Patient perspectives on recall period and response options in patient-reported outcome measures for chronic rhinosinusitis symptomatology: An international multi-centered study

BACKGROUND

Existing patient-reported outcome measures (PROMs) for chronic rhinosinusitis (CRS) use a variety of recall periods and response scales to assess CRS symptom burden. Global perspectives of CRS patients regarding optimal recall periods and response scales for CRS PROMs are unknown.

METHODS

This was a multi-center, cross-sectional study recruiting 461 CRS patients from sites across the United States, Saudi Arabia, New Zealand, and Austria. Participants chose which CRS symptom recall period (1 day, 2 weeks, 1 month, >1 month) was most reflective of their current disease state and upon which to best base treatment recommendations (including surgery). Participants also chose which of six response scales (one visual analogue scale and five Likert scales ranging from four to eight items) was easiest to use, understand, and preferred.

RESULTS

A plurality of participants (40.0%) felt their CRS symptoms' current state was best reflected by a 1-month recall period. However, most patients (56.9%) preferred treatment recommendations to be determined by symptoms experienced over a >1 month period. The four- and five-item Likert scales were the easiest to understand (26.0% and 25.4%, respectively) and use (23.4% and 26.7%, respectively). The five-item (26.4% rating it most preferred and 70.9% rating it preferred) and four-item Likert (22.3% rating it most preferred and 56.4% rating it preferred) response scales were most preferred.

CONCLUSION

Future PROMs for CRS should consider assessment of symptoms over a 1-month period and use a four- or five-item Likert response scale to reflect global patient preferences. These findings also inform interpretation of current CRS PROMs.

Modeling Complex Ligands for High Oxidation State Catalysis: Titanium Hydroamination with Unsymmetrical Ligands

A method for modeling high oxidation state catalysts is used on precatalysts with unsymmetrical and symmetrical bidentate ligands to get a more detailed understanding of how changes to ancillary ligands affect the hydroamination of alkynes catalyzed by titanium. To model the electronic donor ability, the ligand donor parameter (LDP) was used, and to model the steric effects, percent buried volume (% Vbur) was employed. For the modeling study, 7 previously unpublished unsymmetrical Ti(XX')(NMe2)2 precatalysts were prepared, where XX' is a chelating ligand with pyrrolyl/indolyl linkages. The rates of these unsymmetrical and 10 previously reported symmetrical precatalysts were used with the model kobs = a + b(LDP)1 + c(LDP)2 + d(% Vbur)1 + e(% Vbur)2, where a-e were found through least-squares refinement. The model suggests that (1) the two attachment points of the bidentate ligand XX' are in different environments on the metal (e.g., axial and equatorial in a trigonal bipyramidal or square pyramidal structure), (2) the position of the unsymmetrical ligand on the metal is determined by the electronics of the ligand rather than the sterics, and (3) that one side of the chelating ligand's electronics strongly influences the rate, while the other side's sterics more strongly influences the rate. From these studies, we were able to generate catalysts fitting to this model with rate constants larger than the fastest symmetrical catalyst tested.

Design, Synthesis, Antifungal Activity, and Molecular Docking Studies of Novel Chiral Isoxazoline-Benzofuran-Sulfonamide Derivatives

Succinate dehydrogenase (SDH) is one of the most important molecular targets for the development of novel fungicides. With the emerging problem of resistance in plant fungal pathogens, novel compounds with high fungicidal activity need to be developed, but the study of chiral pesticides for the inhibition of highly destructive plant pathogens has been rarely reported in recent years. Therefore, a series of novel chiral isoxazoline-benzofuran-sulfonamide derivatives were designed to investigate potential novel antifungal molecules. The chiral target compound 3a was cultured as a single crystal and confirmed using X-ray diffraction. All the target compounds were tested for antifungal activity, and compounds 3c, 3i, 3s, and 3r were found to have significant antifungal effects against S. sclerotiorum with EC50 values of 0.42 mg/L, 0.33 mg/L, 0.37 mg/L, and 0.40 mg/L, respectively, which were superior to the commercial fungicide fluopyram (EC50 = 0.47 mg/L). The IC50 value of compound 3i against the SDH of S. sclerotiorum was 0.63 mg/mL, which was further demonstrated by enzyme activity assays. Scanning electron microscopy showed that 3i had a significant inhibitory effect on S. sclerotiorum. In addition, the fluorescence quenching analysis assay indicated that compound 3i had a similar effect with the positive control fluopyram. Molecular docking exhibited that target compounds with chiral configuration had better affinity than racemic configuration, and 3i possessed stronger action than fluopyram, which was in keeping with the in vitro test results. These results would provide a basis and reference for the development of novel chiral fungicides.

Promoting a Patient-Centered Understanding of Safety in Acute Mental Health Wards: A User-Centered Design Approach to Develop a Real-Time Digital Monitoring Tool

BACKGROUND

Acute mental health services report high levels of safety incidents that involve both patients and staff. The potential for patients to be involved in interventions to improve safety within a mental health setting is acknowledged, and there is a need for interventions that proactively seek the patient perspective of safety. Digital technologies may offer opportunities to address this need.

OBJECTIVE

This research sought to design and develop a digital real-time monitoring tool (WardSonar) to collect and collate daily information from patients in acute mental health wards about their perceptions of safety. We present the design and development process and underpinning logic model and programme theory.

METHODS

The first stage involved a synthesis of the findings from a systematic review and evidence scan, interviews with patients (n=8) and health professionals (n=17), and stakeholder engagement. Cycles of design activities and discussion followed with patients, staff, and stakeholder groups, to design and develop the prototype tool.

RESULTS

We drew on patient safety theory and the concepts of contagion and milieu. The data synthesis, design, and development process resulted in three prototype components of the digital monitoring tool (WardSonar): (1) a patient recording interface that asks patients to input their perceptions into a tablet computer, to assess how the ward feels and whether the direction is changing, that is, "getting worse" or "getting better"; (2) a staff dashboard and functionality to interrogate the data at different levels; and (3) a public-facing ward interface. The technology is available as open-source code.

CONCLUSIONS

Recent patient safety policy and research priorities encourage innovative approaches to measuring and monitoring safety. We developed a digital real-time monitoring tool to collect information from patients in acute mental health wards about perceived safety, to support staff to respond and intervene to changes in the clinical environment more proactively.

Mental Distress, Label Avoidance, and Use of a Mental Health Chatbot: Results From a US Survey

BACKGROUND

For almost two decades, researchers and clinicians have argued that certain aspects of mental health treatment can be removed from clinicians' responsibilities and allocated to technology, preserving valuable clinician time and alleviating the burden on the behavioral health care system. The service delivery tasks that could arguably be allocated to technology without negatively impacting patient outcomes include screening, triage, and referral.

OBJECTIVE

We pilot-tested a chatbot for mental health screening and referral to understand the relationship between potential users' demographics and chatbot use; the completion rate of mental health screening when delivered by a chatbot; and the acceptability of a prototype chatbot designed for mental health screening and referral. This chatbot not only screened participants for psychological distress but also referred them to appropriate resources that matched their level of distress and preferences. The goal of this study was to determine whether a mental health screening and referral chatbot would be feasible and acceptable to users.

