A palliative care goals model for people with dementia and their family: Consensus achieved in an international Delphi study.

BACKGROUND: Advance care planning in dementia includes supporting the person and their family to consider important goals of care. International research reports the importance of psycho-social-spiritual aspects towards end of life. AIM: To develop a multidimensional international palliative care goals model in dementia for use in practice. DESIGN: International Delphi study integrating consensus and evidence from a meta-qualitative study. The Delphi panel rated statements about the model on a 5-point agreement scale. The criteria for consensus were pre-specified. SETTING/PARTICIPANTS: Seventeen researchers from eight countries developed an initial model, and 169 candidate panellists were invited to the international online Delphi study. RESULTS: Panellists (107; response 63.3%) resided in 33 countries. The model comprised four main care goals: (1) Comfort ensured; (2) Control over function maintained; (3) Identity protected and personhood respected and (4) Coping with grief and loss-person and caregiver supported. The model reflects how needs and care goals change over time with the progression of dementia, concluding with bereavement support. The first version of the model achieved a consensus after which it was slightly refined based on feedback. We did not achieve a consensus on adding a goal of life prolongation, and on use of the model by people with dementia and family themselves. CONCLUSION: A new palliative care goals model for people with dementia and their families includes relationship aspects for use by professionals and achieved a consensus among a panel with diverse cultural background. The position of life prolongation in relation to palliative care goals needs further research.

Goal-directed and flexible modulation of syllable sequence within birdsong.

Songs constitute a complex system of vocal signals for inter-individual communication in songbirds. Here, we elucidate the flexibility which songbirds exhibit in the organizing and sequencing of syllables within their songs. Utilizing a newly devised song decoder for quasi-real-time annotation, we execute an operant conditioning paradigm, with rewards contingent upon specific syllable syntax. Our analysis reveals that birds possess the capacity to modify the contents of their songs, adjust the repetition length of particular syllables and employing specific motifs. Notably, birds altered their syllable sequence in a goal-directed manner to obtain rewards. We demonstrate that such modulation occurs within a distinct song segment, with adjustments made within 10 minutes after cue presentation. Additionally, we identify the involvement of the parietal-basal ganglia pathway in orchestrating these flexible modulations of syllable sequences. Our findings unveil an unappreciated aspect of songbird communication, drawing parallels with human speech.

Influence of age and cognitive demand on motor decision making under uncertainty: a study on goal directed reaching movements.

In everyday life, we constantly make decisions about actions to be performed subsequently. Research on motor decision making has provided empirical evidence for an influence of decision uncertainty on movement execution in young adults. Further, decision uncertainty was suggested to be increased in older adults due to limited cognitive resources for the integration of information and the prediction of the decision outcomes. However, the influence of cognitive aging on decision uncertainty during motor decision making and movement execution has not been investigated, yet. Thus, in the current study, we presented young and older adults with a motor decision making task, in which participants had to decide on pointing towards one out of five potential targets under varying cognitive demands. Statistical analyses revealed stronger decreases in correctly deciding upon the pointing target, i.e. task performance, from low to higher cognitive demand in older as compared to young adults. Decision confidence also decreased more strongly in older adults with increasing cognitive demand, however, only when collapsing across correct and incorrect decision trials, but not when considering correct decision trials, only. Further, older adults executed reaching movements with longer reaction times and increased path length, though the latter, again, not when considering correct decision trials, only. Last, reaction time and variability in movement execution were both affected by cognitive demand. The outcomes of this study provide a differentiated picture of the distinct and joint effects of aging and cognitive demand during motor decision making.

The Complex Role of Botulinum Toxin in Enhancing Goal Achievement for Post-Stroke Patients.

