Major Decision Points Research Articles

Career decisions by Australian police officers: a cross-section of perspectives on entering, staying in and leaving policing careers

Australian police officers (N = 182) who were staying in policing (n = 96), or undecided about staying (n = 57), and former police officers who had changed careers (n = 29) completed free-response questionnaires about their decisions to choose and stay in (or leave) policing careers. Thematic analysis of responses revealed different considerations by group. Categories of the kaleidoscope career model were used to evaluate the relative importance of themes by group. Retention strategies to meet police officers’ needs for authenticity, balance and challenge were suggested in light of salient themes at each major decision point.

Personalized prophylactic anticoagulation decision analysis in patients with membranous nephropathy

Primary membranous nephropathy is associated with increased risk of venous thromboembolic events, which are inversely correlated with serum albumin levels. To evaluate the potential benefit of prophylactic anticoagulation (venous thromboembolic events prevented) relative to the risk (major bleeds), we constructed a Markov decision model. The venous thromboembolic event risk according to serum albumin was obtained from an inception cohort of 898 patients with primary membranous nephropathy. Risk estimates of hemorrhage were obtained from a systematic literature review. Benefit-to-risk ratios were predicted according to bleeding risk and serum albumin. This ratio increased with worsening hypoalbuminemia from 4.5:1 for an albumin under 3 g/dl to 13.1:1 for an albumin under 2 g/dl in patients at low bleeding risk. Patients at intermediate bleeding risk with an albumin under 2 g/dl have a moderately favorable benefit-to-risk ratio (under 5:1). Patients at high bleeding risk are unlikely to benefit from prophylactic anticoagulation regardless of albuminemia. Probabilistic sensitivity analysis, to account for uncertainty in risk estimates, confirmed these trends. From these data, we constructed a tool to estimate the likelihood of benefit based on an individual's bleeding risk profile, serum albumin level, and acceptable benefit-to-risk ratio (www.gntools.com). This tool provides an approach to the decision of prophylactic anticoagulation personalized to the individual's needs and adaptable to dynamic changes in health status and risk profile.

Mapping posttranscriptional regulation of the human glycome uncovers microRNA defining the glycocode

Cell surface glycans form a critical interface with the biological milieu, informing diverse processes from the inflammatory cascade to cellular migration. Assembly of discrete carbohydrate structures requires the coordinated activity of a repertoire of proteins, including glycosyltransferases and glycosidases. Little is known about the regulatory networks controlling this complex biosynthetic process. Recent work points to a role for microRNA (miRNA) in the regulation of specific glycan biosynthetic enzymes. Herein we take a unique systems-based approach to identify connections between miRNA and the glycome. By using our glycomic analysis platform, lectin microarrays, we identify glycosylation signatures in the NCI-60 cell panel that point to the glycome as a direct output of genomic information flow. Integrating our glycomic dataset with miRNA data, we map miRNA regulators onto genes in glycan biosynthetic pathways (glycogenes) that generate the observed glycan structures. We validate three of these predicted miRNA/glycogene regulatory networks: high mannose, fucose, and terminal β-GalNAc, identifying miRNA regulation that would not have been observed by traditional bioinformatic methods. Overall, our work reveals critical nodes in the global glycosylation network accessible to miRNA regulation, providing a bridge between miRNA-mediated control of cell phenotype and the glycome.

The road not taken or how I learned to love the liver: A personal perspective on hepatitis history

The road not taken or how I learned to love the liver: A personal perspective on hepatitis history

Researching together: a CTSA partnership of academicians and communities for translation.

