Core Domain Research Articles

Globale Kompetenzen und Bildung für nachhaltige Entwicklung. Eine bibliometrische Analyse zur Verortung der globalen Kompetenzen der OECD im wissenschaftlichen Diskurs

AbstractThe Programme for International Study Assessment (PISA) regularly assesses a set of interdisciplinary competences in addition to the traditional core domains. With the 2018 assessment of ‘global competences’, the OECD (2019) aims to support evidence-based decisions on the improvement of the curricula and teaching in order to prepare young people to become active and global citizens who contribute to the achievement of the Sustainable Development Goals (SDGs). In assessing this domain, the OECD is entering a field of research characterised by dynamic debates and heterogeneous research strands. The aim of this paper is to visualise the theoretical foundations on which the analytical PISA 2018 Global Competence Framework (OECD 2019) is based, allowing a transparent discussion of the different theoretical reference points. The bibliometric analyses reveal that discourses related to Education for Sustainable Development (ESD) are hardly taken into account in the analytical framework. The paper subsequently formulates impetus from the ESD research field with the aim of linking discourses in the future.

Psychometric properties of the Kidney Disease Quality of Life short form 36 (KDQOL-36) scale for the assessment of quality of life in Colombian patients with chronic kidney disease on dialysis

PurposeConsidering the importance of incorporating quality of life (QoL) construct during the health care of patients with stage 5 chronic kidney disease (CKD) on dialysis, it is necessary to have evidence on the clinimetric properties of the instruments used for its measurement. This study aimed to establish the clinimetric properties of the Kidney Disease Quality of Life Short Form 36 (KDQOL-36) scale in patients with stage 5 CKD on dialysis in Colombia.MethodsA scale validation study was conducted using the classical test theory methodology. The statistical analysis included exploratory factor analysis (EFA) and confirmatory (CFA) techniques performed on two independent subsamples; concurrent criterion validity assessments; internal consistency using four different coefficients; test–retest reliability; and sensitivity to change using mixed model for repeated measures.ResultsThe KDQOL-36 scale was applied to 506 patients with a diagnosis of stage 5 CKD on dialysis, attended in five renal units in Colombia. The EFA endorsed the three-factor structure of the scale, and the CFA showed an adequate fit of both the original and empirical models. Spearman's correlation coefficient values ≥0.50 were found between the domains of the CKD-specific core of the KDQOL-36 scale and the KDQ. Cronbach's alpha, McDonald's omega, Greatest lower bound (GLB), and Guttman's lambda coefficients were ≥0.89, indicating a high degree of consistency. A high level of concordance correlation was found between the two moments of application of the instrument, with values for Lin's concordance correlation coefficient ≥0.7. The application of the instrument after experiencing an event that could modify the quality of life showed statistically significant differences in the scores obtained.ConclusionThe KDQOL-36 scale is an adequate instrument for measuring QoL in Colombian patients with stage 5 CKD on dialysis.

Views of healthcare professionals on their relationships with families of people living with dementia: A qualitative study.

Healthcare professionals as well as families play a vital role in ensuring the quality of care for people living with dementia. However, the relationships between healthcare professionals and families of people living with dementia are not extensively examined, particularly within the Chinese cultural context of dementia. The goal of this study was to explore the views of healthcare professionals on their relationships with families of people living with dementia. This qualitative study was grounded in the interpretative phenomenological analysis framework. Data were collected using focus-group interviews. Qualitative data were transcribed verbatim and analysed using interpretative phenomenological analysis. The study recruited a total of 26 healthcare professionals from 3 long-term care facilities. The study found that conflicts were inherent in the relationships between professionals and families of people living with dementia, and conflicts were found to manifest in three core domains: 1) Families demonstrated a lack of understanding about dementia, 2) Professionals faced challenges in managing families' unrealistic expectations regarding the disease status and the prognosis of people living with dementia, 3) Families did not perceive themselves as being responsible for the care of people living with dementia. The present study found that the prevailing factor underpinning the relational conflicts between healthcare professionals and families of people living with dementia, as reported by healthcare professionals was the perceived lack of understanding about dementia amongst families of those affected.

