Evaluating the appropriateness of elective surgery: The case of spinal fusion (arthrodesis)

Introduction Appropriateness is an essential element of quality of care. Several methods and tools have been developed to measure the appropriateness of care, however, none of these could be used to systematically support providers in keeping the appropriateness under control. Our study aimed to develop a framework to evaluate the appropriateness of care that took into account four dimensions of appropriateness: clinical dimension, equity, service delivery model, outcome. Methods We employed mixed-method approaches. These included a retrospective analysis of administrative data collected from Kinetika Sardinia (Italy) and a qualitative analysis of stakeholders’ experiences and perspectives aimed at supporting data collection, identification of improvement actions and definition of performance indicators. We used arthrodesis as a paradigmatic example of potentially inappropriate elective surgery. Results We collected data from 2,584 patients that underwent arthrodesis between January 1, 2010 and April 30, 2015. Based on the analysis and the exchanges with professionals, we identified 11 improvement actions. Monitoring and evaluation actions were finally conducted for 171 patients that underwent spinal fusion during the first semester of 2016 in order to assess if the improvement actions identified were put into practice and acquired desirable outcomes. Conclusions Our work provides a definition of appropriateness that goes beyond the clinical perspective and includes other perspectives (equity, service delivery and outcome); develops a framework and an approach that can be a valid help to systematically assess the appropriateness of elective surgery, adopt improvement actions, and monitor their impact; discusses what are the competencies necessary for measuring the appropriateness.

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Off-Shell Noether Currents and Potentials for First-Order General Relativity

Symmetry ◽

10.3390/sym13020348 ◽

2021 ◽

Vol 13 (2) ◽

pp. 348

Author(s):

Merced Montesinos ◽

Diego Gonzalez ◽

Rodrigo Romero ◽

Mariano Celada

Keyword(s):

General Relativity ◽

Vector Fields ◽

Killing Vector ◽

Spherically Symmetric ◽

Killing Vector Fields ◽

Arbitrary Vector ◽

Four Dimensions ◽

First Order ◽

Direct Form ◽

Definition Of

We report off-shell Noether currents obtained from off-shell Noether potentials for first-order general relativity described by n-dimensional Palatini and Holst Lagrangians including the cosmological constant. These off-shell currents and potentials are achieved by using the corresponding Lagrangian and the off-shell Noether identities satisfied by diffeomorphisms generated by arbitrary vector fields, local SO(n) or SO(n−1,1) transformations, ‘improved diffeomorphisms’, and the ‘generalization of local translations’ of the orthonormal frame and the connection. A remarkable aspect of our approach is that we do not use Noether’s theorem in its direct form. By construction, the currents are off-shell conserved and lead naturally to the definition of off-shell Noether charges. We also study what we call the ‘half off-shell’ case for both Palatini and Holst Lagrangians. In particular, we find that the resulting diffeomorphism and local SO(3,1) or SO(4) off-shell Noether currents and potentials for the Holst Lagrangian generically depend on the Immirzi parameter, which holds even in the ‘half off-shell’ and on-shell cases. We also study Killing vector fields in the ‘half off-shell’ and on-shell cases. The current theoretical framework is illustrated for the ‘half off-shell’ case in static spherically symmetric and Friedmann–Lemaitre–Robertson–Walker spacetimes in four dimensions.

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Definition of essential sequences and functional equivalence of elements downstream of the adenovirus E2A and the early simian virus 40 polyadenylation sites.

Molecular and Cellular Biology ◽

10.1128/mcb.5.11.2975 ◽

1985 ◽

Vol 5 (11) ◽

pp. 2975-2983 ◽

Cited By ~ 37

Author(s):

R P Hart ◽

M A McDevitt ◽

H Ali ◽

J R Nevins

Keyword(s):