The Colorado Clinical and Translational Sciences Institute (CCTSI) aims to translate discovery into clinical practice. The Partnership of Academicians and Communities for Translation (PACT) represents a robust campus-community partnership. The CCTSI collected data on all PACT activities including meeting notes, staff activity logs, stakeholder surveys and interviews, and several key component in-depth evaluations. Data analysis by Evaluation and Community Engagement Core and PACT Council members identified critical shifts that changed the trajectory of community engagement efforts. Ten "critical shifts" in six broad rubrics created change in the PACT. Critical shifts were decision points in the development of the PACT that represented quantitative and qualitative changes in the work and trajectory. Critical shifts occurred in PACT management and leadership, financial control and resource allocation, and membership and voice. The development of a campus-community partnership is not a smooth linear path. Incremental changes lead to major decision points that represent an opportunity for critical shifts in developmental trajectory. We provide an enlightening, yet cautionary, tale to others considering a campus-community partnership so they may prepare for crucial decisions and critical shifts. The PACT serves as a genuine foundational platform for dynamic research efforts aimed at eliminating health disparities.

Guidelines for thermodynamic sorption modelling in the context of radioactive waste disposal

Thermodynamic sorption models (TSMs) offer the potential to improve the incorporation of sorption in environmental modelling of contaminant migration. One specific application is safety cases for radioactive waste repositories, in which radionuclide sorption on mineral surfaces is usually described using distribution coefficients (Kd values). TSMs can be utilised to provide a scientific basis for the range of Kd values included in the repository safety case, and for assessing the response of Kd to changes in chemical conditions. The development of a TSM involves a series of decisions on model features such as numbers and types of surface sites, sorption reactions and electrostatic correction factors. There has been a lack of consensus on the best ways to develop such models, and on the methods of determination of associated parameter values. The present paper therefore presents recommendations on a number of aspects of model development, which are applicable both to radioactive waste disposal and broader environmental applications.The TSM should be calibrated using a comprehensive sorption data set for the contaminant of interest, showing the impact of major geochemical parameters including pH, ionic strength, contaminant concentration, the effect of ligands, and major competing ions. Complex natural materials should be thoroughly characterised in terms of mineralogy, surface area, cation exchange capacity, and presence of impurities. During the application of numerical optimisation programs to simulate sorption data, it is often preferable that the TSM should be fitted to the experimentally determined Kd parameter, rather than to the frequently used percentage sorbed. Two different modelling approaches, the component additivity and generalised composite, can be used for modelling sorption data for complex materials such as soils. Both approaches may be coupled to the same critically reviewed aqueous thermodynamic data sets, and may incorporate the same, or similar, surface reactions and surface species. The quality of the final sorption model can be assessed against the following characteristics: an appropriate level of complexity, documented and traceable decisions, internal consistency, limitations on the number of adjustable parameter values, an adequate fit to a comprehensive calibration data set, and capability of simulating independent data sets. Key recommendations for the process of TSM development include: definition of modelling objectives, identification of major decision points, a clear decision-making rationale with reference to experimental or theoretical evidence, utilisation of a suitable consultative and iterative model development process, testing to the maximum practicable extent, and thorough documentation of key decisions. These recommendations are consistent with international benchmarks for environmental modelling.

친환경건축물인증 발주자업무 수행역량 제고를 위한 IDEF3 모델기반 관리체계 구축

Owners` efforts to acquire Green building certification, which started in 2002, have been rapidly increasing since 2006. The causes of the increased owners` interests are due to various incentives, legal obligation, and purpose of advertising. As project owners generally are deficient in capabilities and knowledge on how to deal with administrative works on certification, they tend to fulfill the minimum requirements for certification. However, effective administration process need capabilities of identifying individual making decision point and review information. The implementation of green building certification system is expected to provide comfort to both occupants and potential users. Furthermore it contributes to reducing energy costs throughout the phase of O&M. In addition, technology innovation in green industry can be obtained. Therefore, this study is intended to support owners in order that they can clarify certification tasks and make a rational decision-making in time. For this purpose, first of all, the major decision points were selected as the gateways of green building certification process. And then management system based on IDEF3 modeling was developed for supporting owners` decision-making performance. This management system will improve owners` overall capacity in handling all the tasks regarding the certification of Green building.