Phosphorylation of the alpha-I motif in SYMRK drives root nodule organogenesis

Symbiosis receptor-like kinase SYMRK is required for root nodule symbiosis between legume plants and nitrogen-fixing bacteria. To understand symbiotic signaling from SYMRK, we determined the crystal structure to 1.95 Å and mapped the phosphorylation sites onto the intracellular domain. We identified four serine residues in a conserved "alpha-I" motif, located on the border between the kinase core domain and the flexible C-terminal tail, that, when phosphorylated, drives organogenesis. Substituting the four serines with alanines abolished symbiotic signaling, while substituting them with phosphorylation-mimicking aspartates induced the formation of spontaneous nodules in the absence of bacteria. These findings show that the signaling pathway controlling root nodule organogenesis is mediated by SYMRK phosphorylation, which may help when engineering this trait into non-legume plants.

The Biochemical Impact of Extracting an Embedded Adenylate Kinase Domain Using Circular Permutation.

Adenylate kinases (AKs) have evolved AMP-binding and lid domains that are encoded as continuous polypeptides embedded at different locations within the discontinuous polypeptide encoding the core domain. A prior study showed that AK homologues of different stabilities consistently retain cellular activity following circular permutation that splits a region with high energetic frustration within the AMP-binding domain into discontinuous fragments. Herein, we show that mesophilic and thermophilic AKs having this topological restructuring retain activity and substrate-binding characteristics of the parental AK. While permutation decreased the activity of both AK homologues at physiological temperatures, the catalytic activity of the thermophilic AK increased upon permutation when assayed >30 °C below the melting temperature of the native AK. The thermostabilities of the permuted AKs were uniformly lower than those of native AKs, and they exhibited multiphasic unfolding transitions, unlike the native AKs, which presented cooperative thermal unfolding. In addition, proteolytic digestion revealed that permutation destabilized each AK in differing manners, and mass spectrometry suggested that the new termini within the AMP-binding domain were responsible for the increased proteolysis sensitivity. These findings illustrate how changes in contact order can be used to tune enzyme activity and alter folding dynamics in multidomain enzymes.

A qualitative study exploring the epistemology of suffering within a Malaysian Indigenous tribe.

Despite the universal nature of suffering, few studies have examined how Indigenous ethnic minorities in non-western regions understand and respond to adversity. This study explored the epistemology of suffering among the Temiar ethnic group of Peninsular Malaysia using participant observation and semi-structured interviews. Interview transcripts of 43 participants were coded through inductive thematic analysis and a consensual qualitative approach. Three-tier themes were defined and named after subsequent analysis of core ideas and domains in the data. Major adversities reported included a lack of basic needs, lack of land-rights and unjust treatment from authorities, destruction of the forest environment and livelihood, and lack of accessibility and facilities, which were attributed to authorities' negligence of responsibilities, increasing human-animal conflict, environmental threats and imposed lifestyle changes. Faced with adversity, the Temiar endeavoured to survive by working crops and gathering forest resources. They utilized resources from family, fellow villagers, external agencies and spiritual-religious traditions. Theoretical mapping of attribution styles into the Ecological Rationality Framework revealed predominantly external-focused and concrete-perceptual rationalities privileged by strong-ties societies. These findings pointed to the resilience of a strong-ties community while adapting to the systemic suffering and risk factors stemming from a rationality mismatch with modernization and globalization trends. To conclude, we advocate for culture-sensitive mental health and psychiatric practices, as well as sustainable development for the well-being of Indigenous communities locally and globally.

Abstract HUP4: Can A Remote Telehealth-based Program Support Survivors With Varying Social Needs Post-stroke?

