For the successful achievement of evidence-based practice, clinicians, managers and purchasers need evidence on whether a particular intervention works and ways to judge the appropriateness of the outcome criteria and measures used. Guidance is needed on what outcome measure to use, especially within routine clinical care settings. Beginning with a re-clarification of the difference between a health status and an outcome measure, the paper presents an evaluative checklist for use by clinical audit and research staff to review outcome measures for (...) use in routine care settings. Central features include the user-centredness of the measure, its psychometric properties, feasibility of use and utility. The applicability of the checklist is illustrated for outcome measurement in diabetes and stroke care. A modified form of the checklist is proposed for use by the busy clinician as an aid to the critical review of research papers within the context of evidence-based practice and to aid health care practitioners' choice of which outcome measure(s) to use within routine clinical care. (shrink)

Health care organizations are increasingly asked to show accountability about their performance. This paper proposes that accountability can best be achieved through evaluative methods that are based on evidence regarding the relationship between processes of care and expected outcomes. Root cause analysis (RCA) is used as an illustration of how a generic method of inquiring can be transformed into an ongoing monitoring, evaluation, user education and accountability strategy. The role of performance indicators, as well as patient and community expectations, is (...) discussed. (shrink)

The question of how we apply knowledge from biomedical science to medical and public health practice has been the subject of heated debates about generalizability and related concepts, such as applicability and inductive inference. In this essay, I interpret the term from the perspective of two causal models: determinism and indeterminism. I suggest that theories of generalizability can be formulated on the basis of both models and take the form of testable but unverifiable hypotheses, an attribute that is common to (...) all scientific theories. Nonetheless, there is one noteworthy difference between the two models: determinism allows one to rationalize a decision to treat a certain kind of patient but only indirectly a decision to treat any particular patient, whereas indeterminism accommodates both types of decisions. (shrink)

IntroductionBisphenol A is highly debated and studied in relation to a variety of health outcomes. This large variation in the literature makes BPA a topic that is prone to selective use of literature, in order to underpin one’s own findings and opinion. Over time, selective use of literature, by means of citations, can lead to a skewed knowledge development and a biased scientific consensus. In this study, we assess which factors drive citation and whether this results in the overrepresentation of (...) harmful health effects of BPA.MethodsA citation network analysis was performed to test various determinants of citation. A systematic search identified all relevant publications on the human health effect of BPA. Data were extracted on potential determinants of selective citation, such as study outcome, study design, sample size, journal impact factor, authority of the author, self-citation, and funding source. We applied random effect logistic regression to assess whether these determinants influence the likelihood of citation.ResultsOne hundred sixty-nine publications on BPA were identified, with 12,432 potential citation pathways of which 808 citations occurred. The network consisted of 63 cross-sectional studies, 34 cohort studies, 29 case-control studies, 35 narrative reviews, and 8 systematic reviews. Positive studies have a 1.5 times greater chance of being cited compared to negative studies. Additionally, the authority of the author and self-citation are consistently found to be positively associated with the likelihood of being cited. Overall, the network seems to be highly influenced by two highly cited publications, whereas 60 out of 169 publications received no citations.ConclusionIn the literature on BPA, citation is mostly driven by positive study outcome and author-related factors, such as high authority within the network. Interpreting the impact of these factors and the big influence of a few highly cited publications, it can be questioned to which extent the knowledge development in human literature on BPA is actually evidence-based. (shrink)

John Lavery's The First Wounded, London Hospital, August 1914 records a memorable event in the First World War. This painting and the archives of the Royal London Hospital provide a fascinating insight into the nursing and medical care of these early war casualties.

