Beyond linear mediation: Toward a dynamic network approach to study treatment processes

Few clinical scientists would disagree that more research is needed on the underlying mechanisms and processes of change in psychological therapies. In the dominant current approach, processes of change are studied through mediation. The study of mediation has been largely structured around a distinction between moderation and mediation first popularized by Baron and Kenny's (1986) seminal article, which is based on a nomothetic and cross-sectional framework. In this article, we argue that this approach is unable to adequately address change processes in psychological therapies, because it falsely assumes that treatment change is a linear, unidirectional, pauci-variate process and that the statistical assumptions are met to study processes of change in an individual using a nomothetic approach. In contrast, we propose that treatment is a dynamic process involving numerous variables that may form bi-directional and complex relationships that differ between individuals. Such relationships can best be studied using an individual dynamic network approach connected to nomothetic generalization methods that are based on a firm idiographic foundation. We argue that our proposal is available, viable, and can readily be integrated into existing research strategies. We further argue that adopting an individual dynamic network approach combined with experimental analyses will accelerate the study of treatment change processes, which is necessary as the field of evidence-based care moves toward a process-based model. We encourage future research to gather empirical evidence to examine this approach.

Evaluation of the cross-sectional area of acromion process for shoulder impingement syndrome

Background

Anatomic changes in the acromion have been considered a main cause of shoulder impingement syndrome (SIS). To evaluate the relationship between SIS and the acromion process, we devised a new morphological parameter called the acromion process cross-sectional area (APA). We hypothesized that the APA could be an important morphologic diagnostic parameter in SIS.

Methods

We collected APA data from 95 patients with SIS and 126 control subjects who underwent shoulder magnetic resonance imaging (MRI). Then we measured the maximal cross-sectional area of the bone margin of the acromion process on MRI scans.

Results

The mean of APAs were 136.50 ± 21.75 mm² in the male control group and 202.91 ± 31.78 mm² in the male SIS group; SIS patients had significantly greater APAs (P < 0.001). The average of APAs were 105.38 ± 19.07 mm² in the female control group and 147.62 ± 22.90 mm² in the female SIS group, and the SIS patients had significantly greater APAs (P < 0.001). The optimal APA cut-off in the male group was 165.14 mm² with 90.2% sensitivity, 91.4% specificity, and an area under the curve (AUC) of 0.968. In the female group, the optimal cut-off was 122.50 mm² with 85.2% sensitivity, 84.9% specificity, and an AUC of 0.928.

Conclusions

The newly devised APA is a sensitive parameter for assessing SIS; greater APA is associated with a higher possibility of SIS. We think that this result will be helpful for the diagnosis of SIS.

Process evaluation of the community-based newborn care program implementation in Geze Gofa district, south Ethiopia: a case study evaluation design

Background

The Community-Based Newborn Care (CBNC) program is a comprehensive strategy designed to improve the health of newborns during pregnancy, childbirth, and the postnatal period through health extension workers at community levels, although the implementation has not been evaluated yet. Therefore, this study aimed to evaluate the process of the CBNC program implementation in Geze Gofa district, south Ethiopia.

Methods

A case study evaluation design with a mixed method was employed from May 1 to 31, 2017. A total of 321 mothers who gave birth from September 01, 2016 to February 29, 2017, were interviewed. Similarly, 27 direct observations, six-month document reviews, and 14 key informant interviews were conducted. The quantitative data were entered into Epi-Data version 3.1 and exported to SPSS version 20 for analysis. In the multivariable logistic regression analysis, variables with < 0.05 p-values and Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were used to declare factors associated with maternal satisfaction. The qualitative data were transcribed, translated, coded, and analyzed using thematic analysis. The overall process of program implementation was measured based on pre-determined judgmental criteria.

