Can nudge-interventions address health service overuse and underuse? Protocol for a systematic review

IntroductionNudge-interventions aimed at health professionals are proposed to reduce the overuse and underuse of health services. However, little is known about their effectiveness at changing health professionals’ behaviours in relation to overuse or underuse of tests or treatments.ObjectiveThe aim of this study is to systematically identify and synthesise the studies that have assessed the effect of nudge-interventions aimed at health professionals on the overuse or underuse of health services.Methods and analysisWe will perform a systematic review. All study designs that include a control comparison will be included. Any qualified health professional, across any specialty or setting, will be included. Only nudge-interventions aimed at altering the behaviour of health professionals will be included. We will examine the effect of choice architecture nudges (default options, active choice, framing effects, order effects) and social nudges (accountable justification and pre-commitment or publicly declared pledge/contract). Studies with outcomes relevant to overuse or underuse of health services will be included. Relevant studies will be identified by a computer-aided search of the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, CINAHL, Embase and PsycINFO databases. Two independent reviewers will screen studies for eligibility, extract data and perform the risk of bias assessment using the criteria recommended by the Cochrane Effective Practice and Organisation of Care (EPOC) group. We will report our results in a structured synthesis format, as recommended by the Cochrane EPOC group.Ethics and disseminationNo ethical approval is required for this study. Results will be presented at relevant scientific conferences and in peer-reviewed literature

Effect of two behavioural 'nudging' interventions on management decisions for low back pain: A randomised vignette-based study in general practitioners

Objective €Nudges' are subtle cognitive cues thought to influence behaviour. We investigated whether embedding nudges in a general practitioner (GP) clinical decision support display can reduce low-value management decisions. Methods Australian GPs completed four clinical vignettes of patients with low back pain. Participants chose from three guideline-concordant and three guideline-discordant (low-value) management options for each vignette, on a computer screen. A 2×2 factorial design randomised participants to two possible nudge interventions: €partition display' nudge (low-value options presented horizontally, high-value options listed vertically) or €default option' nudge (high-value options presented as the default, low-value options presented only after clicking for more). The primary outcome was the proportion of scenarios where practitioners chose at least one of the low-value care options. Results 120 GPs (72% male, 28% female) completed the trial (n=480 vignettes). Participants using a conventional menu display without nudges chose at least one low-value care option in 42% of scenarios. Participants exposed to the default option nudge were 44% less likely to choose at least one low-value care option (OR 0.56, 95%CI 0.37 to 0.85; p=0.006) compared with those not exposed. The partition display nudge had no effect on choice of low-value care (OR 1.08, 95%CI 0.72 to 1.64; p=0.7). There was no interaction between the nudges (OR 0.94, 95% CI 0.41 to 2.15; p=0.89). Interpretation A default option nudge reduced the odds of choosing low-value options for low back pain in clinical vignettes. Embedding high value options as defaults in clinical decision support tools could improve quality of care. More research is needed into how nudges impact clinical decision-making in different contexts

Study of the characteristics of GEM detectors for the future FAIR experiment CBM

Characteristics of triple GEM detector have been studied systematically. The variation of the effective gain and energy resolution of GEM with variation of the applied voltage has been measured with Fe55 X-ray source for different gas mixtures and with different gas flow rates. Long-term test of the GEM has also been performed.Comment: 2 Pages, 6 figure

Tracking the Endosomal Escape: A Closer Look at Calcein and Related Reporters

Crossing the cellular membrane and delivering active pharmaceuticals or biologicals into the cytosol of cells is an essential step in the development of nanomedicines. One of the most important intracellular processes regarding the cellular uptake of biologicals is the endolysosomal pathway. Sophisticated nanocarriers are developed to overcome a major hurdle, the endosomal entrapment, and delivering their cargo to the required site of action. In parallel, in vitro assays are established analyzing the performance of these nanocarriers. Among them, the release of the membrane‐impermeable dye calcein has become a popular and straightforward method. It is accessible for most researchers worldwide, allows for rapid conclusions about the release potential, and enables the study of release mechanisms. This review is intended to provide an overview and guidance for scientists applying the calcein release assay. It comprises a survey of several applications in the study of endosomal escape, considerations of potential pitfalls, challenges, and limitations of the assay, and a brief summary of complementary methods. Based on this review, it is hoped to encourage further research groups to take advantage of the calcein release assay for their own purposes and help to create a database for more efficient cross‐correlations between nanocarriers

Size effects in ion-neutral complex-mediated alkane eliminations from ionized aliphatic ethers

AbstractThe effects of the size of the ionic and neutral partners on ion-neutral complex-mediated alkane eliminations from ionized aliphatic ethers were determined by obtaining metastable decomposition spectra and photoionization ionization efficiency curves. Increasing the size of the ionic partner decreases the competitiveness of alkane elimination with alkyl loss. This is attributed to decreasing attraction between the partners with increasing distance between the neutral partner and the center of charge in the associated ion. Increasing the size of the neutral partner lowers the threshold for alkane elimination relative to that for simple dissociation when the first threshold is above ΔHf(products). This is attributed to increasing attraction between the partners with increasing polarizability of the radical in the complex. Adding a CH2 to the radical in a complex seems to increase the attraction between the partners by about 24 kJ mol−1

