, Linda; Zary, Nabil; McGrath, Cormac

2016-07-07

Traditional learning in medical education has been transformed with the advent of information technology. We have recently seen global initiatives to produce online activities in an effort to scale up learning opportunities through learning management systems and massive open online courses for both undergraduate and continued professional education. Despite the positive impact of such efforts, factors such as cost, time, resources, and the specificity of educational contexts restrict the design and exchange of online medical educational activities. The goal is to address the stated issues within the health professions education context while promoting learning by proposing the Online Learning Activities for Medical Education (OLAmeD) concept which builds on unified competency frameworks and generic technical standards for education. We outline how frameworks used to describe a set of competencies for a specific topic in medical education across medical schools in the United States and Europe can be compared to identify commonalities that could result in a unified set of competencies representing both contexts adequately. Further, we examine how technical standards could be used to allow standardization, seamless sharing, and reusability of educational content. The entire process of developing and sharing OLAmeD is structured and presented in a set of steps using as example Urology as a part of clinical surgery specialization. Beyond supporting the development, sharing, and repurposing of educational content, we expect OLAmeD to work as a tool that promotes learning and sets a base for a community of medical educational content developers across different educational contexts.

Japan-Specific Key Regulatory Aspects for Development of New Biopharmaceutical Drug Products.

PubMed

Desai, Kashappa Goud; Obayashi, Hirokazu; Colandene, James D; Nesta, Douglas P

2018-03-28

Japan represents the third largest pharmaceutical market in the world. Developing a new biopharmaceutical drug product for the Japanese market is a top business priority for global pharmaceutical companies while aligning with ethical drivers to treat more patients in need. Understanding Japan-specific key regulatory requirements is essential to achieve successful approvals. Understanding the full context of Japan-specific regulatory requirements/expectations is challenging to global pharmaceutical companies due to differences in language and culture. This article summarizes key Japan-specific regulatory aspects/requirements/expectations applicable to new drug development, approval, and postapproval phases. Formulation excipients should meet Japan compendial requirements with respect to the type of excipient, excipient grade, and excipient concentration. Preclinical safety assessments needed to support clinical phases I, II, and III development are summarized. Japanese regulatory authorities have taken appropriate steps to consider foreign clinical data, thereby enabling accelerated drug development and approval in Japan. Other important topics summarized in this article include: Japan new drug application-specific bracketing strategies for critical and noncritical aspects of the manufacturing process, regulatory requirements related to stability studies, release specifications and testing methods, standard processes involved in pre and postapproval inspections, management of postapproval changes, and Japan regulatory authority's consultation services available to global pharmaceutical companies. Copyright © 2018 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.

Implementing psychophysiology in clinical assessments of adolescent social anxiety: use of rater judgments based on graphical representations of psychophysiology.

PubMed

De Los Reyes, Andres; Augenstein, Tara M; Aldao, Amelia; Thomas, Sarah A; Daruwala, Samantha; Kline, Kathryn; Regan, Timothy

2015-01-01

Social stressor tasks induce adolescents' social distress as indexed by low-cost psychophysiological methods. Unknown is how to incorporate these methods within clinical assessments. Having assessors judge graphical depictions of psychophysiological data may facilitate detections of data patterns that may be difficult to identify using judgments about numerical depictions of psychophysiological data. Specifically, the Chernoff Face method involves graphically representing data using features on the human face (eyes, nose, mouth, and face shape). This method capitalizes on humans' abilities to discern subtle variations in facial features. Using adolescent heart rate norms and Chernoff Faces, we illustrated a method for implementing psychophysiology within clinical assessments of adolescent social anxiety. Twenty-two clinic-referred adolescents completed a social anxiety self-report and provided psychophysiological data using wireless heart rate monitors during a social stressor task. We graphically represented participants' psychophysiological data and normative adolescent heart rates. For each participant, two undergraduate coders made comparative judgments between the dimensions (eyes, nose, mouth, and face shape) of two Chernoff Faces. One Chernoff Face represented a participant's heart rate within a context (baseline, speech preparation, or speech-giving). The second Chernoff Face represented normative heart rate data matched to the participant's age. Using Chernoff Faces, coders reliably and accurately identified contextual variation in participants' heart rate responses to social stress. Further, adolescents' self-reported social anxiety symptoms predicted Chernoff Face judgments, and judgments could be differentiated by social stress context. Our findings have important implications for implementing psychophysiology within clinical assessments of adolescent social anxiety.

THE GAP BETWEEN ECONOMIC EVALUATIONS AND CLINICAL PRACTICE: A SYSTEMATIC REVIEW OF ECONOMIC EVALUATIONS ON DABIGATRAN FOR ATRIAL FIBRILLATION.

PubMed

Rolden, Herbert J A; van der Wilt, Gert Jan; Maas, Angela H E M; Grutters, Janneke P C

2018-06-18

As model-based economic evaluations (MBEEs) are widely used to make decisions in the context of policy, it is imperative that they represent clinical practice. Here, we assess the relevance of MBEEs on dabigatran for the prevention of stroke in patients with atrial fibrillation (AF). We performed a systematic review on the basis of a developed questionnaire, tailored to oral anticoagulation in patients with AF. Included studies had a full body text in English, compared dabigatran with a vitamin K antagonist, were not dedicated to one or more subgroup(s), and yielded an incremental cost-effectiveness ratio. The relevance of all MBEEs was assessed on the basis of ten context-independent factors, which encompassed clinical outcomes and treatment duration. The MBEEs performed for the United States were assessed on the basis of seventeen context-dependent factors, which were related to the country's target population and clinical environment. The search yielded twenty-nine MBEEs, of which six were performed for the United States. On average, 54 percent of the context-independent factors were included per study, and 37 percent of the seventeen context-dependent factors in the U.S. The share of relevant factors per study did not increase over time. MBEEs on dabigatran leave out several relevant factors, limiting their usefulness to decision makers. We strongly urge health economic researchers to improve the relevance of their MBEEs by including context-independent relevance factors, and modeling context-dependent factors befitting the decision context concerned.

HPV specific testing: a requirement for oropharyngeal squamous cell carcinoma patients.

PubMed

Robinson, Max; Schache, Andrew; Sloan, Philip; Thavaraj, Selvam

2012-07-01

Human papillomavirus (HPV) testing is now recommended as part of the work up for patients with oropharyngeal squamous cell carcinoma (OPSCC) and those patients with cervical lymph node metastasis of unknown origin. The laboratory testing strategy should accurately assess the presence or absence of oncogenic HPV infection in routinely collected tumour samples that are subject to standard fixation protocols, alcohol-fixed cytological preparations and formalin-fixed tissue samples. The HPV status should correlate with biologically relevant outcome measures such as overall, disease-specific and disease-free survival. Whilst increased expression of p16 by immunohistochemistry is considered to be a surrogate marker of oncogenic HPV infection and is a validated independent prognostic biomarker, only HPV specific tests provide definitive evidence of the aetiological agent. We provide an overview of HPV testing in OPSCC, justifying the use of HPV specific tests. We examine the analytical accuracy of HPV specific tests against the 'reference' test--high risk HPV mRNA in fresh tissue--and contrast this with the performance of p16 immunohistochemistry as a stand alone test. We highlight the added value of HPV specific tests in prognostication, clinical trial design, and population-based disease surveillance. We consider that HPV specific testing is the starting point for developing increasingly informative biomarker panels in the context of 'stratified medicine'. We briefly frame test information in the context of disclosure of HPV status to patients. We conclude that only a testing strategy that includes HPV specific tests can deliver more effective care for patients with OPSCC. The international head and neck oncology community should work together to clearly define the minimum requirements for assigning a diagnosis of HPV-related OPSCC in order to ensure consistent reporting of this emerging and increasingly prevalent disease.

Attentional impairments in Huntington's disease: A specific deficit for the executive conflict.

PubMed

Maurage, Pierre; Heeren, Alexandre; Lahaye, Magali; Jeanjean, Anne; Guettat, Lamia; Verellen-Dumoulin, Christine; Halkin, Stéphane; Billieux, Joël; Constant, Eric

2017-05-01

Huntington's disease (HD) is characterized by motor and cognitive impairments including memory, executive, and attentional functions. However, because earlier studies relied on multidetermined attentional tasks, uncertainty still abounds regarding the differential deficit across attentional subcomponents. Likewise, the evolution of these deficits during the successive stages of HD remains unclear. The present study simultaneously explored 3 distinct networks of attention (alerting, orienting, executive conflict) in preclinical and clinical HD. Thirty-eight HD patients (18 preclinical) and 38 matched healthy controls completed the attention network test, an integrated and theoretically grounded task assessing the integrity of 3 attentional networks. Preclinical HD was not characterized by any attentional deficit compared to controls. Conversely, clinical HD was associated with a differential deficit across the 3 attentional networks under investigation, showing preserved performance for alerting and orienting networks but massive and specific impairment for the executive conflict network. This indexes an impaired use of executive control to resolve the conflict between task-relevant stimuli and interfering task-irrelevant ones. Clinical HD does not lead to a global attentional deficit but rather to a specific impairment for the executive control of attention. Moreover, the absence of attentional deficits in preclinical HD suggests that these deficits are absent at the initial stages of the disease. In view of their impact on everyday life, attentional deficits should be considered in clinical contexts. Therapeutic programs improving the executive control of attention by neuropsychology and neuromodulation should be promoted. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Impact of Body Mass Index, Age, Prostate Volume, and Genetic Polymorphisms on Prostate-specific Antigen Levels in a Control Population.

PubMed

Cornu, Jean-Nicolas; Cancel-Tassin, Geraldine; Cox, David G; Roupret, Morgan; Koutlidis, Nicolas; Bigot, Pierre; Valeri, Antoine; Ondet, Valerie; Gaffory, Cécile; Fournier, Georges; Azzouzi, Abdel-Rahmene; Cormier, Luc; Cussenot, Olivier

2016-07-01

Prostate-specific antigen (PSA) is still the cornerstone of prostate cancer (PCa) screening and diagnosis in both research and current clinical practice. Inaccuracy of PSA is partly due to the influence of a number of genetic, clinical, and biological factors modifying PSA blood levels. In the present study, we detailed the respective influence of each factor among age, body mass index (BMI), prostate volume, and five single-nucleotide polymorphisms-rs10788160 (10q26), rs10993994 (10q11), rs11067228 (12q24), rs17632542 (19q13.33), and rs2928679 (8p21)-on PSA values in a cohort of 1374 men without PCa. Our results show that genetic factors, when risk variants are combined, influence PSA levels with an effect size similar to that of BMI. Taken together, the respective correlations of clinical parameters and genetic parameters would make it possible to correct and adjust PSA values more effectively in each individual. These results establish the basis to understand and implement a more personalised approach for the interpretation of PSA blood levels in the context of PCa screening and diagnosis. Prostate-specific antigen (PSA) values in an individual may vary according to genetic predisposition. The effect size of this variation can be significant, comparable with those resulting from clinical characteristics. Personalised PSA testing should take this into account. Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Review of nanomaterials in dentistry: interactions with the oral microenvironment, clinical applications, hazards, and benefits.

PubMed

Besinis, Alexandros; De Peralta, Tracy; Tredwin, Christopher J; Handy, Richard D

2015-03-24

Interest in the use of engineered nanomaterials (ENMs) as either nanomedicines or dental materials/devices in clinical dentistry is growing. This review aims to detail the ultrafine structure, chemical composition, and reactivity of dental tissues in the context of interactions with ENMs, including the saliva, pellicle layer, and oral biofilm; then describes the applications of ENMs in dentistry in context with beneficial clinical outcomes versus potential risks. The flow rate and quality of saliva are likely to influence the behavior of ENMs in the oral cavity, but how the protein corona formed on the ENMs will alter bioavailability, or interact with the structure and proteins of the pellicle layer, as well as microbes in the biofilm, remains unclear. The tooth enamel is a dense crystalline structure that is likely to act as a barrier to ENM penetration, but underlying dentinal tubules are not. Consequently, ENMs may be used to strengthen dentine or regenerate pulp tissue. ENMs have dental applications as antibacterials for infection control, as nanofillers to improve the mechanical and bioactive properties of restoration materials, and as novel coatings on dental implants. Dentifrices and some related personal care products are already available for oral health applications. Overall, the clinical benefits generally outweigh the hazards of using ENMs in the oral cavity, and the latter should not prevent the responsible innovation of nanotechnology in dentistry. However, the clinical safety regulations for dental materials have not been specifically updated for ENMs, and some guidance on occupational health for practitioners is also needed. Knowledge gaps for future research include the formation of protein corona in the oral cavity, ENM diffusion through clinically relevant biofilms, and mechanistic investigations on how ENMs strengthen the tooth structure.

Prototyping context-aware nursing support mobile system.

PubMed

Esashi, Misa; Nakano, Tomohiro; Onose, Nao; Sato, Kikue; Hikita, Tomoko; Hoya, Reiko; Okamoto, Kazuya; Ohboshi, Naoki; Kuroda, Tomohiro

2016-08-01

A context aware nursing support system to push right information to the right person at the right moment is the key to increase clinical safety under a computerized hospital. We prototyped a system which obtains context from positions of nurses and list of expected clinical procedures. A WoZ test showed that the proposed approach has potential to decrease incidents caused by information delivery error.

Clinical and ethical implications of placebo effects: enhancing patients' benefits from pain treatment.

PubMed

Klinger, Regine; Flor, Herta

2014-01-01

Expectancy and learning are the core psychological mechanisms of placebo analgesia. They interact with further psychological processes such as emotions and motivations (e.g., anxiety, desire for relief), somatic focus, or cognitions (e.g., attitudes toward the treatment). The development of placebo responsiveness and the actual placebo response in a person is the result of the complex interaction between factors traced back to the individual learning history related to analgesic drugs or treatments and factors of the current context referring to the analgesic or placebo treatment. The aim of this chapter is to depict these complex interactions in a new model of analgesic placebo effects. It joins aspects of the learning history (preexisting experiences and preexisting expectations) of a patient with aspects of the current context (current expectation as a result of external and internal situation in which a pain medication/treatment/placebo is taken, e.g., current information about pain medication, current specific context/cues, desire for pain relief, certainty about upcoming pain relief, current expectation about pain reducing course, current selective attention, increased pain experience, or decreased pain experience). In order to exploit placebo efficacy for an analgesic treatment it is worthwhile to assess in which direction each of these factors exerts its influence in order to maximize placebo effects for a specific patient. By applying placebo mechanisms in this differentiated way, the efficacy of pain treatment can be deliberately boosted.

A model-driven privacy compliance decision support for medical data sharing in Europe.

PubMed

Boussi Rahmouni, H; Solomonides, T; Casassa Mont, M; Shiu, S; Rahmouni, M

2011-01-01

Clinical practitioners and medical researchers often have to share health data with other colleagues across Europe. Privacy compliance in this context is very important but challenging. Automated privacy guidelines are a practical way of increasing users' awareness of privacy obligations and help eliminating unintentional breaches of privacy. In this paper we present an ontology-plus-rules based approach to privacy decision support for the sharing of patient data across European platforms. We use ontologies to model the required domain and context information about data sharing and privacy requirements. In addition, we use a set of Semantic Web Rule Language rules to reason about legal privacy requirements that are applicable to a specific context of data disclosure. We make the complete set invocable through the use of a semantic web application acting as an interactive privacy guideline system can then invoke the full model in order to provide decision support. When asked, the system will generate privacy reports applicable to a specific case of data disclosure described by the user. Also reports showing guidelines per Member State may be obtained. The advantage of this approach lies in the expressiveness and extensibility of the modelling and inference languages adopted and the ability they confer to reason with complex requirements interpreted from high level regulations. However, the system cannot at this stage fully simulate the role of an ethics committee or review board.

A smoking-related background helps moderate smokers to focus: An event-related potential study using a Go-NoGo task.

PubMed

Detandt, Sandrine; Bazan, Ariane; Schröder, Elisa; Olyff, Giulia; Kajosch, Hendrik; Verbanck, Paul; Campanella, Salvatore

2017-10-01

Cognitive impairment is a major component in addiction. However, research has been inconclusive as to whether this is also the case for smokers. The present study aims at providing electrophysiological clue for altered inhibitory control in smokers and at investigating whether reduced inhibition was more pronounced during exposure to a smoking cue. ERPs were recorded during a visual Go-NoGo task performed by 18 smokers and 23 controls, in which either a frequent Go signal (letter "M") or a rare No-Go signal ("letter W") were superimposed on three different long-lasting background contexts: black-neutral, smoking-related and non smoking-related. (1) Smokers performed worse and had an earlier NoGo-N2 latency as compared to controls and independently of context, suggesting a general inhibition impairment; (2) with smoking-related backgrounds specifically, smokers made fewer mistakes than they did in other contexts and displayed a larger NoGo P3 amplitude. These data might suggest that background cues related to addiction may help smokers to be more accurate in an inhibition task. Our results show the classical inhibitory impairment in smokers as compared to non-smokers. However, our data also suggest that a smoking-related background may bolster the inhibitory ability of smokers specifically. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

Virulence determinants of Moraxella catarrhalis: distribution and considerations for vaccine development.

PubMed

Blakeway, Luke V; Tan, Aimee; Peak, Ian R A; Seib, Kate L

2017-10-01

Moraxella catarrhalis is a human-restricted opportunistic bacterial pathogen of the respiratory mucosa. It frequently colonizes the nasopharynx asymptomatically, but is also an important causative agent of otitis media (OM) in children, and plays a significant role in acute exacerbations of chronic obstructive pulmonary disease (COPD) in adults. As the current treatment options for M. catarrhalis infection in OM and exacerbations of COPD are often ineffective, the development of an efficacious vaccine is warranted. However, no vaccine candidates for M. catarrhalis have progressed to clinical trials, and information regarding the distribution of M. catarrhalis virulence factors and vaccine candidates is inconsistent in the literature. It is largely unknown if virulence is associated with particular strains or subpopulations of M. catarrhalis, or if differences in clinical manifestation can be attributed to the heterogeneous expression of specific M. catarrhalis virulence factors in the circulating population. Further investigation of the distribution of M. catarrhalis virulence factors in the context of carriage and disease is required so that vaccine development may be targeted at relevant antigens that are conserved among disease-causing strains. The challenge of determining which of the proposed M. catarrhalis virulence factors are relevant to human disease is amplified by the lack of a standardized M. catarrhalis typing system to facilitate direct comparisons of worldwide isolates. Here we summarize and evaluate proposed relationships between M. catarrhalis subpopulations and specific virulence factors in the context of colonization and disease, as well as the current methods used to infer these associations.

Preservice Special Education Teachers' Perceptions: The Influence of University Coursework, Context, and Relationships, during the Clinical Teaching Experience

ERIC Educational Resources Information Center

McElwee, Christine B.; Regan, Kelley; Baker, Pamela Hudson; Weiss, Margaret P.

2018-01-01

The purpose of this study was to investigate to what extent context and relationships influence preservice teachers' appropriation of coursework during the clinical experience. While there is a dearth of research regarding the clinical experience in teacher preparation programs, there are even fewer studies investigating special education teacher…

Improving clinical models based on knowledge extracted from current datasets: a new approach.

PubMed

Mendes, D; Paredes, S; Rocha, T; Carvalho, P; Henriques, J; Morais, J

2016-08-01

The Cardiovascular Diseases (CVD) are the leading cause of death in the world, being prevention recognized to be a key intervention able to contradict this reality. In this context, although there are several models and scores currently used in clinical practice to assess the risk of a new cardiovascular event, they present some limitations. The goal of this paper is to improve the CVD risk prediction taking into account the current models as well as information extracted from real and recent datasets. This approach is based on a decision tree scheme in order to assure the clinical interpretability of the model. An innovative optimization strategy is developed in order to adjust the decision tree thresholds (rule structure is fixed) based on recent clinical datasets. A real dataset collected in the ambit of the National Registry on Acute Coronary Syndromes, Portuguese Society of Cardiology is applied to validate this work. In order to assess the performance of the new approach, the metrics sensitivity, specificity and accuracy are used. This new approach achieves sensitivity, a specificity and an accuracy values of, 80.52%, 74.19% and 77.27% respectively, which represents an improvement of about 26% in relation to the accuracy of the original score.

Research with Pregnant Women: New Insights on Legal Decision-Making

PubMed Central

Mastroianni, Anna C.; Henry, Leslie Meltzer; Robinson, David; Bailey, Theodore; Faden, Ruth R.; Little, Margaret O.; Lyerly, Anne Drapkin

2017-01-01

Although pregnant women rely on medical interventions to treat and prevent a wide variety of health conditions, they are frequently excluded or underrepresented in clinical research. The resulting dearth of pregnancy-specific evidence to guide clinical decisionmaking routinely exposes pregnant women, and their future offspring, to risk of uncertain harms for uncertain benefits. The two legal factors regularly cited as obstacles to such research are the federal regulatory scheme and fear of liability. This article reveals a far more nuanced and complex view of the legal context. First, legal professionals may—at any time from product conception to marketing—influence decisions about research with pregnant women. Second, factors not previously articulated in the literature may prompt legal professionals to slow or halt such research. They include: financial interests, regulatory ambiguity, obstacles to risk management, and site-specific laws unrelated to research. Any efforts to promote the ethical inclusion of pregnant women in research must acknowledge the role of legal decisionmakers and address their professional concerns. PMID:28543423

Performance of uncertainty quantification methodologies and linear solvers in cardiovascular simulations

NASA Astrophysics Data System (ADS)

Seo, Jongmin; Schiavazzi, Daniele; Marsden, Alison

2017-11-01

Cardiovascular simulations are increasingly used in clinical decision making, surgical planning, and disease diagnostics. Patient-specific modeling and simulation typically proceeds through a pipeline from anatomic model construction using medical image data to blood flow simulation and analysis. To provide confidence intervals on simulation predictions, we use an uncertainty quantification (UQ) framework to analyze the effects of numerous uncertainties that stem from clinical data acquisition, modeling, material properties, and boundary condition selection. However, UQ poses a computational challenge requiring multiple evaluations of the Navier-Stokes equations in complex 3-D models. To achieve efficiency in UQ problems with many function evaluations, we implement and compare a range of iterative linear solver and preconditioning techniques in our flow solver. We then discuss applications to patient-specific cardiovascular simulation and how the problem/boundary condition formulation in the solver affects the selection of the most efficient linear solver. Finally, we discuss performance improvements in the context of uncertainty propagation. Support from National Institute of Health (R01 EB018302) is greatly appreciated.

Feasibility study for clinical application of caspase-3 inhibitors in Pemphigus vulgaris.

PubMed

Hariton, William V J; Galichet, Arnaud; Vanden Berghe, Tom; Overmiller, Andrew M; Mahoney, My G; Declercq, Wim; Müller, Eliane J

2017-12-01

The potentially severe side effects of systemic corticosteroids and immunosuppressants used in Pemphigus vulgaris (PV) call for novel therapeutic approaches. In this context, pharmacological inhibition of major pathogenic signalling effectors represents a promising alternative. However, we have also shown that overinhibition of effectors required for epidermal homeostasis can exacerbate PV pathophysiology implicating transepidermal keratinocyte fragility. A feedforward target validation therefore preferentially includes studies on knockout mouse models. We previously reported on successful amelioration of PV blisters following inhibition of non-apoptotic, low-level caspase-3. Here, we use conditional, keratinocyte-specific caspase-3-deficient mice (casp3 EKO ) to demonstrate (i) absence of keratinocyte fragility upon injection of the potent Dsg3-specific antibody AK23 and (ii) amelioration of blistering on the background of known signalling effectors. Our results provide the experimental proof of concept justifying translation of the caspase-3 inhibitor approach into PV clinical trials. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Assessing the clinical utility of agoraphobia in the context of panic disorder.

PubMed

Schmidt, Norman B; Cromer, Kiara R

2008-01-01

In the DSM-IV, a panic disorder (PD) diagnosis includes specification of agoraphobia, which is primarily an index of situational avoidance due to fear of panic. No other anxiety diagnosis requires specification of level of avoidance. This raises the question as to whether agoraphobia provides unique information beyond the core features of PD (i.e., panic attacks and panic-related worry). The incremental validity of agoraphobia, defined using DSM-IV specifiers versus level of situational avoidance, was examined in relation to the expression and treatment of PD (N=146). Analyses indicate that agoraphobia status adds uniquely to the prediction of PD symptoms, impairment, and response to treatment. However, level of situational avoidance, defined either as a continuous or dichotomous variable, appears to have greater utility compared to the DSM-IV method of classifying agoraphobia. In summary, the agoraphobia specifier seems to have clinical utility but this could be improved by focusing on a dimensional assessment of situational avoidance.

Children's resilience and trauma-specific cognitive behavioral therapy: Comparing resilience as an outcome, a trait, and a process.

PubMed

Happer, Kaitlin; Brown, Elissa J; Sharma-Patel, Komal

2017-11-01

Resilience, which is associated with relatively positive outcomes following negative life experiences, is an important research target in the field of child maltreatment (Luthar et al., 2000). The extant literature contains multiple conceptualizations of resilience, which hinders development in research and clinical utility. Three models emerge from the literature: resilience as an immediate outcome (i.e., behavioral or symptom response), resilience as a trait, and resilience as a dynamic process. The current study compared these models in youth undergoing trauma-specific cognitive behavioral therapy. Results provide the most support for resilience as a process, in which increase in resilience preceded associated decrease in posttraumatic stress and depressive symptoms. There was partial support for resilience conceptualized as an outcome, and minimal support for resilience as a trait. Results of the models are compared and discussed in the context of existing literature and in light of potential clinical implications for maltreated youth seeking treatment. Copyright © 2017 Elsevier Ltd. All rights reserved.

Financial strain and smoking cessation among men and women within a self-guided quit attempt.

PubMed

Reitzel, Lorraine R; Langdon, Kirsten J; Nguyen, Nga T; Zvolensky, Michael J

2015-08-01

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt. Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time. Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI=.80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI=.91-1.21, observations=92; p=.48). Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest that financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation. Copyright © 2015 Elsevier Ltd. All rights reserved.

Financial Strain and Smoking Cessation among Men and Women within a Self-Guided Quit Attempt

PubMed Central

Reitzel, Lorraine R.; Langdon, Kirsten J.; Nguyen, Nga T.; Zvolensky, Michael J.

2015-01-01

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt. Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time. Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI= .80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI= .91-1.21, observations=92; p=.48). Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation. PMID:25879712

Integration of 3D 1H-magnetic resonance spectroscopy data into neuronavigation systems for tumor biopsies

NASA Astrophysics Data System (ADS)

Kanberoglu, Berkay; Moore, Nina Z.; Frakes, David; Karam, Lina J.; Debbins, Josef P.; Preul, Mark C.

2013-03-01

Many important applications in clinical medicine can benefit from the fusion of spectroscopy data with anatomical images. For example, the correlation of metabolite profiles with specific regions of interest in anatomical tumor images can be useful in characterizing and treating heterogeneous tumors that appear structurally homogeneous. Such applications can build on the correlation of data from in-vivo Proton Magnetic Resonance Spectroscopy Imaging (1HMRSI) with data from genetic and ex-vivo Nuclear Magnetic Resonance spectroscopy. To establish that correlation, tissue samples must be neurosurgically extracted from specifically identified locations with high accuracy. Toward that end, this paper presents new neuronavigation technology that enhances current clinical capabilities in the context of neurosurgical planning and execution. The proposed methods improve upon the current state-of-the-art in neuronavigation through the use of detailed three dimensional (3D) 1H-MRSI data. MRSI spectra are processed and analyzed, and specific voxels are selected based on their chemical contents. 3D neuronavigation overlays are then generated and applied to anatomical image data in the operating room. Without such technology, neurosurgeons must rely on memory and other qualitative resources alone for guidance in accessing specific MRSI-identified voxels. In contrast, MRSI-based overlays provide quantitative visual cues and location information during neurosurgery. The proposed methods enable a progressive new form of online MRSI-guided neuronavigation that we demonstrate in this study through phantom validation and clinical application.

Functional brain imaging in neuropsychology over the past 25 years.

PubMed

Roalf, David R; Gur, Ruben C

2017-11-01

Outline effects of functional neuroimaging on neuropsychology over the past 25 years. Functional neuroimaging methods and studies will be described that provide a historical context, offer examples of the utility of neuroimaging in specific domains, and discuss the limitations and future directions of neuroimaging in neuropsychology. Tracking the history of publications on functional neuroimaging related to neuropsychology indicates early involvement of neuropsychologists in the development of these methodologies. Initial progress in neuropsychological application of functional neuroimaging has been hampered by costs and the exposure to ionizing radiation. With rapid evolution of functional methods-in particular functional MRI (fMRI)-neuroimaging has profoundly transformed our knowledge of the brain. Its current applications span the spectrum of normative development to clinical applications. The field is moving toward applying sophisticated statistical approaches that will help elucidate distinct neural activation networks associated with specific behavioral domains. The impact of functional neuroimaging on clinical neuropsychology is more circumscribed, but the prospects remain enticing. The theoretical insights and empirical findings of functional neuroimaging have been led by many neuropsychologists and have transformed the field of behavioral neuroscience. Thus far they have had limited effects on the clinical practices of neuropsychologists. Perhaps it is time to add training in functional neuroimaging to the clinical neuropsychologist's toolkit and from there to the clinic or bedside. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

In silico clinical trials: concepts and early adoptions.

PubMed

Pappalardo, Francesco; Russo, Giulia; Tshinanu, Flora Musuamba; Viceconti, Marco

2018-06-02

Innovations in information and communication technology infuse all branches of science, including life sciences. Nevertheless, healthcare is historically slow in adopting technological innovation, compared with other industrial sectors. In recent years, new approaches in modelling and simulation have started to provide important insights in biomedicine, opening the way for their potential use in the reduction, refinement and partial substitution of both animal and human experimentation. In light of this evidence, the European Parliament and the United States Congress made similar recommendations to their respective regulators to allow wider use of modelling and simulation within the regulatory process. In the context of in silico medicine, the term 'in silico clinical trials' refers to the development of patient-specific models to form virtual cohorts for testing the safety and/or efficacy of new drugs and of new medical devices. Moreover, it could be envisaged that a virtual set of patients could complement a clinical trial (reducing the number of enrolled patients and improving statistical significance), and/or advise clinical decisions. This article will review the current state of in silico clinical trials and outline directions for a full-scale adoption of patient-specific modelling and simulation in the regulatory evaluation of biomedical products. In particular, we will focus on the development of vaccine therapies, which represents, in our opinion, an ideal target for this innovative approach.

Clinical reasoning in the context of active decision support during medication prescribing.

PubMed

Horsky, Jan; Aarts, Jos; Verheul, Leonie; Seger, Diane L; van der Sijs, Heleen; Bates, David W

2017-01-01

Describe and analyze reasoning patterns of clinicians responding to drug-drug interaction alerts in order to understand the role of patient-specific information in the decision-making process about the risks and benefits of medication therapy. Insights could be used to inform the design of decision-support interventions. Thirty-two clinicians working with five EHRs in two countries completed sets of six medication orders each and responded to high- and low-severity drug-drug interaction alerts while verbalizing their thoughts in a standard think-aloud protocol. Tasks were recorded and analyzed to describe reasoning patterns about patient-risk assessment and strategies to avoid or mitigate it. We observed a total of 171 prescribing decisions. Clinicians actively sought to reduce risk when responding to high-severity alerts, mostly by monitoring patients and making dose adjustments (52 alerts, 40%). In contrast, they routinely left prescriptions unchanged after low-severity alerts when they felt confident that patients would tolerate the drug combination and that treatment benefits outweighed the risks (30 alerts, 71%). Clinicians used similar reasoning patterns regardless of the EHR used and differences in alert design. Clinicians conceptualized risk as a complex set of interdependent tradeoffs specific to individual patients and had a tendency not to follow advice they considered of low clinical value. Omission of patient-specific data, which was not shown in alerts or included in trigger logic, may have contributed to the constancy of reasoning and to similarities in risk-control strategies we observed despite significant differences in interface design and system function. Declining an alert suggestion was preceded by sometimes brief but often complex reasoning, prioritizing different aspects of care quality and safety, especially when the perceived risk was higher. Clinicians believed that the risk indicated in drug-drug interaction alerts needs to be interpreted as one factor in the broader context of care, specific to a patient. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Expanding the Intertrial Interval During Extinction: Response Cessation and Recovery

PubMed Central

Orinstein, Alyssa J.; Urcelay, Gonzalo P.; Miller, Ralph R.

2010-01-01

We examined trial spacing during extinction following a human contingency learning task. Specifically, we assessed if an expanding retrieval practice schedule (Bjork & Bjork, 1992, 2006), in which the spacing between extinction trials was progressively increased, would result in faster immediate extinction and less recovery from extinction than uniformly spaced extinction trials. We used an ABB vs. ABA renewal design and observed that, whereas the expanding group extinguished faster during extinction treatment, the expanding and constant groups showed the same level of extinction with an immediate test in the extinction context (ABB) and the two groups showed equivalent ABA renewal at test in the training context. We conclude that the faster extinction observed in the expanding groups could be misleading in clinical treatment, if the therapist used the absence of fear during extinction as the basis for terminating treatment. PMID:20171324

A Model-Based Approach to Support Validation of Medical Cyber-Physical Systems.

PubMed

Silva, Lenardo C; Almeida, Hyggo O; Perkusich, Angelo; Perkusich, Mirko

2015-10-30

Medical Cyber-Physical Systems (MCPS) are context-aware, life-critical systems with patient safety as the main concern, demanding rigorous processes for validation to guarantee user requirement compliance and specification-oriented correctness. In this article, we propose a model-based approach for early validation of MCPS, focusing on promoting reusability and productivity. It enables system developers to build MCPS formal models based on a library of patient and medical device models, and simulate the MCPS to identify undesirable behaviors at design time. Our approach has been applied to three different clinical scenarios to evaluate its reusability potential for different contexts. We have also validated our approach through an empirical evaluation with developers to assess productivity and reusability. Finally, our models have been formally verified considering functional and safety requirements and model coverage.

A Model-Based Approach to Support Validation of Medical Cyber-Physical Systems

PubMed Central

Silva, Lenardo C.; Almeida, Hyggo O.; Perkusich, Angelo; Perkusich, Mirko

2015-01-01

Medical Cyber-Physical Systems (MCPS) are context-aware, life-critical systems with patient safety as the main concern, demanding rigorous processes for validation to guarantee user requirement compliance and specification-oriented correctness. In this article, we propose a model-based approach for early validation of MCPS, focusing on promoting reusability and productivity. It enables system developers to build MCPS formal models based on a library of patient and medical device models, and simulate the MCPS to identify undesirable behaviors at design time. Our approach has been applied to three different clinical scenarios to evaluate its reusability potential for different contexts. We have also validated our approach through an empirical evaluation with developers to assess productivity and reusability. Finally, our models have been formally verified considering functional and safety requirements and model coverage. PMID:26528982

Beyond the limitations of best practices: how logic analysis helped reinterpret dual diagnosis guidelines.

PubMed

Brousselle, Astrid; Lamothe, Lise; Mercier, Céline; Perreault, Michel

2007-02-01

The co-occurrence of mental health and substance use disorders is becoming increasingly recognized as a single problem, and professionals recognize that both should be addressed at the same time. Medical best practices recommend integrated treatment. However, criticisms have arisen, particularly concerning the difficulty of implementing integrated teams in specific health-care contexts and the appropriateness of the proposed model for certain populations. Using logic analysis, we identify the key clinical and organizational factors that contribute to successful implementation. Building on both the professional and organizational literatures on integrated services, we propose a conceptual model that makes it possible to analyze integration processes and places integrated treatment within an interpretative framework. Using this model, it becomes possible to identify key factors necessary to support service integration, and suggest new models of practice adapted to particular contexts.