Results

The overall level of the implementation process of the CBNC program was 72.7%, to which maternal satisfaction, availability of resources, and healthcare providers’ compliance with the national guideline contributed 75.0, 81.0, and 68.0%, respectively. Essential drugs and medical equipment, like vitamin K, chlorohexidine ointment, neonatal resuscitation bags, and masks used in the program were out of stock. Very severe diseases were not treated according to the national guidelines, and the identification of neonatal sepsis cases was poor. Trading occupation (AOR: 0.16, 95% CI: 0.03–0.97) and low wealth status (AOR: 3.11, 95% CI: 1.16–8.36) were factors associated with maternal satisfaction.

Conclusion

The process of CBNC program implementation was relatively good, although the compliance of healthcare providers with the national guideline and maternal satisfaction with the services was low. Some essential drugs and medical equipment were out of stock. Merchant and low wealth status affected maternal satisfaction. Therefore, healthcare offices should provide crucial medicines and equipment for better program implementation and improve the wealth status of mothers to enhance maternal satisfaction.

Dynamic Systems, Process and Development

In this article, I answer the questions from Witherington and Boom's introduction to this special issue in the form of an imaginary interview, led by David Boom, equally imaginary editor of The Processual Inquirer, an obscure but interesting journal that appears in imaginary physical print only, and which, as a consequence, has so far left no traces on the Internet….

The Relationship of Forgiveness and Values with Meaning in Life of Polish Students

The purpose of this article was to show the relationship of terminal values and forgiveness with meaning in life in Polish students who consider themselves faithful and practicing. The study involved youth studying at the Jesuit University Ignatianum in Krakow. It was carried out among 368 students. The age of the participants ranged between 19 and 23. Three tools were applied: Rokeach Value Survey, Forgiveness Scale by Toussaint, and the Purpose in Life Test of Crumbaugh and Maholick. The analysis of the results obtained proves that terminal values and forgiveness have a statistically significant relationship with meaning in the life of the studying youth.

Updates on the Facilities, Procedures, and Performance of the Accredited Endoscopy Unit

Endoscopic quality indicators can be classified into three categories, namely facilities and equipment, endoscopic procedures, and outcome measures. In 2019, the Korean Society of Gastrointestinal Endoscopy updated the accreditation of qualified endoscopy unit assessment items for these quality indicators to establish competence and define areas of continuous quality improvement.

Here, we presented the updated program guidelines on the facilities, procedures, and performance of the accredited endoscopy unit. Many of these items have not yet been validated. However, the updated program will help in establishing competence and defining areas of continuous quality improvement in Korean endoscopic practice.

Development and testing of locally-produced ready-to-use therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: lessons learned

Background

Rates of childhood undernutrition are persistently high in Cambodia. Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness. Therefore, our project developed and trialled a locally-produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) with therapeutic and supplementary versions. This ready-to-use food (RUF) is innovative in that, unlike many RUFs, it contains fish instead of milk. Development began in 2013 and the RUF was finalised in 2015. From 2015 until the present, both the RUTF and the RUSF versions were trialled for acceptability and effectiveness.

Methods

This paper draws on project implementation records and semi-structured interviews to describe the partnership between the Cambodian Ministries of Health and Agriculture, Forestry and Fisheries, UNICEF, the French National Research Institute for Sustainable Development (IRD), universities, and Vissot factory. It discusses the project implementation and lessons learned from the development and trialling process, and insights into positioning nutrition on the health agenda in low and middle-income countries.

Results

The lessons learned relate to the importance of project planning, management, and documentation in order to seize opportunities in the research, policy, advocacy, and programming environment while ensuring adequate day-to-day project administration and resourcing.

Conclusions

We conclude that projects such as ours, that collaborate to develop and test novel, locally-produced RUTFs and RUSFs, offer an exciting opportunity to respond to both local programmatic and broader research needs.

