Legal and ethical issues for nurses in treatment of a patient in a forensic psychiatric unit

Uvod: Forenzična psihiatrija je smer klinične psihiatrije, ki obravnava paciente z duševno boleznijo, ki so v obdobju neprištevnosti storili kaznivo dejanje. Medicinska sestra na tem področju se kljub zavedanju načel profesionalne etike nemalokrat znajde v situacijah, ki ji predstavljajo etični izziv. Pomembno je, da vedno ravna v dobro pacienta in si prizadeva za čim boljši terapevtski odnos. Namen zaključnega dela je ugotoviti, s katerimi pravnimi in etičnimi izzivi se najpogosteje srečujejo medicinske sestre na tem področju. Metode: Pri izdelavi zaključnega dela smo opravili pregled literature. Članke smo iskali s pomočjo podatkovnih baz: PubMed, SAGE, ScienceDirect in Web of Science, z upoštevanjem iskalnega niza ter vključitvenih in izključitvenih kriterijev. Celoten potek iskanja literature smo prikazali z diagramom PRISMA. Za prikaz sinteze raziskav smo uporabili narativni opis. Rezultati: Glede na primernost identificiranih raziskav smo v končno analizo vključili 13 člankov. Raziskave so pokazale, da so najpogostejši pravni in etični izzivi medicinskih sester na enoti za forenzično psihiatrijo spoštovanje avtonomije in dostojanstva, informirana privolitev, spoštovanje pravic pacienta, zdravljenje proti volji, uporaba prisilnih varovalnih ukrepov, zagotavljanje enakopravnosti in nudenje kakovostne oskrbe ob stalno prisotnem strahu. Razprava in zaključek: Zaradi naraščanja števila forenzičnih pacientov je pomembno, da se medicinske sestre zavedajo pomena etičnega ravnanja in poznavanja pravne podlage tega področja. Ob pojavu etično sporne situacije je vedno treba delati v dobro pacienta v skladu s svojimi poklicnimi obveznostmi.Introduction: Forensic psychiatry is a branch of clinical psychiatry that treats mentally ill patients who have committed a crime during insanity. Despite being aware of the principles of professional ethics, a nurse in this field often finds herself in situations that pose an ethical challenge. Nurses must always act in the patient’s best interest and strive for the best possible therapeutic relationship. This thesis aims to determine which legal and ethical challenges nurses in this field most often encounter. Methods: A literature review was carried out for the final thesis. We searched for articles using the following databases: PubMed, SAGE, ScienceDirect and Web of Science, using a search string and inclusion and exclusion criteria. The search process of the literature was shown with the PRISMA diagram. A narrative description was used to present the research synthesis. Results: Based on the relevance of the identified studies, 13 articles were included in the final analysis. Research has shown that the most common legal and ethical challenges for nurses in the forensic psychiatric unit are respect for autonomy and dignity, informed consent, respect for patient rights, treatment against their will, the use of coercive protective measures, ensuring equality and providing quality care in the presence of constant fear. Discussion and conclusion: With the increasing number of forensic patients, nurses must be aware of the importance of ethical behaviour and know the legal basis of this field. In an ethically questionable situation, you must always work for the patient’s benefit following your professional responsibilities

Effect of different sterilisation techniques and common holly ( Ilex aquifilium l.) bud type on the success of establishing tissue culture