Introduction: There are significant and longstanding inequities in stroke prevalence and care as well as outcomes. Social determinants of health (SDOH) are known to be a risk factor in post-stroke recovery. SDOH also put individuals at higher risk for 90-day mortality. Social determinants are a significant contributor to disparities in health and specifically addressing SDOH needs may improve the health and outcomes of stroke survivors. Methods: An app-based, virtual care model was used to impact survivor quality of life and outcomes for stroke survivors and their care partners. As a part of program onboarding, the clinical navigator utilized the CMS Accountable Health Communities Health-Related Social Needs Screening Tool to assess survivor needs in five core domains including housing instability, food insecurity, transportation problems, utility needs, and interpersonal safety. As needs were identified, they were cross-walked to pre-populated community resource maps to aid the survivor in their recovery and support subsequent stroke prevention. Results: Of the (n=50) stroke survivors (median age of 62) that completed the 12-week survivor-led Navigator support program, 35% had one SDOH need, 16% had 2 SDOH needs, 16% had 3 SDOH needs, 3% had 4 SDOH needs and 28% had 5 or more SDOH needs. The most regularly identified areas of social need in the cohort were mental health (20%), financial strain (15.7%), employment (13.6%) and transportation (12.9%). These SDOH were addressed throughout the 90-day program based on individual access considerations. The 30- and 90-day all-cause readmission rates for survivors were 5% and 10%, respectively, superior to recent publications reporting 30-day unplanned readmission rates after stroke ranging from 8.7%-12.5%, and 90-day readmissions ranging from 18.9% to 20.7%. Conclusion: By assessing SDOH and providing specifically tailored post-acute resources to meet those needs, a tech-enabled platform with clinical navigator support can improve outcomes for stroke survivors with a variety of SDOH needs. Additional post-acute stroke care and targeted programming are needed to address the ongoing inequalities in the healthcare system as they relate to post-stroke care and recovery in populations with high SDOH needs.

Abstract A012: Emergence of MEK1 mutations in RAF or RAS-mutant solid tumors following treatment with a combination of selective type II RAF inhibitor belvarafenib and MEK inhibitor cobimetinib

Abstract Acquisition of ARAF mutations upon treatment with the potent and selective RAF dimer (type II) inhibitor belvarafenib has been previously observed, but whether these alterations or others are observed in patients treated with a combination of belvarafenib and the MEK inhibitor cobimetinib is unknown. The mutational profiles from circulating tumor DNA (ctDNA) were determined using FoundationOne liquid ctDNA assay from paired baseline (BL) and end of treatment (EOT) peripheral blood samples from 79 patients with locally advanced or metastatic RAF or RAS-mutant solid tumors treated with belvarafenib and cobimetinib in the HM-RAFI-103 trial (NCT03284502). The proportion of mutations were compared between BL and EOT using a McNemar’s test (unadjusted) to identify mutations significantly enriched or lost following treatment. ARAF mutations were not observed to significantly increase following treatment with belvarafenib + cobimetinib (4% BL vs 4% EOT in all solid tumors, p = 1; 6% BL vs 6% EOT in melanoma), and in patients with pre-existing ARAF mutations, the variant allele frequency did not consistently increase following treatment. The MEK1 gene had the greatest increase in mutations following treatment, present in 5% (4/79) patients at BL vs 16% (13/79) at EOT (p = 0.02) across all solid tumors, which included 44 colorectal cancer (CRC) cases (56%), and 18 melanoma (23%). While CRC comprised the largest fraction of all solid tumors in this study, it did not contribute the greatest gain in MEK1 mutations at EOT, with 7% (3/44) of CRC patients having MEK1 mutations at BL vs 14% (6/44) at EOT (p = 0.2). The indication with the greatest number of patients developing previously undetected MEK1 mutations at EOT was melanoma, where MEK1 mutations were present in 0% (0/18) patients at BL vs 28% (5/18) at EOT (p = 0.07). The MEK1 mutations gained in melanoma, which included Q58_E62del, P124L, and C121S, occurred in the N-terminal or catalytic core domains of MEK1, were known to be of functional impact, and all but one patient developing them had ≥ 1 known to be gain of function via the Clinical Knowledge Database; one patient gained three distinct MEK1 mutations following treatment. The MEK1 C121S mutation was previously observed to appear in a melanoma patient who developed resistance to the BRAF V600 inhibitor vemurafenib, and in vitro studies demonstrated it also conferred resistance to MEK inhibition (Wagle et al., 2011). Melanoma patients in the HM-RAFI-103 trial gaining MEK1 mutations at EOT were more commonly BRAF-mutant(mt) or NRAS non-mt melanoma at BL, but sample size is small and results were non-significant (p = 0.3 and 0.3, for association with BRAFmt and NRASmt, respectively, Fisher’s exact test). All melanoma patients who developed MEK1 mutations post treatment had either a partial response (1/5) or stable disease (4/5) as best overall response. Together, these data suggest the acquisition of gain of function MEK1 mutations following treatment of solid tumors, including melanoma, with combined type II RAF dimer and MEK inhibition. Citation Format: Stephanie Hilz, Marissa Chen, Malgorzata Nowicka, Harini Chakravarthy, Maryam Moshref, Luca Gerosa, Jennifer Eng-Wong, Cassie Chou, Young S. Noh, Yoon-hee Hong, Yibing Yan. Emergence of MEK1 mutations in RAF or RAS-mutant solid tumors following treatment with a combination of selective type II RAF inhibitor belvarafenib and MEK inhibitor cobimetinib [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: Translating Cancer Evolution and Data Science: The Next Frontier; 2023 Dec 3-6; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(3 Suppl_2):Abstract nr A012.

