Sex-specific and polygenic effects underlying resting heart rate and associated risk of cardiovascular disease.

AIMS: Resting heart rate (RHR) is associated with cardiovascular disease (CVD) and mortality. This study aimed to identify genetic loci associated with RHR, develop a genome-wide polygenic risk score (PRS) for RHR, and assess associations between the RHR PRS and CVD outcomes, to better understand the biological mechanisms linking RHR to disease. Sex-specific analyses were conducted to potentially elucidate different pathways between the sexes. METHODS: We performed a genome-wide meta-analysis of RHR (n=550,467) using two independent study populations, The Trøndelag Health Study (HUNT) and the UK Biobank (UKB), comprising 69,155 and 481,312 participants, respectively. We also developed a genome-wide PRS for RHR using UKB and tested for association between the PRS and 13 disease outcomes in HUNT. RESULTS: We identified 403, 253, and 167 independent single nucleotide polymorphisms (SNPs) significantly associated with RHR in the total population, women, and men, respectively. The sex-specified analyses indicated differences in the genetic contribution to RHR and revealed loci significantly associated with RHR in only one of the sexes. The SNPs were mapped to genes enriched in heart tissue and cardiac conduction pathways, as well as disease-pathways, including dilated cardiomyopathy. The PRS for RHR was associated with increased risk of hypertension and dilated cardiomyopathy, and decreased risk of atrial fibrillation. CONCLUSION: Our findings provide insight into the pleiotropic effects of the RHR variants, contributing towards an improved understanding of mechanisms linking RHR and disease. In addition, the sex-specific results might contribute to a more refined understanding of RHR as a risk factor for the different diseases.

We conducted a genome-wide meta-analysis on resting heart rate (RHR), created a polygenic risk score for RHR and examined the associations to cardiovascular disease outcomes. Sex-specific analyses indicated differences in the genetic contribution to RHR between men and women.High genetically predicted RHR was associated with increased risk of dilated cardiomyopathy and hypertension, and decreased risk of atrial fibrillation.

Real-world evidence for regulatory decision-making: updated guidance from around the world.

Leveraging the value of real-world evidence (RWE) to make informed regulatory decisions in the field of health care continues to gain momentum. Improving clinical evidence generation by evaluating the outcomes and patient experiences at the point-of-care would help achieve the ultimate aim of ensuring that effective and safe treatments are rapidly approved for patient use. In our previous publication, we assessed the global regulatory landscape with respect to RWE and provided a review of the regional availability of frameworks and guidance through May 2021 on the basis of 3 key regulatory elements: regulatory RWE frameworks, data quality guidance, and study methods guidance. In the current review, we have updated and elaborated upon recent developments in the regulatory RWE environment from a regional perspective under the same 3 regulatory elements stated above. In addition, we have also included a new category on procedural guidance. The review also discusses the perceived gaps and potential opportunities for future development and harmonization in this field to support framework establishment in regions without pre-existing RWE policies. Additionally, the article reviews current developments of health technology assessment (HTA) bodies pertaining to RWE and discusses the status of evidentiary alignment among regulators and HTA agencies.

Implementation of Spaced Repetition by First-Year Medical Students: a Retrospective Comparison Based on Summative Exam Performance.

Many medical students use spaced repetition as a study strategy to improve knowledge retention, and there has been growing interest from medical students in using flashcard software, such as Anki, to implement spaced repetition. Previous studies have provided insights into the relationship between medical students' use of spaced repetition and exam performance, but most of these studies have relied on self-reports. Novel insights about how medical students use spaced repetition can be gleaned from research that takes advantage of the ability of digital interfaces to log detailed data about how students use software. This study is unique in its use of data extracted from students' digital Anki data files, and those data are used to compare study patterns over the first year of medical school. Implementation of spaced repetition was compared between two groups of students who were retrospectively grouped based on average performance on three exams throughout the first year of medical school. Results indicate that students in the higher scoring group studied more total flashcards and implemented spaced repetition via Anki earlier in the year compared to the lower scoring group. These findings raise the possibility that implementing spaced repetition as a study strategy early in medical school may be related to improved knowledge retention and exam performance. Additional research should be performed at more sites to further examine the relationship between spaced repetition implementation and exam performance.

Dispersed white roots in red beetroot influence the accuracy of root identification based on colours for intercropping studies.