Planning assumptions and implementing strategies for co-operative print storage initiatives

This article recounts some of the major decision points addressed by the library directors on the Committee on Institutional Cooperation (CIC) in their efforts to establish a shared print repository for journal back-files widely held across CIC libraries. In 2011, the directors committed to co-invest in a centralized strategy to aggregate 250,000 volumes at Indiana University (IU), with potential for the project to expand over time to address other library formats (i.e. monographs) and encompass other storage host-sites. A focus of the article is an assessment of the costs of such projects, and the potential return on the investments being made by the CIC libraries.

Evaluating Racial and Ethnic Disparities in Criminal Process: Evidence from North Carolina

Much empirical analysis has documented racial disparities at the beginning and end stages of a criminal case. However, our understanding about the perpetuation of - and even corrections for - differential outcomes as the process unfolds remains less than complete. This Article provides a comprehensive examination of criminal dispositions using all DWI cases in North Carolina during the period 2001-2011, focusing on several major decision points in the process. Starting with pretrial hearings and culminating in sentencing results, we track differences in outcomes by race and gender. Before sentencing, significant gaps emerge in the severity of pretrial release conditions that disadvantage black and Hispanic defendants. Yet when prosecutors decide whether to pursue charges, we observe an initial correction mechanism: Hispanic men are almost two-thirds more likely to have those charges dropped relative to white men. Although few cases survive after the plea bargaining stage, a second correction mechanism arises: Hispanic men are substantially less likely to receive harsher sentences and are sent to jail for significantly less time relative to white men. The first mechanism is based in part on prosecutors' reviewing the strength of the evidence but much more on declining to invest scarce resources in the pursuit of defendants who fail to appear for trial. The second mechanism seems to follow more directly from judicial discretion to reverse decisions made by law enforcement. We discuss possible explanations for these novel empirical results and review methods for more precisely identifying causal mechanisms in criminal justice.

Implementing and Maintaining Nurse-Led Healthy Living Programs in Forensic Inpatient Settings: An Illustrative Case Study

Healthy living programs (HLPs) within the context of mental health units are an applied response to the concerns of metabolic syndrome and the associated physical illnesses to which people with serious mental illness are susceptible. To illustrate how nurses, with other health professionals and service users, have established and maintained HLPs in two locked forensic mental health units in New Zealand. This illustrative case study adopts a multimodal approach to data collection and analysis. Across two programs, interviews were undertaken with service users (n = 15) and staff (n = 17), minutes of meetings were analyzed for major decision points, and clinical notes were reviewed to identify which service-user health status measures (body mass index, glucose tolerance test results, blood pressure, and medication use) were recorded. Similarities were identified in the way the HLPs were implemented and maintained by champions who advocated for change, challenged staff attitudes, secured funding, and established new systems and protocols. Successful implementation depended on involvement of the multidisciplinary team. Each program operated within a different physical environment and adopted its own philosophical approach that shaped the style of the program. The HLPs had an impact on nurses, other staff, and on the culture of the institutions. The programs raised dilemmas about restrictions and risk versus autonomy and self-management. Understanding the effects of the clinical and philosophical contexts in which HLPs are established and the way challenges and benefits are affected by context has practical significance for the future development of health programs in forensic settings, prisons, and general mental health units.

Perturbations of MicroRNA Function in Mouse Dicer Mutants Produce Retinal Defects and Lead to Aberrant Axon Pathfinding at the Optic Chiasm