Rationale, aims and objectives Given the increasing prevalence of cataract and demand for cataract extraction surgery, patients must often wait to undergo this procedure. We validated a previously developed priority scoring system in terms of clinical variables, pre-intervention health status, appropriateness of surgery and gain in visual acuity (VA) and health-related quality of life (HRQoL).Methods Explicit prioritization criteria for cataract extraction created by a variation of the Research and Development (RAND) and University of California Los Angeles appropriateness methodology were retrospectively (...) applied to a prospective cohort of 5257 patients on waiting lists to undergo cataract by phacoemulsification at 17 hospitals in Spain. Demographic data, clinical data and data related to surgical technique were collected by trained ophthalmologists. Patients were evaluated by their ophthalmologist before the intervention and 6 weeks afterward. They also completed, by mail, the Visual Function Index (VF-14) before the intervention and 3 months afterward.Results High-priority patients experienced greater improvement in VA and HRQoL than those classified as intermediate or low-priority (P < 0.0001), even after adjusting by VA and the VF-14 score at baseline. The time to intervention was the same for high-priority patients as it was for intermediate and low-priority patients.Conclusions The priority score we developed identified patients most likely to experience the greatest improvements from cataract extraction. Use of this tool could provide a fairer and more rational way to prioritize patients for cataract extraction. (shrink)

Coastal ecosystems are increasingly dominated by humans. Consequently, the human dimensions of sustainability science have become an integral part of emerging coastal governance and management practices. But if we are to avoid the harsh lessons of land management, coastal decision makers must recognize that humans are one of the more coastally dependent species in the biosphere. Management responses must therefore confront both the temporal urgency and the very real compromises and sacrifices that will be necessary to achieve a sustainable coastal (...) ecosystem, one that is economically feasible, socially just, and ecologically sound. (shrink)

There is a popular hypothesis that performance on implicit and explicit memory tasks reflects 2 distinct memory systems. Explicit memory is said to store those experiences that can be consciously recollected, and implicit memory is said to store experiences and affect subsequent behavior but to be unavailable to conscious awareness. Although this division based on awareness is a useful taxonomy for memory tasks, the authors review the evidence that the unconscious character of implicit memory does not necessitate that it be (...) treated as a separate system of human memory. They also argue that some implicit and explicit memory tasks share the same memory representations and that the important distinction is whether the task (implicit or explicit) requires the formation of a new association. The authors review and critique dissociations from the behavioral, amnesia, and neuroimaging literatures that have been advanced in support of separate explicit and implicit memory systems by highlighting contradictory evidence and by illustrating how the data can be accounted for using a simple computational memory model that assumes the same memory representation for those disparate tasks. (shrink)

We assessed how synchronous speech listening and lipreading affects speech recognition in acoustic noise. In simple audiovisual perceptual tasks, inverse effectiveness is often observed, which holds that the weaker the unimodal stimuli, or the poorer their signal-to-noise ratio, the stronger the audiovisual benefit. So far, however, inverse effectiveness has not been demonstrated for complex audiovisual speech stimuli. Here we assess whether this multisensory integration effect can also be observed for the recognizability of spoken words. To that end, we presented audiovisual (...) sentences to 18 native-Dutch normal-hearing participants, who had to identify the spoken words from a finite list. Speech-recognition performance was determined for auditory-only, visual-only (lipreading) and auditory-visual conditions. To modulate acoustic task difficulty, we systematically varied the auditory signal-to-noise ratio. In line with a commonly-observed multisensory enhancement on speech recognition, audiovisual words were more easily recognized than auditory-only words (recognition thresholds of -15 dB and -12 dB, respectively). We here show that the difficulty of recognizing a particular word, either acoustically or visually, determines the occurrence of inverse effectiveness in audiovisual word integration. Thus, words that are better heard or recognized through lipreading, benefit less from bimodal presentation. Audiovisual performance at the lowest acoustic signal-to-noise ratios (45%) fell below the visual recognition rates (60%), reflecting an actual deterioration of lipreading in the presence of excessive acoustic noise. This suggests that the brain may adopt a strategy in which attention has to be divided between listening and lipreading. (shrink)