PURPOSE: Beetroot is a model crop for studying root competition in intercropping systems because its red-coloured roots facilitate non-destructive visual discrimination with other root systems of intercropped plants. However, beetroot also has white roots, which could alter how root competition is interpreted. Here we investigated the quantity of white versus red roots in beetroot to quantify the effect of this phenomenon. METHODS: Beetroot was mono-cropped or inter-cropped with white cabbage in a field trial. The distribution of beetroot roots was recorded to 2.5 m soil depth on three dates following the minirhizotron method. Roots in each 0.5 m soil layer were counted and categorised into groups based on colour (white roots, coloured roots, and white roots traced back to be coloured) to investigate the influence of white roots on accuracy of root registration. A pot experiment was conducted with three cultivars to verify if white roots are a general characteristic of beetroot. RESULTS: White roots in mono-cropped beetroot represented 2.5-4.8% of total roots, on average, across the rooted soil profile. However, white roots represented 6.9% and 11.6% of total roots in the deepest soil layer during August and October, respectively. White roots caused mono-cropped beetroot roots to be underestimated by 1-22% based on root colour discrimination. However, tracing white roots backwards and forwards to coloured parts of roots reduced underestimates to 0.5-15%. Intercropping did not influence the traceability of white roots compared to monocropping. The highest occurrence of white roots appeared during the early growth period and in the deepest soil layers, indicating a linkage to younger roots or higher root proliferation rates. CONCLUSION: Beetroot represents a model crop for visual studies linking eco-physiology and root proliferation. The white roots of beetroot must be incorporated by studies of root competition in intercropping systems that use colour as a criterion.

Factores determinantes sobre la calificación en la fase de oposición de Educación Física en Educación Primaria / Determining factors on the qualification in the competitive examinations for Physical Education in Primary Education

El concurso-oposición de Educación Física en Educación Primaria en España ha sido escasamente estudiado en la literatura científica, pese a que todos los docentes en la enseñanza pública deben realizarlo. El objetivo de esta investigación fue determinar si había una asociación entre la experiencia docente, el número de veces presentado al concurso-oposición, el modo de preparación, los hábitos de los opositores y el método de estudio con respecto al resultado final obtenido en la fase de oposición de Educación Física en 2022. Los 166 opositores participantes realizaron un cuestionario y cuatro de ellos fueron entrevistados. Se calcularon los estadísticos descriptivos y el coeficiente Alfa de Cronbach para medir la fiabilidad de las respuestas proporcionadas por la muestra en el cuestionario, se obtuvieron las correlaciones bivariadas de todas las dimensiones respecto a la nota obtenida y se realizó un análisis de regresión lineal. Los resultados determinaron relaciones estadísticamente significativas entre la nota final y la mayoría de las variables del método de estudio y entre la nota y el hábito de estudio. El 18% de la varianza de la nota final vino explicada por los predictores de práctica de la unidad didáctica, literatura de temas y elaboración de la unidad didáctica. Además, el 4% de la varianza de la nota final tuvo como predictor la variable de hábito de estudio. Los resultados permiten concluir que los factores influyentes en la calificación tienen que ver con el método de estudio y no con la experiencia o el número de veces presentado al concurso-oposición. (AU)

Competitive examinations in primary Physical Education in Spain have been little studied in the scientific literature, although every teacher in state schools has to do them. The aim of this study was to determine whether there is a relationship between teachers' experience, the number of times they have taken competitive examinations, the type of preparation, candidates’ habits, and study methods in relation to the qualifications obtained in competitive examinations in Physical Education in 2022. The 166 participating candidates completed a questionnaire and four of them were interviewed. Descriptive statistics and Cronbach's alpha coefficient were calculated to measure the reliability of the answers given by the sample in the questionnaire, bivariate correlations were obtained for all the dimensions in relation to the mark obtained, and linear regression analysis was carried out. The results showed statistically significant relationships between the final qualification of the competitive examinations and most of the variables of the study method and between the mark and the study habits. 18% of the variance of the final mark was explained by the predictors of the practice of the didactic unit, the literature of the syllabus and the elaboration of the didactic unit. In addition, 4% of the variance in the final mark was explained by the variable study habits.These results allow us to conclude that the factors influencing qualification are related to the method of study and not to experience or the number of times the candidate has taken the competitive examination. (AU)

Educational Videos Versus Question Banks: Maximizing Medical Student Performance on the United States Medical Licensing Examination Step 1 Exam.