INTRODUCTION: The rehabilitation medical team is responsible for the therapeutic management of post-stroke patients and, therefore, for the complex therapeutic approach of spasticity. Considering the generous arsenal at our disposal in terms of both pharmacological treatment, through the possibility of administering botulinum toxin to combat spasticity, and in terms of accurate assessment through developed functional scales such as the GAS (Goal Attainment Scale), one of our purposes is to monitor the parameters that influence the achievement of functional goals set by patients together with the medical team in order to render the patients as close as possible to achieving their proposed functional goals, thus enhancing their quality of life. By assessing and establishing statistical and clinical correlations between the GAS and quantifiable parameters related to the affected post-stroke upper limb, namely degree of spasticity, motor control, pain level and evolution of pain under treatment with BoNT-A (abobotulinum toxin A), and patients' overall response to BoNT-A treatment, we aim to quantify the improvement of the therapeutic management of post-stroke patients with spasticity and develop a more personalized and effective approach to their disability and impairment. RESULTS AND DISCUSSIONS: The analysis concluded that there were two independent predictors of the Achieved GAS-T score (the study's endpoint parameter) motor control at any level of the upper limb and number of prior BoNT-A injections. The number of prior BoNT-A injections was an independent predictor of Achieved GAS-T score improvement but had no significant influence over Baseline GAS-T score. Enhancement in proximal and intermediate motor control showed a GAS score improvement of 3.3 points and a 0.93-point GAS score improvement for wrist motor control progress. From a separate viewpoint, patients with motor deficit on the left side have shown significantly greater improvement in Changed GAS-T scores by 2.5 points compared to patients with deficits on the right side; however, we note as a study limitation the fact that there was no statistical analysis over the dominant cerebral hemisphere of each patient. CONCLUSIONS: Improvement in the Achieved GAS-T score means better achievement of patients' goals. Thus, after the BoNT- A intervention, at follow-up evaluation, GAS was found to be directly correlated with improvement in motor control of the affected upper limb. Mobility of the corresponding limb was enhanced by pain decrease during p-ROM (passive range of motion) and by amelioration of spasticity. MATERIALS AND METHODS: We conducted an observational, non-randomized clinical study on 52 stroke patients, a representative sample of patients with post-stroke spasticity and disability from our neurological rehabilitation clinic, who have been treated and undergone a specific rehabilitation program in our tertiary diagnostic and treatment medical center, including BoNT-A focal treatment for spasticity in the affected upper limb. The primary objective of the study was to assess the influence of abobotulinum toxin A treatment on the Goal Attainment Scale. Secondary objectives of the study included the assessment of BoNT-A treatment efficacy on spasticity with the MAS (Modified Ashworth Scale), pain with the NRS (Numerical Rating Scale), and joint passive range of motion (p-ROM), identifying demographic, clinical, and pharmacological factors that influence the response to BoNT-A treatment, as well as to conduct a descriptive and exploratory analysis of the studied variables.

Stereotyped goal-directed manifold dynamics in the insular cortex.

The insular cortex is involved in diverse processes, including bodily homeostasis, emotions, and cognition. However, we lack a comprehensive understanding of how it processes information at the level of neuronal populations. We leveraged recent advances in unsupervised machine learning to study insular cortex population activity patterns (i.e., neuronal manifold) in mice performing goal-directed behaviors. We find that the insular cortex activity manifold is remarkably consistent across different animals and under different motivational states. Activity dynamics within the neuronal manifold are highly stereotyped during rewarded trials, enabling robust prediction of single-trial outcomes across different mice and across various natural and artificial motivational states. Comparing goal-directed behavior with self-paced free consumption, we find that the stereotyped activity patterns reflect task-dependent goal-directed reward anticipation, and not licking, taste, or positive valence. These findings reveal a core computation in insular cortex that could explain its involvement in pathologies involving aberrant motivations.

Relationship between nutritional goals and pressure injuries in critical care patients receiving enteral nutrition.

OBJECTIVE: To examine the relationship between pressure injury (PI) development and achievement of nutritional goals (protein and caloric), as well as consider the clinical conditions, hospitalisation factors, and risk assessment for PI development in patients who are critically ill and receiving enteral nutrition (EN) in the intensive care unit (ICU). METHOD: An observational cohort study was conducted in the ICU of the University Hospital in São Paulo, Brazil. Inclusion criteria were as follows: age ≥18 years; length of ICU stay ≥24 hours; without PI at ICU admission; and receiving EN exclusively during ICU stay. The development of PI was considered the dependent variable. The Chi-squared test was applied to compare categorical variables, and the Mann-Whitney U test was used to compare continuous variables between groups of patients with and without a PI. The analysis of the achievement of nutritional goals was performed using Fisher's exact test. A significance level of 5% (p-value<0.05) and a confidence interval (CI) of 95% was adopted in all statistical tests. RESULTS: A total of 181 patients met the inclusion criteria, of whom 102 (56.4%) were male and 79 (43.6%) were female. Mean age was 55.1 years, and mean length of ICU stay was 17.5 days. PI development was associated with not achieving nutritional goals. There was a higher percentage (65.3%) of patients without a PI when both protein and caloric goals were achieved. In contrast, 45.6% of patients developed a PI when the goals were not achieved. The mean days for sedation, vasoactive drugs and mechanical ventilation were all significantly higher in patients who developed a PI (p<0.001). CONCLUSION: There was a significant association between patients developing a PI and deficits in caloric and protein intake. Patients who did not develop PIs had a greater calorie and protein intake compared with those who developed a PI.

