Using audit and feedback to increase clinician adherence to clinical practice guidelines in brain injury rehabilitation: v

ObjectiveThis study evaluated whether frequent (fortnightly) audit and feedback cycles over a sustained period of time (>12 months) increased clinician adherence to recommended guidelines in acquired brain injury rehabilitation.DesignA before and after study design.SettingA metropolitan inpatient brain injury rehabilitation unit.ParticipantsClinicians; medical, nursing and allied health staff.InterventionsFortnightly cycles of audit and feedback for 14 months. Each fortnight, medical file and observational audits were completed against 114 clinical indicators.Main outcome measureAdherence to guideline indicators before and after intervention, calculated by proportions, Mann-Whitney U and Chi square analysis.ResultsClinical and statistical significant improvements in median clinical indicator adherence were found immediately following the audit and feedback program from 38.8% (95% CI 34.3 to 44.4) to 83.6% (95% CI 81.8 to 88.5). Three months after cessation of the intervention, median adherence had decreased from 82.3% to 76.6% (95% CI 72.7 to 83.3, pConclusionA fortnightly audit and feedback program increased clinicians’ adherence to guideline recommendations in an inpatient acquired brain injury rehabilitation setting. We propose future studies build on the evidence-based method used in the present study to determine effectiveness and develop an implementation toolkit for scale-up.</div

Topology of amorphous tetrahedral semiconductors on intermediate lengthscales

Using the recently-proposed ``activation-relaxation technique'' for optimizing complex structures, we develop a structural model appropriate to a-GaAs which is almost free of odd-membered rings, i.e., wrong bonds, and possesses an almost perfect coordination of four. The model is found to be superior to structures obtained from much more computer-intensive tight-binding or quantum molecular-dynamics simulations. For the elemental system a-Si, where wrong bonds do not exist, the cost in elastic energy for removing odd-membered rings is such that the traditional continuous-random network is appropriate. Our study thus provides, for the first time, direct information on the nature of intermediate-range topology in amorphous tetrahedral semiconductors.Comment: 4 pages, Latex and 2 postscript figure

Understanding Why Some Whistleblowers are Venerated and Others Vilified

Whistleblowers are individuals who witness a moral infraction committed within their organization and report this infraction publicly to hold the group accountable. Whistleblowers often face ridicule, vilification, and exclusion both within their group and sometimes within broader society. Thus, whistleblowers put themselves at personal risk to adhere to their moral code and protect others; these criteria commonly classify someone as a hero. We argue diverse reactions to whistleblowers are influenced by numerous situational factors that influence perceptions of a whistleblower’s intentions as well as the expected consequences of their whistleblowing. Whether a whistleblower is viewed as a virtuous reformer (i.e., hero) or a harmful dissident may depend partly on the degree to which individuals believe that there is a discrepancy between an organization’s lived values and their stated values. While whistleblowers ostensibly provide evidence that this discrepancy exists, cognitive dissonance processes may forestall acceptance of this evidence in many cases. Believing that one is affiliated with a corrupt organization—while one also believes that they are a good, moral and adequate person—may lead to uncomfortable experiences of dissonance. It may be easier for many to reduce this dissonance by disparaging or discounting whistleblowers, rather than altering their own actions (which may involve becoming a whistleblower themselves) to reflect their personal values

Superconductivity in Fullerides

Experimental studies of superconductivity properties of fullerides are briefly reviewed. Theoretical calculations of the electron-phonon coupling, in particular for the intramolecular phonons, are discussed extensively. The calculations are compared with coupling constants deduced from a number of different experimental techniques. It is discussed why the A_3 C_60 are not Mott-Hubbard insulators, in spite of the large Coulomb interaction. Estimates of the Coulomb pseudopotential $\mu^*$, describing the effect of the Coulomb repulsion on the superconductivity, as well as possible electronic mechanisms for the superconductivity are reviewed. The calculation of various properties within the Migdal-Eliashberg theory and attempts to go beyond this theory are described.Comment: 33 pages, latex2e, revtex using rmp style, 15 figures, submitted to Review of Modern Physics, more information at http://radix2.mpi-stuttgart.mpg.de/fullerene/fullerene.htm

Narcissism and prosocial behavior

There are many motivations for prosocial behavior, some more altruistic and some more egoistic. We posit that more narcissistic people may perform prosocial acts strategically, for example, to improve their reputations or to receive something in return

Randomized, Noncomparative, Phase II Trial of Early Switch From Docetaxel to Cabazitaxel or Vice Versa, With Integrated Biomarker Analysis, in Men With Chemotherapy-Naïve, Metastatic, Castration-Resistant Prostate Cancer

