The Return on Investment of a Province-Wide Quality Improvement Initiative for Reducing In-Hospital Sepsis Rates and Mortality in British Columbia, Canada.

OBJECTIVES: Sepsis is a life-threatening medical emergency. There is a paucity of information on whether quality improvement approaches reduce the in-hospital sepsis caseload or save lives and decrease the healthcare system and society's cost at the provincial/national levels. This study aimed to assess the outcomes and economic impact of a province-wide quality improvement initiative in Canada. DESIGN: Retrospective population-based study with interrupted time series and return on investment analyses. SETTING: The sepsis cases and deaths averted over time for British Columbia were calculated and compared with the rest of Canada (excluding Quebec and three territories). PATIENTS: Aggregate data were obtained from the Canadian Institute for Health Information on risk-adjusted in-hospital sepsis rates and sepsis mortality in acute care sites across Canada. INTERVENTIONS: In 2012, the British Columbia Sepsis Network was formed to reduce sepsis occurrence and mortality through education, knowledge translation, and quality improvement. MEASUREMENTS AND MAIN RESULTS: A return on investment analysis compared the financial investment for the British Columbia Sepsis Network with the savings from averted sepsis occurrence and mortality. An estimated 981 sepsis cases and 172 deaths were averted in the post-British Columbia Sepsis Network period (2014-2018). The total cost, including the development and implementation of British Columbia Sepsis Network, was $449,962. Net savings due to cases averted after program costs were considered were $50.6 million in 2018. This translates into a return of $112.5 for every dollar invested. CONCLUSIONS: British Columbia Sepsis Network appears to have averted a greater number of sepsis cases and deaths in British Columbia than the national average and yielded a positive return on investment. Our findings strengthen the policy argument for targeted quality improvement initiatives for sepsis care and provide a model of care for other provinces in Canada and elsewhere globally.

Inappropriate use of clinical practices in Canada: a systematic review.

BACKGROUND: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. METHODS: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. RESULTS: We included 174 studies, representing 228 clinical practices and 28 900 762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%-56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%-30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). INTERPRETATION: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada.

Tales from three countries: reflections during COVID-19 for mathematical education in the future.

How can school mathematics prepare citizens for a democratic society? Answers to this question are not static; they change as society and its problems change. The SARS-CoV-2 pandemic with its corresponding disease COVID-19 presents such a problem: what is needed to navigate this complex situation that involves, among other things, mathematics? Using the essay genre, we use three narratives from three countries-Italy, the USA (California), and Germany-to reflect on the goals of teaching mathematics during this crisis and examine aspects of each country's standards for mathematics education. These three stories are framed by the authors' backgrounds, experiences, interests, their country's situation, and response to the pandemic. We first present the three narratives and then examine common issues across them that might provide insights beyond this current crisis, for preparing students to become active citizens. In particular, we focus on three issues: (1) developing a positive mindset toward mathematics to engage with and reflect on real-world problems, (2) improving interdisciplinary connections to the sciences to better understand how science professional practices and insights are similar or different from everyday practices, and (3) considering interpersonal and collective matters beyond the individual.

Complex molecular dynamics of a symmetric model discotic liquid crystal revealed by broadband dielectric, thermal and neutron spectroscopy.

The molecular dynamics of the triphenylene-based discotic liquid crystal HAT6 is investigated by broadband dielectric spectroscopy, advanced dynamical calorimetry and neutron scattering. Differential scanning calorimetry in combination with X-ray scattering reveals that HAT6 has a plastic crystalline phase at low temperatures, a hexagonally ordered liquid crystalline phase at higher temperatures and undergoes a clearing transition at even higher temperatures. The dielectric spectra show several relaxation processes: a localized γ-relaxation at lower temperatures and a so called α2-relaxation at higher temperatures. The relaxation rates of the α2-relaxation have a complex temperature dependence and bear similarities to a dynamic glass transition. The relaxation rates estimated by Hyper DSC, Fast Scanning calorimetry and AC Chip calorimetry have a different temperature dependence than the dielectric α2-relaxation and follow the VFT-behavior characteristic for glassy dynamics. Therefore, this process is called α1-relaxation. Its relaxation rates show a similarity with that of polyethylene. For this reason, the α1-relaxation is assigned to the dynamic glass transition of the alkyl chains in the intercolumnar space. Moreover, this process is not observed by dielectric spectroscopy, which supports its assignment. The α2-relaxation is assigned to small scale translatorial and/or small angle fluctuations of the cores. The neutron scattering data reveal two relaxation processes. The process observed at shorter relaxation times is assigned to the methyl group rotation. The second relaxation process at longer time scales agree in the temperature dependence of its relaxation rates with that of the dielectric γ-relaxation.

