Evaluation of Commission and Omission Errors During Differential Reinforcement of Other Behavior

Differential reinforcement of other behavior (DRO) is a reinforcement schedule that commonly includes the delivery of a reinforcer following an interval during which a target behavior did not occur and extinction (i.e., the reinforcer is withheld following any instances of the target behavior). Although interventions using DRO schedules can decrease target behavior when implemented as designed, little is known about the efficacy of DRO interventions when they include fidelity errors. A growing field of literature has demonstrated different ways fidelity errors can affect the outcomes of other interventions (e.g., DRA, response cost, and skill acquisition). One study by Foreman et al. (2023) evaluated how commission errors may change the efficacy of DRO interventions in a human-operant arrangement with college students. For three participants, DRO lost its efficacy at 60% fidelity or lower. However, DRO remained effective in maintaining low rates of target responding at as low as 20% fidelity for the remaining three participants. These results suggest that DRO may have robust effects with commission errors for some but may vary across individuals or other factors. The study of the effects of omission errors during DRO is largely missing from current research. Additionally, the effects of fidelity errors during DRO have not yet been studied in a design arranged to identify potential order effects. Experiment 1 examined effects of DRO implemented with various percentages (100%, 80%, 60%) of fidelity with commission errors in a human-operant arrangement. Experiment 2 systematically replicated Experiment 1 with omission errors. During both experiments, points were delivered contingent on the target response (mouse clicks on a moving circle) during baseline phases, and points were delivered contingent on the absence of the target response during phases with DRO implemented with 100% fidelity. In Experiment 1, DRO was implemented with 60% and 80% fidelity with commission errors, during which DRO was implemented with points delivered on a probabilistic basis contingent on the target response. In Experiment 2, DRO was implemented with 60% and 80% fidelity with omission errors, during which point deliveries according to the DRO schedule were omitted on a probabilistic basis. The results from Experiment 1 suggest that commission errors are detrimental to DRO schedules for some, resulting in increased response rates that often exceeded the levels of responding observed during baseline. Additionally, participants exposed to ascending percentages of fidelity first engaged in more frequent increases in responding during degraded-fidelity phases than participants exposed to the descending percentages of fidelity first. The results from Experiment 2 suggest that omission errors degrade the effects of DRO at 60% fidelity for some, such that response rates increase compared to DRO with 100% fidelity; however, even when responding was elevated during these phases, response rates remained lower than those during baseline phases. The results of the current experiments provide preliminary support for recommendations regarding DRO implementation, training, and fidelity reporting

Evaluating DRO with Asymmetrical Magnitude of Reinforcement

Differential reinforcement of other behavior (DRO) is a reinforcement schedule used in behavior analytic procedures aimed at decreasing various forms of challenging behavior. DRO commonly includes a reinforcement component and an extinction component; a reinforcer is delivered on an interval-based schedule dependent on the omission of a target behavior and the reinforcer is withheld following the occurrence of the target behavior (i.e., extinction). Although interventions using DRO can be effective for challenging behavior, procedures that include extinction can at times be impractical or lead to undesirable side effects. A DRO schedule can be implemented without extinction, but previous research has shown limited utility of this tactic when a function-based reinforcer is delivered contingent on challenging behavior and a non-function-based reinforcer is delivered for meeting the omission-interval requirement (e.g., effective suppression of challenging behavior in a small proportion of participants). One potential solution would be to use an asymmetrical DRO arrangement in which meeting the omission requirement results in a greater magnitude reinforcer than the target behavior that continues to produce a lesser magnitude reinforcer. A growing field of literature has shown that another form of differential reinforcement, differential reinforcement of alternative behavior, can result in decreases in challenging behavior in the absence of extinction with asymmetrical reinforcers arranged by manipulating parameters such as magnitude, immediacy, and quality. This experiment examined the effects of whole-interval DRO with and without asymmetrical magnitude of reinforcement for the omission and emission of the target response. First, target responding was reinforced during baseline. In one treatment condition, a higher magnitude of points was delivered contingent on the absence of the target behavior. In another condition, the magnitude of points for engaging in the target behavior and omitting the target behavior was symmetrical (i.e., the same number of points). In the final condition, the delivery of points contingent on engaging in the target behavior was discontinued (i.e., extinction) and the higher magnitude of points was delivered contingent on the absence of the target behavior. The results obtained do not support the use of DRO without extinction using an asymmetrical magnitude of reinforcement to decrease a target response. Extinction may be a necessary component for DRO schedules to be effective. If there are clinical limitations to implementing extinction, DRO may not be a viable intervention