Time-dependent effects of prazosin on the development of methamphetamine conditioned hyperactivity and context-specific sensitization in mice.

PubMed

White, André O; Rauhut, Anthony S

2014-04-15

The present experiments examined the effects of prazosin, a selective α₁-adrenergic receptor antagonist, on the development of methamphetamine conditioned hyperactivity and context-specific sensitization. Mice received an injection of vehicle (distilled water) or prazosin (0.5, 1.0 or 2.0 mg/kg) 30 min prior to a second injection of vehicle (saline) or methamphetamine (1.0 mg/kg) during the conditioning sessions (Experiment 1). Following the conditioning sessions, mice were tested for conditioned hyperactivity and then tested for context-specific sensitization. In subsequent experiments, mice received an injection of vehicle (distilled water) or prazosin (2.0 mg/kg) immediately (Experiment 2) or 24 h (Experiment 3) after the conditioning sessions and then tested for conditioned hyperactivity and context-specific sensitization. Prazosin dose-dependently blocked the development of methamphetamine conditioned hyperactivity and context-specific sensitization when administered prior to the methamphetamine during the conditioning phase; however nonspecific motor impairments also were observed (Experiment 1). Immediate (Experiment 2), but not the 24-h delay (Experiment 3), post-session administration of prazosin attenuated the development of methamphetamine conditioned hyperactivity and context-specific sensitization. Nonspecific motor impairments were not observed in these latter experiments. Collectively, these results suggest that the α₁-adrenergic receptor mediates the development of methamphetamine-conditioned hyperactivity and context-specific sensitization, perhaps by altering memory consolidation and/or reconsolidation processes. Copyright © 2014 Elsevier B.V. All rights reserved.

Knowledge acquisition for temporal abstraction.

PubMed

Stein, A; Musen, M A; Shahar, Y

1996-01-01

Temporal abstraction is the task of detecting relevant patterns in data over time. The knowledge-based temporal-abstraction method uses knowledge about a clinical domain's contexts, external events, and parameters to create meaningful interval-based abstractions from raw time-stamped clinical data. In this paper, we describe the acquisition and maintenance of domain-specific temporal-abstraction knowledge. Using the PROTEGE-II framework, we have designed a graphical tool for acquiring temporal knowledge directly from expert physicians, maintaining the knowledge in a sharable form, and converting the knowledge into a suitable format for use by an appropriate problem-solving method. In initial tests, the tool offered significant gains in our ability to rapidly acquire temporal knowledge and to use that knowledge to perform automated temporal reasoning.

Blending quantitative and qualitative methods in language research and intervention.

PubMed

Brinton, Bonnie; Fujiki, Martin

2003-05-01

Best practice in speech-language pathology should be informed by current research findings. Traditional research methods are not always geared to address some of the complex, individual questions that arise in clinical intervention, however. Qualitative research methods may provide useful tools for bridging the gap from research to practice. Combinations of qualitative and quantitative procedures may be particularly helpful in sorting out some of the important issues surrounding language intervention in both clinical and research contexts. Examples of research blending qualitative and quantitative methods, as well as the case study of Sid, an 11-year-old boy with specific language impairment, are presented to illustrate how a combination of procedures can be used to enhance language research and intervention.

HIV Genetic Diversity and Drug Resistance

PubMed Central

Santos, André F.; Soares, Marcelo A.

2010-01-01

Most of the current knowledge on antiretroviral (ARV) drug development and resistance is based on the study of subtype B of HIV-1, which only accounts for 10% of the worldwide HIV infections. Cumulative evidence has emerged that different HIV types, groups and subtypes harbor distinct biological properties, including the response and susceptibility to ARV. Recent laboratory and clinical data highlighting such disparities are summarized in this review. Variations in drug susceptibility, in the emergence and selection of specific drug resistance mutations, in viral replicative capacity and in the dynamics of resistance acquisition under ARV selective pressure are discussed. Clinical responses to ARV therapy and associated confounding factors are also analyzed in the context of infections by distinct HIV genetic variants. PMID:21994646

New frontiers in probiotic research.

PubMed

Sleator, R D; Hill, C

2008-02-01

The increasing incidence of antibiotic resistance, coupled with a growing prevalence of cancer and allergic conditions in an aging population, has forced clinical research to explore alternative therapeutic and prophylactic avenues. One such approach involves the use of probiotics: beneficial bacterial cultures, which, when administered as a part of the daily dietary intake, reduce the incidence and severity of acute and chronic infection, facilitate prevention and reduced recurrence of certain cancers and lower the incidence of several atopic conditions. Herein, we review the most recent advances in the emerging area of patho-biotechnology in the context of improving probiotic production, delivery and clinical efficacy, in addition to the emerging area of 'designer probiotics'- strains specifically tailored to target certain pathogens and/or toxins in vivo.

The Role of Test Context in Latent Inhibition of Conditioned Inhibition: Part of a Search for General Principles of Associative Interference

PubMed Central

Miguez, Gonzalo; Soares, Julia S.; Miller, Ralph R.

2015-01-01

Two lick-suppression experiments with rats assessed interference with behavior indicative of conditioned inhibition by a latent inhibition treatment as a function of test context. We asked what effect the test context has, given identical latent inhibition treatment in Phase 1 and identical conditioned inhibition training in Phase 2. In Experiment 1, an AAA vs. AAB context-shift design determined that latent inhibition treatment in Phase 1 attenuated behavior indicative of conditioned inhibition training administered in Phase 2 regardless of the test context, which could reflect a failure to either acquire or express conditioned inhibition. In Experiment 2, an ABA vs. ABB design found that test performance in Contexts A and B reflected the treatments that had been administered in those contexts (i.e., conditioned inhibition was observed in Context B but not A), which could reflect either context specificity of latent inhibition or context specificity of conditioned inhibition. In either case, latent inhibition of conditioned inhibition training in at least some situations was seen to reflect an expression deficit rather than an acquisition deficit. These data, in conjunction with prior reports, suggest that latent inhibition is relatively specific to the context in which it was administered, whereas conditioned inhibition is specific to its training context only when it is the second learned relationship concerning the target cue. These experiments are part of a larger effort to delineate control by the test context of two-phase associative interference as a function of the nature of target training and the nature of interference training. PMID:25875792

Behavioral techniques for attenuating the expression of fear associations in an animal model of anxiety.

PubMed

Laborda, Mario A; Polack, Cody W; Miguez, Gonzalo; Miller, Ralph R

2014-09-01

Recent data indicate that extinguished fear often returns when the testing conditions differ from those of treatment. Several manipulations including extensive extinction training, extinction in multiple contexts, and spacing the extinction trials and sessions reduce the return of fear. Moreover, extensive extinction and extinction in multiple contexts summate in reducing return of fear, and the spacing of the extinction trials and the spacing of extinction sessions summate in reducing return of fear. Here we evaluated whether these techniques also attenuate the context specificity of latent inhibition, and whether they summate to further decrease fear responding at test. In two experiments, with rats as subjects in a lick suppression preparation, we assessed the effects of massive CS preexposure, CS preexposure in multiple contexts, and of spacing the CS-preexposure trials and sessions, in reducing the context specificity of latent inhibition. Fear responding was attenuated by all four manipulations. Moreover, extensive CS preexposure in multiple contexts, and conjoint spacing of the CS-preexposure trials and sessions, were more effective in reducing the context specificity of latent inhibition than each manipulation alone. Our experimental designs evaluated degrees of context specificity of latent inhibition but omitted groups in which latent inhibition was assessed without a context shift away from the context of latent inhibition treatment. This precluded us from drawing conclusions concerning absolute (as opposed to relative) levels of recovery from latent inhibition. Techniques effective in decreasing the return of conditioned fear following extinction are also effective in decreasing the context specificity of latent inhibition in an animal model of anxiety. Fear and anxiety disorders might be prevented in anxious human participants with the same techniques used here, but that is still an empirical question. Copyright © 2014 Elsevier Ltd. All rights reserved.

[Clinical presentation of Ixodes tick-borne borreliosis caused by Borrelia miyamotoi in the context of an immune response to the pathogen].

PubMed

Platonov, A E; Toporkova, M G; Kolyasnikova, N M; Stukolova, O A; Dolgova, A S; Brodovikova, A V; Makhneva, N A; Karan, L S; Koetsveld, J; Shipulin, G A; Maleev, V V

Ixodes tick-borne borreliosis caused by Borrelia miyamotoi (ITBB-BM) is a previously unknown infectious disease discovered in Russia. The present study continues the investigation of the clinical features of ITBB-BM in the context of an immune system-pathogen interaction. The study enrolled 117 patients with ITBB-BM and a comparison group of 71 patients with Lyme disease (LD) that is ITBB with erythema migrans. All the patients were treated at the New Hospital, Yekateringburg. More than 100 clinical, epidemiological and laboratory parameters were obtained from each patient's medical history and included in the general database. A subset of patients hospitalized in 2015 and 2016 underwent additional laboratory examinations. Namely, the levels of B. miyamotoi-specific IgM and IgG antibodies were measured by the protein microarray containing GlpQ protein and four variable major proteins (VMPs): Vlp15/16, Vlp18, Vsp1, and Vlp5. The blood concentration of Borrelia was estimated by quantitative real-time PCR. In contrast to LD, first of all (p<0.001) the following clinical features were typical for ITBB-BM: the absence of erythema migrans (in 95% of patients), fever (93%), fatigue (96%), headache (82%), chill (41%), nausea (28%), lymphopenia (56%), thrombocytopenia (46%), the abnormal levels of alanine aminotransferase (54%) and C-reactive protein (98%), proteinuria (61%). Given the set of these indicators, the course of ITBB-BM was more severe in approximately 70% of patients. At admission, only 13% and 38% of patients had antibodies to GlpQ and VMPs, respectively; at discharge, antibodies to GlpQ and VMPs were detected in 88% of patients. There was no statistically significant association of the antibody response with individual clinical manifestations and laboratory parameters of the disease. However, patients with more severe ITBB-BM produced less IgM antibodies to VMPs and GlpQ at the time of discharge. ITBB-BM is a moderate systemic disease accompanied by the production of specific antibodies in virtually all patients.

The role and potential contribution of clinical research nurses to clinical trials.

PubMed

Spilsbury, Karen; Petherick, Emily; Cullum, Nicky; Nelson, Andrea; Nixon, Jane; Mason, Su

2008-02-01

This study explores the scope and potential contribution of the Clinical Research Nurse (CRN) role to clinical trials of a nursing-specific topic. Over the past two decades, there have been increases in the numbers of nurses working as CRNs because of the increasing global demand for clinical trials. CRNs can influence the quality of clinical trials but the scope and contribution of the role to clinical trials is not known. Qualitative focus group study. A focus group interview was carried out with CRNs (n = 9) employed on a large, multi-centre (six NHS Trusts) randomized controlled trial of pressure area care. The focus group interview was recorded, alongside field notes of participant interactions and behaviours, and transcribed verbatim. Data were analysed for thematic content and process. CRNs described their transition to a clinical research role. They reported a lack of confidence, role conflict as researcher and nurse, the challenges of gaining cooperation of clinical nursing staff to comply with trial protocols and difficulties maintaining their own motivation. CRNs provided their perceptions and observations of pressure area care and prevention. They identified areas of inadequate treatment, management and care, influenced by organizational and clinical aspects of care delivery. The study reveals challenges associated with training and management of CRNs. CRNs are usually associated with trial recruitment and data collection. This study highlights the additional contributions of CRNs for the study of topics specific to nursing as the result of their unique placement in the research centres as informal 'participant observers.' Such observations enhance understanding of the contexts being studied. These findings are relevant to the design and conduct of research studies of nursing care and practice and present ways for investigators to optimize the skills and knowledge of nurses working as CRNs.

Controlled Retrieval of Specific Context Information in Children and Adults.

PubMed

Lorsbach, Thomas C; Friehe, Mary J; Teten, Amy Fair; Reimer, Jason F; Armendarez, Joseph J

2015-01-01

This study adapted a procedure used by Luo and Craik (2009) to examine whether developmental differences exist in the ability to use controlled retrieval processes to access the contextual details of memory representations. Participants from 3 age groups (mean ages 9, 12, and 25 years) were presented with words in 3 study contexts: with a black-and-white picture, with a color picture, or alone without a picture. Six recognition tests were then presented that varied in the demands (high or low) placed on the retrieval of specific contextual information. Each test consisted of a mixture of words that were old targets from 1 study context, distractors (i.e., previously studied words from a different context), and completely new words. A high-specificity and a low-specificity test list was paired with each test question, with high and low specificity being determined by the nature of the distractors used in a test list. High-specificity tests contained words that were studied in similar contexts: old targets (e.g., words studied with black-and-white pictures) and distractors (e.g., words studied with color pictures). In contrast, low-specificity tests contained words that were studied in dissimilar contexts: old targets (e.g., words studied with black-and-white pictures) and distractors (e.g., words previously studied without a picture). Relative to low-specificity tests, the retrieval conditions of high-specificity tests were assumed to place greater demands on the controlled access of specific contextual information. Analysis of recollection scores revealed that age differences were present on high-but not low-specificity tests, with the performance of 9-year-olds disproportionately affected by the retrieval demands of high-specificity tests.

[The educational context to train health care professionals. A qualitative approach].

PubMed

Matus B, Olga; Ortega B, Javiera; Parra P, Paula; Ortiz M, Liliana; Márquez U, Carolina; Stotz R, Melita; Fasce H, Eduardo

2017-07-01

There are differences in the educational context in Health Sciences, between clinical and non-clinical teachers. Therefore, the didactic and reflexive peculiarities of both educational scenarios should be analyzed. To describe the conditions of the educational context in Health Sciences for the practice of the teaching role in a Chilean university. Qualitative study, performed according to Grounded Theory of Strauss and Corbin. Thirty one teachers from six health sciences programs were selected according to Patton's maximum variation criterion and contacted personally, after an informed consent process. Semi-structured interviews and focus group were performed, analyzed by open coding, using the constant comparison method, with the Atlas-ti 7.5.2 software. Six conditions of the educational context that can support the teaching role in these careers emerged. Namely, a clinical field suited for patient attention and teaching, classrooms designed for the new educational models, number of students in the classrooms and clinical settings, insertion programs for teachers' training, teachers' coordination and economic resources of the program. Health Sciences programs are developed in a complex educational context, having to articulate diverse elements to train professionals. Therefore, it is fundamental to understand the conditions of the educational context that can favor the practice of the teaching role, thus generating improvements in teaching-learning process.

Development and validation of an instrument to measure nurse educator perceived confidence in clinical teaching.

PubMed

Nguyen, Van N B; Forbes, Helen; Mohebbi, Mohammadreza; Duke, Maxine

2017-12-01

Teaching nursing in clinical environments is considered complex and multi-faceted. Little is known about the role of the clinical nurse educator, specifically the challenges related to transition from clinician, or in some cases, from newly-graduated nurse to that of clinical nurse educator, as occurs in developing countries. Confidence in the clinical educator role has been associated with successful transition and the development of role competence. There is currently no valid and reliable instrument to measure clinical nurse educator confidence. This study was conducted to develop and psychometrically test an instrument to measure perceived confidence among clinical nurse educators. A multi-phase, multi-setting survey design was used. A total of 468 surveys were distributed, and 363 were returned. Data were analyzed using exploratory and confirmatory factor analyses. The instrument was successfully tested and modified in phase 1, and factorial validity was subsequently confirmed in phase 2. There was strong evidence of internal consistency, reliability, content, and convergent validity of the Clinical Nurse Educator Skill Acquisition Assessment instrument. The resulting instrument is applicable in similar contexts due to its rigorous development and validation process. © 2017 The Authors. Nursing & Health Sciences published by John Wiley & Sons Australia, Ltd.

Regulatory and ethical considerations for linking clinical and administrative databases.

PubMed

Dokholyan, Rachel S; Muhlbaier, Lawrence H; Falletta, John M; Jacobs, Jeffrey P; Shahian, David; Haan, Constance K; Peterson, Eric D

2009-06-01

Clinical data registries are valuable tools that support evidence development, performance assessment, comparative effectiveness studies, and the adoption of new treatments into routine clinical practice. Although these registries do not have important information on long-term therapies or clinical events, administrative claims databases offer a potentially valuable complement. This article focuses on the regulatory and ethical considerations that arise from the use of registry data for research, including linkage of clinical and administrative data sets. (1) Are such activities primarily designed for quality assessment and improvement, research, or both, as this determines the appropriate ethical and regulatory standards? (2) Does the submission of data to a central registry, which may subsequently be linked to other data sources, require review by the institutional review board (IRB) of each participating organization? (3) What levels and mechanisms of IRB oversight are appropriate for the existence of a linked central data repository and the specific studies that may subsequently be developed using it? (4) Under what circumstances are waivers of informed consent and Health Insurance Portability and Accountability Act authorization required? (5) What are the requirements for a limited data set that would qualify a research activity as not involving human subjects and thus not subject to further IRB review? The approaches outlined in this article represent a local interpretation of the regulations in the context of several clinical data registry projects and focuses on a specific case study of the Society of Thoracic Surgeons National Database.

Patient-Reported Outcome and Observer-Reported Outcome Assessment in Rare Disease Clinical Trials: An ISPOR COA Emerging Good Practices Task Force Report.

PubMed

Benjamin, Katy; Vernon, Margaret K; Patrick, Donald L; Perfetto, Eleanor; Nestler-Parr, Sandra; Burke, Laurie

Rare diseases (RDs) affect a small number of people within a population. About 5000 to 8000 distinct RDs have been identified, with an estimated 6% to 8% of people worldwide suffering from an RD. Approximately 75% of RDs affect children. Frequently, these conditions are heterogeneous; many are progressive. Regulatory incentives have increased orphan drug designations and approvals. To develop emerging good practices for RD outcomes research addressing the challenges inherent in identifying, selecting, developing, adapting, and implementing patient-reported outcome (PRO) and observer-reported outcome (ObsRO) assessments for use in RD clinical trials. This report outlines the challenges and potential solutions in determining clinical outcomes for RD trials. It follows the US Food and Drug Administration Roadmap to Patient-Focused Outcome Measurement in Clinical Trials. The Roadmap consists of three columns: 1) Understanding the Disease or Condition, 2) Conceptualizing Treatment Benefit, and 3) Selecting/Developing the Outcome Measure. Challenges in column 1 include factors such as incomplete natural history data and heterogeneity of disease presentation and patient experience. Solutions include using several information sources, for example, clinical experts and patient advocacy groups, to construct the condition's natural history and understand treatment patterns. Challenges in column 2 include understanding and measuring treatment benefit from the patient's perspective, especially given challenges in defining the context of use such as variations in age or disease severity/progression. Solutions include focusing on common symptoms across patient subgroups, identifying short-term outcomes, and using multiple types of COA instruments to measure the same constructs. Challenges in column 3 center around the small patient population and heterogeneity of the condition or study sample. Few disease-specific instruments for RDs exist. Strategies include adapting existing instruments developed for a similar condition or that contain symptoms of importance to the RD patient population, or using a generic instrument validated for the context of use. This report provides state-of-the-art solutions to patient-reported outcome (PRO) and observer-reported outcome (ObsRO) assessments challenges in clinical trials of patients with RDs. These recommended solutions are both pragmatic and creative and posed with clear recognition of the global regulatory context used in RD clinical development programs. Copyright © 2017. Published by Elsevier Inc.

Virtual Knowledge Brokering: Describing the Roles and Strategies Used by Knowledge Brokers in a Pediatric Physiotherapy Virtual Community of Practice.

PubMed

Hurtubise, Karen; Rivard, Lisa; Héguy, Léa; Berbari, Jade; Camden, Chantal

2016-01-01

Knowledge transfer in pediatric rehabilitation is challenging and requires active, multifaceted strategies. The use of knowledge brokers (KBs) is one such strategy noted to promote clinician behavior change. The success of using KBs to transfer knowledge relies on their ability to adapt to ever-changing clinical contexts. In addition, with the rapid growth of online platforms as knowledge transfer forums, KBs must become effective in virtual environments. Although the role of KBs has been studied in various clinical contexts, their emerging role in specific online environments designed to support evidence-based behavior change has not yet been described. Our objective is to describe the roles of, and strategies used by, four KBs involved in a virtual community of practice to guide and inform future online KB interventions. A descriptive design guided this study and a thematic content analysis process was used to analyze online KB postings. The Promoting Action on Research in Health Sciences knowledge transfer framework and online andragogical learning theories assisted in the coding. A thematic map was created illustrating the links between KBs' strategies and emerging roles in the virtual environment. We analyzed 95 posts and identified three roles: 1) context architect: promoting a respectful learning environment, 2) knowledge sharing promoter: building capacity, and 3) linkage creator: connecting research-to-practice. Strategies used by KBs reflected invitational, constructivism, and connectivism approaches, with roles and strategies changing over time. This study increases our understanding of the actions of KBs in virtual contexts to foster uptake of research evidence in pediatric physiotherapy. Our results provide valuable information about the knowledge and skills required by individuals to fulfill this role in virtual environments.

Vets and Videos: Student Learning from Context-Based Assessment in a Pre-Clinical Science Course

ERIC Educational Resources Information Center

Seddon, Jennifer

2008-01-01

To increase the perceived relevance of pre-clinical science courses to undergraduates, a context-based assessment item was introduced to a genetics course that occurs early within a five-year veterinary science programme. The aim was to make a direct link between genetic concepts and the future clinical profession of the students. In the…

Comparing Context Specificity of Extinction and Latent Inhibition

PubMed Central

Miller, Ralph R.; Laborda, Mario A.; Polack, Cody W.; Miguez, Gonzalo

2015-01-01

Exposure to a cue alone either before (i.e., latent inhibition treatment) or after (i.e., extinction) the cue is paired with an unconditioned stimulus (US) results in attenuated conditioned responding to the cue. Here we report two experiments in which potential parallels between the context specificity of the effects of extinction and latent inhibition treatments were directly compared in a lick suppression preparation with rats. The reversed ordering of conditioning and nonreinforcement in extinction and latent inhibition designs allowed us to examine the effect of training order on the context specificity of what is learned given phasic reinforcement and nonreinforcement of a target cue. Experiment 1 found that when CS conditioning and CS nonreinforcement were administered in the same context, both extinction and latent inhibition treatments had reduced impact on test performance relative to excitatory conditioning when testing occurred outside the treatment context. Similarly, Experiment 2 found that when conditioning was administered in one context and nonreinforcement was administered in a second context, the effects of both extinction and latent inhibition treatments were attenuated when testing occurred in a neutral context relative to the context in which the CS was nonreinforced. The observed context specificity of extinction and latent inhibition treatments have both been previously reported, but not in a single experiment under otherwise identical conditions. The results of the two experiments convergently suggest that memory of nonreinforcement becomes context dependent after a cue is both reinforced and nonreinforced independent of the order of training. PMID:26100525

Comparing the context specificity of extinction and latent inhibition.

PubMed

Miller, Ralph R; Laborda, Mario A; Polack, Cody W; Miguez, Gonzalo

2015-12-01

Exposure to a cue alone either before (i.e., latent inhibition treatment) or after (i.e., extinction) the cue is paired with an unconditioned stimulus results in attenuated conditioned responding to the cue. Here we report two experiments in which potential parallels between the context specificity of the effects of extinction and latent inhibition treatments were directly compared in a lick suppression preparation with rats. The reversed ordering of conditioning and nonreinforcement in extinction and latent inhibition designs allowed us to examine the effect of training order on the context specificity of what is learned given phasic reinforcement and nonreinforcement of a target cue. Experiment 1 revealed that when conditioned-stimulus (CS) conditioning and CS nonreinforcement were administered in the same context, both extinction and latent inhibition treatments had reduced impacts on test performance, relative to excitatory conditioning when testing occurred outside the treatment context. Similarly, Experiment 2 showed that when conditioning was administered in one context and nonreinforcement was administered in a second context, the effects of both extinction and latent inhibition treatments were attenuated when testing occurred in a neutral context, relative to the context in which the CS was nonreinforced. The observed context specificity of extinction and latent inhibition treatments has been previously reported in both cases, but not in a single experiment under otherwise identical conditions. The results of the two experiments convergently suggest that memory of nonreinforcement becomes context dependent after a cue is both reinforced and nonreinforced, independent of the order of training.

A fundamental role for context in instrumental learning and extinction.

PubMed

Bouton, Mark E; Todd, Travis P

2014-05-01

The purpose of this article is to review recent research that has investigated the effects of context change on instrumental (operant) learning. The first part of the article discusses instrumental extinction, in which the strength of a reinforced instrumental behavior declines when reinforcers are withdrawn. The results suggest that extinction of either simple or discriminated operant behavior is relatively specific to the context in which it is learned: As in prior studies of Pavlovian extinction, ABA, ABC, and AAB renewal effects can all be observed. Further analysis supports the idea that the organism learns to refrain from making a specific response in a specific context, or in more formal terms, an inhibitory context-response association. The second part of the article then discusses research suggesting that the context also controls instrumental behavior before it is extinguished. Several experiments demonstrate that a context switch after either simple or discriminated operant training causes a decrement in the strength of the response. Over a range of conditions, the animal appears to learn a direct association between the context and the response. Under some conditions, it can also learn a hierarchical representation of context and the response-reinforcer relation. Extinction is still more context-specific than conditioning, as indicated by ABC and AAB renewal. Overall, the results establish that the context can play a significant role in both the acquisition and extinction of operant behavior. Copyright © 2014 Elsevier B.V. All rights reserved.

Optimising a curriculum for clinical haematology and biochemistry in sports medicine: a Delphi approach

PubMed Central

Fallon, K E; Trevitt, A C

2006-01-01

Objectives To investigate issues of curriculum in the context of a postgraduate sports medicine training programme, specifically in the field of clinical biochemistry and haematology. Methods Following the Delphi methodology, a series of sequential questionnaires was administered to curriculum developers, clinical teachers, examiners, and registrars. Results Agreement on a core syllabus for this subject with an indication of the core aims and objectives of teaching and learning in this field and the associated required skills and competencies. An indication of current and ideal teaching and learning methods and reasons for these preferences. A consensus of key features of a teaching module for this field and of appropriate methods of examination. Conclusions The data derived from this study, as well as the experience of engaging in it, will better inform curriculum developers, teachers, and students of one another's perceptions as to what is important in and appropriate to teaching and learning in this field of sports medicine. Engagement in the exercise and broader consideration of the outcomes by those who develop the curriculum, teach, and formulate the examination process will facilitate attainment of the ideal of well aligned teaching, learning, and examination in this specific field. PMID:16432001

Trial Watch

PubMed Central

Pol, Jonathan; Bloy, Norma; Obrist, Florine; Eggermont, Alexander; Galon, Jérôme; Hervé Fridman, Wolf; Cremer, Isabelle; Zitvogel, Laurence; Kroemer, Guido; Galluzzi, Lorenzo

2014-01-01

During the past 2 decades, the possibility that preparations capable of eliciting tumor-specific immune responses would mediate robust therapeutic effects in cancer patients has received renovated interest. In this context, several approaches to vaccinate cancer patients against their own malignancies have been conceived, including the administration of DNA constructs coding for one or more tumor-associated antigens (TAAs). Such DNA-based vaccines conceptually differ from other types of gene therapy in that they are not devised to directly kill cancer cells or sensitize them to the cytotoxic activity of a drug, but rather to elicit a tumor-specific immune response. In spite of an intense wave of preclinical development, the introduction of this immunotherapeutic paradigm into the clinical practice is facing difficulties. Indeed, while most DNA-based anticancer vaccines are well tolerated by cancer patients, they often fail to generate therapeutically relevant clinical responses. In this Trial Watch, we discuss the latest advances on the use of DNA-based vaccines in cancer therapy, discussing the literature that has been produced around this topic during the last 13 months as well as clinical studies that have been launched in the same time frame to assess the actual therapeutic potential of this intervention. PMID:24800178

Measuring energy expenditure in clinical populations: rewards and challenges

PubMed Central

Psota, T; Chen, KY

2013-01-01

The measurement of energy expenditure (EE) is recommended as an important component of comprehensive clinical nutrition assessments in patients with altered metabolic states, who failed to respond to nutrition support and with critical illness that require individualized nutrition support. There is evidence that EE is variable in patients with metabolic diseases, such as chronic renal disease, cirrhosis, HIV, cancer cachexia, cystic fibrosis and patients under intensive care. By using appropriate techniques and interpretations of basal or resting EE, clinicians can facilitate the adequate nutrition support with minimum negative impacts from under- or overfeeding in these patients. This review is based on our current understanding of the different components of EE and the techniques to measure them, and to re-examine advances and challenges to determine energy needs in clinical populations with more focuses on the obese, pediatric and elderly patients. In addition, technological advances have expanded the choices of market-available equipments for assessing EE, which also bring specific challenges and rewards in selecting the right equipment with specific performance criteria. Lastly, analytical considerations of interpreting the results of EE in the context of changing body composition are presented and discussed. PMID:23443826

Trial watch: Immune checkpoint blockers for cancer therapy.

PubMed

Vanpouille-Box, Claire; Lhuillier, Claire; Bezu, Lucillia; Aranda, Fernando; Yamazaki, Takahiro; Kepp, Oliver; Fucikova, Jitka; Spisek, Radek; Demaria, Sandra; Formenti, Silvia C; Zitvogel, Laurence; Kroemer, Guido; Galluzzi, Lorenzo

2017-01-01

Immune checkpoint blockers (ICBs) are literally revolutionizing the clinical management of an ever more diversified panel of oncological indications. Although considerable attention persists around the inhibition of cytotoxic T lymphocyte-associated protein 4 (CTLA4) and programmed cell death 1 (PDCD1, best known as PD-1) signaling, several other co-inhibitory T-cell receptors are being evaluated as potential targets for the development of novel ICBs. Moreover, substantial efforts are being devoted to the identification of biomarkers that reliably predict the likelihood of each patient to obtain clinical benefits from ICBs in the absence of severe toxicity. Tailoring the delivery of specific ICBs or combinations thereof to selected patient populations in the context of precision medicine programs constitutes indeed a major objective of the future of ICB-based immunotherapy. Here, we discuss recent preclinical and clinical advances on the development of ICBs for oncological indications.

Transition to adult-oriented health care: perspectives of youth and adults with complex physical disabilities.

PubMed

Young, Nancy L; Barden, Wendy S; Mills, Wendy A; Burke, Tricia A; Law, Mary; Boydell, Katherine

2009-01-01

The transition to adulthood is extremely difficult for individuals with disabilities. We sought to explore the specific issue of transition to adult-oriented health care in a Canadian context. We conducted semi-structured individual interviews with 15 youth and 15 adults with cerebral palsy, spina bifida, and acquired brain injuries of childhood, and their parents (n = 30). Respondents discussed their health care services, their experience with clinical transition, and contributing factors. We analyzed the transcripts using qualitative methods. All participants identified challenges in transition, including: lack of access to health care; lack of professionals' knowledge; lack of information and uncertainty regarding the transition process. Two solutions were identified: early provision of detailed information and more extensive support throughout the clinical transition process. The challenges of clinical transition were universal. More extensive information and support is needed during transition to ensure an efficient move to appropriate adult-oriented health care.

[Immunopathology of ulcerative colitis and granulomatous colitis (author's transl)].

PubMed

Bläker, F

1975-08-01

There is no convincing evidence as yet for a key role of immunological processes in the pathogenesis of unspecific colitis. However clinical findings as well as immunological data do support the hypothesis that immune reactions are involved primarily or secondarily in the pathogenesis and the clinical course of ulcerative colitis and granulomatous colitis. In such patients a specific adaptation of humoral and cell-bound immune reactions against antigenic material from the colon and other tissues has been found in peripheral blood, lymphatic tissue and bowel wall. In this context it seems to be especially noteworthy, that lymphocytes taken from patients with colitis lead to disintegration of colon epithelial cells in vitro. This cytotoxic effect of the lymphocytes is lost after colectomy or remission of the disease. Ulcerative and granulomatous colitis do have many clinical and immunological peculiarities in common. This makes one think, that possibly the same noxious factors induce differential local reactions because of different hereditary disposition.

Brain-computer interfaces for EEG neurofeedback: peculiarities and solutions.

PubMed

Huster, René J; Mokom, Zacharais N; Enriquez-Geppert, Stefanie; Herrmann, Christoph S

2014-01-01

Neurofeedback training procedures designed to alter a person's brain activity have been in use for nearly four decades now and represent one of the earliest applications of brain-computer interfaces (BCI). The majority of studies using neurofeedback technology relies on recordings of the electroencephalogram (EEG) and applies neurofeedback in clinical contexts, exploring its potential as treatment for psychopathological syndromes. This clinical focus significantly affects the technology behind neurofeedback BCIs. For example, in contrast to other BCI applications, neurofeedback BCIs usually rely on EEG-derived features with only a minimum of additional processing steps being employed. Here, we highlight the peculiarities of EEG-based neurofeedback BCIs and consider their relevance for software implementations. Having reviewed already existing packages for the implementation of BCIs, we introduce our own solution which specifically considers the relevance of multi-subject handling for experimental and clinical trials, for example by implementing ready-to-use solutions for pseudo-/sham-neurofeedback. © 2013.

Demanding Patient or Demanding Encounter?: A Case Study of a Cancer Clinic

PubMed Central

Stacey, Clare Louise; Henderson, Stuart; MacArthur, Kelly R; Dohan, Daniel

2009-01-01

This paper explores the sociological relevance of demanding encounters between doctors and patients. Borrowing from Potter and McKinlay's (2005) reconceptualization of the doctor-patient relationship, we suggest an analytic shift away from `demanding patients' toward `demanding encounters'. Such a shift places provider-patient conflict within a broader sociocultural context, emphasizing constraints facing both doctor and patient as they interact in a clinical setting. Specifically, through an ethnographic study of doctor-patient interactions at the oncology clinic of a US University Hospital, we examine the respective influences of new information technologies and patient consumerism in the production of demanding encounters in oncology. Findings suggest that these interconnected socio-cultural realities, in tandem with patient tendencies to challenge physician judgment or expertise, play a role in demanding encounters. We conclude by considering the implications of demanding encounters for doctors, patients and healthcare organizations. PMID:19619924

The DSM and Professional Practice: Research, Clinical, and Institutional Perspectives.

PubMed

Halpin, Michael

2016-06-01

How mental illnesses are defined has significant ramifications, given the substantial social and individual repercussions of these conditions. Using actor-network theory, I analyze how mental health professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) in their work. Drawing on observations of a neuropsychological laboratory and interviews with 27 professionals (i.e., psychiatrists, psychologists), I investigate how the DSM is used in research, clinical, and institutional work. In research, the DSM influences study design and exclusion/inclusion criteria. In the clinic, the DSM influences how disorders are conceptualized and diagnosed. Institutionally, the DSM aligns the patient-professional encounter to insurance and pharmaceutical interests. I conclude that the DSM operates as multiple, context-specific taxonomies that pervasively influence professional practices, such that all possible actions must orient to DSM criteria, with professionals both a source and an object of institutionalized gaze. © American Sociological Association 2016.

The Social Value of Knowledge and International Clinical Research.

PubMed

Wenner, Danielle M

2015-08-01

In light of the growth in the conduct of international clinical research in developing populations, this paper seeks to explore what is owed to developing world communities who host international clinical research. Although existing paradigms for assigning and assessing benefits to host communities offer valuable insight, I criticize their failure to distinguish between those benefits which can justify the conduct of research in a developing world setting and those which cannot. I argue that the justification for human subjects research is fundamentally grounded in the social value of knowledge, and that this value is context-dependent in a manner which should inform our ethical evaluation of the conduct of research in specific settings. I propose a new framework for the assessment of research benefits assigned to developing world host communities, a natural implication of which is to limit the types of research projects which may permissibly be conducted in developing world settings. © 2013 John Wiley & Sons Ltd.

