Technology-Dependent Pedagogical Process Redesign: Leveraging Lean Methods

Purpose This research compared the efficacy of process outcomes leveraging lean methods versus traditional pedagogy applied to dental education dependent on emerging technology. The pedagogical objective was to improve system efficiency without compromising traditional outcomes of effectiveness (quality). Design/methodology/approach The research team tested the efficacy of a lean A3 framework to identify, remove waste and redesign a technology-dependent simulation laboratory course (CAD/CAM/IR Restorative Dentistry). Students were also sensitized to time-in-chair to introduce a stronger patient focus. Baseline data collected from a control group were statistically compared to the research group\u27s data after the course redesign. In addition, course time allocations were measured and then compared. Findings The results showed the interventions significantly reduced procedure cycle times without compromising quality. Additionally, the course was more efficiently conducted as measured by course time allocations. Practical implications This research demonstrated that the use of the A3 framework enhanced learning through process documentation, reengineering and systems optimization resolving issues of inefficiency associated with the CAD/CAM/IR pedagogy. This work is significant because it demonstrates the practice of using lean interventions to redesign and improve a technology-based healthcare course to maximize benefits. Originality/value This research is the first to examine how to leverage lean methods in a healthcare simulation laboratory, dependent on innovative technology, to educate and train future practitioners. This research applied statistical rigor in a controlled experiment to maximize its applicability and generalizability

Ciclesonide versus other inhaled corticosteroids for chronic asthma in children

Background Inhaled corticosteroids (ICS) are the cornerstone of asthma maintenance treatment in children. Particularly among parents, there is concern about the safety of ICS as studies in children have shown reduced growth. Small-particle-size ICS targeting the smaller airways have improved lung deposition and effective asthma control might be achieved at lower daily doses. Ciclesonide is a relatively new ICS. This small-particle ICS is a pro-drug that is converted in the airways to an active metabolite and therefore with potentially less local (throat infection) and systemic (reduced growth) side effects. It can be inhaled once daily, thereby possibly improving adherence. Objectives To assess the efficacy and adverse effects of ciclesonide compared to other ICS in the management of chronic asthma in children. Search methods We searched the Cochrane Airways Group Register of trials with pre-defined terms. Additional searches of MEDLINE (via PubMed), EMBASE and Clinicalstudyresults. org were undertaken. Searches are up to date to 7 November 2012. Selection criteria Randomised controlled parallel or cross-over studies were eligible for the review. We included studies comparing ciclesonide with other corticosteroids both at nominally equivalent doses or lower doses of ciclesonide. Data collection and analysis Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials. Main results Six studies were included in this review (3256 children, 4 to 17 years of age). Two studies were published as conference abstracts only. Ciclesonide was compared to budesonide and fluticasone. Ciclesonide compared to budesonide (dose ratio 1: 2): asthma symptoms and adverse effect were similar in both groups. Pooled results showed no significant difference in children who experience an exacerbation (risk ratio (RR) 2.20, 95% confidence interval (CI) 0.75 to 6.43). Both studies reported that 24-hour urine cortisol levels showed a statistically significant decrease in the budesonide group compared to the ciclesonide group. Ciclesonide compared to fluticasone (dose ratio 1: 1): no significant differences were found for the outcome asthma symptoms. Pooled results showed no significant differences in number of patients with exacerbations (RR 1.37, 95% CI 0.58 to 3.21) and data from a study that could not be pooled in the meta-analysis reported similar numbers of patients with exacerbations in both groups. None of the studies found a difference in adverse effects. No significant difference was found for 24-hour urine cortisol levels between the groups (mean difference 0.54 nmol/mmol, 95% CI -5.92 to 7.00). Ciclesonide versus fluticasone (dose ratio 1: 2) was assessed in one study and showed similar results between the two corticosteroids for asthma symptoms. The number of children with exacerbations was significantly higher in the ciclesonide group (RR 3.57, 95% CI 1.35 to 9.47). No significant differences were found in adverse effects (RR 0.98, 95% CI 0.81 to 1.14) and 24-hour urine cortisol levels (mean difference 1.15 nmol/mmol, 95% CI 0.07 to 2.23). The quality of evidence was judged 'low' for the outcomes asthma symptoms and adverse events and 'very low' for the outcome exacerbations for ciclesonide versus budesonide (dose ratio 1: 1). The quality of evidence was graded 'moderate' for the outcome asthma symptoms, 'very low' for the outcome exacerbations and 'low' for the outcome adverse events for ciclesonide versus fluticasone (dose ratio 1: 1). For ciclesonide versus fluticasone (dose ratio 1: 2) the quality was rated 'low' for the outcome asthma symptoms and 'very low' for exacerbations and adverse events (dose ratio 1: 2). Authors' conclusions An improvement in asthma symptoms, exacerbations and side effects of ciclesonide versus budesonide and fluticasone could be neither demonstrated nor refuted and the trade-off between benefits and harms of using ciclesonide instead of budesonide or fluticasone is unclear. The resource use or costs of different ICS should therefore also be considered in final decision making. Longer-term superiority trials are needed to identify the usefulness and safety of ciclesonide compared to other ICS. Additionally these studies should be powered for patient relevant outcomes (exacerbations, asthma symptoms, quality of life and side effects). There is a need for studies comparing ciclesonide once daily with other ICS twice daily to assess the advantages of ciclesonide being a pro-drug that can be administered once daily with possibly increased adherence leading to increased control of asthma and fewer side effects