Multiple glassy dynamics in dipole functionalized triphenylene-based discotic liquid crystals revealed by broadband dielectric spectroscopy and advanced calorimetry - assessment of the molecular origin.

A selected series of dipole functionalized triphenylene-based discotic liquid crystals (DLCs) was synthesized and investigated in a systematic way to reveal the phase behavior and molecular dynamics. The later point is of particular importance to understand the charge transport in such systems which is the key property for their applications such as organic field-effect transistors, solar cells or as nanowires in molecular electronics, and also to tune the properties of DLCs. The mesomorphic properties were studied by polarizing optical microscopy, X-ray diffraction, and differential scanning calorimetry, which were compared to the corresponding unfunctionalized DLC. The molecular dynamics were investigated by a combination of state-of-the-art broadband dielectric spectroscopy (BDS) and advanced calorimetry such as fast scanning calorimetry (FSC) and specific heat spectroscopy (SHS). Besides localized fluctuations, surprisingly multiple glassy dynamics were detected for all materials for the first time. Glassy dynamics were proven for both processes unambiguously due to the extraordinary broad frequency range covered. The α1-process is attributed to fluctuations of the alky chains in the intercolumnar space because a polyethylene-like glassy dynamics is observed. This corresponds to a glass transition in a confined three-dimensional space. The α2-process found at temperatures lower than α1-process, is assigned to small scale rotational and/or translational in plane fluctuations of the triphenylene core inside distorted columns. This can be considered as a glass transition in a one-dimensional fluid. Therefore, obtained results are of general importance to understand the glass transition, which is an unsolved problem of condensed matter science.

Randomized Clinical Dose-Response Study to Evaluate Plaque Removal by Three Experimental Sodium Bicarbonate Toothpastes Using a Single Brushing Model.

OBJECTIVES: This randomized, examiner-blind, crossover clinical study compared the plaque removal efficacy of three experimental toothpastes containing 20%, 35%, and 50% w/w sodium bicarbonate (NaHCO3) with commercial toothpastes containing 67% and 0% w/w NaHCO3 (positive and negative controls, respectively). METHODS: Fifty-six adults with a mean Turesky Modification of the Quigley-Hein Plaque Index (TPI) score of = 2.00 at screening and at the first treatment visit (pre-brushing) were randomized to a supervised single, timed (one minute) brushing with a 0%, 20%, 35%, 50%, or 67% w/w NaHCO3-containingtoothpaste. TPI was measured pre- and post-brushing. Participants completed five treatment visits, separated by a four- to six-day washout, and brushed once with each toothpaste. The primary efficacy analysis was change in whole mouth TPI score from pre- to post-brushing between the positive and negative control toothpastes (validation step). Secondary analyses were comparisons between each experimental toothpaste and the control toothpastes. Change in TPI score was analyzed using a mixed effect analysis of covariance. RESULTS: The difference in adjusted mean TPI change from pre- to post-brushing between the 67% and 0% w/w NaHCO3 toothpastes was -0.01 points (95% CI -0.06, 0.04), with no statistically significant difference between them (p = 0.6674). As such, study validity was not attained. Differences in adjusted mean change from pre- to post-brushing between each experimental toothpaste and the positive and negative controls ranged from 0.00 to -0.02 points. Twenty-two treatment-emergent, treatment-related adverse events, all oral, were reported by 17 participants (30.4%). These were spread uniformly across test toothpastes and controls. No serious adverse events were reported. CONCLUSIONS: There was no statistically significant difference in change in mean TPI score between toothpastes containing 67% w/w NaHCO3 and 0% w/w NaHCO3 following a single timed brushing. This unexpected observation may be attributed to lower than expected reduction in overall plaque and a possible Hawthorne effect. As study validation was not met, no further conclusions can be made. The study products were generally well tolerated.

The Case for Quality Improvement.

Healthcare systems around the world are facing increasing public and government scrutiny, financial pressures and challenges from growing complexity. There is a need to accelerate the pace of change, and improve the quality of care while reducing cost. These changes must centre on improving care and increasing accountability for quality in the system. But how do we achieve this goal?

Gamification as a strategy to engage and motivate clinicians to improve care.