Optimizing participation of children with autism spectrum disorder experiencing sensory challenges: a clinical reasoning framework.

PubMed

Ashburner, Jill K; Rodger, Sylvia A; Ziviani, Jenny M; Hinder, Elizabeth A

2014-02-01

Remedial sensory interventions currently lack supportive evidence and can be challenging to implement for families and clinicians. It may be timely to shift the focus to optimizing participation of children with autism spectrum disorders (ASD) through accommodation and self-regulation of their sensory differences. A framework to guide practitioners in selecting strategies is proposed based on clinical reasoning considerations, including (a) research evidence, (b) client- and family-centredness, (c) practice contexts, (d) occupation-centredness, and (e) risks. Information-sharing with families and coaching constitute the basis for intervention. Specific strategies are identified where sensory aversions or seeking behaviours, challenges with modulation of arousal, or sensory-related behaviours interfere with participation. Self-regulatory strategies are advocated. The application of universal design principles to shared environments is also recommended. The implications of this framework for future research, education, and practice are discussed. The clinical utility of the framework now needs to be tested.

What can clinical teachers learn from Harry Potter and the Philosopher's Stone?

PubMed

Conn, Jennifer J

2002-12-01

Many clinical teachers acquire a working knowledge of the principles of teaching and learning through observation, by adopting positive and rejecting negative examples of clinical instruction. Well selected vignettes of teaching behaviours taken from contemporary film and literature may provide rich substrate by which to engage clinical teachers in discourse about instructional technique. This paper draws on J K Rowling's novel and its companion film, Harry Potter and the Philosopher's Stone, and critically analyses the teaching styles of the staff at Hogwarts School of Wizardry and Witchcraft in the context of contemporary generic and medical education literature. Specifically, it argues that effective teachers demonstrate not only an in-depth knowledge of their discipline but possess a keen appreciation of the cognitive changes that occur in their students during the learning process. They are, furthermore, proficient in core instructional skills such as small group facilitation, feedback and questioning. Most importantly, effective teachers model appropriate attitudes in their professional setting and possess highly developed personal qualities such as creativity, flexibility and enthusiasm.

Illustrating idiographic methods for translation research: moderation effects, natural clinical experiments, and complex treatment-by-subgroup interactions.

PubMed

Ridenour, Ty A; Wittenborn, Andrea K; Raiff, Bethany R; Benedict, Neal; Kane-Gill, Sandra

2016-03-01

A critical juncture in translation research involves the preliminary studies of intervention tools, provider training programs, policies, and other mechanisms used to leverage knowledge garnered at one translation stage into another stage. Potentially useful for such studies are rigorous techniques for conducting within-subject clinical trials, which have advanced incrementally over the last decade. However, these methods have largely not been utilized within prevention or translation contexts. The purpose of this manuscript is to demonstrate the flexibility, wide applicability, and rigor of idiographic clinical trials for preliminary testing of intervention mechanisms. Specifically demonstrated are novel uses of state-space modeling for testing intervention mechanisms of short-term outcomes, identifying heterogeneity in and moderation of within-person treatment mechanisms, a horizontal line plot to refine sampling design during the course of a clinic-based experimental study, and the need to test a treatment's efficacy as treatment is administered along with (e.g., traditional 12-month outcomes).

Serological diagnosis of Toxoplasma gondii infection: Recommendations from the French National Reference Center for Toxoplasmosis.

PubMed

Villard, O; Cimon, B; L'Ollivier, C; Fricker-Hidalgo, H; Godineau, N; Houze, S; Paris, L; Pelloux, H; Villena, I; Candolfi, E

2016-01-01

Toxoplasmosis manifests no clinical signs in 80% of cases in immunocompetent patient, causing immunization characterized by the persistence of cysts, particularly in brain, muscles, and retina. Assessing the serological status, based on testing for serum toxoplasma IgG and IgM antibodies, is essential in cases that are increasingly at risk for the more severe disease forms, such as congenital or ocular toxoplasmosis. This disease also exposes immunosuppressed patients to reactivation, which can lead to more widespread forms and increased mortality. By interpreting the serological results, we can estimate the risk of contamination or reactivation and define appropriate prophylactic and preventive measures, such as hygienic and dietetic, therapeutic, biological, and clinical follow-up, according to the clinical context. We hereby propose practical approaches based on serological data, resulting from a consensus of a group of experts from the French National Reference Center Network for Toxoplasmosis, according to both routine and specific clinical situations. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

eHealth and the use of individually tailored information: A systematic review.

PubMed

Conway, Nicholas; Webster, Clare; Smith, Blair; Wake, Deborah

2017-09-01

Tailored messages are those that specifically target individuals following an assessment of their unique characteristics. This systematic review assesses the evidence regarding the effectiveness of tailoring within eHealth interventions aimed at chronic disease management. OVID Medline/Embase databases were searched for randomised control trials, controlled clinical, trials, before -after studies, and time series analyses from inception - May 2014. Objectively measured clinical processes/outcomes were considered. Twenty-two papers were eligible for inclusion: 6/22 used fully tailored messaging and 16/22 used partially tailored messages. Two studies isolated tailoring as the active component. The remainder compared intervention with standard care. In all, 12/16 studies measuring clinical processes and 2/6 studies reporting clinical outcomes showed improvements, regardless of target group. Study quality was low and design did not allow for identification of interventions' active component. Heterogeneity precluded meta-analysis. This review has demonstrated that there is a lack of evidence to suggest that tailoring within an eHealth context confers benefit over non-tailored eHealth interventions.

Data-Driven Asthma Endotypes Defined from Blood Biomarker and Gene Expression Data

PubMed Central

George, Barbara Jane; Reif, David M.; Gallagher, Jane E.; Williams-DeVane, ClarLynda R.; Heidenfelder, Brooke L.; Hudgens, Edward E.; Jones, Wendell; Neas, Lucas; Hubal, Elaine A. Cohen; Edwards, Stephen W.

2015-01-01

The diagnosis and treatment of childhood asthma is complicated by its mechanistically distinct subtypes (endotypes) driven by genetic susceptibility and modulating environmental factors. Clinical biomarkers and blood gene expression were collected from a stratified, cross-sectional study of asthmatic and non-asthmatic children from Detroit, MI. This study describes four distinct asthma endotypes identified via a purely data-driven method. Our method was specifically designed to integrate blood gene expression and clinical biomarkers in a way that provides new mechanistic insights regarding the different asthma endotypes. For example, we describe metabolic syndrome-induced systemic inflammation as an associated factor in three of the four asthma endotypes. Context provided by the clinical biomarker data was essential in interpreting gene expression patterns and identifying putative endotypes, which emphasizes the importance of integrated approaches when studying complex disease etiologies. These synthesized patterns of gene expression and clinical markers from our research may lead to development of novel serum-based biomarker panels. PMID:25643280

Everybody wants it done but nobody wants to do it: an exploration of the barrier and enablers of critical components towards creating a clinical pathway for anxiety and depression in cancer.

PubMed

Rankin, Nicole M; Butow, Phyllis N; Thein, Thida; Robinson, Tracy; Shaw, Joanne M; Price, Melanie A; Clover, Kerrie; Shaw, Tim; Grimison, Peter

2015-01-22

This study aimed to explore barriers to and enablers for future implementation of a draft clinical pathway for anxiety and depression in cancer patients in the Australian context. Health professionals reviewed a draft clinical pathway and participated in qualitative interviews about the delivery of psychosocial care in their setting, individual components of the draft pathway, and barriers and enablers for its future implementation. Five interrelated themes were identified: ownership; resources and responsibility; education and training; patient reluctance; and integration with health services beyond oncology. The five themes were perceived as both barriers and enablers and provide a basis for an implementation plan that includes strategies to overcome barriers. The next steps are to design and deliver the clinical pathway with specific implementation strategies that address team ownership, endorsement by leaders, education and training modules designed for health professionals and patients and identify ways to integrate the pathway into existing cancer services.

Toward modeling locomotion using electromyography-informed 3D models: application to cerebral palsy.

PubMed

Sartori, M; Fernandez, J W; Modenese, L; Carty, C P; Barber, L A; Oberhofer, K; Zhang, J; Handsfield, G G; Stott, N S; Besier, T F; Farina, D; Lloyd, D G

2017-03-01

This position paper proposes a modeling pipeline to develop clinically relevant neuromusculoskeletal models to understand and treat complex neurological disorders. Although applicable to a variety of neurological conditions, we provide direct pipeline applicative examples in the context of cerebral palsy (CP). This paper highlights technologies in: (1) patient-specific segmental rigid body models developed from magnetic resonance imaging for use in inverse kinematics and inverse dynamics pipelines; (2) efficient population-based approaches to derive skeletal models and muscle origins/insertions that are useful for population statistics and consistent creation of continuum models; (3) continuum muscle descriptions to account for complex muscle architecture including spatially varying material properties with muscle wrapping; (4) muscle and tendon properties specific to CP; and (5) neural-based electromyography-informed methods for muscle force prediction. This represents a novel modeling pipeline that couples for the first time electromyography extracted features of disrupted neuromuscular behavior with advanced numerical methods for modeling CP-specific musculoskeletal morphology and function. The translation of such pipeline to the clinical level will provide a new class of biomarkers that objectively describe the neuromusculoskeletal determinants of pathological locomotion and complement current clinical assessment techniques, which often rely on subjective judgment. WIREs Syst Biol Med 2017, 9:e1368. doi: 10.1002/wsbm.1368 For further resources related to this article, please visit the WIREs website. © 2016 Wiley Periodicals, Inc.

Severe Delayed Cutaneous and Systemic Reactions to Drugs: A Global Perspective on the Science and Art of Current Practice.

PubMed

Peter, Jonathan Grant; Lehloenya, Rannakoe; Dlamini, Sipho; Risma, Kimberly; White, Katie D; Konvinse, Katherine C; Phillips, Elizabeth J

Most immune-mediated adverse drug reactions (IM-ADRs) involve the skin, and many have additional systemic features. Severe cutaneous adverse drug reactions (SCARs) are an uncommon, potentially life-threatening, and challenging subgroup of IM-ADRs with diverse clinical phenotypes, mechanisms, and offending drugs. T-cell-mediated immunopathology is central to these severe delayed reactions, but effector cells and cytokines differ by clinical phenotype. Strong HLA-gene associations have been elucidated for specific drug-SCAR IM-ADRs such as Stevens-Johnson syndrome/toxic epidermal necrolysis, although the mechanisms by which carriage of a specific HLA allele is necessary but not sufficient for the development of many IM-ADRs is still being defined. SCAR management is complicated by substantial short- and long-term morbidity/mortality and the potential need to treat ongoing comorbid disease with related medications. Multidisciplinary specialist teams at experienced units should care for patients. In the setting of SCAR, patient outcomes as well as preventive, diagnostic, treatment, and management approaches are often not generalizable, but rather context specific, driven by population HLA-genetics, the pharmacology and genetic risk factors of the implicated drug, severity of underlying comorbid disease necessitating ongoing treatments, and cost considerations. In this review, we update the basic and clinical science of SCAR diagnosis and management. Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.

Severe delayed cutaneous and systemic reactions to drugs: a global perspective on the science and art of current practice

PubMed Central

Peter, Jonathan Grant; Lehloenya, Rannakoe; Dlamini, Sipho; Risma, Kimberly; White, Katie D.; Konvinse, Katherine C.; Phillips, Elizabeth J.

2017-01-01

The majority of immune-mediated adverse drug reactions (IM-ADRs) involve the skin, and many have additional systemic features. Severe cutaneous adverse drug reactions (SCAR) are an uncommon, potentially life-threatening and challenging sub-group of IM-ADRs with diverse clinical phenotypes, mechanisms and offending drugs. T-cell mediated immunopathology is central to these severe delayed reactions, but effector cells and cytokines differ by clinical phenotype. Strong HLA-gene associations have been elucidated for specific drug-SCAR IM-ADRs such as Stevens-Johnson Syndrome/toxic epidermal necrolysis (SJS/TEN); although the mechanisms by which carriage of a specific HLA allele is necessary but not sufficient for the development of many IM-ADRs is still being defined. SCAR management is complicated by substantial short and long-term morbidity/ mortality and the potential need to treat ongoing co-morbid disease with related medications. Multidisciplinary specialist teams at experienced units should care for patients. In the setting of SCAR, patient outcomes as well as preventive,diagnostic, treatment and management approaches are often not generalizable, but rather context specific, driven by population HLA-genetics, the pharmacology and genetic risk factors of the implicated drug, severity of underlying co-morbid disease necessitating ongoing treatments, and cost considerations. In this review, we update the basic and clinical science of SCAR diagnosis and management. PMID:28483310

The Controlled Retrieval of Specific Context Information in Children and Adults

PubMed Central

Lorsbach, Thomas C.; Reimer, Jason F.; Friehe, Mary J.; Armendarez, Joseph J.; Teten, Amy Fair

2017-01-01

The present study adapted a procedure used recently by Luo and Craik (2009) in order to examine whether developmental differences exist in the ability to use controlled retrieval processes to access the specific contextual details of memory representations. Participants from three age groups (Mean ages: 9, 12, and 25 years) were presented with words in three study contexts: with a black-and-white picture, with a color picture, or alone without a picture. Six recognition tests were then presented that varied in the demands (high or low) placed on the retrieval of specific contextual information. Each test consisted of a mixture of words that were old targets from one study context, distractors (i.e., previously studied words from a different context), and completely new words. A “high specificity” and a “low specificity” test list was paired with each test question, with “high” and “low” specificity being determined by the nature of the distractors used in a test list. High specificity tests contained words that were studied in similar contexts: old targets (e.g., words studied with black-and-white pictures) and distractors (e.g., words studied with color pictures). In contrast, low specificity tests contained words that were studied in dissimilar contexts: old targets (e.g., words studied with black-and-white pictures) and distractors (e.g., words previously studied without a picture). Relative to low specificity tests, the retrieval conditions of high specificity tests were assumed to place greater demands on the controlled access of specific contextual information. Analysis of recollection scores revealed that age differences were present on high, but not low specificity tests, with the performance of 9-year olds being disproportionately affected by the retrieval demands of high specificity tests. PMID:26219173

Clinical Ethics in Gabon: The Spectrum of Clinical Ethical Issues Based on Findings from In-Depth Interviews at Three Public Hospitals.

PubMed

Sippel, Daniel; Marckmann, Georg; Ndzie Atangana, Etienne; Strech, Daniel

2015-01-01

Unlike issues in biomedical research ethics, ethical challenges arising in daily clinical care in Sub-Saharan African countries have not yet been studied in a systematic manner. However this has to be seen as a distinct entity as we argue in this paper. Our aim was to give an overview of the spectrum of clinical ethical issues and to understand what influences clinical ethics in the Sub-Saharan country of Gabon. In-depth interviews with 18 health care professionals were conducted at three hospital sites in Gabon. Interview transcripts were analyzed using a grounded theory approach (open and axial coding), giving a qualitative spectrum of categories for clinical ethical issues. Validity was checked at a meeting with study participants and other health care experts in Gabon after analysis of the data. Twelve main categories (with 28 further-specified subcategories) for clinical ethical issues were identified and grouped under three core categories: A) micro level: "confidentiality and information", "interpersonal, relational and behavioral issues", "psychological strain of individuals", and "scarce resources"; B) meso level: "structural issues of medical institutions", "issues with private clinics", "challenges connected to the family", and "issues of education, training and competence"; and C) macro level: "influence of society, culture, religion and superstition", "applicability of western medicine", "structural issues on the political level", and "legal issues". Interviewees reported a broad spectrum of clinical ethical issues that go beyond challenges related to scarce financial and human resources. Specific socio-cultural, historical and educational backgrounds also played an important role. In fact these influences are central to an understanding of clinical ethics in the studied local context. Further research in the region is necessary to put our study into perspective. As many participants reported a lack of awareness of ethical issues amongst other health care professionals in daily clinical practice, we suggest that international organizations and national medical schools should consider infrastructure and tools to improve context-sensitive capacity building in clinical ethics for Sub-Saharan African countries like Gabon.

Models for truth-telling in physician-patient encounters: what can we learn from Yoruba concept of Ooto?

PubMed

Ewuoso, Cornelius

2017-09-29

Empirical studies have now established that many patients make clinical decisions based on models other than Anglo American model of truth-telling and patient autonomy. Some scholars also add that current medical ethics frameworks and recent proposals for enhancing communication in health professional-patient relationship have not adequately accommodated these models. In certain clinical contexts where health professional and patients are motivated by significant cultural and religious values, these current frameworks cannot prevent communication breakdown, which can, in turn, jeopardize patient care, cause undue distress to a patient in certain clinical contexts or negatively impact his/her relationship with the community. These empirical studies have now recommended that additional frameworks developed around other models of truth-telling; and which take very seriously significant value-differences which sometimes exist between health professional and patients, as well as patient's cultural/religious values or relational capacities, must be developed. This paper contributes towards the development of one. Specifically, this study proposes a framework for truth-telling developed around African model of truth-telling by drawing insights from the communitarian concept of ootọ́ amongst the Yoruba people of south west Nigeria. I am optimistic that if this model is incorporated into current medical ethics codes and curricula, it will significantly enhance health professional-patient communication. © 2017 John Wiley & Sons Ltd.

Social Psychotherapy in Brazil.

PubMed

Fleury, Heloisa J; Marra, Marlene M; Knobel, Anna M

2015-10-01

This paper describes the practice of sociodrama, a method created by J. L. Moreno in the 1930s, and the Brazilian contemporary socio-psychodrama. In 1970, after the Fifth International Congress of Psychodrama was held in Brazil, group psychotherapy began to flourish both in private practice and hospital clinical settings. Twenty years later, the Brazilian health care system added group work as a reimbursable mental health procedure to improve social health policies. In this context, socio-psychodrama became a key resource for social health promotion within groups. Some specific conceptual contributions by Brazilians on sociodrama are also noteworthy.

Childhood visual impairment: normal and abnormal visual function in the context of developmental disability.

PubMed

Nyong'o, Omondi L; Del Monte, Monte A

2008-12-01

Abnormal or failed development of vision in children may give rise to varying degrees of visual impairment and disability. Disease and organ-specific mechanisms by which visual impairments arise are presented. The presentation of these mechanisms, along with an explanation of established pathologic processes and correlative up-to-date clinical and social research in the field of pediatrics, ophthalmology, and rehabilitation medicine are discussed. The goal of this article is to enhance the practitioner's recognition and care for children with developmental disability associated with visual impairment.

An unexplored ethical issue in clinical research: disclosure of individual findings in the Creando Posibilidades [Creating Possibilities] study.

PubMed

Stein, Karen Farchaus; Keller, Colleen; Fishstrom, Astrid

2013-06-01

Individual disclosure refers to the presumptive ethical responsibility of an investigator to communicate to a study participant information that was collected as a part of a research study protocol and is specific to the individual. Currently, there are no federal regulatory guidelines specifying the conditions and management of disclosure of health-related individual-specific information. In this report, the authors discuss the challenges associated with individual disclosure in the context of a longitudinal descriptive study. Arguments favoring disclosure and those challenging disclosure as a general ethical duty are presented. Finally, strategies for addressing individual disclosure are discussed using a research exemplar in which risk behaviors related to health outcomes were measured. Copyright © 2013 Wiley Periodicals, Inc.

Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain.

PubMed

Rossettini, Giacomo; Carlino, Elisa; Testa, Marco

2018-01-22

Placebo and nocebo effects are embodied psycho-neurobiological responses capable of modulating pain and producing changes at different neurobiological, body at perceptual and cognitive levels. These modifications are triggered by different contextual factors (CFs) presented in the therapeutic encounter between patient and healthcare providers, such as healing rituals and signs. The CFs directly impact on the quality of the therapeutic outcome: a positive context, that is a context characterized by the presence of positive CFs, can reduce pain by producing placebo effects, while a negative context, characterized by the presence of negative CFs, can aggravate pain by creating nocebo effects. Despite the increasing interest about this topic; the detailed study of CFs as triggers of placebo and nocebo effects is still lacked in the management of musculoskeletal pain.Increasing evidence suggest a relevant role of CFs in musculoskeletal pain management. CFs are a complex sets of internal, external or relational elements encompassing: patient's expectation, history, baseline characteristics; clinician's behavior, belief, verbal suggestions and therapeutic touch; positive therapeutic encounter, patient-centered approach and social learning; overt therapy, posology of intervention, modality of treatment administration; marketing features of treatment and health care setting. Different explanatory models such as classical conditioning and expectancy can explain how CFs trigger placebo and nocebo effects. CFs act through specific neural networks and neurotransmitters that were described as mediators of placebo and nocebo effects.Available findings suggest a relevant clinical role and impact of CFs. They should be integrated in the clinical reasoning to increase the number of treatment solutions, boosts their efficacy and improve the quality of the decision-making. From a clinical perspective, the mindful manipulation of CFs represents a useful opportunity to enrich a well-established therapy in therapeutic setting within the ethical border. From a translational perspective, there is a strong need of research studies on CFs close to routine and real-world clinical practice in order to underline the uncertainty of therapy action and help clinicians to implement knowledge in daily practice.

What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals?

PubMed

English, Mike; Ayieko, Philip; Nyamai, Rachel; Were, Fred; Githanga, David; Irimu, Grace

2017-02-02

The creation of a clinical network was proposed as a means to promote implementation of a set of recommended clinical practices targeting inpatient paediatric care in Kenya. The rationale for selecting a network as a strategy has been previously described. Here, we aim to describe network activities actually conducted over its first 2.5 years, deconstruct its implementation into specific components and provide our 'insider' interpretation of how the network is functioning as an intervention. We articulate key activities that together have constituted network processes over 2.5 years and then utilise a recently published typology of implementation components to give greater granularity to this description from the perspective of those delivering the intervention. Using the Behaviour Change Wheel we then suggest how the network may operate to achieve change and offer examples of change before making an effort to synthesise our understanding in the form of a realist context-mechanism-outcome configuration. We suggest our network is likely to comprise 22 from a total of 73 identifiable intervention components, of which 12 and 10 we consider major and minor components, respectively. At the policy level, we employed clinical guidelines, marketing and communication strategies with intervention characteristics operating through incentivisation, persuasion, education, enablement, modelling and environmental restructuring. These might influence behaviours by enhancing psychological capability, creating social opportunity and increasing motivation largely through a reflective pathway. We previously proposed a clinical network as a solution to challenges implementing recommended practices in Kenyan hospitals based on our understanding of theory and context. Here, we report how we have enacted what was proposed and use a recent typology to deconstruct the intervention into its elements and articulate how we think the network may produce change. We offer a more generalised statement of our theory of change in a context-mechanism-outcome configuration. We hope this will complement a planned independent evaluation of 'how things work', will help others interpret results of change reported more formally in the future and encourage others to consider further examination of networks as means to scale up improvement practices in health in lower income countries.

Validity assessment and the neurological physical examination.

PubMed

Zasler, Nathan D

2015-01-01

The assessment of any patient or examinee with neurological impairment, whether acquired or congenital, provides a key set of data points in the context of developing accurate diagnostic impressions and implementing an appropriate neurorehabilitation program. As part of that assessment, the neurological physical exam is an extremely important component of the overall neurological assessment. In the aforementioned context, clinicians often are confounded by unusual, atypical or unexplainable physical exam findings that bring into question the organicity, veracity, and/or underlying cause of the observed clinical presentation. The purpose of this review is to provide readers with general directions and specific caveats regarding validity assessment in the context of the neurological physical exam. It is of utmost importance for health care practitioners to be aware of assessment methodologies that may assist in determining the validity of the neurological physical exam and differentiating organic from non-organic/functional impairments. Maybe more importantly, the limitations of many commonly used strategies for assessment of non-organicity should be recognized and consider prior to labeling observed physical findings on neurological exam as non-organic or functional.

Cure rate is not a valid indicator for assessing drug efficacy and impact of preventive chemotherapy interventions against schistosomiasis and soil-transmitted helminthiasis

PubMed Central

Montresor, Antonio

2017-01-01

Every year, in endemic countries, several million individuals are given anthelminthic drugs in the context of preventive chemotherapy programmes for morbidity control of schistosomiasis and soil-transmitted helminthiasis. The capacity of accurately evaluating the efficacy of the drugs used as well as the health impact produced by treatment is of utmost importance for the appropriate planning and implementation of these interventions. The cure rate is an indicator of drug efficacy that was originally developed for assessing the clinical efficacy of antibiotics on selected bacterial diseases. Over time, this indicator has also been widely applied to anthelminthic drugs and consequently used to monitor and evaluate preventive chemotherapy interventions. In the author's opinion, however, measurement of cure rate provides information of limited usefulness in the context of helminth control programmes. The present article analyses the peculiarities of helminth infections and those of the drugs used in preventive chemotherapy, explaining the reasons why the cure rate is not an adequate indicator in this specific public health context. PMID:21612808

Interprofessional student clinics: an economic evaluation of collaborative clinical placement education.

PubMed

Haines, Terry P; Kent, Fiona; Keating, Jennifer L

2014-07-01

Interprofessional student clinics can be used to create clinical education placements for health professional students in addition to traditional hospital-based placements and present an opportunity to provide interprofessional learning experiences in a clinical context. To date, little consideration has been given in research literature as to whether such clinics are economically viable for a university to run. We conducted an economic evaluation based upon data generated during a pilot of an interprofessional student clinic based in Australia. Cost-minimization analyses of the student clinic as opposed to traditional profession-specific clinical education in hospitals were conducted from university, Commonwealth Government, state government and societal perspectives. Cost data gathered during the pilot study and market prices were used where available, while $AUD currency at 2011 values were used. Per student day of clinical education, the student clinic cost an additional $289, whereas the state government saved $49 and the Commonwealth Government saved $66. Overall, society paid an additional $175 per student day of clinical education using the student clinic as opposed to conventional hospital-based placements, indicating that traditional hospital-based placements are a cost-minimizing approach overall for providing clinical education. Although interprofessional student clinics have reported positive patient and student learning outcomes, further research is required to determine if these benefits can justify the additional cost of this model of education. Considerations for clinic sustainability are proposed.

Neurobehavioral and self-awareness changes after traumatic brain injury: Towards new multidimensional approaches.

PubMed

Arnould, A; Dromer, E; Rochat, L; Van der Linden, M; Azouvi, P

2016-02-01

Neurobehavioral and self-awareness changes are frequently observed following traumatic brain injury (TBI). These disturbances have been related to negative consequences on functional outcomes, caregiver distress and social reintegration, representing therefore a challenge for clinical research. Some studies have recently been conducted to specifically explore apathetic and impulsive manifestations, as well as self-awareness impairments in patients with TBI. These findings underlined the heterogeneity of clinical manifestations for each behavioral disturbance and the diversity of psychological processes involved. In this context, new multidimensional approaches taking into account the various processes at play have been proposed to better understand and apprehend the complexity and dynamic nature of these problematic behaviors. In addition, the involvement of social and environmental factors as well as premorbid personality traits have increasingly been addressed. These new multidimensional frameworks have the potential to ensure targeted and effective rehabilitation by allowing a better identification and therefore consideration of the various mechanisms involved in the onset of problematic behaviors. In this context, the main objective of this position paper was to demonstrate the interest of multidimensional approaches in the understanding and rehabilitation of problematic behaviors in patients with TBI. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Systems Biology, Systems Medicine, Systems Pharmacology: The What and The Why.

PubMed

Stéphanou, Angélique; Fanchon, Eric; Innominato, Pasquale F; Ballesta, Annabelle

2018-05-09

Systems biology is today such a widespread discipline that it becomes difficult to propose a clear definition of what it really is. For some, it remains restricted to the genomic field. For many, it designates the integrated approach or the corpus of computational methods employed to handle the vast amount of biological or medical data and investigate the complexity of the living. Although defining systems biology might be difficult, on the other hand its purpose is clear: systems biology, with its emerging subfields systems medicine and systems pharmacology, clearly aims at making sense of complex observations/experimental and clinical datasets to improve our understanding of diseases and their treatments without putting aside the context in which they appear and develop. In this short review, we aim to specifically focus on these new subfields with the new theoretical tools and approaches that were developed in the context of cancer. Systems pharmacology and medicine now give hope for major improvements in cancer therapy, making personalized medicine closer to reality. As we will see, the current challenge is to be able to improve the clinical practice according to the paradigm shift of systems sciences.

Non-invasive urinary metabolomic profiling discriminates prostate cancer from benign prostatic hyperplasia.

PubMed

Pérez-Rambla, Clara; Puchades-Carrasco, Leonor; García-Flores, María; Rubio-Briones, José; López-Guerrero, José Antonio; Pineda-Lucena, Antonio

2017-01-01

Prostate cancer (PCa) is one of the most common malignancies in men worldwide. Serum prostate specific antigen (PSA) level has been extensively used as a biomarker to detect PCa. However, PSA is not cancer-specific and various non-malignant conditions, including benign prostatic hyperplasia (BPH), can cause a rise in PSA blood levels, thus leading to many false positive results. In this study, we evaluated the potential of urinary metabolomic profiling for discriminating PCa from BPH. Urine samples from 64 PCa patients and 51 individuals diagnosed with BPH were analysed using 1 H nuclear magnetic resonance ( 1 H-NMR). Comparative analysis of urinary metabolomic profiles was carried out using multivariate and univariate statistical approaches. The urine metabolomic profile of PCa patients is characterised by increased concentrations of branched-chain amino acids (BCAA), glutamate and pseudouridine, and decreased concentrations of glycine, dimethylglycine, fumarate and 4-imidazole-acetate compared with individuals diagnosed with BPH. PCa patients have a specific urinary metabolomic profile. The results of our study underscore the clinical potential of metabolomic profiling to uncover metabolic changes that could be useful to discriminate PCa from BPH in a clinical context.

On the effects of alternative optima in context-specific metabolic model predictions

PubMed Central

Nikoloski, Zoran

2017-01-01

The integration of experimental data into genome-scale metabolic models can greatly improve flux predictions. This is achieved by restricting predictions to a more realistic context-specific domain, like a particular cell or tissue type. Several computational approaches to integrate data have been proposed—generally obtaining context-specific (sub)models or flux distributions. However, these approaches may lead to a multitude of equally valid but potentially different models or flux distributions, due to possible alternative optima in the underlying optimization problems. Although this issue introduces ambiguity in context-specific predictions, it has not been generally recognized, especially in the case of model reconstructions. In this study, we analyze the impact of alternative optima in four state-of-the-art context-specific data integration approaches, providing both flux distributions and/or metabolic models. To this end, we present three computational methods and apply them to two particular case studies: leaf-specific predictions from the integration of gene expression data in a metabolic model of Arabidopsis thaliana, and liver-specific reconstructions derived from a human model with various experimental data sources. The application of these methods allows us to obtain the following results: (i) we sample the space of alternative flux distributions in the leaf- and the liver-specific case and quantify the ambiguity of the predictions. In addition, we show how the inclusion of ℓ1-regularization during data integration reduces the ambiguity in both cases. (ii) We generate sets of alternative leaf- and liver-specific models that are optimal to each one of the evaluated model reconstruction approaches. We demonstrate that alternative models of the same context contain a marked fraction of disparate reactions. Further, we show that a careful balance between model sparsity and metabolic functionality helps in reducing the discrepancies between alternative models. Finally, our findings indicate that alternative optima must be taken into account for rendering the context-specific metabolic model predictions less ambiguous. PMID:28557990

On the effects of alternative optima in context-specific metabolic model predictions.

PubMed

Robaina-Estévez, Semidán; Nikoloski, Zoran

2017-05-01

The integration of experimental data into genome-scale metabolic models can greatly improve flux predictions. This is achieved by restricting predictions to a more realistic context-specific domain, like a particular cell or tissue type. Several computational approaches to integrate data have been proposed-generally obtaining context-specific (sub)models or flux distributions. However, these approaches may lead to a multitude of equally valid but potentially different models or flux distributions, due to possible alternative optima in the underlying optimization problems. Although this issue introduces ambiguity in context-specific predictions, it has not been generally recognized, especially in the case of model reconstructions. In this study, we analyze the impact of alternative optima in four state-of-the-art context-specific data integration approaches, providing both flux distributions and/or metabolic models. To this end, we present three computational methods and apply them to two particular case studies: leaf-specific predictions from the integration of gene expression data in a metabolic model of Arabidopsis thaliana, and liver-specific reconstructions derived from a human model with various experimental data sources. The application of these methods allows us to obtain the following results: (i) we sample the space of alternative flux distributions in the leaf- and the liver-specific case and quantify the ambiguity of the predictions. In addition, we show how the inclusion of ℓ1-regularization during data integration reduces the ambiguity in both cases. (ii) We generate sets of alternative leaf- and liver-specific models that are optimal to each one of the evaluated model reconstruction approaches. We demonstrate that alternative models of the same context contain a marked fraction of disparate reactions. Further, we show that a careful balance between model sparsity and metabolic functionality helps in reducing the discrepancies between alternative models. Finally, our findings indicate that alternative optima must be taken into account for rendering the context-specific metabolic model predictions less ambiguous.

Perceptions of Radiation Oncologists and Urologists on Sources and Type of Evidence to Inform Prostate Cancer Treatment Decisions

DOE Office of Scientific and Technical Information (OSTI.GOV)

Han, Leona C.; Delpe, Sophia; Shah, Nilay D.

2014-06-01

Purpose: To perform a national survey of radiation oncologists and urologists about the type of resources used and the level of evidence needed to change clinical practice in localized prostate cancer. Methods and Materials: From a random sample, 1422 physicians were mailed a survey assessing the types of information used and what level of evidence could alter their clinical practice in prostate cancer. Multivariable logistic regression models were used to identify differences in physician characteristics for each outcome. Results: Survey response rates were similar for radiation oncologists and urologists (44% vs 46%; P=.46). Specialty-specific journals represented the most commonly usedmore » resource for informing the clinical practice for radiation oncologists (65%) and urologists (70%). Relative to radiation oncologists, urologists were less likely to report utilizing top-tier medical journals (25% vs 39%; adjusted odds ratio [OR] 0.50; P=.01) or cancer journals (22% vs 51%; adjusted OR 0.50; P<.001) but more likely to rely on clinical guidelines (46% vs 38%; adjusted OR 1.6; P=.006). Both radiation oncologists and urologists most commonly reported large randomized, clinical trials as the level of evidence to change treatment recommendations for localized prostate cancer (85% vs 77%; P=.009). Conclusions: Both specialties rely on their own specialty-specific journals and view randomized, clinical trials as the level of evidence needed to change clinical practice. Our study provides a context on meaningful ways of disseminating evidence for localized prostate cancer.« less

WE-G-BRC-02: Risk Assessment for HDR Brachytherapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mayadev, J.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-01: Risk Assessment for Radiosurgery

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, G.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

WE-G-BRC-03: Risk Assessment for Physics Plan Review

DOE Office of Scientific and Technical Information (OSTI.GOV)

Parker, S.

