Retraction Notice: Liver tumor segmentation method based on U-Net architecture: a review

FigureThe concept of peer review can be interpreted very differently among nurses and healthcare professionals. Some think of a subject expert reviewing a manuscript for a journal's editorial staff. Others think of regulatory bodies requiring hospitals to have an internal process to ensure that healthcare team members are competent and able to perform within their scope of practice.1 Still others think of peer review as a quality assurance process in which healthcare team members audit each other's documentation to validate care standardization. We provide insight into a nursing peer review process designed to evaluate performance, and the journey to its implementation. A well-defined peer review process and tool, utilized in conjunction with a nurse's annual performance evaluation, is one way to infuse meaningful peer input into a performance appraisal. This system allows nurses to provide insight into one another's strengths and opportunities for growth. A detailed approach was used to create, develop, and sustain a nursing peer review program that's flexible enough to be used by all staff members within a pediatric hospital system. In addition to promoting professional growth among nursing staff, this process also meets the current peer review standards set by the Magnet Recognition Program® and The Joint Commission. The ultimate goal of sharing this information is to help other organizations that are just beginning the peer review process and those that have struggled in the past with development and implementation to bring about a sustainable change. This, in turn, will promote nursing cohesiveness and professionalism as we work together to bring healthcare into a new era. Organizational standardization Our organization embarked on an initiative to create a standardized peer review process that would be utilized by all nursing departments. The process needed to be integrated organizationally and applicable to clinical nurses within both inpatient and outpatient environments. This journey began with a review of the current literature and an examination of the current peer review practice at other Magnet® facilities. Through this process, it was discovered that the majority of these facilities utilized and defined peer review in a variety of ways. We identified variation in the management of the peer review process within our own organization. Acknowledging the vast array of discrepancies within and external to the organization, a task force of clinical nurses was developed to redefine the way our organization administered the clinical nurse peer review process. This task force also included two leadership liaisons who served as resources to the clinical nurses during this development and provided insight into the management side of the peer review process. There were four steps in our process: (1) defining a peer, (2) developing a peer review form, (3) transforming the process, and (4) implementing the process. Who's a peer? The first step in our work involved evaluating, discussing, and reaching a consensus on the definition of peer. In order to standardize the peer review process, the task force recognized a true definition was needed to measure success with the new process. Looking at previous peer review practice in the organization, many nurses and department directors had different definitions and ideas of what it meant to be a peer. Some departments included other disciplines in a nurse's specialty for evaluations, whereas others utilized only fellow nursing staff members. The task force agreed that the purpose of peer review is to foster professional growth and development among staff members by utilizing a process through which measurable outcomes are assessed. After much dialog, the task force adopted the definition of peer utilized by the American Nurses Association, which defines a peer as an individual of the same rank or standing according to the established standards of practice.2 Form development The next step in redefining the peer review process was to develop a new peer review tool that could be transferrable and applicable among the various nursing specialties and departments. Key areas identified by the task force for development of this tool included creating a short, concise form that's easy to understand with limited directions and applicable to all clinical nursing departments. To achieve this goal, the task force worked collaboratively to establish eight domains that would provide nurses with a peer evaluation framework. These domains were established through open dialog, including question-and-answer sessions, review of current job descriptions, and evaluation of other tools utilized by various Magnet facilities. Through this work, a common set of core expectations were identified and utilized in the development of each domain. These domains encompass the essential clinical nurse job functions, behavioral competencies, and basic roles and responsibilities throughout the organization. The domains can be found in Table 1.Table 1: The eight domains of peer evaluationTo further guide and support high-quality peer feedback, three to five specific, measurable objectives were created and listed under each domain for nurses to measure performance. These objectives were developed to guide peers in evaluating each nurse by providing focused, pertinent feedback. The task force wanted to eliminate vague, nonspecific feedback that didn't facilitate the identification of future growth opportunities. The objectives created by the task force assist peers in identifying evidence from the nurse's daily work, communication, time management, and interdisciplinary interactions. Each domain also included a comment field, allowing nurses the autonomy to provide open-ended feedback and elaborate on outstanding work or opportunities for the employee's growth and improvement. The comment section was extremely important in the solicitation of meaningful feedback because it allowed nurses to provide examples to reinforce the ratings selected for the objectives. The directions on the new tool clearly state that comments are mandatory for certain ratings to allow for elaboration and examples. The task force believed a Likert rating scale was essential to standardize the peer review process. The previous process utilized a vague, numerical score that hadn't historically provided nurses with adequate descriptions of their work ethic and performance. Lower scores were considered negative responses, whereas higher scores equated to positive responses. After review of the current literature, the task force employed a 4-point Likert scale comprising "not met," "approaching," "meets expectations," and "exceeds expectations." In addition to the scaled questions, an open-ended question "Do you feel comfortable working with this nurse?" was added to the form. Utilizing a mixed-method methodology, Likert scale, and open-ended question format allowed the evaluating nurse a better opportunity to provide real-life contextual examples related to the evaluated nurse's care.3 Process transformation After the peer evaluation tool was created, the task force focused its attention on creating a framework to aid departments in implementing the new peer review process. Throughout our hospital, there are units of vastly different sizes. Some nursing departments have four to six clinical nurses, whereas other departments have as many as 150 to 200 clinical nurses on staff. The variability in staff sizes meant that the task force had to be creative in determining how many peer reviewers should evaluate each nurse annually and how these reviewers should be selected. With the new process, each nurse receives feedback from two to four RNs. Limiting the number of peer evaluations eliminated the previous dissatisfaction and/or barrier of evaluators being asked to fill out 20 to 30 peer evaluations a month due to exceedingly large nursing departments. The task force also allowed clinical nurses to select one to two peers of their choice to provide feedback; the management team selected the remaining peers. Implementation After the task force completed the new peer review tool and process recommendations, the nursing department directors and the CNO gave the approval for implementation. The standardized peer review form, along with the revised process, was implemented using various educational modalities. The first presentation was provided to the inpatient and outpatient nursing directors to inform them about the new form and the revised process. The directors were provided with handouts outlining the changes and educational fact sheets for the staff members to use as a reference. The task force increased its availability to ensure educational consistency to all clinical nurses by attending and presenting at unit-based councils, charge nurse meetings, and department-wide staff development programs. The feedback received from the different educational presentations was extremely positive. Feedback discussed the tool's ease of use, applicability to all nursing departments, appropriate form length, and measurable objectives that allowed nurses to comment on focused job roles and responsibilities. Other feedback included the improved functionality of the new rating scale and the process change that limited the number of requests for peer evaluations. Some directors expressed resistance to changing their current peer review practice. Certain directors thought feedback from four nurses wasn't enough if the department had a high number of nursing staff members. After an open discussion with the task force chairperson and the directors of large departments, it was agreed that meaningful feedback from four people would be adequate. Other directors mentioned that they liked the idea of adding specific clinical skills for peer evaluation. However, we couldn't add specific skills because they wouldn't universally apply to the various nursing department specialties. The task force collected all comments and feedback, and created a frequently asked questions document to address these concerns and explain the thought process behind the decisions made about the tool and recommendations. Directors were then provided with answers to and rationales for their specific questions and concerns, creating a consistent message and clarity to all departments. All education and implementation occurred over the course of 4 months. During this time, the task force worked with web development to formulate an electronic version of the peer evaluation document for the purpose of online submission. The electronic document was widely popular because it eliminated the use of paper and facilitated tool access for all clinical nurses. Staff members were able to complete the tool online and submit the evaluation through the organization's intranet directly to the person who requested the feedback. The task force also concluded that in order for this new tool and process to remain functional and meaningful, continued evaluation of its use would be essential. Reaching the top As we diligently work to move the nursing profession forward, it's important to remember that peer review can positively impact not only an individual's nursing practice, but also an entire hospital system. Nurses are at the forefront of healthcare transformation and are integral to sustainable practice improvement. By empowering clinical nurses to lead this initiative, we've been able to successfully introduce, develop, and support a valuable peer review process across our organization. Utilizing a comprehensive peer review tool can help organizations improve patient outcomes and patient satisfaction.

