Distributed expertise: Qualitative study of a British network of multidisciplinary teams supporting parents of children with chronic kidney disease

© 2014 The Authors. Background: Long-term childhood conditions are often managed by hospital-based multidisciplinary teams (MDTs) of professionals with discipline specific expertise of a condition, in partnership with parents. However, little evidence exists on professional-parent interactions in this context. An exploration of professionals' accounts of the way they individually and collectively teach parents to manage their child's clinical care at home is, therefore, important for meeting parents' needs, informing policy and educating novice professionals. Using chronic kidney disease as an exemplar this paper reports on one aspect of a study of interactions between professionals and parents in a network of 12 children's kidney units in Britain. Methods: We conducted semi-structured, qualitative interviews with a convenience sample of 112 professionals (clinical-psychologists, dietitians, doctors, nurses, pharmacists, play-workers, therapists and social workers), exploring accounts of their parent-educative activity. We analysed data using framework and the concept of distributed expertise. Results: Four themes emerged that related to the way expertise was distributed within and across teams: (i) recognizing each other's' expertise, (ii) sharing expertise within the MDT, (iii) language interpretation, and (iv) acting as brokers. Two different professional identifications were also seen to co-exist within MDTs, with participants using the term 'we' both as the intra-professional 'we' (relating to the professional identity) when describing expertise within a disciplinary group (for example: 'As dietitians we aim to give tailored advice to optimize children's growth'), and the inter-professional 'we' (a 'team-identification'), when discussing expertise within the team (for example: 'We work as a team and make sure we're all happy with every aspect of their training before they go home'). Conclusions: This study highlights the dual identifications implicit in 'being professional' in this context (to the team and to one's profession) as well as the unique role that each member of a team contributes to children's care. Our methodology and results have the potential to be transferred to teams managing other conditions

Legal aspects of contraceptive implants

Key message points - There has been litigation in relation to the three types of harm associated with contraceptive implants: non-insertion, deep insertion and nerve injury. - Recommendations for safe clinical practice can be derived from analysis of legal cases and published case reports. - Nerve injury has invariably been caused by clinicians without upper limb surgical skills attempting difficult removals. - The launch of the updated single-rod implant (Nexplanon®) may hold the best possibility for harm reduction. - Litigation in relation to side effects can lead to the withdrawal of safe and effective contraceptive products, so reducing choice for wome

Least Adaptive Optimal Search with Unreliable Tests

AbstractWe consider the basic problem of searching for an unknown m-bit number by asking the minimum possible number of yes–no questions, when up to a finite number e of the answers may be erroneous. In case the (i+1)th question is adaptively asked after receiving the answer to the ith question, the problem was posed by Ulam and Rényi and is strictly related to Berlekamp's theory of error correcting communication with noiseless feedback. Conversely, in the fully non-adaptive model when all questions are asked before knowing any answer, the problem amounts to finding a shortest e-error correcting code. Let qe(m) be the smallest integer q satisfying Berlekamp’s bound ∑i=0e(qi)⩽2q−m. Then at least qe(m) questions are necessary, in the adaptive, as well as in the non-adaptive model. In the fully adaptive case, optimal searching strategies using exactly qe(m) questions always exist up to finitely many exceptional m's. At the opposite non-adaptive case, searching strategies with exactly qe(m) questions—or equivalently, e-error correcting codes with 2m codewords of length qe(m)—are rather the exception, already for e=2, and are generally not known to exist for e>2. In this paper, for each e>1 and all sufficiently large m, we exhibit searching strategies that use a first batch of m non-adaptive questions and then, only depending on the answers to these m questions, a second batch of qe(m)−m non-adaptive questions. These strategies are automatically optimal. Since even in the fully adaptive case, qe(m)−1 questions do not suffice to find the unknown number, and qe(m) questions generally do not suffice in the non-adaptive case, the results of our paper provide e fault tolerant searching strategies with minimum adaptiveness and minimum number of tests

Willingness to Pay for a Quality-Adjusted Life-Year: The Individual Perspective

AbstractObjectiveThe aim of this study was to elicit the individual willingness to pay (WTP) for a quality-adjusted life-year (QALY).MethodsIn a Web-based questionnaire containing contingent valuation exercises, respondents valued health changes in five scenarios. In each scenario, the respondents first valued two health states on a visual analog scale (VAS) and expressed their WTP for avoiding a decline in health from the better health state to the worse, using a payment scale followed by a bounded open contingent valuation question.AnalysisWTP per QALY was calculated for QALY gains calculated using VAS valuations, as well as the Dutch EQ-5D tariffs, the two steps in the WTP estimations and each scenario. Heterogeneity in WTP per QALY ratios was examined from the perspective of: 1) household income; and 2) the level of certainty in WTP indicated by respondents. Theoretical validity was analyzed using clustered multivariate regressions.ResultsA total of 1091 respondents, representative of the Dutch population, participated in the survey. Mean WTP per QALY was €12,900 based on VAS valuations, and €24,500 based on the Dutch EuroQoL tariffs. WTP per QALY was strongly associated with income, varying from €5000 in the lowest to €75,400 in the highest income group. Respondents indicating higher certainty exhibited marginally higher WTP. Regression analyses confirmed expected relations between WTP per QALY, income, and other personal characteristics.ConclusionIndividual WTP per QALY values elicited in this study are similar to those found in comparable studies. The use of individual valuations in social decision-making deserves attention, however

Novel genetic loci associated with hippocampal volume

The hippocampal formation is a brain structure integrally involved in episodic memory, spatial navigation, cognition and stress responsiveness. Structural abnormalities in hippocampal volume and shape are found in several common neuropsychiatric disorders. To identify the genetic underpinnings of hippocampal structure here we perform a genome-wide association study (GWAS) of 33,536 individuals and discover six independent loci significantly associated with hippocampal volume, four of them novel. Of the novel loci, three lie within genes (ASTN2, DPP4 and MAST4) and one is found 200 kb upstream of SHH. A hippocampal subfield analysis shows that a locus within the MSRB3 gene shows evidence of a localized effect along the dentate gyrus, subiculum, CA1 and fissure. Further, we show that genetic variants associated with decreased hippocampal volume are also associated with increased risk for Alzheimer’s disease (rg=−0.155). Our findings suggest novel biological pathways through which human genetic variation influences hippocampal volume and risk for neuropsychiatric illness

P.0035 Structural brain correlates of childhood inhibited temperament: rationale and methodology for an ENIGMA-Anxiety mega-analysis

NWORubicon 019.201SG.022Pathways through Adolescenc