Ethical climate and intention to leave among critical care clinicians : an observational study in 68 intensive care units across Europe and the United States

PurposeApart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one's job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics.MethodsPerceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries.ResultsOf 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62-0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77-0.98]) were all associated with a lower intent to leave.ConclusionThis is the first large multicenter study showing an independent association between clinicians' intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL

Not all KIT 557/558 codons mutations have the same prognostic influence on recurrence-free survival: breaking the exon 11 mutations in gastrointestinal stromal tumors (GISTs)

Background: Although the gastrointestinal stromal tumor (GIST) genotype is not currently included in risk-stratification systems, a growing body of evidence shows that the pathogenic variant (PV) type and codon location hold a strong prognostic influence on recurrence-free survival (RFS). This information has particular relevance in the adjuvant setting, where an accurate prognostication could help to better identify high-risk tumors and guide clinical decision-making. Materials and Methods: Between January 2005 and December 2020, 96 patients with completely resected GISTs harboring a KIT proto-oncogene receptor tyrosine kinase (KIT) exon 11 PV were included in the study. We analyzed the type and codon location of the PV according to clinicopathological characteristics and clinical outcome; the metastatic sites in relapsed patients were also investigated. Results: Tumors harboring a KIT exon 11 deletion or deletion/insertion involving the 557 and/or 558 codons, showed a more aggressive clinical behavior compared with tumors carrying deletion/deletion/insertion in other codons, or tumors with duplication/insertion/single-nucleotide variant (SNV) (7-year RFS: 50% versus 73.1% versus 88.2%, respectively; p < 0.001). Notably, among 18 relapsed patients with 557 and/or 558 deletion or deletion/insertion, 14 patients (77.8%) harbored deletions simultaneously involving 557 and 558 codons, while only 4 patients (22.2%) harbored deletions involving only 1 of the 557/558 codons. Thus, when 557 or 558 deletions occurred separately, the tumor showed a prognostic behavior similar to the GIST carrying deletions outside the 557/558 position. Remarkably, patients with GISTs stratified as intermediate risk, but carrying the 557/558 deletion, showed a similar outcome to the high-risk patients with tumors harboring deletions in codons other than 557/558, or duplication/insertion/SNV. Conclusion: Our data support the inclusion of the PV type and codon location in routine risk prediction models, and suggest that intermediate-risk patients whose GISTs harbor 557/558 deletions may also need to be treated with adjuvant imatinib like the high-risk patients

<i>Gaia</i> Data Release 1. Summary of the astrometric, photometric, and survey properties

Context. At about 1000 days after the launch of Gaia we present the first Gaia data release, Gaia DR1, consisting of astrometry and photometry for over 1 billion sources brighter than magnitude 20.7. Aims. A summary of Gaia DR1 is presented along with illustrations of the scientific quality of the data, followed by a discussion of the limitations due to the preliminary nature of this release. Methods. The raw data collected by Gaia during the first 14 months of the mission have been processed by the Gaia Data Processing and Analysis Consortium (DPAC) and turned into an astrometric and photometric catalogue. Results. Gaia DR1 consists of three components: a primary astrometric data set which contains the positions, parallaxes, and mean proper motions for about 2 million of the brightest stars in common with the HIPPARCOS and Tycho-2 catalogues – a realisation of the Tycho-Gaia Astrometric Solution (TGAS) – and a secondary astrometric data set containing the positions for an additional 1.1 billion sources. The second component is the photometric data set, consisting of mean G-band magnitudes for all sources. The G-band light curves and the characteristics of ∼3000 Cepheid and RR-Lyrae stars, observed at high cadence around the south ecliptic pole, form the third component. For the primary astrometric data set the typical uncertainty is about 0.3 mas for the positions and parallaxes, and about 1 mas yr−1 for the proper motions. A systematic component of ∼0.3 mas should be added to the parallax uncertainties. For the subset of ∼94 000 HIPPARCOS stars in the primary data set, the proper motions are much more precise at about 0.06 mas yr−1. For the secondary astrometric data set, the typical uncertainty of the positions is ∼10 mas. The median uncertainties on the mean G-band magnitudes range from the mmag level to ∼0.03 mag over the magnitude range 5 to 20.7. Conclusions. Gaia DR1 is an important milestone ahead of the next Gaia data release, which will feature five-parameter astrometry for all sources. Extensive validation shows that Gaia DR1 represents a major advance in the mapping of the heavens and the availability of basic stellar data that underpin observational astrophysics. Nevertheless, the very preliminary nature of this first Gaia data release does lead to a number of important limitations to the data quality which should be carefully considered before drawing conclusions from the data