The American Journal of Psychiatry Residents' Journal: Training the Next Generation of Academic Psychiatrists.

Brain tumor segmentation is critical in medical imaging due to its significance in accurate diagnosis and treatment planning. Deep learning (DL) methods, particularly the U-Net architecture, have demonstrated considerable promise. However, optimizing U-Net variants to enhance performance and computational efficiency remains challenging. To develop an optimized Residual U-Net (Res-UNET) architecture enhanced by deep supervision techniques to improve segmentation accuracy of brain tumors on MRI datasets, specifically addressing challenges of conventional segmentation methods. The study implemented a detailed evaluation of multiple U-Net variations, including basic U-Net, Res-UNet with Autoencoder regularization, and attention-enhanced U-Net architectures. Training was conducted using the BraTS 2018 public MRI dataset. Deep supervision was integrated to improve gradient propagation and segmentation accuracy. The model employed a Dice loss combined with focal loss to handle data imbalance effectively. The proposed network was evaluated using extensive ablation studies, examining the effects of encoder complexity, convolutional filter count, and strategic post-processing. The proposed Res-UNET with deep supervision outperformed other variants, achieving an average Dice score of 0.9498 through five-fold cross-validation. Post-processing strategies improved the robustness of segmentation, particularly enhancing the accuracy of small tumor regions. Comparatively, conventional U-Net architectures yielded lower Dice scores and required significantly longer training times. The study indicates the benefit of integrating deep supervision and residual connections for enhanced model performance. Optimized Res-UNET with deep supervision significantly enhances segmentation accuracy for brain tumors in MRI images, surpassing traditional U-Net models. This model addresses critical issues such as dataset imbalance, lack of annotated data, and computational inefficiencies. Future studies should consider the broader application of optimized U-Net variants across other medical imaging segmentation tasks.

Civility in Nursing Peer Review: Giving and Receiving Feedback

Peer Review: The Best of the Blemished?

Liver cancer is a disease with a high incidence and high probability of deterioration, and for the rapid diagnosis of liver disease, CT scans must be used to segment the liver tumors. For the past few years, with the rapid development of deep learning, many deep learning methods for liver tumor segmentation using abdominal computed tomography (CT) images have appeared, and the clinical application of these methods is of important significance for computer-aided diagnosis of liver tumors. The U-Net, with its unique U-shape network structure, exhibits excellent performance in medical image segmentation field and has been extensively utilized in various medical image segmentation applications. In this paper, we summarize the researches of U-Net and its improved networks in CT image segmentation of liver tumors by deep learning methods and classify various U-Net-based convolutional neural networks (CNNs) into 2D (two-dimensional), 3D (three-dimensional), and 2.5D (2.5-dimensional). In this paper, 2D, 3D, and 2.5D convolutional neural networks are summarized. In addition, this paper summarizes the advantages and disadvantages as well as the improvement methods of each type of network, which provides a useful reference for the studies of deep learning based on liver tumor segmentation field. Finally, this paper envisions future research trends for deep learning segmentation methods in the context of liver tumors.