The induction and maintenance of in vitro plant morphogenesis as viewed from a new perspective, with theoretical and constructive implications

In plant tissue culture research, the non-traditional growth regulators, methylglyoxal and ascorbic acid, have been used to induce and promote in vitro morphogenesis from plant callus, generally having the initial characteristics of a type of neoplasm, and in many cases overcoming recalcitrant morphogenesis. In other investigations methylglyoxal, most likely with ascorbic acid, also promoted such morphogenesis. In the various investigations, low concentrations of methylglyoxal were used and proved to be the most effective in promoting in vitro morphogenesis. In many cases, the growth of such neoplastic-like calli was concurrently inhibited on culture media containing these chemicals. When methylglyoxal was present in high concentration, morphogenesis was also inhibited. Such chemicals, it would appear likely, allowed for the generation of cohesive forces within regions of the calli, reversing the neoplastic state in such regions, due to very low internal cohesion, and through such cohesive forces of particular magnitude, morphogenesis ensued, as an adaptive response to the stress of such cohesive forces. This would suggest a deeper, underlying biological process, with developmental features, that is perhaps universal among plants and perhaps in all biological organisms. This particular, consistent avenue and theme of plant tissue culture research, manifested over four decades and across four continents, may have revealed a unifying, dynamical process in both the biological and physical worlds, with constructive implications for agriculture and medicine.

Science and art of protein formulation development

Protein pharmaceuticals have become a significant class of marketed drug products and are expected to grow steadily over the next decade. Development of a commercial protein product is, however, a rather complex process. A critical step in this process is formulation development, enabling the final product configuration. A number of challenges still exist in the formulation development process. This review is intended to discuss these challenges, to illustrate the basic formulation development processes, and to compare the options and strategies in practical formulation development.

'Never drop without your significant other, cause that way lies ruin': The boundary work of couples who use MDMA together

MDMA has a variety of pro-social effects, such as increased friendliness and heightened empathy, yet there is a distinct lack of research examining how these effects might intertwine with a romantic relationship. This article seeks to compensate for this absence and explore heterosexual couples' use of MDMA through the lens of the boundaries they construct around these experiences. Three couple interviews, two diary interviews and eight written diaries about couples' MDMA practices were analysed. Douglas' (2001) and Stenner's (2013) work around order, disorder and what lies at the threshold between the two are employed here. This conceptual approach allows us to see what happens at the border of MDMA experiences as crucial to their constitution. Two main themes are identified in the data. First, MDMA use was boundaried from daily life both temporally and corporeally: the drug was tied to particular times in people's lives as well as the performance of rituals which engaged the material world and reenchanted everyday spaces and selves. Secondly, other people are excluded from MDMA experiences to varying degrees in order to preserve the emotionally intense space for the couple alone. This paper claims that MDMA use forms part of a spectrum of relationship 'work' practices; a unique kind of 'date night' that revitalises couples' connection. Hence, MDMA should be recognised as transforming couple as well as individual practices. Finally, it is suggested that harm reduction initiatives could distinguish more 'messy' forms of emotional harm and engage with users' language of 'specialness' to limit negative impacts of MDMA use.

Management of medical care, a fundamental tool for resident doctors

In the area of medical education, and particularly in our country, medical residencies are the best educational programs for a graduated physicians; however, when young medical doctors begin a residence at hospitals, they hardly possess knowledge about the way medical services work as well as the processes they involve, which directly affects the fulfillment of their tasks, their process of learning and more importantly, it interferes in the services provided by the hospital. Therefore, it is imperative to immerse residents in the management of medical care and let them know that its main function is to harmoniously articulate every medical-administrative process related to patients as well as human, material and financial resources. One of the main goals is to achieve the fulfillment of the hospital's mission and vision with operational efficiency and humanism. This path will help physicians to make the best decisions, as well as achieving an adequate management of resources always remembering that quality in medical services and patient's safety are important.

14-3-3 Proteins: a window for a deeper understanding of fungal metabolism and development

Isoforms of 14-3-3 proteins, similar to their highly conserved homologs in mammals and plants, are both transcriptionally and functionally affected by their extracellular and intracellular environments. These proteins bind to phosphorylated client proteins to modulate their functions in fungi. Since phosphorylation regulates a plethora of different physiological responses in organisms, 14-3-3 proteins play roles in multiple physiological functions, including those controlling metabolisms, cell division, and responses to environmental stimulation. These proteins could also modulate signaling pathways that transduce inputs from the environment and downstream proteins that elicit physiological responses. Increasing evidence supports a prominent role for 14-3-3 proteins in regulating development and metabolism at various levels. In this review, we first provide a brief summary of the molecular structure of 14-3-3 proteins. Second, we discuss the potential roles of 14-3-3 proteins in the regulation of development and metabolism. Third, we review the roles of 14-3-3 proteins in the regulation of their binding partners, including receptors, protein kinases, and some protein kinase substrates. Finally, this review examines recent advances that further elucidate the role of 14-3-3 proteins in signaling transduction in response to environmental stress.