Purpose The TAXYNERGY trial ( ClinicalTrials.gov identifier: NCT01718353) evaluated clinical benefit from early taxane switch and circulating tumor cell (CTC) biomarkers to interrogate mechanisms of sensitivity or resistance to taxanes in men with chemotherapy-naïve, metastatic, castration-resistant prostate cancer. Patients and Methods Patients were randomly assigned 2:1 to docetaxel or cabazitaxel. Men who did not achieve ≥ 30% prostate-specific antigen (PSA) decline by cycle 4 (C4) switched taxane. The primary clinical endpoint was confirmed ≥ 50% PSA decline versus historical control (TAX327). The primary biomarker endpoint was analysis of post-treatment CTCs to confirm the hypothesis that clinical response was associated with taxane drug-target engagement, evidenced by decreased percent androgen receptor nuclear localization (%ARNL) and increased microtubule bundling. Results Sixty-three patients were randomly assigned to docetaxel (n = 41) or cabazitaxel (n = 22); 44.4% received prior potent androgen receptor-targeted therapy. Overall, 35 patients (55.6%) had confirmed ≥ 50% PSA responses, exceeding the historical control rate of 45.4% (TAX327). Of 61 treated patients, 33 (54.1%) had ≥ 30% PSA declines by C4 and did not switch taxane, 15 patients (24.6%) who did not achieve ≥ 30% PSA declines by C4 switched taxane, and 13 patients (21.3%) discontinued therapy before or at C4. Of patients switching taxane, 46.7% subsequently achieved ≥ 50% PSA decrease. In 26 CTC-evaluable patients, taxane-induced decrease in %ARNL (cycle 1 day 1 v cycle 1 day 8) was associated with a higher rate of ≥ 50% PSA decrease at C4 ( P = .009). Median composite progression-free survival was 9.1 months (95% CI, 4.9 to 11.7 months); median overall survival was not reached at 14 months. Common grade 3 or 4 adverse events included fatigue (13.1%) and febrile neutropenia (11.5%). Conclusion The early taxane switch strategy was associated with improved PSA response rates versus TAX327. Taxane-induced shifts in %ARNL may serve as an early biomarker of clinical benefit in patients treated with taxanes

Secondary Science and Mathematics Teachers’ Environmental Issues Engagement through SocioScientific Reasoning

Among the many responsibilities of K-12 educators is to promote the development of environmental literacy among their students. Contentious environmental issues are often considered socioscientific issues (SSI; e.g., climate change) in that they are rooted in science, but a myriad of non-scientific (e.g., cultural, political, economic, etc.) factors must be addressed if those issues are to be successfully resolved. Teachers often report being ill-equipped to address these non-scientific factors, which may be due to struggles with employing socioscientific reasoning (SSR). SSR includes understanding the complexity of SSI, engaging in perspective-taking and ongoing inquiry about SSI, employing skepticism when dealing with potentially biased information concerning SSI, and recognizing the affordances of science and non-science considerations in resolving those issues. In this study, mathematics and science teachers who engaged in an SSI-oriented professional development demonstrated a range of sophistication across the dimensions of SSR, with science teachers tending to exhibit more sophistication in their SSR than mathematics teachers. Herein, we share and discuss the results of the study, including the prompts and scoring rubrics with exemplars, which can be used to prepare teachers to teach about contentious SSI and enable them to more effectively instruct and evaluate their students when doing so

Supporting at-risk older adults transitioning from hospital to home : Who benefits from an evidence-based patient-centered discharge planning intervention? Post-hoc analysis from a randomized trial