V letu 2023 smo na Fakulteti za kmetijstvo in biosistemske vede v Mariboru opravili poskus, v katerem smo proučevali vpliv različnih načinov sterilizacije in vpliv tipa brstov (apikalni in aksilarni) na vzpostavitev tkivne kulture navadne bodike (Ilex aquifolium L.). Za razkuževanje smo uporabili dve različni sterilizacijski sredstvi, dikloroizocianurno kislino (DICA) in natrijev hipoklorit (NaClO), v različnih koncentracijah in z različnim časom tretiranja. V raziskavo je bilo vključenih 640 brstov, na katerih smo skupno opravili 7 različnih načinov sterilizacije. Vse brste smo predhodno tretirali v 70-% etanolu za 40 sekund. Razkužene brste smo prenesli na osnovno gojišče McCown Woody Plant in spremljali rast. Ugotovili smo, da tako način sterilizacije kot tudi tip brstov vplivata na pridobljeno število vitalnih poganjkov. Skupno smo uspešno sterilizirali 22 brstov. Za uspešnejše so se izkazali apikalni brsti. Pri primerjavi sterilizacijskih sredstev se je tretiranje z DICA izkazalo za uspešnejše, pridobili smo 18 vitalnih brstov. Najuspešnejša je bila sterilizacija brstov z DICA in časom tretiranja 5 minut, kjer smo pridobili 7 vitalnih brstov.In 2023, an experiment was conducted at the Faculty of Agriculture and Life Sciences in Maribor, to investigate the effect of different sterilisation techniques and the influence of bud type (apical and axillary) on the establishment of tissue culture of common holly (Ilex aquifolium L.). Two different sterilising agents, dichloroisocyanuric acid (DICA) and sodium hypochlorite (NaClO), were used in different concentrations and treatment times for disinfection. The study included 640 buds and seven sterilisation treatments. All buds were first treated in 70 % ethanol for 40 seconds. After disinfection, the buds were placed on McCown Woody Plant Medium and their growth was observed. The results showed that both the method of sterilisation and the type of buds influenced the number of viable shoots obtained. Of the 640 buds, only 22 were successfully sterilised, with the apical buds proved to be more successful. When comparing the sterilisation methods, the DICA treatment proved to be more successful, as 18 viable buds were obtained. The most effective sterilization method was a 5-minute treatment of the buds with DICA, which produced seven viable buds

Primerjava in implementacija poškodbenih modelov termo-mehanskega utrujanja

The basis of the master thesis is an in-depth and comprehensive analysis of the scientific literature on damage models of thermo-mechanical fatigue. The aim of the thesis is to investigate and determine the suitability of damage models for their application in numerical simulations of components subjected to thermo-mechanical loading with in-phase, out-of-phase or constant temperature cycles. The theoretical background of material behavior under static and dynamic loads (e.g. low-cycle fatigue, high-cycle fatigue) is presented. The work also includes an overview of damage mechanisms typical of time-temperature varying loading conditions (e.g. cyclic softening and hardening of the material, mean stress relaxation, material creep, visco-plasticity, etc.). This is followed by a structured review of several damage models of thermo-mechanical fatigue (e.g. Neu-Sehitoglu, DTMF, Coffin-Manson, Ostergren, Smith-Watson-Topper, Unified Energy Approach, etc.). An overview of the experimental tests on aluminum alloy and cast iron carried out at temperatures up to 800 °C is given. The idea of processing the raw experimental data including the calibration procedure of the thermo-mechanical fatigue damage models is schematically illustrated and described. The basic mathematical laws of constitutive material models for both material types are given. In the conclusion of the MSc thesis, the correlations of the calibrated damage models are presented, which, together with the constructive opinions, give an important message on the application of the individual damage models depending on the type of material and the loading method.Temelj magistrskega dela je poglobljena in izčrpna analiza znanstvene literature s področja poškodbenih modelov termo-mehanskega utrujanja. Namen dela je raziskati in ugotoviti primernost poškodbenih modelov, za aplikacije le-teh, v numeričnih simulacijah komponent, ki so izpostavljene termo-mehanskemu obremenjevanju s cikli v fazi, cikli iz faze ali konstantni temperaturi. Predstavljeno je teoretično ozadje obnašanja materiala pri statičnih in dinamičnih obremenitvah (npr. malo-ciklično utrujanje, veliko-ciklično utrujanje). Delo prav tako zajema pregled poškodbenih mehanizmov, ki so tipični za časovno-temperaturno se spreminjajoče obremenitvene pogoje (npr. ciklično mehčanje in utrjevanje materiala, sprostitev vpliva srednje napetosti, lezenje materiala, visko-plastičnost,…). Sledi strukturiran pregled več poškodbenih modelov termo-mehanskega utrujanja (npr. Neu-Sehitoglu, DTMF, Coffin-Manson, Ostergren, Smith-Watson-Topper, Unified Energy Approach,…). Podan je pregled eksperimentalnih testov aluminijeve zlitine in litega železa, ki so bili izvedeni pri temperaturah do 800 °C. Shematsko je prikazana in opisana ideja obdelave surovih eksperimentalnih podatkov vključno s postopkom kalibracije poškodbenih modelov termo-mehanskega utrujanja. Podane so osnovne matematične zakonitosti konstitutivnih materialnih modelov za obe vrsti materiala. V zaključku magistrskega dela so predstavljene korelacije kalibriranih poškodbenih modelov, ki skupaj s konstruktivnimi mnenji, podajo pomembno sporočilo o aplikaciji posameznih poškodbenih modelov v odvisnosti od vrste materiala in načina obremenjevanja