Measuring patient and family perceptions of team processes and outcomes in healthcare teams: questionnaire development and psychometric evaluation

BACKGROUND

There is a lack of validated instruments examining dimensions of team functioning from the perspective of patients and families consistent with a conceptual framework. The study aimed to develop and assess the psychometric properties of the Patient-Perceptions of Team Effectiveness (PTE) questionnaire.

METHODS

A cross-sectional survey was undertaken in three studies. Data were collected from May-October 2016 for Study 1, April 2018-ongoing for Study 2, and October 2016 to June 2017 for Study 3. Online and paper versions of the self-administered questionnaire were available in English and in French. The initial questionnaire included 41 items. Study 1 included 320 respondents. Reliability was assessed using Cronbach alpha. Face validity (n = 250) was assessed using a structured questionnaire. Content validity was examined using subject matter experts and Spearman's item-total correlations. Construct validity was examined using known group comparisons (i.e., clinical specialty, education, length of follow-up, reason of consultation). Content analysis was used for open-ended questions.

RESULTS

The questionnaire took 10 to 15 min to complete. Positive assessments were noted for instructions, formatting, font size and logical ordering of questions. In Study 1, reliability indices for the PTE-Overall, Team Processes and Outcomes subscales ranged from 0.72 to 0.84. Item-total correlations ranged from 0.551 to 0.794 (p <  0.001). Differences were noted between clinical specialties, education, length of follow-up, reason of consultation, low and high functioning teams. No differences were noted between English and French language respondents. Psychometric properties were re-assessed in Study 2 and 3 after unclear questions were reworked. Reliability indices for the subscales ranged from 0.76 to 0.94 and differences remained significant between low and high functioning teams.

CONCLUSION

The final 43-item instrument is easy to administer to patients and families. The studies provide evidence of validity to support the propositions in the conceptual framework. The patient-level measures can be aggregated to the team, organizational or system level. The information can be used to assess healthcare team functioning in acute and primary care and determine the role patients and families are playing in teams. Further testing is needed with patients and families who are hospitalized or receiving care from teams in rural areas.

Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods

A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1–5 scale).

Results

In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5).

Conclusion

This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0842-6) contains supplementary material, which is available to authorized users.

Pathway to Electroconvulsive Treatment for Minors

The decision-making process of prescribing electroconvulsive treatment (ECT) to minors often extends outside of medicine. The legal arena is commonly involved in many jurisdictions, and some states have legislation governing the administration of this treatment in addition to hospital policies and regulations. Treatment failures, additional opinions, explicit consent, and legal tribunals are sometimes needed to deliver ECT to a minor in need. This article describes a process to which a provider can refer in navigating this confusing, and sometimes alien, pathway to provide ECT to his or her patient. Individual state statutes pertaining to ECT are provided.

How to execute Context, Input, Process, and Product evaluation model in medical health education

Improvements to education are necessary in order to keep up with the education requirements of today. The Context, Input, Process, and Product (CIPP) evaluation model was created for the decision-making towards education improvement, so this model is appropriate in this regard. However, application of this model in the actual context of medical health education is considered difficult in the education environment. Thus, in this study, literature survey of previous studies was investigated to examine the execution procedure of how the CIPP model can be actually applied. For the execution procedure utilizing the CIPP model, the criteria and indicators were determined from analysis results and material was collected after setting the material collection method. Afterwards, the collected material was analyzed for each CIPP element, and finally, the relationship of each CIPP element was analyzed for the final improvement decision-making. In this study, these steps were followed and the methods employed in previous studies were organized. Particularly, the process of determining the criteria and indicators was important and required a significant effort. Literature survey was carried out to analyze the most widely used criteria through content analysis and obtained a total of 12 criteria. Additional emphasis is necessary in the importance of the criteria selection for the actual application of the CIPP model. Also, a diverse range of information can be obtained through qualitative as well as quantitative methods. Above all, since the CIPP evaluation model execution result becomes the basis for the execution of further improved evaluations, the first attempt of performing without hesitation is essential.

