On the role of the UMLS in supporting diagnosis generation proposed by Large Language Models.

OBJECTIVE: Traditional knowledge-based and machine learning diagnostic decision support systems have benefited from integrating the medical domain knowledge encoded in the Unified Medical Language System (UMLS). The emergence of Large Language Models (LLMs) to supplant traditional systems poses questions of the quality and extent of the medical knowledge in the models' internal knowledge representations and the need for external knowledge sources. The objective of this study is three-fold: to probe the diagnosis-related medical knowledge of popular LLMs, to examine the benefit of providing the UMLS knowledge to LLMs (grounding the diagnosis predictions), and to evaluate the correlations between human judgments and the UMLS-based metrics for generations by LLMs. METHODS: We evaluated diagnoses generated by LLMs from consumer health questions and daily care notes in the electronic health records using the ConsumerQA and Problem Summarization datasets. Probing LLMs for the UMLS knowledge was performed by prompting the LLM to complete the diagnosis-related UMLS knowledge paths. Grounding the predictions was examined in an approach that integrated the UMLS graph paths and clinical notes in prompting the LLMs. The results were compared to prompting without the UMLS paths. The final experiments examined the alignment of different evaluation metrics, UMLS-based and non-UMLS, with human expert evaluation. RESULTS: In probing the UMLS knowledge, GPT-3.5 significantly outperformed Llama2 and a simple baseline yielding an F1 score of 10.9% in completing one-hop UMLS paths for a given concept. Grounding diagnosis predictions with the UMLS paths improved the results for both models on both tasks, with the highest improvement (4%) in SapBERT score. There was a weak correlation between the widely used evaluation metrics (ROUGE and SapBERT) and human judgments. CONCLUSION: We found that while popular LLMs contain some medical knowledge in their internal representations, augmentation with the UMLS knowledge provides performance gains around diagnosis generation. The UMLS needs to be tailored for the task to improve the LLMs predictions. Finding evaluation metrics that are aligned with human judgments better than the traditional ROUGE and BERT-based scores remains an open research question.

An Extensible Evaluation Framework Applied to Clinical Text Deidentification Natural Language Processing Tools: Multisystem and Multicorpus Study.

BACKGROUND: Clinical natural language processing (NLP) researchers need access to directly comparable evaluation results for applications such as text deidentification across a range of corpus types and the means to easily test new systems or corpora within the same framework. Current systems, reported metrics, and the personally identifiable information (PII) categories evaluated are not easily comparable. OBJECTIVE: This study presents an open-source and extensible end-to-end framework for comparing clinical NLP system performance across corpora even when the annotation categories do not align. METHODS: As a use case for this framework, we use 6 off-the-shelf text deidentification systems (ie, CliniDeID, deid from PhysioNet, MITRE Identity Scrubber Toolkit [MIST], NeuroNER, National Library of Medicine [NLM] Scrubber, and Philter) across 3 standard clinical text corpora for the task (2 of which are publicly available) and 1 private corpus (all in English), with annotation categories that are not directly analogous. The framework is built on shell scripts that can be extended to include new systems, corpora, and performance metrics. We present this open tool, multiple means for aligning PII categories during evaluation, and our initial timing and performance metric findings. Code for running this framework with all settings needed to run all pairs are available via Codeberg and GitHub. RESULTS: From this case study, we found large differences in processing speed between systems. The fastest system (ie, MIST) processed an average of 24.57 (SD 26.23) notes per second, while the slowest (ie, CliniDeID) processed an average of 1.00 notes per second. No system uniformly outperformed the others at identifying PII across corpora and categories. Instead, a rich tapestry of performance trade-offs emerged for PII categories. CliniDeID and Philter prioritize recall over precision (with an average recall 6.9 and 11.2 points higher, respectively, for partially matching spans of text matching any PII category), while the other 4 systems consistently have higher precision (with MIST's precision scoring 20.2 points higher, NLM Scrubber scoring 4.4 points higher, NeuroNER scoring 7.2 points higher, and deid scoring 17.1 points higher). The macroaverage recall across corpora for identifying names, one of the more sensitive PII categories, included deid (48.8%) and MIST (66.9%) at the low end and NeuroNER (84.1%), NLM Scrubber (88.1%), and CliniDeID (95.9%) at the high end. A variety of metrics across categories and corpora are reported with a wider variety (eg, F2-score) available via the tool. CONCLUSIONS: NLP systems in general and deidentification systems and corpora in our use case tend to be evaluated in stand-alone research articles that only include a limited set of comparators. We hold that a single evaluation pipeline across multiple systems and corpora allows for more nuanced comparisons. Our open pipeline should reduce barriers to evaluation and system advancement.