Objective The aim of this research was to determine if medical students' use of the active study strategy of working practice questions is associated with improved performance on the United States Medical Licensing Examination (USMLE) Step 1 exam when compared to students who used the passive study strategy of watching educational videos. Methods The study used a correlational design. Participants were students from two cohorts in a United States medical school (N=164 and N=163) who completed their first two years and took the USMLE Step 1 exam. Data collected retrospectively included the number of practice questions completed, educational videos watched, Step 1 exam scores, average scores on in-class exams, and scores on the Medical College Admission Test (MCAT). Results The number of videos watched was negatively and significantly correlated with the Step 1 score for cohort 2022 (r= -0.294, α=0.01) and cohort 2023 (r= -0.175, α=0.05). The number of practice questions worked was positively and significantly correlated with the Step 1 score for cohort 2022 (r=0.176, α=0.05) and cohort 2023 (r=0.143 though not significant). The number of practice questions was a significant positive predictor of Step 1 score for cohort 2022 (ß=0.141, p=0.017) and cohort 2023 (ß=0.133, p=0.015). Videos were significant negative predictors for cohort 2023 (ß= -0.118, p=0.034). Conclusions Answering practice questions appears to be a more effective study method than passively watching videos. Though other studies have supported the use of active learning methods, this study is unique in finding a negative correlation between test scores and the number of educational videos watched. Medical students should be urged to make the most effective use of study time by incorporating working practice questions and limiting watching educational videos.

Developing an implementation research logic model: using a multiple case study design to establish a worked exemplar.

BACKGROUND: Implementation science frameworks explore, interpret, and evaluate different components of the implementation process. By using a program logic approach, implementation frameworks with different purposes can be combined to detail complex interactions. The Implementation Research Logic Model (IRLM) facilitates the development of causal pathways and mechanisms that enable implementation. Critical elements of the IRLM vary across different study designs, and its applicability to synthesizing findings across settings is also under-explored. The dual purpose of this study is to develop an IRLM from an implementation research study that used case study methodology and to demonstrate the utility of the IRLM to synthesize findings across case sites. METHOD: The method used in the exemplar project and the alignment of the IRLM to case study methodology are described. Cases were purposely selected using replication logic and represent organizations that have embedded exercise in routine care for people with cancer or mental illness. Four data sources were selected: semi-structured interviews with purposely selected staff, organizational document review, observations, and a survey using the Program Sustainability Assessment Tool (PSAT). Framework analysis was used, and an IRLM was produced at each case site. Similar elements within the individual IRLM were identified, extracted, and re-produced to synthesize findings across sites and represent the generalized, cross-case findings. RESULTS: The IRLM was embedded within multiple stages of the study, including data collection, analysis, and reporting transparency. Between 33-44 determinants and 36-44 implementation strategies were identified at sites that informed individual IRLMs. An example of generalized findings describing "intervention adaptability" demonstrated similarities in determinant detail and mechanisms of implementation strategies across sites. However, different strategies were applied to address similar determinants. Dependent and bi-directional relationships operated along the causal pathway that influenced implementation outcomes. CONCLUSIONS: Case study methods help address implementation research priorities, including developing causal pathways and mechanisms. Embedding the IRLM within the case study approach provided structure and added to the transparency and replicability of the study. Identifying the similar elements across sites helped synthesize findings and give a general explanation of the implementation process. Detailing the methods provides an example for replication that can build generalizable knowledge in implementation research.

Who is essential in care? Reflections from the pandemic's backstage.

Since the beginning of the pandemic spread of the Coronavirus, societies have been reminded that the impact of Covid-19 and public health measures of infection containment reflect known gradients of inequality. Measures focusing only the (acknowledged) frontstage of the pandemic and neglecting its (unacknowledged) backstage-understood as those framework conditions indispensable for societies to thrive-have worsened the impact of social determinants of health on the most vulnerable, as shown by the deleterious effects of prolonged social isolation of residents of nursing homes. To reflect this phenomenon ethically, a framework is proposed which is inspired by the feminist philosopher Margret Little. At its core stands the assumption that caring for people and moral ends allows us to identify what is morally salient. This epistemological stance allows a critical look at the alleged dilemmas invoked to enforce brute, long-lasting policies of closing nursing homes in many places-especially in the light of their dubious effectiveness in preventing viral spread and the severe physical and psychological consequences for those affected. If moral salience is only fully perceived through the closeness of the caring relationship, the human suffering resulting from these policies reveals the utter inadequacy of the dilemma rhetoric used to justify them. This insight is illustrated by the personal experience of the author: He describes his role as an essential care partner of his mother living in a nursing home and forced into the role of a "visitor" who witnessed a constant deterioration of care. Based on an epistemological understanding of caring for making reliable moral judgments, potentially exclusionary effects of distinguishing essential from non-essential groups in care will be addressed together with the need to overcome strict boundaries between front- and backstage. Such efforts will strengthen the moral community of persons needing care, professional care givers and essential care partners.