Processes, practices and influence: a mixed methods study of public health contributions to alcohol licensing in local government

BACKGROUND

Public health in England has opportunities to reduce alcohol-related harms via shaping the availability and accessibility of alcohol through the licensing function in local government. While the constraints of licensing legislation have been recognised, what is currently little understood are the day-to-day realities of how public health practitioners enact the licensing role, and how they can influence the local alcohol environment.

METHODS

To address this, a mixed-methods study was conducted across 24 local authorities in Greater London between 2016 and 17. Data collection involved ethnographic observation of public health practitioners' alcohol licensing work (in eight local authorities); a survey of public health practitioners (n = 18); interviews with licensing stakeholders (n = 10); and analysis of public health licensing data from five local authorities. Fieldnotes and interview transcripts were analysed thematically, and quantitative data were analysed using descriptive statistics.

RESULTS

Results indicated that some public health teams struggle to justify the resources required to engage with licensing processes when they perceive little capacity to influence licensing decisions. Other public health teams consider the licensing role as important for shaping the local alcohol environment, and also as a strategic approach for positioning public health within the council. Practitioners use different processes to assess the potential risks of licence applications but also the potential strengths of their objections, to determine when and how actions should be taken. Identifying the direct influence of public health on individual licences is challenging, but the study revealed how practitioners did achieve some level of impact, for example through negotiation with applicants.

CONCLUSIONS

This study shows public health impact following alcohol licensing work is difficult to measure in terms of reducing alcohol-related harms, which poses challenges for justifying this work amid resource constraints. However, there is potential added value of the licensing role in strategic positioning of public health in local government to influence broader determinants of health.

Management of medical care, a fundamental tool for resident doctors

In the area of medical education, and particularly in our country, medical residencies are the best educational programs for a graduated physicians; however, when young medical doctors begin a residence at hospitals, they hardly poses knowledge about the way medical services work as well as the processes they involve, which directly affects the fulfillment of their tasks, their process of learning and more importantly, it interferes in the services provided by the hospital. Therefore, it is imperative to immerse residents in the management of medical care and let them know that its main function is to harmoniously articulate every medical-administrative process related to patients as well as human, material and financial resources. One of the main goals is to achieve the fulfillment of the hospital's mission and vision with operational efficiency and humanism. This path will help physicians to make the best decisions, as well as achieving an adequate management of resources always remembering that quality in medical services and patient's safety are important.

Development of a positron emission tomography risks map

Patient safety is an essential component of quality of care, especially when the complexity of care has reached extreme levels. Currently achieving this safety is considered a basic strategy of the National Health System. Nuclear Medicine departments have certain peculiarities that make them special in terms of patient safety, with situations that go beyond the common healthcare practice of other departments. Namely, that both encapsulated and non-encapsulated ionizing radiation is used in daily practice, and numerous groups of professionals must be coordinated to undertake positron emission tomography (PET) specifically, from the clinical management unit itself, and from other departments of the hospital (as well as companies outside the hospital itself and the Public Health System). The objective of this paper was to identify the risks to which a patient who is to be explored through PET can be exposed in a Nuclear Medicine department and draw up a risk map for the PET process. The methodology used is part of the proposal of the Ministry of Health (2007), and its practical implementation (given the limited literature available on Nuclear Medicine), follows as far as possible that of related care areas (radiodiagnosis and radiotherapy). For this purpose, a multidisciplinary team of professionals directly related to the PET process was created, using the modal analysis of faults and effects methodology to identify possible failures, their causes and the potential adverse events causing each. As a final step, a risk map was created, locating the previously identified faults at each stage of the process. This paper exposes the PET process, and describes the risks that patients might run when a PET scan is required, as well as the adverse events deriving from it. All this is shown in a risk map of the PET process.