Carbohydrates – Guidelines on Parenteral Nutrition, Chapter 5

The main role of carbohydrates in the human body is to provide energy. Carbohydrates should always be infused with PN (parenteral nutrition) in combination with amino acids and lipid emulsions to improve nitrogen balance. Glucose should be provided as a standard carbohydrate for PN, whereas the use of xylite is not generally recommended. Fructose solutions should not be used for PN. Approximately 60% of non-protein energy should be supplied as glucose with an intake of 3.0–3.5 g/kg body weight/day (2.1–2.4 mg/kg body weight/min). In patients with a high risk of hyperglycaemia (critically ill, diabetes, sepsis, or steroid therapy) an lower initial carbohydrate infusion rate of 1–2 g/kg body weight/day is recommended to achieve normoglycaemia. One should aim at reaching a blood glucose level of 80–110 mg/dL, and at least a glucose level <145 mg/dL should be achieved to reduce morbidity and mortality. Hyperglycaemia may require addition of an insulin infusion or a reduction (2.0–3.0 g/kg body weight/day) or even a temporary interruption of glucose infusion. Close monitoring of blood glucose levels is highly important

Controlling photocurrent channels in scanning tunneling microscopy

We investigate photocurrents driven by femtosecond laser excitation of a (sub)-nanometer tunnel junction in an ultrahigh vacuum low-temperature scanning tunneling microscope (STM). The optically driven charge transfer is revealed by tip retraction curves showing a current contribution for exceptionally large tip-sample distances, evidencing a strongly reduced effective barrier height for photoexcited electrons at higher energies. Our measurements demonstrate that the magnitude of the photo-induced electron transport can be controlled by the laser power as well as the applied bias voltage. In contrast, the decay constant of the photocurrent is only weakly affected by these parameters. Stable STM operation with photoelectrons is demonstrated by acquiring constant current topographies. An effective non-equilibrium electron distribution as a consequence of multiphoton absorption is deduced by the analysis of the photocurrent using a one-dimensional potential barrier model

Effect of information format on intentions and beliefs regarding diagnostic imaging for non-specific low back pain: A randomised controlled trial in members of the public

Objective To evaluate the effects of information format on intentions to request diagnostic imaging for non-specific low back pain in members of the public. Methods We performed a three arm, 1:1:1, superiority randomised trial on members of the public. Participants were randomised to one of the three groups: a Standard Care Leaflet group (standard information on low back pain), a Neutral Leaflet group (balanced information on the benefits and harms of imaging) and a Nudge Leaflet group (with behavioural cues to emphasise the harms of unnecessary imaging). Our primary outcome was intention to request imaging for low back pain. Results 418 participants were randomised. After reading the leaflet, intention to request imaging (measured on an 11-point scale (0 = definitely would not request to 10 = definitely would request) was lower in the Nudge Leaflet group (mean =&thinsp;4.6, SD =&thinsp;3.4) compared with the Standard Care Leaflet group (mean =&thinsp;5.3, SD =&thinsp;3.3) and the Neutral Leaflet group (mean =&thinsp;5.3, SD =&thinsp;3.0) (adjusted mean difference between Nudge and Neutral, −1.0 points, 95%CI −1.6 to −0.4). Conclusion Framing information to emphasise potential harms from overdiagnosis reduced intention to request diagnostic imaging for low back pain. Practice implications Nudge leaflets could help clinicians manage patient pressure for unnecessary tests.Dr Mary O'Keeffe is supported by funding from the European Union's Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 75049

Postoperative Immune Suppression in Visceral Surgery: Characterisation of an Intestinal Mouse Model

Background: Postoperatively acquired immune dysfunction is associated with a higher mortality rate in case of septic complications. As details of this severe clinical problem are still unknown, animal models are essential to characterise the mechanisms involved. Methods: Mice were laparotomised and the small intestine was pressed smoothly in antegrade direction. For extension of trauma, the intestine was manipulated three times consecutively. Following this, the ex vivo cytokine release of splenocytes was determined. The degree of surgical trauma was analysed by detection of HMGB1 and IL-6 in serum and by neutrophil staining in the muscularis mucosae. Results: We adapted the previously described animal model of intestinal manipulation to provide a model of surgically induced immune dysfunction. Following intestinal manipulation, the mice showed elevated serum levels of HMGB1 and IL-6 and increased infiltration of granulocytes into the muscularis mucosae. Ex vivo cytokine release by splenocytes was suppressed in the postoperative period. The degree of suppression correlated with the extent of surgical trauma. Conclusions: In this study, we describe a surgically induced immune dysfunction animal model, in which a significant surgical trauma is followed by an immune dysfunction. This model may be ideal for the characterisation of the postoperative immune dysfunction syndrome