Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients

BACKGROUND: Prior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy. METHODS: Initial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews. RESULTS: The proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments. CONCLUSION: A patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial

Testing a Simplified Method for Measuring Velocity Integration in Saccades Using a Manipulation of Target Contrast

A growing number of studies in vision research employ analyses of how perturbations in visual stimuli influence behavior on single trials. Recently, we have developed a method along such lines to assess the time course over which object velocity information is extracted on a trial-by-trial basis in order to produce an accurate intercepting saccade to a moving target. Here, we present a simplified version of this methodology, and use it to investigate how changes in stimulus contrast affect the temporal velocity integration window used when generating saccades to moving targets. Observers generated saccades to one of two moving targets which were presented at high (80%) or low (7.5%) contrast. In 50% of trials, target velocity stepped up or down after a variable interval after the saccadic go signal. The extent to which the saccade endpoint can be accounted for as a weighted combination of the pre- or post-step velocities allows for identification of the temporal velocity integration window. Our results show that the temporal integration window takes longer to peak in the low when compared to high contrast condition. By enabling the assessment of how information such as changes in velocity can be used in the programming of a saccadic eye movement on single trials, this study describes and tests a novel methodology with which to look at the internal processing mechanisms that transform sensory visual inputs into oculomotor outputs

Identification of cyst nematode B-type CLE peptides and modulation of the vascular stem cell pathway for feeding cell formation.

Stem cell pools in the SAM (shoot apical meristem), RAM (root apical meristem) and vascular procambium/cambium are regulated by CLE-receptor kinase-WOX signaling modules. Previous data showed that cyst nematode CLE-like effector proteins delivered into host cells through a stylet, act as ligand mimics of plant A-type CLE peptides and are pivotal for successful parasitism. Here we report the identification of a new class of CLE peptides from cyst nematodes with functional similarity to the B-type CLE peptide TDIF (tracheary element differentiation inhibitory factor) encoded by the CLE41 and CLE44 genes in Arabidopsis. We further demonstrate that the TDIF-TDR (TDIF receptor)-WOX4 pathway, which promotes procambial meristem cell proliferation, is involved in beet cyst nematode Heterodera schachtii parasitism. We observed activation of the TDIF pathway in developing feeding sites, reduced nematode infection in cle41 and tdr-1 wox4-1 mutants, and compromised syncytium size in cle41, tdr-1, wox4-1 and tdr-1 wox4-1 mutants. By qRT-PCR and promoter:GUS analyses, we showed that the expression of WOX4 is decreased in a clv1-101 clv2-101 rpk2-5 mutant, suggesting that WOX4 is a potential downstream target of nematode CLEs. Exogenous treatment with both nematode A-type and B-type CLE peptides induced massive cell proliferation in wild type roots, suggesting that the two types of CLEs may regulate cell proliferation during feeding site formation. These findings highlight an important role of the procambial cell proliferation pathway in cyst nematode feeding site formation

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

Background: Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation. Methods: Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders. Discussion At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes. Trial registration Clinicaltrials.gov identifier NCT0133706

The peer reviewers' openness initiative:Incentivising open research practices through peer review

Openness is one of the central values of science. Open scientific practices such as sharing data, materials and analysis scripts alongside published articles have many benefits, including easier replication and extension studies, increased availability of data for theory-building and meta-analysis, and increased possibility of review and collaboration even after a paper has been published. Although modern information technology makes sharing easier than ever before, uptake of open practices had been slow. We suggest this might be in part due to a social dilemma arising from misaligned incentives and propose a specific, concrete mechanism—reviewers withholding comprehensive review—to achieve the goal of creating the expectation of open practices as a matter of scientific principle

Deformation analysis of a metropolis from C- to X-band PSI: proof-of-concept with Cosmo-Skymed over Rome, Italy

Stability of monuments and subsidence of residential quarters in Rome (Italy) are depicted based on geospatial analysis of more than 310,000 Persistent Scatterers (PS) obtained from Stanford Method for Persistent Scatterers (StaMPS) processing of 32 COSMO-SkyMed 3m-resolution HH StripMap ascending mode scenes acquired between 21 March 2011 and 10 June 2013. COSMO-SkyMed PS densities and associated displacement velocities are compared with almost 20 years of historical C-band ERS- 1/2, ENVISAT and RADARSAT-1/2 imagery. Accounting for differences in image processing algorithms and satellite acquisition geometries, we assess the feasibility of ground motion monitoring in big cities and metropolitan areas by coupling newly acquired and legacy SAR in full time series. Limitations and operational benefits of the transition from medium resolution C-band to high resolution X-band PS data are discussed, alongside the potential impact on the management of expanding urban environments

A weak scientific basis for gaming disorder: let us err on the side of caution

We greatly appreciate the care and thought that is evident in the 10 commentaries that discuss our debate paper, the majority of which argued in favor of a formalized ICD-11 gaming disorder. We agree that there are some people whose play of video games is related to life problems. We believe that understanding this population and the nature and severity of the problems they experience should be a focus area for future research. However, moving from research construct to formal disorder requires a much stronger evidence base than we currently have. The burden of evidence and the clinical utility should be extremely high, because there is a genuine risk of abuse of diagnoses. We provide suggestions about the level of evidence that might be required: transparent and preregistered studies, a better demarcation of the subject area that includes a rationale for focusing on gaming particularly versus a more general behavioral addictions concept, the exploration of non-addiction approaches, and the unbiased exploration of clinical approaches that treat potentially underlying issues, such as depressive mood or social anxiety first. We acknowledge there could be benefits to formalizing gaming disorder, many of which were highlighted by colleagues in their commentaries, but we think they do not yet outweigh the wider societal and public health risks involved. Given the gravity of diagnostic classification and its wider societal impact, we urge our colleagues at the WHO to err on the side of caution for now and postpone the formalization

The need for speed : target velocity integration in saccades to moving tatgets

EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Loot box spending is associated with problem gambling but not mental wellbeing

There are emerging concerns that loot boxes – digital video game items that can be purchased for a chance at randomised rewards – are associated with problematic gambling behaviours and, in turn, are potentially harmful. Current research suggests consistent correlations between loot box spending and problematic gambling symptomology, however little research has looked at relationships with mental wellbeing. Here, we used a Bayesian hypothesis testing framework to assess the relative strength of evidence for relationships between loot box spending, excessive gaming, problem gambling, mental wellbeing and psychological distress. 2,728 participants who reported playing games containing loot box mechanics in the past month answered a survey assessing the above measures, as well as other forms of digital spending. The results showed extremely strong evidence for a positive correlation between loot box spending and problem gambling; however there was no evidence to suggest relationships between such spending and mental wellbeing or psychological distress. Exploratory results suggested that individuals who spend money on loot boxes also spend more across a range of digital purchases generally. The findings highlight an urgent need to understand what constitutes harm when considering loot box spending effects, and provide further context for discussions regarding how best to regulate such mechanisms