ChatGPT: Literate or intelligent about UN sustainable development goals?

Generative AI tools, such as ChatGPT, are progressively transforming numerous sectors, demonstrating a capacity to impact human life dramatically. This research seeks to evaluate the UN Sustainable Development Goals (SDGs) literacy of ChatGPT, which is crucial for diverse stakeholders involved in SDG-related policies. Experimental outcomes from two widely used Sustainability Assessment tests-the UN SDG Fitness Test and Sustainability Literacy Test (SULITEST) - suggest that ChatGPT exhibits high SDG literacy, yet its comprehensive SDG intelligence needs further exploration. The Fitness Test gauges eight vital competencies across introductory, intermediate, and advanced levels. Accurate mapping of these to the test questions is essential for partial evaluation of SDG intelligence. To assess SDG intelligence, the questions from both tests were mapped to 17 SDGs and eight cross-cutting SDG core competencies, but both test questionnaires were found to be insufficient. SULITEST could satisfactorily map only 5 out of 8 competencies, whereas the Fitness Test managed to map 6 out of 8. Regarding the coverage of the Fitness Test and SULITEST, their mapping to the 17 SDGs, both tests fell short. Most SDGs were underrepresented in both instruments, with certain SDGs not represented at all. Consequently, both tools proved ineffective in assessing SDG intelligence through SDG coverage. The study recommends future versions of ChatGPT to enhance competencies such as collaboration, critical thinking, systems thinking, and others to achieve the SDGs. It concludes that while AI models like ChatGPT hold considerable potential in sustainable development, their usage must be approached carefully, considering current limitations and ethical implications.

A hippocampus-accumbens code guides goal-directed appetitive behavior.

The dorsal hippocampus (dHPC) is a key brain region for the expression of spatial memories, such as navigating towards a learned reward location. The nucleus accumbens (NAc) is a prominent projection target of dHPC and implicated in value-based action selection. Yet, the contents of the dHPC→NAc information stream and their acute role in behavior remain largely unknown. Here, we found that optogenetic stimulation of the dHPC→NAc pathway while mice navigated towards a learned reward location was both necessary and sufficient for spatial memory-related appetitive behaviors. To understand the task-relevant coding properties of individual NAc-projecting hippocampal neurons (dHPC→NAc), we used in vivo dual-color two-photon imaging. In contrast to other dHPC neurons, the dHPC→NAc subpopulation contained more place cells, with enriched spatial tuning properties. This subpopulation also showed enhanced coding of non-spatial task-relevant behaviors such as deceleration and appetitive licking. A generalized linear model revealed enhanced conjunctive coding in dHPC→NAc neurons which improved the identification of the reward zone. We propose that dHPC routes specific reward-related spatial and behavioral state information to guide NAc action selection.

How does the external context affect an implementation processes? A qualitative study investigating the impact of macro-level variables on the implementation of goal-oriented primary care.