2016-06-15

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

Failure Mode and Effects Analysis (FMEA) originated as an industrial engineering technique used for risk management and safety improvement of complex processes. In the context of radiotherapy, the AAPM Task Group 100 advocates FMEA as the framework of choice for establishing clinical quality management protocols. However, there is concern that widespread adoption of FMEA in radiation oncology will be hampered by the perception that implementation of the tool will have a steep learning curve, be extremely time consuming and labor intensive, and require additional resources. To overcome these preconceptions and facilitate the introduction of the tool into clinical practice, themore » medical physics community must be educated in the use of this tool and the ease in which it can be implemented. Organizations with experience in FMEA should share their knowledge with others in order to increase the implementation, effectiveness and productivity of the tool. This session will include a brief, general introduction to FMEA followed by a focus on practical aspects of implementing FMEA for specific clinical procedures including HDR brachytherapy, physics plan review and radiosurgery. A description of common equipment and devices used in these procedures and how to characterize new devices for safe use in patient treatments will be presented. This will be followed by a discussion of how to customize FMEA techniques and templates to one’s own clinic. Finally, cases of common failure modes for specific procedures (described previously) will be shown and recommended intervention methodologies and outcomes reviewed. Learning Objectives: Understand the general concept of failure mode and effect analysis Learn how to characterize new equipment for safety Be able to identify potential failure modes for specific procedures and learn mitigation techniques Be able to customize FMEA examples and templates for use in any clinic.« less

Effects of Extinction Context and Retrieval Cues on Renewal of Alcohol-Cue Reactivity Among Alcohol-Dependent Outpatients

PubMed Central

Stasiewicz, Paul R.; Brandon, Thomas H.; Bradizza, Clara M.

2013-01-01

Pavlovian conditioning models have led to cue-exposure treatments for drug abuse. However, conditioned responding to drug stimuli can return (be renewed) following treatment. Animal research and a previous study of social drinkers indicated that extinction is highly context dependent but that renewal could be reduced by the inclusion of a cue from the extinction context. This study extends this research to a clinical sample. Alcohol-dependent outpatients (N = 143) completed an extinction trial to reduce craving and salivation responses to alcohol cues. They were then randomized to renewal tests in either the same context as extinction, a different context, the different context containing an extinction cue, or the different context with cue plus a manipulation to increase the salience of the cue. Contrary to predictions, the different context did not produce the expected renewal effect. Although the generalization of extinction effects beyond the cue-exposure context is a positive clinical finding, it is inconsistent with basic research findings on the context dependence of extinction. Possible explanations for this inconsistency are discussed. PMID:17563145

Effects of extinction context and retrieval cues on renewal of alcohol-cue reactivity among alcohol-dependent outpatients.

PubMed

Stasiewicz, Paul R; Brandon, Thomas H; Bradizza, Clara M

2007-06-01

Pavlovian conditioning models have led to cue-exposure treatments for drug abuse. However, conditioned responding to drug stimuli can return (be renewed) following treatment. Animal research and a previous study of social drinkers indicated that extinction is highly context dependent but that renewal could be reduced by the inclusion of a cue from the extinction context. This study extends this research to a clinical sample. Alcohol-dependent outpatients (N = 143) completed an extinction trial to reduce craving and salivation responses to alcohol cues. They were then randomized to renewal tests in either the same context as extinction, a different context, the different context containing an extinction cue, or the different context with cue plus a manipulation to increase the salience of the cue. Contrary to predictions, the different context did not produce the expected renewal effect. Although the generalization of extinction effects beyond the cue-exposure context is a positive clinical finding, it is inconsistent with basic research findings on the context dependence of extinction. Possible explanations for this inconsistency are discussed.

Choosing the Rules: Distinct and Overlapping Frontoparietal Representations of Task Rules for Perceptual Decisions

PubMed Central

Kriegeskorte, Nikolaus; Carlin, Johan D.; Rowe, James B.

2013-01-01

Behavior is governed by rules that associate stimuli with responses and outcomes. Human and monkey studies have shown that rule-specific information is widely represented in the frontoparietal cortex. However, it is not known how establishing a rule under different contexts affects its neural representation. Here, we use event-related functional MRI (fMRI) and multivoxel pattern classification methods to investigate the human brain's mechanisms of establishing and maintaining rules for multiple perceptual decision tasks. Rules were either chosen by participants or specifically instructed to them, and the fMRI activation patterns representing rule-specific information were compared between these contexts. We show that frontoparietal regions differ in the properties of their rule representations during active maintenance before execution. First, rule-specific information maintained in the dorsolateral and medial frontal cortex depends on the context in which it was established (chosen vs specified). Second, rule representations maintained in the ventrolateral frontal and parietal cortex are independent of the context in which they were established. Furthermore, we found that the rule-specific coding maintained in anticipation of stimuli may change with execution of the rule: representations in context-independent regions remain invariant from maintenance to execution stages, whereas rule representations in context-dependent regions do not generalize to execution stage. The identification of distinct frontoparietal systems with context-independent and context-dependent task rule representations, and the distinction between anticipatory and executive rule representations, provide new insights into the functional architecture of goal-directed behavior. PMID:23864675

Bringing prosocial values to translational, disease-specific stem cell research

PubMed Central

2014-01-01

Background Disease-specific stem cell therapies, created from induced pluripotent stem cell lines containing the genetic defects responsible for a particular disease, have the potential to revolutionize the treatment of refractory chronic diseases. Given their capacity to differentiate into any human cell type, these cell lines might be reprogrammed to correct a disease-causing genetic defect in any tissue or organ, in addition to offering a more clinically realistic model for testing new drugs and studying disease mechanisms. Clinical translation of these therapies provides an opportunity to design a more systematic, accessible and patient-influenced model for the delivery of medically innovative treatments to chronically ill patients. Discussion I focus on disease-specific cell therapies because the types of patients who would benefit from them have congenital, severe, high-maintenance chronic conditions. They accordingly have a very strong claim for medical need and therapeutic intervention, must interact regularly with health providers, and so have the greatest stake in influencing, at a systemic level, the way their care is delivered. Given such patients’ shared, aggregate needs for societal support and access to medical innovation, they constitute “patient communities”. To reify the relevance of patient communities within a clinical context, I propose competitive grants or “prizes” to spur innovation in delivery of care, promoting “prosocial” values of transparency, equity, patient empowerment, and patient-provider and inter-institutional collaboration. As facilitators of participant-driven advocacy for health and quality of life-improving measures, patient communities may be synergistic with the broad-based, geo-culturally embedded public health networks typically referred to as “communities” in the public health literature. Summary Prosocial values acquire a strong ethical justification based on shared need, and can be clearly defined as grant criteria, when applied to patients such as those who will benefit from disease-specific stem cell treatments. Within this context, prosociality aims not just to expand patients’ treatment choices, but also their opportunities to take a more active role in the management of their own care and contribute towards shared goals through better-informed advocacy. Accordingly, prosociality promotes relational autonomy as well as other basic bioethical principles, including beneficence and a holistic, relational conception of human dignity. PMID:24575864

Temperament, Parenting, and Moral Development: Specificity of Behavior and Context.

PubMed

Augustine, Mairin E; Stifter, Cynthia A

2015-05-01

This longitudinal study highlights the role of specific parenting behaviors in specific contexts when predicting moral development in children of varying temperament types. A sample of mother-child dyads took part in a competing demands task involving differing "do" and "don't" contextual demands when the child was 2 years of age. Child temperament was also assessed at this time, yielding inhibited, exuberant, and low-reactive temperament groups. Children's moral behavior was assessed at 5.5 years of age. Models examining the interaction of temperament and mother behaviors in each context indicated that mother's reasoning/explanation and ignoring in the "do" context predicted later moral behavior in inhibited children, whereas redirection and commands in the "don't" context predicted moral behavior in exuberant children.

Problem-oriented drug information: physicians' expectations and impact on clinical practice.

PubMed

Hedegaard, U; Damkier, P

2009-05-01

Problem-oriented drug information (POD) is a service in which health professionals provide evidence-based answers to clinical questions posed by physicians. The objective of this study was to evaluate the user satisfaction and clinical impact of POD, to investigate predictors for use and to examine the kind of sources physicians search before applying for POD. To evaluate POD, a questionnaire was distributed with problem-oriented answers sent from a drug information centre to physicians during the period of April 2006 to March 2007. Of 197 questionnaires, 183 (93%) were returned. The information from the POD service was highly valued by the physicians, and 90% of the answers led to reported impact on clinical practice in the specific clinical situation. Furthermore, 74% of the answers were intended to be used in a wider context either for future patients (67%) or for dissemination to colleagues (51%). Secondary-care physicians more often than general practitioners (GPs) used the information for dissemination to colleagues (63 vs. 39%, P = 0.0008), while GPs more often used the answer to support patient information (88 vs. 70%, P = 0.0029). The most prominent motive for applying for POD was a request for evidence-based information (78%), and the service was used to overcome barriers to practicing evidence-based medicine such as lack of time (36%), skills for searching (26%), and appraising the literature (13%). Before inquiring, 74% of the physicians had tried other information sources; the most frequent sources used were a drug reference (68%) and consulting a colleague (24%). Secondary-care physicians reported fewer barriers than GPs when seeking information, and secondary-care physicians searched other sources more often than GPs before contacting the service (81 vs. 67%, P = 0.031). POD represents a useful source for acquiring evidence-based drug information by physicians. POD is highly valued by the users. It was reported to have an impact on clinical practice for the specific patient but is also intended to be used in a wider context for future patients or for dissemination to colleagues. GPs' and secondary-care physicians' use of POD differs with GPs having more focus on patient information and secondary-care physicians having more focus on dissemination of the information to colleagues.

Unravelling functional neurology: a scoping review of theories and clinical applications in a context of chiropractic manual therapy.

PubMed

Meyer, Anne-Laure; Meyer, Amanda; Etherington, Sarah; Leboeuf-Yde, Charlotte

2017-01-01

Functional Neurology (FN), a seemingly attractive treatment approach used by some chiropractors, proposes to have an effect on a multitude of conditions but some of its concepts are controversial. A scoping review was performed to describe, in the context of chiropractic manual therapy, 1) the FN theories, and 2) its clinical applications (i.e. its indications, examination procedures, treatment modalities, treatment plans, and clinical outcomes) using four sources: i) one key textbook, ii) the scientific peer-reviewed literature, iii) websites from chiropractors using FN, and iv) semi-structured interviews of chiropractors using FN. The scientific literature was searched in PubMed, PsycINFO, and SPORTDiscus, completed by a hand search in the journal Functional Neurology, Rehabilitation and Ergonomics (November 2016 and March 2017, respectively). The only textbook on the topic we found was included and articles were chosen if they had an element of manual therapy. There was no restriction for study design but discussion papers were excluded. Websites were found in Google using the search term "Functional Neurology". Chiropractors, known to use FN, were invited based on their geographical location. Theories were mainly uncovered in the textbook as were all aspects of the clinical applications except treatment plans. The other three sources were used for the five aspects of clinical applications. Results were summarized and reported extensively in tables. Eleven articles were included, five websites scrutinized, and four semi-structured interviews performed. FN is based on the belief that reversible lesions in the nervous system are the cause of a multitude of conditions and that specific clusters of neurons can be positively affected by manipulative therapy, but also by many other stimuli. Diagnostic procedures include both conventional and unusual tests, with an interpretation specific to FN. Initial treatment is intense and clinical outcomes reported as positive. FN gives the impression to be a complex alternative to the old variant of the chiropractic subluxation model, in which the vertebral subluxation is replaced by "physiological lesions" of the brain, and the treatment, spinal adjustments, are complemented by various neurological stimuli. Both models purport to treat not the symptoms but the cause. We conclude there is a need for more scientific documentation on the validity of FN.

Leveraging workflow control patterns in the domain of clinical practice guidelines.

PubMed

Kaiser, Katharina; Marcos, Mar

2016-02-10

Clinical practice guidelines (CPGs) include recommendations describing appropriate care for the management of patients with a specific clinical condition. A number of representation languages have been developed to support executable CPGs, with associated authoring/editing tools. Even with tool assistance, authoring of CPG models is a labor-intensive task. We aim at facilitating the early stages of CPG modeling task. In this context, we propose to support the authoring of CPG models based on a set of suitable procedural patterns described in an implementation-independent notation that can be then semi-automatically transformed into one of the alternative executable CPG languages. We have started with the workflow control patterns which have been identified in the fields of workflow systems and business process management. We have analyzed the suitability of these patterns by means of a qualitative analysis of CPG texts. Following our analysis we have implemented a selection of workflow patterns in the Asbru and PROforma CPG languages. As implementation-independent notation for the description of patterns we have chosen BPMN 2.0. Finally, we have developed XSLT transformations to convert the BPMN 2.0 version of the patterns into the Asbru and PROforma languages. We showed that although a significant number of workflow control patterns are suitable to describe CPG procedural knowledge, not all of them are applicable in the context of CPGs due to their focus on single-patient care. Moreover, CPGs may require additional patterns not included in the set of workflow control patterns. We also showed that nearly all the CPG-suitable patterns can be conveniently implemented in the Asbru and PROforma languages. Finally, we demonstrated that individual patterns can be semi-automatically transformed from a process specification in BPMN 2.0 to executable implementations in these languages. We propose a pattern and transformation-based approach for the development of CPG models. Such an approach can form the basis of a valid framework for the authoring of CPG models. The identification of adequate patterns and the implementation of transformations to convert patterns from a process specification into different executable implementations are the first necessary steps for our approach.

Veterans with recent substance use and aggression: PTSD, substance use, and social network behaviors.

PubMed

Sexton, Minden B; Davis, Alan K; Buchholz, Katherine R; Winters, Jamie J; Rauch, Sheila A M; Yzquibell, Maegan; Bonar, Erin E; Friday, Steven; Chermack, Stephen T

2018-04-23

Violence is a salient concern among veterans, yet relationships between psychiatric comorbidity, social networks, and aggression are poorly understood. We examined associations between biopsychosocial factors (substance use, posttraumatic stress disorder [PTSD], and social network behaviors) with aggression. We recruited veterans endorsing past-year aggression and substance use (N = 180) from Department of Veterans Affairs outpatient treatment clinics. Main and interaction effects between probable PTSD, substance use, social network violence and substance use, and veteran violence were examined with negative binomial regressions-specifically, physical aggression toward a relationship partner (PA-P), physical injury of a partner (PI-P), physical aggression toward nonpartners (PA-NP), and physical injury of nonpartners (PI-NP). Alcohol use yielded consistent main effects. PTSD and social network violence demonstrated main effects for PA-NP and PI-NP. PTSD and social network violence interacted to predict PA-P such that social network violence appeared salient only in the context of PTSD. PTSD was associated with PI-P, PA-NP, and PI-NP in social network substance use models. In the PA-P model including social network substance use, veterans with PTSD reported greater PA-P in the context of greater social network substance use, whereas veterans without PTSD endorsed PA-P concurrent with greater alcohol frequency. For PI-P, PTSD interacted with alcohol to predict a greater likelihood of partner injury in the context of social network substance use. Investigated variables demonstrated unique associations within the context of specific relationships and the severity of behaviors. Overall, the findings underscore the importance of biopsychosocial models for understanding veteran violence. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Teaching for clinical reasoning - helping students make the conceptual links.

PubMed

McMillan, Wendy Jayne

2010-01-01

Dental educators complain that students struggle to apply what they have learnt theoretically in the clinical context. This paper is premised on the assumption that there is a relationship between conceptual thinking and clinical reasoning. The paper provides a theoretical framework for understanding the relationship between conceptual learning and clinical reasoning. A review of current literature is used to explain the way in which conceptual understanding influences clinical reasoning and the transfer of theoretical understandings to the clinical context. The paper argues that the connections made between concepts are what is significant about conceptual understanding. From this point of departure the paper describes teaching strategies that facilitate the kinds of learning opportunities that students need in order to develop conceptual understanding and to be able to transfer knowledge from theoretical to clinical contexts. Along with a variety of teaching strategies, the value of concept maps is discussed. The paper provides a framework for understanding the difficulties that students have in developing conceptual networks appropriate for later clinical reasoning. In explaining how students learn for clinical application, the paper provides a theoretical framework that can inform how dental educators facilitate the conceptual learning, and later clinical reasoning, of their students.

Clinical Ethics in Gabon: The Spectrum of Clinical Ethical Issues Based on Findings from In-Depth Interviews at Three Public Hospitals

PubMed Central

Sippel, Daniel; Marckmann, Georg; Ndzie Atangana, Etienne; Strech, Daniel

2015-01-01

Introduction Unlike issues in biomedical research ethics, ethical challenges arising in daily clinical care in Sub-Saharan African countries have not yet been studied in a systematic manner. However this has to be seen as a distinct entity as we argue in this paper. Our aim was to give an overview of the spectrum of clinical ethical issues and to understand what influences clinical ethics in the Sub-Saharan country of Gabon. Materials and Methods In-depth interviews with 18 health care professionals were conducted at three hospital sites in Gabon. Interview transcripts were analyzed using a grounded theory approach (open and axial coding), giving a qualitative spectrum of categories for clinical ethical issues. Validity was checked at a meeting with study participants and other health care experts in Gabon after analysis of the data. Results Twelve main categories (with 28 further-specified subcategories) for clinical ethical issues were identified and grouped under three core categories: A) micro level: “confidentiality and information”, “interpersonal, relational and behavioral issues”, “psychological strain of individuals”, and “scarce resources”; B) meso level: “structural issues of medical institutions”, “issues with private clinics”, “challenges connected to the family”, and “issues of education, training and competence”; and C) macro level: “influence of society, culture, religion and superstition”, “applicability of western medicine”, “structural issues on the political level”, and “legal issues”. Discussion Interviewees reported a broad spectrum of clinical ethical issues that go beyond challenges related to scarce financial and human resources. Specific socio-cultural, historical and educational backgrounds also played an important role. In fact these influences are central to an understanding of clinical ethics in the studied local context. Further research in the region is necessary to put our study into perspective. As many participants reported a lack of awareness of ethical issues amongst other health care professionals in daily clinical practice, we suggest that international organizations and national medical schools should consider infrastructure and tools to improve context-sensitive capacity building in clinical ethics for Sub-Saharan African countries like Gabon. PMID:26161655

Evidence-based practice within nutrition: what are the barriers for improving the evidence and how can they be dealt with?

PubMed

Laville, Martine; Segrestin, Berenice; Alligier, Maud; Ruano-Rodríguez, Cristina; Serra-Majem, Lluis; Hiesmayr, Michael; Schols, Annemie; La Vecchia, Carlo; Boirie, Yves; Rath, Ana; Neugebauer, Edmund A M; Garattini, Silvio; Bertele, Vittorio; Kubiak, Christine; Demotes-Mainard, Jacques; Jakobsen, Janus C; Djurisic, Snezana; Gluud, Christian

2017-09-11

Evidence-based clinical research poses special barriers in the field of nutrition. The present review summarises the main barriers to research in the field of nutrition that are not common to all randomised clinical trials or trials on rare diseases and highlights opportunities for improvements. Systematic academic literature searches and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. Many nutrients occur in multiple forms that differ in biological activity, and several factors can alter their bioavailability which raises barriers to their assessment. These include specific difficulties with blinding procedures, with assessments of dietary intake, and with selecting appropriate outcomes as patient-centred outcomes may occur decennia into the future. The methodologies and regulations for drug trials are, however, applicable to nutrition trials. Research on clinical nutrition should start by collecting clinical data systematically in databases and registries. Measurable patient-centred outcomes and appropriate study designs are needed. International cooperation and multistakeholder engagement are key for success.

Context-sensitive autoassociative memories as expert systems in medical diagnosis

PubMed Central

Pomi, Andrés; Olivera, Fernando

2006-01-01

Background The complexity of our contemporary medical practice has impelled the development of different decision-support aids based on artificial intelligence and neural networks. Distributed associative memories are neural network models that fit perfectly well to the vision of cognition emerging from current neurosciences. Methods We present the context-dependent autoassociative memory model. The sets of diseases and symptoms are mapped onto a pair of basis of orthogonal vectors. A matrix memory stores the associations between the signs and symptoms, and their corresponding diseases. A minimal numerical example is presented to show how to instruct the memory and how the system works. In order to provide a quick appreciation of the validity of the model and its potential clinical relevance we implemented an application with real data. A memory was trained with published data of neonates with suspected late-onset sepsis in a neonatal intensive care unit (NICU). A set of personal clinical observations was used as a test set to evaluate the capacity of the model to discriminate between septic and non-septic neonates on the basis of clinical and laboratory findings. Results We show here that matrix memory models with associations modulated by context can perform automatic medical diagnosis. The sequential availability of new information over time makes the system progress in a narrowing process that reduces the range of diagnostic possibilities. At each step the system provides a probabilistic map of the different possible diagnoses to that moment. The system can incorporate the clinical experience, building in that way a representative database of historical data that captures geo-demographical differences between patient populations. The trained model succeeds in diagnosing late-onset sepsis within the test set of infants in the NICU: sensitivity 100%; specificity 80%; percentage of true positives 91%; percentage of true negatives 100%; accuracy (true positives plus true negatives over the totality of patients) 93,3%; and Cohen's kappa index 0,84. Conclusion Context-dependent associative memories can operate as medical expert systems. The model is presented in a simple and tutorial way to encourage straightforward implementations by medical groups. An application with real data, presented as a primary evaluation of the validity and potentiality of the model in medical diagnosis, shows that the model is a highly promising alternative in the development of accuracy diagnostic tools. PMID:17121675

Evaluating the effectiveness of a multifaceted, multilevel continuous quality improvement program in primary health care: developing a realist theory of change

PubMed Central

2013-01-01

Background Variation in effectiveness of continuous quality improvement (CQI) interventions between services is commonly reported, but with little explanation of how contextual and other factors may interact to produce this variation. Therefore, there is scant information available on which policy makers can draw to inform effective implementation in different settings. In this paper, we explore how patterns of change in delivery of services may have been achieved in a diverse range of health centers participating in a wide-scale program to achieve improvements in quality of care for Indigenous Australians. Methods We elicited key informants’ interpretations of factors explaining patterns of change in delivery of guideline-scheduled services over three or more years of a wide-scale CQI project, and inductively analyzed these interpretations to propose fine-grained realist hypotheses about what works for whom and in what circumstances. Data were derived from annual clinical audits from 36 health centers operating in diverse settings, quarterly project monitoring reports, and workshops with 12 key informants who had key roles in project implementation. We abstracted potential context-mechanism-outcome configurations from the data, and based on these, identified potential program-strengthening strategies. Results Several context-specific, mechanism-based explanations for effectiveness of this CQI project were identified. These were collective valuing of clinical data for improvement purposes; collective efficacy; and organizational change towards a population health orientation. Health centers with strong central management of CQI, and those in which CQI efforts were more dependent on local health center initiative and were adapted to resonate with local priorities were both favorable contexts for collective valuing of clinical data. Where health centers had prior positive experiences of collaboration, effects appeared to be achieved at least partly through the mechanism of collective efficacy. Strong community linkages, staff ability to identify with patients, and staff having the skills and support to take broad ranging action, were favorable contexts for the mechanism of increased population health orientation. Conclusions Our study provides evidence to support strategies for program strengthening described in the literature, and extends the understanding of mechanisms through which strategies may be effective in achieving particular outcomes in different contexts. PMID:24098940

Testing Components of a Self-Management Theory in Adolescents With Type 1 Diabetes Mellitus.

PubMed

Verchota, Gwen; Sawin, Kathleen J

The role of self-management in adolescents with type 1 diabetes mellitus is not well understood. The purpose of the research was to examine the relationship of key individual and family self-management theory, context, and process variables on proximal (self-management behaviors) and distal (hemoglobin A1c and diabetes-specific health-related quality of life) outcomes in adolescents with type 1 diabetes. A correlational, cross-sectional study was conducted to identify factors contributing to outcomes in adolescents with Type 1 diabetes and examine potential relationships between context, process, and outcome variables delineated in individual and family self-management theory. Participants were 103 adolescent-parent dyads (adolescents ages 12-17) with Type 1 diabetes from a Midwest, outpatient, diabetes clinic. The dyads completed a self-report survey including instruments intended to measure context, process, and outcome variables from individual and family self-management theory. Using hierarchical multiple regression, context (depressive symptoms) and process (communication) variables explained 37% of the variance in self-management behaviors. Regimen complexity-the only significant predictor-explained 11% of the variance in hemoglobin A1c. Neither process variables nor self-management behaviors were significant. For the diabetes-specific health-related quality of life outcome, context (regimen complexity and depressive symptoms) explained 26% of the variance at step 1; an additional 9% of the variance was explained when process (self-efficacy and communication) variables were added at step 2; and 52% of the variance was explained when self-management behaviors were added at Step 3. In the final model, three variables were significant predictors: depressive symptoms, self-efficacy, and self-management behaviors. The individual and family self-management theory can serve as a cogent theory for understanding key concepts, processes, and outcomes essential to self-management in adolescents and families dealing with Type 1 diabetes mellitus.

From Usability Testing to Clinical Simulations: Bringing Context into the Design and Evaluation of Usable and Safe Health Information Technologies. Contribution of the IMIA Human Factors Engineering for Healthcare Informatics Working Group.

PubMed

Kushniruk, A; Nohr, C; Jensen, S; Borycki, E M

2013-01-01

The objective of this paper is to explore human factors approaches to understanding the use of health information technology (HIT) by extending usability engineering approaches to include analysis of the impact of clinical context through use of clinical simulations. Methods discussed are considered on a continuum from traditional laboratory-based usability testing to clinical simulations. Clinical simulations can be conducted in a simulation laboratory and they can also be conducted in real-world settings. The clinical simulation approach attempts to bring the dimension of clinical context into stronger focus. This involves testing of systems with representative users doing representative tasks, in representative settings/environments. Application of methods where realistic clinical scenarios are used to drive the study of users interacting with systems under realistic conditions and settings can lead to identification of problems and issues with systems that may not be detected using traditional usability engineering methods. In conducting such studies, careful consideration is needed in creating ecologically valid test scenarios. The evidence obtained from such evaluation can be used to improve both the usability and safety of HIT. In addition, recent work has shown that clinical simulations, in particular those conducted in-situ, can lead to considerable benefits when compared to the costs of running such studies. In order to bring context of use into the testing of HIT, clinical simulation, involving observing representative users carrying out tasks in representative settings, holds considerable promise.

Cynefin as Reference Framework to Facilitate Insight and Decision-Making in Complex Contexts of Biomedical Research.

PubMed

Kempermann, Gerd

2017-01-01

The Cynefin scheme is a concept of knowledge management, originally devised to support decision making in management, but more generally applicable to situations, in which complexity challenges the quality of insight, prediction, and decision. Despite the fact that life itself, and especially the brain and its diseases, are complex to the extent that complexity could be considered their cardinal feature, complex problems in biomedicine are often treated as if they were actually not more than the complicated sum of solvable sub-problems. Because of the emergent properties of complex contexts this is not correct. With a set of clear criteria Cynefin helps to set apart complex problems from "simple/obvious," "complicated," "chaotic," and "disordered" contexts in order to avoid misinterpreting the relevant causality structures. The distinction comes with the insight, which specific kind of knowledge is possible in each of these categories and what are the consequences for resulting decisions and actions. From student's theses over the publication and grant writing process to research politics, misinterpretation of complexity can have problematic or even dangerous consequences, especially in clinical contexts. Conceptualization of problems within a straightforward reference language like Cynefin improves clarity and stringency within projects and facilitates communication and decision-making about them.

Nutritional supplementation and artificial reproductive technique (ART) outcomes.

PubMed

Kermack, A J; Macklon, N S

2015-05-01

Approximately one in six couples suffer from subfertility, and many seek treatment with artificial reproductive technologies (ART). Despite improvements in laboratory techniques and ovarian stimulation, ongoing pregnancy rates per cycle remain at ~25%. Couples wanting to improve their chances may turn to adjuvant therapies, such as nutritional supplements. There is growing evidence that periconceptional nutritional status is a key determinant of fertility and long-term health of the offspring, and a lucrative market has developed to meet the demand based on these benefits. However, the practice of routine dietary supplementation before and during IVF treatment has not been subject to well-powered prospective randomised trials. In this article, the potential roles of specific nutritional supplements in the context of improving IVF outcomes are reviewed and an assessment is made of the evidence base supporting their clinical use in this context. Finally, current research needs in the field are outlined.

Volume curtaining: a focus+context effect for multimodal volume visualization

NASA Astrophysics Data System (ADS)

Fairfield, Adam J.; Plasencia, Jonathan; Jang, Yun; Theodore, Nicholas; Crawford, Neil R.; Frakes, David H.; Maciejewski, Ross

2014-03-01

In surgical preparation, physicians will often utilize multimodal imaging scans to capture complementary information to improve diagnosis and to drive patient-specific treatment. These imaging scans may consist of data from magnetic resonance imaging (MR), computed tomography (CT), or other various sources. The challenge in using these different modalities is that the physician must mentally map the two modalities together during the diagnosis and planning phase. Furthermore, the different imaging modalities will be generated at various resolutions as well as slightly different orientations due to patient placement during scans. In this work, we present an interactive system for multimodal data fusion, analysis and visualization. Developed with partners from neurological clinics, this work discusses initial system requirements and physician feedback at the various stages of component development. Finally, we present a novel focus+context technique for the interactive exploration of coregistered multi-modal data.

Beyond the limitations of best practices: How logic analysis helped reinterpret dual diagnosis guidelines

PubMed Central

Brousselle, Astrid; Lamothe, Lise; Mercier, Céline; Perreault, Michel

2012-01-01

The co-occurrence of mental health and substance use disorders is becoming increasingly recognized as a single problem, and professionals recognize that both should be addressed at the same time. Medical best practices recommend integrated treatment. However, criticisms have arisen, particularly concerning the difficulty of implementing integrated teams in specific health-care contexts and the appropriateness of the proposed model for certain populations. Using logic analysis, we identify the key clinical and organizational factors that contribute to successful implementation. Building on both the professional and organizational literatures on integrated services, we propose a conceptual model that makes it possible to analyze integration processes and places integrated treatment within an interpretative framework. Using this model, it becomes possible to identify key factors necessary to support service integration, and suggest new models of practice adapted to particular contexts. PMID:17689316

New insights into iron deficiency and iron deficiency anemia.

PubMed

Camaschella, Clara

2017-07-01

Recent advances in iron metabolism have stimulated new interest in iron deficiency (ID) and its anemia (IDA), common conditions worldwide. Absolute ID/IDA, i.e. the decrease of total body iron, is easily diagnosed based on decreased levels of serum ferritin and transferrin saturation. Relative lack of iron in specific organs/tissues, and IDA in the context of inflammatory disorders, are diagnosed based on arbitrary cut offs of ferritin and transferrin saturation and/or marker combination (as the soluble transferrin receptor/ferritin index) in an appropriate clinical context. Most ID patients are candidate to traditional treatment with oral iron salts, while high hepcidin levels block their absorption in inflammatory disorders. New iron preparations and new treatment modalities are available: high-dose intravenous iron compounds are becoming popular and indications to their use are increasing, although long-term side effects remain to be evaluated. Copyright © 2017 Elsevier Ltd. All rights reserved.

Biobanks for non-clinical purposes and the new law on forensic biobanks: does the Italian context protect the rights of minors?

PubMed

Tozzo, Pamela; Pegoraro, Renzo; Caenazzo, Luciana

2010-12-01

Biobanks are an important resource for medical research. Genetic research on biological material from minors can yield valuable information that can improve our understanding of genetic-environmental interactions and the genesis and development of early onset genetic disorders. The major ethical concerns relating to biobanks concern consent, privacy, confidentiality, commercialisation, and the right to know or not to know. However, research on paediatric data raises specific governance and ethical questions with regard to consent and privacy. We have considered the Italian normative context focusing on what is mentioned in each document on the ethical and legal requirements that guarantee the rights of minors. We found out that there is no systematic reflection on the ethical and policy issues arising from the participation of minors in biobank research. Moreover, we have focused on the same aspects for the new Italian Law on the National Forensic Biobank.

Issues in transferring preclinical skill learning to the clinical context.

PubMed

Chambers, D W

1987-05-01

The relationship between student performance in preclinical technique laboratory courses and in clinic is not straightforward. While American dental education in the preclinical courses is effective in teaching mastery of fundamentals to most students and identifying those who should not proceed to patient care, the prediction from technique laboratory performance of who will do well in clinic is weak. Factors accounting for this poor correlation include differences in the mix of skills required in the two contexts, failure to teach for transfer of skills to new settings, and laboratory education practices that create clinically dysfunctional habits. As a means of understanding the transfer issue, a distinction is made among task as given by the instructor, task as interpreted by the student, and task as negotiated in the interpersonal context of dental education.

The development, evolution, and modifications of ICD-10: challenges to the international comparability of morbidity data.

PubMed

Jetté, Nathalie; Quan, Hude; Hemmelgarn, Brenda; Drosler, Saskia; Maass, Christina; Moskal, Lori; Paoin, Wansa; Sundararajan, Vijaya; Gao, Song; Jakob, Robert; Ustün, Bedihran; Ghali, William A

2010-12-01

The United States is about to make a major nationwide transition from ICD-9-CM coding of hospital discharges to ICD-10-CM, a country-specific modification of the World Health Organization's ICD-10. As this transition occurs, the WHO is already in the midst of developing ICD-11. Given this context, we undertook this review to discuss: (1) the history of the International Classification of Diseases (a core information "building block" for health systems everywhere) from its introduction to the current era of ICD-11 development; (2) differences across country-specific ICD-10 clinical modifications and the challenges that these differences pose to the international comparability of morbidity data; (3) potential strategic approaches to achieving better international ICD-11 comparability. A literature review and stakeholder consultation was carried out. The various ICD-10 clinical modifications (ICD-10-AM [Australia], ICD-10-CA [Canada], ICD-10-GM [Germany], ICD-10-TM [Thailand], ICD-10-CM [United States]) were compared. These ICD-10 modifications differ in their number of codes, chapters, and subcategories. Specific conditions are present in some but not all of the modifications. ICD-11, with a similar structure to ICD-10, will function in an electronic health records environment and also provide disease descriptive characteristics (eg, causal properties, functional impact, and treatment). The threat to the comparability of international clinical morbidity is growing with the development of many country-specific ICD-10 versions. One solution to this threat is to develop a meta-database including all country-specific modifications to ensure more efficient use of people and resources, decrease omissions and errors but most importantly provide a platform for future ICD updates.

Impulsivity makes more susceptible to overeating after contextual appetitive conditioning.

PubMed

van den Akker, Karolien; Jansen, Anita; Frentz, Florentine; Havermans, Remco C

2013-11-01

Animals can learn that specific contexts are associated with important biological events such as food intake through classical conditioning. Very few studies suggest this is also possible in humans and contextual appetitive conditioning might even be a main determinant of habitual overeating in vulnerable humans. A Virtual Reality laboratory was used to test whether humans show conditioned responding (increased food desires and expectations, increased salivation and increased food intake) to a specific context after repeated pairings of this context with intake. It was also examined whether the personality trait impulsivity strengthens this contextual appetitive conditioning. Conditioned context-induced reactivity was indeed demonstrated and impulsivity predicted increased intake in only the intake-associated context. It is concluded that humans easily learn desires to eat in intake-related environments. The data also suggest that in particular more impulsive people are vulnerable for conditioned context-induced overeating. This relatively easy learning of associations between specific contexts and intake might stimulate habitual overeating and contribute to increased obesity prevalence. Copyright © 2013 Elsevier Ltd. All rights reserved.

Context-dependent control of attention capture: Evidence from proportion congruent effects.