A hallmark of professional practice, nursing peer review is the process by which practicing RNs systematically assess, monitor, and give feedback to peers about the quality of nursing care measured against professional standards of practice.1 Nursing peer review supports self-regulation of clinical

Dispirited Away: The Peer Review Process

The vital importance of nature to people, and of people to the future of that nature, is self-evident. The understanding of those linkages is, nonetheless, being critically transformed and enriched by research that transcends the barriers between ecology and other traditional disciplines. Such studies are not new, but the dramatic growth in their number and influence is, and reflects the growing need for such work in rapidly changing times and circumstances. People and Nature is founded upon a recognition of these developments, and of the need of authors and readers for a journal that is focussed on them. The motivation and opportunity to conduct interdisciplinary, cross-disciplinary, multidisciplinary, and transdisciplinary research involving ecology and related disciplines has blossomed in recent years (from this point on, we use interdisciplinary research as a catch-all also including cross-disciplinary, multidisciplinary, and transdisciplinary research, while recognising that these can refer to markedly different things). It is increasingly understood that knowledge of the interactions between people and nature is crucial to both. There is a need to sustain and foster creative dialogues between ecology and a host of other disciplines in order to elaborate understandings of people and nature that are both critical and applied in scope. This means dialogues across the natural sciences, social sciences and the humanities. People and Nature is a venue (and invitation) for disciplinary engagements that encompass, for example, economics, geography, history, law, literature, medicine, philosophy, politics, psychology, and sociology, as well as other related disciplines. The British Ecological Society has added new titles to its family of journals as the field of ecology has developed, with the establishment of Journal of Ecology in 1913, Journal of Animal Ecology in 1932, Journal of Applied Ecology in 1964, Functional Ecology in 1987, and Methods in Ecology and Evolution in 2010. People and Nature is a further extension of this highly successful approach. While these other internationally significant journals, and most conspicuously Journal of Applied Ecology, have published papers at the interface of ecology and other disciplines, the focus has been on ecology itself, and thus viewing interdisciplinary scholarship as the adjunct of questions that are fundamentally ecological in intent. People and Nature takes a rather broader view, which can loosely be characterised as a requirement that all contributions have something meaningful to say both about the “People” and the “Nature” components of its title. Breaking down the barriers between disciplines brings its own challenges to authors, reviewers, and readers of articles. Although People and Nature presumes and encourages conversations across quite different arenas of knowledge production, this ambition can encounter remarkably durable disciplinary wisdoms about how research should be framed. People and Nature is committed to working to minimise the challenges associated with disciplinary difference. First, we feel strongly that researchers doing high-quality work should be able to expect a professional, respectful, and constructive publishing experience regardless of their disciplinary norms. We strive to welcome and evaluate every submission on its own terms; we cannot promise to “get it” on first read, but we can promise to try. We recognise that a large proportion of work within the scope of People and Nature is undertaken by researchers from disciplines beyond ecology, sometimes this is in collaboration with ecologists, but often it is not. Our ethos is inclusive and we have set up our submission, peer review, and publication processes with a number of features to ensure our journal caters to different needs. Importantly, we welcome conceptual and empirical research and we do not prioritise one over the other. All research styles have an important role to play when addressing issues within our scope. Relatedly, we are not prescriptive when it comes to word limits or section headings. Of course, our editorial board will assess manuscript formats for appropriateness but we recognise that different disciplines have different conventions and norms and therefore do not ask authors to conform to arbitrary word limits or fixed structures. Second, when scoping the journal, we heard from a lot of researchers who had experienced painful review processes for their interdisciplinary work. We commit to being a leading light of interdisciplinary editing and peer review. It can be difficult for journal editors to make decisions on interdisciplinary work that is often necessarily reviewed by people working in very different spheres. Understandably, reviewers tend to comment more critically on aspects of work with which they are most familiar and provide fewer comments on aspects they know less about. This can be problematic for authors who, for example, use mixed methodologies. The editorial board we recruited is intimately familiar with interdisciplinary research and peer review, and has the tools and the confidence to make active and fair editorial decisions. The editors know that interpreting differences of opinions from contrasting peer reviews takes work, both for ourselves and for authors, but it is crucial to ensure that People and Nature articles can speak across boundaries. Further to this, in recognition of the splintering of largely separate conversations in different niche (but often interdisciplinary) journals, we are working with authors to ensure that their papers actively speak to a range of relevant fields and disciplines. People and Nature thus aspires to be not a collection of unlike contributions to different literatures, but rather the nexus where these various literatures about human-nature relationships convene. This aspiration will take years to achieve, and steering from an editorial team expert in interdisciplinary integration. For this reason and its own sake, a diversity of voices on our growing editorial board is key: our Associate Editors currently hail from 18 countries and innumerable fields and disciplines, with a 46%:54% male:female gender balance. As well as ensuring that the editorial board has the right tools to make objective decisions, we have introduced two important additions to our peer review process. We ask reviewers to specify in their reports which aspects of a manuscript they are most comfortable assessing. This is a small, but important, way to help handling editors assess reviews in their proper context. When we have received the required number of reviews on a manuscript, all of the comments to the authors are then passed first to all reviewers who are invited to enter into a conversation on fellow reviewers’ reports. We hope that this will draw out disciplinary differences in reviews and help editors to ensure that any requested revisions to manuscripts are appropriate. Third, while the primary audience of our journal will be academic researchers, we recognise that topics within our scope are of importance to practitioners and policymakers, and we want to ensure that we actively engage with them. We welcome submissions from these groups and our Perspective article type is particularly suited to non-academic audiences. Access to primary research is a perennial problem for those who do not work for an academic institution and this is one reason we decided that the Journal would be fully open access—all articles are published under a CC-BY licence, free to read, and reuse. We also recognise that such a broad scope will in turn have a very broad readership and we hope that people will engage with all of our content, whether or not it is from their discipline. To facilitate this, like one of our sister BES journals, Functional Ecology, all articles have a plain language summary published alongside them as part of their supporting information. We recognise the international nature of research within our scope and, like all the BES journals, allow authors to publish their abstract in another language of their choice alongside the English abstract. In general, as a BES journal we benefit from a dedicated and highly experienced in-house editorial office team, giving us the ability to provide a level of service and additional promotion for authors that is unavailable to many journals. Early interest in the journal has been excellent and, in order to help ensure fast publication for our authors, content is being published as soon as it is ready and will subsequently be collected into balanced issues published quarterly. We hope our first volume will help set the agenda in this interdisciplinary space, and that subsequent volumes will expand it further. As People and Nature develops, we will endeavour to learn from, and adapt, our processes to provide the best interdisciplinary publication experience that we can for authors, reviewers and readers. We cannot do this in isolation. We want to build a community around this exciting new venture. We have welcomed pre-submission enquiries since before we opened for submissions, and we are still happy to provide feedback to potential authors before they submit. We also welcome feedback from the community more broadly. Do you have suggestions to improve our peer review process or article layout, for example? Is your subject area not represented on our editorial board? If you have any feedback do get in touch with our office. To foster a two-way conversation we have established a blog (which includes all of our plain language summaries of papers) and a Twitter feed, and encourage discussion and debate within the journal’s pages. Please join us on this journey.

