GRADE guidance 37: rating imprecision in a body of evidence on test accuracy.

OBJECTIVES: To provide guidance on rating imprecision in a body of evidence assessing the accuracy of a single test. This guide will clarify when Grading of Recommendations Assessment, Development and Evaluation (GRADE) users should consider rating down the certainty of evidence by one or more levels for imprecision in test accuracy. STUDY DESIGN AND SETTING: A project group within the GRADE working group conducted iterative discussions and presentations at GRADE working group meetings to produce this guidance. RESULTS: Before rating the certainty of evidence, GRADE users should define the target of their certainty rating. GRADE recommends setting judgment thresholds defining what they consider a very accurate, accurate, inaccurate, and very inaccurate test. These thresholds should be set after considering consequences of testing and effects on people-important outcomes. GRADE's primary criterion for judging imprecision in test accuracy evidence is considering confidence intervals (i.e., CI approach) of absolute test accuracy results (true and false, positive, and negative results in a cohort of people). Based on the CI approach, when a CI appreciably crosses the predefined judgment threshold(s), one should consider rating down certainty of evidence by one or more levels, depending on the number of thresholds crossed. When the CI does not cross judgment threshold(s), GRADE suggests considering the sample size for an adequately powered test accuracy review (optimal or review information size [optimal information size (OIS)/review information size (RIS)]) in rating imprecision. If the combined sample size of the included studies in the review is smaller than the required OIS/RIS, one should consider rating down by one or more levels for imprecision. CONCLUSION: This paper extends previous GRADE guidance for rating imprecision in single test accuracy systematic reviews and guidelines, with a focus on the circumstances in which one should consider rating down one or more levels for imprecision.

Who is the majority group? Signaling majority group membership with name-based treatments in multilingual contexts: The case of Catalonia.

An increasing body of work has shown how the selection of names shapes patterns of ethnic and racial discrimination in hiring observed in correspondence audit studies. A clear limitation of the existing research on name perceptions and ethnic discrimination in employment is that is predominantly based in the US, which limits its applicability to contexts with high linguistic diversity among the majority population. These territories confront a reality where language preferences and uses, social class, and ancestry are associated with specific names among the native majority group. The result is notable diversity in the labor market (dis)advantages conferred by different names within the majority population. To fill this gap, this article focuses on Catalonia, a diverse multilingual region and Spain's second most populated area. Using two complementary studies, this work identifies the direct influence of names in the hiring process (Study 1) and evaluates the associations between names and perceptions of geographic origin, social class, and linguistic competence (Study 2). The results show that having a Catalan name confers an advantage in the labour market via three mechanisms. First, names inform a perception of language proficiency, which is tied to an expectation of productivity. Second, names signal social class and certain names in the majority group (applicants with two Catalan surnames, a minority within the region), indicate higher social class, which affords an advantage. Third, some advantage could be linked to tastes that favor an ingroup for reasons of assumed cultural, historical, or political compatibility. The approach adopted in this article holds significant relevance to other research on ethnic discrimination conducted in multilingual contexts with comparable autochthonous diversity.

Allocating municipal services to individuals with complex rehabilitation needs - a discourse analysis of individual administrative decision letters.

BACKGROUND: Rehabilitation is considered paramount for enhancing quality of life and reducing healthcare costs. As a result of healthcare reforms, Norwegian municipalities have been given greater responsibility for allocating rehabilitation services following discharge from hospital. Individual decision letters serve as the basis for implementing services and they have been described as information labels on the services provided by the municipality. They play an important role in planning and implementing the services in collaboration with the individual applicants. Research indicates that the implementation of policies may lead to unintended consequences, as individuals receiving municipal services perceive them as fragmented. This perception is characterised by limited user involvement and a high focus on body functions. The aim of this study was to examine how municipal decision letters about service allocation incorporate the recommendations made in the official national guideline and reflect a holistic approach to rehabilitation, coordination and user involvement for individuals with comprehensive needs. METHODS: The decision letters of ten individuals with moderate to severe brain injury allocating rehabilitation services in two municipalities were examined. It was assessed whether the content was in accordance with the authorities' recommendations, and a discourse analysis was conducted using four tools adapted from an established integrated approach. RESULTS: The letters primarily contained standard texts concerning legal and administrative regulations. They were predominantly in line with the official guideline to municipal service allocation. From a rehabilitation perspective, the focus was mainly on medically oriented care, scarcely referring to psychosocial needs, activity, and participation. The intended user involvement seemed to vary between active and passive status, while the coordination of services was given limited attention. CONCLUSIONS: The written decision letters did fulfil legal and administrative recommendations for service allocation. However, they did not fulfil their potential to serve as a means of conveying rehabilitation issues, such as specification of the allocated services, a holistic approach to health, coordination, or the involvement of users in decision processes. These elements must be incorporated throughout the allocation process if the policies are to be implemented as intended. Findings can have international relevance for discussions between clinicians and policy makers.