Clinical ethics committees in nursing homes: what good can they do? Analysis of a single case consultation.

BACKGROUND: Ought nursing homes to establish clinical ethics committees (CECs)? An answer to this question must begin with an understanding of how a clinical ethics committee might be beneficial in a nursing home context - to patients, next of kin, professionals, managers, and the institution. With the present article, we aim to contribute to such an understanding. AIM: We ask, in which ways can clinical ethics committees be helpful to stakeholders in a nursing home context? We describe in depth a clinical ethics committee case consultation deemed successful by stakeholders, then reflect on how it was helpful. RESEARCH DESIGN: Case study using the clinical ethics committee's written case report and self-evaluation form, and two research interviews, as data. PARTICIPANTS AND RESEARCH CONTEXT: The nursing home's ward manager and the patient's son participated in research interviews. ETHICAL CONSIDERATIONS: Data were collected as part of an implementation study. Clinical ethics committee members and interviewed stakeholders consented to study participation, and also gave specific approval for the publication of the present article. FINDINGS/RESULTS: Six different roles played by the clinical ethics committee in the case consultation are described: analyst, advisor, support, moderator, builder of consensus and trust, and disseminator. DISCUSSION: The case study indicates that clinical ethics committees might sometimes be of help to stakeholders in moral challenges in nursing homes. CONCLUSIONS: Demanding moral challenges arise in the nursing home setting. More research is needed to examine whether clinical ethics committees might be suitable as ethics support structures in nursing homes and community care.

Métodos de estudo no ensino superior: construção e validação de um questionário / Study methods in higher education: the construction and validating a questionnaire / Métodos de estudio en ensenanza superior: creación y validación de un cuestionario

Face às exigências do processo de ensino-aprendizagem na universidade, a literatura mostra a importância de se identificar dimensões que melhor descrevam os métodos de estudo para explicar o rendimento acadêmico dos estudantes. Este artigo descreve a construção e os estudos preliminares de validação de um questionário de avaliação dos métodos de estudo e de aprendizagem de estudantes do Ensino Superior. Os estudantes foram abordados sobre suas condutas habituais de estudo, dentro e fora de sala de aula, nomeadamente aqueles que melhor explicam ou predizem seus níveis de rendimento acadêmico. Após a uma primeira sistematização do conteúdo das respostas dos estudantes um questionário com 45 itens foi aplicado em 132 estudantes de Portugal, abrangendo diferentes cursos em Ciências e Humanidades, maioritariamente do sexo feminino (81%), do 1º ano, com a idade mais frequente de 18 anos (37,9%). Os resultados da análise fatorial exploratória permitem identificar quatro dimensões: organização e planejamento do estudo (alfa=.76); persistência nas tarefas de estudo (alfa=.78); autoeficácia no estudo (alfa=.65) e participação ativa na sala de aula (alfa=.64). Estas dimensões refletem métodos de estudo que combinam aspectos cognitivos, motivacionais e atitudinais que algumas vezes, aparecem diferenciadas na investigação, podendo o estudante combinar ainda abordagens superficiais e profundas quando necessárias ao seu estudo. (AU)

Given the requirements of the teaching-learning process at the university, the literature highlights the importance of identifying dimensions that best describe study methods to explain students´ academic performance. This article presents the construction and preliminary studies of validation of a questionnaire assessing the study and learning methods of college students. Students were asked about their usual study behaviours, in and out of the classroom, especially those habits that best explain or predict their levels of academic performance. After a first systematization of the content of the students' answers in a questionnaire formed by 45 items, this was applied to a sample of 198 students in Brazil and 132 students in Portugal, covering different undergraduate courses in Sciences and Humanities domains. The data presented in this article refer to the Portuguese students characterized mainly by the female sex (81%), the first year (79%), with the most frequent age of 18 years (37.9%). The results of the exploratory factorial analysis allow to identify four dimensions: organization and planning of the study (alpha = .76); persistence in the tasks of study (alpha = .78); self-efficacy in the study (alpha = .65); and participation in the classroom (alpha = .64). These dimensions explicit study methods that combine cognitive, motivational and attitudinal aspects that sometimes appear differentiated in the investigation, being able the student to combine superficial and deep approaches when necessary for their study. (AU)