Approaching change through seeking commitment rather than requiring compliance is an effective way to promote desired behaviours in healthcare. Gamification was explored as a technique to engage clinicians in the adoption of sepsis identification and management tools. Positive extrinsic (eg, feedback and rewards) and intrinsic (eg, mastery, autonomy, relatedness, and purpose) motivators were integrated into a campaign to save lives, leading to a significant reduction in severe sepsis mortality and improvement in processes of care.

Exploring distributed leadership in the BC Sepsis Network.

Commissioned research was undertaken to explore the role of networks in supporting large-scale change and improvement. Participatory action research and social network analysis were used to study the BC Sepsis Network. Findings of this research include insights into distributed leadership, enablers and barriers within a network approach; the importance of relationships and trust; and the need for meaningful and timely data. Recommendations are made for health leaders who are considering utilizing networks for improving patient quality and safety.

How dogs scan familiar and inverted faces: an eye movement study.

Faces play an important role in communication and identity recognition in social animals. Domestic dogs often respond to human facial cues, but their face processing is weakly understood. In this study, facial inversion effect (deficits in face processing when the image is turned upside down) and responses to personal familiarity were tested using eye movement tracking. A total of 23 pet dogs and eight kennel dogs were compared to establish the effects of life experiences on their scanning behavior. All dogs preferred conspecific faces and showed great interest in the eye area, suggesting that they perceived images representing faces. Dogs fixated at the upright faces as long as the inverted faces, but the eye area of upright faces gathered longer total duration and greater relative fixation duration than the eye area of inverted stimuli, regardless of the species (dog or human) shown in the image. Personally, familiar faces and eyes attracted more fixations than the strange ones, suggesting that dogs are likely to recognize conspecific and human faces in photographs. The results imply that face scanning in dogs is guided not only by the physical properties of images, but also by semantic factors. In conclusion, in a free-viewing task, dogs seem to target their fixations at naturally salient and familiar items. Facial images were generally more attractive for pet dogs than kennel dogs, but living environment did not affect conspecific preference or inversion and familiarity responses, suggesting that the basic mechanisms of face processing in dogs could be hardwired or might develop under limited exposure.

Thermotropic orientational order of discotic liquid crystals in nanochannels: an optical polarimetry study and a Landau-de Gennes analysis.

Optical polarimetry measurements of the orientational order of a discotic liquid crystal based on a pyrene derivative confined in parallelly aligned nanochannels of monolithic, mesoporous alumina, silica, and silicon as a function of temperature, channel radius (3-22 nm) and surface chemistry reveal a competition of radial and axial columnar orders. The evolution of the orientational order parameter of the confined systems is continuous, in contrast to the discontinuous transition in the bulk. For channel radii larger than 10 nm we suggest several, alternative defect structures, which are compatible both with the optical experiments on the collective molecular orientation presented here and with a translational, radial columnar order reported in previous diffraction studies. For smaller channel radii our observations can semi-quantitatively be described by a Landau-de Gennes model with a nematic shell of radially ordered columns (affected by elastic splay deformations) that coexists with an orientationally disordered, isotropic core. For these structures, the cylindrical phase boundaries are predicted to move from the channel walls to the channel centres upon cooling, and vice-versa upon heating, in accord with the pronounced cooling/heating hystereses observed and the scaling behavior of the transition temperatures with the channel diameter. The absence of experimental hints of a paranematic state is consistent with a biquadratic coupling of the splay deformations to the order parameter.

Vibrational density of states of triphenylene based discotic liquid crystals: dependence on the length of the alkyl chain.

The vibrational density of states of a series of homologous triphenylene-based discotic liquid crystals HATn (n = 5, 6, 8, 10, 12) depending on the length of the aliphatic side chain is investigated by means of inelastic neutron scattering. All studied materials have a plastic crystalline phase at low temperatures, followed by a hexagonally ordered liquid crystalline phase at higher temperatures and a quasi isotropic phase at the highest temperatures. The X-ray scattering pattern for the plastic crystalline phase of all materials shows a sharp Bragg reflection corresponding to the intercolumnar distance in the lower q-range and a peak at circa 17 nm(-1) related to intracolumnar distances between the cores perpendicular to the columns as well as a broad amorphous halo related to the disordered structure of the methylene groups in the side chains in the higher q-range. The intercolumnar distance increases linearly with increasing chain length for the hexagonal columnar ordered liquid crystalline phase. A similar behaviour is assumed for the plastic crystalline phase. Besides n = 8 all materials under study exhibit a Boson peak. With increasing chain length, the frequency of the Boson peak decreases and its intensity increases. This can be explained by a self-organized confinement model. The peaks for n = 10, 12 are much narrower than for n = 5, 6 which might imply the transformation from a rigid system to a softer one with increasing chain length. Moreover the results can also be discussed in the framework of a transition from an uncorrelated to a correlated disorder with increasing n where n = 8 might be speculatively considered as a transitional state.