METHODS

We conducted an internet-based survey among a sample of US-based adults. Our survey collected demographic data along with a battery of measures assessing behavioral health and symptoms, stigma (label avoidance and perceived stigma), attitudes toward treatment-seeking, readiness for change, and technology readiness and acceptance. Participants were then offered to engage with our chatbot. Those who engaged with the chatbot completed a mental health screening, received a distress score based on this screening, were referred to resources appropriate for their current level of distress, and were asked to rate the acceptability of the chatbot.

RESULTS

We found that mental health screening using a chatbot was feasible, with 168 (75.7%) of our 222 participants completing mental health screening within the chatbot sessions. Various demographic characteristics were associated with a willingness to use the chatbot. The participants who used the chatbot found it to be acceptable. Logistic regression produced a significant model with perceived usefulness and symptoms as significant positive predictors of chatbot use for the overall sample, and label avoidance as the only significant predictor of chatbot use for those currently experiencing distress.

CONCLUSIONS

Label avoidance, the desire to avoid mental health services to avoid the stigmatized label of mental illness, is a significant negative predictor of care seeking. Therefore, our finding regarding label avoidance and chatbot use has significant public health implications in terms of facilitating access to mental health resources. Those who are high on label avoidance are not likely to seek care in a community mental health clinic, yet they are likely willing to engage with a mental health chatbot, participate in mental health screening, and receive mental health resources within the chatbot session. Chatbot technology may prove to be a way to engage those in care who have previously avoided treatment due to stigma.

Exploring Scaffold Hopping for Novel 2-(Quinolin-4-yloxy)acetamides with Enhanced Antimycobacterial Activity

Utilizing a scaffold-hopping strategy from the drug candidate telacebec, a novel series of 2-(quinolin-4-yloxy)acetamides was synthesized and evaluated as inhibitors of Mycobacterium tuberculosis (Mtb) growth. These compounds demonstrated potent activity against drug-sensitive and multidrug-resistant strains (MIC ≤ 0.02 μM). Leading compounds were evaluated against a known qcrB resistant strain (T313A), and their loss in activity suggested that the cytochrome bc1 complex is the likely target. Additionally, these structures showed high selectivity regarding mammalian cells (selectivity index > 500) and stability across different aqueous media. Furthermore, some of the synthesized quinolines demonstrated aqueous solubility values that exceeded those of telacebec, while maintaining low rates of metabolism. Finally, a selected compound prevented Mtb growth by more than 1.7 log10 colony forming units in a macrophage model of tuberculosis (TB) infection. These findings validate the proposed design and introduce new 2-(quinolin-4-yloxy)acetamides with potential for development in TB drug discovery campaigns.

National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study

BACKGROUND

In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics.

OBJECTIVE

The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention.

METHODS

The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite).

RESULTS

The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation.

CONCLUSIONS

This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/47525.

Efficacy of a Virtual 3D Simulation-Based Digital Training Module for Building Dental Technology Students' Long-Term Competency in Removable Partial Denture Design: Prospective Cohort Study

Background

Removable partial denture (RPD) design is crucial to long-term success in dental treatment, but shortcomings in RPD design training and competency acquisition among dental students have persisted for decades. Digital production is increasing in prevalence in stomatology, and a digital RPD (D-RPD) module, under the framework of the certified Objective Manipulative Skill Examination of Dental Technicians (OMEDT) system reported in our previous work, may improve on existing RPD training models for students.

Objective

We aimed to determine the efficacy of a virtual 3D simulation-based progressive digital training module for RPD design compared to traditional training.

Methods

We developed a prospective cohort study including dental technology students at the Stomatology College of Chongqing Medical University. Cohort 1 received traditional RPD design training (7 wk). Cohort 2 received D-RPD module training based on text and 2D sketches (7 wk). Cohort 3 received D-RPD module pilot training based on text and 2D sketches (4 wk) and continued to receive training based on 3D virtual casts of real patients (3 wk). RPD design tests based on virtual casts were conducted at 1 month and 1 year after training. We collected RPD design scores and the time spent to perform each assessment.

Results

We collected the RPD design scores and the time spent to perform each assessment at 1 month and 1 year after training. The study recruited 109 students, including 58 (53.2%) female and 51 male (56.8%) students. Cohort 1 scored the lowest and cohort 3 scored the highest in both tests (cohorts 1-3 at 1 mo: mean score 65.8, SD 21.5; mean score 81.9, SD 6.88; and mean score 85.3, SD 8.55, respectively; P<.001; cohorts 1-3 at 1 y: mean score 60.3, SD 16.7; mean score 75.5, SD 3.90; and mean score 90.9, SD 4.3, respectively; P<.001). The difference between cohorts in the time spent was not statistically significant at 1 month (cohorts 1-3: mean 2407.8, SD 1370.3 s; mean 1835.0, SD 1329.2 s; and mean 1790.3, SD 1195.5 s, respectively; P=.06) but was statistically significant at 1 year (cohorts 1-3: mean 2049.16, SD 1099.0 s; mean 1857.33, SD 587.39 s; and mean 2524.3, SD 566.37 s, respectively; P<.001). Intracohort comparisons indicated that the differences in scores at 1 month and 1 year were not statistically significant for cohort 1 (95% CI -2.1 to 13.0; P=.16), while cohort 3 obtained significantly higher scores 1 year later (95% CI 2.5-8.7; P=.001), and cohort 2 obtained significantly lower scores 1 year later (95% CI -8.8 to -3.9; P<.001).

Conclusions

Cohort 3 obtained the highest score at both time points with retention of competency at 1 year, indicating that progressive D-RPD training including virtual 3D simulation facilitated improved competency in RPD design. The adoption of D-RPD training may benefit learning outcomes.

Design and evaluation of a web-based electronic health record for amblyopia

Introduction

Amblyopia, or lazy eye, is a type of visual impairment in which the eyesight is not complete, even with the use of glasses. For the treatment of this disease, accurate and continuous examinations are needed. Nowadays, patient-centered care, by relying on web-based electronic records for amblyopia, has the potential to reduce treatment costs, increase the quality of care, and improve the safety and effectiveness of treatment. Therefore, the purpose of this study is to design and evaluate an Electronic Health Record (EHR) for patients with amblyopia.

Methods

The present study is applied developmental research. Using a Morgan table as a sampling tool, a straightforward random sampling technique selected 150 records from 1,500 records that were free of flaws. The design of the electronic version proceeded in a cascading manner so that after the design of each part, it was presented to the amblyopia experts, and if approved, the next part was designed. To design this EHR, the C# programming language and MySQL database were used. A system evaluation was performed by entering and recording patient information. For this purpose, the standard Questionnaire of User Interaction Satisfaction (QUIS), consisting of 18 questions, was used.

Results

According to the amblyopia EHR data elements, the data of physician and patient, examinations, website members, and members' roles were determined. After defining the fields and classes that explain the tables, the EHR was designed. The usability evaluation of the system showed that the mean selection of very good and good options by the users of EHRs was over 90%, indicating the patients' acceptance of web-based EHRs.

Conclusion

The design of an EHR for amblyopia is an effective step toward integrating and improving the information management of these patients. It will also enable the storage and retrieval of patients' information to reduce and facilitate the control of amblyopia complications.