Dadas las exigencias del proceso de enseñanza-aprendizaje en la universidad, la literatura muestra la importancia de identificar las dimensiones que mejor describan los métodos de estudio para explicar el rendimiento académico de los estudiantes. Este artículo describe la construcción y los estudios preliminares de validación de un cuestionario para evaluar los métodos de estudio y aprendizaje de los estudiantes en la educación superior. Se abordó a los estudiantes sobre sus conductas habituales de estudio, dentro y fuera del aula, es decir, aquellas que mejor explican o predicen sus niveles de rendimiento académico. Tras una primera sistematización del contenido de las respuestas de los alumnos en un cuestionario de 45 ítems, este se aplicó a 132 alumnos de Portugal, que cubrían diferentes cursos de Ciencias y Humanidades, en su mayoría mujeres (81%), de 1º año, de mayor edad. frecuente 18 años (37,9%). Los resultados del análisis factorial exploratorio permiten identificar cuatro dimensiones: organización y planificación del estudio (alfa=.76); persistencia en las tareas de estudio (alfa=.78); autoeficacia en el estudio (alfa=.65) y participación en el aula (alfa=.64). Estas dimensiones reflejan métodos de estudio que combinan aspectos cognitivos, motivacionales y actitudinales que en ocasiones aparecen diferenciados en la investigación, pudiendo el estudiante combinar también enfoques superficiales y profundos cuando sea necesario para su estudio. (AU)

Evaluating complex interventions in context: systematic, meta-narrative review of case study approaches.

BACKGROUND: There is a growing need for methods that acknowledge and successfully capture the dynamic interaction between context and implementation of complex interventions. Case study research has the potential to provide such understanding, enabling in-depth investigation of the particularities of phenomena. However, there is limited guidance on how and when to best use different case study research approaches when evaluating complex interventions. This study aimed to review and synthesise the literature on case study research across relevant disciplines, and determine relevance to the study of contextual influences on complex interventions in health systems and public health research. METHODS: Systematic meta-narrative review of the literature comprising (i) a scoping review of seminal texts (n = 60) on case study methodology and on context, complexity and interventions, (ii) detailed review of empirical literature on case study, context and complex interventions (n = 71), and (iii) identifying and reviewing 'hybrid papers' (n = 8) focused on the merits and challenges of case study in the evaluation of complex interventions. RESULTS: We identified four broad (and to some extent overlapping) research traditions, all using case study in a slightly different way and with different goals: 1) developing and testing complex interventions in healthcare; 2) analysing change in organisations; 3) undertaking realist evaluations; 4) studying complex change naturalistically. Each tradition conceptualised context differently-respectively as the backdrop to, or factors impacting on, the intervention; sets of interacting conditions and relationships; circumstances triggering intervention mechanisms; and socially structured practices. Overall, these traditions drew on a small number of case study methodologists and disciplines. Few studies problematised the nature and boundaries of 'the case' and 'context' or considered the implications of such conceptualisations for methods and knowledge production. CONCLUSIONS: Case study research on complex interventions in healthcare draws on a number of different research traditions, each with different epistemological and methodological preferences. The approach used and consequences for knowledge produced often remains implicit. This has implications for how researchers, practitioners and decision makers understand, implement and evaluate complex interventions in different settings. Deeper engagement with case study research as a methodology is strongly recommended.

A qualitative exploration of the factors influencing the decision to transfuse elective platelets in cancer care.

OBJECTIVES: To explore factors contributing to decisions to transfuse platelets in cancer care outside guidelines using case study methods. METHODS: Two case studies were examined, using instrumental case study methodology, to qualitatively explore factors that influence the decision to transfuse platelets. Interviews (n=10) were conducted around cases in haematology and critical care. In-depth review of documentary evidence was undertaken and propositions were developed to provide rigour during the investigation. Thematic analysis and triangulation of documents was undertaken to find specific factors, and propositions analysed, as per instrumental case study methods. RESULTS: Both cases emphasised how patient complexity, and individual response to platelet administration, was an influencing factor. Other themes included uncertainty of clinical situations coupled with uncertainty about platelet availability. Other factors worthy of further investigation include the concept of professional safety and the trustworthiness of platelet thresholds against platelet monitoring for bleeding episodes. CONCLUSION: The findings indicated several factors influence decisions to transfuse, including clinical context, and individual ability to trust guidelines and assume any perceived risks.