PubMed

Crump, Matthew J C; Milliken, Bruce; Leboe-McGowan, Jason; Leboe-McGowan, Launa; Gao, Xiaoqing

2018-06-01

There are several independent demonstrations that attentional phenomena can be controlled in a context-dependent manner by cues associated with differing attentional control demands. The present set of experiments provide converging evidence that attention-capture phenomena can be modulated in a context-dependent fashion. We determined whether methods from the proportion congruent literature (listwide and item- and context-specific proportion congruent designs) that are known to modulate distractor interference effects in Stroop and flanker tasks are capable of modulating attention capture by salient feature singletons. Across experiments we found evidence that attention capture can be modulated by listwide, item-specific, and context-specific manipulations of proportion congruent. We discuss challenges associated with interpreting results from proportion congruent studies but propose that our findings converge with existing work that has demonstrated context-dependent control of attention capture. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Policy for Promotion of Women's Mental Health: Insight from Analysis of Policy on Postnatal Depression in Mexico.

PubMed

Place, Jean Marie S; Billings, Deborah L; Frongillo, Edward A; Blake, Christine E; Mann, Joshua R; deCastro, Filipa

2016-03-01

This article critically examines federal, state and facility-level policies, as well as clinical practice guidelines regarding postnatal depression in Mexico. Thirteen documents including national health plans, national action plans, federal and state laws and regulations, clinical practice guidelines, and public-sector healthcare facility policies were collected and evaluated according to whether they included a statement of intent and/or actions related to the care of women at risk for or experiencing postnatal depression. While postnatal depression is included in several policies in Mexico, it is not addressed in ways that guide actions to manage postnatal depression. Specific direction on postnatal depression in policies would bridge a gap in maternal mental healthcare given that medication, treatment, and timing of interventions is unique in the postpartum context.

Management of patients with amyotrophic lateral sclerosis.

PubMed

Pautex, Sophie; Janssens, Jean-Paul; Vuagnat, Hubert; Conne, Pierre; Zulian, Gilbert B

2005-10-15

Standard recommendations for the clinical management of patient with ALS have been edited in recent years. These documents emphasise the importance of patient's autonomy. To measure how these different recommendations can be applied in the context of a general hospital without a specific ALS clinic. Review of medical records of 21 patients with an ALS diagnosis treated by the University Hospitals Geneva who died from 1996-2002. Patients suffered from distressing symptoms during their last hospitalisation. Artificial nutrition was given to 5 patients. Six patients had non invasive ventilation (NIV). Written advance directives were only available in 2 cases. Discussions about theses issues were also conducted late in the evolution of the disease. Some discrepancies between our daily practice and the existing recommendations exist, particularly regarding the key issues of artificial nutrition and ventilatory support.

Perspectives on the Role of Patient-Centered Medical Homes in HIV Care

PubMed Central

Yujiang, Jia; Seiler, Naomi; Malcarney, Mary-Beth; Horton, Katherine; Shaikh, Irshad; Freehill, Gunther; Alexander, Carla; Akhter, Mohammad N.; Hidalgo, Julia

2014-01-01

To strengthen the quality of HIV care and achieve improved clinical outcomes, payers, providers, and policymakers should encourage the use of patient-centered medical homes (PCMHs), building on the Ryan White CARE Act Program established in the 1990s. The rationale for a PCMH with HIV-specific expertise is rooted in clinical complexity, HIV’s social context, and ongoing gaps in HIV care. Existing Ryan White HIV/AIDS Program clinicians are prime candidates to serve HIV PCMHs, and HIV-experienced community-based organizations can play an important role. Increasingly, state Medicaid programs are adopting a PCMH care model to improve access and quality to care. Stakeholders should consider several important areas for future action and research with regard to development of the HIV PCMH. PMID:24832431

Olfactory epithelium: Cells, clinical disorders, and insights from an adult stem cell niche

PubMed Central

Choi, Rhea

2018-01-01

Disorders causing a loss of the sense of smell remain a therapeutic challenge. Basic research has, however, greatly expanded our knowledge of the organization and function of the olfactory system. This review describes advances in our understanding of the cellular components of the peripheral olfactory system, specifically the olfactory epithelium in the nose. The article discusses recent findings regarding the mechanisms involved in regeneration and cellular renewal from basal stem cells in the adult olfactory epithelium, considering the strategies involved in embryonic olfactory development and insights from research on other stem cell niches. In the context of clinical conditions causing anosmia, the current view of adult olfactory neurogenesis, tissue homeostasis, and failures in these processes is considered, along with current and future treatment strategies. Level of Evidence NA PMID:29492466

Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems

PubMed Central

Elwyn, Glyn; Dehlendorf, Christine; Epstein, Ronald M.; Marrin, Katy; White, James; Frosch, Dominick L.

2014-01-01

Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient’s preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems. PMID:24821899

A systematic literature review of evidence-based clinical practice for rare diseases: what are the perceived and real barriers for improving the evidence and how can they be overcome?

PubMed

Rath, Ana; Salamon, Valérie; Peixoto, Sandra; Hivert, Virginie; Laville, Martine; Segrestin, Berenice; Neugebauer, Edmund A M; Eikermann, Michaela; Bertele, Vittorio; Garattini, Silvio; Wetterslev, Jørn; Banzi, Rita; Jakobsen, Janus C; Djurisic, Snezana; Kubiak, Christine; Demotes-Mainard, Jacques; Gluud, Christian

2017-11-22

Evidence-based clinical practice is challenging in all fields, but poses special barriers in the field of rare diseases. The present paper summarises the main barriers faced by clinical research in rare diseases, and highlights opportunities for improvement. Systematic literature searches without meta-analyses and internal European Clinical Research Infrastructure Network (ECRIN) communications during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. Barriers specific to rare diseases comprise the difficulty to recruit participants because of rarity, scattering of patients, limited knowledge on natural history of diseases, difficulties to achieve accurate diagnosis and identify patients in health information systems, and difficulties choosing clinically relevant outcomes. Evidence-based clinical practice for rare diseases should start by collecting clinical data in databases and registries; defining measurable patient-centred outcomes; and selecting appropriate study designs adapted to small study populations. Rare diseases constitute one of the most paradigmatic fields in which multi-stakeholder engagement, especially from patients, is needed for success. Clinical research infrastructures and expertise networks offer opportunities for establishing evidence-based clinical practice within rare diseases.

[Clinical practice guidelines (II): searching and critical evaluation].

PubMed

Alonso, P; Bonfill, X

2007-01-01

Clinical practice guidelines have unique characteristics of the Internet era in which they are starting to be increasingly popular. The fact that they are often elaborated by governmental agencies and are not published in conventional journals means that they may not be accessible using the usual search methods employed for other types of scientific studies and documents (clinical trials, reviews, etc.). The Internet has become an essential tool for locating clinical practice guidelines, and meta-search engines, specific databases, directories, and elaborating institutions are of special importance. The relative lack of indexing of clinical practice guides means that Medline and Embase are not as useful in this context as in searching for original studies. With the aim of evaluating the validity, reproducibility, and reliability of clinical practice guidelines, a series of European institutions designed a tool to evaluate clinical practice guidelines at the end of the 1990s. This instrument, named AGREE, aims to offer a framework for the evaluation of the quality of clinical practice guidelines. It can also be useful in the design of new clinical practice guidelines as well as in the evaluation of the validity of guidelines to be updated or adapted. The AGREE instrument has become the reference for those that use guidelines, those that elaborate them, and for healthcare providers.

Ethical Challenges and Lessons Learned During the Clinical Development of a Group A Meningococcal Conjugate Vaccine.

PubMed

Martellet, Lionel; Sow, Samba O; Diallo, Aldiouma; Hodgson, Abraham; Kampmann, Beate; Hirve, Siddhivinayak; Tapia, Milagritos; Haidara, Fadima Cheick; Ndiaye, Assane; Diarra, Bou; Ansah, Patrick Odum; Akinsola, Adebayo; Idoko, Olubukola T; Adegbola, Richard A; Bavdekar, Ashish; Juvekar, Sanjay; Viviani, Simonetta; Enwere, Godwin C; Marchetti, Elisa; Chaumont, Julie; Makadi, Marie-Francoise; Pallardy, Flore; Kulkarni, Prasad S; Preziosi, Marie-Pierre; LaForce, F Marc

2015-11-15

The group A meningococcal vaccine (PsA-TT) clinical development plan included clinical trials in India and in the West African region between 2005 and 2013. During this period, the Meningitis Vaccine Project (MVP) accumulated substantial experience in the ethical conduct of research to the highest standards. Because of the public-private nature of the sponsorship of these trials and the extensive international collaboration with partners from a diverse setting of countries, the ethical review process was complex and required strategic, timely, and attentive communication to ensure the smooth review and approval for the clinical studies. Investigators and their site teams fostered strong community relationships prior to, during, and after the studies to ensure the involvement and the ownership of the research by the participating populations. As the clinical work proceeded, investigators and sponsors responded to specific questions of informed consent, pregnancy testing, healthcare, disease prevention, and posttrial access. Key factors that led to success included (1) constant dialogue between partners to explore and answer all ethical questions; (2) alertness and preparedness for emerging ethical questions during the research and in the context of evolving international ethics standards; and (3) care to assure that approaches were acceptable in the diverse community contexts. Many of the ethical issues encountered during the PsA-TT clinical development are familiar to groups conducting field trials in different cultural settings. The successful approaches used by the MVP clinical team offer useful examples of how these problems were resolved. ISRCTN17662153 (PsA-TT-001); ISRTCN78147026 (PsA-TT-002); ISRCTN87739946 (PsA-TT-003); ISRCTN46335400 (PsA-TT-003a); ISRCTN82484612 (PsA-TT-004); CTRI/2009/091/000368 (PsA-TT-005); PACTR ATMR2010030001913177 (PsA-TT-006); PACTR201110000328305 (PsA-TT-007). © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.

Emotion and Value in the Evaluation of Medical Decision-Making Capacity: A Narrative Review of Arguments

PubMed Central

Hermann, Helena; Trachsel, Manuel; Elger, Bernice S.; Biller-Andorno, Nikola

2016-01-01

Ever since the traditional criteria for medical decision-making capacity (understanding, appreciation, reasoning, evidencing a choice) were formulated, they have been criticized for not taking sufficient account of emotions or values that seem, according to the critics and in line with clinical experiences, essential to decision-making capacity. The aim of this paper is to provide a nuanced and structured overview of the arguments provided in the literature emphasizing the importance of these factors and arguing for their inclusion in competence evaluations. Moreover, a broader reflection on the findings of the literature is provided. Specific difficulties of formulating and measuring emotional and valuational factors are discussed inviting reflection on the possibility of handling relevant factors in a more flexible, case-specific, and context-specific way rather than adhering to a rigid set of operationalized criteria. PMID:27303329

Perceived job-anxiety and general psychosomatic symptom load and perceived social support - Is there a relationship?

PubMed

Muschalla, Beate; Markova, Mariya; Linden, Michael

2010-01-01

Job-related distress has often been found to be related with low social support at work. The question is whether dimensions of social support outside work have a similar relation with job-anxiety or whether they are independent. A sample of 154 employed inpatients from a psychosomatic rehabilitation center (70% women) participated in this study. Participants completed self-rating questionnaires on perceived symptom load in the domain of work (job-anxiety) and in general life (general psychosomatic symptom load), and on perceived social support at work and outside work. Job-anxiety showed moderate correlations with the perceived level of social support through colleagues. Thereby the social support dimensions of "consolation and encouragement" and "criticism, overload, rejection" were more strongly related to job-anxiety than the dimension of "practical support". There were no significant correlations between job-anxiety and social support through household members, leisure time partners or neighbors. Social support is in a specific way important in the context of work other than concerning general mental health outside the work-context. Job-anxiety is a domain-specific clinical phenomenon and independent from perceived social support outside the workplace.

Axl as a mediator of cellular growth and survival

PubMed Central

Axelrod, Haley; Pienta, Kenneth J.

2014-01-01

The control of cellular growth and proliferation is key to the maintenance of homeostasis. Survival, proliferation, and arrest are regulated, in part, by Growth Arrest Specific 6 (Gas6) through binding to members of the TAM receptor tyrosine kinase family. Activation of the TAM receptors leads to downstream signaling through common kinases, but the exact mechanism within each cellular context varies and remains to be completely elucidated. Deregulation of the TAM family, due to its central role in mediating cellular proliferation, has been implicated in multiple diseases. Axl was cloned as the first TAM receptor in a search for genes involved in the progression of chronic to acute-phase leukemia, and has since been established as playing a critical role in the progression of cancer. The oncogenic nature of Axl is demonstrated through its activation of signaling pathways involved in proliferation, migration, inhibition of apoptosis, and therapeutic resistance. Despite its recent discovery, significant progress has been made in the development of effective clinical therapeutics targeting Axl. In order to accurately define the role of Axl in normal and diseased processes, it must be analyzed in a cell type-specific context. PMID:25344858

Developing a competency framework for academic physicians.

PubMed

Daouk-Öyry, Lina; Zaatari, Ghazi; Sahakian, Tina; Rahal Alameh, Boushra; Mansour, Nabil

2017-03-01

There is a mismatch between the requirements of the multifaceted role of academic physicians and their education. Medical institutions use faculty development initiatives to support their junior academic physicians, however, these rarely revolve around academic physician competencies. The aim of this study was to identify these academic physician competencies and develop a competency framework customized to an organizational context. The authors conducted semi-structured interviews and Critical Incident Technique with 25 academic physicians at a teaching medical center in the Middle East region inquiring about the behaviors of academic physicians in teaching, clinical, research, and administrative roles. Using content analysis, the authors identified 16 competencies: five "Supporting Competencies", common to all four roles of academic physicians, and 11 "Function-Specific Competencies", specific to the role being fulfilled. The developed framework shared similarities with frameworks reported in the literature but also had some distinctions. The framework developed represents a step towards closing the gap between the skills medical students are taught and the skills required of academic physicians. The model was customized to the context of the current organization and included a future orientation and addressed the literature calling for increasing focus on the administrative skills of academic physicians.

Endometrial fluid associated with Essure implants placed before in vitro fertilization: Considerations for patient counseling and surgical management

PubMed Central

Walsh, David J; Jones, Christopher A; Wood, Samuel H

2015-01-01

Essure (Bayer) received approval from the U.S. Food and Drugs Administration as a permanent non-hormonal contraceptive implant in November 2002. While the use of Essure in the management of hydrosalpinx prior to in vitro fertilization (IVF) remains off-label, it has been used specifically for this purpose since at least 2007. Although most published reports on Essure placement before IVF have been reassuring, clinical experience remains limited, and no randomized studies have demonstrated the safety or efficacy of Essure in this context. In fact, no published guidelines deal with patient selection or counseling regarding the Essure procedure specifically in the context of IVF. Although Essure is an irreversible birth control option, some patients request the surgical removal of the implants for various reasons. While these patients could eventually undergo hysterectomy, at present no standardized technique exists for simple Essure removal with conservation of the uterus. This article emphasizes new aspects of the Essure procedure, as we describe the first known association between the placement of Essure implants and the subsequent development of fluid within the uterine cavity, which resolved after the surgical removal of both devices. PMID:26473113

Measures of fine motor skills in people with tremor disorders: appraisal and interpretation.

PubMed

Norman, Kathleen E; Héroux, Martin E

2013-01-01

People with Parkinson's disease, essential tremor, or other movement disorders involving tremor have changes in fine motor skills that are among the hallmarks of these diseases. Numerous measurement tools have been created and other methods devised to measure such changes in fine motor skills. Measurement tools may focus on specific features - e.g., motor skills or dexterity, slowness in movement execution associated with parkinsonian bradykinesia, or magnitude of tremor. Less obviously, some tools may be better suited than others for specific goals such as detecting subtle dysfunction early in disease, revealing aspects of brain function affected by disease, or tracking changes expected from treatment or disease progression. The purpose of this review is to describe and appraise selected measurement tools of fine motor skills appropriate for people with tremor disorders. In this context, we consider the tools' content - i.e., what movement features they focus on. In addition, we consider how measurement tools of fine motor skills relate to measures of a person's disease state or a person's function. These considerations affect how one should select and interpret the results of these tools in laboratory and clinical contexts.

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process.

PubMed

Shaw, Joanne M; Price, Melanie A; Clayton, Josephine M; Grimison, Peter; Shaw, Tim; Rankin, Nicole; Butow, Phyllis N

2016-01-01

People with cancer and their families experience high levels of psychological morbidity. However, many cancer services do not routinely screen patients for anxiety and depression, and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context. A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Co-operative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point Likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the Likert scale. Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after two Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings. This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.

Community Partners' Perspectives of Community-University Partnerships that Support Service-Learning

ERIC Educational Resources Information Center

Witchger Hansen, Anne Marie

2010-01-01

Community partner voices are important to understand because they provide the contexts in which occupational therapy students meet course objectives by applying clinical reasoning theory and developing clinical reasoning skills in a natural context (Witchger-Hansen et al., 2007; Provident, et al., 2011). To sustain these community-university…

Understanding osteoporosis and fractures: an introduction to the use of qualitative research.

PubMed

Hoang-Kim, A; Schemitsch, E; Sale, J E M; Beaton, D; Warmington, K; Kulkarni, A V; Reeves, S

2014-02-01

Qualitative research has been recognized in recent years as a field of inquiry used to understand people's beliefs, attitudes, behaviors, culture or lifestyle. While quantitative results are challenging to apply in everyday practice, the qualitative paradigm can be useful to fill in a research context that is poorly understood or ill-defined. It can provide an in-depth study of interactions, a way to incorporate context, and a means to hear the voices of participants. Understanding experiences, motivation, and beliefs can have a profound effect on the interpretation of quantitative research and generating hypotheses. In this paper, we will review different qualitative approaches that healthcare providers and researchers may find useful to implement in future study designs, specifically in the context of osteoporosis and fracture. We will provide insight into the qualitative paradigm gained from the osteoporosis literature on fractures using examples from the database Scopus. Five prominent qualitative techniques (narratives, phenomenology, grounded theory, ethnography, and case study) can be used to generate meanings of the social and clinical world. We have highlighted how these strategies are implemented in qualitative research on osteoporosis and fractures and are anchored to specific methodological practices. We focus on studies that explore patient psychosocial experiences of diagnosis and treatment, cultural boundaries, and interprofessional communication. After reviewing the research, we believe that action research, that is not frequently used, could also effectively be used by many professions to improve programs and policies affecting those dealing with osteoporosis issues.

How, why, and when may atrial defibrillation find a specific role in implantable devices? A clinical viewpoint.

PubMed

Boriani, Giuseppe; Diemberger, Igor; Biffi, Mauro; Martignani, Cristian; Ziacchi, Matteo; Bertini, Matteo; Valzania, Cinzia; Bronzetti, Gabriele; Rapezzi, Claudio; Branzi, Angelo

2007-03-01

This viewpoint article discusses the potential for incorporation of atrial defibrillation capabilities in modern multi-chamber devices. In the late 1990s, the possibility of using shock-only therapy to treat selected patients with recurrent atrial fibrillation (AF) was explored in the context of the stand-alone atrial defibrillator. The failure of this strategy can be attributed to the technical limitations of the stand-alone device, low tolerance of atrial shocks, difficulties in patient selection, a lack of predictive knowledge about the evolution of AF, and, last but not least, commercial considerations. An open question is how atrial defibrillation capability may now assume a specific new role in devices implanted for sudden death prevention or cardiac resynchronization. For patients who already have indications for implantable devices, device-based atrial defibrillation appears attractive as a "backup" option for managing AF when preventive pharmacological/electrical measures fail. This and several other personalized hybrid therapeutic approaches await exploration, though assessment of their efficacy is methodologically challenging. Achievement of acceptance by patients is an essential premise for any updated atrial defibrillation strategy. Strategies that are being investigated to improve patient tolerance include waveform shaping, pharmacologic modulation of pain, and patient-activated defibrillation (patients might also perceive the problem of discomfort somewhat differently in the context of a backup therapy). The economic impact of implementing atrial defibrillation features in available devices is progressively decreasing, and financial feasibility need not be a major issue. Future studies should examine clinically relevant outcomes and not be limited (as occurred with stand-alone defibrillators) to technical or other soft endpoints.

On the Analysis of Case-Control Studies in Cluster-correlated Data Settings.

PubMed

Haneuse, Sebastien; Rivera-Rodriguez, Claudia

2018-01-01

In resource-limited settings, long-term evaluation of national antiretroviral treatment (ART) programs often relies on aggregated data, the analysis of which may be subject to ecological bias. As researchers and policy makers consider evaluating individual-level outcomes such as treatment adherence or mortality, the well-known case-control design is appealing in that it provides efficiency gains over random sampling. In the context that motivates this article, valid estimation and inference requires acknowledging any clustering, although, to our knowledge, no statistical methods have been published for the analysis of case-control data for which the underlying population exhibits clustering. Furthermore, in the specific context of an ongoing collaboration in Malawi, rather than performing case-control sampling across all clinics, case-control sampling within clinics has been suggested as a more practical strategy. To our knowledge, although similar outcome-dependent sampling schemes have been described in the literature, a case-control design specific to correlated data settings is new. In this article, we describe this design, discuss balanced versus unbalanced sampling techniques, and provide a general approach to analyzing case-control studies in cluster-correlated settings based on inverse probability-weighted generalized estimating equations. Inference is based on a robust sandwich estimator with correlation parameters estimated to ensure appropriate accounting of the outcome-dependent sampling scheme. We conduct comprehensive simulations, based in part on real data on a sample of N = 78,155 program registrants in Malawi between 2005 and 2007, to evaluate small-sample operating characteristics and potential trade-offs associated with standard case-control sampling or when case-control sampling is performed within clusters.

[Pharmacogenomics of the first-line treatment for gastric cancer: advances in the identification of genomic biomarkers for clinical response to chemotherapy].

PubMed

Castro-Rojas, Carlos; Ortiz-Lópezj, Rocío; Rojas-Martínez, Augusto

2014-06-01

Gastric cancer (GC) is often diagnosed at later stages due to the lack of specificity of symptoms associated with the neoplasm, causing high mortality rates worldwide. The first line of adjuvant and neoadjuvant treatment includes cytotoxic fluoropyrimidines and platin-containing compounds which cause the formation of DNA adducts. The clinical outcome with these antineoplastic agents depends mainly on tumor sensitivity, which is conditioned by the expression level of the drug targets and the DNA-repair system enzymes. In addition, some germ line polymorphisms, in genes linked to drug metabolism and response to chemotherapy, have been associated with poor responses and the development of adverse effects, even with fatal outcomes in GC patients. The identification of genomic biomarkers, such as individual gene polymorphisms or differential expression patterns of specific genes, in a patient-by-patient context with potential clinical application is the main focus of current pharmacogenomic research, which aims at developing a rational and personalized therapy (i.e., a therapy that ensures maximum efficacy with no predictable side effects). However, because of the future application of genomic technologies in the clinical setting, it is necessary to establish the prognostic value of these genomic biomarkers with genotype-phenotype association studies and to evaluate their prevalence in the population under treatment. These issues are important for their cost-effectiveness evaluation, which determines the feasibility of using these medical genomic research products for GC treatment in the clinical setting.

Identifying and applying psychological theory to setting and achieving rehabilitation goals.

PubMed

Scobbie, Lesley; Wyke, Sally; Dixon, Diane

2009-04-01

Goal setting is considered to be a fundamental part of rehabilitation; however, theories of behaviour change relevant to goal-setting practice have not been comprehensively reviewed. (i) To identify and discuss specific theories of behaviour change relevant to goal-setting practice in the rehabilitation setting. (ii) To identify 'candidate' theories that that offer most potential to inform clinical practice. The rehabilitation and self-management literature was systematically searched to identify review papers or empirical studies that proposed a specific theory of behaviour change relevant to setting and/or achieving goals in a clinical context. Data from included papers were extracted under the headings of: key constructs, clinical application and empirical support. Twenty-four papers were included in the review which proposed a total of five theories: (i) social cognitive theory, (ii) goal setting theory, (iii) health action process approach, (iv) proactive coping theory, and (v) the self-regulatory model of illness behaviour. The first three of these theories demonstrated most potential to inform clinical practice, on the basis of their capacity to inform interventions that resulted in improved patient outcomes. Social cognitive theory, goal setting theory and the health action process approach are theories of behaviour change that can inform clinicians in the process of setting and achieving goals in the rehabilitation setting. Overlapping constructs within these theories have been identified, and can be applied in clinical practice through the development and evaluation of a goal-setting practice framework.

Using a Context-aware Medical Application to Address Information Needs for Extubation Decisions

PubMed Central

Zhu, Xinxin; Lord, William

2005-01-01

Information overload has been one of the causes of preventable medical errors [1] and escalating costs [2]. A context-aware application with embedded clinical knowledge is proposed to provide practitioners with the appropriate amount of information and content. We developed a prototype of a context-aware medical application to address clinicians’ information needs that arise in a data-intensive unit, the Cardio-Thoracic Intensive Care Unit (CTICU). A major clinical decision supported by the prototype, the extubation decision, is illustrated. PMID:16779455

Designing authentic assessment: strategies for nurse educators.

PubMed

Poindexter, Kathleen; Hagler, Debra; Lindell, Deborah

2015-01-01

Increased emphasis on health care safety requires renewed attention to teaching and learning processes for future health care professionals. When presented with problems situated in a clinical context, learners have rich opportunities to demonstrate integration of concepts. Authentic assessment is an approach to evaluation of learning through which students can demonstrate acquired knowledge, skills, and attitudes in the context of real-world or realistic nursing practice activities. This article describes features, approaches, and examples of authentic assessment processes in the context of classroom, clinical, and online nursing education.

Photosensitizer fluorescence and singlet oxygen luminescence as dosimetric predictors of topical 5-aminolevulinic acid photodynamic therapy induced clinical erythema.

PubMed

Mallidi, Srivalleesha; Anbil, Sriram; Lee, Seonkyung; Manstein, Dieter; Elrington, Stefan; Kositratna, Garuna; Schoenfeld, David; Pogue, Brian; Davis, Steven J; Hasan, Tayyaba

2014-02-01

The need for patient-specific photodynamic therapy (PDT) in dermatologic and oncologic applications has triggered several studies that explore the utility of surrogate parameters as predictive reporters of treatment outcome. Although photosensitizer (PS) fluorescence, a widely used parameter, can be viewed as emission from several fluorescent states of the PS (e.g., minimally aggregated and monomeric), we suggest that singlet oxygen luminescence (SOL) indicates only the active PS component responsible for the PDT. Here, the ability of discrete PS fluorescence-based metrics (absolute and percent PS photobleaching and PS re-accumulation post-PDT) to predict the clinical phototoxic response (erythema) resulting from 5-aminolevulinic acid PDT was compared with discrete SOL (DSOL)-based metrics (DSOL counts pre-PDT and change in DSOL counts pre/post-PDT) in healthy human skin. Receiver operating characteristic curve (ROC) analyses demonstrated that absolute fluorescence photobleaching metric (AFPM) exhibited the highest area under the curve (AUC) of all tested parameters, including DSOL based metrics. The combination of dose-metrics did not yield better AUC than AFPM alone. Although sophisticated real-time SOL measurements may improve the clinical utility of SOL-based dosimetry, discrete PS fluorescence-based metrics are easy to implement, and our results suggest that AFPM may sufficiently predict the PDT outcomes and identify treatment nonresponders with high specificity in clinical contexts.

The relation between societal factors and different forms of prejudice: A cross-national approach on target-specific and generalized prejudice.

PubMed

Meeusen, Cecil; Kern, Anna

2016-01-01

The goal of this paper was to investigate the generalizability of prejudice across contexts by analyzing associations between different types of prejudice in a cross-national perspective and by investigating the relation between country-specific contextual factors and target-specific prejudices. Relying on the European Social Survey (2008), results indicated that prejudices were indeed positively associated, confirming the existence of a generalized prejudice component. Next to substantial cross-national differences in associational strength, also within country variance in target-specific associations was observed. This suggested that the motivations for prejudice largely vary according to the intergroup context. Two aspects of the intergroup context - economic conditions and cultural values - showed to be related to generalized and target-specific components of prejudice. Future research on prejudice and context should take an integrative approach that considers both the idea of generalized and specific prejudice simultaneously. Copyright © 2015 Elsevier Inc. All rights reserved.

Attention toward contexts modulates context-specificity of behavior in human predictive learning: Evidence from the n-back task.

PubMed

Uengoer, Metin; Lucke, Sara; Lachnit, Harald

2018-02-20

According to the attentional theory of context processing (ATCP), learning becomes context specific when acquired under conditions that promote attention toward contextual stimuli regardless of whether attention deployment is guided by learning experience or by other factors unrelated to learning. In one experiment with humans, we investigated whether performance in a predictive learning task can be brought under contextual control by means of a secondary task that was unrelated to predictive learning, but supposed to modulate participants' attention toward contexts. Initially, participants acquired cue-outcome relationships presented in contexts that were each composed of two elements from two dimensions. Acquisition training in the predictive learning task was combined with a one-back task that required participants to match across consecutive trials context elements belonging to one of the two dimensions. During a subsequent test, we observed that acquisition behavior in the predictive learning task was disrupted by changing the acquisition context along the dimension that was relevant for the one-back task, while there was no evidence for context specificity of predictive learning when the acquisition context was changed along the dimension that was irrelevant for the one-back task. Our results support the generality of the principles advocated by ATCP.

Sport specificity of mental disorders: the issue of sport psychiatry.

PubMed

Bär, Karl-Jürgen; Markser, Valentin Z

2013-11-01

The prevalence of psychiatric conditions among elite athletes is still under debate. More and more evidence has accumulated that high-performance athletes are not protected from mental disorders as previously thought. The authors discuss the issue of the sport specificity of selected mental diseases in elite athletes. Specific aspects of eating disorders, exercise addiction, chronic traumatic encephalopathy and mood disorders in the context of overtraining syndrome are examined. In particular, the interrelationship between life and work characteristics unique to elite athletes and the development of mental disorders are reviewed. Differences of clinical presentation and some therapeutic consequences are discussed. The authors suggest that the physical and mental strains endured by elite athletes might influence the onset and severity of their psychiatric disorder. Beside the existing research strategies dealing with the amount of exercise, its intensity and lack of recreation experienced by athletes, further research on psycho-social factors is needed to better understand the sport-specific aetiology of mental disorders in high-performance athletes.

Context-specific and/or context-free challenges and opportunities in writing scholarly reviews in health care management: a conceptual note.

PubMed

Blair, John D

2011-01-01

Challenges and opportunities arise from the significantly different perspectives of context-specific versus context-free researchers and the literatures they contribute to. Reviews of one type or the other or both types of literatures may provide different understandings of the state of the art in a particular area of health care management. Suggestions for writing quality reviews are also included along with suggested topics for future reviews.

Context-aware brain-computer interfaces: exploring the information space of user, technical system and environment

NASA Astrophysics Data System (ADS)

Zander, T. O.; Jatzev, S.

2012-02-01

Brain-computer interface (BCI) systems are usually applied in highly controlled environments such as research laboratories or clinical setups. However, many BCI-based applications are implemented in more complex environments. For example, patients might want to use a BCI system at home, and users without disabilities could benefit from BCI systems in special working environments. In these contexts, it might be more difficult to reliably infer information about brain activity, because many intervening factors add up and disturb the BCI feature space. One solution for this problem would be adding context awareness to the system. We propose to augment the available information space with additional channels carrying information about the user state, the environment and the technical system. In particular, passive BCI systems seem to be capable of adding highly relevant context information—otherwise covert aspects of user state. In this paper, we present a theoretical framework based on general human-machine system research for adding context awareness to a BCI system. Building on that, we present results from a study on a passive BCI, which allows access to the covert aspect of user state related to the perceived loss of control. This study is a proof of concept and demonstrates that context awareness could beneficially be implemented in and combined with a BCI system or a general human-machine system. The EEG data from this experiment are available for public download at www.phypa.org. Parts of this work have already been presented in non-journal publications. This will be indicated specifically by appropriate references in the text.

Cytogenetic prognostication within medulloblastoma subgroups.

PubMed

Shih, David J H; Northcott, Paul A; Remke, Marc; Korshunov, Andrey; Ramaswamy, Vijay; Kool, Marcel; Luu, Betty; Yao, Yuan; Wang, Xin; Dubuc, Adrian M; Garzia, Livia; Peacock, John; Mack, Stephen C; Wu, Xiaochong; Rolider, Adi; Morrissy, A Sorana; Cavalli, Florence M G; Jones, David T W; Zitterbart, Karel; Faria, Claudia C; Schüller, Ulrich; Kren, Leos; Kumabe, Toshihiro; Tominaga, Teiji; Shin Ra, Young; Garami, Miklós; Hauser, Peter; Chan, Jennifer A; Robinson, Shenandoah; Bognár, László; Klekner, Almos; Saad, Ali G; Liau, Linda M; Albrecht, Steffen; Fontebasso, Adam; Cinalli, Giuseppe; De Antonellis, Pasqualino; Zollo, Massimo; Cooper, Michael K; Thompson, Reid C; Bailey, Simon; Lindsey, Janet C; Di Rocco, Concezio; Massimi, Luca; Michiels, Erna M C; Scherer, Stephen W; Phillips, Joanna J; Gupta, Nalin; Fan, Xing; Muraszko, Karin M; Vibhakar, Rajeev; Eberhart, Charles G; Fouladi, Maryam; Lach, Boleslaw; Jung, Shin; Wechsler-Reya, Robert J; Fèvre-Montange, Michelle; Jouvet, Anne; Jabado, Nada; Pollack, Ian F; Weiss, William A; Lee, Ji-Yeoun; Cho, Byung-Kyu; Kim, Seung-Ki; Wang, Kyu-Chang; Leonard, Jeffrey R; Rubin, Joshua B; de Torres, Carmen; Lavarino, Cinzia; Mora, Jaume; Cho, Yoon-Jae; Tabori, Uri; Olson, James M; Gajjar, Amar; Packer, Roger J; Rutkowski, Stefan; Pomeroy, Scott L; French, Pim J; Kloosterhof, Nanne K; Kros, Johan M; Van Meir, Erwin G; Clifford, Steven C; Bourdeaut, Franck; Delattre, Olivier; Doz, François F; Hawkins, Cynthia E; Malkin, David; Grajkowska, Wieslawa A; Perek-Polnik, Marta; Bouffet, Eric; Rutka, James T; Pfister, Stefan M; Taylor, Michael D

2014-03-20

Medulloblastoma comprises four distinct molecular subgroups: WNT, SHH, Group 3, and Group 4. Current medulloblastoma protocols stratify patients based on clinical features: patient age, metastatic stage, extent of resection, and histologic variant. Stark prognostic and genetic differences among the four subgroups suggest that subgroup-specific molecular biomarkers could improve patient prognostication. Molecular biomarkers were identified from a discovery set of 673 medulloblastomas from 43 cities around the world. Combined risk stratification models were designed based on clinical and cytogenetic biomarkers identified by multivariable Cox proportional hazards analyses. Identified biomarkers were tested using fluorescent in situ hybridization (FISH) on a nonoverlapping medulloblastoma tissue microarray (n = 453), with subsequent validation of the risk stratification models. Subgroup information improves the predictive accuracy of a multivariable survival model compared with clinical biomarkers alone. Most previously published cytogenetic biomarkers are only prognostic within a single medulloblastoma subgroup. Profiling six FISH biomarkers (GLI2, MYC, chromosome 11 [chr11], chr14, 17p, and 17q) on formalin-fixed paraffin-embedded tissues, we can reliably and reproducibly identify very low-risk and very high-risk patients within SHH, Group 3, and Group 4 medulloblastomas. Combining subgroup and cytogenetic biomarkers with established clinical biomarkers substantially improves patient prognostication, even in the context of heterogeneous clinical therapies. The prognostic significance of most molecular biomarkers is restricted to a specific subgroup. We have identified a small panel of cytogenetic biomarkers that reliably identifies very high-risk and very low-risk groups of patients, making it an excellent tool for selecting patients for therapy intensification and therapy de-escalation in future clinical trials.