Effects of Community-Wide Teen Pregnancy Prevention Initiatives on Local Teen Birth Rates in the United States: A Synthetic Control Approach.

The impact of community-wide teen pregnancy prevention initiatives (CWIs) on local U.S. birth rates among adolescents aged 15 to 19 years was examined using synthetic control methodology within a quasi-experimental design. CWIs were implemented in 10 U.S. communities from 2010 to 2015. Each initiative implemented evidence-based teen pregnancy prevention interventions at local organizations and enhanced best practices in adolescent reproductive health care at local health centers, while engaging diverse community sectors. The synthetic control method was used to estimate the impact of each CWI on overall and race- and ethnicity-specific teen births relative to rates in synthetic control communities. Additionally, we estimated the overall effect of CWIs across communities by pooling results from the 10 synthetic control case studies using the mean percentile rank. Pooled data across all 10 communities indicated an estimated average of 6.6 fewer births per 1000 teens per year overall during the initiative relative to each community's synthetic control (p = .001). By race and ethnicity, there were an estimated average of 6.4 fewer births per 1000 teens per year among Black teens (p = .03), 10.7 fewer births among Hispanic teens (p = .03), and 4.2 fewer births (p = .10) among White teens. Results from individual communities indicated an intervention effect on overall and/or race/ethnicity-specific teen birth rates in five communities. This study demonstrates the value of synthetic control methods in evaluating community-level outcomes of programmatic efforts. Findings indicate the CWIs had a positive impact on teen birth rates and have the potential to address racial and ethnic disparities in those rates.

A proposed methodology to evaluate the influence of climate change on drinking water treatments and costs.

Drinking water (DW) production treatments can be affected by climate change, in particular intense rainfall events, having an impact on the availability and quality of the water source. The current study proposes a methodology for the evaluation of the costs of the different treatment steps for surface water (SW) and groundwater (GW), through the analysis and quantification of the main cost items. It provides the details to count for strong variations in the key quality parameters of inlet water following severe rainfalls (namely turbidity, iron, manganese, and E. coli). This methodology is then applied to a large drinking water treatment plant (DWTP) in Italy, which treats both SW, around 70 %, and GW, around 30%. It discusses the overall DW production costs (from 7.60 c€/m3 to 10.43 c€/m3) during the period 2019-2021 and analyzes the contributions of the different treatment steps in water and sludge trains. Then it focuses on the effects on the treatments of significant variations in SW turbidity (up to 1863 NTU) due to intense rainfalls, and on the daily costs of DW with respect to the average (baseline) costs evaluated on the annual basis. It emerges that, when SW has low turbidity levels, the energy-based steps have the biggest contribution on the costs (final pumping 22 % for SW and 10 % for GW, withdrawal 15 % and 14 %, respectively), whereas at very high turbidity levels, sludge greatly increases, and its treatment and disposal costs become significant (up to 14 % and 50 %). Efforts are being made to adopt the best strategies for the management of DWTPs in these adverse conditions, with the aim to guarantee potable water and optimize water production costs. A mitigation measure consists of increasing GW withdrawal up to the authorized flow rate, thus reducing SW withdrawal. In this context, the study is completed by discussing the potential upgrading of the DWTP by only treating GW withdrawn from riverbank filtration. The DW production cost would be 7.76 c€/m3, which is lower than that seen for the same year (2021) with the current plant configuration (8.32 c€/m3).

Researching Compassionate Communities: Identifying theoretical frameworks to evaluate the complex processes behind public health palliative care initiatives.