[An overview of natural entheogens]. / Un aperçu des enthéogènes naturels.

Entheogens are a group of little-known psychoactive substances which consumption is nevertheless frequently mentioned in outpatient care and which can have harmful effects. This raises the question of appropriate management of their effects, as well as the treatment of any overdose. In this article, we focus on five of these substances, which are rarely described in the medical literature. At present, few studies exist on their long-term effects on health, and this type of niche consumption does not seem problematic from the authorities' point of view. Rapid screening is unavailable because it has not been developed, and the management of overdoses is often limited to non-specific supportive treatment with benzodiazepines.

Les enthéogènes sont un groupe de substances psychoactives méconnues mais dont la consommation apparaît toutefois lors de consultations ambulatoires et qui peuvent engendrer des effets néfastes. Se pose alors la question de la prise en charge adaptée concernant leurs effets mais également le traitement d'un éventuel surdosage. Dans cet article, le focus a été mis sur cinq de ces substances peu décrites dans la littérature médicale. Actuellement, peu d'études existent sur leurs effets à long terme sur la santé et ce type de consommation de niche ne semble pas problématique du point de vue des autorités. Le dépistage rapide n'est pas disponible car pas développé et la prise en charge des surdosages se limite souvent à un traitement de soutien non spécifique par benzodiazépines.

Research on the factors and path of sports industry development in China: A fsQCA study of 31 provinces.

The advancement of the sports industry's development constitutes a critical concern shared by regional authorities and the scholarly community, reflecting its significant role in economic and social development. This study employs a Fuzzy-set Qualitative Comparative Analysis (fsQCA) methodology to examine the 31 provincial-level administrative units in China. The objective is to elucidate the influence of technological, organizational, and environmental factors on the industry's development level, considering both a holistic national framework and dissected regional approaches (Eastern, Central, and Western China). This paper's contribution to the literature is structured around the following core findings: (1) The study establishes that a singular condition does not suffice as an essential prerequisite for achieving a heightened development state within the sports industry. (2) At the national level, there are three pathways to enhance the development level of the sports industry, specifically identified as "network-human resources dominant pathway," "technological innovation-human resources dominant pathway," and "comprehensive synergistic pathway."(3) From a regional perspective, the Eastern region has two pathways for sports industry enhancement: "network-economic pathway" and "comprehensive synergistic pathway." The Central region follows a "technology pathway," while the Western region has three pathways: "organization-environment pathway," "network-organization-environment pathway," and "organization pathway."(4) The synthesis of these findings underscores the multifactorial nature of sports industry development, suggesting a paradigm where diverse routes can lead to equivalent outcomes. This heterogeneity indicates that provinces or regions can tailor their development strategies to their unique situational contexts.

Emergent teaching movements in leadership development: Group relations, case-in-point, and intentional emergence.

In a post-pandemic context, the need for leadership students to navigate ambiguous conditions and examine their automatic responses to authority has increased. Yet, common approaches to teaching leadership, such as group discussions and simulations, overlook the potential for using development spaces as living laboratories. This article explores three emergent-based pedagogies (group relations, case-in-point, and intentional emergence) that de-center the instructor, prioritize co-creation and emergence, and provide living laboratories for students to examine their assumptions and default behaviors related to leadership.

Group Health & Wellness Coaching: development and validation of the required competencies.

BACKGROUND: As the popularity and demonstrated effectiveness of Health and Wellness Coaching (HWC) continue to grow to address chronic disease prevalence worldwide, delivery of this approach in a group format is gaining traction, particularly in healthcare. Nonetheless, very little empirical work exists on group coaching and there are currently no published competencies for Group Health and Wellness Coaching (GHWC). METHODS: We used a well-established two-phase (Development and Judgment) process to create and validate GHWC competencies with strong content validity. RESULTS: Seven highly qualified Subject Matter Experts systematically identified and proposed the GHWC competencies, which were then validated by 78 National Board Certified Health and Wellness Coaches (NBC-HWCs) currently practicing GHWC who rated the importance and use frequency of each one. The validation study led to 72 competencies which are organized into the structure and process of GHWC. CONCLUSIONS: GHWC requires not only coaching skills, but significant group facilitation skills to guide the group process to best support members in maximizing health and well-being through self-directed behavioral change. As the presence of HWC continues to grow, it is imperative that GHWC skill standards be accepted and implemented for the safety of the public, the effectiveness of the intervention, and the value analysis of the field. Such standards will guide curriculum development, allow for a more robust research agenda, and give practical guidance for health and wellness coaches to responsibly run groups. High quality standards for GHWC are particularly needed in health care, where a Level III Current Procedural Terminology (CPT®) code for GHWC has been approved in the United States since 2019 and reimbursement of such has been approved by the Centers for Medicare and Medicaid for 2024.