Response to Lawrence DJ: The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: A systematic review of the literature

Thank you for the opportunity to respond to the Letter to the Editor by Dana J. Lawrence. In his letter, Lawrence states that the results of our systematic review may be due to bias. However, he does not adequately substantiate his claims..

Integrated methodological framework fos assesing the risk of failure in water supply incorporating drought forecast. Case study: Andean regulated river basin

[EN] Hydroclimatic drought conditions can affect the hydrological services offered by mountain river basins causing severe impacts on the population, becoming a challenge for water resource managers in Andean river basins. This study proposes an integrated methodological framework for assessing the risk of failure in water supply, incorporating probabilistic drought forecasts, which assists in making decisions regarding the satisfaction of consumptive, non-consumptive and environmental requirements under water scarcity conditions. Monte Carlo simulation was used to assess the risk of failure in multiple stochastic scenarios, which incorporate probabilistic forecasts of drought events based on a Markov chains (MC) model using a recently developed drought index (DI). This methodology was tested in the Machángara river basin located in the south of Ecuador. Results were grouped in integrated satisfaction indexes of the system (DSIG). They demonstrated that the incorporation of probabilistic drought forecasts could better target the projections of simulation scenarios, with a view of obtaining realistic situations instead of optimistic projections that would lead to riskier decisions. Moreover, they contribute to more effective results in order to propose multiple alternatives for prevention and/or mitigation under drought conditions.This study was part of the doctoral thesis of Aviles A. at the Technical University of Valencia. This research was funded by the University of Cuenca through its Research Department (DIUC) and the Municipal public enterprise of telecommunications, drinking water, sewage and sanitation of Cuenca (ETAPA) through the projects: BIdentificacion de los procesos hidrometeorologicos que desencadenan inundaciones en la ciudad de Cuenca usando un radar de precipitacion" and "Ciclos meteorologicos y evapotranspiracion a lo largo de una gradiente altitudinal del Parque Nacional Cajas". The authors also thank INAMHI and the CBRM for providing the information for this study. The authors wish to thank the Spanish Ministry of Economy and Competitiveness for its financial support through the ERAS project (CTM2016-77804-P). We thank Angel Vazquez, who helped in the programming of the multiple simulations. Also we thank to the TropiSeca project.Avilés-Añazco, A.; Solera Solera, A.; Paredes Arquiola, J.; Pedro Monzonís, M. (2018). Integrated methodological framework fos assesing the risk of failure in water supply incorporating drought forecast. Case study: Andean regulated river basin. Water Resources Management. 32(4):1209-1223. https://doi.org/10.1007/s11269-017-1863-7S12091223324Andreu J, Capilla J, Sanchís E (1996) AQUATOOL, a generalized decision-support system for water-resources planning and operational management. J Hydrol 177(3-4):269–291. https://doi.org/10.1016/0022-1694(95)02963-XAndreu J, Solera A, Capilla J, Ferrer J (2007) Modelo SIMGES para simulación de cuencas. Manual de usuario v3. 00. Universidad Politécnica de Valencia, ValenciaAndreu J, Ferrer J, Perez MA et al (2013) Drought planning and management in the Júcar River Basin, Spain. In: Schwabe K et al (eds) Drought in arid and semi-arid regions. Springer science, Dordrecht, pp 237–249. https://doi.org/10.1007/978-94-007-6636-5_13Avilés A, Solera A (2013) Análisis de sistemas de recursos hídricos de la cuenca del rio Tomebamba en Ecuador, mediante modelos estocásticos y de gestión. In: Solera A, Paredes J, Andreu J (eds) Aplicaciones de sistemas soporte a la decisión en planificación y gestión integradas de cuencas hidrográficas. Marcombo, Barcelona, España pp 51–61Avilés A, Célleri R, Paredes J, Solera A (2015) Evaluation of Markov chain based drought forecasts in an Andean Regulated River basin using the skill scores RPS and GMSS. Water Resour Manag 29(6):1949–1963. https://doi.org/10.1007/s11269-015-0921-2Avilés A, Célleri R, Solera A, Paredes J (2016) Probabilistic forecasting of drought events using Markov chain-and Bayesian network-based models: a case study of an Andean Regulated River Basin. Water 8:1–16Barua S, Ng A, Perera B (2012) Drought assessment and forecasting: a case study on the Yarra River catchment in Victoria, Australia. Aust J Water Resour 15(2):95–108. https://doi.org/10.7158/W10-848.2012.15.2Bazaraa MS, Jarvis JJ, Sherali HD (2011) Linear