BACKGROUND: Compassionate Communities have been put forward as a new model for community-based palliative care to positively impact the health and wellbeing of those experiencing challenges of serious illness, death, dying, and loss. Despite the growing international movement to develop these public health initiatives to end-of-life care, only a handful of initiatives have undergone some form of evaluation. AIM: To provide guidance on designing evaluation research by identifying theoretical frameworks to understand the development, implementation, and underlying mechanisms of Compassionate Communities. METHODS: To identify suitable theoretical frameworks for the study of Compassionate Communities, we applied two steps. The first step examined the characteristics of Compassionate Communities and translated them into assessment criteria for the selection of theoretical frameworks. The second step consisted of applying the identified assessment criteria to a list of widely used and highly cited theoretical frameworks. RESULTS: Three well-established theoretical frameworks were identified as being most suitable to study the development, implementation, and underlying mechanisms of Compassionate Communities: The Consolidated Framework for Implementation Research (CFIR), the integrated-Promoting Action on Research Implementation in Health Services framework (i-PARIHS), and the Extended Normalization Process Theory (ENPT). CONCLUSIONS: The article supports and encourages the use of theoretical frameworks to evaluate the complex processes behind public health palliative care initiatives. The complementary use of two determinant frameworks and an implementation theory provides theoretical grounding to gain rich insights into the emergent and shifting interplays between agency, social processes, and contextual factors that shape the development and implementation of Compassionate Communities.

Barriers to delirium screening and management during hospital admission: a qualitative analysis of inpatient nursing perspectives.

BACKGROUND: Delirium in hospitalized patients is a major public health issue, yet delirium is often unrecognized and missed during inpatient admission. The objective of this study was to identify barriers to delirium screening, identification, and management from a nursing perspective on inpatient, acute care units. METHODS: This was a pre-implementation, diagnostic evaluation study to determine current practice patterns and potential barriers to optimizing delirium care at a major university hospital. A qualitative approach was used, which included focus groups of inpatient nurses working on major medical and surgical acute care units. Focus groups were conducted until signs of thematic saturation were present, and data were analyzed via inductive thematic analysis, without predetermined theories or structures. A consensus approach was utilized for transcript coding, and final themes were generated after multiple reviews of initial themes against transcript datasets. RESULTS: Focus group sessions (n = 3) were held with 18 nurses across two major inpatient units. Nurses reported several barriers to successful delirium screening and management. Specific challenges included difficulty with using delirium screening tools, an organizational culture not conducive to delirium prevention, and competing clinical priorities. Proposed solutions were also discussed, including decision-support systems with automated pager alerts and associated delirium order sets, which may help improve delirium care coordination and standardization. CONCLUSION: At a major university hospital, nurses affirm the difficulty experienced with delirium screening and identification, particularly due to screening tool challenges, cultural barriers, and clinical workload. These impediments may serve as targets for a future implementation trial to improve delirium screening and management.

Video-based paired comparison to evaluate some cosmetic products under camera movement for dynamic performance.

OBJECTIVE: Until now, standardized evaluation of cosmetic effects was conducted mainly in still conditions such as pictures. In real life, the consumers' experience of their cosmetics' effects is dynamic and some of the benefits can be better observed under movement. In order to capture motion-related performance of cosmetics, we developed a video-based paired comparison on an online platform. METHODS: We validated this new tool through the evaluation of eyeshadow with high light reflection and colour gradation, especially visible under motion according to the observer point of view. This formula was compared with two marketed benchmarks. The three products were applied sequentially on the eyelid of eight Japanese women. Videos were taken in standardized light, speed and face position with a rotating camera around the face. The videos were uploaded on an online secured platform and eyelid 3D effect, highlight and colour gradation were evaluated through paired comparison test by 60 Japanese women from home on their PC or tablets. Those results were compared with picture-based paired comparison by the same observers. RESULTS: Video-based paired comparison provided higher discrimination of products compared to picture-based comparison. CONCLUSION: As compared to still camera acquisition, the evaluation of cosmetics based on videos is closer to real-life experience and can bring higher discrimination, especially for motion-related attributes.