Pilot Vending Machines with Food in Hospitals, Health Centers and Public Social Welfare Institutions

Prodajni avtomati z živili so v zadnjih letih vse bolj pod drobnogledom, saj je njihova ponudba največkrat sestavljena iz izdelkov, ki imajo visoko energijsko vrednost, visoko vrednost maščob, sladkorjev in soli. Zdravstveni in socialnovarstveni zavodi bi morali predstavljati zgled pri ponudbi zdravih živil v prodajnih avtomatih, saj veljajo kot vodilne institucije za promocijo zdravega prehranjevanja. V magistrskem delu smo preverjali kupne navade potrošnikov s spremljanjem prodaje na prodajnih avtomatih s standardno ponudbo in na prodajnih avtomatih z bolj zdravo ponudbo živil. Kupne navade smo preverjali s pomočjo anketnega vprašalnika. Raziskavo smo izvajali v izbrani bolnišnici, zdravstvenem domu in v javnem socialnovarstvenem zavodu v štajerski regiji, v letu 2021 in 2022. V raziskavi smo ugotovili, da dosedanji pregled standardne ponudbe prodajnih avtomatov prikazuje dejstvo, da so le-ti v večini napolnjeni s prigrizki in pijačami z nizko hranilno in visoko energijsko vrednostjo. Zdrave izbire so le redko na voljo. Rezultati statistične analize potrjujejo, da ponudba v prodajnih avtomatih vpliva na izbiro potrošnikov, saj bi se kupci zaradi bolj zdrave ponudbe živil statistično značilno večkrat odločili za nakup na prodajnem avtomatu. Raziskava prav tako potrjuje, da so potrošniki mnenja, da je prodajni avtomat z bolj zdravo ponudbo živil primernejši za nameščanje v zdravstvenih in socialnovarstvenih ustanovah. Mednarodne aktivnosti za uveljavljanje takega tipa živil v prodajnih avtomatih dajejo spodbudne rezultate. Z različnimi ukrepi, kot je informiranje o pomenu zdrave prehrane ter postopno povečevanje ponudbe bolj zdravih živil v prodajnih avtomatih, bomo sčasoma oblikovali okolje, v katerem bo zdrava in uravnotežena izbira preprosta.Vending machines with food have come under increasing scrutiny in recent years, as their offerings often consist of products with high energy value, high levels of fats, sugars, and salt. Health and social care institutions should serve as an example in promoting healthy eating by providing healthy food options in vending machines. In this master\u27s thesis, we examined consumer purchasing habits by monitoring sales in vending machines with standard offerings and those with a healthier food selection. Purchasing habits were assessed through a questionnaire survey conducted in a selected hospital, health center, and public social care institution in the Styria region in 2021 and 2022. The study revealed that the analysis of standard vending machine offerings demonstrates that they are mostly stocked with snacks and beverages with low nutritional and high energy value. Healthy choices are rarely available. Statistical analysis results confirm that vending machine offerings influence consumer choices, as buyers statistically significantly prefer purchasing from vending machines with healthier food options. The research also affirms that consumers believe vending machines with a healthier food selection are more suitable for placement in health and social care institutions. International efforts to promote such food types in vending machines yield promising results. Through various measures, such as raising awareness about the importance of healthy eating and gradually increasing the availability of healthier food options in vending machines, we will eventually create an environment where making a healthy and balanced choice is easy