Received from the Department of Anesthesiology, Montefiore Medical Center and the Albert Einstein College of Medicine, Bronx, New York.IN 1999 the Institute of Medicine (IOM) published a report entitled To Err is Human: Building a Safer Health Care System. 1In that report, the Committee on Quality of Health Care in America for the IOM asserted, “Anesthesia is an area in which very impressive improvements in safety have been made.” In support of this assertion the Committee stated that anesthesia mortality rates have decreased from 2 deaths per 10,000 anesthetics administered in the 1980s to about 1 death per 200,000 to 300,000 anesthetics administered today. The reference for such “impressive” gains, however, does not identify the studies that led to this conclusion. 2Multiple sources, including the Committee on Healthcare in America, have attributed this dramatic decrease in anesthesia mortality to a variety of mechanisms including improved monitoring techniques, the development and widespread adoption of practice guidelines, and other systematic approaches to reducing errors. †1,3–6In so doing, anesthesiology has been established as a model of safety, and other specialties are encouraged to engage in similar risk reduction strategies.Because the implications of establishing anesthesiology as a model of safety can have a far-reaching impact on the allocation of scarce healthcare resources, it is imperative that the basis for these claims be critically examined. Consequently, this author reviews the medical literature pertaining to anesthesia-related mortality rates, published over the last 35 years, with a focus on methodology and operational definitions applied by the various investigators. More recent perioperative mortality data, collected from two university-based anesthesia practices from January 1, 1992 through December 31, 1999, are also introduced.The Medline and HealthStar databases were searched using subject keywords “anesthesia AND mortality” from 1966 to 2000 and from 1975 to 2000, respectively. Publications were included in this review if their titles or abstracts were available in English and suggested a perioperative mortality rate related to anesthetic management in a general patient population over a specified period of time based on original data. Publications were excluded if the anesthetic management was limited to a particular technique, or the patient population was limited to a particular procedure, associated disease state, or age group. Each publication was then reviewed as needed to identify author(s), study period, data source, perioperative mortality rate, anesthesia-related mortality rate, mortality rate for which anesthesia was solely responsible, and preventable anesthetic mortality rate as defined by each study.Anesthesia-related mortality rates taken from the literature review were plotted against each study's midpoint on an “attribute P chart.” Attribute P charts reflect the number of defectives (anesthesia-related deaths) as a proportion of variable sample size. 7Studies with the same midpoint of the time period under investigation were combined into one sample, so that one data point could be generated for a single point in time. Upper control limits (three standard deviations from the average proportion defective) were established based on a binomial distribution. Systems were considered “out of control” if a point fell outside of the control limits or a “run” or “trend” was detected. A run is defined as a succession of seven points that are above or below the average. A trend is defined as a succession of seven points that are rising or falling. In a system without special causes for variation, a run or trend has approximately the same probability of occurring as a point outside a control limit, or .005. 7All cases of perioperative mortality, defined previously as death during or within two postprocedure days, 8,9which occurred at a suburban university hospital network between January 1, 1992 and December 31, 1994, were referred to the Department of Anesthesiology for peer review. Similarly, all cases of perioperative mortality, which occurred at an urban university hospital network between January 1, 1995 and December 31, 1999, were also referred for departmental peer review. A standardized model of peer review was used at both institutions under the author's supervision during these sequential time periods. 9Multiple referral sources were used, including the anesthesiologists, other clinical personnel using hospital incident reports, a follow-up phone call by nursing staff to ambulatory surgery patients, and concurrent chart reviewers. Contact was made with the anesthesiologist involved, and/or the medical record was reviewed, so that an abstract could be prepared by a preliminary group of two to four anesthesiologists for presentation to the respective departmental peer review committees. The peer review committees consisted of all available clinical members of the Departments of Anesthesiology for both suburban and urban hospital networks (approximately 25 staff anesthesiologists and 15 residents per committee for each). Each committee met on a monthly basis to participate in a structured peer review 9of the cases presented. The peer review process determined whether the mortality was solely the result of “system error” or whether there was a “human error” contribution. The American Society of Anesthesiologists (ASA) Physical Status of all patients undergoing anesthesia for operative procedures was only recorded at the suburban hospital network during 1994 and the urban hospital network from January 1, 1992 through December 31, 1999. Therefore, data collected during these years was used to extrapolate the distribution of ASA Physical Status over the two study populations. The Risk Management Departments of the respective institutions were also queried to determine whether legal action, previously defined as a letter of intent, claim, or closed claim, 10was initiated within 1 yr of any procedure that resulted in a perioperative death determined by peer review to be due, at least in part, to human error by an anesthesia practitioner.The principle underlying the peer review process is that all adverse outcomes are the result of “error,” either human or system. 9Nominal definitions for subcategorizing these two types of errors were used to add structure and increase the objectivity of the peer review process. 9,11,12Error here was defined as an act that through ignorance, deficiency, or accident departs from or fails to achieve a desired outcome. 13Human errors included failing to perform a technique properly, misuse of equipment, disregarding available data, failing to seek appropriate data, and responding incorrectly to available data due to a lack of knowledge. These human errors were considered deviations from the standard of care.System errors, on the other hand, result in adverse outcomes that might otherwise be considered unavoidable and ordinarily dropped from the peer review process. 14,15System errors included accidental occurrences resulting from performing a technique properly, equipment failure despite proper use, missed communication while following established protocol, inability to diagnose a disease process due to limitations of currently available screening and monitoring standards, inability to treat a disease process due to limitations in current standards of care, and inability to meet the demands for resources of equipment or personnel. Supervision by an attending anesthesiologist working with more than one resident or nurse anesthetist was viewed as a unique resource whose limitations were recorded separately from other resources. The peer review processes used by both Departments of Anesthesiology considered human errors on the part of nonanesthesia practitioners to be system errors if they were outside the control of the anesthesia provider. This would not prevent nonanesthesia practitioners from categorizing these adverse outcomes as human errors during their independent departmental reviews, but this process was unrelated to the anesthesiology peer review process. The error categories used by the Departments of Anesthesiology are summarized in tables 1 and 2along with common examples of each. 9,10Anesthesia-related mortality was defined as perioperative death to which human error on the part of the anesthesia provider, as defined by the peer review process, had contributed. If the departmental peer review committees determined that human error had contributed to an adverse outcome, they judged the degree to which the anesthesia care provider had contributed to that outcome. Contribution was graded on a three-point Likert scale ranging from minor to major. All determinations of the peer review committees were based on consensus.The Medline and HealthStar database queries identified 3,566 and 525 publications respectively. Review of the published abstracts that met inclusion criteria identified 23 anesthesia-related mortality rates determined between 1955 and 1992 by 21 different investigators. The results can