OBJECTIF: Jusqu'à présent, l'évaluation standardisée des effets cosmétiques a été réalisée principalement dans des conditions immobiles telles que des photos. Dans la vie réelle, l'expérience des consommateurs des effets de leurs cosmétiques est dynamique, et certains des avantages peuvent être mieux observés en mouvement. Afin de saisir les performances des produits cosmétiques liées au mouvement, nous avons mis au point une comparaison par paires basée sur des vidéos sur une plateforme en ligne. MÉTHODES: Nous avons validé ce nouvel outil en évaluant un fard à paupières à forte réflexion lumineuse et à gradation de couleurs, particulièrement visible en mouvement selon le point de vue de l'observateur. Cette formule a été comparée à deux références commercialisées. Les trois produits ont été appliqués successivement sur la paupière de huit femmes japonaises. Les vidéos ont été prises dans des conditions de lumière, de vitesse et de position du visage normalisées, avec une caméra tournant autour du visage. Les vidéos ont été téléchargées sur une plateforme sécurisée en ligne, et l'effet 3D des paupières, l'accentuation et la gradation des couleurs ont été évalués au moyen d'un test de comparaison par paires par 60 femmes japonaises depuis leur domicile sur leur PC ou leur tablette. Ces résultats ont été mis en parallèle à une comparaison par paires sur photo par les mêmes observateurs. RÉSULTATS: La comparaison par paires sur vidéo a permis de mieux distinguer les produits par rapport à la comparaison sur photo. CONCLUSION: Par rapport à l'acquisition d'images fixes, l'évaluation des cosmétiques à partir de vidéos est plus proche de l'expérience réelle et peut permettre de mieux distinguer les produits, en particulier pour les attributs liés au mouvement.

Developing a framework to guide the evaluation of training in research skills for health and care professionals.

Background: Delivering research skills training to health professionals through short, applied sessions outside a formal higher education program, can help fill gaps in training and build research capacity in clinical settings. This has been the endeavor of some of the Applied Research Collaborations funded by the National Institute for Health and Care Research in England since 2014. How to evaluate this type of training in terms of the wider impact it may have, has not featured heavily in the literature and methods have largely borrowed from more generic approaches to training evaluation which can over-simplify outcomes and ignore longer-term impacts. Methods: We developed the framework in four stages: mapping potential impacts of our research skills training courses to identify key concepts; shaping into three domains in which impact could be expected, informed by established definitions of research capacity building; testing the initial framework and adapting wording of impacts; refining the framework into a practical tool. Results: The final framework specifies types of impact in three domains of influence - individual, group/organization and health system, and maps these against key questions to guide inquiry, as well as suggested methods for capturing the impact and expected timeframe for each type of impact. Discussion: The framework provides a structure for guiding the evaluation of research training as well as a focus on medium-longer term impacts, encouraging a broader and continuous approach to evaluation. It is hoped this will support educators in other contexts and fields, in the planning of a wider range of training evaluation activities, to capture impact more fully.

Conceptualizing and Fostering the Quality of CES Through a Dutch National Network on CES (NEON).

The prevalence of Clinical ethics support (CES) services is increasing. Yet, questions about what quality of CES entails and how to foster the quality of CES remain. This paper describes the development of a national network (NEON), which aimed to conceptualize and foster the quality of CES in the Netherlands simultaneously. Our methodology was inspired by a responsive evaluation approach which shares some of our key theoretical presuppositions of CES. A responsive evaluation methodology engages stakeholders in developing quality standards of a certain practice, instead of evaluating a practice by predefined standards. In this paper, we describe the relationship between our theoretical viewpoint on CES and a responsive evaluation methodology. Then we describe the development of the network (NEON) and focus on three activities that exemplify our approach. In the discussion, we reflect on the similarities and differences between our approach and other international initiatives focusing on the quality of CES.

[Exploration and reflection on evaluation methodology of human use experience for new Chinese drug development].