Development of a core domain set for nailfold capillaroscopy reporting

BackgroundThe peripheral microangiopathy may be well evaluated and studied by nailfold capillaroscopy (NFC) which is a safe and non-invasive technique. NFC has been reported to have both diagnostic and prognostic values in patients presenting with Raynaud's phenomenon. ObjectiveThe overarching objective of this work was to make a consensus on what domains should be included in a capillaroscopy report and that it can be used in daily clinical practice and clinical research in the area of rheumatology. MethodsA Delphi questionnaire was developed regarding capillaroscopy report from a literature review and expert consensus. The first Delphi round included 14 core areas, its 18 domains with 50 subdomains, derived from a systematic literature review. The level of evidence was determined for each core set using the Oxford Centre for Evidence-based Medicine (CEBM) system. Nine response categories have been set per each item ranging between 1 and 9. Round 2, aimed to reach preliminary consensus “in” or “out” for domains. It included all items that were rated “critical” by at least 80% of the participants as well as any new domains proposed in round 1. ResultsThe participants to the first, and second round were 11 experts. Fourteen domains were discussed in the two rounds. At the end of the survey, the final report template of NFC in rheumatology reached a consensus. ConclusionA nailfold capillaroscopy report template has been developed by this study, based on outcomes of a Delphi process, by international participants panel. All domains met the 80% voting threshold set in this work. The reporting template can be used for both clinical research as well as day to day practice to provide guidance and standardize the NFC reporting.

Abstract NS4: Can a Remote Telehealth-Based Program Support Survivors With Varying Social Needs Post-Stroke?

Introduction: There are significant and longstanding inequities in stroke prevalence and care as well as outcomes. Social determinants of health (SDOH) are known to be a risk factor in post-stroke recovery. SDOH also put individuals at higher risk for 90-day mortality. Social determinants are a significant contributor to disparities in health and specifically addressing SDOH needs may improve the health and outcomes of stroke survivors. Methods: An app-based, virtual care model was used to impact survivor quality of life and outcomes for stroke survivors and their care partners. As a part of program onboarding, the clinical navigator utilized the CMS Accountable Health Communities Health-Related Social Needs Screening Tool to assess survivor needs in five core domains including housing instability, food insecurity, transportation problems, utility needs, and interpersonal safety. As needs were identified, they were cross-walked to pre-populated community resource maps to aid the survivor in their recovery and support subsequent stroke prevention. Results: Of the (n=50) stroke survivors (median age of 62) that completed the 12-week survivor-led Navigator support program, 35% had one SDOH need, 16% had 2 SDOH needs, 16% had 3 SDOH needs, 3% had 4 SDOH needs and 28% had 5 or more SDOH needs. The most regularly identified areas of social need in the cohort were mental health (20%), financial strain (15.7%), employment (13.6%) and transportation (12.9%). These SDOH were addressed throughout the 90-day program based on individual access considerations. The 30- and 90-day all-cause readmission rates for survivors were 5% and 10%, respectively, superior to recent publications reporting 30-day unplanned readmission rates after stroke ranging from 8.7%-12.5%, and 90-day readmissions ranging from 18.9% to 20.7%. Conclusion: By assessing SDOH and providing specifically tailored post-acute resources to meet those needs, a tech-enabled platform with clinical navigator support can improve outcomes for stroke survivors with a variety of SDOH needs. Additional post-acute stroke care and targeted programming are needed to address the ongoing inequalities in the healthcare system as they relate to post-stroke care and recovery in populations with high SDOH needs.