People with lived experience (PWLE) of depression: describing and reflecting on an explicit patient engagement process within depression research priority setting in Alberta, Canada

PLAIN ENGLISH SUMMARY

The Alberta Depression Research Priority Setting Project aimed to meaningfully involve patients, families and clinicians in determining a research agenda aligned to the needs of Albertans who have experienced depression. The project was modeled after a process developed in the UK by the James Lind Alliance and adapted to fit the Alberta, Canada context. This study describes the processes used to ensure the voices of people with lived experience of depression were integrated throughout the project stages. The year long project culminated with a facilitated session to identify the top essential areas of depression research focus. People with lived experience were engaged as part of the project's Steering Committee, as survey participants and as workshop participants. It is hoped this process will guide future priority setting opportunities and advance depression research in Alberta.

ABSTRACT

Background The Depression Research Priority Setting (DRPS) project has the clear aim of describing the patient engagement process used to identify depression research priorities and to reflect on the successes of this engagement approach, positive impacts and opportunities for improvement. To help support patient-oriented depression research priority setting in Alberta, the Patient Engagement (PE) Platform of the Alberta Strategy for Patient Oriented Research Support for People and Patient-Oriented Research and Trials (SUPPORT) Unit designed, along with the support of their partners in addictions and mental health, an explit process to engage patients in the design and execution of the DRPS. Methods The UK's James Lind Alliance (JLA) Priority Setting Partnership (PSP) method was adapted into a six step process to ensure voices of "people with lived experience" (PWLE) with depression were included throughout the project stages. This study uses an explicit and parallel patient engagement process throughout each estage of the PSP designed by the PE Platform. Patient engagement was divided into a five step process: i) Awareness and relationship building; ii) Co-designing and co-developing a shared decision making process; iii) Collaborative communication; iv) Collective sensemaking; and v) Acknowledgement, celebration and recognition. A formative evaluation of the six PE processes was undertaken to explore the success of the parallel patient engagement process. Results This project was successful in engaging people with lived depression experience as partners in research priority setting, incorporating their voices into the discussions and decisions that led to the top 25 depression research questions. Conclusions The DRPS project has positively contributed to depression research in Canada by identifying the priorities of Albertans who have experienced depression for depression research. Dissemination activities to promote further knowledge exchange of prioritized research questions, with emphasis on the importance of process in engaging the voices of PWLE of depression are planned.

Do I focus on the process of cycling or try to put my mind elsewhere? A comparison of concentration strategies for use in pacing by novice riders

The ability to hold a pace is a key skill for endurance athletes. The present study compared the influence of different strategies on how athletes learn to pace at 80% of their maximum performance for a 3-min cycle time trial. Participants first completed three maximal 3-min tests to establish maximal performance. During subsequent visits we asked participants to ride at 80% of their average maximal 3-min power output for four 3-min efforts under different conditions. Participants were blinded to feedback for three of the four conditions with participants (a) riding on feel (all feedback blinded), (b) associating on the task by focusing attention on the skills needed for efficient cycling, and (c) dissociating from the task by intentionally focusing concentration elsewhere (d) and finally, participants rode with full feedback where pace could be regulated via observation. All participants completed the blind condition first, the full feedback condition last, with association focus and dissociation focus rides being alternated. As expected, results showed participants rode close to the 80% goal when observing full feedback. Participants rode at 82% of maximum in the blind "ride on feel" condition, 79% in the associative condition, and 70% in the dissociative condition. We suggest results show that simple strategies related to concentration can influence the accuracy of pacing efforts. The difference in the ability to pace while using an associative or dissociative attentional focus was consistent with theory. The differences we observed occurred with minimal input from participants in terms of actively learning psychological skills. Future research is needed to investigate how athletes learn to use pacing strategies to help performance.