generally be summarized in four major categories: (1) overall perioperative mortality ranged from 1 death in 53 anesthetics to 1 in 5,417 anesthetics, (2) anesthesia-related mortality ranged from 1 in 1,388 anesthetics to 1 in 85,708 anesthetics, (3) anesthesia considered solely responsible for perioperative death ranged from 1 in 6,795 anesthetics to 1 in 200,200 anesthetics, and (4) preventable anesthetic mortality ranged from 1 in 1,707 anesthetics to 1 in 48,748 anesthetics. Results of the literature review are summarized in table 3and plotted on an attribute P chart in figure 1.One hundred fifteen perioperative deaths occurred at the suburban university hospital network between January 1, 1992 and December 31, 1994. Two hundred thirty-two perioperative deaths occurred at the urban university hospital network between January 1, 1995 and December 31, 1999. Anesthetic caseloads were 37,924 for the suburban hospital network and 146,548 for the urban hospital network during those time frames. Calculated perioperative mortality rates were 30.3/10,000 anesthetics (1:332) and 15.8/10,000 (1:632) anesthetics respectively with an overall perioperative mortality of 18.9/10,000 anesthetics (1:532) as summarized in table 4. When broken down by ASA Physical Status the perioperative mortality rates in the suburban hospital network were 0 for 8,210 class I patients, 2 for 15,625 class II patients, 8 for 10,877 class III patients, 34 for 2,939 class IV patients, and 71 for 273 class V patients. Similarly, in the urban hospital network, perioperative mortality rates were 4 for 35,025 class I patients, 22 for 67,851 class II patients, 53 for 34,146 class III patients, 67 for 9086 class IV patients, and 86 for 440 class V patients. Perioperative mortality rates as a function of ASA Physical Status are shown in figure 2.Peer review determined that human error by an anesthesia practitioner contributed to 3 of the 115 (2.6%) perioperative deaths at the suburban university hospital network and 11 of the 232 (4.7%) perioperative deaths at the urban hospital network. Anesthesia-related mortality, defined as a perioperative death to which human error by an anesthesia practitioner contributed, occurred at a rate of 0.79 per 10,000 (1:12,641) anesthetics in the suburban setting and 0.75 per 10,000 (1:13,322) in the urban setting as summarized in table 4. When broken down by ASA Physical Status the anesthesia-related mortality rates in the suburban hospital network were 0 for 8,210 class I patients, 0 for 15,625 class II patients, 2 for 10,877 class III patients, 0 for 2,939 class IV patients, and 1 for 273 class V patients. Similarly, in the urban hospital network, anesthesia-related mortality rates were 0 for 35,025 class I patients, 3 for 67,851 class II patients, 2 for 34,146 class III patients, 6 for 9086 class IV patients, and 0 for 440 class V patients. Overall anesthesia-related mortality rate as a function of ASA Physical Status throughout the study period is shown in figure 3.Of the 14 anesthesia-related deaths overall, four were the result of major contributions from the anesthesia personnel (1:46,118 anesthetics), but only three resulted in legal action in the form of a letter of intent, claim, or closed claim (1:61,490 anesthetics). Of the three resulting in legal action, only one occurred in a patient with an ASA Physical Status of 1 or 2 (1:126,711 anesthetics in ASA Physical Status 1 to 2 patients).Our current original data suggest an overall perioperative mortality rate of approximately 1/500 anesthetics. This is consistent with the literature review, but the medical literature review offers a wide range of values. The wide range of perioperative mortality rates offered by the literature may be caused by differences in operational definitions and reporting sources. This is best illustrated by Pedersen (table 3), who described markedly different perioperative mortality rates in the same population depending on the timing of the patients’ deaths. 16Our current data are consistent with the perioperative mortality rate recorded by the JCAHO (approximately 1/300 anesthetics), which used the same definition and similar mandatory reporting for participating hospitals. ‡Our overall mortality rate (1:532) is also similar to the perioperative mortality rate reported by Vacanti et al. for 68,388 elective and emergency surgeries performed in 11 U.S. Naval Hospitals between 1964 and 1966 (1:25717). There are differences, however, when these perioperative mortality rates are stratified by ASA Physical Status. For example, Vacanti et al. 17reported a perioperative mortality rate of 1:1179 versus our rate of 1:10,809 for ASA Physical Status 1, and 1:11 versus our rate of 1:4.5 for ASA Physical Status 5. These differences may be caused by the small number of patients in both studies and our need to extrapolate the distribution of ASA Physical Status from a limited data set. Another possibility is differences in the application of ASA Physical Status designations. For example, by definition, ASA Physical Status 5 patients are not expected to survive 24 h with or without their planned operative procedure, thus our higher mortality figures for this class of patients seem more credible. It is also possible that not all of the perioperative deaths were captured. Our use of mandatory reporting to a nonpunitive peer review process, multiple reporting sources, and the severity of the outcome assure a high capture rate for this occurrence 18and may also account for some of the difference between our data and that of Vacanti. Vacanti's study was excluded from our literature review because it did not include an anesthesia-related mortality rate.Twenty-three anesthesia-related mortality rates were identified, however, by our literature review. Wide variation in anesthesia-related mortality rates reported over the last 35 years may also be due to differences in operational definitions. Definitions varied from intraoperative deaths 19–22to deaths occurring within 30 days 23or prior to discharge from the hospital. 16In some studies, perioperative “death” also included patients who failed to regain consciousness after anesthetic management, 24–26or who died any time during their hospital stay following an intraoperative cardiac arrest. 27This author used the 1992 JCAHO (Joint Commission on Accreditation of Healthcare Organizations) definition of perioperative mortality. “Death of patients during or within two postprocedure days” was one of the JCAHO Perioperative Performance Indicators that survived α and β testing for face validity and feasibility of data collection in a broad range of healthcare institutions. 28Anesthesia-related mortality was defined as perioperative death to which human error on the part of the anesthesia provider, as defined by our peer review process, had contributed.The principle underlying our peer review process is that all adverse outcomes are the result of “error” defined as an act that through ignorance, deficiency, or accident departs from or fails to achieve a desired outcome. 13This definition of error is consistent with the IOM definition:“Failure of a planned action to be completed as intended” or “use of a wrong plan to achieve an aim; the accumulation of errors results in accidents.”1Both of these definitions allow reviewers to look at the system as critically as they look at each other, thus making peer review less threatening. Katz and Lagasse have shown that anesthesiologists will comply with a system of self-reporting if the process is nonpunitive and can result in real improvements in patient care. 18In addition to its effect on self-reporting rates, peer review can also affect published anesthesia-related mortality rates through the accuracy of its judgments.Although the accuracy of judgments by a peer group can never be assured, interrater reliability can give some indication of the reproducibility of the data. Several measures have been taken to improve the reliability of our peer review process. Use of multiple reviewers who meet to discuss the case has been shown to markedly increase consensus among reviewers. 11,12,29,30During the course of this study, the faculty of the departments of anesthesiology remained relatively constant so that the members of the peer review groups remained stable. Structured assessment procedures have also been recommended to decrease differences in reviewers’ understanding of their task and thus to increase the objectivity of implicit peer review. 11,12By using nominal definitions for categorizing peer review opinions regarding adverse outcomes, the error analysis was relatively easy to apply so that the errors could be reliably identified and grouped. Structured peer review and a stable pool of reviewers allow the error categories to become more sharply defined over time. 9Shared expertise in a particular area also improves agreement among reviewers. 31All of our reviewers were anesthesiologists or resident anesthesiologists as defined by the composition of each department. Although some investigators have suggested that outcome data be withheld when determining appropriateness of care, 32others have suggested that outcome data are necessary to assure adequate agreement among multiple reviewers. 