Background Speech understanding may rely not only on auditory, but also on visual information. Non-invasive functional neuroimaging techniques can expose the neural processes underlying the integration of multisensory processes required for speech understanding in humans. Nevertheless, noise (from fMRI) limits the usefulness in auditory experiments, and electromagnetic artefacts caused by electronic implants worn by subjects can severely distort the scans (EEG, fMRI). Therefore, we assessed audio-visual activation of temporal cortex with a silent, optical neuroimaging technique: functional near-infrared spectroscopy (fNIRS). Methods (...) We studied temporal cortical activation as represented by concentration changes of oxy- and deoxy-hemoglobin in four, easy-to-apply fNIRS optical channels of 33 normal-hearing adult subjects and 5 post-lingually deaf cochlear implant (CI) users in response to supra-threshold unisensory auditory and visual, as well as to congruent auditory-visual speech stimuli. Results Activation effects were not visible from single fNIRS channels. However, by discounting physiological noise through reference channel subtraction, auditory, visual and audiovisual speech stimuli evoked concentration changes for all sensory modalities in both cohorts (p<0.001). Auditory stimulation evoked larger concentration changes than visual stimuli (p<0.001). A saturation effect was observed for the audiovisual condition. Conclusions Physiological, systemic noise can be removed from fNIRS signals by reference channel subtraction. The observed multisensory enhancement of an auditory cortical channel can be plausibly described by a simple addition of the auditory and visual signals with saturation. (shrink)

Nous nous inscrivons dans une culture, nous sommes les heritiers de multiples traditions. Le romantisme qui a su remettre la tradition a l'honneur, aussi bien que les Lumieres avec leur mefiance - allant jusqu'au refus - vis-a-vis de toute tradition, sont pour nous de telles traditions. Nous devons nous rapporter a nos traditions en Aufklarer, les soumettre a l'examen critique, mais nous devons savoir egalement que l'elucidation de la tradition ne peut se resoudre dans la pure maitrise de la critique, (...) qu'elle est reflexion a partir d'une appartenance. (shrink)

The introduction of novel diagnostic techniques in clinical domains such as genomics and radiology has led to a rich ethical debate on how to handle unsolicited findings that result from these innovations. Yet while unsolicited findings arise in both genomics and radiology, most of the relevant literature to date has tended to focus on only one of these domains. In this article, we synthesize and critically assess similarities and differences between “scanning the body” and “sequencing the genome” from an ethical (...) perspective. After briefly describing the novel diagnostic contexts leading to unsolicited findings, we synthesize and reflect on six core ethical issues that relate to both specialties: terminology; benefits and risks; autonomy; disclosure of unsolicited findings to children; uncertainty; and filters and routine screening. We identify ethical rationales that pertain to both fields and may contribute to more ethically sound policies. Considerations of preserving public trust and ensuring that people perceive healthcare policies as fair also support the need for a combined debate. (shrink)

The prospect of using cell-based interventions to treat neurological conditions raises several important ethical and policy questions. In this target article, we focus on issues related to the unique constellation of traits that characterize CBIs targeted at the central nervous system. In particular, there is at least a theoretical prospect that these cells will alter the recipients' cognition, mood, and behavior—brain functions that are central to our concept of the self. The potential for such changes, although perhaps remote, is cause (...) for concern and careful ethical analysis. Both to enable better informed consent in the future and as an end in itself, we argue that early human trials of CBIs for neurological conditions must monitor subjects for changes in cognition, mood, and behavior; further, we recommend concrete steps for that monitoring. Such steps will help better characterize the potential risks and benefits of CBIs as they are tested and potentially used for treatment. (shrink)

Initial responses to questionnaires used to assess participants' understanding of informed consent for malaria vaccine trials conducted in the United States and Mali were tallied. Total scores were analyzed by age, sex, literacy (if known), and location. Ninety-two percent (92%) of answers by United States participants and 85% of answers by Malian participants were correct. Questions more likely to be answered incorrectly in Mali related to risk, and to the type of vaccine. For adult participants, independent predictors of higher scores (...) were younger age and female sex in the United States, and male sex in Mali. Scores in the United States were higher than in Mali (P = 0.005). Despite this difference participants at both sites were well informed overall. Although interpretation must be qualified because questionnaires were not intended as research tools and were not standardized among sites, these results do not support concerns about systematic low understanding among research participants in developing versus developed countries. (shrink)