Proteomics for heart failure risk stratification: a systematic review

BackgroundHeart failure (HF) is a complex clinical syndrome with persistently high mortality. High-throughput proteomic technologies offer new opportunities to improve HF risk stratification, but their contribution remains to be clearly defined. We aimed to systematically review prognostic studies using high-throughput proteomics to identify protein signatures associated with HF mortality.MethodsWe searched four databases and two clinical trial registries for articles published from 2012 to 2023. HF proteomics studies measuring high numbers of proteins using aptamer or antibody-based affinity platforms on human plasma or serum with outcomes of all-cause or cardiovascular death were included. Two reviewers independently screened articles, extracted data, and assessed the risk of bias. A third reviewer resolved conflicts. We assessed the risk of bias using the Risk Of Bias In Non-randomized Studies—of Exposure tool.ResultsOut of 5131 unique articles identified, nine articles were included in the review. The nine studies were observational; three used the aptamer platform, and six used the antibody platform. We found considerable heterogeneity across studies in measurement panels, HF definitions, ejection fraction categorization, follow-up duration, and outcome definitions, and a lack of risk estimates for most protein associations. Hence, we proceeded with a systematic review rather than a meta-analysis. In two comparable aptamer studies in patients with HF with reduced ejection fraction, 21 proteins were identified in common for the association with all-cause death. Among these, one protein, WAP four-disulfide core domain protein 2 was also reported in an antibody study on HFrEF and for the association with CV death. We proposed standardized reporting criteria to facilitate the interpretation of future studies.ConclusionsIn this systematic review of nine studies evaluating the association of proteomics with mortality in HF, we identified a limited number of proteins common across several studies. Heterogeneity across studies compromised drawing broad inferences, underscoring the importance of standardized approaches to reporting.

Artificial Intelligence in Surgery: The Future is Now.

Background Clinical Artificial intelligence (AI) has reached a critical inflection point. Advances in algorithmic science and increased understanding of operational considerations in AI deployment are opening the door to widespread clinical pathway transformation. For surgery in particular, the application of machine learning algorithms in fields such as computer vision and operative robotics are poised to radically change how we screen, diagnose, risk-stratify, treat and follow-up patients, in both pre- and post-operative stages, and within operating theatres. Summary In this paper, we summarise the current landscape of existing and emerging integrations within complex surgical care pathways. We investigate effective methods for practical use of AI throughout the patient pathway, from early screening and accurate diagnosis to intraoperative robotics, post-operative monitoring and follow-up. Horizon scanning of AI technologies in surgery is used to identify novel innovations that can enhance surgical practice today, with potential for paradigm shifts across core domains of surgical practice in the future. Any AI-driven future must be built on responsible and ethical usage, reinforced by effective oversight of data governance, and of risks to patient safety in deployment. Implementation is additionally bound to considerations of usability and pathway feasibility, and the need for robust healthcare technology assessment and evidence generation. While these factors are traditionally seen as barriers to translating AI into practice, we discuss how holistic implementation practices can create a solid foundation for scaling AI across pathways. Key Messages The next decade will see rapid translation of experimental development into real-world impact. AI will require evolution of work practices, but will also enhance patient safety, enhance surgical quality outcomes, and provide significant value for surgeons and health systems. Surgical practice has always sat on a bedrock of technological innovation. For those that follow this tradition, the future of AI in surgery starts now.

Sequence differences between BAX and BAK core domains manifest as differences in their interactions with lipids.