The "triple combination" review system provides an opportunity for the transformation of human use experience into new Chinese drugs. However, there are some methodological and technical limitations in the assessment of human experience. Hence, the efficacy and safety evaluation methods should be established in accordance with the characteristics of Chinese herbs. This study summarized some evidence-based methodology to promote the transformation of human use experience to new Chinese drugs, mainly including the individualized pragmatic randomized controlled trial(RCT), cluster RCT, single-case RCT, single arm RCT with objective performance criteria, and partially nested RCT. As the real world data can be used to support the transformation of human experience, attention should be paid to convenient and efficient collection of data, prudent selection of design types, and adoption of appropriate ana-lysis methods to deal with confounding bias, including multi-factor regression model and propensity score. The newly proposed mixed research method can also be utilized to assess the human use experience, which is suitable for mining the theory of traditional Chinese medicine(TCM) and expert experience from different aspects. Meanwhile, considering the study design requirements and TCM cha-racteristics, this study put forward the common problems and solutions in the development of new Chinese drugs based on human use experience, including how to select the feasible outcome indicators, how to collect prescription data in the case of herb and dosage adjustment, and how to evaluate the comprehensive effectiveness of TCM from the perspective of "combination of disease and syndrome".

A plea for standardization of confocal microscopy and optical coherence tomography parameters to evaluate physiological and para-physiological skin conditions in cosmetic science.

Non-invasive reflectance confocal microscopy (RCM) and optical coherence tomography (OCT) have been extended to the dermo-cosmetic field, for skin pathophysiology understanding and therapeutics monitoring. However, standardized methodology and parameters to interpret structures and changes in these settings are still lacking. Present study aimed to propose a validated standard methodology and a list of defined parameters for objective non-pathological skin assessments in the cosmetically sensitive cheekbone area of the face. OCT and RCM quantitative, semi-quantitative and qualitative features were considered for assessments. Validation process included 50 sets of images divided into two age groups. Inter-rater reliability was explored to assess the influence of the proposed methodology. Quantitative OCT parameters of "epidermal thickness," "density and attenuation coefficients" and "vascular density" were considered and calculated. Severity scales were developed for semi-quantitative OCT features of "disruption of collagen" and "vascular asset," while extent scales were produced for semi-quantitative RCM "irregular honeycomb," "mottled pigmentation" and "polycyclic papillary contours." Qualitative assessment was obtained for RCM type of collagen, and comparison between age groups was performed for all features considered. Severity visual scales assistance proved excellent inter-rater agreement across all semi-quantitative and qualitative domains. The assistance of shareable software systems allows for objective OCT quantitative parameters measurement. The use of standard reference scales, within a defined assessment methodology, offers high inter-rater reliability and thus reproducibility for semi-quantitative and qualitative OCT and RCM parameters. Taken together, our results may represent a starting point for a standardized application of RCM and OCT in dermo-cosmetic research and practice.

Assessing the performance of indicators during their life cycle: the mixed QUID method.

BACKGROUND: Quality indicators (QI) are mandatory in French hospitals. After a decade of use, the Ministry of Health set up an expert workgroup to enhance informed decision-making regarding currently used national QI, i.e. to propose a decision of withdrawing, revising or continuing their use. We report the development of an integrated method for a comprehensive appraisal of quality/safety indicators (QI) during their life cycle, for three purposes, quality improvement, public disclosure and regulation purposes. The method was tested on 10 national QI on use for up to 10 years to identify operational issues. METHODS: A modified Delphi technique to select relevant criteria and a development of a mixed evaluation method by the workgroup. A 'real-life' test on 10 national QI. RESULTS: Twelve criteria were selected for the appraisal of QI used for regulation goals, 11 were selected for hospital improvement and seven for public disclosure. The perceived feasibility and relevance were studied including hospital workers, patients and health authorities professionals; the scientific soundness of the indicator development phase was reviewed by analyzing reference documents; the metrological performance (limited to the discriminatory power and dynamics of change during the life cycle dimensions) was analyzed on the national datasets.Applied to the 10 QI, the workgroup proposed to withdraw four of them and to modify or suspend the six others. CONCLUSIONS: The value of the method was supported by the clear-cut conclusions and endorsement of the proposed decisions by the health authorities.

Intra- and inter-investigator reliabilities of oral moisture measured using an oral moisture-checking device.