BACKGROUND: Although the importance of context in implementation science is not disputed, knowledge about the actual impact of external context variables on implementation processes remains rather fragmented. Current frameworks, models, and studies merely describe macro-level barriers and facilitators, without acknowledging their dynamic character and how they impact and steer implementation. Including organizational theories in implementation frameworks could be a way of tackling this problem. In this study, we therefore investigate how organizational theories can contribute to our understanding of the ways in which external context variables shape implementation processes. We use the implementation process of goal-oriented primary care in Belgium as a case. METHODS: A qualitative study using in-depth semi-structured interviews was conducted with actors from a variety of primary care organizations. Data was collected and analyzed with an iterative approach. We assessed the potential of four organizational theories to enrich our understanding of the impact of external context variables on implementation processes. The organizational theories assessed are as follows: institutional theory, resource dependency theory, network theory, and contingency theory. Data analysis was based on a combination of inductive and deductive thematic analysis techniques using NVivo 12. RESULTS: Institutional theory helps to understand mechanisms that steer and facilitate the implementation of goal-oriented care through regulatory and policy measures. For example, the Flemish government issued policy for facilitating more integrated, person-centered care by means of newly created institutions, incentives, expectations, and other regulatory factors. The three other organizational theories describe both counteracting or reinforcing mechanisms. The financial system hampers interprofessional collaboration, which is key for GOC. Networks between primary care providers and health and/or social care organizations on the one hand facilitate GOC, while on the other hand, technology to support interprofessional collaboration is lacking. Contingent variables such as the aging population and increasing workload and complexity within primary care create circumstances in which GOC is presented as a possible answer. CONCLUSIONS: Insights and propositions that derive from organizational theories can be utilized to expand our knowledge on how external context variables affect implementation processes. These insights can be combined with or integrated into existing implementation frameworks and models to increase their explanatory power.

Iran's research prioritization: Are we meeting the goals? A study based on clinical trial registry data.

The prioritization of research topics in the health domain is a critical step toward channelling efforts and resources into areas that have received less attention. The objective of this study is to evaluate the implementation of research priorities determined at the national level within Iran for the period spanning five years between 2009 and 2013. We extracted the required data from the Iranian Registry of Clinical Trials (IRCT) website. Then we conducted a matching process between the titles of trials registered in the IRCT until December 3rd, 2013, and the list of national health research priorities in the domains of communicable and non-communicable diseases. The latter was compiled and regulated by the Research and Technology Deputy of the Ministry of Health since 2008. Out of the total 5,049 clinical trials registered in IRCT, 92.3% were carried out within the domain of non-communicable diseases, while 6.1% pertained to the field of communicable diseases and the remaining 1.3% in other fields. 56.4% of the clinical trials conducted in the field of communicable diseases and 32.8% of those conducted in the field of non-communicable diseases were consistent with the research priorities determined in these two fields. During the five-year period of the prioritization goal, there was no significant improvement in adherence to the list of priorities compared to the previous five-year period. Furthermore, certain priorities were neglected within both areas during these periods. It is possible to evaluate the effectiveness of research prioritization using the data obtained from the registration centers of clinical trials. Our study has revealed that the list of priorities has not garnered adequate attention from the research community within the country. Hence, remedial measures are imperative to ensure the priorities are given more attention after publication.

Understanding factors that influence goal setting in rehabilitation for paediatric acquired brain injury: a qualitative study using the Theoretical Domains Framework.

Background While goal setting with children and their families is considered best practice during rehabilitation following acquired brain injury, its successful implementation in an interdisciplinary team is not straightforward. This paper describes the application of a theoretical framework to understand factors influencing goal setting with children and their families in a large interdisciplinary rehabilitation team. Methods A semi-structured focus group was conducted with rehabilitation clinicians and those with lived experience of paediatric acquired brain injury (ABI). The 90-min focus group was audio-recorded and transcribed verbatim. Data were thematically coded and mapped against the Theoretical Domains Framework (TDF) to understand influencing factors, which were then linked to the Capability, Opportunity, Motivation - Behaviour (COM-B) model. Results A total of 11 participants (nine paediatric rehabilitation clinicians, one parent and one young person with lived experience of paediatric ABI) participated in the focus group. Factors influencing collaborative goal setting mapped to the COM-B and six domains of the TDF: Capabilities (Skills, Knowledge, Beliefs about capabilities, and Behavioural regulation), Opportunities (Environmental context and resources), and Motivation (Social/professional role and identity). Results suggest that a multifaceted intervention is needed to enhance rehabilitation clinicians' and families' skills and knowledge of goal setting, restructure the goal communication processes, and clarify the roles clinicians play in goal setting within the interdisciplinary team. Conclusion The use of the TDF and COM-B enabled a systematic approach to understanding the factors influencing goal setting for children with acquired brain injury in a large interdisciplinary rehabilitation team, and develop a targeted, multifaceted intervention for clinical use. These represent important considerations for the improvement of collaborative goal setting in paediatric rehabilitation services to ensure that best practice approaches to goal setting are implemented effectively in clinical practice.