11A recent study of structured peer review models showed no relation between severe outcomes and subsequent classification as human error. 12This study also showed that the peer review model used in the current study has excellent interrater reliability when used in the manner described.As pointed out by Keats 33more than two decades ago, high interrater reliability in a peer review process does not assure that judgments are accurate. Judgments are shaped by the knowledge, experience, and current norms of the reviewers, and therefore, may vary over time. Consequently, to make valid comparisons with historical controls, outcomes databases must record the circumstances surrounding each event in addition to the judgments rendered. This allows subsequent peer review at a later date and removes the potential bias of an evolving peer review process. Although the author's database contains abstracts of each event for subsequent review at a future date, one can a more database that is to an of data recorded by a clinical anesthesia management system for similar current study defined anesthesia-related mortality as perioperative death to which human error on the part of the anesthesia provider, as defined by our peer review process, had contributed. Although the review mechanisms this was the definition used in the studies reviewed for this (table all however, to this for example, reported an mortality rate that was to perioperative mortality rate of anesthetics, but on to report a preventable anesthetic mortality of anesthetics. anesthesia mortality was defined by and other as death of patients in care on the part of the anesthesia provider was to have resulted in patient mortality rate that was reported in the literature reviewed was that in which anesthesia was considered solely This mortality rate was defined as patients a perioperative death as a result of human error on the part of the anesthetist perioperative mortality as a result of the anesthetics patients in anesthesia-related deaths were to be due to patient of anesthesia-related deaths to deaths in which anesthesia was considered solely responsible may have led the IOM to that anesthesia mortality rates have decreased from 2 deaths per 10,000 anesthetics administered in the 1980s to about 1 death per 200,000 to 300,000 anesthetics administered one in our literature review reported an anesthesia mortality rate of less than 1 in 200,000 anesthetics. study, intraoperative deaths in ASA Physical Status 1 and 2 patients, which were reported to the between and were considered to be solely to this time period, anesthetics were administered to ASA Physical Status 1 and 2 patients, thus a rate of death solely to anesthesia of 1 per 200,200 one be that the data the of the claim by the IOM that anesthesia mortality rates have decreased by an of over the two it is to these into by with our current original data. The study on data reported to a the current data at human error as determined by peer review. A recent study showed that risk as defined by a letter of intent, claim, or closed claim has no to human errors by anesthesiologists that result in patient as determined by peer review. study only considered intraoperative deaths that occurred in patients with an ASA Physical Status of 1 to 2 in which anesthesia was considered the the 14 anesthesia-related deaths reported in the current original data, only 4 were the result of major contributions from the anesthesia or 1 per anesthetics. Of our peer review process has never considered a death to be due solely to anesthetic disease or other have been to be Of the four deaths with major contributions by the only one occurred in a patient with an ASA Physical Status of 1 to 2 and resulted in over the period in which anesthetics were performed in these of patients. this single death did not and would not have met the inclusion criteria of the Therefore, our are consistent with the study, which may have been the basis of the IOM our literature some on the in anesthesia safety, in of anesthesia related mortality, there are some it fails to anesthesia-related mortality reported prior to 1966 because of the limitations of the Medline In and reviewed anesthetics administered in institutions and reported a perioperative mortality rate of 1 in These investigators reported that anesthesia was the of mortality in 1 in cases and was in 1 in and reported a of deaths in anesthetics administered between and was attributed solely to anesthesia in 1 in anesthetics and in 1 in patients. et at the of reported perioperative deaths within 30 days of the approximately anesthetics performed between and was considered a to death in 1 in anesthetics and 1 in general anesthetics. this report by et al. no deaths in any of the patients with ASA Physical Status Although these studies suggest improvements in anesthesia safety over the years, they have not been included in our control chart because it is to assure of all studies the Medline database a lack of appropriate risk it to in anesthesia safety because study may both and with to perioperative For example, in and that anesthetic procedures had by a similar was in When for the increase in the showed that the rate of anesthetic procedures had from to per More patients and those with higher ASA Physical Status showed the In between and the number of anesthetic procedures for patients with an ASA Physical Status of 1 had by while the number of procedures for patients with an ASA Physical Status of 3 had by this trend were it could improvements in anesthesia trend concurrent disease could also make the author's use of to the distribution of ASA Physical Status for the current original data less than In the current study, that could have resulted in an of patient disease because ASA Physical Status was in the of each study period and and to the of ASA Physical Status might then have resulted in a mortality rate that is than than the of the of ASA Physical Status between the urban and suburban hospital networks a higher of ASA Physical Status 4 and 5 patients this is more to be due to differences than a trend in perioperative addition to patient differences may also variation in practice standards, resources, and reporting These might be when the differences different This may have resulted in in the anesthesia-related mortality rates in our process control chart and in to support this can be in the anesthesia-related mortality studies in a single For example, in New there to be in anesthesia-related mortality. a in anesthesia-related mortality from approximately in to in and in Similarly, a in anesthesia-related mortality over a period at a hospital in these single studies not dramatic improvements in anesthesia-related mortality rates over the three in safety have been in other that on The safety of for has in this but the there has been in may be due to the effect that improved safety has had on has made it possible to meet of the by more and with less between this potential improvements in This may be to the practice of anesthesiology in which improvements in medical have led to anesthetic management of patients with more concurrent have shown 1 and the risk of death in these patients as does the risk of death in which human error by an anesthesiologist is is not that our control charts did not a trend in anesthesia-related mortality over time. The of our data points are more than three standard deviations from the anesthesia-related mortality of deaths per 10,000 anesthetics, which anesthesia-related deaths that occurred in anesthetics reported in the anesthesia-related mortality is not a stable system. A system that is does not have a In other one in anesthesia safety in of anesthesia-related mortality special causes of variation have been These special causes of variation may real differences in anesthesia safety between the various or differences in the used to anesthesia-related mortality current data that the overall perioperative mortality rate for patients ASA Physical Status is approximately 1 per anesthetics. The literature suggest a wide range of perioperative mortality rates, which are caused by differences in operational definitions and reporting sources, as as a lack of appropriate risk Our current data, however, are consistent with reported perioperative mortality rates using the same definition and similar mandatory reporting for participating hospitals. Our data suggest that the anesthesia-related mortality rate, as determined by peer review, has been stable over the last at approximately 1 death per anesthetics. Wide based on differences reported in the literature make it to in anesthesia on these the are It is time to the that is not any must the that anesthesia-related mortality has improved by an of does not support this must then our to our methodology of data collection and analysis so that can data data will allow to risk models and identify best then can anesthesia become a model of