A Serious Game for Cognitive Stimulation of Older People With Mild Cognitive Impairment: Design and Pilot Usability Study

Background

Cognitive stimulation of older people helps prevent, and even treat, age-related diseases, such as mild cognitive impairment. Playing games reduces the probability of experiencing this pathology, which is related to the loss of the ability to carry out some instrumental activities of daily living.

Objective

This work describes the design and development of a serious game for the cognitive stimulation of older people, with exercises related to the daily life task of shopping. A pilot study for its preliminary usability validation is also presented.

Methods

The designed serious game includes 4 exercises consisting of shopping in a hypermarket, ordering products, making payments, and organizing the purchase, thus dealing with the most frequent cognitive problems of older people associated with episodic declarative memory, naming, calculation, and organization, respectively.

Results

A total of 19 older people participated in the pilot study for the usability validation of the serious game. They indicated that they like the aesthetic and interesting topic of the game. They reported that it provides a high level of entertainment and could be useful in daily life for mental stimulation. The participants found the serious game to be intuitive, but the ease of use and readability of the instructions could be improved.

Conclusions

This study suggests that the innovative serious game developed could be accepted by older people for their cognitive stimulation to prevent or treat mild cognitive impairment, although a long-term intervention study should be performed as future work. Its ecological validity design, with everyday tasks, adaptable levels of difficulty, and motivational mechanisms, is a differentiating factor compared to similar serious games.

Using ChatGPT in Psychiatry to Design Script Concordance Tests in Undergraduate Medical Education: Mixed Methods Study

Background

Undergraduate medical studies represent a wide range of learning opportunities served in the form of various teaching-learning modalities for medical learners. A clinical scenario is frequently used as a modality, followed by multiple-choice and open-ended questions among other learning and teaching methods. As such, script concordance tests (SCTs) can be used to promote a higher level of clinical reasoning. Recent technological developments have made generative artificial intelligence (AI)-based systems such as ChatGPT (OpenAI) available to assist clinician-educators in creating instructional materials.

Objective

The main objective of this project is to explore how SCTs generated by ChatGPT compared to SCTs produced by clinical experts on 3 major elements: the scenario (stem), clinical questions, and expert opinion.

Methods

This mixed method study evaluated 3 ChatGPT-generated SCTs with 3 expert-created SCTs using a predefined framework. Clinician-educators as well as resident doctors in psychiatry involved in undergraduate medical education in Quebec, Canada, evaluated via a web-based survey the 6 SCTs on 3 criteria: the scenario, clinical questions, and expert opinion. They were also asked to describe the strengths and weaknesses of the SCTs.

Results

A total of 102 respondents assessed the SCTs. There were no significant distinctions between the 2 types of SCTs concerning the scenario (P=.84), clinical questions (P=.99), and expert opinion (P=.07), as interpretated by the respondents. Indeed, respondents struggled to differentiate between ChatGPT- and expert-generated SCTs. ChatGPT showcased promise in expediting SCT design, aligning well with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria, albeit with a tendency toward caricatured scenarios and simplistic content.

Conclusions

This study is the first to concentrate on the design of SCTs supported by AI in a period where medicine is changing swiftly and where technologies generated from AI are expanding much faster. This study suggests that ChatGPT can be a valuable tool in creating educational materials, and further validation is essential to ensure educational efficacy and accuracy.

Part 1: system description

PURPOSE

This is the first of two papers summarizing studies reporting on the design of electronic graphic symbol-based augmentative and alternative communication (AAC) systems, to determine the state of the field. The aim of this paper was to provide an overview of the general characteristics of the studies and to describe the features of the systems designed.

METHODS

A scoping review was conducted. A multifaceted search resulted in the identification of 28 studies meeting the selection criteria. Data were extracted relating to four areas of interest, namely (1) the general characteristics of the studies, (2) features of the systems designed, (3) availability of the systems to the public, and (4) the design processes followed. In this paper, findings relating to the first three areas are presented.

RESULTS

Most study authors were affiliated to fields of engineering and/or computer science and came from high-income countries. Most studies reported the design of AAC applications loaded onto mobile technology devices. Common system features included customizable vocabulary items, the inclusion of graphic symbols from both established AAC libraries and other sources, a dynamic grid display, and the inclusion of digital and/or synthetic speech output. Few systems were available to the public.

CONCLUSIONS

Limited justifications for many of the complex design decisions were provided in the studies, possibly due to limited involvement of rehabilitation professionals during the design process. Furthermore, few studies reported on the design of graphic symbol-based AAC systems specifically for middle- and low-income contexts and also for multilingual populations.Implications for rehabilitationComplex design decisions about electronic graphic symbol-based augmentative and alternative communication (AAC) systems should be made purposefully and with sufficient justification.Increased collaboration between designers and rehabilitation professionals during the design of electronic graphic symbol-based systems could improve the products.Design of AAC systems for populations residing in low and middle-income contexts and also for multilingual populations are urgently needed.

Bridging gaps in the design and implementation of socially assistive technologies for dementia care: the role of occupational therapy

Dementia is a global health challenge, and people living with dementia (PLWD) are especially susceptible to reduced engagement in meaningful occupations, including social participation. In the past few decades, socially assistive technologies continue to be developed amidst a rapidly evolving technological landscape to support the social health of PLWD and their caregivers. Examples include social robots, virtual reality, smart home technology, and various digital technologies, such as mobile applications for tablets and smartphones. Despite an increasing body of research and interest in this field, several gaps relating to the design and implementation process of socially assistive technologies continue to undermine their relevance for PLWD in daily life. In this paper, some of these gaps are highlighted and the role of occupational therapy in the design and implementation of socially assistive technology is presented. In the design process, occupational therapists are uniquely skilled to advise and advocate for the tailoring and personalisation of technology to address the occupational needs of PLWD. In the implementation of socially assistive technologies, occupational therapists are skilled to educate, train, and conduct ongoing evaluations with PLWD and their caregivers, to incorporate socially assistive technologies into their routine and daily lives. We recommend that occupational therapists should continue to be acquainted with such technologies through continuous professional development and educational curricula. Moreover, we highlight the necessary collaboration between occupational therapists, technology developers, and researchers to enhance the process of designing and implementing socially assistive technology, so that their relevance for PLWD and their caregivers can be maximised.Implications for rehabilitationDevelopers and designers of socially assistive technology should consider the disease trajectory of different types of dementia, as well as the different needs, abilities, preferences, occupations and routines of people living with dementia (PLWD) and/or their caregivers.Collaborations between technology developers, researchers, and occupational therapists should take place iteratively throughout the process of designing and implementing socially assistive technology to maximise their relevance and applicability for people living with dementia and their caregivers.To continue enhancing the current role of occupational therapy in socially assistive technology provision, occupational therapists should keep up to date with socially assistive technology that are being developed to support the social health of PLWD.

When should factorial designs be used for late-phase randomised controlled trials?

BACKGROUND

A 2×2 factorial design evaluates two interventions (A versus control and B versus control) by randomising to control, A-only, B-only or both A and B together. Extended factorial designs are also possible (e.g. 3×3 or 2×2×2). Factorial designs often require fewer resources and participants than alternative randomised controlled trials, but they are not widely used. We identified several issues that investigators considering this design need to address, before they use it in a late-phase setting.

METHODS

We surveyed journal articles published in 2000-2022 relating to designing factorial randomised controlled trials. We identified issues to consider based on these and our personal experiences.