A construção de competências nas etapas iniciais da formação médica: Um relato de experiência / The building of skills in the initial stages of medical training: An experience report

Introdução: A graduação em Medicina tem passado por diversas mudanças curriculares, com transferência gradativa do ensino tradicional para metodologias ativas, as quais preconizam a aprendizagem significativa e a participação ativa dos discentes. Orientado pelas Diretrizes Curriculares Nacionais vigentes, o curso de graduação em Medicina da Universidade Federal do Pampa (UNIPAMPA), contempla essa nova perspectiva formativa. Apresenta como foco as construções de competências médicas, desenvolvidas desde etapas iniciais do curso, com ênfase no vínculo entre teoria e prática. Método: O presente estudo aborda um relato de experiência e tem por objetivo refletir acerca da implementação da disciplina "Introdução à Psicologia e Habilidades Médicas" (IPHM). Resultados: Por meio das atividades do referido componente curricular, é ofertado desde o primeiro semestre o contato dos discentes com a entrevista médica, com ênfase na construção da anamnese e na compreensão dos aspectos relacionais e comunicacionais englobados. Ainda que outras instituições desenvolvam a construção de aspectos relacionados à anamnese médica em fases iniciais, o curso de Medicina da Unipampa apresenta inovações na forma como conduz esse trabalho, com emprego de metodologias ativas associadas às situações clínicas simuladas (Role-play), com foco tanto na redação, como nas relações interpessoais e qualidade da comunicação na relação médico-paciente. Conclusões: Por meio da abordagem dos desafios e potencialidades do processo de implementação do referido componente curricular, cumpre reconhecer a adequação e a pertinência da experiência, no sentido de estabelecer um espaço de construção de competências profissionais para a entrevista médica, em momento inicial da formação acadêmica.

Introduction: Graduation in Medicine has experienced several changes in the training curriculum, by changing from the traditional way of teaching to active methodologies, providing meaningful learning and active participation by students. Guided by the National Curriculum Guidelines, the undergraduate course in Medicine, from the Federal University of Pampa (Unipampa), contemplates this new formative perspective, through curricular innovations in the methodological and organizational fields. It focuses on the construction of medical skills, developed since the initial stages of the course, with emphasis on the link between theory and practice. Method: This study is an experience report, with a qualitative approach and aims to reflect on the implementation of the IPHM discipline. Results: Through the activities of this curricular component, student´s contact with the medical interview is offered in the first semester, emphasis on the construction off the anamnesis and the knowlegment of its relational and communicational aspects. Although other academies develop the construction of aspects related to medical anamnesis in early stages, the Unipampa's Medicine course introduced a inovation in the way that conducts it's work, using active methodologies associated with simulated clinical situations (Roleplay), focusing both writing, interpersonal relationship and quality of communication between doctor and patient. Conclusions: Through addressing the challenges and potentialities of the implementation process of the said curricular component, it is important to recognize the adequacy and relevance of the experience, in order to establish a space for the construction of professional skills for the medical interview, at the beginning of academic training.

Measuring Goal-Concordant Care: Results and Reflections From Secondary Analysis of a Trial to Improve Serious Illness Communication.

CONTEXT: Many consider goal-concordant care (GCC) to be the most important of advance care planning and palliative care. Researchers face significant challenges in attempting to measure this outcome. We conducted a randomized controlled trial to assess the effects of a system-level intervention to improve serious illness communication on GCC and other outcomes. OBJECTIVES: To describe our measurement approach to GCC, present findings from a post-hoc analysis of trial data, and discuss lessons learned about measuring GCC. METHODS: Using trial data collected to measure GCC, we analyzed ratings and rankings from a nonvalidated survey of patient priorities in the setting of advanced cancer, the Life Priorities Scale, and compared outcomes with correlative measures. RESULTS: Participants commonly rated several predetermined and literature-derived priorities as important but did so in ways that were commonly incongruent with rankings. Ratings were frequently stable over time; rankings less so. Rankings are more likely to help assess the degree to which care is goal concordant but may be best augmented by corollary measures that signal achievement of a given priority. CONCLUSION: Measuring GCC remains a fundamental challenge to palliative care researchers. Ratings attest to the fact that many things matter to patients; however, rankings can better determine what matters most. Insights gained from our experience may guide future research aiming to use this outcome to assess the effect of intervention to improve serious illness care.