Cytogenetic Prognostication Within Medulloblastoma Subgroups

PubMed Central

Shih, David J.H.; Northcott, Paul A.; Remke, Marc; Korshunov, Andrey; Ramaswamy, Vijay; Kool, Marcel; Luu, Betty; Yao, Yuan; Wang, Xin; Dubuc, Adrian M.; Garzia, Livia; Peacock, John; Mack, Stephen C.; Wu, Xiaochong; Rolider, Adi; Morrissy, A. Sorana; Cavalli, Florence M.G.; Jones, David T.W.; Zitterbart, Karel; Faria, Claudia C.; Schüller, Ulrich; Kren, Leos; Kumabe, Toshihiro; Tominaga, Teiji; Shin Ra, Young; Garami, Miklós; Hauser, Peter; Chan, Jennifer A.; Robinson, Shenandoah; Bognár, László; Klekner, Almos; Saad, Ali G.; Liau, Linda M.; Albrecht, Steffen; Fontebasso, Adam; Cinalli, Giuseppe; De Antonellis, Pasqualino; Zollo, Massimo; Cooper, Michael K.; Thompson, Reid C.; Bailey, Simon; Lindsey, Janet C.; Di Rocco, Concezio; Massimi, Luca; Michiels, Erna M.C.; Scherer, Stephen W.; Phillips, Joanna J.; Gupta, Nalin; Fan, Xing; Muraszko, Karin M.; Vibhakar, Rajeev; Eberhart, Charles G.; Fouladi, Maryam; Lach, Boleslaw; Jung, Shin; Wechsler-Reya, Robert J.; Fèvre-Montange, Michelle; Jouvet, Anne; Jabado, Nada; Pollack, Ian F.; Weiss, William A.; Lee, Ji-Yeoun; Cho, Byung-Kyu; Kim, Seung-Ki; Wang, Kyu-Chang; Leonard, Jeffrey R.; Rubin, Joshua B.; de Torres, Carmen; Lavarino, Cinzia; Mora, Jaume; Cho, Yoon-Jae; Tabori, Uri; Olson, James M.; Gajjar, Amar; Packer, Roger J.; Rutkowski, Stefan; Pomeroy, Scott L.; French, Pim J.; Kloosterhof, Nanne K.; Kros, Johan M.; Van Meir, Erwin G.; Clifford, Steven C.; Bourdeaut, Franck; Delattre, Olivier; Doz, François F.; Hawkins, Cynthia E.; Malkin, David; Grajkowska, Wieslawa A.; Perek-Polnik, Marta; Bouffet, Eric; Rutka, James T.; Pfister, Stefan M.; Taylor, Michael D.

2014-01-01

Purpose Medulloblastoma comprises four distinct molecular subgroups: WNT, SHH, Group 3, and Group 4. Current medulloblastoma protocols stratify patients based on clinical features: patient age, metastatic stage, extent of resection, and histologic variant. Stark prognostic and genetic differences among the four subgroups suggest that subgroup-specific molecular biomarkers could improve patient prognostication. Patients and Methods Molecular biomarkers were identified from a discovery set of 673 medulloblastomas from 43 cities around the world. Combined risk stratification models were designed based on clinical and cytogenetic biomarkers identified by multivariable Cox proportional hazards analyses. Identified biomarkers were tested using fluorescent in situ hybridization (FISH) on a nonoverlapping medulloblastoma tissue microarray (n = 453), with subsequent validation of the risk stratification models. Results Subgroup information improves the predictive accuracy of a multivariable survival model compared with clinical biomarkers alone. Most previously published cytogenetic biomarkers are only prognostic within a single medulloblastoma subgroup. Profiling six FISH biomarkers (GLI2, MYC, chromosome 11 [chr11], chr14, 17p, and 17q) on formalin-fixed paraffin-embedded tissues, we can reliably and reproducibly identify very low-risk and very high-risk patients within SHH, Group 3, and Group 4 medulloblastomas. Conclusion Combining subgroup and cytogenetic biomarkers with established clinical biomarkers substantially improves patient prognostication, even in the context of heterogeneous clinical therapies. The prognostic significance of most molecular biomarkers is restricted to a specific subgroup. We have identified a small panel of cytogenetic biomarkers that reliably identifies very high-risk and very low-risk groups of patients, making it an excellent tool for selecting patients for therapy intensification and therapy de-escalation in future clinical trials. PMID:24493713

Specific barriers to the conduct of randomised clinical trials on medical devices.

PubMed

Neugebauer, Edmund A M; Rath, Ana; Antoine, Sunya-Lee; Eikermann, Michaela; Seidel, Doerthe; Koenen, Carsten; Jacobs, Esther; Pieper, Dawid; Laville, Martine; Pitel, Séverine; Martinho, Cecilia; Djurisic, Snezana; Demotes-Mainard, Jacques; Kubiak, Christine; Bertele, Vittorio; Jakobsen, Janus C; Garattini, Silvio; Gluud, Christian

2017-09-13

Medical devices play an important role in the diagnosis, prevention, treatment and care of diseases. However, compared to pharmaceuticals, there is no rigorous formal regulation for demonstration of benefits and exclusion of harms to patients. The medical device industry argues that the classical evidence hierarchy cannot be applied for medical devices, as randomised clinical trials are impossible to perform. This article aims to identify the barriers for randomised clinical trials on medical devices. Systematic literature searches without meta-analysis and internal European Clinical Research Infrastructure Network (ECRIN) communications taking place during face-to-face meetings and telephone conferences from 2013 to 2017 within the context of the ECRIN Integrating Activity (ECRIN-IA) project. In addition to the barriers that exist for all trials, we identified three major barriers for randomised clinical trials on medical devices, namely: (1) randomisation, including timing of assessment, acceptability, blinding, choice of the comparator group and considerations on the learning curve; (2) difficulties in determining appropriate outcomes; and (3) the lack of scientific advice, regulations and transparency. The present review offers potential solutions to break down the barriers identified, and argues for applying the randomised clinical trial design when assessing the benefits and harms of medical devices.

Fundamentals of Clinical Outcomes Assessment for Spinal Disorders: Clinical Outcome Instruments and Applications

PubMed Central

Vavken, Patrick; Ganal-Antonio, Anne Kathleen B.; Quidde, Julia; Shen, Francis H.; Chapman, Jens R.; Samartzis, Dino

2015-01-01

Study Design A broad narrative review. Objectives Outcome assessment in spinal disorders is imperative to help monitor the safety and efficacy of the treatment in an effort to change the clinical practice and improve patient outcomes. The following article, part two of a two-part series, discusses the various outcome tools and instruments utilized to address spinal disorders and their management. Methods A thorough review of the peer-reviewed literature was performed, irrespective of language, addressing outcome research, instruments and tools, and applications. Results Numerous articles addressing the development and implementation of health-related quality-of-life, neck and low back pain, overall pain, spinal deformity, and other condition-specific outcome instruments have been reported. Their applications in the context of the clinical trial studies, the economic analyses, and overall evidence-based orthopedics have been noted. Additional issues regarding the problems and potential sources of bias utilizing outcomes scales and the concept of minimally clinically important difference were discussed. Conclusion Continuing research needs to assess the outcome instruments and tools used in the clinical outcome assessment for spinal disorders. Understanding the fundamental principles in spinal outcome assessment may also advance the field of “personalized spine care.” PMID:26225283

A dictionary server for supplying context sensitive medical knowledge.

PubMed

Ruan, W; Bürkle, T; Dudeck, J

2000-01-01

The Giessen Data Dictionary Server (GDDS), developed at Giessen University Hospital, integrates clinical systems with on-line, context sensitive medical knowledge to help with making medical decisions. By "context" we mean the clinical information that is being presented at the moment the information need is occurring. The dictionary server makes use of a semantic network supported by a medical data dictionary to link terms from clinical applications to their proper information sources. It has been designed to analyze the network structure itself instead of knowing the layout of the semantic net in advance. This enables us to map appropriate information sources to various clinical applications, such as nursing documentation, drug prescription and cancer follow up systems. This paper describes the function of the dictionary server and shows how the knowledge stored in the semantic network is used in the dictionary service.

Context factors in general practitioner-patient encounters and their impact on assessing communication skills--an exploratory study.

PubMed

Essers, Geurt; Kramer, Anneke; Andriesse, Boukje; van Weel, Chris; van der Vleuten, Cees; van Dulmen, Sandra

2013-05-22

Assessment of medical communication performance usually focuses on rating generically applicable, well-defined communication skills. However, in daily practice, communication is determined by (specific) context factors, such as acquaintance with the patient, or the presented problem. Merely valuing the presence of generic skills may not do justice to the doctor's proficiency.Our aim was to perform an exploratory study on how assessment of general practitioner (GP) communication performance changes if context factors are explicitly taken into account. We used a mixed method design to explore how ratings would change. A random sample of 40 everyday GP consultations was used to see if previously identified context factors could be observed again. The sample was rated twice using a widely used assessment instrument (the MAAS-Global), first in the standard way and secondly after context factors were explicitly taken into account, by using a context-specific rating protocol to assess communication performance in the workplace. In between first and second rating, the presence of context factors was established. Item score differences were calculated using paired sample t-tests. In 38 out of 40 consultations, context factors prompted application of the context-specific rating protocol. Mean overall score on the 7-point MAAS-Global scale increased from 2.98 in standard to 3.66 in the context-specific rating (p<0.00); the effect size for the total mean score was 0.84. In earlier research the minimum standard score for adequate communication was set at 3.17. Applying the protocol, the mean overall score rose above the level set in an earlier study for the MAAS-Global scores to represent 'adequate GP communication behaviour'. Our findings indicate that incorporating context factors in communication assessment thus makes a meaningful difference and shows that context factors should be considered as 'signal' instead of 'noise' in GP communication assessment. Explicating context factors leads to a more deliberate and transparent rating of GP communication performance.

The Role of Oncology Nurses in Discussing Clinical Trials.

PubMed

Flocke, Susan A; Antognoli, Elizabeth; Daly, Barbara J; Jackson, Brigid; Fulton, Sarah E; Liu, Tasnuva M; Surdam, Jessica; Manne, Sharon; Meropol, Neal J

2017-09-01

To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
. A qualitative study designed to elicit narratives from oncology nurses. 
. Community- and academic-based oncology clinics throughout the United States.
. 33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
. In-depth interviews were conducted and analyzed using a 
immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
. Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
. These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
. Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Exploring Prospective Teachers' Reflections in the Context of Conducting Clinical Interviews

ERIC Educational Resources Information Center

Taylan, Rukiye Didem

2018-01-01

This study investigated prospective mathematics teachers' reflections on the experience of designing and conducting one-to-one clinical interviews with middle school students in the context of an elective course on use of video in teacher learning. Prospective teachers were asked to write about weaknesses and strengths in student understanding as…

The role of information and communication technology in the transformation of the healthcare business model: a case study of Slovenia.

PubMed

Stanimirovic, Dalibor; Vintar, Mirko

The Slovenian healthcare business model (BM) has largely failed to integrate information and communication technologies (ICT) into its operational context, instead maintaining its rigid structure and traditional 'way of doing business'wo managers of public clinics). Findings present a roadmap for the redefinition of BM elements and the transformation of the Slovenian healthcare BM. It includes the specific reconfiguration of BM actors and their interactions, and the application of advanced ICT solutions, which could facilitate more effective utilisation of healthcare resources and promote an improved delivery of healthcare services and products. The presented development approach and derived conceptual solution could be transferable to other countries with similar socio-economic characteristics and comparable healthcare systems, subject to certain adjustments and inclusion of national specifics.

Advances in targeted genome editing.

PubMed

Perez-Pinera, Pablo; Ousterout, David G; Gersbach, Charles A

2012-08-01

New technologies have recently emerged that enable targeted editing of genomes in diverse systems. This includes precise manipulation of gene sequences in their natural chromosomal context and addition of transgenes to specific genomic loci. This progress has been facilitated by advances in engineering targeted nucleases with programmable, site-specific DNA-binding domains, including zinc finger proteins and transcription activator-like effectors (TALEs). Recent improvements have enhanced nuclease performance, accelerated nuclease assembly, and lowered the cost of genome editing. These advances are driving new approaches to many areas of biotechnology, including biopharmaceutical production, agriculture, creation of transgenic organisms and cell lines, and studies of genome structure, regulation, and function. Genome editing is also being investigated in preclinical and clinical gene therapies for many diseases. Copyright © 2012 Elsevier Ltd. All rights reserved.

Working appreciatively to improve services for children and families.

PubMed

Onyett, Steve

2009-10-01

Service improvement approaches are described that specifically focus on appreciating the positive that individuals bring to contexts related to children and family services. This includes application of Solution-Focused approaches, Appreciative Inquiry and other approaches that promote a positive emotional climate and focus on what works. Their conceptual foundations are explored and particularly their value in supporting working well with complex adaptive systems. Specific applications described include leadership and management practice, work in school settings, engaging clinicians in healthcare improvement, establishing clinical networks, work with homeless youth, child protection and approaches to drawing out best practice and community development. The theme that unites is a focus on developing effective relationships at all levels and a pragmatic focus on what works so that we can find opportunities to do more of it.

Maternal risk factors in fetal alcohol syndrome: provocative and permissive influences.

PubMed

Abel, E L; Hannigan, J H

1995-01-01

We present an hypothesis integrating epidemiological, clinical case, and basic biomedical research to explain why only relatively few women who drink alcohol during pregnancy give birth to children with alcohol-related birth defects (ARBDs), in particular, Fetal Alcohol Syndrome (FAS). We argue that specific sociobehavioral risk factors, e.g., low socioeconomic status, are permissive for FAS in that they provide the context for increased vulnerability. We illustrate how these permissive factors are related to biological factors, e.g., decreased antioxidant status, which in conjunction with alcohol, provoke FAS/ARBDs in vulnerable fetuses. We propose an integrative heuristic model hypothesizing that these permissive and provocative factors increase the likelihood of FAS/ARBDs because they potentiate two related mechanisms of alcohol-induced teratogenesis, specifically, maternal/fetal hypoxia and free radical formation.

Development and Validation of a Protein Based Signature for the Detection of Ovarian Cancer

PubMed Central

Kim, Kyongjin; Visintin, Irene; Alvero, Ayesha B.; Mor, Gil

2009-01-01

In order to overcome the significant mortality associated with ovarian cancer, a highly sensitive and specific screening test is urgently needed. CA125 is used to monitor response to chemotherapy, detect recurrence and detect late stage ovarian cancer. However, CA-125 alone or in combination with ultrasonography has not been adequate for early detection of ovarian cancer. Here we discuss our recent report of a novel multiplex assay that uses a panel of six serum biomarkers:Leptin, Prolactin, Osteopontin, Insulin-Like Growth Factor II, Macrophage Inhibitory Factor and CA-125. The combination of these six proteins yielded 95.3 % sensitivity and 99.4% specificity. The application of this test in the clinical context and the most appropriate population which could benefit of the test is discussed. PMID:19389550

Context and contingency in the history of post World War II nursing scholarship in the United States.

PubMed

Fairman, Julie

2008-01-01

To examine the context for the development of nursing scholarship post World War II. Historiographical analysis of the social, political, and cultural context of nursing scholarship in the postwar period, with an understanding of how this context shaped nursing scholarship. The development of nursing scholarship was influenced by three contextual strands: Nurses' use of experiential clinical knowledge to situate practice questions in the changing clinical care milieu of the 1950s to the 1970s; The development of an intellectual genealogy through new educational opportunities at the baccalaureate and graduate level from the 1960s to the 1980s that provided the foundation for reintegrating practice and education; and the creation of a growing cadre of nurse scholars and their political influence on the relationship between power, knowledge, and clinical practice. These formulations are critical for understanding how scholarship changed over time and help us understand contemporary clinical practice, its authority structure, how it helps us define a body of knowledge from which practice proceeds, and then, how it responds to public demands. Nursing scholarship is nested in a particular social, political, economic, and cultural context. This context also determines how and why it is generated, debated, and used. Its production does not always follow a rational, logical pattern. Nursing knowledge development is influenced as much by the political underpinnings of health care as it is by social, economic, cultural, and scientific foundations.

Statistical context shapes stimulus-specific adaptation in human auditory cortex

PubMed Central

Henry, Molly J.; Fromboluti, Elisa Kim; McAuley, J. Devin

2015-01-01

Stimulus-specific adaptation is the phenomenon whereby neural response magnitude decreases with repeated stimulation. Inconsistencies between recent nonhuman animal recordings and computational modeling suggest dynamic influences on stimulus-specific adaptation. The present human electroencephalography (EEG) study investigates the potential role of statistical context in dynamically modulating stimulus-specific adaptation by examining the auditory cortex-generated N1 and P2 components. As in previous studies of stimulus-specific adaptation, listeners were presented with oddball sequences in which the presentation of a repeated tone was infrequently interrupted by rare spectral changes taking on three different magnitudes. Critically, the statistical context varied with respect to the probability of small versus large spectral changes within oddball sequences (half of the time a small change was most probable; in the other half a large change was most probable). We observed larger N1 and P2 amplitudes (i.e., release from adaptation) for all spectral changes in the small-change compared with the large-change statistical context. The increase in response magnitude also held for responses to tones presented with high probability, indicating that statistical adaptation can overrule stimulus probability per se in its influence on neural responses. Computational modeling showed that the degree of coadaptation in auditory cortex changed depending on the statistical context, which in turn affected stimulus-specific adaptation. Thus the present data demonstrate that stimulus-specific adaptation in human auditory cortex critically depends on statistical context. Finally, the present results challenge the implicit assumption of stationarity of neural response magnitudes that governs the practice of isolating established deviant-detection responses such as the mismatch negativity. PMID:25652920

Prototype Development: Context-Driven Dynamic XML Ophthalmologic Data Capture Application

PubMed Central

Schwei, Kelsey M; Kadolph, Christopher; Finamore, Joseph; Cancel, Efrain; McCarty, Catherine A; Okorie, Asha; Thomas, Kate L; Allen Pacheco, Jennifer; Pathak, Jyotishman; Ellis, Stephen B; Denny, Joshua C; Rasmussen, Luke V; Tromp, Gerard; Williams, Marc S; Vrabec, Tamara R; Brilliant, Murray H

2017-01-01

Background The capture and integration of structured ophthalmologic data into electronic health records (EHRs) has historically been a challenge. However, the importance of this activity for patient care and research is critical. Objective The purpose of this study was to develop a prototype of a context-driven dynamic extensible markup language (XML) ophthalmologic data capture application for research and clinical care that could be easily integrated into an EHR system. Methods Stakeholders in the medical, research, and informatics fields were interviewed and surveyed to determine data and system requirements for ophthalmologic data capture. On the basis of these requirements, an ophthalmology data capture application was developed to collect and store discrete data elements with important graphical information. Results The context-driven data entry application supports several features, including ink-over drawing capability for documenting eye abnormalities, context-based Web controls that guide data entry based on preestablished dependencies, and an adaptable database or XML schema that stores Web form specifications and allows for immediate changes in form layout or content. The application utilizes Web services to enable data integration with a variety of EHRs for retrieval and storage of patient data. Conclusions This paper describes the development process used to create a context-driven dynamic XML data capture application for optometry and ophthalmology. The list of ophthalmologic data elements identified as important for care and research can be used as a baseline list for future ophthalmologic data collection activities. PMID:28903894

Therapeutic use of Aldara in chronic myeloid leukemia.

PubMed

Marleau, Annette M; Lipton, Jeffrey H; Riordan, Neil H; Ichim, Thomas E

2007-01-25

The potent clinical responses seen in patients with chronic myeloid leukemia (CML) after administration of donor-specific lymphocytes, as well as the correlation between the presence of antigen specific T cells and prolonged remission in these patients, suggests a role for the immunological control of CML. Here we propose Aldara, a clinically used formulation of imiquimod, as an agent for augmenting immune responses to CML antigens. Our proposition is based upon 3 tenets: 1) Endogenous dendritic cells (DC) of CML patients, which are known to be derived from the malignant clone, express and present various leukemic antigens; 2) CML-antigen reactive T cell clones exist in the patient but in many situations are ineffectively stimulated to cause significant hematological responses; and 3) Antigen presentation by mature, activated DC, which endogenously express CML-antigens may endow the pre-existing ineffective T cell responses with ability to control CML progression. The practical use of Aldara as a localized activator of DC in the context of present day leukemic therapeutics, as well as various properties of this unique immune modulator will be discussed.

Structural neuroimaging across early-stage psychosis: Aberrations in neurobiological trajectories and implications for the staging model.

PubMed

Bartholomeusz, Cali F; Cropley, Vanessa L; Wannan, Cassandra; Di Biase, Maria; McGorry, Patrick D; Pantelis, Christos

2017-05-01

This review critically examines the structural neuroimaging evidence in psychotic illness, with a focus on longitudinal imaging across the first-episode psychosis and ultra-high-risk of psychosis illness stages. A thorough search of the literature involving specifically longitudinal neuroimaging in early illness stages of psychosis was conducted. The evidence supporting abnormalities in brain morphology and altered neurodevelopmental trajectories is discussed in the context of a clinical staging model. In general, grey matter (and, to a lesser extent, white matter) declines across multiple frontal, temporal (especially superior regions), insular and parietal regions during the first episode of psychosis, which has a steeper trajectory than that of age-matched healthy counterparts. Although the ultra-high-risk of psychosis literature is considerably mixed, evidence indicates that certain volumetric structural aberrations predate psychotic illness onset (e.g. prefrontal cortex thinning), while other abnormalities present in ultra-high-risk of psychosis populations are potentially non-psychosis-specific (e.g. hippocampal volume reductions). We highlight the advantages of longitudinal designs, discuss the implications such studies have on clinical staging and provide directions for future research.

Context management platform for tourism applications.

PubMed

Buján, David; Martín, David; Torices, Ortzi; López-de-Ipiña, Diego; Lamsfus, Carlos; Abaitua, Joseba; Alzua-Sorzabal, Aurkene

2013-06-24

The notion of context has been widely studied and there are several authors that have proposed different definitions of context. However, context has not been widely studied in the framework of human mobility and the notion of context has been imported directly from other computing fields without specifically addressing the tourism domain requirements. In order to store and manage context information a context data model and a context management platform are needed. Ontologies have been widely used in context modelling, but many of them are designed to be applied in general ubiquitous computing environments, do not contain specific concepts related to the tourism domain or some approaches do not contain enough concepts to represent context information related to the visitor on the move. That is why we propose a new approach to provide a better solution to model context data in tourism environments, adding more value to our solution reusing data about tourist resources from an Open Data repository and publishing it as Linked Data. We also propose the architecture for a context information management platform based on this context data model.

Context Management Platform for Tourism Applications

PubMed Central

Buján, David; Martín, David; Torices, Ortzi; López-de-Ipiña, Diego; Lamsfus, Carlos; Abaitua, Joseba; Alzua-Sorzabal, Aurkene

2013-01-01

The notion of context has been widely studied and there are several authors that have proposed different definitions of context. However, context has not been widely studied in the framework of human mobility and the notion of context has been imported directly from other computing fields without specifically addressing the tourism domain requirements. In order to store and manage context information a context data model and a context management platform are needed. Ontologies have been widely used in context modelling, but many of them are designed to be applied in general ubiquitous computing environments, do not contain specific concepts related to the tourism domain or some approaches do not contain enough concepts to represent context information related to the visitor on the move. That is why we propose a new approach to provide a better solution to model context data in tourism environments, adding more value to our solution reusing data about tourist resources from an Open Data repository and publishing it as Linked Data. We also propose the architecture for a context information management platform based on this context data model. PMID:23797739

Validation of biomarkers to predict response to immunotherapy in cancer: Volume II - clinical validation and regulatory considerations.

PubMed

Dobbin, Kevin K; Cesano, Alessandra; Alvarez, John; Hawtin, Rachael; Janetzki, Sylvia; Kirsch, Ilan; Masucci, Giuseppe V; Robbins, Paul B; Selvan, Senthamil R; Streicher, Howard Z; Zhang, Jenny; Butterfield, Lisa H; Thurin, Magdalena

2016-01-01

There is growing recognition that immunotherapy is likely to significantly improve health outcomes for cancer patients in the coming years. Currently, while a subset of patients experience substantial clinical benefit in response to different immunotherapeutic approaches, the majority of patients do not but are still exposed to the significant drug toxicities. Therefore, a growing need for the development and clinical use of predictive biomarkers exists in the field of cancer immunotherapy. Predictive cancer biomarkers can be used to identify the patients who are or who are not likely to derive benefit from specific therapeutic approaches. In order to be applicable in a clinical setting, predictive biomarkers must be carefully shepherded through a step-wise, highly regulated developmental process. Volume I of this two-volume document focused on the pre-analytical and analytical phases of the biomarker development process, by providing background, examples and "good practice" recommendations. In the current Volume II, the focus is on the clinical validation, validation of clinical utility and regulatory considerations for biomarker development. Together, this two volume series is meant to provide guidance on the entire biomarker development process, with a particular focus on the unique aspects of developing immune-based biomarkers. Specifically, knowledge about the challenges to clinical validation of predictive biomarkers, which has been gained from numerous successes and failures in other contexts, will be reviewed together with statistical methodological issues related to bias and overfitting. The different trial designs used for the clinical validation of biomarkers will also be discussed, as the selection of clinical metrics and endpoints becomes critical to establish the clinical utility of the biomarker during the clinical validation phase of the biomarker development. Finally, the regulatory aspects of submission of biomarker assays to the U.S. Food and Drug Administration as well as regulatory considerations in the European Union will be covered.

WE-D-204-03: CAMPEP Residencies in a Canadian Context: Comprehensive Cancer Centers and Integrated Learning Environments

DOE Office of Scientific and Technical Information (OSTI.GOV)

Parker, W.

Speakers in this session will present overview and details of a specific rotation or feature of their Medical Physics Residency Program that is particularly exceptional and noteworthy. The featured rotations include foundational topics executed with exceptional acumen and innovative educational rotations perhaps not commonly found in Medical Physics Residency Programs. A site-specific clinical rotation will be described, where the medical physics resident follows the physician and medical resident for two weeks into patient consultations, simulation sessions, target contouring sessions, planning meetings with dosimetry, patient follow up visits, and tumor boards, to gain insight into the thought processes of the radiationmore » oncologist. An incident learning rotation will be described where the residents learns about and practices evaluating clinical errors and investigates process improvements for the clinic. The residency environment at a Canadian medical physics residency program will be described, where the training and interactions with radiation oncology residents is integrated. And the first month rotation will be described, where the medical physics resident rotates through the clinical areas including simulation, dosimetry, and treatment units, gaining an overview of the clinical flow and meeting all the clinical staff to begin the residency program. This session will be of particular interest to residency programs who are interested in adopting or adapting these curricular ideas into their programs and to residency candidates who want to learn about programs already employing innovative practices. Learning Objectives: To learn about exceptional and innovative clinical rotations or program features within existing Medical Physics Residency Programs. To understand how to adopt/adapt innovative curricular designs into your own Medical Physics Residency Program, if appropriate.« less

Chemical approaches to targeted protein degradation through modulation of the ubiquitin-proteasome pathway.

PubMed

Collins, Ian; Wang, Hannah; Caldwell, John J; Chopra, Raj

2017-03-15

Manipulation of the ubiquitin-proteasome system to achieve targeted degradation of proteins within cells using chemical tools and drugs has the potential to transform pharmacological and therapeutic approaches in cancer and other diseases. An increased understanding of the molecular mechanism of thalidomide and its analogues following their clinical use has unlocked small-molecule modulation of the substrate specificity of the E3 ligase cereblon (CRBN), which in turn has resulted in the advancement of new immunomodulatory drugs (IMiDs) into the clinic. The degradation of multiple context-specific proteins by these pleiotropic small molecules provides a means to uncover new cell biology and to generate future drug molecules against currently undruggable targets. In parallel, the development of larger bifunctional molecules that bring together highly specific protein targets in complexes with CRBN, von Hippel-Lindau, or other E3 ligases to promote ubiquitin-dependent degradation has progressed to generate selective chemical compounds with potent effects in cells and in vivo models, providing valuable tools for biological target validation and with future potential for therapeutic use. In this review, we survey recent breakthroughs achieved in these two complementary methods and the discovery of new modes of direct and indirect engagement of target proteins with the proteasome. We discuss the experimental characterisation that validates the use of molecules that promote protein degradation as chemical tools, the preclinical and clinical examples disclosed to date, and the future prospects for this exciting area of chemical biology. © 2017 The Author(s).

The structure, correlates, and treatment related changes of mindfulness facets across the anxiety disorders and obsessive compulsive disorder.

PubMed

Hawley, Lance L; Rogojanski, Jenny; Vorstenbosch, Valerie; Quilty, Lena C; Laposa, Judith M; Rector, Neil A

2017-06-01

Research with non-clinical and clinical samples has examined how mindfulness concepts relate to psychological symptom presentations. However, there is less clarity when examining treatment-seeking patients who experience DSM-diagnosed anxiety and obsessional disorders - both cross-sectionally, and following empirically-supported treatments. The Five Facet Mindfulness Questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) conceptualizes mindfulness as consisting of five facets: Observing, Describing, Acting with Awareness, Nonreactivity, and Nonjudging. The current study examines the factor structure and predictive validity of the FFMQ in a large sample of treatment-seeking individuals with obsessive compulsive disorder (OCD), panic disorder with or without agoraphobia (PD/A), social anxiety disorder (SAD), and generalized anxiety disorder (GAD). Confirmatory factor analyses (CFA) established that both four and five-factor models (i.e., with and without inclusion of the Observing factor) provided an acceptable representation of the underlying FFMQ structure, but did not support a one-factor solution. For each of these diagnostic groups, hierarchical regression analyses clarified the association between specific FFMQ facets and diagnosis specific symptom change during CBT treatment. These findings are discussed in the context of the possible transdiagnostic relevance of specific mindfulness facets, and how these facets are differentially associated with diagnosis specific symptom alleviation during CBT. Copyright © 2017 Elsevier Ltd. All rights reserved.

Viewpoint: Cultural competence and the African American experience with health care: The case for specific content in cross-cultural education.

PubMed

Eiser, Arnold R; Ellis, Glenn

2007-02-01

Achieving cultural competence in the care of a patient who is a member of an ethnic or racial minority is a multifaceted project involving specific cultural knowledge as well as more general skills and attitude adjustments to advance cross-cultural communication in the clinical encounter. Using the important example of the African American patient, the authors examine relevant historical and cultural information as it relates to providing culturally competent health care. The authors identify key influences, including the legacy of slavery, Jim Crow discrimination, the Tuskegee syphilis study, religion's interaction with health care, the use of home remedies, distrust, racial concordance and discordance, and health literacy. The authors propose that the awareness of specific information pertaining to ethnicity and race enhances cross-cultural communication and ways to improve the cultural competence of physicians and other health care providers by providing a historical and social context for illness in another culture. Cultural education, modular in nature, can be geared to the specific populations served by groups of physicians and provider organizations. Educational methods should include both information about relevant social group history as well as some experiential component to emotively communicate particular cultural needs. The authors describe particular techniques that help bridge the cross-cultural clinical communication gaps that are created by patients' mistrust, lack of cultural understanding, differing paradigms for illness, and health illiteracy.

IT Infrastructure Components for Biobanking

PubMed Central

Prokosch, H.U.; Beck, A.; Ganslandt, T.; Hummel, M.; Kiehntopf, M.; Sax, U.; Ückert, F.; Semler, S.

2010-01-01

Objective Within translational research projects in the recent years large biobanks have been established, mostly supported by homegrown, proprietary software solutions. No general requirements for biobanking IT infrastructures have been published yet. This paper presents an exemplary biobanking IT architecture, a requirements specification for a biorepository management tool and exemplary illustrations of three major types of requirements. Methods We have pursued a comprehensive literature review for biobanking IT solutions and established an interdisciplinary expert panel for creating the requirements specification. The exemplary illustrations were derived from a requirements analysis within two university hospitals. Results The requirements specification comprises a catalog with more than 130 detailed requirements grouped into 3 major categories and 20 subcategories. Special attention is given to multitenancy capabilities in order to support the project-specific definition of varying research and bio-banking contexts, the definition of workflows to track sample processing, sample transportation and sample storage and the automated integration of preanalytic handling and storage robots. Conclusion IT support for biobanking projects can be based on a federated architectural framework comprising primary data sources for clinical annotations, a pseudonymization service, a clinical data warehouse with a flexible and user-friendly query interface and a biorepository management system. Flexibility and scalability of all such components are vital since large medical facilities such as university hospitals will have to support biobanking for varying monocentric and multicentric research scenarios and multiple medical clients. PMID:23616851

IT Infrastructure Components for Biobanking.

PubMed

Prokosch, H U; Beck, A; Ganslandt, T; Hummel, M; Kiehntopf, M; Sax, U; Uckert, F; Semler, S

2010-01-01

Within translational research projects in the recent years large biobanks have been established, mostly supported by homegrown, proprietary software solutions. No general requirements for biobanking IT infrastructures have been published yet. This paper presents an exemplary biobanking IT architecture, a requirements specification for a biorepository management tool and exemplary illustrations of three major types of requirements. We have pursued a comprehensive literature review for biobanking IT solutions and established an interdisciplinary expert panel for creating the requirements specification. The exemplary illustrations were derived from a requirements analysis within two university hospitals. The requirements specification comprises a catalog with more than 130 detailed requirements grouped into 3 major categories and 20 subcategories. Special attention is given to multitenancy capabilities in order to support the project-specific definition of varying research and bio-banking contexts, the definition of workflows to track sample processing, sample transportation and sample storage and the automated integration of preanalytic handling and storage robots. IT support for biobanking projects can be based on a federated architectural framework comprising primary data sources for clinical annotations, a pseudonymization service, a clinical data warehouse with a flexible and user-friendly query interface and a biorepository management system. Flexibility and scalability of all such components are vital since large medical facilities such as university hospitals will have to support biobanking for varying monocentric and multicentric research scenarios and multiple medical clients.

Domain-specific rationality in human choices: violations of utility axioms and social contexts.

PubMed

Wang, X T

1996-07-01

This study presents a domain-specific view of human decision rationality. It explores social and ecological domain-specific psychological mechanisms underlying choice biases and violations of utility axioms. Results from both the USA and China revealed a social group domain-specific choice pattern. The irrational preference reversal in a hypothetical life-death decision problem (a classical example of framing effects) was eliminated by providing a small group or family context in which most subjects favored a risky choice option regardless of the positive/negative framing of choice outcomes. The risk preference data also indicate that the subjective scope of small group domain is larger for Chinese subjects, suggesting that human choice mechanisms are sensitive to culturally specific features of group living. A further experiment provided evidence that perceived fairness might be one major factor regulating the choice preferences found in small group (kith-and-kin) contexts. Finally, the violation of the stochastic dominance axiom of the rational theory of choice was predicted and tested. The violations were found only when the "life-death" problem was presented in small group contexts; the strongest violation was found in a family context. These results suggest that human decisions and choices are regulated by domain-specific choice mechanisms designed to solve evolutionary recurrent and adaptively important problems.

Crossing boundaries in interprofessional education: A call for instructional integration of two script concepts.