Visual event-related potentials of dogs: a non-invasive electroencephalography study.

Previously, social and cognitive abilities of dogs have been studied within behavioral experiments, but the neural processing underlying the cognitive events remains to be clarified. Here, we employed completely non-invasive scalp-electroencephalography in studying the neural correlates of the visual cognition of dogs. We measured visual event-related potentials (ERPs) of eight dogs while they observed images of dog and human faces presented on a computer screen. The dogs were trained to lie still with positive operant conditioning, and they were neither mechanically restrained nor sedated during the measurements. The ERPs corresponding to early visual processing of dogs were detectable at 75-100 ms from the stimulus onset in individual dogs, and the group-level data of the 8 dogs differed significantly from zero bilaterally at around 75 ms at the most posterior sensors. Additionally, we detected differences between the responses to human and dog faces in the posterior sensors at 75-100 ms and in the anterior sensors at 350-400 ms. To our knowledge, this is the first illustration of completely non-invasively measured visual brain responses both in individual dogs and within a group-level study, using ecologically valid visual stimuli. The results of the present study validate the feasibility of non-invasive ERP measurements in studies with dogs, and the study is expected to pave the way for further neurocognitive studies in dogs.

Landmarks in nature to support wayfinding: the effects of seasons and experimental methods.

Landmarks constitute an essential basis for a structural understanding of the spatial environment. Therefore, they are crucial factors in external spatial representations such as maps and verbal route descriptions, which are used to support wayfinding. However, selecting landmarks for these representations is a difficult task, for which an understanding of how people perceive and remember landmarks in the environment is needed. We investigated the ways in which people perceive and remember landmarks in nature using the thinking aloud and sketch map methods during both the summer and the winter seasons. We examined the differences between methods to identify those landmarks that should be selected for external spatial representations, such as maps or route descriptions, in varying conditions. We found differences in the use of landmarks both in terms of the methods and also between the different seasons. In particular, the participants used passage and tree-related landmarks at significantly different frequencies with the thinking aloud and sketch map methods. The results are likely to reflect the different roles of the landmark groups when using the two methods, but also the differences in counting landmarks when using both methods. Seasonal differences in the use of landmarks occurred only with the thinking aloud method. Sketch maps were drawn similarly in summertime and wintertime; the participants remembered and selected landmarks similarly independent of the differences in their perceptions of the environment due to the season. The achieved results may guide the planning of external spatial representations within the context of wayfinding as well as when planning further experimental studies.

Dogs do look at images: eye tracking in canine cognition research.

Despite intense research on the visual communication of domestic dogs, their cognitive capacities have not yet been explored by eye tracking. The aim of the current study was to expand knowledge on the visual cognition of dogs using contact-free eye movement tracking under conditions where social cueing and associative learning were ruled out. We examined whether dogs spontaneously look at actual objects within pictures and can differentiate between pictures according to their novelty or categorical information content. Eye movements of six domestic dogs were tracked during presentation of digital color images of human faces, dog faces, toys, and alphabetic characters. We found that dogs focused their attention on the informative regions of the images without any task-specific pre-training and their gazing behavior depended on the image category. Dogs preferred the facial images of conspecifics over other categories and fixated on a familiar image longer than on novel stimuli regardless of the category. Dogs' attraction to conspecifics over human faces and inanimate objects might reflect their natural interest, but further studies are needed to establish whether dogs possess picture object recognition. Contact-free eye movement tracking is a promising method for the broader exploration of processes underlying special socio-cognitive skills in dogs previously found in behavioral studies.

Efficacy of an intervention to reduce the use of media violence and aggression: an experimental evaluation with adolescents in Germany.