Evolution of Spur-Length Diversity in Aquilegia Petals is Achieved solely through Cell-Shape Anisotropy

The role of petal spurs and specialized pollinator interactions has been studied since Darwin. Aquilegia petal spurs exhibit striking size and shape diversity, correlated with specialized pollinators ranging from bees to hawkmoths in a textbook example of adaptive radiation. Despite the evolutionary significance of spur length, remarkably little is known about Aquilegia spur morphogenesis and its evolution. Using experimental measurements, both at tissue and cellular levels, combined with numerical modelling, we have investigated the relative roles of cell divisions and cell shape in determining the morphology of the Aquilegia petal spur. Contrary to decades-old hypotheses implicating a discrete meristematic zone as the driver of spur growth, we find that Aquilegia petal spurs develop via anisotropic cell expansion. Furthermore, changes in cell anisotropy account for 99 per cent of the spur-length variation in the genus, suggesting that the true evolutionary innovation underlying the rapid radiation of Aquilegia was the mechanism of tuning cell shape

Feedback of patient-reported outcomes to healthcare professionals for comparing health service performance: a scoping review

Objective: Patient-reported outcomes (PROs) provide self-reported patient assessments of their quality of life, daily functioning, and symptom severity after experiencing an illness and having contact with the health system. Feeding back summarised PROs data, aggregated at the health-service level, to healthcare professionals may inform clinical practice and quality improvement efforts. However, little is known about the best methods for providing these summarised data in a way that is meaningful for this audience. Therefore, the aim of this scoping review was to summarise the emerging approaches to PROs data for &lsquo;service-level&rsquo; feedback to healthcare professionals. Setting: Healthcare professionals receiving PROs data feedback at the health-service level. Data sources: Databases selected for the search were Embase, Ovid Medline, Scopus, Web of Science and targeted web searching. The main search terms included: &lsquo;patient-reported outcome measures&rsquo;, &lsquo;patient-reported outcomes&rsquo;, &lsquo;patient-centred care&rsquo;, &lsquo;value-based care&rsquo;, &lsquo;quality improvement&rsquo; and &lsquo;feedback&rsquo;. Studies included were those that were published in English between January 2009 and June 2019. Primary and secondary outcome measures: Data were extracted on the feedback methods of PROs to patients or healthcare providers. A standardised template was used to extract information from included documents and academic publications. Risk of bias was assessed using Joanna Briggs Institute Levels of Evidence for Effectiveness. Results: Overall, 3480 articles were identified after de-duplication. Of these, 19 academic publications and 22 documents from the grey literature were included in the final review. Guiding principles for data display methods and graphical formats were identified. Seven major factors that may influence PRO data interpretation and use by healthcare professionals were also identified. Conclusion: While a single best format or approach to feedback PROs data to healthcare professionals was not identified, numerous guiding principles emerged to inform the field.</jats:sec

Gas Kinematics on GMC scales in M51 with PAWS: cloud stabilization through dynamical pressure

We use the high spatial and spectral resolution of the PAWS CO(1-0) survey of the inner 9 kpc of the iconic spiral galaxy M51 to examine the effect of gas streaming motions on the star-forming properties of individual GMCs. We compare our view of gas flows in M51 -- which arise due to departures from axi-symmetry in the gravitational potential (i.e. the nuclear bar and spiral arms) -- with the global pattern of star formation as traced by Halpha and 24\mu m emission. We find that the dynamical environment of GMCs strongly affects their ability to form stars, in the sense that GMCs situated in regions with large streaming motions can be stabilized, while similarly massive GMCs in regions without streaming go on to efficiently form stars. We argue that this is the result of reduced surface pressure felt by clouds embedded in an ambient medium undergoing large streaming motions, which prevents collapse. Indeed, the variation in gas depletion time expected based on the observed streaming motions throughout the disk of M51 quantitatively agrees with the variation in observed gas depletion time scale. The example of M51 shows that streaming motions, triggered by gravitational instabilities in the form of bars and spiral arms, can alter the star formation law; this can explain the variation in gas depletion time among galaxies with different masses and morphologies. In particular, we can explain the long gas depletion times in spiral galaxies compared to dwarf galaxies and starbursts. We suggest that adding a dynamical pressure term to the canonical free-fall time produces a single star formation law that can be applied to all star-forming regions and galaxies, across cosmic time.Comment: 28 pages, 14 figures, accepted for publication in Ap

The PdBI Arcsecond Whirlpool Survey (PAWS): Multi-phase cold gas kinematic of M51