RESULTS

We identified clinical, practical, statistical and external issues that make factorial randomised controlled trials more desirable. Clinical issues are (1) interventions can be easily co-administered; (2) risk of safety issues from co-administration above individual risks of the separate interventions is low; (3) safety or efficacy data are wanted on the combination intervention; (4) potential for interaction (e.g. effect of A differing when B administered) is low; (5) it is important to compare interventions with other interventions balanced, rather than allowing randomised interventions to affect the choice of other interventions; (6) eligibility criteria for different interventions are similar. Practical issues are (7) recruitment is not harmed by testing many interventions; (8) each intervention and associated toxicities is unlikely to reduce either adherence to the other intervention or overall follow-up; (9) blinding is easy to implement or not required. Statistical issues are (10) a suitable scale of analysis can be identified; (11) adjustment for multiplicity is not required; (12) early stopping for efficacy or lack of benefit can be done effectively. External issues are (13) adequate funding is available and (14) the trial is not intended for licensing purposes. An overarching issue (15) is that factorial design should give a lower sample size requirement than alternative designs. Across designs with varying non-adherence, retention, intervention effects and interaction effects, 2×2 factorial designs require lower sample size than a three-arm alternative when one intervention effect is reduced by no more than 24%-48% in the presence of the other intervention compared with in the absence of the other intervention.

CONCLUSIONS

Factorial designs are not widely used and should be considered more often using our issues to consider. Low potential for at most small to modest interaction is key, for example, where the interventions have different mechanisms of action or target different aspects of the disease being studied.

Toward Patient Centricity: Why Do Patients With Inflammatory Bowel Disease Participate in Pharmaceutical Clinical Trials? A Mixed-Methods Exploration of Study Participants

Background

A better understanding of motivations to participate as well as recommendations to reduce barriers to enrollment may assist in design of future clinical trials.

Methods

We developed a 32-item electronic questionnaire to explore motivations, experiences, and recommendations of inflammatory bowel disease patients, who had participated in pharmaceutical clinical trials in a tertiary center in Canada over the last decade. We employed a mixed-methods approach that integrates both quantitative and qualitative research methods.

Results

We distributed a total of 69 e-mails with surveys and received 46 responses (66.6% response rate). Study participants were mostly male (27/46, 58.7%), non-Hispanic White (43/46, 93.5%), with a mean age of 45.5 years (SD 10.9). Most decided to participate in a clinical trial to benefit future patients (29/46, 63.0%). Half of the participants (23/46, 50.0%) reported they were worried about the possibility of receiving placebo, although the majority (29/46, 63.0%) understood they could improve on placebo. The most challenging aspect reported was the number and length of questionnaires (15/46, 32.6%), as well as the number of colonoscopies (14/46, 30.4%). Strategies recommended to increase enrollment were reduction of the chance of receiving placebo (20/46, 43.5%), facilitating inclusion of patients who have failed multiple therapies (20/46, 43.5%), allowing virtual visits (18/46, 39.1%), including subtypes of disease traditionally excluded from trials (16/46, 34.8%) and improving outreach to underrepresented populations (13/46, 28.3%). The vast majority (37/46, 80.4%) reported their experience of participation to be better than expected.

Conclusions

These results should help inform the design of future clinical trials with a focus on patient-centricity.

Target Product Profile for a Machine Learning-Automated Retinal Imaging Analysis Software for Use in English Diabetic Eye Screening: Protocol for a Mixed Methods Study

BACKGROUND

Diabetic eye screening (DES) represents a significant opportunity for the application of machine learning (ML) technologies, which may improve clinical and service outcomes. However, successful integration of ML into DES requires careful product development, evaluation, and implementation. Target product profiles (TPPs) summarize the requirements necessary for successful implementation so these can guide product development and evaluation.

OBJECTIVE

This study aims to produce a TPP for an ML-automated retinal imaging analysis software (ML-ARIAS) system for use in DES in England.

METHODS

This work will consist of 3 phases. Phase 1 will establish the characteristics to be addressed in the TPP. A list of candidate characteristics will be generated from the following sources: an overview of systematic reviews of diagnostic test TPPs; a systematic review of digital health TPPs; and the National Institute for Health and Care Excellence's Evidence Standards Framework for Digital Health Technologies. The list of characteristics will be refined and validated by a study advisory group (SAG) made up of representatives from key stakeholders in DES. This includes people with diabetes; health care professionals; health care managers and leaders; and regulators and policy makers. In phase 2, specifications for these characteristics will be drafted following a series of semistructured interviews with participants from these stakeholder groups. Data collected from these interviews will be analyzed using the shortlist of characteristics as a framework, after which specifications will be drafted to create a draft TPP. Following approval by the SAG, in phase 3, the draft will enter an internet-based Delphi consensus study with participants sought from the groups previously identified, as well as ML-ARIAS developers, to ensure feasibility. Participants will be invited to score characteristic and specification pairs on a scale from "definitely exclude" to "definitely include," and suggest edits. The document will be iterated between rounds based on participants' feedback. Feedback on the draft document will be sought from a group of ML-ARIAS developers before its final contents are agreed upon in an in-person consensus meeting. At this meeting, representatives from the stakeholder groups previously identified (minus ML-ARIAS developers, to avoid bias) will be presented with the Delphi results and feedback of the user group and asked to agree on the final contents by vote.

RESULTS

Phase 1 was completed in November 2023. Phase 2 is underway and expected to finish in March 2024. Phase 3 is expected to be complete in July 2024.

CONCLUSIONS

The multistakeholder development of a TPP for an ML-ARIAS for use in DES in England will help developers produce tools that serve the needs of patients, health care providers, and their staff. The TPP development process will also provide methods and a template to produce similar documents in other disease areas.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50568.

Mitigating Intensive Care Unit Noise: Design-Led Modeling Solutions, Calculated Acoustic Outcomes, and Cost Implications

OBJECTIVES, PURPOSE, OR AIM

The study aimed to decrease noise levels in the ICU, anticipated to have adverse effects on both patients and staff, by implementing enhancements in acoustic design.

BACKGROUND

Recognizing ICU noise as a significant disruptor of sleep and a potential hindrance to patient recovery, this study was conducted at a 40-bed ICU in Fiona Stanley Hospital in Perth, Australia.

METHODS

A comprehensive mixed-methods approach was employed, encompassing surveys, site analysis, and acoustic measurements. Survey data highlighted the importance of patient sleep quality, emphasizing the negative impact of noise on work performance, patient connection, and job satisfaction. Room acoustics analysis revealed noise levels ranging from 60 to 90 dB(A) in the presence of patients, surpassing sleep disruption criteria.

RESULTS

Utilizing an iterative 3D design modeling process, the study simulated significant acoustic treatment upgrades. The design integrated effective acoustic treatments within patient rooms, aiming to reduce noise levels and minimize transmission to adjacent areas. Rigorous evaluation using industry-standard acoustic software highlights the design's efficacy in reducing noise transmission in particular. Additionally, cost implications were examined, comparing standard ICU construction with acoustically treated options for new construction and refurbishment projects.