Practices of falls risk assessment and prevention in acute hospital settings: a realist investigation.

Background: Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Aim: To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Design: Realist review and multisite case study. (1) Systematic searches to identify stakeholders' theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Setting: Three Trusts, one orthopaedic and one older person ward in each. Results: Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Limitations: Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Conclusions: (1) Leadership: There should be a clear distinction between senior nurses' roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Future work: (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. Study registration: This study is registered as PROSPERO CRD42020184458. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Many accidental falls by older people in hospitals could be avoided. There are guidelines to prevent falls, but some hospitals are better at following them than others. This study aimed to find out why. First, we looked at research and hospitals' falls policies for ideas about what stops falls. With advice from service users, we tested these ideas in four hospitals in England, watching how falls were prevented on wards for older people and people who need bone care, and talking to 50 staff, 28 patients and 3 carers. We found the following: Falls leadership: wards had staff called falls link practitioners who supported falls prevention, but senior nurses, not link practitioners, made the most important decisions. Sharing responsibility: patients with falls risks were monitored to try to stop falls. Because only nursing teams were always present to monitor patients, they had most responsibility for preventing falls. This limited sharing responsibility with other staff. Computer tools: nurses used computers to record prevention work, but high workloads could make this a 'tick-box' exercise. Computer tools reminded them to do this, although tools varied. Patients had individual falls plans, but they were also ranked more generally as high or low risk of falling, with 'high-risk' patients being monitored. Patient involvement: nursing staff did not have time to explain to patients how to prevent falls, but other staff could have such conversations. Many patients had problems like dementia and found it difficult to follow safety advice, although some could take steps to keep safe, with sensitive staff support. We need to involve patients, carers and different staff in falls prevention. Hospitals could develop computer systems to support this, think how to involve more ward staff, and provide guidance on helpful ways to talk with patients about falls.

A Microcosm of the outside world: Intentional emergence around current events, factions, and polarization.

Teaching leadership in today's world requires a combination of introducing theory and best practices, as well as allowing moments that are happening in real-time, both current events and interactions from the "laboratory" of the classroom, to affect the teaching agenda. Instructors can lean into the model of Intentional Emergence (IE) to help guide them toward welcoming these "real-life moment" as vital parts of the curriculum. The authors review inside events, outside events, and Temporary Authority Skills Challenges (or TASCs) as examples of IE pedagogy.

Using intentional emergence to dethrone the sage on the stage.

Intentional emergence (IE) as a pedagogy centers students in learning and calls for the educator or facilitator to take a different role. It is important for educators to mindfully regulate their presence in the classroom to allow students to notice the role of authority in leadership practice. This article provides recommendations for productive learning when authority is de-centered and learners are encouraged to take up their authority. Facilitators who reflect and consider their identities and the identities of their participants will be more prepared for what emerges in the classroom. Finally, educators center student learning by intentionally creating a safe container before giving back the work to students in meaningful ways, allowing themselves to take a backseat and observe students exercising leadership.

Attending to the complexities of leadership learning and practice: Emergent-based assessment and evaluation strategies.

In emergence-based leadership education, the knowledge and experiences co-created in the classroom may violate some of the assumptions behind traditional teaching and learning assessment methods. Thus, traditional assessment, evaluation, and outcomes for courses utilizing emergence-based methods, such as intentional emergence, case-in-point, dialogic group process consultations, and group relations/dynamics, are counterintuitive and must be reconsidered. We provide recommendations regarding how to conduct assessment when utilizing emergence-based teaching methods in leadership education. We review the use of inductive forms of assessment and provide recommendations for broadening learning outcomes and engaging in learning outcomes beyond the knowledge domain.

The prefigurative politics of leadership education: Connecting our practice to broader movements.