Exploration of the Practices of Credentialing of Nurse Practitioners in Acute Care Hospital Settings

Abstract The nursing shortage, physician shortage, advancing age of the population, and concerns about equalizing access to health care have supported the movement of the Nurse Practitioner (NP) role into the acute care hospital setting (ACHS). Expansion of the role has resulted in efforts by regulatory and accreditation bodies to require standardized processes to ensure that credentialing and privileging supports the role of the NP in the acute care hospital setting. Historically credentialing processes have been developed with the physician role as the template. However, it is not clear that those processes support the role of the NP in the acute care setting. The purpose of the study is to understand and describe the processes by which Nurse Practitioners are credentialed and granted privileges to practice within the acute care hospital setting. A qualitative multi-sited case study approach was used to identify the rules and norms of the credentialing process of Nurse Practitioners. From three acute care hospitals, a purposeful sample of NPs (n=9) and other members of the credentialing bodies (n=3) were interviewed, a demographic survey completed, and documents defining structure collected. Analysis of the data included development of themes across the interviews and cross-case analysis for the three sites. Three major areas were identified that gave rise to specific themes: a) required activities that Nurse Practitioners must complete to receive organizational approval to practice in the advanced role; b) nurse practitioner perceptions of the credentialing process; and c) enhancement of the credentialing process for the Nurse Practitioner. Themes within the area of required activities that Nurse Practitioners must complete to receive organizational approval to practice in the advanced role are: a) required information for acute care credentialing; b) importance of timeliness of completing the process; c) steps for adding and maintaining competencies; d) people involved in the process; and e) common barriers to the credentialing process. Nurse practitioner perceptions of the credentialing process themes are: a) emotional responses of NPs to the credentialing process; b) fit of the credentialing process with the intended role of the NP; and c) involvement of the right people in the credentialing process. Themes within the area of enhancement of the credentialing process for the Nurse Practitioner are: a) reduction of barriers in the NP credentialing process; and b) external factors impacting the NP credentialing process. Cross-case analysis revealed these differences among the sites. Employed NPs and those not employed by the ACHS enter the credentialing process at the same point at two of the study sites. The human resources department is the entry point for employed NPs at the third site, while NPs not employed by the ACHS enter through the medical staff office. The same two sites have implemented a nurse credentialing committee as the first review of the completed application. The third site did not have a nurse credentialing committee at the time of the interviews. The governing body at Site One and Two is the final decision making body for credentialing. Site Three uses the governing body for NPs not employed by the ACHS and the human resources department for approval of employed NPs. The required documents for proof of education, licensure, and competency and other credentialing structures are similar across all three sites. Structure and content of the credentialing process for all three sites were similar. However, variation and barriers were identified by the participants. Findings from this study include opportunities to further standardize and enhance the credentialing process for NPs. Opportunities for standardization and enhancement include: a) communicate needed information about the credentialing process-during the NP educational experience; b) determine consistencies for core competencies and specialty competencies validation across disciplines; c) clearly define methods for obtaining and verifying new psychomotor competencies; d) advocate that the right people, not just functional groups, are involved in the credentialing process within the acute care setting; e) include a contact person for NP credentialing; f) automate and streamline required paperwork, remove confusing language, focus privileging forms on the specialty education of the NP; and g) promote the value of a central verification organization (CVO) to include NP credentialing to the national organizations that represent advance practice nurses. Continued refinement of the credentialing process as well as the implementation of strategies listed above that will enhance the process and may assist in reducing some of the barriers and frustrations identified in this study

Oral mucosal injury caused by mammalian target of rapamycin inhibitors: emerging perspectives on pathobiology and impact on clinical practice.