Background Subgroups of older patients experience difficulty performing activities of daily living (ADL) following hospital discharge, as well as unplanned hospital readmissions and emergency department (ED) presentations. We examine whether these subgroups of “at-risk” older patients benefit more than their counterparts from an evidence-based discharge planning intervention, on the following outcomes: (1) independence in ADL, (2) participation in life roles, (3) unplanned re-hospitalizations, and (4) ED presentations. Trial design and methods This study used data from a randomized control trial involving 400 hospitalized older patients with acute and medical conditions, recruited through 5 sites in Australia. Participants receive either HOME, a patient-centered discharge planning intervention led by an occupational therapist; or a structured in-hospital consultation. HOME uses a collaborative approach for goal setting and includes pre and post-discharge home visits as well as telephone follow-up. Characteristics associated with higher risks of adverse outcomes were recorded and at-risk subgroups were created (mild cognitive impairment, walking difficulty, comorbidity, living alone and no support from family). Independence in ADL and participation in life roles were assessed with validated questionnaires. The number of unplanned re-hospitalizations and ED presentations were extracted from medical files. Linear regression models were conducted to detect variation in response to the intervention at 3-months, according to patients’ characteristics. Results Analyses revealed significant interaction effects for intervention by cognitive status for unplanned re-hospitalization (p = 0.003) and ED presentations (p = 0.021) at 3 months. Within the at-risk subgroup of mild cognitively impaired, the HOME intervention significantly reduced unplanned hospitalizations (p = 0.027), but the effect did not reach significance in ED visits. While the effect of HOME differed according to support received from family for participation in life roles (p = 0.019), the participation observed in HOME patients with no support was not significantly improved. Conclusions Findings show that hospitalized older adults with mild cognitive impairment benefit from the HOME intervention, which involves preparation and post-discharge support in the environment, to reduce unplanned re-hospitalizations. Improved discharge outcomes in this at-risk subgroup following an occupational therapist-led intervention may enable best care delivery as patients transition from hospital to home. Trial registration The trial was registered before commencement (ACTRN12611000615987)

Activity, participation, and goal awareness after acquired brain injury : A prospective observational study of inpatient rehabilitation

Objective To examine the frequency and timing of inpatient engagement in meaningful activities within rehabilitation (within and outside of structured therapy times) and determine the associations between activity type, goal awareness, and patient affect. Methods This prospective observational study performed behavioral mapping in a 42-bed inpatient brain injury rehabilitation unit by recording patient activity every 15 minutes (total 42 hours). The participants were randomly selected rehabilitation inpatients with acquired brain injury; all completed the study. The main outcome measures included patient demographics, observation of activity, participation, goal awareness, and affect. Results The inpatients spent 61% of the therapeutic day (8:30 to 16:30) in their single room and were alone 49% of the time. They were physically socially inactive for 76% and 74% of their awake time, respectively, with neutral affect observed for about half of this time. Goal-related activities were recorded for only 25% of the inpatients’ awake time. The odds of physical activity were 10.3-fold higher among in patients receiving support to address their goals within their rehabilitation program (odds ratio=10.3; 95% confidence interval, 5.02–21.16). Conclusion Inpatients in a mixed brain injury rehabilitation unit spent a large amount of their awake hours inactive and only participated in goal-related activities for a quarter of their awake time. Rehabilitation models that increase opportunities for physical, cognitive, and social activities outside of allied health sessions are recommended to increase overall activity levels during inpatient rehabilitation

Study design and methods of the BoTULS trial: a randomised controlled trial to evaluate the clinical effect and cost effectiveness of treating upper limb spasticity due to stroke with botulinum toxin type A

Background Following a stroke, 55–75% of patients experience upper limb problems in the longer term. Upper limb spasticity may cause pain, deformity and reduced function, affecting mood and independence. Botulinum toxin is used increasingly to treat focal spasticity, but its impact on upper limb function after stroke is unclear. The aim of this study is to evaluate the clinical and cost effectiveness of botulinum toxin type A plus an upper limb therapy programme in the treatment of post stroke upper limb spasticity. Methods Trial design : A multi-centre open label parallel group randomised controlled trial and economic evaluation. Participants : Adults with upper limb spasticity at the shoulder, elbow, wrist or hand and reduced upper limb function due to stroke more than 1 month previously. Interventions : Botulinum toxin type A plus upper limb therapy (intervention group) or upper limb therapy alone (control group). Outcomes : Outcome assessments are undertaken at 1, 3 and 12 months. The primary outcome is upper limb function one month after study entry measured by the Action Research Arm Test (ARAT). Secondary outcomes include: spasticity (Modified Ashworth Scale); grip strength; dexterity (Nine Hole Peg Test); disability (Barthel Activities of Daily Living Index); quality of life (Stroke Impact Scale, Euroqol EQ-5D) and attainment of patient-selected goals (Canadian Occupational Performance Measure). Health and social services resource use, adverse events, use of other antispasticity treatments and patient views on the treatment will be compared. Participants are clinically reassessed at 3, 6 and 9 months to determine the need for repeat botulinum toxin type A and/or therapy. Randomisation : A web based central independent randomisation service. Blinding : Outcome assessments are undertaken by an assessor who is blinded to the randomisation group. Sample size : 332 participants provide 80% power to detect a 15% difference in treatment successes between intervention and control groups. Treatment success is defined as improvement of 3 points for those with a baseline ARAT of 0–3 and 6 points for those with ARAT of 4–56