programming and network flows, fourth Edi. John Wiley & Sons, New JerseyBrown C, Baroang KM, Conrad E et al (2010) IRI technical report 10–15, managing climate risk in water supply systems. Palisades, NYCancelliere A, Di Mauro G, Bonaccorso B, Rossi G (2007) Drought forecasting using the standardized precipitation index. Water Resour Manag 21(5):801–819. https://doi.org/10.1007/s11269-006-9062-yCancelliere A, Nicolosi V, Rossi G (2009) Assessment of drought risk in water supply systems in coping with drought risk in agriculture and water supply systems. Advances in natural and technological hazards research 26. In: Coping with drought risk in agriculture. Springer, pp 93–109. https://doi.org/10.1007/978-1-4020-9045-5_8Chen YD, Zhang Q, Xiao M, Singh VP, Zhang S (2016) Probabilistic forecasting of seasonal droughts in the Pearl River basin, China. Stoch Environ Res Risk Assess 30(7):2031–2040. https://doi.org/10.1007/s00477-015-1174-6Gong G, Wang L, Condon L, Shearman A, Lall U (2010) A simple framework for incorporating seasonal Streamflow forecasts into existing water resource management practices. JAWRA J Am Water Resour Assoc 46(3):574–585. https://doi.org/10.1111/j.1752-1688.2010.00435.xHaro D, Solera A, Paredes J, Andreu J (2014) Methodology for drought risk assessment in within-year regulated reservoir systems. Application to the Orbigo River system (Spain). Water Resour Manag 28(11):3801–3814. https://doi.org/10.1007/s11269-014-0710-3Haro-Monteagudo D, Solera A, Andreu J (2017) Drought early warning based on optimal risk forecasts in regulated river systems: application to the Jucar River basin (Spain). J Hydrol 544:36–45. https://doi.org/10.1016/j.jhydrol.2016.11.022Hashimoto T, Loucks DP, Stedinger JR (1982) Reliability, resiliency, and vulnerability criteria. Water Resour Res 18(1):14–20. https://doi.org/10.1029/WR018i001p00014Hwang Y, Carbone GJ (2009) Ensemble forecasts of drought indices using a conditional residual resampling technique. J Appl Meteorol Climatol 48(7):1289–1301. https://doi.org/10.1175/2009JAMC2071.1Kao S-C, Govindaraju RS (2010) A copula-based joint deficit index for droughts. J Hydrol 380(1-2):121–134. https://doi.org/10.1016/j.jhydrol.2009.10.029Keyantash JA, Dracup JA (2004) An aggregate drought index: assessing drought severity based on fluctuations in the hydrologic cycle and surface water storage. Water Resour Res 40(9):1–13. https://doi.org/10.1029/2003WR002610Khadr M (2016) Forecasting of meteorological drought using hidden Markov model (case study: the upper Blue Nile river basin, Ethiopia). Ain Shams Eng J 7(1):47–56. https://doi.org/10.1016/j.asej.2015.11.005Madadgar S, Moradkhani H (2013) A Bayesian framework for probabilistic seasonal drought forecasting. J Hydrometeorol 14(6):1685–1706. https://doi.org/10.1175/JHM-D-13-010.1Madadgar S, Moradkhani H (2014) Spatio-temporal drought forecasting within Bayesian networks. J Hydrol 512:134–146. https://doi.org/10.1016/j.jhydrol.2014.02.039Mahmoudzadeh H, Mahmoudzadeh H, Afshar M, Yousefi S (2016) Applying first-order Markov chains and SPI drought index to monitor and forecast drought in West Azerbaijan Province of Iran. Int J Geo Sci Environ Plan 1:44–53. 10.22034/ijgsep.2016.40669Mishra AK, Singh VP (2010) Review paper a review of drought concepts. J Hydrol 391(1-2):202–216. https://doi.org/10.1016/j.jhydrol.2010.07.012Nalbantis I, Tsakiris G (2009) Assessment of hydrological drought revisited. Water Resour Manag 23(5):881–897. https://doi.org/10.1007/s11269-008-9305-1Ochola WO, Kerkides P (2003) A Markov chain simulation model for predicting critical wet and dry spells in Kenya: Analysing rainfall events in the kano plains. Irrig Drain 52(4):327–342. https://doi.org/10.1002/ird.094Paulo AA, Pereira LS (2007) Prediction of SPI drought class transitions using Markov chains. Water Resour Manag 21(10):1813–1827. https://doi.org/10.1007/s11269-006-9129-9Phan TD, Smart JCR, Capon SJ, Hadwen WL, Sahin O (2016) Applications of Bayesian belief networks in water resource management: a systematic review. Environ Model Softw 85:98–111. https://doi.org/10.1016/j.envsoft.2016.08.006Pouget L, Roldán T, Gómez M et al (2015) Use of seasonal climate predictions in the water sector—preliminary results from the EUPORIAS project. In: Andreu J, Solera A, Paredes J et al (eds) Drought: research and science-policy interfacing. Taylor & Francis Group, London, UK, p 247Rossi G, Cancelliere A (2013) Managing drought risk in water supply systems in Europe: a review. Int J Water Resour Dev 29(2):272–289. https://doi.org/10.1080/07900627.2012.713848Rossi G, Caporali E, Garrote L (2012) Definition of risk indicators for reservoirs management optimization. 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Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Gaia Data Release 2: The astrometric solution