PubMed

Kiesewetter, Jan; Kollar, Ingo; Fernandez, Nicolas; Lubarsky, Stuart; Kiessling, Claudia; Fischer, Martin R; Charlin, Bernard

2016-09-01

Clinical work occurs in a context which is heavily influenced by social interactions. The absence of theoretical frameworks underpinning the design of collaborative learning has become a roadblock for interprofessional education (IPE). This article proposes a script-based framework for the design of IPE. This framework provides suggestions for designing learning environments intended to foster competences we feel are fundamental to successful interprofessional care. The current literature describes two script concepts: "illness scripts" and "internal/external collaboration scripts". Illness scripts are specific knowledge structures that link general disease categories and specific examples of diseases. "Internal collaboration scripts" refer to an individual's knowledge about how to interact with others in a social situation. "External collaboration scripts" are instructional scaffolds designed to help groups collaborate. Instructional research relating to illness scripts and internal collaboration scripts supports (a) putting learners in authentic situations in which they need to engage in clinical reasoning, and (b) scaffolding their interaction with others with "external collaboration scripts". Thus, well-established experiential instructional approaches should be combined with more fine-grained script-based scaffolding approaches. The resulting script-based framework offers instructional designers insights into how students can be supported to develop the necessary skills to master complex interprofessional clinical situations.

Autoantibodies and their antigens in autoimmune hepatitis.

PubMed

Bogdanos, Dimitrios P; Mieli-Vergani, Giorgina; Vergani, Diego

2009-08-01

Autoantibody detection assists in the diagnosis and allows differentiation of autoimmune hepatitis (AIH) type 1 (AIH-1), characterized by antinuclear antibody (ANA) and/or smooth muscle antibody (SMA), and type 2 (AIH-2), distinguished by the presence of antibodies to liver-kidney microsome type 1 (anti-LKM1) and/or antibodies to liver cytosol type 1 (anti-LC1). Detection of atypical perinuclear antineutrophil cytoplasmic antibodies (pANCA) and anti-soluble liver antigen (SLA) antibodies can act as an additional pointer toward the diagnosis of AIH, particularly in the absence of the conventional autoantibodies. Routine autoantibody testing by indirect immunofluorescence has been recently complemented by molecular assays based on purified or recombinant antigens. Although the AIH-1-specific ANA and SMA targets need better definition, those of anti-LKM1 and anti-LC1 in AIH-2 have been clearly identified; the fine specificity of antibody reactivity and its clinical relevance to disease pathogenesis are the focus of ongoing investigation. This article critically discusses the current knowledge of the diagnostic and clinical significance of AIH-related autoantibody reactivities, focusing on key issues that the physician needs to be aware of to be able to request the appropriate testing and to interpret correctly the laboratory results within the clinical context of the patient. Copyright Thieme Medical Publishers.

The interface of self psychology, infant research, and neuroscience in clinical practice.

PubMed

Rustin, Judith

2009-04-01

This article focuses on the integration of self psychology with findings from infant research and neuroscience. While Kohut's psychology of the self provides a useful theoretical model for psychoanalytic practice, aspects of infant research and neuroscience offer specificity and nuance to basic self-psychological concepts. Kohut proposed that self-psychological psychoanalysis ameliorates derailed development through patient-analyst interaction, while a listening stance of empathic immersion begins the curative process of derailed development and sets the stage for reparative psychoanalytic work. Findings from infant research delineate much more specifically the nature of attunement both in early mother-infant and analyst-patient interactions. Findings from neuroscientific research delineate how early mother-infant experiences are encoded in implicit memory and explicates the emotional substrate of affects and feelings. This emotional substrate exists at birth and provides a means of communication both in infancy and adulthood. Additionally, infant research delineates the mutuality of the interactive process. Thus, both infant research and neuroscience add subtlety and nuance to basic self-psychological concepts. This subtlety opens up new ways of understanding patients and expands the clinical repertoire. Three clinical vignettes demonstrate how this nuance and expansion of self-psychological concepts are applied in the context of an ongoing psychoanalytic treatment.

Calibration of Clinical Audio Recording and Analysis Systems for Sound Intensity Measurement.

PubMed

Maryn, Youri; Zarowski, Andrzej

2015-11-01

Sound intensity is an important acoustic feature of voice/speech signals. Yet recordings are performed with different microphone, amplifier, and computer configurations, and it is therefore crucial to calibrate sound intensity measures of clinical audio recording and analysis systems on the basis of output of a sound-level meter. This study was designed to evaluate feasibility, validity, and accuracy of calibration methods, including audiometric speech noise signals and human voice signals under typical speech conditions. Calibration consisted of 3 comparisons between data from 29 measurement microphone-and-computer systems and data from the sound-level meter: signal-specific comparison with audiometric speech noise at 5 levels, signal-specific comparison with natural voice at 3 levels, and cross-signal comparison with natural voice at 3 levels. Intensity measures from recording systems were then linearly converted into calibrated data on the basis of these comparisons, and validity and accuracy of calibrated sound intensity were investigated. Very strong correlations and quasisimilarity were found between calibrated data and sound-level meter data across calibration methods and recording systems. Calibration of clinical sound intensity measures according to this method is feasible, valid, accurate, and representative for a heterogeneous set of microphones and data acquisition systems in real-life circumstances with distinct noise contexts.

Findings from a Clinical Learning Needs Survey at Ireland's first children's hospice.

PubMed

Quinn, Claire; Hillis, Rowan

2015-12-01

Caring for children with life-limiting conditions places exceptional demands on health professionals. Staff require the optimal skills and expertise necessary to provide the highest quality of care and to achieve this it is essential to understand their learning requirements. The aim is to share the main findings from a Clinical Learning Needs Survey conducted at LauraLynn, currently Ireland's only children's hospice. To date no other Irish service has conducted a formal identification of professional learning and development needs specific to the Irish context. The findings from the study assist workforce planning by providing a glimpse into the immediate study needs of staff working in a children's palliative care setting. The study had two main aims: a) Assist clinical staff within one organisation to identify their own professional learning priorities in children's palliative care and b) Inform the design and delivery of a responsive suite of workshops, programmes and study sessions for children's palliative care. The study identified the key learning needs as end-of-life care, palliative emergencies, communication skill development and bereavement support. These findings are similar to those found internationally and demonstrate the commitment of a new organisation to ensure that specific employee learning requirements are met if the organisation and wider specialty of Irish children's palliative care is to continue its evolution.

Mortality risk prediction in burn injury: Comparison of logistic regression with machine learning approaches.

PubMed

Stylianou, Neophytos; Akbarov, Artur; Kontopantelis, Evangelos; Buchan, Iain; Dunn, Ken W

2015-08-01

Predicting mortality from burn injury has traditionally employed logistic regression models. Alternative machine learning methods have been introduced in some areas of clinical prediction as the necessary software and computational facilities have become accessible. Here we compare logistic regression and machine learning predictions of mortality from burn. An established logistic mortality model was compared to machine learning methods (artificial neural network, support vector machine, random forests and naïve Bayes) using a population-based (England & Wales) case-cohort registry. Predictive evaluation used: area under the receiver operating characteristic curve; sensitivity; specificity; positive predictive value and Youden's index. All methods had comparable discriminatory abilities, similar sensitivities, specificities and positive predictive values. Although some machine learning methods performed marginally better than logistic regression the differences were seldom statistically significant and clinically insubstantial. Random forests were marginally better for high positive predictive value and reasonable sensitivity. Neural networks yielded slightly better prediction overall. Logistic regression gives an optimal mix of performance and interpretability. The established logistic regression model of burn mortality performs well against more complex alternatives. Clinical prediction with a small set of strong, stable, independent predictors is unlikely to gain much from machine learning outside specialist research contexts. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.

Whither countertransference in couples and family therapy: a systemic perspective.

PubMed

Kaslow, F W

2001-08-01

This study addresses various perspectives on transference and countertransference dynamics from the context of couples and family therapy. It considers the phenomena of countertransference in couple and family therapy and illustrates treatment with three specific kinds of patient populations: adult survivors of childhood incest who receive therapy with their partner; couples group therapy; and psychotherapists and their families. How supervisors help trainees recognize and deal with the transference and countertransference in clinical practice also is explored. These reciprocal phenomena are even more complex to identify and handle in couple and family treatment than in individual therapy.

Domestic violence in the Arab American population: transforming environmental conditions through community education.

PubMed

Kulwicki, A D; Miller, J

1999-01-01

The purpose of this research was to assess and provide community interventions for victims of domestic violence in the Arab American immigrant population in a large midwestern city of the United States. The theoretical framework of critical social theory provided the context for the research. A survey tool for assessing domestic violence was administered in the homes of 202 Arab American immigrants, followed by open discussion with the Arabic data collector. Findings from the research were used to develop and implement specific community education programs and clinic resources for the local immigrant population.

Adoption and resistance: reflections on human, organizational, and information technologies in picture archive and communication systems (PACS)

NASA Astrophysics Data System (ADS)

Sappington, Rodney W.

2005-04-01

In research conducted at academic and community hospitals in the United States since 2001, this paper examines complex human and technological relationships employed to renegotiate behavior within hospital administrative and clinical cultures. In the planning and implementation of PACS in a four-facility hospital we will enter into what can be described as processes of "adoption" and "resistance", seemingly opposite approaches to system implementation, which I argue are in fact key responses to planning, design, and customization of imaging and information systems in a context of convergence. In a larger context of convergence known as NBIC tools (nanotechnology, biotechnology, information technology, and cognitive sciences) it has become increasingly clear to leaders in the field that it is essential to redesign organizational technologies. A novel system has little chance of being fully utilized by conventional organizational structures in an era of system convergence. The challenge of embracing a larger systems perspective lies in opening untapped potential within the healthcare enterprise by preparing the ground for reflection on new approaches to training, and bridging specialized knowledge across computer engineering, clinical decision making, and organizational perspectives for the benefit of patient care. Case studies will demonstrate how organizational and system design technologies are crucial in insuring that PACS implementation strategies can encourage the emergence of new levels of quality for patient care. The goal is to provide successful design-build models that are true to organizational specificity, persons, and clinical practices undergoing change and uncertainty.

The importance of source and cue type in time-based everyday prospective memory.

PubMed

Oates, Joyce M; Peynircioğlu, Zehra F

2014-01-01

We examined the effects of the source of a prospective memory task (provided or generated) and the type of cue (specific or general) triggering that task in everyday settings. Participants were asked to complete both generated and experimenter-provided tasks and to send a text message when each task was completed. The cue/context for the to-be-completed tasks was either a specific time or a general deadline (time-based cue), and the cue/context for the texting task was the completion of the task itself (activity-based cue). Although generated tasks were completed more often, generated cues/contexts were no more effective than provided ones in triggering the intention. Furthermore, generated tasks were completed more often when the cue/context comprised a specific time, whereas provided tasks were completed more often when the cue/context comprised a general deadline. However, texting was unaffected by the source of the cue/context. Finally, emotion modulated the effects. Results are discussed within a process-driven framework.

Specific previous experience affects perception of harmony and meter.

PubMed

Creel, Sarah C

2011-10-01

Prior knowledge shapes our experiences, but which prior knowledge shapes which experiences? This question is addressed in the domain of music perception. Three experiments were used to determine whether listeners activate specific musical memories during music listening. Each experiment provided listeners with one of two musical contexts that was presented simultaneously with a melody. After a listener was familiarized with melodies embedded in contexts, the listener heard melodies in isolation and judged the fit of a final harmonic or metrical probe event. The probe event matched either the familiar (but absent) context or an unfamiliar context. For both harmonic (Experiments 1 and 3) and metrical (Experiment 2) information, exposure to context shifted listeners' preferences toward a probe matching the context that they had been familiarized with. This suggests that listeners rapidly form specific musical memories without explicit instruction, which are then activated during music listening. These data pose an interesting challenge for models of music perception which implicitly assume that the listener's knowledge base is predominantly schematic or abstract.

Where Do Female Sex Workers Seek HIV and Reproductive Health Care and What Motivates These Choices? A Survey in 4 Cities in India, Kenya, Mozambique and South Africa.

PubMed

Lafort, Yves; Greener, Ross; Roy, Anuradha; Greener, Letitia; Ombidi, Wilkister; Lessitala, Faustino; Haghparast-Bidgoli, Hassan; Beksinska, Mags; Gichangi, Peter; Reza-Paul, Sushena; Smit, Jenni A; Chersich, Matthew; Delva, Wim

2016-01-01

A baseline cross-sectional survey among female sex workers (FSWs) was conducted in four cities within the context of an implementation research project aiming to improve FSWs' access to HIV, and sexual and reproductive health (SRH) services. The survey measured where FSWs seek HIV/SRH care and what motivates their choice. Using respondent-driven sampling (RDS), FWSs were recruited in Durban, South Africa (n = 400), Tete, Mozambique (n = 308), Mombasa, Kenya (n = 400) and Mysore, India (n = 458) and interviewed. RDS-adjusted proportions were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests. Across cities, FSWs most commonly sought care for the majority of HIV/SRH services at public health facilities, most especially in Durban (ranging from 65% for condoms to 97% for HIV care). Services specifically targeting FSWs only had a high coverage in Mysore for STI care (89%) and HIV testing (79%). Private-for-profit clinics were important providers in Mombasa (ranging from 17% for STI care and HIV testing to 43% for HIV care), but not in the other cities. The most important reason for the choice of care provider in Durban and Mombasa was proximity, in Tete 'where they always go', and in Mysore cost of care. Where available, clinics specifically targeting FSWs were more often chosen because of shorter waiting times, perceived higher quality of care, more privacy and friendlier personnel. The place where care is sought for HIV/SRH services differs substantially between cities. Targeted services have limited coverage in the African cities compared to Mysore. Convenience appears more important for choosing the place of care than aspects of quality of care. The best model to improve access, linking targeted interventions with general health services, will need to be tailored to the specific context of each city.

Pharmacogenomics and Global Precision Medicine in the Context of Adverse Drug Reactions: Top 10 Opportunities and Challenges for the Next Decade.

PubMed

Alessandrini, Marco; Chaudhry, Mamoonah; Dodgen, Tyren M; Pepper, Michael S

2016-10-01

In a move indicative of the enthusiastic support of precision medicine, the U.S. President Barack Obama announced the Precision Medicine Initiative in January 2015. The global precision medicine ecosystem is, thus, receiving generous support from the United States ($215 million), and numerous other governments have followed suit. In the context of precision medicine, drug treatment and prediction of its outcomes have been important for nearly six decades in the field of pharmacogenomics. The field offers an elegant solution for minimizing the effects and occurrence of adverse drug reactions (ADRs). The Clinical Pharmacogenetics Implementation Consortium (CPIC) plays an important role in this context, and it aims at specifically guiding the translation of clinically relevant and evidence-based pharmacogenomics research. In this forward-looking analysis, we make particular reference to several of the CPIC guidelines and their role in guiding the treatment of highly relevant diseases, namely cardiovascular disease, major depressive disorder, cancer, and human immunodeficiency virus, with a view to predicting and managing ADRs. In addition, we provide a list of the top 10 crosscutting opportunities and challenges facing the fields of precision medicine and pharmacogenomics, which have broad applicability independent of the drug class involved. Many of these opportunities and challenges pertain to infrastructure, study design, policy, and science culture in the early 21st century. Ultimately, rational pharmacogenomics study design and the acquisition of comprehensive phenotypic data that proportionately match the genomics data should be an imperative as we move forward toward global precision medicine.

Pharmacogenomics and Global Precision Medicine in the Context of Adverse Drug Reactions: Top 10 Opportunities and Challenges for the Next Decade

PubMed Central

Alessandrini, Marco; Chaudhry, Mamoonah; Dodgen, Tyren M.

2016-01-01

Abstract In a move indicative of the enthusiastic support of precision medicine, the U.S. President Barack Obama announced the Precision Medicine Initiative in January 2015. The global precision medicine ecosystem is, thus, receiving generous support from the United States ($215 million), and numerous other governments have followed suit. In the context of precision medicine, drug treatment and prediction of its outcomes have been important for nearly six decades in the field of pharmacogenomics. The field offers an elegant solution for minimizing the effects and occurrence of adverse drug reactions (ADRs). The Clinical Pharmacogenetics Implementation Consortium (CPIC) plays an important role in this context, and it aims at specifically guiding the translation of clinically relevant and evidence-based pharmacogenomics research. In this forward-looking analysis, we make particular reference to several of the CPIC guidelines and their role in guiding the treatment of highly relevant diseases, namely cardiovascular disease, major depressive disorder, cancer, and human immunodeficiency virus, with a view to predicting and managing ADRs. In addition, we provide a list of the top 10 crosscutting opportunities and challenges facing the fields of precision medicine and pharmacogenomics, which have broad applicability independent of the drug class involved. Many of these opportunities and challenges pertain to infrastructure, study design, policy, and science culture in the early 21st century. Ultimately, rational pharmacogenomics study design and the acquisition of comprehensive phenotypic data that proportionately match the genomics data should be an imperative as we move forward toward global precision medicine. PMID:27643672

Redesigning Radiotherapy Quality Assurance: Opportunities to Develop an Efficient, Evidence-Based System to Support Clinical Trials

PubMed Central

Bekelman, Justin E.; Deye, James A.; Vikram, Bhadrasain; Bentzen, Soren M.; Bruner, Deborah; Curran, Walter J.; Dignam, James; Efstathiou, Jason A.; FitzGerald, T. J.; Hurkmans, Coen; Ibbott, Geoffrey S.; Lee, J. Jack; Merchant, Timothy E.; Michalski, Jeff; Palta, Jatinder R.; Simon, Richard; Ten Haken, Randal K.; Timmerman, Robert; Tunis, Sean; Coleman, C. Norman; Purdy, James

2012-01-01

Background In the context of national calls for reorganizing cancer clinical trials, the National Cancer Institute (NCI) sponsored a two day workshop to examine the challenges and opportunities for optimizing radiotherapy quality assurance (QA) in clinical trial design. Methods Participants reviewed the current processes of clinical trial QA and noted the QA challenges presented by advanced technologies. Lessons learned from the radiotherapy QA programs of recent trials were discussed in detail. Four potential opportunities for optimizing radiotherapy QA were explored, including the use of normal tissue toxicity and tumor control metrics, biomarkers of radiation toxicity, new radiotherapy modalities like proton beam therapy, and the international harmonization of clinical trial QA. Results Four recommendations were made: 1) Develop a tiered (and more efficient) system for radiotherapy QA and tailor intensity of QA to clinical trial objectives. Tiers include (i) general credentialing, (ii) trial specific credentialing, and (iii) individual case review; 2) Establish a case QA repository; 3) Develop an evidence base for clinical trial QA and introduce innovative prospective trial designs to evaluate radiotherapy QA in clinical trials; and 4) Explore the feasibility of consolidating clinical trial QA in the United States. Conclusion Radiotherapy QA may impact clinical trial accrual, cost, outcomes and generalizability. To achieve maximum benefit, QA programs must become more efficient and evidence-based. PMID:22425219

Epidemiologic natural history and clinical management of Human Papillomavirus (HPV) Disease: a critical and systematic review of the literature in the development of an HPV dynamic transmission model

PubMed Central

2009-01-01

Background Natural history models of human papillomavirus (HPV) infection and disease have been used in a number of policy evaluations of technologies to prevent and screen for HPV disease (e.g., cervical cancer, anogenital warts), sometimes with wide variation in values for epidemiologic and clinical inputs. The objectives of this study are to: (1) Provide an updated critical and systematic review of the evidence base to support epidemiologic and clinical modeling of key HPV disease-related parameters in the context of an HPV multi-type disease transmission model which we have applied within a U.S. population context; (2) Identify areas where additional studies are particularly needed. Methods Consistent with our and other prior HPV natural history models, the literature review was confined to cervical disease and genital warts. Between October 2005 and January 2006, data were gathered from the published English language medical literature through a search of the PubMed database and references were examined from prior HPV natural history models and review papers. Study design and data quality from individual studies were compared and analyses meeting pre-defined criteria were selected. Results Published data meeting review eligibility criteria were most plentiful for natural history parameters relating to the progression and regression of cervical intraepithelial neoplasia (CIN) without HPV typing, and data concerning the natural history of HPV disease due to specific HPV types were often lacking. Epidemiologic evidence to support age-dependency in the risk of progression and regression of HPV disease was found to be weak, and an alternative hypothesis concerning the time-dependence of transition rates is explored. No data were found on the duration of immunity following HPV infection. In the area of clinical management, data were observed to be lacking on the proportion of clinically manifest anogenital warts that are treated and the proportion of cervical cancer cases that become symptomatic by stage. Conclusion Knowledge of the natural history of HPV disease has been considerably enhanced over the past two decades, through the publication of an increasing number of relevant studies. However, considerable opportunity remains for advancing our understanding of HPV natural history and the quality of associated models, particularly with respect to examining HPV age- and type-specific outcomes, and acquired immunity following infection. PMID:19640281

Identification and validation of loss of function variants in clinical contexts.

PubMed

Lescai, Francesco; Marasco, Elena; Bacchelli, Chiara; Stanier, Philip; Mantovani, Vilma; Beales, Philip

2014-01-01

The choice of an appropriate variant calling pipeline for exome sequencing data is becoming increasingly more important in translational medicine projects and clinical contexts. Within GOSgene, which facilitates genetic analysis as part of a joint effort of the University College London and the Great Ormond Street Hospital, we aimed to optimize a variant calling pipeline suitable for our clinical context. We implemented the GATK/Queue framework and evaluated the performance of its two callers: the classical UnifiedGenotyper and the new variant discovery tool HaplotypeCaller. We performed an experimental validation of the loss-of-function (LoF) variants called by the two methods using Sequenom technology. UnifiedGenotyper showed a total validation rate of 97.6% for LoF single-nucleotide polymorphisms (SNPs) and 92.0% for insertions or deletions (INDELs), whereas HaplotypeCaller was 91.7% for SNPs and 55.9% for INDELs. We confirm that GATK/Queue is a reliable pipeline in translational medicine and clinical context. We conclude that in our working environment, UnifiedGenotyper is the caller of choice, being an accurate method, with a high validation rate of error-prone calls like LoF variants. We finally highlight the importance of experimental validation, especially for INDELs, as part of a standard pipeline in clinical environments.

The Influence of Context on Residents' Evaluations: Effects of Priming on Clinical Judgment and Affect

ERIC Educational Resources Information Center

Teunissen, P. W.; Stapel, D. A.; Scheele, F.; Scherpbier, A. J. J. A.; Boor, K.; van Diemen-Steenvoorde, J. A. A. M.; van der Vleuten, C. P. M.

2009-01-01

Different lines of research have suggested that context is important in acting and learning in the clinical workplace. It is not clear how contextual information influences residents' constructions of the situations in which they participate. The category accessibility paradigm from social psychology appears to offer an interesting perspective for…

An analysis of narratives to identify critical thinking contexts in psychiatric clinical practice.

PubMed

Mun, Mi Suk

2010-02-01

The development of students' critical thinking abilities is one of the greatest challenges facing contemporary nursing educators. Nursing educators should know about what kind of contents or situations need critical thinking. The research was undertaken to identify the critical thinking contexts that nursing students confront in psychiatric clinical practices. Students were asked to document their everyday experience. The narratives were analysed and interpreted from the philosophical notion of hermeneutics. Four themes emerged as critical thinking contexts: anxiety, conflict, hyper-awareness, dilemmas. Writing narratives appear to provide opportunities for reflection in addition to facilitating critical thinking and communicative skills in students. Also, for the instructor, students' clinical narratives could provide insight to understand how students are thinking and to share student's personal difficulties.

A dictionary server for supplying context sensitive medical knowledge.

PubMed Central

Ruan, W.; Bürkle, T.; Dudeck, J.

2000-01-01

The Giessen Data Dictionary Server (GDDS), developed at Giessen University Hospital, integrates clinical systems with on-line, context sensitive medical knowledge to help with making medical decisions. By "context" we mean the clinical information that is being presented at the moment the information need is occurring. The dictionary server makes use of a semantic network supported by a medical data dictionary to link terms from clinical applications to their proper information sources. It has been designed to analyze the network structure itself instead of knowing the layout of the semantic net in advance. This enables us to map appropriate information sources to various clinical applications, such as nursing documentation, drug prescription and cancer follow up systems. This paper describes the function of the dictionary server and shows how the knowledge stored in the semantic network is used in the dictionary service. PMID:11079978

Closed-Loop Neuromodulation Systems: Next-Generation Treatments for Psychiatric Illness

PubMed Central

Lo, Meng-Chen; Widge, Alik S.

2017-01-01

Despite deep brain stimulation’s positive early results in psychiatric disorders, well-designed clinical trials have yielded inconsistent clinical outcomes. One path to more reliable benefit is closed-loop therapy: stimulation that is automatically adjusted by a device or algorithm in response to changes in the patient’s electrical brain activity. These interventions may provide more precise and patient-specific treatments. In this article, we first introduce the available closed-loop neuromodulation platforms, which have shown clinical efficacy in epilepsy and strong early results in movement disorders. We discuss the strengths and limitations of these devices in the context of psychiatric illness. We then describe emerging technologies to address these limitations, including pre-clinical developments such as wireless deep neurostimulation and genetically targeted neuromodulation. Finally, we discuss ongoing challenges and limitations for closed-loop psychiatric brain stimulation development, most notably the difficulty of identifying meaningful biomarkers for titration. We consider this in the recently-released Research Domain Criteria (RDoC) framework and describe how neuromodulation and RDoC are jointly very well suited to address the problem of treatment-resistant illness. PMID:28523978

RS3PE syndrome: a clinical and immunogenetical study.

PubMed

Queiro, Rubén

2004-03-01

This study analyses the clinical, radiological, evolutive, and immunogenetical characteristics of a series of patients diagnosed with remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome. Reviewed were the clinical charts and human leukocyte antigen (HLA) profiles of all patients treated at a single teaching hospital fulfilling the features of this syndrome according to the definition of McCarty. Twelve cases were detected in ten men and two women aged from 62 to 85 years. Rheumatoid factor was negative in all cases, and antinuclear antibodies (ANA) were positive in two. All patients achieved complete resolution of their condition within 1 year with glucocorticoid (GC) use. Two relapsed after remission but responded again to low doses of GC. Four patients showed clinical and electrodiagnostic studies consistent with carpal tunnel syndrome. No specific HLA association could be found in this report. To date, none of these patients has developed definite rheumatic diseases, infections, or malignant diseases. Although the real nature of the syndrome is still a matter of debate, at least in our context, RS3PE remains a definite condition with an excellent prognosis.

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

PubMed Central

Shah, Nirali M; Wang, Wenjuan; Bishai, David M

2011-01-01

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific. PMID:21729919

Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?

PubMed

Shah, Nirali M; Wang, Wenjuan; Bishai, David M

2011-07-01

Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.

Becoming a teacher of clinical reasoning.

PubMed

Trowbridge, Robert L; Olson, Andrew P J

2018-03-28

Diagnostic reasoning is one of the most challenging and rewarding aspects of clinical practice. As a result, facility in teaching diagnostic reasoning is a core necessity for all medical educators. Clinician educators' limited understanding of the diagnostic process and how expertise is developed may result in lost opportunities in nurturing the diagnostic abilities of themselves and their learners. In this perspective, the authors describe their journeys as clinician educators searching for a coherent means of teaching diagnostic reasoning. They discuss the initial appeal and immediate applicability of dual process theory and cognitive biases to their own clinical experiences and those of their trainees, followed by the eventual and somewhat belated recognition of the importance of context specificity. They conclude that there are no quick fixes in guiding learners to expertise of diagnostic reasoning, but rather the development of these abilities is best viewed as a long, somewhat frustrating, but always interesting journey. The role of the teacher of clinical reasoning is to guide the learners on this journey, recognizing true mastery may not be attained, but should remain a goal for teacher and learner alike.

A cognitive perspective on medical expertise: theory and implication.

PubMed

Schmidt, H G; Norman, G R; Boshuizen, H P

1990-10-01

A new theory of the development of expertise in medicine is outlined. Contrary to existing views, this theory assumes that expertise is not so much a matter of superior reasoning skills or in-depth knowledge of pathophysiological states as it is based on cognitive structures that describe the features of prototypical or even actual patients. These cognitive structures, referred to as "illness scripts," contain relatively little knowledge about pathophysiological causes of symptoms and complaints but a wealth of clinically relevant information about disease, its consequences, and the context under which illness develops. By contrast, intermediate-level students without clinical experience typically use pathophysiological, causal models of disease when solving problems. The authors review evidence supporting the theory and discuss its implications for the understanding of five phenomena extensively documented in the clinical-reasoning literature: (1) content specificity in diagnostic performance; (2) typical differences in data-gathering techniques between medical students and physicians; (3) difficulties involved in setting standards; (4) a decline in performance on certain measures of clinical reasoning with increasing expertise; and (5) a paradoxical association between errors and longer response times in visual diagnosis.

Ethical challenges for using human cells in clinical cell therapy.

PubMed

Hermerén, Göran

2012-01-01

In this chapter, different challenges for using human cells in clinical cell therapy are identified and discussed. Several types of challenges are defined and described, with particular attention to the relation between ethical and scientific challenges. Some challenges are cell and disease specific: they are raised by research on special types of cells with certain methods in order to pave the way for cell therapies of particular diseases. But since scientific work is carried out in a societal and value-loaded context, the relations between scientific, ethical, and regulatory challenges are complex. Three theses are first discussed: there is not one fixed list of ethical challenges, some challenges are disease and cell type specific; there are challenges at all stages of the translation from bench to bedside, and the challenges are related to the various stages of translation. Moreover, experimental and ethical research needs to be integrated. Finally, a fourth thesis is suggested: if a constructive and well-argued position is desired, it is necessary to be specific not only about the scientific details but also about the value premises. Everybody is for justice, integrity, and respect for persons. But what precisely does this mean when it is applied to the choices scientists and regulators have to face in their daily work? Copyright © 2012 Elsevier B.V. All rights reserved.

Clinical review: optimizing enteral nutrition for critically ill patients - a simple data-driven formula

PubMed Central

2011-01-01

In modern critical care, the paradigm of 'therapeutic nutrition' is replacing traditional 'supportive nutrition'. Standard enteral formulas meet basic macro- and micronutrient needs; therapeutic enteral formulas meet these basic needs and also contain specific pharmaconutrients that may attenuate hyperinflammatory responses, enhance the immune responses to infection, or improve gastrointestinal tolerance. Choosing the right enteral feeding formula may positively affect a patient's outcome; targeted use of therapeutic formulas can reduce the incidence of infectious complications, shorten lengths of stay in the ICU and in the hospital, and lower risk for mortality. In this paper, we review principles of how to feed (enteral, parenteral, or both) and when to feed (early versus delayed start) patients who are critically ill. We discuss what to feed these patients in the context of specific pharmaconutrients in specialized feeding formulations, that is, arginine, glutamine, antioxidants, certain ω-3 and ω-6 fatty acids, hydrolyzed proteins, and medium-chain triglycerides. We summarize current expert guidelines for nutrition in patients with critical illness, and we present specific clinical evidence on the use of enteral formulas supplemented with anti-inflammatory or immune-modulating nutrients, and gastrointestinal tolerance-promoting nutritional formulas. Finally, we introduce an algorithm to help bedside clinicians make data-driven feeding decisions for patients with critical illness. PMID:22136305

Fast, cheap, and out of control? Speculations and ethical concerns in the conduct of outsourced clinical trials in India.

PubMed

Kamat, Vinay R

2014-03-01

The globalization of biopharmaceutical clinical trials and their offshore outsourcing, from the West to low and middle-income countries, has come under increasing scrutiny from academic scholars, practitioners, regulatory agencies and the media. This article reports the results of a study conducted in Bangalore and Hyderabad between 2007 and 2009, to elicit the perspectives of stakeholders, concerning media representations of their work and the ethical issues that emanate from their engagement in the clinical trials enterprise. In acknowledging the inherently problematic nature of the outsourcing of clinical trials to low income countries, I argue that the practice of not prioritizing research on diseases that are most prevalent among communities, from which subjects are recruited, demands a coordinated and sustained critique. I propose that the critical discourse on the outsourcing of clinical trials should not only emphasize the perils of this practice, but also address some broader issues of equity and distributive justice that determine people's access to basic health care in low income countries. Close attention to the specific context of clinical trials in an increasingly neoliberal medical and health environment in emerging economies such as India can provide critical insights into the on-the-ground complexities and challenges of outsourced global clinical trials. Copyright © 2013 Elsevier Ltd. All rights reserved.

Contextualized Language and Transferential Aspects of Context.

PubMed

Movahedi, Siamak

2015-08-01

The analytic process, in which the patient's and the analyst's internal characters struggle to create a script through the analysand's mouth and the analyst's pen, resembles Pirandello's Six Characters in Search of an Author (1921): different characters come together on the analytic stage to rehearse the analyst's role as coauthor of a play that depicts the ongoing analytic saga. To compose the text for the interplay of characters, the author must search for contexts that may confer meaning upon the words and actions of characters. This involves a search for a mise en scène (stage) that will assign mise en sens (meaning) to the actors' role-specific dialogue. Yet mise en scène, in the theatrical sense, is a set of iconic signs set with its own décor, props, and costumes. In contrast, the psychoanalytic scene is a symbolic stage for the play of words--words that may contain unconscious codes for switching into particular language games. A clinical case report describes a struggle with the contextual analysis of an aspect of a treatment that involved reported episodes of verbal indiscretions "taken out of context" with unwanted consequences. © 2015 by the American Psychoanalytic Association.

Challenges for Multilevel Health Disparities Research in a Transdisciplinary Environment

PubMed Central

Holmes, John H.; Lehman, Amy; Hade, Erinn; Ferketich, Amy K.; Sarah, Gehlert; Rauscher, Garth H.; Abrams, Judith; Bird, Chloe E.

2008-01-01

Numerous factors play a part in health disparities. Although health disparities are manifested at the level of the individual, other contexts should be considered when investigating the associations of disparities with clinical outcomes. These contexts include families, neighborhoods, social organizations, and healthcare facilities. This paper reports on health disparities research as a multilevel research domain from the perspective of a large national initiative. The Centers for Population Health and Health Disparities (CPHHD) program was established by the NIH to examine the highly dimensional, complex nature of disparities and their effects on health. Because of its inherently transdisciplinary nature, the CPHHD program provides a unique environment in which to perform multilevel health disparities research. During the course of the program, the CPHHD centers have experienced challenges specific to this type of research. The challenges were categorized along three axes: sources of subjects and data, data characteristics, and multilevel analysis and interpretation. The CPHHDs collectively offer a unique example of how these challenges are met; just as importantly, they reveal a broad range of issues that health disparities researchers should consider as they pursue transdisciplinary investigations in this domain, particularly in the context of a large team science initiative. PMID:18619398

Cure rate is not a valid indicator for assessing drug efficacy and impact of preventive chemotherapy interventions against schistosomiasis and soil-transmitted helminthiasis.

PubMed

Montresor, Antonio

2011-07-01

Every year in endemic countries, several million individuals are given anthelminthic drugs in the context of preventive chemotherapy programmes for morbidity control of schistosomiasis and soil-transmitted helminthiasis. The capacity to evaluate accurately the efficacy of the drugs used as well as the health impact produced by treatment is of utmost importance for appropriate planning and implementation of these interventions. Cure rate is an indicator of drug efficacy that was originally developed for assessing the clinical efficacy of antibiotics on selected bacterial diseases. Over time, this indicator has also been widely applied to anthelminthic drugs and consequently used to monitor and evaluate preventive chemotherapy interventions. In the author's opinion, however, measurement of cure rate provides information of limited usefulness in the context of helminth control programmes. The present article analyses the peculiarities of helminth infections and those of the drugs used in preventive chemotherapy, explaining the reasons why the cure rate is not an adequate indicator in this specific public health context. Copyright © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

The selective determination of sulfates, sulfonates, and phosphates in urine by capillary electrophoresis/mass spectrometry.