BACKGROUND: Oral mucosal moisture determined using oral moisture-checking devices is used as a mouth dryness evaluation method. Such devices are capable of evaluating the state of mouth dryness in a simple manner and have applicability in a wide range of subjects; however, their intra- and inter-investigator reliabilities have not yet been clarified. OBJECTIVE: This study aims to investigate the intra- and inter-investigator reliabilities of measuring oral moisture using an oral moisture-checking device for a wide range of age groups. METHODS: Intra- and inter-investigator reliabilities were investigated in 28 young subjects and 19 older subjects aged ≥65 years. Three trained investigators independently measured oral mucosal moisture values using an oral moisture-checking device. Intra-investigator reliability was assessed using the coefficient of variation (CV) and intraclass correlation coefficient (ICC) (1.1), and inter-investigator reliability was assessed using ICC (2.1). RESULTS: Mean CV was 0.015 and 0.016, mean ICC (1.1) was 0.806 and 0.877, and ICC (2.1) was 0.873 and 0.829 in the young and older subjects, respectively. CONCLUSION: In young subjects, the mean values of ICC (1.1) and ICC (2.1) of the oral moisture-checking device were 0.806 and 0.873, respectively, whereas in older subjects, these values were 0.877 and 0.829, respectively. Thus, this confirms that the examination of oral mucosal moisture using the oral moisture-checking device has sufficient intra- and inter-investigator reliabilities for a wide range of age groups.

Evaluation of a Tennessee statewide initiative to reduce early elective deliveries using quasi-experimental methods.

BACKGROUND: Concerted quality improvement (QI) efforts have been taken to discourage the practice of early elective deliveries (EEDs), but few studies have robustly examined the impact of directed QI interventions in reducing EED practices. Using quasi-experimental methods, we sought to evaluate the impact of a statewide QI intervention to reduce the practice of EEDs. METHODS: Retrospective cohort study of vital records data (2007 to 2013) for all singleton births occurring ≥36 weeks in 66 Tennessee hospitals grouped into three QI cohorts. We used interrupted-time series to estimate the effect of the QI intervention on the likelihood of an EED birth statewide, and by hospital cohort. We compared the distribution of hospital EED percentages pre- and post-intervention. Lastly, we used multivariable logistic regression to estimate the effect of QI interventions on maternal and infant outcomes. RESULTS: Implementation of the QI intervention was associated with significant declines in likelihood of EEDs immediately following the intervention (odds ratio, OR = 0.72; p < 0.001), but these results varied by hospital cohort. Hospital risk-adjusted EED percentages ranged from 1.6-13.6% in the pre-intervention period, which significantly declined to 2.2-9.6% in the post-intervention period (p < 0.001). The QI intervention was also associated with significant reductions in operative vaginal delivery and perineal laceration, and immediate infant ventilation, but increased NICU admissions. CONCLUSIONS: A statewide QI intervention to reduce EEDs was associated with modest but significant declines in EEDs beyond concurrent and national trends, and showed mixed results in related infant and maternal outcomes.

Quantifying Use of a Health Virtual Community of Practice for General Practitioners' Continuing Professional Development: A Novel Methodology and Pilot Evaluation.

BACKGROUND: Health care practitioners (HPs), in particular general practitioners (GPs), are increasingly adopting Web-based social media platforms for continuing professional development (CPD). As GPs are restricted by time, distance, and demanding workloads, a health virtual community of practice (HVCoP) is an ideal solution to replace face-to-face CPD with Web-based CPD. However, barriers such as time and work schedules may limit participation in an HVCoP. Furthermore, it is difficult to gauge whether GPs engage actively or passively in HVCoP knowledge-acquisition for Web-based CPD, as GPs' competencies are usually measured with pre- and posttests. OBJECTIVE: This study investigated a method for measuring the engagement features needed for an HVCoP (the Community Fracture Capture [CFC] Learning Hub) for learning and knowledge sharing among GPs for their CPD activity. METHODS: A prototype CFC Learning Hub was developed using an Igloo Web-based social media software platform and involved a convenience sample of GPs interested in bone health topics. This Hub, a secure Web-based community site, included 2 key components: an online discussion forum and a knowledge repository (the Knowledge Hub). The discussion forum contained anonymized case studies (contributed by GP participants) and topical discussions (topics that were not case studies). Using 2 complementary tools (Google Analytics and Igloo Statistical Tool), we characterized individual participating GPs' engagement with the Hub. We measured the GP participants' behavior by quantifying the number of online sessions of the participants, activities undertaken within these online sessions, written posts made per learning topic, and their time spent per topic. We calculated time spent in both active and passive engagement for each topic. RESULTS: Seven GPs participated in the CFC Learning Hub HVCoP from September to November 2017. The complementary tools successfully captured the GP participants' engagement in the Hub. GPs were more active in topics in the discussion forum that had direct clinical application as opposed to didactic, evidence-based discussion topics (ie, topical discussions). From our knowledge hub, About Osteoporosis and Prevention were the most engaging topics, whereas shared decision making was the least active topic. CONCLUSIONS: We showcased a novel complementary analysis method that allowed us to quantify the CFC Learning Hub's usage data into (1) sessions, (2) activities, (3) active or passive time spent, and (4) posts made to evaluate the potential engagement features needed for an HVCoP focused on GP participants' CPD process. Our design and evaluation methods for ongoing use and engagement in this Hub may be useful to evaluate future learning and knowledge-sharing projects for GPs and may allow for extension to other HPs' environments. However, owing to the limited number of GP participants in this study, we suggest that further research with a larger cohort should be performed to validate and extend these findings.