Why develop leaders? What politics are implicit in our practice? This paper uses the history and practice of Popular Education as a comparative framework to survey the politics of intentional emergence leadership pedagogy, surfacing potential alliances for building social change movements. Using a case analysis, the article elucidates the ways the classroom embodies an opportunity to explore and enact a prefigurative politics of significant social change that upends traditional relationships to authority, hierarchy, and decision-making. Exploring the opportunities and dangers of connecting the classroom to broader social movements, the article concludes by advocating that such connections could offer a firmer and more explicit stance to the question: why develop leaders?

Lessons learned from the pandemic: expanding the collaboration between clinical and logistics activities in a hospital.

PURPOSE: The Covid-19 pandemic generated significant changes in the operating methods of hospital logistics departments. The objective of this research is to understand how these changes took place, what collaboration mechanisms were developed with clinical authorities and, to what extent, logistics and clinical care activities should be decoupled to maximize each area's contribution? DESIGN/METHODOLOGY/APPROACH: The case study is selected to investigate practices implemented during the COVID-19 pandemic in hospitals in Canada. The pandemic presented an opportunity to contrast practices implemented in response to this crisis with those historically used in this environment. FINDINGS: The strategy of decoupling logistical tasks of an operational nature from clinical activities is well-founded and helps free clinical staff from tasks for which they are not trained. However, the decoupling of operational tasks should be combined with an integration of the clinical information flow to the logistics hub players. With this clinical information, the logistics hub can generate its full potential enabling better inventory management decisions to be made. ORIGINALITY/VALUE: The concept of decoupling is studied to identify configurations that offer the best benefits for clinical staff.

Group membership modulates empathic neural responses to pain in deaf individuals.

Empathy deficiencies are prevalent among deaf individuals. It has yet to be determined whether they exhibit an ingroup bias in empathic responses. This study employed explicit and implicit empathy tasks (i.e. attention-to-pain-cue [A-P] task and attention-to-nonpain-cue [A-N] task) to explore the temporal dynamics of neural activities when deaf individuals were processing painful/nonpainful stimuli from both ingroup models (deaf people) and outgroup models (hearing people), which aims to not only assist deaf individuals in gaining a deeper understanding of their intergroup empathy traits but also to aid in the advancement of inclusive education. In the A-P task, we found that (i) ingroup priming accelerated the response speed to painful/nonpainful pictures; (ii) the N2 amplitude of painful pictures was significantly more negative than that of nonpainful pictures in outgroup priming trials, whereas the N2 amplitude difference between painful and nonpainful pictures was not significant in ingroup priming trials. For N1 amplitude of the A-N task, we have similar findings. However, this pattern was reversed for P3/late positive component amplitude of the A-P task. These results suggest that the deaf individuals had difficulty in judging whether hearing individuals were in pain. However, their group identification and affective responses could shape the relatively early stage of pain empathy.

Can group membership modulate the social abilities of autistic people? An intergroup bias in smile perception.

Autistic adults struggle to reliably differentiate genuine and posed smiles. Intergroup bias is a promising factor that may modulate smile discrimination performance, which has been shown in neurotypical adults, and which could highlight ways to make social interactions easier. However, it is not clear whether this bias also exists in autistic people. Thus, the current study aimed to investigate this in autism using a minimal group paradigm. Seventy-five autistic and sixty-one non-autistic adults viewed videos of people making genuine or posed smiles and were informed (falsely) that some of the actors were from an in-group and others were from an out-group. The ability to identify smile authenticity of in-group and out-group members and group identification were assessed. Our results revealed that both groups seemed equally susceptible to ingroup favouritism, rating ingroup members as more genuine, but autistic adults also generally rated smiles as less genuine and were less likely to identify with ingroup members. Autistic adults showed reduced sensitivity to the different smile types but the absence of an intergroup bias in smile discrimination in both groups seems to indicate that membership can only modulate social judgements but not social abilities. These findings suggest a reconsideration of past findings that might have misrepresented the social judgements of autistic people through introducing an outgroup disadvantage, but also a need for tailored support for autistic social differences that emphasizes similarity and inclusion between diverse people.

When patients demur: Resisting diagnostic closure in US primary care.