Several longitudinal studies and meta-analytic reviews have demonstrated that exposure to violent media is linked to aggression over time. However, evidence on effective interventions to reduce the use of violent media and promote critical viewing skills is limited. The current study examined the efficacy of an intervention designed to reduce the use of media violence and aggression in adolescence, covering a total period of about 12 months. A sample of 683 7th and 8th graders in Germany (50.1% girls) were assigned to two conditions: a 5-week intervention and a no-intervention control group. Measures of exposure to media violence and aggressive behavior were obtained about 3 months prior to the intervention (T1) and about 7 months post-intervention (T2). The intervention group showed a significantly larger decrease in the use of violent media from T1 to T2 than the control group. Participants in the intervention group also scored significantly lower on self-reported aggressive behavior (physical aggression and relational aggression) at T2 than those in the control group, but the effect was limited to those with high levels of initial aggression. This effect was mediated by an intervention-induced decrease in the normative acceptance of aggression. No gender differences in program efficacy were found. The results show that a 5-week school-based intervention can produce changes in the use of media violence, aggressive norms, and behaviors sustained over several months.

BC Patient Safety & Quality Council: using network and social movement theory to improve healthcare.

The BC Patient Safety & Quality Council has a mandate to bring health system stakeholders together in a collaborative partnership to improve quality of care. Our experience has demonstrated the value of networks to provide a forum for individuals to "think like a system," considering the perspectives of others in addressing system issues. This transition from silo-based thinking is important as we move to improve the quality of care at the pace that is required.

Improving care for British Columbians: the critical role of physician engagement.

Canadian provinces are addressing quality of care and patient safety in a systemic way, but obtaining physician involvement in system improvement continues to be a challenge. To address this issue, individual physicians, physician groups, the British Columbia Medical Association, the health authorities, the BC Patient Safety & Quality Council (BCPSQC) and the Ministry of Health have come together to support physician involvement and foster physician satisfaction. Building on earlier work on patient safety, in 2010 the ministry developed a comprehensive strategy for system-wide improvement, focusing on achieving critical population, patient and sustainability outcomes. Central to this plan is the acknowledged need to involve healthcare providers of all disciplines, in particular physicians. Today, BC physicians are leading large-scale provincial clinical improvement in three interdependent areas: Clinical Care Management, Integrated Primary and Community Care, and the National Surgical Quality Improvement Program. To further physicians' key contributions to BC's healthcare system, the BCPSQC, physician-ministry committees, health authorities and the Ministry will continue to engage physicians through practice support, feedback, financial recognition and information exchange, and by supporting improvements in the care provided to patients.

Developing sense of coherence in educational contexts: making progress in promoting mental health in children.

The notion of salutogenesis was developed by Aaron Antonovsky to achieve a fundamental innovative approach to promoting mental health. Within the concept of salutogenesis, the author defined the sense of coherence (SOC) as a global life orientation, and he suggests that it emerges in the early years of childhood. In order to develop coherence and its components it is necessary to explore certain health resources. In this paper the following questions will be discussed: (1) which are the individual and social resources to keep healthy, and (2) how can these resources be activated? Selected empirical findings will be presented to respond to these research questions. The results show that resources such as self-worth and a sense of belonging are fundamental health factors. They can be developed most effectively in the early years of childhood and through the formal educational system, e.g. in kindergartens and primary schools. However, the findings show that professionals need to be trained to be able to deliver educational programmes in terms of salutogenesis. At the same time, experience shows that promoting health resources in children successfully depends on the participation of the parents and their support by the professional educators. This paper aims to present new ideas and experiences in the area of a practical realization of the concept of salutogenesis in educational systems. Particularly, health promotion programmes, for example 'The I am I programme' ( Krause, 2009 ), could be implemented successfully in kindergartens with a high quota of children with an immigrant background, due to the fact that this programme includes the reflection and experience of cultural traditions, food, songs, dancing, and family rituals.

Sign Language in Light of Mathematics Education: An Exploration Within Semiotic and Embodiment Theories of Learning Mathematics.

Research rarely focuses on how deaf and hard of hearing (DHH) students address mathematical ideas. Complexities involved in using sign language (SL) in mathematics classrooms include not just challenges, but opportunities that accompany mathematics learning in this gestural-somatic medium. The authors consider DHH students primarily as learners of mathematics, and their SL use as a special case of language in the mathematics classroom. More specifically, using SL in teaching and learning mathematics is explored within semiotic and embodiment perspectives to gain a better understanding of how using SL affects the development, conceptualization, and representation of mathematical meaning. The theoretical discussion employs examples from the authors' work and research on geometry, arithmetic, and fraction concepts with Deaf German and Austrian learners and experts. The examples inform the context of mathematics teaching and learning more generally by illuminating SL features that distinguish mathematics learning for DHH learners.