CONCLUSIONS

This study provides valuable insights into design-based solutions for addressing noise-related challenges in the ICU. While the focus is on improving the acoustic environment by reducing noise levels and minimizing transmission to adjacent areas. It is important to clarify that direct measurements of patient outcomes were not conducted. The potential impact of these solutions on health outcomes, particularly sleep quality, remains a crucial aspect for consideration.

Designing Chinese hospital emergency departments to leverage artificial intelligence-a systematic literature review on the challenges and opportunities

Artificial intelligence (AI) has witnessed rapid advances in the healthcare domain in recent years, especially in the emergency field, where AI is likely to radically reshape medical service delivery. Although AI has substantial potential to enhance diagnostic accuracy and operational efficiency in hospitals, research on its applications in Emergency Department building design remains relatively scarce. Therefore, this study aims to investigate Emergency Department facility design by identifying the challenges and opportunities of using AI. Two systematic literature reviews are combined, one in AI and the other in sensors, to explore their potential application to support decision-making, resource optimisation and patient monitoring. These reviews have then informed a discussion on integrating AI sensors in contemporary Emergency Department designs for use in China to support the evidence base on resuscitation units, emergency operating rooms and Emergency Department Intensive Care Unit (ED-ICU) design. We hope to inform the strategic implementation of AI sensors and how they might transform Emergency Department design to support medical staff and enhance the patient experience.

Multi-activity 3D printed assistive technology in children: a case study

Congenital limb defects occur when a limb does not develop normally during pregnancy. The quality of each person's everyday life is significantly impacted by any of these defects and there is no concrete treatment. 3D modeling and printing, enables the creation and customization of precise virtual and/or physical models, including models of the human anatomy. These technologies provide a novel method of producing new devices with optimized design and production time, improving adaptability, and incorporating functionality. To this end, we propose a method of designing and producing 3D printed assistive devices and we also present an example of an assistive device, done in the 3D Printing Center for Health, as well as its impact on the patient's daily life. With this device, the patient became able to play the guitar and hold a knife, thus helping on these two activities.

User-Friendly Chatbot to Mitigate the Psychological Stress of Older Adults During the COVID-19 Pandemic: Development and Usability Study

BACKGROUND

To safeguard the most vulnerable individuals during the COVID-19 pandemic, numerous governments enforced measures such as stay-at-home orders, social distancing, and self-isolation. These social restrictions had a particularly negative effect on older adults, as they are more vulnerable and experience increased loneliness, which has various adverse effects, including increasing the risk of mental health problems and mortality. Chatbots can potentially reduce loneliness and provide companionship during a pandemic. However, existing chatbots do not cater to the specific needs of older adult populations.

OBJECTIVE

We aimed to develop a user-friendly chatbot tailored to the specific needs of older adults with anxiety or depressive disorders during the COVID-19 pandemic and to examine their perspectives on mental health chatbot use. The primary research objective was to investigate whether chatbots can mitigate the psychological stress of older adults during COVID-19.

METHODS

Participants were older adults belonging to two age groups (≥65 years and <65 years) from a psychiatric outpatient department who had been diagnosed with depressive or anxiety disorders by certified psychiatrists according to the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. The participants were required to use mobile phones, have internet access, and possess literacy skills. The chatbot's content includes monitoring and tracking health data and providing health information. Participants had access to the chatbot for at least 4 weeks. Self-report questionnaires for loneliness, depression, and anxiety were administered before and after chatbot use. The participants also rated their attitudes toward the chatbot.

RESULTS

A total of 35 participants (mean age 65.21, SD 7.51 years) were enrolled in the trial, comprising 74% (n=26) female and 26% (n=9) male participants. The participants demonstrated a high utilization rate during the intervention, with over 82% engaging with the chatbot daily. Loneliness significantly improved in the older group ≥65 years. This group also responded positively to the chatbot, as evidenced by changes in University of California Los Angeles Loneliness Scale scores, suggesting that this demographic can derive benefits from chatbot interaction. Conversely, the younger group, <65 years, exhibited no significant changes in loneliness after the intervention. Both the older and younger age groups provided good scores in relation to chatbot design with respect to usability (mean scores of 6.33 and 6.05, respectively) and satisfaction (mean scores of 5.33 and 5.15, respectively), rated on a 7-point Likert scale.

CONCLUSIONS

The chatbot interface was found to be user-friendly and demonstrated promising results among participants 65 years and older who were receiving care at psychiatric outpatient clinics and experiencing relatively stable symptoms of depression and anxiety. The chatbot not only provided caring companionship but also showed the potential to alleviate loneliness during the challenging circumstances of a pandemic.

Hierarchically Porous Covalent Organic Frameworks: Synthesis Methods and Applications

Covalent organic frameworks (COFs) with high porosity have garnered considerable interest for various applications owing to their robust and customizable structure. However, conventional COFs are hindered by their narrow pore size, which poses limitations for applications such as heterogeneous catalysis and guest delivery that typically involve large molecules. The development of hierarchically porous COF (HP-COF), featuring a multi-scale aperture distribution, offers a promising solution by significantly enhancing the diffusion capacity and mass transfer for larger molecules. This review focuses on the recent advances in the synthesis strategies of HP-COF materials, including topological structure design, in-situ templating, monolithic COF synthesis, defect engineering, and crystalline self-transformation. The specific operational principles and affecting factors in the synthesis process are summarized and discussed, along with the applications of HP-COFs in heterogeneous catalysis, toxic component treatment, optoelectronics, and the biomedical field. Overall, this review builds a bridge to understand HP-COFs and provides guidance for further development of them on synthesis strategies and applications.

Boundary Integrity Testing of Containment Level 3 (Biological Safety Level 3) Laboratories

Background

Containment Level 3 (CL3) laboratories may require boundary integrity testing. Existing guidelines for CL3 room leakage are often subjective, lacking a definitive standard for what constitutes a "sealed" room.

Methods

This study reviews global biocontainment guidelines and standards, and it compares multiple test results from global CL3 facilities by standardizing test data to an equivalent test pressure of 250 Pa.

Results

Our analysis revealed that 55% of rooms constructed using typical CL3 methodologies met the proposed testing criteria. The United States Department of Agriculture (USDA) Agricultural Research Service (ARS) greenhouse leakage rate acceptance criterion of 0.139 L/s per square meter (0.027 cfm per square foot) at a room differential pressure of 250 Pa was found to be a challenging, yet achievable standard.

Conclusions

A two-step process is recommended for boundary integrity testing: (1) Initial leaks are identified using smoke pencil or soap bubble tests, followed by necessary repairs; (2) The room is then subjected to quantifiable leakage rate testing to verify it meets minimum requirements. In the absence of definitive local guidelines, we recommend the published ARS greenhouse leakage rate at a room differential pressure of 300 Pa of 0.152 L/s per square meter of surface area as an acceptable criterion for testing construction boundaries of CL3 laboratories built using current CL3 construction practices. For primary containment CL3 rooms, a more stringent criterion following the German Verein Deutscher Ingenieure guidelines at a room pressure differential of 250 Pa is noted as 0.03620 L/s per square meter of room surface area is more appropriate.