Legal scholarship has an ambiguous identity, somewhere between the humanities and the social sciences, having features in common with both. It shares many of the characteristics of social sciences since the law is a social phenomenon, but when normativity and legal certainty are concerned, legal scholarship is probably closer to humanities (Peruginelli & Faro, 2018). At the same time law is distinct from both. There is an interesting debate on the role of academic legal research in which consideration is given to 'law as a practical discipline', 'law as humanities' and 'law as social sciences' (Siems & Mac Sithigh, 2012). Because of the peculiarities of legal scholarship, it is not easy to assess legal journals according to the standard quantitative metrics applied in social sciences, and qualitative assessment of the published content is more appropriate. Therefore, we compared the peer review process employed by legal journals in three countries, Croatia, Italy and Spain, to find out their characteristics. In this study, 34 Croatian, 36 Spanish and 40 Italian law journals (selected randomly from the 153 top ranking Italian law journals) were analysed. For each journal, we collected basic set of metadata, as well as a document providing the description of the peer-review process. We collected 107 documents in four languages (English, Croatian, Italian and Spanish) which were analysed in order to find out characteristics of the peer review process. For text analysis, we developed an extensive categorization dictionary. Nine main categories in the Categorization dictionary are peer review (process and reviewers), reviewer's characteristics (academic level, autonomy, competence), reviewer's provenance (external, internal), peer review blindness/openness (single-blind, double-blind, open), number of reviewers (one, two), evaluation criteria for submissions (originality, methods, relevance, clarity, accuracy, etc.), peer review outcome (report, acceptance, rejection), ethical issues (editorial standards and codes, conflict of interests, confidentiality, research integrity), manuscript type (original scientific article, professional article, etc.). The most frequent categories are "peer review", "submissions' evaluation criteria" and "manuscript type", present in more than 90% of the collected documents. "Reviewer's competences" are the most represented subcategory in "“reviewer's characteristics“, as high level of reviewers expertise in the legal sciences is important for law journals. 73% of analyzed journals are declaring anonymous peer review, 25% double-blind peer review, and only one journal employ single-blind peer review. 42% of documents contained information on "two reviewers", 8% "one reviewer" and 7% "three or more reviewers". Ethical issues are certainly under-represented in documents describing peer review process and editorial policies issued by Italian, Spanish and Croatian law journals. Only 32% of the documents mention conflict of interests, and all other subcategories are present even less than 30%. Croatian legal journals are addressing research misconduct and different publication types more than the other two countries. Also, they consider manuscript originality as very important, but some important submission evaluation criteria, reviewer characteristics and peer review outcomes are not present. On the other hand, Spanish legal journals are addressing more reviewer's competences, but some important ethical issues are missing. Italian legal journals take care about the reviewer's competences, academic level and objectivity, as well as anonymity of the peer review process, but expected peer review outcomes and ethical issues should be mentioned in a greater extent.