Essential Element ◽

Simian Virus 40 ◽

Simian Virus ◽

Cleavage Sites ◽

Multiple Sequence ◽

Polyadenylic Acid ◽

Sequence Elements ◽

Cleavage And Polyadenylation ◽

Definition Of ◽

A Site

In addition to the highly conserved AATAAA sequence, there is a requirement for specific sequences downstream of polyadenylic acid [poly(A)] cleavage sites to generate correct mRNA 3' termini. Previous experiments demonstrated that 35 nucleotides downstream of the E2A poly(A) site were sufficient but 20 nucleotides were not. The construction and assay of bidirectional deletion mutants in the adenovirus E2A poly(A) site indicates that there may be redundant multiple sequence elements that affect poly(A) site usage. Sequences between the poly(A) site and 31 nucleotides downstream were not essential for efficient cleavage. Further deletion downstream (3' to +31) abolished efficient cleavage in certain constructions but not all. Between +20 and +38 the sequence T(A/G)TTTTT was duplicated. Function was retained when one copy of the sequence was present, suggesting that this sequence represents an essential element. There may also be additional sequences distal to +43 that can function. To establish common features of poly(A) sites, we also analyzed the early simian virus 40 (SV40) poly(A) site for essential sequences. An SV40 poly(A) site deletion that retained 18 nucleotides downstream of the cleavage site was fully functional while one that retained 5 nucleotides downstream was not, thus defining sequences required for cleavage. Comparison of the SV40 sequences with those from E2A did not reveal significant homologies. Nevertheless, normal cleavage and polyadenylation could be restored at the early SV40 poly(A) site by the addition of downstream sequences from the adenovirus E2A poly(A) site to the SV40 +5 mutant. The same sequences that were required in the E2A site for efficient cleavage also restored activity to the SV40 poly(A) site.

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Measuring business schools’ service quality in an emerging market using an extended SERVQUAL instrument

South African Journal of Business Management ◽

10.4102/sajbm.v47i1.53 ◽

2016 ◽

Vol 47 (1) ◽

pp. 61-74 ◽

Cited By ~ 4

Author(s):

E. R. Mbise ◽

R. S.J. Tuninga

Keyword(s):

Service Quality ◽

Service Delivery ◽

Market Economy ◽

Business Schools ◽

Emerging Market ◽

Student Experiences ◽

Level Of Service ◽

Improve Quality ◽

Four Dimensions ◽

Scarce Resources

An extended SERVQUAL instrument is developed, validated and used to measure perceived service quality delivered to students by business schools in an emerging market economy. A longitudinal survey is conducted with selected students in their final year of study from two business schools in an emerging market economy. The use of the extended SERVQUAL model is suggested to monitor student/employee expectations and perceptions during and after the education service delivery process. Students attach different weights to the service quality dimensions. A new Process Outcome dimension is found to substantially add to the SERVQUAL model and is more important than the other dimensions. The validity of the extended SERVQUAL model for practical use is α >0.95. Prediction of the level of service quality delivered, using four dimensions, indicates that the level of service quality is explained mostly by Process Outcome and Tangibles dimensions. It is suggested that using the extended SERVQUAL model as a tool can enable managers of business schools to identify the factors on which students/employees base their quality assessment of the education services they receive. Knowledge of these factors will enable managers in emerging economies to periodically assess, sustain and improve quality of the whole service delivery process. Priorities can be set to allocate scarce resources properly to make effective investment decisions to improve quality per school and in higher education, in general. The paper further suggests that regulatory bodies make use of this model when comparing performance of business schools, focusing on student experiences as a supplement to the traditional performance measures.

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Does It Pay to Be Real? Understanding Authenticity in TV Advertising

Journal of Marketing ◽

10.1177/0022242918815880 ◽

2018 ◽

Vol 83 (1) ◽

pp. 24-50 ◽

Cited By ~ 15

Author(s):

Maren Becker ◽

Nico Wiegand ◽

Werner J. Reinartz

Keyword(s):

Consumer Behavior ◽

Essential Element ◽

Purchase Decisions ◽

Four Dimensions ◽

Advertising Context ◽

Hedonic Products ◽

Hedonic And Utilitarian Products ◽

The Impact ◽

Common Understanding ◽

Positive Effect

Marketing managers and creatives alike believe that authenticity is an essential element for effective advertising. However, no common understanding of authenticity in advertising exists, and empirical knowledge about its impact on consumer behavior is limited. In this study, the authors use a comprehensive literature review and qualitative studies to identify four dimensions of authenticity in an advertising context. By examining 323 television ads across 67 brands and four years, they investigate these dimensions’ effects on the sales performance of advertised products. Because the impact of authenticity may depend on brand or product characteristics, the authors also analyze how these effects vary with brand size or across hedonic and utilitarian products. The results suggest that authenticity influences consumer behavior in a more nuanced manner than previously recognized. For instance, whereas an ad congruent with the brand’s essence has a positive effect on sales in most cases, an overly honest advertising message can actually hurt performance; the latter is true especially for hedonic products, for which consumers rely more on subjective information when making purchase decisions.