Technologies of care and the engineering imaginary: Two approaches to assistive device design for the Global South

Assistive devices serve as vectors for the ideals, judgments, and goals that their society of origin has towards people with disabilities. For some Ugandan inventors and prosthetists, familiarity with sociocultural norms and consistent feedback allow them to design prosthetic limbs as technologies of care that specifically meet the needs of Ugandans using these devices. In contrast, many biomedical engineers living in the United States rely on what I call the "engineering imaginary" to produce universalized forms of assistive technology intended for people living in an essentialized Global South. Drawing on research with engineers, prosthetists, and people living with limb loss in Uganda and the United States, I investigate the social and cultural aspects of prosthetic limb design and argue that there is a cross-cultural mismatch about what a prosthetic device does and what kinds of limbs it should fit. This mismatch becomes inscribed in the prosthetic device itself.

Machine-Learning-Assisted Nanozyme Design: Lessons from Materials and Engineered Enzymes

Nanozymes are nanomaterials that exhibit enzyme-like biomimicry. In combination with intrinsic characteristics of nanomaterials, nanozymes have broad applicability in materials science, chemical engineering, bioengineering, biochemistry, and disease theranostics. Recently, the heterogeneity of published results has highlighted the complexity and diversity of nanozymes in terms of consistency of catalytic capacity. Machine learning (ML) shows promising potential for discovering new materials, yet it remains challenging for the design of new nanozymes based on ML approaches. Alternatively, ML is employed to promote optimization of intelligent design and application of catalytic materials and engineered enzymes. Incorporation of the successful ML algorithms used in the intelligent design of catalytic materials and engineered enzymes can concomitantly facilitate the guided development of next-generation nanozymes with desirable properties. Here, recent progress in ML, its utilization in the design of catalytic materials and enzymes, and how emergent ML applications serve as promising strategies to circumvent challenges associated with time-expensive and laborious testing in nanozyme research and development are summarized. The potential applications of successful examples of ML-aided catalytic materials and engineered enzymes in nanozyme design are also highlighted, with special focus on the unified aims in enhancing design and recapitulation of substrate selectivity and catalytic activity.

Research on dynamic comfort maintenance by measuring lower limb edema and seat pressure during simulated seated sleep in flight

Objectives. Seated sleep during flight can bring significant discomfort to passengers. The objective of this research was to study passengers' dynamic comfort maintenance strategies in lower limb postural shifting during seated sleep in flight. Methods. Studies on seated sleep postures and sitting comfort were conducted. First, 40 participants were recruited to the observational research for collecting typical leg postures during seated sleep. Then, an experiment was conducted with the participants simulating seated sleep in the aircraft seat. The changes in lower limb edema and seat pressure in different postures were measured with a bioelectrical impedance device, near-infrared spectroscopy device and pressure mapping device. Results. Six postures were selected through the observational research. The experiment showed that tissues of the thighs and buttocks suffer alternate higher compression by shifting between the six postures. Lower limb edema is higher when the shanks are forward, while the tissue under the ischial tuberosity suffers higher compression when the shanks are neutral. Conclusion. Six motivations for passengers to shift each sitting posture to achieve dynamic comfort were summarized, which helps obtain alternating rest in different body parts. The suggestion of a leg position adjustment system was also proposed.

Twelve tips for designing, implementing and sustaining interprofessional training units on hospital wards

Dedicated Interprofessional Training Units (ITUs) in hospital wards are one way to prepare healthcare students for Interprofessional patient-centered care. Based on theoretical foundations, research, and our lived experiences of successes as well as failures, we propose 12 tips on how to prepare, implement, and sustain a dedicated ITU, combining the Grol & Wensing model for planning change with the Self-determination Theory of motivation. Start with a steering group, with a dedicated project leader, to translate awareness of the need for an ITU into wider awareness and motivation among stakeholders, with the ITU being a solution to authentic problems. Create shared ownership by jointly formulating feasible educational goals and starting with a pilot to provide opportunities for change. Motivate all stakeholders by stimulating their autonomy, interprofessional competence as well as relatedness to each other, in line with the Self-determination Theory. Confirm the value of the ITU at all stages and embed the ITU in the organizational strategy.

Multidimensional Thresholding for Individual-Level Preference Elicitation

OBJECTIVES

Multiple methods are available for collecting health preference information. However, information on the design and analysis of novel methods is limited. This article aims to provide the first introduction into the design and analysis of multidimensional thresholding (MDT).

METHODS

We introduce MDT as a 2-step approach: First, participants rank the largest possible improvements in all considered attributes by their importance. Second, participants complete a series of systematically combined trade-off questions. Hit-and-Run sampling is used for obtaining preference weights. We also use a computational experiment to compare different MDT designs.

RESULTS

The outlined MDT can generate preference information suitable for specifying a multiattribute utility function at the individual level. The computational experiment demonstrates the method's ability to recover preference weights at a high level of precision. While all designs in the computation experiment perform comparably well on average, the design outlined in the paper stands out with a high level of precision even if differences in relative attribute importance are large.

CONCLUSION

MDT is suitable for preference elicitation, in particular if sample sizes are small. Future research should help improve the methods (e.g., remove the need for an initial ranking) to increase the potential reach of MDT.

Assessing the Importance of Content Versus Design for Successful Crowdfunding of Health Education Games: Online Survey Study

Background

Health education games make health-related tasks enjoyable and interactive, thereby encouraging user participation. Entrepreneurs and health educators can leverage online crowdfunding platforms, such as Kickstarter, to transform their innovative ideas into funded projects.

Objective

This research focuses on health education game initiatives on Kickstarter. Through an online user survey, it aims to understand user perceptions and evaluate the significance of 8 distinct components that may influence the success of such crowdfunding initiatives.

Methods

A total of 75 participants evaluated games using 8 dimensions: game rules, learning objectives, narrative, content organization, motivation, interactivity, skill building, and assessment and feedback. The survey data were analyzed using descriptive statistical analysis, exploratory factor analysis, the Wilcoxon-Mann-Whitney test, and multivariate analysis.

Results

Exploratory data analysis showed that, among the 8 dimensions, skill building, content organization, and interactivity were the top-ranking dimensions most closely associated with crowdfunding health education game. The 8 dimensions can be grouped into 3 categories from the exploratory factor analysis: game content-, instruction-, and game design-related components. Further statistical analysis confirmed the correlation between these dimensions with the successful crowdfunding of health education games.

Conclusions

This empirical analysis identified critical factors for game proposal design that can increase the likelihood of securing crowdfunding support.

Lessons learned spanning 17 years of experience with three consecutive nationwide competency based medical education training plans

Introduction

Curricula for postgraduate medical education have transformed since the introduction of competency based medical education (CBME). Postgraduate training plans offer broader training with different competencies and an outcome-based approach, in addition to the medical technical aspects of training. However, CBME also has its challenges. Over the past years, critical views have been shared on the potential drawbacks of CBME, such as assessment burden and conflicts with practicality in the workplace. Recent studies identified a need for a better understanding of how the evolving concept of CBME has been translated to curriculum design and implemented in the practice of postgraduate training. The aim of this study was to describe the development of CBME translations to curriculum design, based on three consecutive postgraduate training programs spanning 17 years.

Method

We performed a document analysis of three consecutive Dutch gynecology and obstetrics training plans that were implemented in 2005, 2013, and 2021. We used template analysis to identify changes over time.