The present study investigated the types of peer reviews and revisions by Korean EFL college students on their writing, and described students’ perception towards peer review. It comprised of a sample of twelve college students joined in this peer review and revision process through surveys and in-depth interviews. The results demonstrate that the participants’ peer review paid more attention to addition and positive praise, and their revisions focused on corrections, additions, and no revision. Based on the holistic and analytic scoring results, it indicates that the peer review activity did not reach the expected increase in writing quality. However, participants increased in C-test scores and vocabulary, and employed many writing strategies from their peers. After the peer review process, the participants recognized that the peer review interaction helped them improve their learning: how to share ideas, organize their writing, compare different thoughts of peers, read each other’s writings, and find out their own strengths and weaknesses. The results showed that the participants became more positive towards writing in English because they became less anxious in writing as they repeatedly engaged in the peer review process.

Double- vs single-blind peer review effect on acceptance rates: a systematic review and meta-analysis of randomized trials

Peer review on the Internet: A better class of conversation

Under BEPS Action 14, members of the OECD/G20 Inclusive Framework on BEPS have committed to implement a minimum standard to strengthen the effectiveness and efficiency of the mutual agreement procedure (MAP). The MAP is included in Article 25 of the OECD Model Tax Convention and commits countries to endeavour to resolve disputes related to the interpretation and application of tax treaties. The BEPS Action 14 Minimum Standard has been translated into specific terms of reference and a methodology for the peer review and monitoring process. The initial peer review process was conducted in two stages. Stage 1 assessed countries against the terms of reference of the minimum standard according to an agreed schedule of review. Stage 2 focused on monitoring the follow-up of any recommendations resulting from jurisdictions' Stage 1 peer review report. Following the conclusion of the initial peer review process in 2022, a continued monitoring process has started whereby all Inclusive Framework member jurisdictions will be subject to continued monitoring: jurisdictions that have "meaningful MAP experience" would undergo a full peer review process once every four years and those that do not would undergo a two-stage simplified peer review process. This report reflects the outcome of Stage 1 of the simplified peer review of the implementation of the BEPS Action 14 Minimum Standard by the Dominican Republic.