A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice

My Brother’s Keeper: Two Black Men Navigating the Tenure-Track Experience

This study explores the tenure-track experiences of two junior faculty Black men in higher education, while growing still remains vastly unexplored in higher education. Using an autoethnography approach with a critical race theory lens, the authors explore how race and institutional expectations shape their experiences along the primary components of the tenure process: research, teaching and service. While one author is beginning their tenure journey while the other is ending, findings highlight commonalities along teaching and service experiences are being mediated by their identities as Black men. Their research experiences are distinct from one another given the different research expectations of their respective institutions. The authors suggest recommendations for faculty, staff, and institutional leadership to support Black men who seek tenure and promotion in higher education. This article was published Open Access through the CCU Libraries Open Access Publishing Fund. The article was first published in Race Ethnicity and Education: https://doi.org/10.1080/13613324.2023.224889

Space Station Facilities and Operations at the Kennedy Space Center

The Spaca Station Program potentially will a significant Impact on the Kennedy Space Canter Current and past programs have had their major Impact on KSC In the prelaunch and launch operations area with program support, subsequent to liftoff, generally performed at other locations. The Space Station Program also will Impact pre- launch and launch operations at KSC but, due to Its proposed 10-year operational lifetime, KSC also could have a significant role in support of the operational program. Support operations of the Space Station Program may be performed elsewhere; however, centralizing them at KSC has a number of attractive features which warrant study

A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences

Background: The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented. Methods: The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed. Results: Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway. Conclusion: Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation

Endogenous fantasy and learning in digital games.

Many people believe that educational games are effective because they motivate children to actively engage in a learning activity as part of playing the game. However, seminal work by Malone (1981), exploring the motivational aspects of digital games, concluded that the educational effectiveness of a digital game depends on the way in which learning content is integrated into the fantasy context of the game. In particular, he claimed that content which is intrinsically related to the fantasy will produce better learning than that which is merely extrinsically related. However, this distinction between intrinsic and extrinsic (or endogenous and exogenous) fantasy is a concept that has developed a confused standing over the following years. This paper will address this confusion by providing a review and critique of the empirical and theoretical foundations of endogenous fantasy, and its relevance to creating educational digital games. Substantial concerns are raised about the empirical basis of this work and a theoretical critique of endogenous fantasy is offered, concluding that endogenous fantasy is a misnomer, in so far as the "integral and continuing relationship" of fantasy cannot be justified as a critical means of improving the effectiveness of educational digital games. An alternative perspective on the intrinsic integration of learning content is described, incorporating game mechanics, flow and representations

Multi-wavelength observations of 2HWC J1928+177: dark accelerator or new TeV gamma-ray binary?

2HWC J1928+177 is a Galactic TeV gamma-ray source detected by the High Altitude Water Cherenkov (HAWC) Observatory up to ~ 56 TeV. The HAWC source, later confirmed by H.E.S.S., still remains unidentified as a dark accelerator since there is no apparent supernova remnant or pulsar wind nebula detected in the lower energy bands. The radio pulsar PSR J1928+1746, coinciding with the HAWC source position, has no X-ray counterpart. Our SED modeling shows that inverse Compton scattering in the putative pulsar wind nebula can account for the TeV emission only if the unseen nebula is extended beyond r ~ 4 [arcmin]. Alternatively, TeV gamma rays may be produced by hadronic interactions between relativistic protons from an undetected supernova remnant associated with the radio pulsar and a nearby molecular cloud G52.9+0.1. NuSTAR and Chandra observations detected a variable X-ray point source within the HAWC error circle, potentially associated with a bright IR source. The X-ray spectra can be fitted with an absorbed power-law model with $N_{\rm H} = (9\pm3)\times10^{22}$ cm$^{-2}$ and $\Gamma_X = 1.6\pm0.3$ and exhibit long-term X-ray flux variability over the last decade. If the X-ray source, possibly associated with the IR source (likely an O star), is the counterpart of the HAWC source, it may be a new TeV gamma-ray binary powered by collisions between the pulsar wind and stellar wind. Follow-up X-ray observations are warranted to search for diffuse X-ray emission and determine the nature of the HAWC source.Comment: accepted to ApJ, 8 pages, 7 figure