The influence of breastfeeding on the emotional connection of mother and infant

Uvod: Dojenje je naravni način hranjenja dojenčka z materinim mlekom. Je edinstvena priložnost za vzpostavitev posebne čustvene vezi med materjo in dojenčkom. Ima pozitiven vpliv tako na fizično kot duševno zdravje obeh. S pregledom literature smo raziskali, ali dojenje res doprinese veliko dobrega v sam odnos matere in dojenčka. Metode: Izvedli smo pregled literature s področja vpliva dojenja na čustveno povezanost matere in dojenčka. Literaturo smo pridobili z iskalnim nizom ter vključitvenimi, izključitvenimi kriteriji in limiti v mednarodnih podatkovnih bazah CINAHL, Medline, PubMed in SAGE. Uporabljali smo le literaturo z odprtim dostopom do polnega besedila. Pri poteku iskanja, pregleda in izbora relevantne literature smo upoštevali smernice PRISMA. Izvedli smo analizo in sintezo zbranih podatkov. Pri tem smo uporabili deskriptivno metodo dela. Rezultati: V končno analizo smo vključili 6 študij. Glavna ugotovitev je bila, da težave pri dojenju negativno vplivajo na psihično počutje matere. Glavno vlogo podpornika pri soočanju s težavami pri dojenju imajo oče, družina in tudi zdravstveni delavci, ki znajo motivirati in nuditi strokovne nasvete. Razprava in sklep: Doječe matere kažejo večjo navezanost na dojenčka kot matere, ki ne dojijo. Interakcija mati-dojenček je oslabljena, kadar je pri materi prisotno splošno slabo psihično počutje ali če mati sploh ne doji. Dojenje je temelj za vzpostavitev varne, tople in ljubeče čustvene vezi med materjo in otrokom.Introduction: Breastfeeding is the natural way of feeding an infant. It\u27s a unique way to establish a special emotional bond. It has a positive influence on the physical and mental health of both. By reviewing the literature, we investigated whether breastfeeding really contributes a lot of good to the relationship between mother and infant. Methods: We conducted a literature review on the influence of breastfeeding on the emotional connection between mother and infant. Literature was obtained using a search string, inclusion and exclusion criteria and limits in the international databases CINAHL, Medline, PubMed and SAGE. We used literature with open access to the full text. During the search, review and selection of relevant literature, we followed the PRISMA guidelines. We performed the analysis and synthesis of the collected data. We used the descriptive method. Results: 6 studies were included in analysis. The main finding was that problems with breastfeeding negatively affect the psychological well-being of the mother. The main supportive role in coping with breastfeeding problems is played by the father, family and also by health professionals who know how to motivate and provide expert advice. Discussion and conclusion: Breastfeeding mothers show greater attachment to their infant than non-breastfeeding mothers. The mother-infant interaction is weakened when the mother is generally ill or when she doesn\u27t breastfeed at all. Breastfeeding is the foundation for establishing a safe, warm and loving emotional bond between mother and infant

The effect of adding enrichment objects on the welfare of weaning piglets

Obogatitev okolja je ena od metod, ki se uporablja za ublažitev agresije pri odstavitvi mladih pujskov, ki običajno izbruhne, ko jih mešamo iz neznanih gnezd, ter negativno vpliva na rastnost in dobro počutje pujskov. V diplomskem delu smo preizkusili preprost pristop s povečanjem količine obstoječih obogatitvenih predmetov za ublažitev agresije po odstavitvi. V vsaki od 10 ponovitev (5 kontrolnih, 5 testnih) smo v odstavitveni boks skupaj odstavili 3 ali 4 gnezda. V kontrolni skupini smo za obogatitev uporabili en viseč plastični predmet rdeče barve in en kos smrekovega lesa. Pri testu je bila obogatitev pomnožena glede na število odstavljenih gnezd. Med poskusom smo spremljali parametre agresije (grizenje repov, poškodbe/rane, šepavost) in pogostost pojavljanja različnih vrst interakcij (pozitivne, negativne, ukvarjanje z opremo/predmeti za zaposlitev), in sicer 1., 3., 5., 7., 14. in 21. dan po odstavitvi. Na koncu poskusa (21. dan po odstavitvi) smo ocenili še splošno stopnjo dobrega počutja pujskov z uporabo protokola Welafre Quality®. V testni skupini smo zabeležili 4-kratno povečanje ukvarjanja pujskov s predmeti za zaposlitev. Posledično je bilo 5-krat manj negativnih interakcij in 50 % manj šepanja in ran/poškodb na telesu, vključno z znaki grizenja repov. Tudi splošna stopnja počutja pujskov je bila višja v testni skupini. Uporabljena obogatitev boksa, prilagojena številu odstavljenih gnezd, se je izkazala za učinkovit način izboljšanja dobrega počutja odstavljenih pujskov.Pen enrichment is a method of reducing post-weaning aggression that commonly occurs when piglets from unknown litters are mixed and is known to have a negative effect on piglet growth and welfare. In our study, a simple approach to reduce post-weaning aggression was tested by increasing the amount of enrichment objects present. In each of the 10 replicates (5 controls, 5 tests), 3 or 4 litters were weaned together in a weaning pen. In the control group, a hanging red plastic object and a piece of spruce wood were used as the pen enrichment. In the test group, the enrichment was multiplied by the number of litters weaned. During the experiment, the aggression parameters (tail biting, injuries/wounds, lameness) and the frequency of different types of interactions (positive, negative, preoccupation with equipment and enrichment objects) were monitored on days 1, 3, 5, 7, 14 and 21. At the end of the experiment (day 21 post-weaning), an overall assessment of the piglets’ welfare was carried out using the Welfare Quality® protocol. In the test group, we recorded a 4-fold increase in occupation with enrichment objects. As a result, there were 5 times fewer negative interactions and 50% less lameness and wounds/injuries on the body, including signs of tail biting. The overall welfare status of the piglets was also better in the test group. Pen enrichment tailored to the number of weaned litters proved to be an effective means of improving the welfare of weaned piglets