The B-cell lymphoma 2 (BCL2) family members, BCL2-associated protein X (BAX) and BCL2 homologous antagonist killer (BAK), are required for programmed cell death via the mitochondrial pathway. When cells are stressed, damaged or redundant, the balance of power between the BCL2 family of proteins shifts towards BAX and BAK, allowing their transition from an inactive, monomeric state to a membrane-active oligomeric form that releases cytochrome c from the mitochondrial intermembrane space. That oligomeric state has an essential intermediate, a symmetric homodimer of BAX or BAK. Here we describe crystal structures of dimers of the core domain of BAX, comprising its helices α2-α5. These structures provide an atomic resolution description of the interactions that drive BAX homo-dimerisation and insights into potential interaction between core domain dimers and membrane lipids. The previously identified BAK lipid-interacting sites are not conserved with BAX and are likely to determine the differences between them in their interactions with lipids. We also describe structures of heterodimers of BAK/BAX core domains, yielding further insight into the differences in lipid binding between BAX and BAK.

Consensus on the definitions and descriptions of the domains of the OMERACT Core Outcome Set for shared decision making interventions in rheumatology trials

ObjectiveTo gain consensus on the definitions and descriptions of the domains of the Outcome Measures in Rheumatology (OMERACT) core domain set for rheumatology trials evaluating shared decision making (SDM) interventions. MethodsFollowing the OMERACT Handbook methods, our Working Group (WG), comprised of 90 members, including 17 patient research partners (PRPs) and 73 clinicians and researchers, had six virtual meetings in addition to email exchanges to develop draft definitions and descriptions. The WG then conducted an international survey of its members to gain consensus on the definitions and descriptions. Finally, the WG members had virtual meetings and e-mail exchanges to review survey results and finalize names, definitions and descriptions of the domains. ResultsWG members contributed to developing the definitions. Fifty-two members representing four continents and 13 countries completed the survey, including 15 PRPs, 33 clinicians and 37 researchers. PRPs and clinicians/researchers agreed with all definitions and descriptions with agreements ranging from 87% to 100%. Respondents suggested wording changes to the names, definitions and descriptions to better reflect the domains. Discussions led to further simplification and clarification to address common questions/concerns about the domains. ConclusionOur WG reached consensus on the definitions and descriptions of the domains of the core domain set for rheumatology trials of SDM interventions. This step is crucial to understand each domain and provides the foundation to identify instruments to measure each domain for inclusion in the Core Outcome Measurement Set. Clinical significanceThe current study provides consensus-based definitions and descriptions for the domains of the OMERACT core domain set for shared decision making interventions from patients/caregivers, clinicians and researchers. This is a crucial step to understand each domain and provides the foundation to identify instruments to measure each domain for inclusion in the Core Outcome Measurement Set for trials of SDM interventions.

Conversational Agents in Palliative Care: Potential Benefits, Risks, and Next Steps.

Conversational agents (sometimes called chatbots) are technology-based systems that use artificial intelligence to simulate human-to-human conversations. Research on conversational agents in health care is nascent but growing, with recent reviews highlighting the need for more robust evaluations in diverse settings and populations. In this article, we consider how conversational agents might function in palliative care-not by replacing clinicians, but by interacting with patients around select uncomplicated needs while facilitating more targeted and appropriate referrals to specialty palliative care services. We describe potential roles for conversational agents aligned with the core domains of quality palliative care and identify risks that must be considered and addressed in the development and use of these systems for people with serious illness. With careful consideration of risks and benefits, conversational agents represent promising tools that should be explored as one component of a multipronged approach for improving patient and family outcomes in serious illness.

Teaching Sideways: Implementing a Peer-Led Medical Student Orientation Bootcamp and Survival Guide for Internal Medicine Clerkship.