Modeling Surface and Subsurface Pesticide Transport Under Three Field Conditions Using PRZM-3 and GLEAMS

Contaminant transport models should be evaluated over a wide range of conditions to determine their limitations. The models PRZM and GLEAMS have been evaluated many times, but few studies are available in which predicted movement in runoff and percolate were simultaneously evaluated against field data. Studies of this type are essential because pesticide leaching and runoff are mutually dependent processes. For this reason, PRZM-3 and GLEAMS were evaluated for their ability to predict metribuzin concentrations in runoff, sediment, subsurface soil, and pan lysimeters under three field conditions (yard waste compost amended, no-till, and conventional-till) on a Lowell silt loam soil. Sensitive input parameters were either site specific (climatic, soil, and chemical) or calibrated (K-factor, C-factor, curve number). In general, both models under-predicted metribuzin concentration in runoff water, runoff sediment, subplow layer soil (15-75 cm), and pan lysimeter water (75 cm). Contrary to field data, both models predicted that a large percentage (\u3e 50%) of metribuzin would move below the “mixing zone” (top 1 cm) during the first rainfall event after application. Relatively little metribuzin was predicted to move beyond the plow layer (top 15 cm) into the pan lysimeters or subsurface soil throughout the simulation period, possibly due to the lack of a macropore component in the models. High metribuzin concentrations in sediment (field data) indicated that relatively little metribuzin moved below the “mixing zone”, possibly because of hysteresis but much of the metribuzin that did move was quickly transported into the pan lysimeters, probably due to macropore flow. GLEAMS more accurately predicted pesticide concentration in sediment and PRZM predicted subsurface soil concentration somewhat more accurately than GLEAMS. Little difference in accuracy was detected between models on metribuzin concentration in runoff or metribuzin concentration in percolate. Although both models generally under-predicted metribuzin concentration in runoff, runoff transport (mass of metribuzin in runoff) for the study period was over-predicted by both models which emphasizes the importance of accurately predicting herbicide concentration and runoff volume soon after application when the surface pesticide concentrations are highest

A Nation-Wide Survey of High School Baseball Coaches’ Perceptions Indicates Their Arm Care Programs Play a Role in Injury Prevention

Background Arm care programs consisting of upper extremity strengthening and stretching have been recommended for injury prevention for pitchers of all ages. There has been no investigation into high school baseball coaches’ usage and perceptions of arm care programs to mitigate physical impairments associated with injuries in baseball players. Hypothesis/Purpose The purpose of this study was to investigate the current usage of arm care programs by high school baseball coaches. The primary objective was to determine if coaches use group-based or individualized arm care programs. The secondary objective sought to determine if the use of arm care programs is influenced by coaches’ age, education, and experience level. Finally, this study explored the potential barriers to arm care implementation and high school baseball coaches’ current awareness and beliefs of injury prevention. Study Design Descriptive cross-sectional survey Methods A 29-item online survey was emailed to 18,500 high school baseball coaches throughout the United States. Data were collected for three months, and the response rate was 3.7%. Results A total of 87.3% (n=571/654) of responding coaches use arm care programs with their players. Of coaches performing arm care, only 18.5% of 571 individualize their arm care exercises based on specific player needs. However, older and more experienced coaches are more likely to individualize their programs. Among the 12.7% (n=83/654) of coaches who do not use arm care programs, the two most commonly cited reasons for not implementing arm care were lack of observed benefit (41%) and insufficient staff (31%). Although 42% of 654 coaches recognized reduced shoulder mobility as a major contributor to injury, risk factors such as throwing with a fatigued arm, previous injury history, and throwing \u3e 8 months per year were not consistently identified as primary risk factors. Conclusion The results of this study suggest that the majority high school baseball coaches implement group-based arm care exercise programs to prevent injury. Lack of confidence in the effectiveness and staffing limitations were major barriers to implementation of arm care programming. However, the responding coaches exhibited inconsistent risk factor awareness and dated injury prevention beliefs. Therefore, better educational collaboration between rehabilitation professionals and high school coaches regarding injury risk factors and preventative strategies is warranted. Level of Evidence Level

The Effect of Pre-Diagnostic Alcohol Consumption on Survival after Breast Cancer in Young Women.