BackgroundDuring development axons encounter a variety of choice points where they have to make appropriate pathfinding decisions. The optic chiasm is a major decision point for retinal ganglion cell (RGC) axons en route to their target in order to ensure the correct wiring of the visual system. MicroRNAs (miRNAs) belong to the class of small non-coding RNA molecules and have been identified as important regulators of a variety of processes during embryonic development. However, their involvement in axon guidance decisions is less clear.Methodology/Principal FindingsWe report here that the early loss of Dicer, an essential protein for the maturation of miRNAs, in all cells of the forming retina and optic chiasm leads to severe phenotypes of RGC axon pathfinding at the midline. Using a conditional deletion approach in mice, we find in homozygous Dicer mutants a marked increase of ipsilateral projections, RGC axons extending outside the optic chiasm, the formation of a secondary optic tract and a substantial number of RGC axons projecting aberrantly into the contralateral eye. In addition, the mutant mice display a microphthalmia phenotype.ConclusionsOur work demonstrates an important role of Dicer controlling the extension of RGC axons to the brain proper. It indicates that miRNAs are essential regulatory elements for mechanisms that ensure correct axon guidance decisions at the midline and thus have a central function in the establishment of circuitry during the development of the nervous system.

Monitoring integrated care with a clinical logic model

Introduction: The Dutch Healthcare Inspectorate is in search for a better insight into how to measure the quality of integrated care. The central purpose of this study was to identify indicators that provide insight into the performance of the chain as a whole, by means of a clinical logic model. Theory and methods: Chain care makes high demands on communication and transfer of information between caregivers. The extent to which such requirements are met constitutes an indicator of the quality of care delivered. In order to be able to identify suitable indicators, chain care is charted in the form of a schematic model, a so-called ‘clinical logic’. A clinical logic captures the elements of the disease process and the care chain to which it gives rise. The components of the model and the factors that determine the quality of care are described in an analytical manner, based on scientific evidence. Measures are selected that capture the following questions: ‘What are the key elements of care at each step in the process?’, ‘How does the patient flow through the care system?’, ‘Where are the major decision points in treatment related to the goal?’ Results and conclusions: Clinical logics were applied on three patient groups: dementia, heart failure and depression. On the basis of the clinical logic for heart failure patients 15 indicators were proposed, for dementia 9 indicators and for depression 12 indicators. Clinical logics have proven to be a sound method to chart chain/integrated care, but it is mainly focused on the process of care. It is more concrete than the chronic care model. Next, the identified indicators will be tested into practice.

The Examination for Professional Practice in Psychology (EPPP) in the era of evidence-based practice.

Professional psychology has increasingly moved toward evidence-based practice. However, instrumentsused to assess psychologists seeking licensure, such as the Examination for Professional Practice inPsychology (EPPP), have received relatively little empirical scrutiny. Therefore, the authors evaluatedthe available evidence in support of the EPPP’s validity and current use as a core component ofprofessional licensure. Although the EPPP has in many ways been extensively evaluated, there is apaucity of criterion, predictive, and incremental validity evidence available. Further, several aspects ofthe content validation studies were examined, and the authors question whether the EPPP, as currentlyconstructed, can meet its stated goals. Given that the EPPP is a high-stakes examination and given theauthors’ best estimate (based on a sample of 16 states) that 35% of applicants fail the examination, it isrecommended that the EPPP be more extensively evaluated. An outline of major decision points in thisproposed evaluation process is provided, several suggestions for further research are proposed, and thefield is encouraged to discuss these issues further.Keywords: ExaminationforProfessionalPracticeinPsychology,EPPP,licensure,educationandtraining,competence