Impact of motor task execution on an individual's ability to mirror forearm positions.

This work is motivated by our goal of determining why individuals with stroke are impaired when locating their arms in space. We assessed the ability of individuals without neurological impairments to mirror their forearms during various motor tasks so that we could identify baseline performance in an unimpaired population. Nine right-hand dominant participants without neurological impairments mirrored forearm positions bi-directionally (i.e., right forearm mirrors left forearm, vice versa) for three motor tasks (i.e., passive, passive/active, and active) and two position identification modes (i.e., mirroring to a position stored in working memory versus concurrently felt by the opposite arm). During each trial, the participant's reference forearm moved to a flexion ([Formula: see text]) or extension ([Formula: see text]) position, and then, their opposite forearm mirrored the position of their reference forearm. The main finding across all tested conditions is that participants mirrored forearm positions with an average magnitude of error [Formula: see text]. When controlling their forearms' movements (active motor task), participants mirrored forearm positions more accurately by up to, on average, [Formula: see text] at the flexion location than at the extension location. Moreover, participants mirrored forearm positions more accurately by up to, on average, [Formula: see text] when their forearms were moved for them rather than when they controlled their forearms' movements. Task directionality and position identification mode did not significantly affect participant arm mirroring accuracy. These findings are relevant for interpreting in future work the reason why impairments occur, on similar tasks, in individuals with altered motor commands, working memory, and arm impedance, e.g., post-stroke hemiparesis.

Cross-cultural adaptation and psychometric evaluation of the Juvenile Arthritis Multidimensional Assessment Report (JAMAR) in 54 languages across 52 countries: review of the general methodology.

The aim of this project was to cross-culturally adapt and validate the Juvenile Arthritis Multidimensional Assessment Report (JAMAR) questionnaire in 54 languages across 52 different countries that are members of the Paediatric Rheumatology International Trials Organisation (PRINTO). This effort was part of a wider project named Epidemiology and Outcome of Children with Arthritis (EPOCA) to obtain information on the frequency of juvenile idiopathic arthritis (JIA) categories in different geographic areas, the therapeutic approaches adopted, and the disease status of children with JIA currently followed worldwide. A total of 13,843 subjects were enrolled from the 49 countries that took part both in the cross-cultural adaptation phase and in the related validation and data collection: Algeria, Argentina, Belgium, Brazil, Bulgaria, Canada, Chile, Colombia, Croatia, Czech Republic, Denmark, Ecuador, Egypt, Estonia, Finland, France, Georgia, Germany, Greece, Hungary, India, Islamic Republic of Iran, Israel, Italy, Latvia, Libya, Lithuania, Mexico, Netherlands, Norway, Oman, Paraguay, Poland, Portugal, Romania, Russian Federation, Saudi Arabia, Serbia, Slovakia, Slovenia, South Africa, Spain, Sweden, Switzerland, Thailand, Turkey, Ukraine, United Kingdom and United States of America. 9021 patients had JIA (10.7% systemic arthritis, 41.9% oligoarthritis, 23.5% RF negative polyarthritis, 4.2% RF positive polyarthritis, 3.4% psoriatic arthritis, 10.6% enthesitis-related arthritis and 5.7% undifferentiated arthritis) while 4822 were healthy children. This introductory paper describes the overall methodology; results pertaining to each country are fully described in the accompanying manuscripts. In conclusion, the JAMAR translations were found to have satisfactory psychometric properties and it is thus a reliable and valid tool for the multidimensional assessment of children with JIA.