Deep learning-based fully automatic segmentation of wrist cartilage in MR images.

The study objective was to investigate the performance of a dedicated convolutional neural network (CNN) optimized for wrist cartilage segmentation from 2D MR images. CNN utilized a planar architecture and patch-based (PB) training approach that ensured optimal performance in the presence of a limited amount of training data. The CNN was trained and validated in 20 multi-slice MRI datasets acquired with two different coils in 11 subjects (healthy volunteers and patients). The validation included a comparison with the alternative state-of-the-art CNN methods for the segmentation of joints from MR images and the ground-truth manual segmentation. When trained on the limited training data, the CNN outperformed significantly image-based and PB-U-Net networks. Our PB-CNN also demonstrated a good agreement with manual segmentation (Sørensen-Dice similarity coefficient [DSC] = 0.81) in the representative (central coronal) slices with a large amount of cartilage tissue. Reduced performance of the network for slices with a very limited amount of cartilage tissue suggests the need for fully 3D convolutional networks to provide uniform performance across the joint. The study also assessed inter- and intra-observer variability of the manual wrist cartilage segmentation (DSC = 0.78-0.88 and 0.9, respectively). The proposed deep learning-based segmentation of the wrist cartilage from MRI could facilitate research of novel imaging markers of wrist osteoarthritis to characterize its progression and response to therapy.

Moral dilemmas involving anthropological and ethical dimensions in healthcare curriculum.

BACKGROUND: Currently a variety of novel scenarios have appeared within nursing practice such as confidentiality of a patient victim of abuse, justice in insolvent patients, poorly informed consent delivery, non-satisfactory medicine outputs, or the possibility to reject a recommended treatment. These scenarios presuppose skills that are not usually acquired during the degree. Thus, the implementation of teaching approaches that promote the acquisition of these skills in the nursing curriculum is increasingly relevant. OBJECTIVE: The article analyzes an academic model which integrates in the curriculum a series of specific theoretical concepts together with practical skills to acquire the basic ethic assessment competency. RESEARCH DESIGN: The project includes designing two subjects, General Anthropology and Ethics-Bioethics, with an applied approach in the nursing curriculum. The sequential structure of the curriculum in both subjects is constituted by three learning domains (theoretical, practical, and communicative) with different educational strategies. ETHICAL CONSIDERATIONS: No significant ethical considerations as this is a discussion paper. FINDINGS: The model was structured from the anthropology's concepts and decision-making process, applied to real situations. The structure of the three domains theoretical-practical-communicative is present in each session. DISCUSSION: It is observed that theoretical domain fosters the capacity for critical analysis and subsequent ability to judge diverse situations. The practical domain reflected two significant difficulties: students' resistance to internalizing moral problems and the tendency to superficial criticism. The communicative domain has frequently shown that the conflicting points are in the principles to be applied. CONCLUSION: We conclude that this design achieves its objectives and may provide future nursing professionals with ethical competences especially useful in healthcare practice. The three domains of the presented scheme are associated with the same process used in decision making at individual levels, where the exercise of clinical prudence acquires particular relevance.

What will it take? Using an implementation research framework to identify facilitators and barriers in implementing a school-based referral system for sexual health services.