Transitioning from classroom learning to clerkships presents a challenge for medical students because there is often sparse preparation material on how to effectively contribute to the medical team as a clerkship student. Although some medical schools have implemented transition-to-clerkship sessions, they often are led by faculty and lack the practical and contemporary guidance from students who have recently completed clerkships themselves. Using a sideways mentorship approach, we implemented a 1-hour near-peer Internal Medicine (IM) clerkship orientation bootcamp at our medical school and wrote an accompanying survival guide to teach students how to function as part of a medical team and to increase the transparency of student expectations and evaluations during the clerkship. The 1-hour session covered the following core topics: clerkship logistics, how to gather/present clinical information, a resident/student question-and-answer panel, and how to contribute to the medical team. A postclerkship medical student and second-year IM resident conducted the bootcamp for four student cohorts (105 students total) during the January to December 2022 clerkship year before the IM rotation of each cohort. After the bootcamp, students received a copy of the survival guide to solidify concepts covered in the session. A preclerkship survey included questions to assess student confidence in 10 core IM clerkship domains pre- and postbootcamp. Both pre- and postclerkship surveys asked students to provide feedback on bootcamp strengths and weaknesses. Wilcoxon signed rank tests revealed a significant increase in postbootcamp student confidence rating for all 10 clerkship domains in the early clerkship cohort and in the late clerkship cohort for all of the domains, except finding clinical reference resources (P = 0.15). The bootcamp had the largest effect size (r) on student confidence in both early and late clerkship cohorts for the following clerkship domains: familiarity with IM clerkship evaluation (early: r = 0.61, P < 0.001; late: r = 0.56, P = 0.002), identification of ways to contribute to the medical team (early: r = 0.58, P < 0.001; late: r = 0.63, P < 0.001), and prerounding/chart checking (early r = 0.52, P < 0.001; late: r = 0.55, P = 0.001). The percentage of students rating the helpfulness of both the bootcamp and survival guide as a 3 to 5 on a 5-point Likert scale in the postclerkship survey was highest for the following domains: being familiar with the structure of a subjective, objective, assessment, and plan presentation (88% and 97%), prerounding/chart checking (82% and 95%), writing progress notes (82% and 92%), and identifying ways to contribute to the medical team (82% and 95%). Students commented that the main strengths of the bootcamp included its specific tips on synthesizing and presenting clinical information and its transparency about student expectations and experiences. A structured student-led bootcamp can increase clerkship preparation in core domains. The bootcamp is now part of mandatory clerkship didactics at our medical school, given its success during the 2022 clerkship year, and its content is continuing to be expanded upon by postclerkship students and residents. In addition, the format of the bootcamp also is being adapted to other clerkships, including surgery and obstetrics/gynecology.

Where are the values in evaluating palliative care? Learning from community-based palliative care provision.

The World Health Organization Astana Declaration of 2018 sees primary healthcare as key to universal health coverage and gives further support to the goal of building sustainable models of community palliative care. Yet evaluating the benefits of such models continues to pose methodological and conceptual challenges. To explore evaluation issues associated with a community-based palliative care approach in Kerala, India. An illuminative case study using a rapid evaluation methodology. Qualitative interviews, documentary analysis and observations of home care and community organising. We appraise a community palliative care programme in Kerala, India, using three linked 'canvases' of enquiry: (1) 'complex' multi-factorial community-based interventions and implications for evaluation; (2) 'axiological' orientations that foreground values in any evaluation process and (3) the status of evaluative evidence in postcolonial contexts. Three values underpinning the care process were significant: heterogeneity, voice and decentralisation. We identify 'objects of interest' related to first-, second- and third-order outcomes: (1) individuals and organisations; (2) unintended targets outside the core domain and (3) indirect, distal effects within and outside the domain. We show how evaluation of palliative care in complex community circumstances can be successfully accomplished when attending to the significance of community care values.

Provider Perspectives of Facilitators and Barriers to Reaching and Utilizing Chronic Pain Healthcare for Persons With Traumatic Brain Injury: A Qualitative NIDILRR and VA TBI Model Systems Collaborative Project.