Results

Over time, CBME-based curriculum design changed in several domains. Assessment changed from a model with a focus on summative decision to one with an emphasis on formative, low-stakes assessments aimed at supporting learning. The training plans evolved in parallel to evolving educational insights, e.g., by placing increasing emphasis on personal development. The curricula focused on a competency-based concept by introducing training modules and personalized authorization based on feedback rather than on a set duration of internships. There was increasing freedom in personalized training trajectories in the training plans, together with increasing trust towards the resident.

Conclusion

The way CBME was translated into training plans has evolved in the course of 17 years of experience with CMBE-based education. The main areas of change were the structure of the training plans, which became increasingly open, the degree to which learning outcomes were mandatory or not, and the way these outcomes were assessed.

Design of a Porous Silicon Biosensor: Characterization, Modeling, and Application to the Indirect Detection of Bacteria

The design of a porous silicon (PSi) biosensor is not often documented, but is of the upmost importance to optimize its performance. In this work, the motivation behind the design choices of a PSi-based optical biosensor for the indirect detection of bacteria via their lysis is detailed. The transducer, based on a PSi membrane, was characterized and models were built to simulate the analyte diffusion, depending on the porous nanostructures, and to optimize the optical properties. Once all performances and properties were analyzed and optimized, a theoretical response was calculated. The theoretical limit of detection was computed as 104 CFU/mL, based on the noise levels of the optical setup. The experimental response was measured using 106 CFU/mL of Bacillus cereus as model strain, lysed by bacteriophage-coded endolysins PlyB221. The obtained signal matched the expected response, demonstrating the validity of our design and models.

Recent Advances in Structural Optimization of Quinazoline-Based Protein Kinase Inhibitors for Cancer Therapy (2021-Present)

Cancer is a complicated, multifaceted disease that can impact any organ in the body. Various chemotherapeutic agents have a low selectivity and are very toxic when used alone or in combination with others. Resistance is one of the most important hurdles that develop due to the use of many anticancer therapeutics. As a result, treating cancer requires a target-specific palliative care strategy. Remarkable scientific discoveries have shed light on several of the molecular mechanisms underlying cancer, resulting in the development of various targeted anticancer agents. One of the most important heterocyclic motifs is quinazoline, which has a wide range of biological uses and chemical reactivities. Newer, more sophisticated medications with quinazoline structures have been found in the last few years, and great strides have been made in creating effective protocols for building these pharmacologically active scaffolds. A new class of chemotherapeutic agents known as quinazoline-based derivatives possessing anticancer properties consists of several well-known compounds that block different protein kinases and other molecular targets. This review highlights recent updates (2021-2024) on various quinazoline-based derivatives acting against different protein kinases as anticancer chemotherapeutics. It also provides guidance for the design and synthesis of novel quinazoline analogues that could serve as lead compounds.

Visual communication design: a neglected factor in nutrition promotion via packaged food labels

Packaging design is a communication device and a critical component in branding strategy, and has relevance for food policy. Presently, packaging-related nutrition policy initiatives focus on the role of regulated claims, nutrition information panels and front-of-pack nutrition labels to help guide consumer food choices and address high prevalences of discretionary and ultra-processed food consumption in many countries. However, these nutrition labelling systems are not optimized as public health policy tools as many consumers do not use them to inform their food choices. Visual communication design theory posits that a designer orders the elements and principles of design into hierarchies that prioritize certain elements over others, and that some of these elements are more dominant and given more emphasis than others. The overall design of the package thereby directs consumer attention to some aspects of pack design (e.g., characters, contents of the package) and away from others (e.g., nutrition details). Dual processing frameworks propose that food decisions are made with the interplay between automatic and rational thinking processes. Packaging designs affect whether consumers rely predominantly on automatic or rational thinking to select a food. This narrative review outlines the role of food packaging design and how it impacts the clear communication of nutrition aspects of food products and how the use of nutrition information by consumers to make decisions may depend upon design structures in packaging. This article attests that nutrition scientists and policy makers should incorporate visual communication design into research on the food packaging as a public health promotion tool. A stronger focus on the communication of regulated front-of-pack nutrition information can be made with a re-evaluation of the hierarchy of elements in the front-of-pack design enabling consumers to make healthier decisions.

Improving shared decision-making about cancer treatment through design-based data-driven decision-support tools and redesigning care paths: an overview of the 4D PICTURE project

Background

Patients with cancer often have to make complex decisions about treatment, with the options varying in risk profiles and effects on survival and quality of life. Moreover, inefficient care paths make it hard for patients to participate in shared decision-making. Data-driven decision-support tools have the potential to empower patients, support personalized care, improve health outcomes and promote health equity. However, decision-support tools currently seldom consider quality of life or individual preferences, and their use in clinical practice remains limited, partly because they are not well integrated in patients' care paths.

Aim and objectives

The central aim of the 4D PICTURE project is to redesign patients' care paths and develop and integrate evidence-based decision-support tools to improve decision-making processes in cancer care delivery. This article presents an overview of this international, interdisciplinary project.

Design methods and analysis

In co-creation with patients and other stakeholders, we will develop data-driven decision-support tools for patients with breast cancer, prostate cancer and melanoma. We will support treatment decisions by using large, high-quality datasets with state-of-the-art prognostic algorithms. We will further develop a conversation tool, the Metaphor Menu, using text mining combined with citizen science techniques and linguistics, incorporating large datasets of patient experiences, values and preferences. We will further develop a promising methodology, MetroMapping, to redesign care paths. We will evaluate MetroMapping and these integrated decision-support tools, and ensure their sustainability using the Nonadoption, Abandonment, Scale-Up, Spread, and Sustainability (NASSS) framework. We will explore the generalizability of MetroMapping and the decision-support tools for other types of cancer and across other EU member states.

Ethics

Through an embedded ethics approach, we will address social and ethical issues.

Discussion

Improved care paths integrating comprehensive decision-support tools have the potential to empower patients, their significant others and healthcare providers in decision-making and improve outcomes. This project will strengthen health care at the system level by improving its resilience and efficiency.

Applying propensity methods to the United States transplant registry for external real-world evidence control arms for 5-year survival in the BENEFIT study

To address the challenges of assessing the impact of a reasonably likely surrogate endpoint on long-term graft survival in prospective kidney transplant clinical trials, the Transplant Therapeutics Consortium established a real-world evidence workgroup evaluating the scientific value of using transplant registry data as an external control to supplement the internal control group. The United Network for Organ Sharing retrospectively simulated the use of several distinct contemporaneous external control groups, applied multiple cause inference methods, and compared treatment effects to those observed in the BENEFIT study. Applying BENEFIT study enrollment criteria produced a smaller historical cyclosporine control arm (n = 153) and a larger, alternative (tacrolimus) historical control arm (n = 1069). Following covariate-balanced propensity scoring, Kaplan-Meier 5-year all-cause graft survivals were 81.3% and 81.7% in the Organ Procurement and Transplantation Network (OPTN) tacrolimus and cyclosporine external control arms, similar to 80.3% observed in the BENEFIT cyclosporine treatment arm. Five-year graft survival in the belatacept-less intensive arm was significantly higher than the OPTN controls using propensity scoring for comparing cyclosporine and tacrolimus. Propensity weighting using OPTN controls closely mirrored the BENEFIT study's long-term control (cyclosporine) arm's survival rate and the less intensive arm's treatment effect (significantly higher survival vs control). This study supports the feasibility and validity of using supplemental external registry controls for long-term survival in kidney transplant clinical trials.