Philosophy of nature and organism's autonomy: on Hegel, Plessner and Jonas' theories of living beings

Following the revival in the last decades of the concept of "organism", scholarly literature in philosophy of science has shown growing historical interest in the theory of Immanuel Kant, one of the "fathers" of the concept of self-organisation. Yet some recent theoretical developments suggest that self-organisation alone cannot fully account for the all-important dimension of autonomy of the living. Autonomy appears to also have a genuine "interactive" dimension, which concerns the organism's functional interactions with the environment and does not simply derive from its internal organisation. Against this background, we focus on a family of natural philosophical approaches that historically have already strongly taken in account this aspect of autonomy, notably going beyond Kant's perspective on self-organisation. We thus review Hegel, Plessner, and Jonas' different perspectives on living beings, focussing in particular on four points: the distinction between organic and inorganic, the theory of biological organisation, the processuality of the living, and the "boundary" between inside and outside, through which the organism establishes its relationship to the environment. We, then, compare the three perspectives on these four points, and finally address the question of what advantages their contribution present-especially compared to Kant's theory-with respect to the topic of organism's autonomy. This could help-we hope-to better understand what is at the stake still today.

Existing evidence summarization methods cannot guarantee trustworthy patient decision aids

OBJECTIVES

Our aim was to evaluate how organizations that develop patient decision aids conduct their evidence summarization process and assess whether their current processes provide sufficient information to instill confidence that patient decision aids are trustworthy and up to date.

STUDY DESIGN AND SETTING

We identified 23 organizations from a public inventory of patient decision aid developers and included only organizations that have produced five or more tools. These organizations were asked to complete a 17-item survey and to share relevant documents.

RESULTS

Of the 23 organizations, 18 completed the survey, and 15 were eligible for analysis. Most organizations reported using existing systematic reviews and clinical practice guidelines. Seven of 15 had a documented approach for summarizing evidence, but the documents offered varying levels of detail. Common steps identified are tool-relevant question formation, search strategies, evidence appraisals, and updating policies.

CONCLUSIONS

Organizations do not use a standardized process to summarize evidence for the patient decision aids that they develop. This is problematic, given that the information they contain is known to influence patients' decisions. Further attention to how organizations summarize evidence for these tools is required.

Key Elements of a Family Intervention for Schizophrenia: A Qualitative Analysis of an RCT

Schizophrenia is a complex biopsychosocial condition in which expressed emotion in family members is a robust predictor of relapse. Not surprisingly, family interventions are remarkably effective and thus recommended in current treatment guidelines. Their key elements seem to be common therapeutic factors, followed by education and coping skills training. However, few studies have explored these key elements and the process of the intervention itself. We conducted a qualitative and quantitative analysis of the records from a pioneering family intervention trial addressing expressed emotion, published by Leff and colleagues four decades ago. Records were analyzed into categories and data explored using descriptive statistics. This was complemented by a narrative evaluation using an inductive approach based on emotional markers and markers of change. The most used strategies in the intervention were addressing needs, followed by coping skills enhancement, advice, and emotional support. Dealing with overinvolvement and reframing were the next most frequent. Single-family home sessions seemed to augment the therapeutic work conducted in family groups. Overall the intervention seemed to promote cognitive and emotional change in the participants, and therapists were sensitive to the emotional trajectory of each subject. On the basis of our findings, we developed a longitudinal framework for better understanding the process of this treatment approach.

Handover in Intensive Care

Handover is a frequent and complex task that also implies the transfer of the responsibility of the care. The deficiencies in this process are associated with important gaps in clinical safety and also in patient and professional dissatisfaction, as well as increasing health cost. Efforts to standardize this process have increased in recent years, appearing numerous mnemonic tools. Despite this, local are heterogeneous and the level of training in this area is low. The purpose of this review is to highlight the importance of IT while providing a methodological structure that favors effective IT in ICU, reducing the risk associated with this process. Specifically, this document refers to the handover that is established during shift changes or nursing shifts, during the transfer of patients to other diagnostic and therapeutic areas, and to discharge from the ICU. Emergency situations and the potential participation of patients and relatives are also considered. Formulas for measuring quality are finally proposed and potential improvements are mentioned especially in the field of training.