Setting restorative goals with a regional outlook: Mine-rehabilitation outcomes influence landscape connectivity.

Mining is increasing worldwide and is typically associated with highly negative environmental impacts, such as habitat loss and fragmentation. To counteract these effects and improve restoration practices, decisions, such as setting mine rehabilitation goals, could incorporate the assessment and restoration of landscape connectivity into their regional and local-scale planning. The overarching goal of this work was to assess landscape connectivity for flora and fauna and explore mine-rehabilitation scenarios that can be used as a tool for prioritising biodiversity outcomes. Our study area comprised the Fitzroy Basin (Queensland, Australia), where the disturbance footprints from mining cover a cumulative area of 121,239 ha. We considered two scenarios: rehabilitation to agriculture and restoration to native ecosystems. To compare these scenarios, we created differential maps, which highlighted that restoring to native ecosystems represented connectivity gains over agricultural rehabilitation goals. These maps revealed three ways to prioritise rehabilitation outcomes, giving priority to mines that: 1) presented medium to high connectivity values, 2) covered a large area of influence (contributing to connectivity on a larger scale, regardless of current flow values), and 3) showed a gain of important paths/corridors. We explored four case studies and found that three benefited from restoration outcomes, while the fourth did not benefit by either scenario. Our methods can be used for decision-making in restoration ecology and conservation, including mine rehabilitation priorities and goals, as well as for evaluating connectivity gains or losses.

Construct validity, reliability, and threshold value for treatment goals of the Thai version of the 12-item Psoriatic Arthritis Impact of Disease Questionnaire for patients with psoriatic arthritis.

OBJECTIVE: To determine the construct validity, reliability, and treatment goal threshold of a Thai-language version of the 12-item Psoriatic Arthritis Impact of Disease (Thai-PsAID) questionnaire in patients with psoriatic arthritis (PsA). METHODS: This cross-sectional study involved administering the proposed Thai-PsAID to 117 Thai patients with PsA. Reliability was assessed by Cronbach's α test and intraclass correlation coefficient (ICC). Construct validity was assessed using Spearman correlation with clinical disease activity index for psoriatic arthritis (cDAPSA), the Health Assessment Questionnaire (HAQ), EQ-5D index, and the patient-acceptable symptom state (PASS). The optimal cutoff score of the Thai-PsAID for minimal disease activity (MDA) was determined by receiver operating characteristic curves. RESULTS: Participants had a mean age of 49.5 years, 61 (52.1%) were female, and the median disease duration was 5 years. The median Thai-PsAID score was 2.1, with a Cronbach's α coefficient of .95 and an ICC of 0.77. The mean time to complete the Thai-PsAID was 2.1 min, with no missing data. The Thai-PsAID score demonstrated a moderate correlation with the cDAPSA, HAQ, and EQ-5D with indices (Spearman's rho of .64, .54, and -.55, respectively). The cutoff of 2.7 has 81%-84% sensitivity and 69%-85% specificity for classifying patients with MDA, satisfied PASS, and indicating no need to escalate medication. CONCLUSIONS: The Thai-PsAID is a valid, reliable, and feasible tool for measuring PsA prognosis. A cutoff of 2.7 accurately discriminates MDA and PASS and indicates no need for medication escalation. The Thai-PsAID may be used as a standalone measure.

Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer: a randomized controlled trial.