The kinematic complexity and the favorable position of M51 on the sky make this galaxy an ideal target to test different theories of spiral arm dynamics. Taking advantage of the new high resolution PdBI Arcsecond Whirlpool Survey (PAWS) data, we undertake a detailed kinematic study of M51 to characterize and quantify the origin and nature of the non-circular motions. Using a tilted-ring analysis supported by several other archival datasets we update the estimation of M51's position angle (PA=(173 +/- 3) deg) and inclination (i=(22 +/- 5) deg). Harmonic decomposition of the high resolution (40 pc) CO velocity field shows the first kinematic evidence of an m=3 wave in the inner disk of M51 with a corotation at R(CR,m=3)=1.1 +/- 0.1 kpc and a pattern speed of Omega_p(m=3) = 140 km/(s kpc). This mode seems to be excited by the nuclear bar, while the beat frequencies generated by the coupling between the m=3 mode and the main spiral structure confirm its density-wave nature. We observe also a signature of an m=1 mode that is likely responsible for the lopsidedness of M51 at small and large radii. We provide a simple method to estimate the radial variation of the amplitude of the spiral perturbation (Vsp) attributed to the different modes. The main spiral arm structure has =50-70 km/s, while the streaming velocity associated with the m=1 and m=3 modes is, in general, 2 times lower. Our joint analysis of HI and CO velocity fields at low and high spatial resolution reveals that the atomic and molecular gas phases respond differently to the spiral perturbation due to their different vertical distribution and emission morphology.Comment: 42 pages, 12 figures, accepted for publication in Ap

The PdBI Arcsecond Whirlpool Survey (PAWS): Environmental Dependence of Giant Molecular Cloud Properties in M51

Using data from the PdBI Arcsecond Whirlpool Survey (PAWS), we have generated the largest extragalactic Giant Molecular Cloud (GMC) catalog to date, containing 1,507 individual objects. GMCs in the inner M51 disk account for only 54% of the total 12CO(1-0) luminosity of the survey, but on average they exhibit physical properties similar to Galactic GMCs. We do not find a strong correlation between the GMC size and velocity dispersion, and a simple virial analysis suggests that 30% of GMCs in M51 are unbound. We have analyzed the GMC properties within seven dynamically-motivated galactic environments, finding that GMCs in the spiral arms and in the central region are brighter and have higher velocity dispersions than inter-arm clouds. Globally, the GMC mass distribution does not follow a simple power law shape. Instead, we find that the shape of the mass distribution varies with galactic environment: the distribution is steeper in inter-arm region than in the spiral arms, and exhibits a sharp truncation at high masses for the nuclear bar region. We propose that the observed environmental variations in the GMC properties and mass distributions are a consequence of the combined action of large-scale dynamical processes and feedback from high mass star formation. We describe some challenges of using existing GMC identification techniques for decomposing the 12CO(1-0) emission in molecule-rich environments, such as M51's inner disk.Comment: 73 pages, 18 figures, 14 tables, accepted for publication in Ap

A Comparative Study of Giant Molecular Clouds in M51, M33 and the Large Magellanic Cloud

We compare the properties of giant molecular clouds (GMCs) in M51 identified by the Plateau de Bure Interferometer Whirlpool Arcsecond Survey (PAWS) with GMCs identified in wide-field, high resolution surveys of CO emission in M33 and the Large Magellanic Cloud (LMC). We find that GMCs in M51 are larger, brighter and have higher velocity dispersions relative to their size than equivalent structures in M33 and the LMC. These differences imply that there are genuine variations in the average mass surface density of the different GMC populations. To explain this, we propose that the pressure in the interstellar medium surrounding the GMCs plays a role in regulating their density and velocity dispersion. We find no evidence for a correlation between size and linewidth in any of M51, M33 or the LMC when the CO emission is decomposed into GMCs, although moderately robust correlations are apparent when regions of contiguous CO emission (with no size limitation) are used. Our work demonstrates that observational bias remains an important obstacle to the identification and study of extragalactic GMC populations using CO emission, especially in molecule-rich galactic environments.Comment: 25 pages, 11 figures, accepted for publication in ApJ. Uses emulateapj LaTeX macros. For more information on PAWS, further papers and data, see http://www.mpia.de/PAWS

Suicidal students' use of and attitudes to primary care prevention services

Aim The aims of this study were to improve responses to students in distress and who are feeling suicidal, to help practitioners to increase their responsiveness to those at high risk of suicide and to develop effective responses to those affected by their deaths. The study sought to build a detailed picture of students’ patterns of service use. Background National suicide prevention strategies emphasise that suicide prevention requires the collaboration of a wide range of organisations. Among these, primary care services play a key role in relation to suicide prevention for young people in crisis. Methods This study, undertaken between 2004 and 2007, focused on 20 case studies of student suicide that took place in the United Kingdom between May 2000 and June 2005. It adopted a psychological autopsy approach to learn from a wide range of informants, including parents, friends, university staff and the records of coroners or procurator fiscals. Twenty families gave permission for their son’s or daughter’s death to be included in the study and agreed to participate in the study. Informants were interviewed in person and the data were analysed thematically. Analysis of the case study data suggested that in a number of cases students had failed to engage with services sufficiently early or in sufficient depth. Primary care practitioners need to be proactive in communicating concerns about vulnerable students to student support services. At local levels, collaboration between student support and National Health Service practitioners varied considerably and channels of communication need to be developed