When Knowledge and Decision-making Meet

Ocenjevanje varnostnih tveganj predstavlja temelj strateškega upravljanja varnosti razvitih držav. V monografiji je predstavljen širok pregled različnih usmeritev in pristopov za ocenjevanje varnostnih tveganj in ogroženosti. Predstavljamo tako nacionalne strateške in zakonodajne podlage kot tudi ključne strokovne vire, mednarodne standarde in smernice. Poleg splošnih usmeritev monografija prikazuje nekatere prakse tujih držav ocenjevanja varnostnih tveganj in ogroženosti. Osrednji doprinos tega dela predstavlja predlagani model za ocenjevanje ogroženosti in tveganj na področju javne varnosti, ki je primarno namenjen organizacijam, ki delujejo na področju javne varnosti. Gre za model, ki je v svoji osnovi celovit, enovit in praktično uporaben. Model predstavlja vodilo in orodje za izvajalce (analitike) ter je zasnovan v obliki navodila, ki omogoča izvedbo ocene skozi analitično in sistematično zasnovan proces, skozi katerega se odločevalcem zagotovi ustrezna informacijska podpora za odločanje. Zaradi specifičnih pričakovanj in zahtev je model predlagan v polni in skrajšani različici.Assessing security risks is the cornerstone of strategic security management in developed nations. This monograph provides a broad overview of various orientations and approaches to assessing security risks and vulnerabilities. It encompasses national strategic and legislative frameworks, essential professional resources, international standards, and guidelines. In addition to general orientations, the monograph presents selected practices of foreign countries in assessing security risks and threats. The central contribution of this work lies in the proposed model for assessing threats and risks in the realm of public security, primarily intended for organizations operating in the field of public security. The model is fundamentally comprehensive, cohesive, and practically applicable. Serving as a guiding tool, it is designed for analysts to conduct assessments through an analytical and systematic process, thereby providing decision-makers with appropriate informational support. Due to specific expectations and requirements, the model is presented in both full and short versions

Calculation of the catenary sag of a power line under various climatic conditions

Diplomsko delo obravnava avtomatsko merjenje klimatskih razmer in analizo njihovega vpliva na poves daljnovoda. Avtomatske meteorološke postaje, ki beležijo podatke o temperaturi, vetru in relativni vlažnosti zraka, so nameščene na dveh 110 kV daljnovodih na relaciji Železnik – Bohinj. V okviru diplomskega dela bomo analizirali podatke meritev in jih primerjali s podatki, pridobljenimi z najbližjih avtomatskih meteoroloških postaj v lasti Agencije Republike Slovenije za okolje. V drugem delu naloge bomo na osnovi pridobljenih meritev izračunali poves daljnovodov ter analizirali, v kolikšni meri razlike v meritvah bistveno vplivajo na končni poves daljnovodov.The following thesis deals with the automatic measurement of climatic conditions and the analysis of their impact on power line sag. Automatic weather stations, which record data on temperature, wind, and relative humidity, are installed on two 110 kV transmission lines on the Železnik - Bohinj route. As part of the thesis, we will analyze measurement data and compare them with data obtained from the nearest automatic weather stations owned by the Slovenian Environment Agency. In the second part of the thesis, based on the obtained measurements, we will calculate the power line sag and analyze to what extent differences in measurements significantly affect the final sag of the power lines