In recent years oral mucosal injury has been increasingly recognized as an important toxicity associated with mammalian target of rapamycin (mTOR) inhibitors, including in patients with breast cancer who are receiving everolimus. This review addresses the state-of-the-science regarding mTOR inhibitor-associated stomatitis (mIAS), and delineates its clinical characteristics and management. Given the clinically impactful pain associated with mIAS, this review also specifically highlights new research focusing on the study of the molecular basis of pain. The incidence of mIAS varies widely (2-78%). As reported across multiple mTOR inhibitor clinical trials, grade 3/4 toxicity occurs in up to 9% of patients. Managing mTOR-associated oral lesions with topical oral, intralesional, and/or systemic steroids can be beneficial, in contrast to the lack of evidence supporting steroid treatment of oral mucositis caused by high-dose chemotherapy or radiation. However, steroid management is not uniformly efficacious in all patients receiving mTOR inhibitors. Furthermore, technology does not presently exist to permit clinicians to predict a priori which of their patients will develop these lesions. There thus remains a strategic need to define the pathobiology of mIAS, the molecular basis of pain, and risk prediction relative to development of the clinical lesion. This knowledge could lead to novel future interventions designed to more effectively prevent mIAS and improve pain management if clinically significant mIAS lesions develop

Low exposure long-baseline neutrino oscillation sensitivity of the DUNE experiment

The Deep Underground Neutrino Experiment (DUNE) will produce world-leading neutrino oscillation measurements over the lifetime of the experiment. In this work, we explore DUNE's sensitivity to observe charge-parity violation (CPV) in the neutrino sector, and to resolve the mass ordering, for exposures of up to 100 kiloton-megawatt-years (kt-MW-yr). The analysis includes detailed uncertainties on the flux prediction, the neutrino interaction model, and detector effects. We demonstrate that DUNE will be able to unambiguously resolve the neutrino mass ordering at a 3$\sigma$ (5$\sigma$) level, with a 66 (100) kt-MW-yr far detector exposure, and has the ability to make strong statements at significantly shorter exposures depending on the true value of other oscillation parameters. We also show that DUNE has the potential to make a robust measurement of CPV at a 3$\sigma$ level with a 100 kt-MW-yr exposure for the maximally CP-violating values \delta_{\rm CP}} = \pm\pi/2. Additionally, the dependence of DUNE's sensitivity on the exposure taken in neutrino-enhanced and antineutrino-enhanced running is discussed. An equal fraction of exposure taken in each beam mode is found to be close to optimal when considered over the entire space of interest

A Gaseous Argon-Based Near Detector to Enhance the Physics Capabilities of DUNE

This document presents the concept and physics case for a magnetized gaseous argon-based detector system (ND-GAr) for the Deep Underground Neutrino Experiment (DUNE) Near Detector. This detector system is required in order for DUNE to reach its full physics potential in the measurement of CP violation and in delivering precision measurements of oscillation parameters. In addition to its critical role in the long-baseline oscillation program, ND-GAr will extend the overall physics program of DUNE. The LBNF high-intensity proton beam will provide a large flux of neutrinos that is sampled by ND-GAr, enabling DUNE to discover new particles and search for new interactions and symmetries beyond those predicted in the Standard Model