PubMed

Bunz, Svenja-Catharina; Neusüß, Christian

2013-01-01

Metabolite identification and metabolite profiling are of major importance in the pharmaceutical and clinical context. However, anions of biological relevance such as sulfates, sulfonates, and phosphates are rarely included in common techniques for metabolite studies. In this protocol, we demonstrate a unique method to selectively determine these anions. The method comprises a capillary electrophoresis separation using an acidic background electrolyte (pH ≤ 2) and anodic detection by mass spectrometry via negative electrospray ionization. In this way, only anions of strong acids like sulfates are determined. The selectivity for sulfur-containing species is proved based on the specific isotopic ratios. In conjunction with the accurate mass from the time-of-flight mass spectrometer, the presented method is well suited for clinical and pharmaceutical applications to identify possible metabolites and to quantify known metabolites.

Value and Payment in Sleep Medicine.

PubMed

Wickwire, Emerson M; Verma, Tilak

2018-05-15

Value, like beauty, exists in the eye of the beholder. This article places the value of clinical sleep medicine services in historical context and presents a vision for the value-based sleep of the future. First, the history of value and payment in sleep medicine is reviewed from the early days of the field, to innovative disruption, to the widespread adoption of home sleep apnea testing. Next, the importance of economic perspective is discussed, with emphasis on cost containment and cost-shifting between payers, employers, providers, and patients. Specific recommendations are made for sleep medicine providers and the field at large to maximize the perceived value of sleep. Finally, alternate payment models and value-based care are presented, with an eye toward the future for clinical service providers as well as integrated health delivery networks. © 2018 American Academy of Sleep Medicine.

Apparent elevated creatinine after ingestion of nitromethane: interference with the Jaffe reaction.

PubMed

Killorn, Erin; Lim, Rodrick K; Rieder, Michael

2011-02-01

We assessed a 2-year 4-month-old boy found to have a persistently elevated serum creatinine (peak 926 μmol/L) as measured by the Jaffe reaction after ingesting an unknown quantity of fuel for a model car, which commonly contains nitromethane. The patient was otherwise clinically well and the remaining investigations were unremarkable. When creatinine concentrations were measured with specific enzymatic testing on these same blood samples, all values were within normal limits. Nitromethane has been shown to interfere with the determination of serum creatinine through the Jaffe reaction. Because many ingestions present only rarely, it is not possible for the emergency department clinician to be aware of all toxin factors affecting patient management. This case illustrates the importance of analysis of laboratory results in the context of the patient's clinical status.

Pre-emptive and therapeutic adoptive immunotherapy for nasopharyngeal carcinoma: Phenotype and effector function of T cells impact on clinical response.

PubMed

Smith, Corey; Lee, Victor; Schuessler, Andrea; Beagley, Leone; Rehan, Sweera; Tsang, Janice; Li, Vivian; Tiu, Randal; Smith, David; A Neller, Michelle; Matthews, Katherine K; Gostick, Emma; Price, David A; Burrows, Jacqueline; Boyle, Glen M; Chua, Daniel; Panizza, Benedict; Porceddu, Sandro V; Nicholls, John; Kwong, Dora; Khanna, Rajiv

2017-01-01

Adoptive T cell therapy has emerged as a powerful strategy to treat human cancers especially haematological malignancies. Extension of these therapies to solid cancers remains a significant challenge especially in the context of defining immunological correlates of clinical responses. Here we describe results from a clinical study investigating autologous Epstein-Barr virus (EBV)-specific T cells generated using a novel AdE1-LMPpoly vector to treat patients with nasopharyngeal carcinoma (NPC) either pre-emptively in at-risk patients with no or minimal residual disease (N/MRD) or therapeutically in patients with active recurrent/metastatic disease (ARMD). Tolerability, safety and efficacy, including progression-free survival (PFS) and overall survival (OS), were evaluated following adoptive T-cell immunotherapy. Twenty-nine patients, including 20 with ARMD and nine with N/MRD, successfully completed T-cell therapy. After a median follow-up of 18.5 months, the median PFS was 5.5 months (95% CI 2.1 to 9.0 months) and the median OS was 38.1 months (95% CI 17.2 months to not reached). Post-immunotherapy analyses revealed that disease stabilization in ARMD patients was significantly associated with the functional and phenotypic composition of in vitro -expanded T cell immunotherapy. These included a higher proportion of effector CD8 + T-cells and an increased number of EBV-specific T-cells with broader antigen specificity. These observations indicate that adoptive immunotherapy with AdE1-LMPpoly-expanded T cells stabilizes relapsed, refractory NPC without significant toxicity. Promising clinical outcomes in N/MRD patients further suggest a potential role for this approach as a consolidation treatment following first-line chemotherapy.

Contextually Aided Recovery (CARe): a scientific theory for innate healing.

PubMed

Newell, Dave; Lothe, Lise R; Raven, Timothy J L

2017-01-01

The chiropractic profession emerged when scientific explanations for causes of health and disease were still in infancy and the co-existence of notions such as innate healing and vitalism were perhaps admissible within such a historical context. Notwithstanding, within the scientific culture of the 21 st Century all healthcare paradigms require evidential support which in regard these early concepts are in large part, absent. Nevertheless, a large body of emerging scientific evidence supports the existence of innate healing phenomena that may explain a plethora of clinical outcomes observed during chiropractic care. However, in contrast to the notion that removing the putative subluxation constitutes the mechanism by which this healing is initiated, the evidentially supported explanation is one that invokes the impact of contextual factors inherent in the skilful care and authority of the healthcare provider. This perspective is presented here as the scientific model of Contextually Aided Recovery (CARe). This paper contends that;Contextual effects are powerful and desirable and are triggered by contextual factors present in all therapeutic encounters including those encountered in chiropractic practice.These factors can elicit large clinical effects with substantive evidence supporting pain, immune and motor modulation.The compartmentalisation of specific and non-specific effects is a biologically and scientifically false dichotomy, erroneously invoked to de-legitimise treatment approaches that expertly construct contextual healing scenarios.The use of factors to construct contextual healing scenarios that maximise positive (placebo) and minimize negative (nocebo) effects is a skilful clinical art within the multimodal approach that describes modern chiropractic care and should be presented and defended as a legitimate component of orthodox healthcare Clinical improvement during chiropractic care, beyond any biologically specific treatment effects of manipulation and other modalities, may be largely understood considering contextual factors as described by a Contextually Aided Recovery (CARe) model.

Approaches to preparing young scholars for careers in interdisciplinary team science.

PubMed

Begg, Melissa D; Crumley, Gene; Fair, Alecia M; Martina, Camille A; McCormack, Wayne T; Merchant, Carol; Patino-Sutton, Cecilia M; Umans, Jason G

2014-01-01

To succeed as a biomedical researcher, the ability to flourish in interdisciplinary teams of scientists is becoming ever more important. Institutions supported by the Clinical and Translational Science Awards (CTSAs) from the National Institutes of Health have a specific mandate to educate the next generation of clinical and translational researchers. While they strive to advance integrated and interdisciplinary approaches to education and career development in clinical and translational science, general approaches and evaluation strategies may differ, as there is no single, universally accepted or standardized approach. It is important, therefore, to learn about the different approaches used to determine what is effective. We implemented a Web-based survey distributed to education leaders at the 60 funded CTSA institutions; 95% responded to the survey, which included questions on the importance of preparation for interdisciplinary team science careers, methods used to provide such training, and perceived effectiveness of these training programs. The vast majority (86%) of education leaders reported that such training is important, and about half (52%) of the institutions offer such training. Methods of training most often take the form of courses and seminars, both credit bearing and noncredit. These efforts are, by and large, perceived as effective by the training program leaders, although long-term follow-up of trainees would be required to fully evaluate ultimate effectiveness. Results from the survey suggest that CTSA education directors believe that specific training in interdisciplinary team science for young investigators is very important, but few methodologies are universally practiced in CTSA institutions to provide training or to assess performance. Four specific recommendations are suggested to provide measurable strategic goals for education in team science in the context of clinical and translational research.

Gene integrated set profile analysis: a context-based approach for inferring biological endpoints

PubMed Central

Kowalski, Jeanne; Dwivedi, Bhakti; Newman, Scott; Switchenko, Jeffery M.; Pauly, Rini; Gutman, David A.; Arora, Jyoti; Gandhi, Khanjan; Ainslie, Kylie; Doho, Gregory; Qin, Zhaohui; Moreno, Carlos S.; Rossi, Michael R.; Vertino, Paula M.; Lonial, Sagar; Bernal-Mizrachi, Leon; Boise, Lawrence H.

2016-01-01

The identification of genes with specific patterns of change (e.g. down-regulated and methylated) as phenotype drivers or samples with similar profiles for a given gene set as drivers of clinical outcome, requires the integration of several genomic data types for which an ‘integrate by intersection’ (IBI) approach is often applied. In this approach, results from separate analyses of each data type are intersected, which has the limitation of a smaller intersection with more data types. We introduce a new method, GISPA (Gene Integrated Set Profile Analysis) for integrated genomic analysis and its variation, SISPA (Sample Integrated Set Profile Analysis) for defining respective genes and samples with the context of similar, a priori specified molecular profiles. With GISPA, the user defines a molecular profile that is compared among several classes and obtains ranked gene sets that satisfy the profile as drivers of each class. With SISPA, the user defines a gene set that satisfies a profile and obtains sample groups of profile activity. Our results from applying GISPA to human multiple myeloma (MM) cell lines contained genes of known profiles and importance, along with several novel targets, and their further SISPA application to MM coMMpass trial data showed clinical relevance. PMID:26826710

Extending the theoretical framework for curriculum integration in pre-clinical medical education.

PubMed

Vergel, John; Stentoft, Diana; Montoya, Juny

2017-08-01

Curriculum integration is widely discussed in medical education but remains ill defined. Although there is plenty of information on logistical aspects of curriculum integration, little attention has been paid to the contextual issues that emerge from its practice and may complicate students' knowledge integration. Therefore, we aimed to uncover how curriculum integration is manifested through context. We collected data from the official curriculum and interviewed ten participants (including curriculum designers, facilitators, and students) in the bachelor's medical program at Aalborg University. We observed various learning activities focused on pre-clinical education. Inspired by grounded theory, we analyzed the information we gathered. The following theoretical constructs emerged after the inductive analysis: 1) curriculum integration complexity is embedded in the institutional learning perspectives; 2) curriculum integration is used to harmonize conflicting learning perspectives in curriculum practice; 3) curriculum integration creates tensions that self-organize its structure; and 4) curriculum integration becomes visible in collaborative learning spaces. These constructs provide a framework for analyzing curriculum integration in the context in which it is meant to appear, which may assist educationalists to gain a more specific understanding of the term. This may enable effective curriculum integration since contextual issues are addressed in addition to the goals specified in the official curriculum.

"Black folk don't get no severe depression": Meanings and expressions of depression in a predominantly black urban neighborhood in Midwestern United States.

PubMed

Alang, Sirry M

2016-05-01

Discrepancies exist between how some Black populations perceive depression and how depression is conceptualized within research and clinical settings. Based on a 12-month ethnography of mental health in a predominantly Black disadvantaged urban neighborhood in Midwestern United States, the current study identifies meanings and common ways of expressing depression among African Americans. Depression was often considered a sign of weakness rather than a health problem that might need medical attention. Associated emotions like sadness and hopelessness were inconsistent with notions of strength. Common indicators of depression included classic symptoms such as hopelessness, loss of sleep, and feeling worthless. However, expressions of depression such as anger, agitation, violent behavior, and a frantic search for social interaction that are inconsistent with DSM-V criteria were also common. These findings have implications for the clinical assessment of depression and for the measurement of depression in community surveys. In addition, the context and meaning of symptoms play an important role in determining whether experiences are indicative of depression. This paper underscores that the provision of patient-centered mental health care requires a better understanding of the conceptualization of disorders within specific contexts. Copyright © 2016 Elsevier Ltd. All rights reserved.

Cognitive Analysis of Decision Support for Antibiotic Prescribing at the Point of Ordering in a Neonatal Intensive Care Unit

PubMed Central

Sheehan, Barbara; Kaufman, David; Stetson, Peter; Currie, Leanne M.

2009-01-01

Computerized decision support systems have been used to help ensure safe medication prescribing. However, the acceptance of these types of decision support has been reported to be low. It has been suggested that decreased acceptance may be due to lack of clinical relevance. Additionally, cognitive fit between the user interface and clinical task may impact the response of clinicians as they interact with the system. In order to better understand clinician responses to such decision support, we used cognitive task analysis methods to evaluate clinical alerts for antibiotic prescribing in a neonatal intensive care unit. Two methods were used: 1) a cognitive walkthrough; and 2) usability testing with a ‘think-aloud’ protocol. Data were analyzed for impact on cognitive effort according to categories of cognitive distance. We found that responses to alerts may be context specific and that lack of screen cues often increases cognitive effort required to use a system. PMID:20351922

Enacting the ‘neuro’ in practice: Translational research, adhesion and the promise of porosity

PubMed Central

Michael, Mike

2014-01-01

This article attends to the processes through which neuroscience and the neuro are enacted in a specific context: a translational neuroscience research group that was the setting of an ethnographic study. The article therefore provides a close-up perspective on the intersection of neuroscience and translational research. In the scientific setting we studied, the neuro was multiple and irreducible to any particular entity or set of practices across a laboratory and clinical divide. Despite this multiplicity, the group’s work was held together through the ‘promise of porosity’ – that one day there would be translation of lab findings into clinically effective intervention. This promise was embodied in the figure of the Group Leader whose expertise spanned clinical and basic neurosciences. This is theorized in terms of a contrast between cohesion and adhesion in interdisciplinary groupings. We end by speculating on the role of ‘vivification’ – in our case mediated by the Group Leader – in rendering ‘alive’ the expectations of interdisciplinary collaboration. PMID:25362829

Factors That Influence the Efficacy of Stretching Programs for Patients With Hypomobility

PubMed Central

Jacobs, Cale A.; Sciascia, Aaron D.

2011-01-01

Context: Passive stretching exercise protocols, as part of outpatient treatment or home exercise programs, are used to improve hypomobility. Despite the cosmopolitan use of stretching exercises, little is known about the forces being applied to the joint during these routine treatments. Type of Study: Clinical review. Evidence Acquisition: Articles were identified using MEDLINE and Google Scholar databases, with searches initially limited to those articles published after 1995. Seminal articles that were referenced were also included. Results: Many factors contribute to the clinical success of a stretching program, including the frequency, intensity, and duration of the stretching exercises, as well as patient- and joint-specific factors. Conclusions: The goal of a stretching protocol is to maximize total end-range time both in the clinic and at home. Higher intensity, prolonged, and frequent stretching (10- to 15-minute bouts, 3 to 6 times per day) used as an adjunct to high-grade mobilizations may be beneficial for certain hypomobility conditions. PMID:23016052

Integrating cost information with health management support system: an enhanced methodology to assess health care quality drivers.

PubMed

Kohli, R; Tan, J K; Piontek, F A; Ziege, D E; Groot, H

1999-08-01

Changes in health care delivery, reimbursement schemes, and organizational structure have required health organizations to manage the costs of providing patient care while maintaining high levels of clinical and patient satisfaction outcomes. Today, cost information, clinical outcomes, and patient satisfaction results must become more fully integrated if strategic competitiveness and benefits are to be realized in health management decision making, especially in multi-entity organizational settings. Unfortunately, traditional administrative and financial systems are not well equipped to cater to such information needs. This article presents a framework for the acquisition, generation, analysis, and reporting of cost information with clinical outcomes and patient satisfaction in the context of evolving health management and decision-support system technology. More specifically, the article focuses on an enhanced costing methodology for determining and producing improved, integrated cost-outcomes information. Implementation issues and areas for future research in cost-information management and decision-support domains are also discussed.

Suicide after absconding from inpatient care in England: an exploration of mental health professionals' experiences.

PubMed

Hunt, Isabelle M; Clements, Caroline; Saini, Pooja; Rahman, Mohammad Shaiyan; Shaw, Jenny; Appleby, Louis; Kapur, Nav; Windfuhr, Kirsten

2016-06-01

Absconding from inpatient care is associated with suicide risk in psychiatric populations. However, little is known about the real world context of suicide after absconding from a psychiatric ward or the experiences of clinical staff caring for these patients. To identify the characteristics of inpatients who died by suicide after absconding and to explore these and further key issues related to suicide risk from the perspective of clinical staff. A mixed-methods study using quantitative data of all patient suicides in England between 1997 and 2011 and a thematic analysis of semi-structured interviews with 21 clinical staff. Four themes were identified as areas of concern for clinicians: problems with ward design, staffing problems, difficulties in assessing risk, and patient specific factors. Results suggest that inpatients who died by suicide after absconding may have more complex and severe illness along with difficult life events, such as homelessness. Closer monitoring of inpatients and access points, and improved risk assessments are important to reduce suicide in this patient group.

Context-Sensitive Clinical Alert Packages Written in Arden Syntax.

PubMed

Zeckl, Julia; Adlassnig, Katharina; Fossler, Renate; Blacky, Alexander; de Bruin, Jeroen S; Koller, Walter; Rappelsberger, Andrea; Adlassnig, Klaus-Peter

2017-01-01

An increasing body of raw patient data is generated on each day of a patient's stay at a hospital. It is of paramount importance that critical patient information be extracted from these large data volumes and presented to the patient's clinical caregivers as early as possible. Contemporary clinical alert systems attempt to provide this service with moderate success. The efficacy of the systems is limited by the fact that they are too general to fit specific patient populations or healthcare institutions. In this study we present an extendable alerting framework implemented in Arden Syntax, which can be configured to the needs and preferences of healthcare institutions and individual patient caregivers. We illustrate the potential of this alerting framework via an alert package that analyzes hematological laboratory results with data from intensive care units at the Vienna General Hospital, Austria. The results show the effectiveness of this alert package and its ability to generate key alerts while avoiding over-alerting.

Context-Specific Outdoor Time and Physical Activity among School-Children Across Gender and Age: Using Accelerometers and GPS to Advance Methods

PubMed Central

Klinker, Charlotte Demant; Schipperijn, Jasper; Kerr, Jacqueline; Ersbøll, Annette Kjær; Troelsen, Jens

2014-01-01

Introduction: Being outdoors has a positive influence on health among children. Evidence in this area is limited and many studies have used self-reported measures. Objective context-specific assessment of physical activity patterns and correlates, such as outdoor time, may progress this field. Aims: To employ novel objective measures to assess age and gender differences in context-specific outdoor weekday behavior patterns among school-children [outdoor time and outdoor moderate to vigorous physical activity (MVPA)] and to investigate associations between context-specific outdoor time and MVPA. Methods: A total of 170 children had at least one weekday of 9 h combined accelerometer and global positioning system data and were included in the analyses. The data were processed using the personal activity and location measurement system (PALMS) and a purpose-built PostgreSQL database resulting in context-specific measures for outdoor time, outdoor MVPA, and overall daily MVPA. In addition, 4 domains (leisure, school, transport, and home) and 11 subdomains (e.g., urban green space and sports facilities) were created and assessed. Multilevel analyses provided results on age and gender differences and the association between outdoor time and MVPA. Results: Girls compared to boys had fewer outdoor minutes (p < 0.05), spent a smaller proportion of their overall daily time outdoors (p < 0.05), had fewer outdoor MVPA minutes during the day (p < 0.001) and in 11 contexts. Children compared to adolescents had more outdoor minutes (p < 0.05). During school and within recess, children compared to adolescents had more outdoor MVPA (p < 0.001) and outdoor time (p < 0.001). A 1-h increase in outdoor time was associated with 9.9 more minutes of MVPA (p < 0.001). Conclusion: A new methodology to assess the context-specific outdoor time and physical activity patterns has been developed and can be expanded to other populations. Different context-specific patterns were found for gender and age, suggesting different strategies may be needed to promote physical activity. PMID:24653983

A bayesian translational framework for knowledge propagation, discovery, and integration under specific contexts.

PubMed

Deng, Michelle; Zollanvari, Amin; Alterovitz, Gil

2012-01-01

The immense corpus of biomedical literature existing today poses challenges in information search and integration. Many links between pieces of knowledge occur or are significant only under certain contexts-rather than under the entire corpus. This study proposes using networks of ontology concepts, linked based on their co-occurrences in annotations of abstracts of biomedical literature and descriptions of experiments, to draw conclusions based on context-specific queries and to better integrate existing knowledge. In particular, a Bayesian network framework is constructed to allow for the linking of related terms from two biomedical ontologies under the queried context concept. Edges in such a Bayesian network allow associations between biomedical concepts to be quantified and inference to be made about the existence of some concepts given prior information about others. This approach could potentially be a powerful inferential tool for context-specific queries, applicable to ontologies in other fields as well.

Understanding the context of balanced scorecard implementation: a hospital-based case study in Pakistan.

PubMed

Rabbani, Fauziah; Lalji, Sabrina Nh; Abbas, Farhat; Jafri, Sm Wasim; Razzak, Junaid A; Nabi, Naheed; Jahan, Firdous; Ajmal, Agha; Petzold, Max; Brommels, Mats; Tomson, Goran

2011-03-31

As a response to a changing operating environment, healthcare administrators are implementing modern management tools in their organizations. The balanced scorecard (BSC) is considered a viable tool in high-income countries to improve hospital performance. The BSC has not been applied to hospital settings in low-income countries nor has the context for implementation been examined. This study explored contextual perspectives in relation to BSC implementation in a Pakistani hospital. Four clinical units of this hospital were involved in the BSC implementation based on their willingness to participate. Implementation included sensitization of units towards the BSC, developing specialty specific BSCs and reporting of performance based on the BSC during administrative meetings. Pettigrew and Whipp's context (why), process (how) and content (what) framework of strategic change was used to guide data collection and analysis. Data collection methods included quantitative tools (a validated culture assessment questionnaire) and qualitative approaches including key informant interviews and participant observation. Method triangulation provided common and contrasting results between the four units. A participatory culture, supportive leadership, financial and non-financial incentives, the presentation of clear direction by integrating support for the BSC in policies, resources, and routine activities emerged as desirable attributes for BSC implementation. The two units that lagged behind were more involved in direct inpatient care and carried a considerable clinical workload. Role clarification and consensus about the purpose and benefits of the BSC were noted as key strategies for overcoming implementation challenges in two clinical units that were relatively ahead in BSC implementation. It was noted that, rather than seeking to replace existing information systems, initiatives such as the BSC could be readily adopted if they are built on existing infrastructures and data networks. Variable levels of the BSC implementation were observed in this study. Those intending to apply the BSC in other hospital settings need to ensure a participatory culture, clear institutional mandate, appropriate leadership support, proper reward and recognition system, and sensitization to BSC benefits.

A face for all seasons: Searching for context-specific leadership traits and discovering a general preference for perceived health

PubMed Central

Spisak, Brian R.; Blaker, Nancy M.; Lefevre, Carmen E.; Moore, Fhionna R.; Krebbers, Kleis F. B.

2014-01-01

Previous research indicates that followers tend to contingently match particular leader qualities to evolutionarily consistent situations requiring collective action (i.e., context-specific cognitive leadership prototypes) and information processing undergoes categorization which ranks certain qualities as first-order context-general and others as second-order context-specific. To further investigate this contingent categorization phenomenon we examined the “attractiveness halo”—a first-order facial cue which significantly biases leadership preferences. While controlling for facial attractiveness, we independently manipulated the underlying facial cues of health and intelligence and then primed participants with four distinct organizational dynamics requiring leadership (i.e., competition vs. cooperation between groups and exploratory change vs. stable exploitation). It was expected that the differing requirements of the four dynamics would contingently select for relatively healthier- or intelligent-looking leaders. We found perceived facial intelligence to be a second-order context-specific trait—for instance, in times requiring a leader to address between-group cooperation—whereas perceived health is significantly preferred across all contexts (i.e., a first-order trait). The results also indicate that facial health positively affects perceived masculinity while facial intelligence negatively affects perceived masculinity, which may partially explain leader choice in some of the environmental contexts. The limitations and a number of implications regarding leadership biases are discussed. PMID:25414653

Self-face recognition in social context.

PubMed

Sugiura, Motoaki; Sassa, Yuko; Jeong, Hyeonjeong; Wakusawa, Keisuke; Horie, Kaoru; Sato, Shigeru; Kawashima, Ryuta

2012-06-01

The concept of "social self" is often described as a representation of the self-reflected in the eyes or minds of others. Although the appearance of one's own face has substantial social significance for humans, neuroimaging studies have failed to link self-face recognition and the likely neural substrate of the social self, the medial prefrontal cortex (MPFC). We assumed that the social self is recruited during self-face recognition under a rich social context where multiple other faces are available for comparison of social values. Using functional magnetic resonance imaging (fMRI), we examined the modulation of neural responses to the faces of the self and of a close friend in a social context. We identified an enhanced response in the ventral MPFC and right occipitoparietal sulcus in the social context specifically for the self-face. Neural response in the right lateral parietal and inferior temporal cortices, previously claimed as self-face-specific, was unaffected for the self-face but unexpectedly enhanced for the friend's face in the social context. Self-face-specific activation in the pars triangularis of the inferior frontal gyrus, and self-face-specific reduction of activation in the left middle temporal gyrus and the right supramarginal gyrus, replicating a previous finding, were not subject to such modulation. Our results thus demonstrated the recruitment of a social self during self-face recognition in the social context. At least three brain networks for self-face-specific activation may be dissociated by different patterns of response-modulation in the social context, suggesting multiple dynamic self-other representations in the human brain. Copyright © 2011 Wiley-Liss, Inc.

Statistical context shapes stimulus-specific adaptation in human auditory cortex.

PubMed

Herrmann, Björn; Henry, Molly J; Fromboluti, Elisa Kim; McAuley, J Devin; Obleser, Jonas

2015-04-01

Stimulus-specific adaptation is the phenomenon whereby neural response magnitude decreases with repeated stimulation. Inconsistencies between recent nonhuman animal recordings and computational modeling suggest dynamic influences on stimulus-specific adaptation. The present human electroencephalography (EEG) study investigates the potential role of statistical context in dynamically modulating stimulus-specific adaptation by examining the auditory cortex-generated N1 and P2 components. As in previous studies of stimulus-specific adaptation, listeners were presented with oddball sequences in which the presentation of a repeated tone was infrequently interrupted by rare spectral changes taking on three different magnitudes. Critically, the statistical context varied with respect to the probability of small versus large spectral changes within oddball sequences (half of the time a small change was most probable; in the other half a large change was most probable). We observed larger N1 and P2 amplitudes (i.e., release from adaptation) for all spectral changes in the small-change compared with the large-change statistical context. The increase in response magnitude also held for responses to tones presented with high probability, indicating that statistical adaptation can overrule stimulus probability per se in its influence on neural responses. Computational modeling showed that the degree of coadaptation in auditory cortex changed depending on the statistical context, which in turn affected stimulus-specific adaptation. Thus the present data demonstrate that stimulus-specific adaptation in human auditory cortex critically depends on statistical context. Finally, the present results challenge the implicit assumption of stationarity of neural response magnitudes that governs the practice of isolating established deviant-detection responses such as the mismatch negativity. Copyright © 2015 the American Physiological Society.

Clinical Education in Athletic Training

ERIC Educational Resources Information Center

Edler, Jessica R.; Eberman, Lindsey E.; Walker, Stacy

2017-01-01

Context: Clinical education is a foundational component of healthcare education by which students acquire, practice, and demonstrate competency in clinical proficiencies through classroom, laboratory, and clinical experiences. Currently, the most common practice of clinical education in athletic training is clinical integration. Objective: The…

The role of test context in latent inhibition of conditioned inhibition: Part of a search for general principles of associative interference.

PubMed

Miguez, Gonzalo; Soares, Julia S; Miller, Ralph R

2015-09-01

In two lick suppression experiments with rats, we assessed interference with behavior indicative of conditioned inhibition by a latent inhibition treatment as a function of test context. We asked what effect the test context has, given identical latent inhibition treatments in Phase 1 and identical conditioned inhibition trainings in Phase 2. In Experiment 1, an AAA versus AAB context-shift design determined that the latent inhibition treatment in Phase 1 attenuated behavior indicative of the conditioned inhibition training administered in Phase 2, regardless of the test context, which could reflect a failure to either acquire or express conditioned inhibition. In Experiment 2, an ABA versus ABB design showed that test performance in Contexts A and B reflected the treatments that had been administered in those contexts (i.e., conditioned inhibition was observed in Context B but not A), which could reflect either the context specificity of either latent inhibition or conditioned inhibition. In either case, latent inhibition of conditioned inhibition training in at least some situations was seen to reflect an expression deficit rather than an acquisition deficit. These data, in conjunction with prior reports, suggest that latent inhibition is relatively specific to the context in which it was administered, whereas conditioned inhibition is specific to its training context only when it is the second-learned relationship concerning the target cue. These experiments are part of a larger effort to delineate control by the test context of two-phase associative interference, as a function of the nature of target training and the nature of interference training.

Clinical microsystems, Part 3. Transformation of two hospitals using microsystem, mesosystem, and macrosystem strategies.

PubMed

Godfrey, Marjorie M; Melin, Craig N; Muething, Stephen E; Batalden, Paul B; Nelson, Eugene C

2008-10-01

Two hospitals-a large, urban academic medical center and a rural, community hospital-have each chosen a similar microsystem-based approach to improvement, customizing the engagement of the micro-, meso-, and macrosystems and the improvement targets on the basis of an understanding of the local context. CINCINNATI CHILDREN'S HOSPITAL MEDICAL CENTER (CCHMC): Since 2004, strategic changes have been developed to support microsystems and their leaders through (1) ongoing improvement training for all macro-, meso-, and microsystem leaders; (2) financial support for physicians who are serving as co-leaders of clinical microsystems; (3) increased emphasis on aligning academic pursuits with improvement work at the clinical front lines; (4) microsystem leaders' continuous access to unit-level data through the organization's intranet; and (5) encouragement of unit leaders to share outcomes data with families. CDH has moved from near closure to a survival-turnaround focus, significant engagement in quality and finally, a complete reframing of a quality focus in 2004. Since then, it has deployed the clinical microsystems approach in one pilot care unit (West 2, a medical surgery unit), broadened it to two, then six more, and is now spreading it organizationwide. In "2+2 Charters," interdisciplinary teams address two strategic goals set by senior leadership and two goals set by frontline microsystem leaders and staff CCHMC and CDH have had a clear focus on developing alignment, capability, and accountability to fuse together the work at all levels of the hospital, unifying the macrosystem with the mesosystem and microsystem. Their improvement experience suggests tips and actions at all levels of the organization that could be adapted with specific context knowledge by others.

Child-care quality moderates the association between maternal depression and children's behavioural outcome.

PubMed

Charrois, Justine; Côté, Sylvana M; Japel, Christa; Séguin, Jean R; Paquin, Stéphane; Tremblay, Richard E; Herba, Catherine M

2017-11-01

Maternal depression is a risk factor for adverse outcomes in the child, including emotional and behavioural difficulties. There is evidence that child care attendance during the preschool years may moderate associations between familial risk factors and child outcome. However, the possibility that high-quality child care provides protection for children exposed to maternal depression or that low-quality child care provides additional risk has not been investigated. We study whether child-care quality moderates the association between probable history of maternal depression (PMD) and child behavioural and emotional outcomes over the preschool period. Within a longitudinal study, we examined PMD (no depression; clinical PMD before the child's birth; subclinical PMD from 0 to 5 years; clinical PMD from 0 to 5 years), child-care quality and child emotional and behavioural difficulties at the ages of 2, 3 and 4 years. Child-care quality was evaluated in settings, and trajectories were calculated to reflect (a) global quality and (b) two quality subfactors: 'Teaching and interactions' and 'Provision for learning'. Data were analysed for 264 families. Significant interactions emerged between clinical PMD and global quality of child care for children's externalising behaviour (b = -.185, p = .008), more specifically hyperactivity/inattention (b = -.237, p = .002). In the context of clinical PMD, children attending high-quality child care presented fewer difficulties than those attending a low-quality care. Child-care quality was not associated with outcomes for children whose mothers did not report a PMD or a PMD before their birth. In the context of PMD, high-quality child care was associated with fewer behavioural problems and may thus constitute a protective factor. © 2017 Association for Child and Adolescent Mental Health.

The use and impact of quality of life assessment tools in clinical care settings for cancer patients, with a particular emphasis on brain cancer: insights from a systematic review and stakeholder consultations.

PubMed

King, Sarah; Exley, Josephine; Parks, Sarah; Ball, Sarah; Bienkowska-Gibbs, Teresa; MacLure, Calum; Harte, Emma; Stewart, Katherine; Larkin, Jody; Bottomley, Andrew; Marjanovic, Sonja

2016-09-01

Patient-reported data are playing an increasing role in health care. In oncology, data from quality of life (QoL) assessment tools may be particularly important for those with limited survival prospects, where treatments aim to prolong survival while maintaining or improving QoL. This paper examines the use and impact of using QoL measures on health care of cancer patients within a clinical setting, particularly those with brain cancer. It also examines facilitators and challenges, and provides implications for policy and practice. We conducted a systematic literature review, 15 expert interviews and a consultation at an international summit. The systematic review found no relevant intervention studies specifically in brain cancer patients, and after expanding our search to include other cancers, 15 relevant studies were identified. The evidence on the effectiveness of using QoL tools was inconsistent for patient management, but somewhat more consistent in favour of improving patient-physician communication. Interviews identified unharnessed potential and growing interest in QoL tool use and associated challenges to address. Our findings suggest that the use of QoL tools in cancer patients may improve patient-physician communication and have the potential to improve care, but the tools are not currently widely used in clinical practice (in brain cancer nor some other cancer contexts) although they are in clinical trials. There is a need for further research and stakeholder engagement on how QoL tools can achieve most impact across cancer and patient contexts. There is also a need for policy, health professional, research and patient communities to strengthen information exchange and debate, support awareness raising and provide training on tool design, use and interpretation.

Urinary tract infections in pregnancy: evaluation of diagnostic framework.

PubMed

Jido, Tukur Ado

2014-01-01

This study was performed with the objective to examine the diagnostic framework for urinary tract infection (UTI) in pregnancy and physician response to the clinical diagnosis and to correlate responses to the results of urine culture and sensitivity. Over a 6-month period, 81 consecutive patients attending the labor ward admission of a district general hospital with the diagnosis of UTI during pregnancy were analyzed. Relevant information on symptom complex, result of dipstick urinalysis and culture and sensitivity were recorded. Data were analyzed using descriptive statistics. Of the 78 patients analyzed, 79% had increased urinary frequency, 73.1% had suprapubic pains and 53.1% had dysuria. All the patients had urinalysis with dipsticks, 41 (52.6%) were positive for nitrites and 64 (82.1%) were positive for leukocyte esterase. All 78 patients had urine culture and sensitivity, 21 (26.8%) of who were positive, and coliforms were the most commonly isolated pathogens. The sensitivity for nitrite was 80.9%, specificity 57.9% and positive predictive value 41.4%. The corresponding figures for leukocyte esterase were sensitivity 100%, specificity 24.6% and positive predictive value 32.8%. Sixty-six (84.6%) patients had treatment started on the basis of the clinical diagnosis, mostly with co-amoxyclavullinic acid or amoxicillin alone. A high resistance rate to these empirically chosen antibiotics was seen in the sensitivity pattern of isolated pathogens. Current clinical diagnostic algorithms for the diagnosis of UTI when applied in the context of pregnancy have low specificity and positive predictive values; yet, empirical antibiotics are frequently employed on this basis. These are often not in keeping with the sensitivity pattern of isolated organisms. There is need for a continuing research for more specific bedside tests.