OBJECTIVE: The use of goal-directed fluid therapy (GDFT) has been shown to reduce complications and improve prognosis in high-risk abdominal surgery patients. However, the utilization of pulse pressure variation (PPV) guided GDFT in laparoscopic surgery remains a subject of debate. We hypothesized that utilizing PPV guidance for GDFT would optimize short-term prognosis in elderly patients undergoing laparoscopic radical resection for colorectal cancer compared to conventional fluid therapy. METHODS: Elderly patients undergoing laparoscopic radical resection of colorectal cancer were randomized to receive either PPV guided GDFT or conventional fluid therapy and explore whether PPV guided GDFT can optimize the short-term prognosis of elderly patients undergoing laparoscopic radical resection of colorectal cancer compared with conventional fluid therapy. RESULTS: The incidence of complications was significantly lower in the PPV group compared to the control group (32.8% vs. 57.1%, P = .009). Additionally, the PPV group had a lower occurrence of gastrointestinal dysfunction (19.0% vs. 39.3%, P = .017) and postoperative pneumonia (8.6% vs. 23.2%, P = .033) than the control group. CONCLUSION: Utilizing PPV as a monitoring index for GDFT can improve short-term prognosis in elderly patients undergoing laparoscopic radical resection of colorectal cancer. REGISTRATION NUMBER: ChiCTR2300067361; date of registration: January 5, 2023.

Factors associated with the performance and achieving goals of specialized periodontal procedures in Brazilian dental specialties centers.

BACKGROUND: The Brazilian Dental Specialty Centers (CEO, in Portuguese) represent the strategy of the National Oral Health Policy to provide secondary-level dental care. They offer more complex procedures, such as the treatment of periodontitis. This study aims to investigate the factors associated with the performance and the achievement goals of specialized procedures and the achievement gols of periodontics in CEO. METHODOLOGY: Analytical and cross-sectional study using secondary data. The database of the second cycle of the External Evaluation of the National Program for Improving Access and Quality in CEO (PMAQ-CEO, in Portuguese), was utilized, which assessed 1,042 CEO on-site in 2018. The data were analyzed using multiple Poisson regression, estimating the prevalence ratio (PR) (p < 0.05). RESULTS: A third of the CEO (n = 305) performed all specialized procedures, with a higher prevalence observed in those with more than one bicarbonate jet prophylaxis unit (RP = 2.12; 95% CI: 1.160-3.881; p = 0.015) and when they had a higher percentage of specialist professionals (RP = 1.004; 95% CI: 1.002-1.006; p < 0.001). The periodontics goal was achieved by 617 (59.2%) CEO, with a higher prevalence among those who had a manager with supplementary training (PR = 1.21; 95% CI: 1.100-1.335; p < 0.001) and with a higher workload for the periodontist dentist (PR = 1.15; 95% CI: 1.103-1.201; p < 0,001). CONCLUSION: Although most CEOs do not perform allspecialized periodontics procedures, more than half achieved the established goals. The provision of specialized periodontics services in CEO and the achievement of goals are influenced by the quantity and professional qualifications, as well as the availability of equipment.

Feasibility of Goal-Directed Fluid Therapy in Patients with Transcatheter Aortic Valve Replacement - An Ambispective Analysis.

INTRODUCTION: Goal-directed fluid therapy (GDFT) has been shown to reduce postoperative complications. The feasibility of GDFT in transcatheter aortic valve replacement (TAVR) patients under general anesthesia has not yet been demonstrated. We examined whether GDFT could be applied in patients undergoing TAVR in general anesthesia and its impact on outcomes. METHODS: Forty consecutive TAVR patients in the prospective intervention group with GDFT were compared to 40 retrospective TAVR patients without GDFT. Inclusion criteria were age ≥ 18 years, elective TAVR in general anesthesia, no participation in another interventional study. Exclusion criteria were lack of ability to consent study participation, pregnant or nursing patients, emergency procedures, preinterventional decubitus, tissue and/or extremity ischemia, peripheral arterial occlusive disease grade IV, atrial fibrillation or other severe heart rhythm disorder, necessity of usage of intra-aortic balloon pump. Stroke volume and stroke volume variation were determined with uncalibrated pulse contour analysis and optimized according to a predefined algorithm using 250 ml of hydroxyethyl starch. RESULTS: Stroke volume could be increased by applying GDFT. The intervention group received more colloids and fewer crystalloids than control group. Total volume replacement did not differ. The incidence of overall complications as well as intensive care unit and hospital length of stay were comparable between both groups. GDFT was associated with a reduced incidence of delirium. Duration of anesthesia was shorter in the intervention group. Duration of the interventional procedure did not differ. CONCLUSION: GDFT in the intervention group was associated with a reduced incidence of postinterventional delirium.