Background: Dementia care at home often involves decisions in which the caregiver must weigh safety concerns with respect for autonomy. These dilemmas can lead to situations where caregivers provide care against the will of persons living with dementia, referred to as involuntary treatment. To prevent this, insight is needed into how family caregivers of persons living with dementia deal with care situations that can lead to involuntary treatment. Objective: To identify and describe family caregivers’ experiences regarding care decisions for situations (...) that can lead to involuntary treatment use in persons living with dementia at home. Research design: A qualitative descriptive interview design. Data were analysed using the Qualitative Analysis Guide of Leuven. Participants and research context: A total of 10 family caregivers providing care for 13 persons living with dementia participated in in-depth semi-structured interviews. Participants were recruited by registered nurses via purposive sampling. Ethical consideration: The study protocol was approved by the Ethics Committee of the University Hospitals Leuven and the Medical Ethical Test Committee Zuyderland. Findings: Family caregivers experience the decision-making process concerning care dilemmas that can lead to involuntary treatment as complicated, stressful and exhausting. Although they consider safety and autonomy as important values, they struggle with finding the right balance between them. Due to the progressive and unpredictable nature of dementia, they are constantly seeking solutions while they adapt to new situations. Family caregivers feel responsible and experience social pressure for the safety of persons living with dementia. They may be blamed if something adverse happens to the persons living with dementia, which increases an already stressful situation. Their experience is influenced by characteristics of the care triad such as practical and emotional support, knowledge, and previous experiences. Discussion and conclusion: To prevent involuntary treatment, professionals need to proactively inform family caregivers, and they need to support each other in dealing with complex care situations. (shrink)

_ Source: _Volume 40, Issue 1, pp 104 - 115 It is intended in this study to present initial reliability and validity data for the Russian adaptation of the Multidimensional Inventory of Religious/Spiritual Well-being, as being related to personality factors and psychopathology. Therefore, the first version of the MI-RSWB-R was applied to a sample of 192 non-clinical subjects, together with the NEO Five Factor Inventory and the Symptom-Check-List. The original six-factor structure of the scale could be replicated for the MI-RSWB-R, (...) which also provides satisfying psychometric properties. In accordance with previous research the RSWB total score was linked to more favorable personality traits such as Extraversion, Openness to Experience, and Agreeableness, which was paralleled by substantial negative correlations with increased psychopathology. Our findings support the reliability and structural validity of the MI-RSWB-R as a standardized instrument for addressing the spiritual dimension in Russian populations. Further research in clinical surroundings is now recommended. (shrink)

In this paper we describe a method for the specification of computationalmodels of argument using dialogue games. The method, which consists ofsupplying a set of semantic definitions for the performatives making upthe game, together with a state transition diagram, is described in full.Its use is illustrated by some examples of varying complexity, includingtwo complete specifications of particular dialogue games, Mackenzie's DC,and the authors' own TDG. The latter is also illustrated by a fully workedexample illustrating all the features of the game.

There is general acknowledgement that both the anterior cingulate and orbitofrontal cortex are implicated in reinforcement-guided decision making, and emotion and social behaviour. Despite the interest that these areas generate in both the cognitive neuroscience laboratory and the psychiatric clinic, ideas about the distinctive contributions made by each have only recently begun to emerge. This reflects an increasing understanding of the component processes that underlie reinforcement- guided decision making, such as the representation of reinforcement expectations, the exploration, updating and representation (...) of action values, and the appreciation that choices are guided not just by the prospect of reward but also by the costs that action entails. Evidence is emerging to suggest that the anterior cingulate and orbitofrontal cortex make distinct contributions to each of these aspects of decision making. (shrink)

Background Informed consent is a requirement for all research. It is not, however, clear how much information is sufficient to make an informed decision about participation in research. Information on an online questionnaire about childhood development was provided through an unfolding electronic participant sheet in three levels of information. Methods 552 participants, who completed the web-based survey, accessed and spent time reading the participant information sheet (PIS) between July 2008 and November 2009. The information behaviour of the participants was investigated. (...) The first level contained less information than might be found on a standard PIS, the second level corresponded to a standard PIS, and the third contained more information than on a standard PIS. The actual time spent on reading the information provided in three incremental levels and the participants' evaluation of the information were calculated. Results 77% of the participants chose to access the first level of information, whereas 12% accessed the first two levels, 6% accessed all three levels of information and 23% participated without accessing information. The most accessed levels of information were those that corresponded to the average reading times. Conclusion The brief information provided in the first level was sufficient for participants to make informed decisions, while a sizeable minority of the participants chose not to access any information at all. This study adds to the debate about how much information is required to make a decision about participation in research and the results may help inform the future development of information sheets by providing data on participants' actual needs when deciding about questionnaire surveys. (shrink)