123I-MIBG Scintigraphy and 18F-FDG PET in Neuroblastoma

The purpose of this study was to compare the diagnostic utility of (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy and (18)F-FDG PET in neuroblastoma. A total of 113 paired (123)I-MIBG and (18)F-FDG PET scans in 60 patients with neuroblastoma were retrospectively reviewed. Paired scans were acquired within 14 days of each other. For stage 1 and 2 neuroblastoma (13 scans, 10 patients), (18)F-FDG depicted more extensive primary or residual neuroblastoma in 9 of 13 scans. (123)I-MIBG and (18)F-FDG showed equal numbers of lesions in 1 of 13 scans, and 3 of 13 scan results were normal. For stage 3 neuroblastoma (15 scans, 10 patients), (123)I-MIBG depicted more extensive primary neuroblastoma or local or regional metastases in 5 of 15 scans. (18)F-FDG depicted more extensive primary neuroblastoma or local or regional metastases in 4 of 15 scans. (123)I-MIBG and (18)F-FDG were equal in 2 of 15 scans, and 4 of 15 scan results were normal. For stage 4 neuroblastoma (85 scans, 40 patients), (123)I-MIBG depicted more neuroblastoma sites in 44 of 85 scans. (18)F-FDG depicted more neuroblastoma sites in 11 of 85 scans. (123)I-MIBG and (18)F-FDG were equivalent or complementary in 13 of 85 scans, and 17 of 85 scan results were normal. (18)F-FDG is superior in depicting stage 1 and 2 neuroblastoma, although (123)I-MIBG may be needed to exclude higher-stage disease. (18)F-FDG also provides important information for patients with tumors that weakly accumulate (123)I-MIBG and at major decision points during therapy (i.e., before stem cell transplantation or before surgery). (18)F-FDG can also better delineate disease extent in the chest, abdomen, and pelvis. (123)I-MIBG is overall superior in the evaluation of stage 4 neuroblastoma, especially during initial chemotherapy, primarily because of the better detection of bone or marrow metastases.

The Ordinary Miracle of Cancer Clinical Trials

The Ordinary Miracle of Cancer Clinical Trials

Steps and Time to Process Clinical Trials at the Cancer Therapy Evaluation Program

To examine the processes and document the calendar time required for the National Cancer Institute's Cancer Therapy Evaluation Program (CTEP) and Central Institutional Review Board (CIRB) to evaluate and approve phase III clinical trials. Process steps were documented by (1) interviewing CTEP and CIRB staff regarding the steps required to activate a trial from initial concept submission to trial activation by a cooperative group, (2) reviewing standard operating procedures, and (3) inspecting trial records and documents for selected trials to identify any additional steps. Calendar time was collected from initial concept submission to activation using retrospective data from the CTEP Protocol and Information Office. At least 296 distinct processes are required for phase III trial activation: at least 239 working steps, 52 major decision points, 20 processing loops, and 11 stopping points. Of the 195 trials activated during the January 1, 2000, to December 31, 2007, study period, a sample of 167 (85.6%) was used for gathering timing data. Median calendar days from initial formal concept submission to CTEP to trial activation by a cooperative group was 602 days (interquartile range, 454 to 861 days). This time has not significantly changed over the past 8 years. There is a high variation in the time required to activate a clinical trial. Because of their complexity, the overall development time for phase III clinical trials is lengthy, process laden, and highly variable. To streamline the process, a solution must be sought that includes all parties involved in developing trials.

Development of Clinical Trials in a Cooperative Group Setting: The Eastern Cooperative Oncology Group

We examine the processes and document the calendar time required to activate phase II and III clinical trials by an oncology group: the Eastern Cooperative Oncology Group (ECOG). Setup steps were documented by (a) interviewing ECOG headquarters and statistical center staff, and committee chairs, (b) reviewing standard operating procedure manuals, and (c) inspecting study records, documents, and e-mails to identify additional steps. Calendar time was collected for each major process for each study in this set. Twenty-eight phase III studies were activated by ECOG during the January 2000 to July 2006 study period. We examined a sample from 16 of those studies in detail. More than 481 distinct processes were required for study activation: 420 working steps, 61 major decision points, 26 processing loops, and 13 stopping points. Median calendar days to activate a trial in the phase III subset was 783 days (range, 285-1,542 days) from executive approval and 808 days (range, 435-1,604 days) from initial conception of the study. Data were collected for all phase II and phase III trials activated and completed during this time period (n = 52) for which development time represented 43.9% and 54.1% of the total trial time, respectively. The steps required to develop and activate a clinical trial may require as much or more time than the actual completion of a trial. The data shows that to improve the activation process, research should to be directed toward streamlining both internal and external groups and processes.