Snowmass Neutrino Frontier: DUNE Physics Summary

The Deep Underground Neutrino Experiment (DUNE) is a next-generation long-baseline neutrino oscillation experiment with a primary physics goal of observing neutrino and antineutrino oscillation patterns to precisely measure the parameters governing long-baseline neutrino oscillation in a single experiment, and to test the three-flavor paradigm. DUNE's design has been developed by a large, international collaboration of scientists and engineers to have unique capability to measure neutrino oscillation as a function of energy in a broadband beam, to resolve degeneracy among oscillation parameters, and to control systematic uncertainty using the exquisite imaging capability of massive LArTPC far detector modules and an argon-based near detector. DUNE's neutrino oscillation measurements will unambiguously resolve the neutrino mass ordering and provide the sensitivity to discover CP violation in neutrinos for a wide range of possible values of δCP. DUNE is also uniquely sensitive to electron neutrinos from a galactic supernova burst, and to a broad range of physics beyond the Standard Model (BSM), including nucleon decays. DUNE is anticipated to begin collecting physics data with Phase I, an initial experiment configuration consisting of two far detector modules and a minimal suite of near detector components, with a 1.2 MW proton beam. To realize its extensive, world-leading physics potential requires the full scope of DUNE be completed in Phase II. The three Phase II upgrades are all necessary to achieve DUNE's physics goals: (1) addition of far detector modules three and four for a total FD fiducial mass of at least 40 kt, (2) upgrade of the proton beam power from 1.2 MW to 2.4 MW, and (3) replacement of the near detector's temporary muon spectrometer with a magnetized, high-pressure gaseous argon TPC and calorimeter

Snowmass Neutrino Frontier: DUNE Physics Summary

The Deep Underground Neutrino Experiment (DUNE) is a next-generation long-baseline neutrino oscillation experiment with a primary physics goal of observing neutrino and antineutrino oscillation patterns to precisely measure the parameters governing long-baseline neutrino oscillation in a single experiment, and to test the three-flavor paradigm. DUNE's design has been developed by a large, international collaboration of scientists and engineers to have unique capability to measure neutrino oscillation as a function of energy in a broadband beam, to resolve degeneracy among oscillation parameters, and to control systematic uncertainty using the exquisite imaging capability of massive LArTPC far detector modules and an argon-based near detector. DUNE's neutrino oscillation measurements will unambiguously resolve the neutrino mass ordering and provide the sensitivity to discover CP violation in neutrinos for a wide range of possible values of $\delta_{CP}$. DUNE is also uniquely sensitive to electron neutrinos from a galactic supernova burst, and to a broad range of physics beyond the Standard Model (BSM), including nucleon decays. DUNE is anticipated to begin collecting physics data with Phase I, an initial experiment configuration consisting of two far detector modules and a minimal suite of near detector components, with a 1.2 MW proton beam. To realize its extensive, world-leading physics potential requires the full scope of DUNE be completed in Phase II. The three Phase II upgrades are all necessary to achieve DUNE's physics goals: (1) addition of far detector modules three and four for a total FD fiducial mass of at least 40 kt, (2) upgrade of the proton beam power from 1.2 MW to 2.4 MW, and (3) replacement of the near detector's temporary muon spectrometer with a magnetized, high-pressure gaseous argon TPC and calorimeter.Comment: Contribution to Snowmass 202

A Gaseous Argon-Based Near Detector to Enhance the Physics Capabilities of DUNE

This document presents the concept and physics case for a magnetized gaseous argon-based detector system (ND-GAr) for the Deep Underground Neutrino Experiment (DUNE) Near Detector. This detector system is required in order for DUNE to reach its full physics potential in the measurement of CP violation and in delivering precision measurements of oscillation parameters. In addition to its critical role in the long-baseline oscillation program, ND-GAr will extend the overall physics program of DUNE. The LBNF high-intensity proton beam will provide a large flux of neutrinos that is sampled by ND-GAr, enabling DUNE to discover new particles and search for new interactions and symmetries beyond those predicted in the Standard Model.Comment: Contribution to Snowmass 202