BACKGROUND: Across the United States, sexually transmitted infections and unintended pregnancy rates are alarmingly high among youth. Schools, due to their proximity and access to youth, can increase student access to sexual health services (SHS) by creating referral systems (RS) to link students to school- and community-based SHS. From 2013 to 2018, the Centers for Disease Control and Prevention's Division of Adolescent and School Health funded 17 Local Education Agencies (LEA) to partner with priority schools and stakeholders to develop and implement RS to increase student access to SHS. Cicatelli Associates Inc. (CAI) was funded to provide capacity-building to LEA. In 2016-2017, CAI conducted case studies at two LEA, both large and urban sites, but representing different geographical and political contexts, to elucidate factors that influence RS implementation. METHODS: Nineteen LEA and community-based healthcare (CBH) staff were interviewed in the Southeastern (n = 9) and Western U.S. (n = 10). Key constructs (e.g., leadership engagement, resources, state and district policies) across the five domains of the Consolidated Framework for Implementation Research (CFIR) framework guided the methodology and analysis. Qualitative data was analyzed using the Framework Method and contextual factors and themes that led to RS implementation were identified. RESULTS: Interviewees strongly believed that school-based RS can decrease STI, HIV and unintended pregnancy and increase students' educational attainment. We identified the following contextual key factors that facilitate successful implementation and integration of an RS: enforcing state and district policies, strong LEA and CBH collaboration, positive school culture towards adolescent health, knowledgeable and supportive staff, leveraging of existing resources and staffing structures, and influential district and school building-level leadership and champions. Notably, this case study challenged our initial assumptions that RS are easily implemented in states with comprehensive SHS policies. Rather, our conversations revealed how districts and local-level policies can have significant impact and influence to impede or promote those policies. CONCLUSIONS: Through the use of the CFIR framework, the interviews identified important contextual factors and themes associated with LEAs' implementation barriers and facilitators. The study's results present key recommendations that other LEA can consider to optimize integration of RS-related evidence-based practices, systems, and policies in their districts.

The curious and neglected soft-bodied meiofauna: Rouphozoa (Gastrotricha and Platyhelminthes).

Gastrotricha and Platyhelminthes form a clade called Rouphozoa. Representatives of both taxa are main components of meiofaunal communities, but their role in the trophic ecology of marine and freshwater communities is not sufficiently studied. Traditional collection methods for meiofauna are optimized for Ecdysozoa, and include the use of fixatives or flotation techniques that are unsuitable for the preservation and identification of soft-bodied meiofauna. As a result, rouphozoans are usually underestimated in conventional biodiversity surveys and ecological studies. Here, we give an updated outline of their diversity and taxonomy, with some phylogenetic considerations. We describe successfully tested techniques for their recovery and study, and emphasize current knowledge on the ecology, distribution and dispersal of freshwater gastrotrichs and microturbellarians. We also discuss the opportunities and pitfalls of (meta)barcoding studies as a means of overcoming the taxonomic impediment. Finally, we discuss the importance of rouphozoans in aquatic ecosystems and provide future research directions to fill in crucial gaps in the biology of these organisms needed for understanding their basic role in the ecology of benthos and their place in the trophic networks linking micro-, meio- and macrofauna of freshwater ecosystems.

An Argument for Adolescent and Young Adult Cancer Registry: One Model.

Over the last several years, there has been increasing awareness around the unique challenges faced by adolescent and young adult (AYA) cancer patients. More cancer centers across the United States are introducing AYA-specific programs to help improve outcomes for these patients. However, given the nature of the United States health care system, there is little ability to track the efficacy of these programs and identify important variables with respect to both interdisciplinary interventions offered and medical and psychosocial outcomes. One program offers an argument as to why tracking these data is important, with a description of the registry they have developed.

The role of scientific evidence in decisions to adopt complex innovations in cancer care settings: a multiple case study in Nova Scotia, Canada.

BACKGROUND: Health care delivery and outcomes can be improved by using innovations (i.e., new ideas, technologies, and practices) supported by scientific evidence. However, scientific evidence may not be the foremost factor in adoption decisions and is rarely sufficient. The objective of this study was to examine the role of scientific evidence in decisions to adopt complex innovations in cancer care. METHODS: Using an explanatory, multiple case study design, we examined the adoption of complex innovations in five purposively sampled cases in Nova Scotia, Canada. Data were collected via documents and key informant interviews. Data analysis involved an in-depth analysis of each case, followed by a cross-case analysis to develop theoretically informed, generalizable knowledge on the role of scientific evidence in innovation adoption that may be applied to similar settings and contexts. RESULTS: The analyses identified key concepts alongside important caveats and considerations. Key concepts were (1) scientific evidence underpinned the adoption process, (2) evidence from multiple sources informed decision-making, (3) decision-makers considered three key issues when making decisions, and (4) champions were essential to eventual adoption. Caveats and considerations related to the presence of urgent problems and short-term financial pressures and minimizing risk. CONCLUSIONS: The findings revealed the different types of issues decision-makers consider while making these decisions and why different sources of evidence are needed in these processes. Future research should examine how different types of evidence are legitimized and why some types are prioritized over others.