Will Emergency Health Care Providers Respond to Mass Casualty Incidents?

Introduction: Emergency response plans often call on health care providers to respond to the workplace outside of their normal working pattern. Hypothesis. Providers will report to work during a mass casualty emergency regardless of family duties, type of incident, or availability of treatment. Methods. Survey of emergency personnel needed to respond to a mass casualty incident. Two scenarios were presented: one involving the release of a nontransmissible biological agent with proven treatment andthe other the release of a transmissible biological agent with no treatment. At critical time points, participants were asked whether they would report to work. Additional questions considered the effect of commonly used treatment dissemination methods. Results. A total of 186 surveys were issued andreturned. (45 physicians, 29 nurses, 86 EMS personnel, and20 support staff); 6 were incomplete andexcluded. Initial commitment rates were 78%. The highest commitment rate identified was 84% andthe lowest was 18%. Any treatment dissemination method excluding providers' family members led to decreases in commitment rate, as did agents identified to be transmissible. Conclusions. As an event develops, fewer health care providers will report to work andat no time will all providers report when asked. This conclusion may be generalizable to several types of incidents ranging from pandemic influenza to bioterrorism. Identification of the causative agent is a major decision point for providers to return to or stay away from work. Offering on-site treatment of providers' family increases commitment to work. These factors should be considered in emergency planning.

A timing and process flow analysis of opening clinical trials within an oncology cooperative group setting: The case of the CALGB

6015 Background: Cooperative oncology groups are major sponsors of Phase III clinical trials, yet the number of steps and times required to setup and open such a trial have yet to be studied. This study assesses these items in the Cancer and Leukemia Group B (CALGB) for all Phase III studies opened in a 3 year period. Methods: Step 1: headquarters and statistical center staff were interviewed to discover the detailed steps required for a study to transit from initial concept submission by a potential study chair to final activation of the study. The formal procedures manuals were also reviewed. All study records and draft protocol documents were inspected to verify and identify additional setup steps. Finally, data was collected through direct contact with study chairs and disease committee chairs. Step 2: timing data for each of the major functions or processes were collected. All times are from initial initiation of the function to the final completion of the task. Times represent calendar time. Step 3: creation of stream-lined process flows, currently underway. Members from the CALGB and the Vanderbilt Center for Management Research in Healthcare (cmrhc.org) will spend 2 days creating a process to significantly reduce the time and the number of steps to opening a trial. Results: A total of 13 Phase III studies were activated during the 3 years study period. 372 processes are required to open a Phase III at CALGB, which include 314 work steps, 43 major decision points. Interesting, most of the decision points (63%) are external to CALGB. There are 23 processing loops that require repeating processes. The process map, which lists all processes, is a chart 243.5” × 41 in 8 pt font (or about the length of a 20 passenger bus). Median calendar days to activate a Phase III study at CALGB is 767 days (min = 488, max = 1,441). The three functions requiring the greatest median days are protocol development (477), forms development (434), and regulatory affairs (350). Conclusion: It can require years to open a Phase III study at a major cooperative oncology group. Using process redesign techniques, we expect to be able to significantly streamline the process. Support provided by the NCI. No significant financial relationships to disclose.

The Effects of Seeking Punitive Damages on the Processing of Tort Claims

Abstract Punitive damages are a controversial aspect of tort litigation and have been the subjct of numerous theoretical, empirical, and experimental studies. Critics have argued that the uncertainty and unpredictability that punitive damages claims inject into a case may increase the rate and amount of settlements and carry systemic consequences for the general processing of tort claims. This paper represents the first empirical examination of this hypothesis. With one of the most comprehensive data sets of tort litigation, we analyze cases that are likely to have caps on punitive damages awards and cases that are likely to be uncapped. We examine the effect of the decision to seek punitive damages on several major decision points in the tort litigation process in a series of logit regression models. With extensive control variables, we find that seeking punitive damages has no statistically significant effect on most phases of the tort litigation process.