Gaia Data Release 2 (Gaia DR2) contains results for 1693 million sources in the magnitude range 3 to 21 based on observations collected by the European Space Agency Gaia satellite during the first 22 months of its operational phase. We describe the input data, models, and processing used for the astrometric content of Gaia DR2, and the validation of these results performed within the astrometry task. Some 320 billion centroid positions from the pre-processed astrometric CCD observations were used to estimate the five astrometric parameters (positions, parallaxes, and proper motions) for 1332 million sources, and approximate positions at the reference epoch J2015.5 for an additional 361 million mostly faint sources. Special validation solutions were used to characterise the random and systematic errors in parallax and proper motion. For the sources with five-parameter astrometric solutions, the median uncertainty in parallax and position at the reference epoch J2015.5 is about 0.04 mas for bright (G<14 mag) sources, 0.1 mas at G=17 mag, and 0.7 mas at G=20 mag. In the proper motion components the corresponding uncertainties are 0.05, 0.2, and 1.2 mas/yr, respectively. The optical reference frame defined by Gaia DR2 is aligned with ICRS and is non-rotating with respect to the quasars to within 0.15 mas/yr. From the quasars and validation solutions we estimate that systematics in the parallaxes depending on position, magnitude, and colour are generally below 0.1 mas, but the parallaxes are on the whole too small by about 0.03 mas. Significant spatial correlations of up to 0.04 mas in parallax and 0.07 mas/yr in proper motion are seen on small (<1 deg) and intermediate (20 deg) angular scales. Important statistics and information for the users of the Gaia DR2 astrometry are given in the appendices.Includes STFC

Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States

Purpose: Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one’s job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics. Methods: Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within I

Gaia Data Release 1: Testing parallaxes with local Cepheids and RR Lyrae stars

Context. Parallaxes for 331 classical Cepheids, 31 Type II Cepheids, and 364 RR Lyrae stars in common between Gaia and the Hipparcos and Tycho-2 catalogues are published in Gaia Data Release 1 (DR1) as part of the Tycho-Gaia Astrometric Solution (TGAS). Aims. In order to test these first parallax measurements of the primary standard candles of the cosmological distance ladder, which involve astrometry collected by Gaia during the initial 14 months of science operation, we compared them with literature estimates and derived new period-luminosity (PL), period-Wesenheit (PW) relations for classical and Type II Cepheids and infrared PL, PL-metallicity (PLZ), and optical luminosity-metallicity (M V -[Fe/H]) relations for the RR Lyrae stars, with zero points based on TGAS. Methods. Classical Cepheids were carefully selected in order to discard known or suspected binary systems. The final sample comprises 102 fundamental mode pulsators with periods ranging from 1.68 to 51.66 days (of which 33 with σ Ω /Ω < 0.5). The Type II Cepheids include a total of 26 W Virginis and BL Herculis stars spanning the period range from 1.16 to 30.00 days (of which only 7 with σ Ω /Ω < 0.5). The RR Lyrae stars include 200 sources with pulsation period ranging from 0.27 to 0.80 days (of which 112 with σ Ω /Ω < 0.5). The new relations were computed using multi-band (V,I,J,K s ) photometry and spectroscopic metal abundances available in the literature, and by applying three alternative approaches: (i) linear least-squares fitting of the absolute magnitudes inferred from direct transformation of the TGAS parallaxes; (ii) adopting astrometry-based luminosities; and (iii) using a Bayesian fitting approach. The last two methods work in parallax space where parallaxes are used directly, thus maintaining symmetrical errors and allowing negative parallaxes to be used. The TGAS-based PL,PW,PLZ, and M V - [Fe/H] relations are discussed by comparing the distance to the Large Magellanic Cloud provided by different types of pulsating stars and alternative fitting methods. Results. Good agreement is found from direct comparison of the parallaxes of RR Lyrae stars for which both TGAS and HST measurements are available. Similarly, very good agreement is found between the TGAS values and the parallaxes inferred from the absolute magnitudes of Cepheids and RR Lyrae stars analysed with the Baade-Wesselink method. TGAS values also compare favourably with the parallaxes inferred by theoretical model fitting of the multi-band light curves for two of the three classical Cepheids and one RR Lyrae star, which were analysed with this technique in our samples. The K-band PL relations show the significant improvement of the TGAS parallaxes for Cepheids and RR Lyrae stars with respect to the Hipparcos measurements. This is particularly true for the RR Lyrae stars for which improvement in quality and statistics is impressive. Conclusions. TGAS parallaxes bring a significant added value to the previous Hipparcos estimates. The relations presented in this paper represent the first Gaia-calibrated relations and form a work-in-progress milestone report in the wait for Gaia-only parallaxes of which a first solution will become available with Gaia Data Release 2 (DR2) in 2018. © ESO, 2017