Background: Alcohol consumption has been comprehensively investigated as an etiologic risk factor for breast cancer but has received little attention in terms of its impact on prognosis after breast cancer, particularly for young women. Methods: 1286 women diagnosed with invasive breast cancer at or before 45 years of age from two population-based case-control studies in the Seattle-Puget Sound region were followed from their diagnosis of breast cancer (between January 1983 and December 1992) for survival through June 2002, during which time 364 women had died. Cox proportional hazards modeling was used to assess the effect of pre-diagnostic alcohol consumption on the risk of dying. Results: After adjusting for age and diagnosis year, compared to non-drinkers, women who consumed alcohol in the 5 years prior to diagnosis had a decreased risk of death [>0 to <3 drinks per week: HR(hazard ratio) = 0.7 (95% CI: 0.6-0.95); 3 to <7 drinks per week: RR = 0.6 (95% CI: 0.4-0.8); ≥ 7 drinks per week: RR = 0.7 (95% CI: 0.5-0.9)]. This association was unchanged upon additional adjustment for potential confounders including most notably treatment, stage at diagnosis, and mammogram history. Conclusion: These results suggest that women who consume alcohol prior to a diagnosis of breast cancer have improved survival which does not appear to be attributable to differences in stage, screening or treatment

Three-dimensional photoacoustic imaging and inversion for accurate quantification of chromophore distributions

Photoacoustic tomography can, in principle, provide quantitatively accurate, high-resolution, images of chromophore distributions in 3D in vivo. However, achieving this goal requires not only dealing with the optical fluence-related spatial and spectral distortion but also having access to high quality, calibrated, measurements and using image reconstruction algorithms free from inaccurate assumptions. Furthermore, accurate knowledge of experimental parameters, such as the positions of the ultrasound detectors and the illumination pattern, is necessary for the reconstruction step. A meticulous and rigorous experimental phantom study was conducted to show that highly-resolved 3D estimation of chromophore distributions can be achieved: a crucial step towards in vivo implementation. The phantom consisted of four 580 μm diameter tubes with different ratios of copper sulphate and nickel sulphate as hemoglobin analogues, submersed in a background medium of intralipid and india ink. The optical absorption, scattering, photostability, and Grüneisen parameter were characterised for all components independently. A V-shaped imaging scanner enabled 3D imaging with the high resolution, high sensitivity, and wide bandwidth characteristic of Fabry-Pérot ultrasound sensors, but without the limited-view disadvantage of single-plane scanners. The optical beam profile and position were determined experimentally. Nine wavelengths between 750 and 1110 nm were used. The images of the chromophore concentrations were obtained using a model-based, two-step, procedure, that did not require image segmentation. First, the acoustic reconstruction was solved with an iterative time-reversal algorithm to obtain images of the initial acoustic pressure at each of the nine wavelengths for an 18×17×13 mm3 volume with 50μm voxels. Then, 3D high resolution estimates of the chromophore concentrations were obtained by using a diffusion model of light transport in an iterative nonlinear optimisation scheme. Among the lessons to be drawn from this study, one is fundamental: in order to obtain accurate estimates of chromophores (or their ratios) it is not only necessary to model the light fluence accurately, but it is just as crucial to obtain accurate estimates of the initial acoustic pressure distributions, and to account for variations in the thermoelastic efficiency (Grüneisen parameter). © (2017) COPYRIGHT Society of Photo-Optical Instrumentation Engineers (SPIE). Downloading of the abstract is permitted for personal use only