Patients are more engaged in their healthcare than ever before, including in the process of diagnostic sensemaking. But in acute primary care encounters, the interactional flow of the visit is shaped by an orientation toward the physician as the authority over diagnostic reasoning. Once physicians close diagnostic inquiry and transition into counseling, their assessment - and the extent to which it converges with the patient's perspective - comes into full view. Yet this is precisely when patients have reduced occasions to speak up if they do have concerns, as the "train has left the station" both diagnostically and interactionally. Using conversation analysis and a dataset of 75 video recordings of acute primary care encounters in the US, this article examines how patients speak up in this constrained environment. The concept of diagnosis demurral is proposed to describe how patients resist diagnostic closure by renewing the relevance of diagnostic inquiry, either in response to a diagnosis or at any point following the transition into counseling. Findings suggest that patients demur more frequently than prior studies on diagnosis resistance may have predicted, but they do so in ways that maintain deference to the physician's authority over matters of diagnosis: speaking up primarily outside the diagnostic moment, relying on actions in their own domain of expertise (e.g., their illness experience), and working to additionally soften the epistemic and interactional inappositeness of their demurral. This behavior sits at the nexus of two opposing forces: patients may be more engaged, but their participation is constrained by a continued legacy of medical authority over diagnosis, to which patients themselves continue to respond and reproduce.

"How to article:" guidelines for serving on an expert panel.

Academics in medicine are frequently asked to serve on panels to discuss their clinical, research, education, administrative or personal expertise. While panel discussions are often the highlight of a conference or event, in the medical literature, there is very little published on how an individual can effectively prepare and present as an expert panelist. This paper offers guidelines that will enable academics to prepare, deliver, and engage in active dialogue during a panel discussion. Specific tactics include how to accept invitations to serve on a panel, conducting pre-panel conference meetings and background research, preparing concise opening statements and new insights, connecting with the audience, answering questions in a collaborative spirit, and debriefing after the panel. These guidelines will be valuable to any individual invited to serve on a panel discussion and will promote future panelists in engaging in constructive and fulfilling dialogue, with the ultimate goal of leaving the audience with a greater understanding of the topic of discourse.

Super-additive cooperation.

Repeated interactions provide an evolutionary explanation for one-shot human cooperation that is counterintuitive but orthodox1-3. Intergroup competition4-7 provides an explanation that is intuitive but heterodox. Here, using models and a behavioural experiment, we show that neither mechanism reliably supports cooperation. Ambiguous reciprocity, a class of strategies that is generally ignored in models of reciprocal altruism, undermines cooperation under repeated interactions. This finding challenges repeated interactions as an evolutionary explanation for cooperation in general, which further challenges the claim that repeated interactions in the past can explain one-shot cooperation in the present. Intergroup competitions also do not reliably support cooperation because groups quickly become extremely similar, which limits scope for group selection. Moreover, even if groups vary, group competitions may generate little group selection for multiple reasons. Cooperative groups, for example, may tend to compete against each other8. Whereas repeated interactions and group competitions do not support cooperation by themselves, combining them triggers powerful synergies because group competitions constrain the corrosive effect of ambiguous reciprocity. Evolved strategies often consist of cooperative reciprocity with ingroup partners and uncooperative reciprocity with outgroup partners. Results from a behavioural experiment in Papua New Guinea fit exactly this pattern. They thus suggest neither an evolutionary history of repeated interactions without group competition nor a history of group competition without repeated interactions. Instead, our results suggest social motives that evolved under the joint influence of both mechanisms.

Projecting the Future Pediatric Subspecialty Workforce: Summary and Recommendations.

This article summarizes the findings of a Pediatrics supplement addressing the United States workforce for 15 pediatric subspecialties. It includes results from a microsimulation model projecting supply through 2040; growth is forecasted to be uneven across the subspecialties with worsening geographic maldistribution. Although each subspecialty has unique characteristics, commonalities include (1) the changing demographics and healthcare needs of children, including mental health; (2) poor outcomes for children experiencing adverse social drivers of health, including racism; and (3) dependence on other subspecialties. Common healthcare delivery challenges include (1) physician shortages for some subspecialties; (2) misalignment between locations of training programs and subspecialists and areas of projected child population growth; (3) tension between increasing subsubspecialization to address rare diseases and general subspecialty care; (4) the need to expand clinical reach through collaboration with other physicians and advanced practice providers; (5) the lack of parity between Medicare, which funds much of adult care, and Medicaid, which funds over half of pediatric subspecialty care; and (6) low compensation of pediatric subspecialists compared with adult subspecialists. Overall, subspecialists identified the lack of a central authority to monitor and inform child healthcare provided by pediatric subspecialists as a challenge. Future research on the pediatric subspecialty workforce and the children it serves will be necessary to ensure these children's needs are met. Together, these articles provide overarching and subspecialty-specific recommendations to improve training, recruitment, and retention of a diverse workforce, implement innovative models of care, drive policy changes, and advise future research.