The invisibilization of health promotion in Australian public health initiatives.

The field of health promotion has arguably shifted over the past thirty years from being socially proactive to biomedically defensive. In many countries this has been accompanied by a gradual decline, or in some cases the almost complete removal of health promotion designated positions within Government health departments. The language or discourse used to describe the practice and discipline of health promotion is reflective of such changes. In this study, critical discourse analysis was used to determine the representation of health promotion as a practice and a discipline within 10 Australian Government weight-related public health initiatives. The analysis revealed the invisibilization of critical health promotion in favour of an agenda described as 'preventive health'. This was achieved primarily through the textual practices of overlexicalization and lexical suppression. Excluding document titles, there were 437 uses of the terms health promotion, illness prevention, disease prevention, preventive health, preventative health in the documents analysed. The term 'health promotion' was used sparingly (16% of total terms), and in many instances was coupled with the term 'illness prevention'. Conversely, the terms 'preventive health' and 'preventative health' were used extensively, and primarily used alone. The progressive invisibilization of critical health promotion has implications for the perceptions and practice of those identifying as health promotion professionals and for people with whom we work to address the social and structural determinants of health and wellbeing. Language matters, and the language and intent of critical health promotion will struggle to survive if its speakers are professionally unidentifiable or invisible.

Photovoice Ethics: Critical Reflections From Men's Mental Health Research.

As photovoice continues to grow as a method for researching health and illness, there is a need for rigorous discussions about ethical considerations. In this article, we discuss three key ethical issues arising from a recent photovoice study investigating men's depression and suicide. The first issue, indelible images, details the complexity of consent and copyright when participant-produced photographs are shown at exhibitions and online where they can be copied and disseminated beyond the original scope of the research. The second issue, representation, explores the ethical implications that can arise when participants and others have discordant views about the deceased. The third, vicarious trauma, offers insights into the potenial for triggering mental health issues among researchers and viewers of the participant-produced photographs. Through a discussion of these ethical issues, we offer suggestions to guide the work of health researchers who use, or are considering the use of, photovoice.

Sequential allocation trial design in anesthesia: an introduction to methods, modeling, and clinical applications.

Estimation of the dose-response curve for new anesthetic protocols typically focuses on identifying minimum effective doses. The application of a sequential experimental method is appropriate, as it minimizes sample size requirements by updating dose assignments based on information accrued from successive subjects. One approach is the up-and-down method for estimating the median effective dose in a patient population (ED50 ). Designs better suited for achieving greater than 50% effectiveness, include the biased coin approach, and continual reassessment method. In this review we introduce different sequential design methods, provide examples of their use, and show through simulation how the method employed influences sample size and the accuracy of the estimated dose. Simulation studies are presented to illustrate the effects of dose parameter and stopping rule choice for up-and-down method and biased coin approach. For continual reassessment method, the effects of assumed dose-response model, prior guess, and cohort size are simulated. A binary response regression curve was fit to the data in Saidman and Eger's endtidal halothane dose-finding study to provide a dose-response curve for generating simulations. A range of options exist when designing a study using sequential allocation with biased coin approach or continual reassessment method. Method choice influences the required sample size and confidence in estimated effect. In the halothane example, up-and-down method decreases the required sample size by 20-30% when the choice of design parameters is optimal. For both up-and-down method and biased coin approach designs, greater sample sizes, arising from adjusted stopping criteria, might be required to achieve reliable estimates. The continual reassessment method is only efficient if a limited range of doses can be chosen a priori. In conclusion the up-and-down method can be more efficient than nonsequential designs for the estimation of the median dose/intervention level for a given intervention (ED50 ). The biased coin approach or continual reassessment method are preferred for the estimation of higher or lower tail quantiles such as ED90 or ED10 . Continual reassessment method may be superior if knowledge of the dose-response relationship is available for the drug of interest.