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Beyond Permanency Planning

Children Australia ◽

10.1017/s0312897000012212 ◽

1984 ◽

Vol 9 (3) ◽

pp. 7-12 ◽

Cited By ~ 3

Author(s):

Anthony N. Maluccio ◽

Edith Fein ◽

Jane Hamilton ◽

Jo Lynn Klier ◽

Darryl Ward

Keyword(s):

Foster Care ◽

Service Delivery ◽

Permanency Planning ◽

Definition Of

With permanency planning taking the spotlight increasingly in the field of foster care, i t becomes urgent to examine the definition of permanency, the effect on practice, and the implications for service delivery.

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Development of downscaled Climate Change Scenarios for Central America. Lessons learned and next steps

10.5194/ems2021-99 ◽

2021 ◽

Author(s):

Jorge Tamayo ◽

Ernesto Rodriguez-Camino ◽

Sara Covaleda

Keyword(s):

Climate Change ◽

Central America ◽

Essential Element ◽

Climate Change Impacts ◽

Lessons Learned ◽

Second Phase ◽

Climate Change Scenarios ◽

Definition Of ◽

Hydrological Services ◽

Different Sources

The intersectoral workshop held in December 2016 among the Ibero-American networks on water (CODIA), climate change (RIOCC) and meteorology (CIMHET) identified the need to dispose of downscaled climate change scenarios for Central America. Such scenarios would be developed by National Meteorological and Hydrological Services (NMHS) in the region, based on a common methodology, allowing the assessment of climate change impacts on water resources and extreme hydro-meteorological events.One final outcome of the project has been a freely accessible web viewer, installed on the Centro Clima webpage (https://centroclima.org/escenarios-cambio-climatico/), managed by CRRH-SICA, where all information generated during the project is available for consultation and data downloading by the different sectors of users.A key element in this project has been to integrate many downscaled projections based on different methods (dynamical and statistical), totalizing 45 different projections, and aiming at estimating the uncertainty coming from different sources in the best possible way.Another essential element has been the strong involvement of the different user sectors through national workshops, first, at the beginning of the project for the identification and definition of viewer features the project, and then for the presentation of results and planning of its use by prioritized sectors.In a second phase of the project, a regional working group made up of experts from the NMHSs will be in charge of viewer maintenance and upgrade, including new sectoral parameters, developed in collaboration with interested users, and computation and addition of new downscaled projections from CMIP 6 in collaboration with AEMET.Finally, following the request of CIMHET, the possibility of replicating this project for other areas of Ibero-America is being evaluated.

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Unpacking Scientific Competence for Effective Integration in the Curriculum Design

10.20944/preprints201810.0771.v2 ◽

2019 ◽

Author(s):

María Napal Fraile ◽

Ana María Mendióroz Lacambra ◽

Alicia Peñalva Vélez

Keyword(s):

Curriculum Design ◽

Four Dimensions ◽

General Terms ◽

Multimedia Resources ◽

Societal Changes ◽

Scientific Competence ◽

Definition Of ◽

Effective Integration ◽

Specific Definition ◽

Selection Of

Educating for Sustainability involves promoting sustainable competences in students. Not in vain, wider societal changes that ensure a balance between economic growth, respect for the environment and social justice must start with individual actions, implying knowledge, capacity and willingness to act. However, and although there is wide consensus that education should promote the development of competences for life, putting this theoretical tenet into may entail more problems. Competence is most often expressed in general terms without a specific definition of the intervening elements (knowledge, skills, values, attitudes), which may collide with the necessity of teachers – as learning planners - concrete entities on which to base their process of design. So that, in this work we propose a series of indicators that serve to characterize the four dimensions of scientific competence – contents of science, contents about science, value of science and utility of science-. Although they are primarily intended to be used to filter multimedia resources in an educational platform, this proposal of indicators can be extrapolated to the management and selection of a variety of resources and activities, and for sharing the objectives and evidences for the acquisition of competencies.

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Incidence and Predictors of Difficult and Impossible Mask Ventilation

Anesthesiology ◽

10.1097/00000542-200611000-00007 ◽

2006 ◽

Vol 105 (5) ◽

pp. 885-891 ◽

Cited By ~ 348

Author(s):

Sachin Kheterpal ◽

Richard Han ◽

Kevin K. Tremper ◽

Amy Shanks ◽

Alan R. Tait ◽

...