Hybrid recommendation of universal decimal classification codes

V doktorski disertaciji predlagamo hibridni pristop za priporočanje vrstilcev univerzalne decimalne klasifikacije (UDK) za elektronske dokumente, ne glede na globino hierarhije UDK. Razvit hibridni pristop priporočanja vrstilcev UDK temelji na metodah vsebinskega filtriranja in uporablja strukturirane metapodatke v slovenskem jeziku za klasifikacijo področja znanosti in priporočanje ustreznih vrstilcev. Ker se dokumenti pogosto nanašajo na več področij znanosti, mora biti pristop sposoben identificirati interdisciplinarnost in vrniti več ustreznih vrstilcev UDK. Predlagani hibridni pristop uporablja kaskadno hibridizacijo in je razdeljen na dva kaskadna koraka. Najprej z rangirno funkcijo BM25 zagotovimo začetni seznam vrstilcev UDK. V prvem kaskadnem koraku začetni seznam vrstilcev UDK preuredimo s seznamom, ki je rezultat večznačnega klasifikatorja. Večznačni klasifikator temelji na globoki nevronski mreži BERT in je prilagojen na hierarhično topologijo UDK. V drugem kaskadnem koraku s pomočjo seznama najbolj pogostih vrstilcev UDK v organizaciji, iz katere izvira dokument, preuredimo seznam iz prvega koraka. Za kaskadno hibridizacijo se izvedejo postopki naknadne obdelave, ki preuredijo sezname priporočil glede na vrhnje področje in glede na specifičnost, omogočajo pa tudi rezanje seznama. Disertacija vključuje vrednotenje na množici zaključnih del v slovenskem jeziku, ki so del repozitorijev slovenskih univerz in že imajo ročno določene vrstilce UDK s strani knjižničarjev. Na testni množici dokumentov s predlaganano metodo po metriki HR@K dosežemo povprečne vrednosti 0,574 (K = 1), 0,869 (K = 3) in 0,892 (K = 5). Po metriki NDCG@K dosežemo povprečne vrednosti 0,993 (K = 1), 0,921 (K = 3) in 0,916 (K = 5), po metrikah MRR in MAP pa povprečne vrednosti vrednosti 0,782 (MRR) in 0,785 (MAP). V primerjavi z obstoječimi pristopi pokažemo, da uporaba predlaganega pristopa vodi v statistično značilne izboljšave.In the doctoral dissertation, we propose a hybrid approach for recommending Universal Decimal Classification (UDC) notations for electronic documents, regardless of the field of science or the depth of the UDC hierarchy. The developed hybrid approach for recommending UDC notations is based on content filtering methods and uses structured metadata in the Slovenian language for classifying the field of science and recommendation of the appropriate notations. Since documents often relate to multiple fields of science, the approach must be able to identify interdisciplinarity and return multiple relevant UDC notations that can represent different fields of science. The hybrid approach uses the cascade hybridization approach and is divided into two cascading steps. First, the BM25 ranking function is used to provide the initial list of recommended notations for a new document. In the first cascade step, the initial list of recommended notations is re-ranked using the list obtained with a multi-label classifier. The multi-label classifier is based on the deep neural network BERT and is adapted to the hierarchical topology of UDC. In the second cascade step, the resulting list from the first cascade step is re-ranked using a list of most common notations used in the document’s source organization. Following the cascade hybridization are the post-processing procedures that re-rank and alter the recommendation lists based on the top-level branches of the UDC hierarchy and specificity, as well as cut-off rate. The dissertation includes an evaluation on a set of theses in the Slovenian language that are part of the repositories of Slovenian universities and have UDC notations manually catalogued by librarians. In the evaluation on a test set of documents we achieve mean values for the metric HR@K of 0,574 (K = 1), 0,869 (K = 3) and 0,892 (K = 5). For the metric NDCG@K we achieve values 0,993 (K = 1), 0,921 (K = 3) and 0,916 (K= 5). For metrics MRR and MAP we achieve values 0,782 (MRR) and 0,785 (MAP). Compared to existing approaches, we show that the use of the proposed approach leads to statistically significant improvements