To identify facilitators and barriers to reaching and utilizing chronic pain treatments for persons with traumatic brain injury (TBI) organized around an Access to Care framework, which includes dimensions of access to healthcare as a function of supply (ie, provider/system) and demand (ie, patient) factors for a specified patient population. Community. Clinicians (n = 63) with experience treating persons with TBI were interviewed between October 2020 and November 2021. Descriptive, qualitative study. Semistructured open-ended interview of chronic pain management for persons with TBI. Informed by the Access to Care framework, responses were coded by and categorized within the core domains (reaching care, utilizing care) and relevant subdimensions from the supply (affordability of providing care, quality, coordination/continuity, adequacy) and demand (ability to pay, adherence, empowerment, caregiver support) perspective. Themes from provider interviews focused on healthcare reaching and healthcare utilization resulted in 19 facilitators and 9 barriers reaching saturation. The most themes fell under the utilization core domain, with themes identified that impact the technical and interpersonal quality of care and care coordination/continuity. Accessibility and availability of specialty care and use of interdisciplinary team that permitted matching patients to treatments were leading thematic facilitators. The leading thematic barrier identified primarily by medical providers was cognitive disability, which is likely directly linked with other leading barriers including high rates of noncompliance and poor follow-up in health care. Medical and behavioral health complexity was also a leading barrier to care and potentially interrelated to other themes identified. This is the first evidence-based study to inform policy and planning for this complex population to improve access to high-quality chronic pain treatment. Further research is needed to gain a better understanding of the perspectives of individuals with TBI/caregivers to inform interventions to improve access to chronic pain treatment for persons with TBI.

Opening decision spaces: A case study on the opportunities and constraints in the public health sector of Mpumalanga Province, South Africa.

Decentralised and evidence-informed health systems rely on managers and practitioners at all levels having sufficient 'decision space' to make timely locally informed and relevant decisions. Our objectives were to understand decision spaces in terms of constraints and enablers and outline opportunities through which to expand them in an understudied rural context in South Africa. This study examined decision spaces within Mpumalanga Province, using data and insights generated through a participatory action research process with local communities and health system stakeholders since 2015, which was combined with published documents and research team participant observation to produce findings on three core domains at three levels of the health system. Although capacity for decision making exists in the system, accessing it is frequently made difficult due to a number of intervening factors. While lines of authority are generally well-defined, personal networks take on an important dimension in how stakeholders can act. This is expressed through a range of informal coping strategies built on local relationships. There are constraints in terms of limited formal external accountability to communities, and internal accountability which is weak in places for individuals and focused more on meeting performance targets set at higher levels and less on enabling effective local leadership. More generally, political and personal factors are clearly identified at higher levels of the system, whereas at sub-district and facility levels, the dominant theme was constrained capacity. By examining the balance of authority, accountability and capacity across multiple levels of the provincial health system, we are able to identify emergent decision space and areas for enlargement. Creating spaces to support more constructive relationships and dialogue across system levels emerges as important, as well as reinforcing horizontal networks to problem solve, and developing the capacity of link-agents such as community health workers to increase community accountability.

Quality of primary health care for chronic diseases in low-resource settings: Evidence from a comprehensive study in rural China.

There is a paucity of evidence regarding the definition of the quality of primary health care (PHC) in China. This study aims to evaluate the PHC quality for chronic diseases in rural areas based on a modified conceptual framework tailored to the context of rural China. This comprehensive study, involving a patient survey, a provider survey and chart abstraction, and second-hand registered data, was set in three low-resource counties in rural China from 2021 to 2022. Rural patients with hypertension or type 2 diabetes, and health care workers providing care on hypertension or diabetes were involved. The modified PHC quality framework encompasses three core domains: a competent PHC system (comprehensiveness, accessibility, continuity, and coordination), effective clinical care (assessment, diagnosis, treatment, disease management, and provider competence), and positive user experience (information sharing, shared decision-making, respect for patient's preferences, and family-centeredness). Standardized PHC quality score was generated by arithmetic means or Rasch models of Item Response Theory. This study included 1355 patients, 333 health care providers and 2203 medical records. Ranging from 0 (the worst) to 1 (the best), the average quality score for the PHC system was 0.718, with 0.887 for comprehensiveness, 0.781 for accessibility, 0.489 for continuity, and 0.714 for coordination. For clinical care, average quality was 0.773 for disease assessment, 0.768 for diagnosis, 0.677 for treatment, 0.777 for disease management, and 0.314 for provider competence. The average quality for user experience was 0.727, with 0.933 for information sharing, 0.657 for shared decision-making, 0.936 for respect for patients' preferences, and 0.382 for family-centeredness. The differences in quality among population subgroups, although statistically significant, were small. The PHC quality in rural China has shown strengths and limitations. We identified large gaps in continuity of care, treatment, provider competence, family-centeredness, and shared decision-making. Policymakers should invest more effort in addressing these gaps to improve PHC quality.