Keyword(s):

Body Mass Index ◽

Body Mass ◽

Difficult Intubation ◽

Essential Element ◽

Mask Ventilation ◽

Jaw Protrusion ◽

Neck Anatomy ◽

Grade 3 ◽

Definition Of ◽

Mandibular Protrusion

Background Mask ventilation is an essential element of airway management that has rarely been studied as the primary outcome. The authors sought to determine the incidence and predictors of difficult and impossible mask ventilation. Methods A four-point scale to grade difficulty in performing mask ventilation (MV) is used at the authors' institution. They used a prospective, observational study to identify cases of grade 3 MV (inadequate, unstable, or requiring two providers), grade 4 MV (impossible to ventilate), and difficult intubation. Univariate and multivariate analyses of a variety of patient history and physical examination characteristics were used to establish risk factors for grade 3 and 4 MV. Results During a 24-month period, 22,660 attempts at MV were recorded. 313 cases (1.4%) of grade 3 MV, 37 cases (0.16%) of grade 4 MV, and 84 cases (0.37%) of grade 3 or 4 MV and difficult intubation were observed. Body mass index of 30 kg/m or greater, a beard, Mallampati classification III or IV, age of 57 yr or older, severely limited jaw protrusion, and snoring were identified as independent predictors for grade 3 MV. Snoring and thyromental distance of less than 6 cm were independent predictors for grade 4 MV. Limited or severely limited mandibular protrusion, abnormal neck anatomy, sleep apnea, snoring, and body mass index of 30 kg/m or greater were independent predictors of grade 3 or 4 MV and difficult intubation. Conclusions The authors observed the incidence of grade 3 MV to be 1.4%, similar to studies with the same definition of difficult MV. Presence of a beard is the only easily modifiable independent risk factor for difficult MV. The mandibular protrusion test may be an essential element of the airway examination.

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Quality assurance and the critical care nurse

Critical Care Nurse ◽

10.4037/ccn1991.11.9.34 ◽

1991 ◽

Vol 11 (9) ◽

pp. 34-40

Author(s):

P Brown-Stewart

Keyword(s):

Quality Assurance ◽

Critical Care ◽

Critically Ill ◽

Monitoring And Evaluation ◽

Critical Care Nurses ◽

Care Nurse ◽

Critical Care Nurse ◽

Appropriateness Of Care ◽

External Sources ◽

The Way

Care of the critically ill has become increasingly challenging due to demands from external sources to measure the quality and appropriateness of care provided. Quality assurance is the responsibility of every critical care nurse and requires vigilance as well as a knowledge of the principles of standards, monitoring and evaluation. Through quality assurance activities, the contribution of critical care nurses in the achievement of patient outcomes can be measured. Quality assurance challenges us to evaluate the way we practice, and assists us to continuously improve the way we provide care to critically ill patients.

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Teacher leadership: toward a new conceptual framework

Journal of Professional Capital and Community ◽

10.1108/jpcc-06-2018-0017 ◽

2019 ◽

Vol 4 (1) ◽

pp. 2-14 ◽

Cited By ~ 4

Author(s):

Jill Harrison Berg ◽

Bill Zoellick

Keyword(s):

Conceptual Framework ◽

Knowledge Base ◽

Teacher Leadership ◽

Research Literature ◽

Teacher Leader ◽

Content Type ◽

Four Dimensions ◽

Education Leaders ◽

Definition Of ◽

Teaching Learning

Purpose Conceptual ambiguity about the term “teacher leadership” has retarded development of useful research on this topic. The purpose of this paper is to propose a conceptual framework that researchers might utilize to clarify key assumptions embedded in their use of the term “teacher leadership,” enabling members of this research community to better understand and build upon each other’s work and to develop a knowledge base on teacher leadership. Design/methodology/approach In 2016 a community of researchers convened in a conversation about their varied conceptions of teacher leadership. The authors analyzed documentation from this convening to identify key ways in which members’ conceptions of teacher leadership diverged. They then drew upon the teacher–leader research literature and their own experiences with teacher–leader initiatives to propose a conceptual framework that would support researchers to define teacher leadership in ways that meet established criteria for an empirically-useful concept. Findings Four dimensions of teacher leadership that should be referenced in an empirically-useful definition of teacher leadership are: legitimacy, support, objective and method. It is hypothesized that clarifying one’s assumptions about each of these dimensions and providing descriptive evidence of how they are instantiated will address the conceptual ambiguity that currently stymies the accumulation of knowledge in this field. Originality/value This paper presents a framework that can provide a strong foundation for the development of a knowledge base on teacher leadership, which is needed to inform education leaders’ efforts to maximize teachers’ leadership influence as asset for improving teaching, learning and schools.

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