Practical applications of three-dimensional printing for process improvement in the cytopathology laboratory

With the increased availability of three-dimensional (3D) printers, innovative teaching and training materials have been created in medical fields. For pathology, the use of 3D printing has been largely limited to anatomic representations of disease processes or the development of supplies during the coronavirus disease 2019 pandemic. Herein, an institution's 3D printing laboratory and staff with expertise in additive manufacturing illustrate how this can address design issues in cytopathology specimen collection and processing. The authors' institutional 3D printing laboratory, along with students and trainees, used computer-aided design and 3D printers to iterate on design, create prototypes, and generate final usable materials using additive manufacturing. The program Microsoft Forms was used to solicit qualitative and quantitative feedback. The 3D-printed models were created to assist with cytopreparation, rapid on-site evaluation, and storage of materials in the preanalytical phase of processing. These parts provided better organization of materials for cytology specimen collection and staining, in addition to optimizing storage of specimens with multiple sized containers to optimize patient safety. The apparatus also allowed liquids to be stabilized in transport and removed faster at the time of rapid on-site evaluation. Rectangular boxes were also created to optimally organize all components of a specimen in cytopreparation to simplify and expedite the processes of accessioning and processing, which can minimize errors. These practical applications of 3D printing in the cytopathology laboratory demonstrate the utility of the design and printing process on improving aspects of the workflow in cytopathology laboratories to maximize efficiency, organization, and patient safety.

Application and evolution of design in oral health: A systematic mapping study with an interactive evidence map

OBJECTIVES

There is increasing recognition of the value and capabilities of design in healthcare. Beyond the development of medical devices, design is increasingly being applied to intangible, complex and systemic healthcare problems. However, there is limited evidence on the use of design specifically in the field of oral health. This systematic mapping study aims to collate and catalogue evidence of design in oral health.

METHODS

A systematic search of academic databases and grey literature was performed. Duplicate results were removed, and publications relating to the same project were grouped. Reviewers from design and oral health independently screened a sample of the dataset. Projects of both relevance to oral health, and with input from a designer or clear implementation of a design methodology or approach were included. Projects were coded and plotted on a novel interactive evidence map.

RESULTS

119 design and oral health projects were included between 1973 and 2022. Interventional (n = 94, 79%), empirical (n = 46, 39%), methodological (n = 35, 29%) and theoretical (n = 7, 6%) design contributions were identified across the projects. The projects were categorized by four orders of design: first-graphics (n = 6, 5%), second-products (n = 41, 34%), third-interactions (n = 70, 59%), and fourth-systems (n = 2, 2%). Design was found in a diverse range of contexts in oral health; most commonly being relevant to general patients (n = 61, 51%), and for use in general dental practice (n = 56, 47%). Further design outcome categories (digital material; printed material; object; room or space; apparel; process; smart device; tangible interface; graphical interface; virtual reality; service; policy; system) and oral health themes (oral health literacy; oral care training; dental clinic design; dental instruments and equipment; personal oral care; dental appliance; clinician health and productivity; clinical information systems; informed consent; oral health promotion and prevention; oral care training; patient interactions and experience) were identified.

CONCLUSIONS

The novel interactive evidence map of design in oral health created enables ongoing and open-ended multivariant documentation and analysis of the evidence, as well as identification of strategic opportunities. Future research and policy implications include; recognition and engagement with the full capabilities of design; integration of design experts; fostering inclusive engagement and collaboration; disentangling patient and public involvement; advancing human-centred systems approaches; adopting design-led approaches for policy-making.

Data Representation Structure to Support Clinical Decision-Making in the Pediatric Intensive Care Unit: Interview Study and Preliminary Decision Support Interface Design

BACKGROUND

Clinical decision-making is a complex cognitive process that relies on the interpretation of a large variety of data from different sources and involves the use of knowledge bases and scientific recommendations. The representation of clinical data plays a key role in the speed and efficiency of its interpretation. In addition, the increasing use of clinical decision support systems (CDSSs) provides assistance to clinicians in their practice, allowing them to improve patient outcomes. In the pediatric intensive care unit (PICU), clinicians must process high volumes of data and deal with ever-growing workloads. As they use multiple systems daily to assess patients' status and to adjust the health care plan, including electronic health records (EHR), clinical systems (eg, laboratory, imaging and pharmacy), and connected devices (eg, bedside monitors, mechanical ventilators, intravenous pumps, and syringes), clinicians rely mostly on their judgment and ability to trace relevant data for decision-making. In these circumstances, the lack of optimal data structure and adapted visual representation hinder clinician's cognitive processes and clinical decision-making skills.

OBJECTIVE

In this study, we designed a prototype to optimize the representation of clinical data collected from existing sources (eg, EHR, clinical systems, and devices) via a structure that supports the integration of a home-developed CDSS in the PICU. This study was based on analyzing end user needs and their clinical workflow.

METHODS

First, we observed clinical activities in a PICU to secure a better understanding of the workflow in terms of staff tasks and their use of EHR on a typical work shift. Second, we conducted interviews with 11 clinicians from different staff categories (eg, intensivists, fellows, nurses, and nurse practitioners) to compile their needs for decision support. Third, we structured the data to design a prototype that illustrates the proposed representation. We used a brain injury care scenario to validate the relevance of integrated data and the utility of main functionalities in a clinical context. Fourth, we held design meetings with 5 clinicians to present, revise, and adapt the prototype to meet their needs.

RESULTS

We created a structure with 3 levels of abstraction-unit level, patient level, and system level-to optimize clinical data representation and display for efficient patient assessment and to provide a flexible platform to host the internally developed CDSS. Subsequently, we designed a preliminary prototype based on this structure.

CONCLUSIONS

The data representation structure allows prioritizing patients via criticality indicators, assessing their conditions using a personalized dashboard, and monitoring their courses based on the evolution of clinical values. Further research is required to define and model the concepts of criticality, problem recognition, and evolution. Furthermore, feasibility tests will be conducted to ensure user satisfaction.

Formative Evaluation of a Comprehensive Self-Management Intervention for Irritable Bowel Syndrome, Comorbid Anxiety, and Depression: Mixed Methods Study

BACKGROUND

Irritable bowel syndrome (IBS) is a disorder of the gut-brain interaction that is associated with abdominal pain, altered bowel patterns, and reduced quality of life. Up to 50% of patients with IBS also report anxiety or depressive symptoms. Although effective self-management interventions exist for individuals with IBS, few have been effectively implemented, and most do not consider the unique needs of patients with comorbid IBS and anxiety or depression.

OBJECTIVE

This study aimed to determine the anticipated acceptability, appropriateness, feasibility, and usability of a comprehensive self-management intervention using an implementation science and human-centered design approach among individuals with comorbid IBS and anxiety or depression and health care providers.

METHODS

A convergent mixed methods design was used to elicit feedback on the comprehensive self-management intervention outline and content to identify refinement needs before testing. Patients with IBS and moderate to severe anxiety or depression and health care providers were purposefully sampled from primary care and gastroenterology settings. Participants completed semistructured interviews and surveys on anticipated acceptability, appropriateness, feasibility, and usability.

RESULTS

Patient participants (n=12) were on average 36.8 (SD 12.2) years of age, and 42% (5/12) were currently receiving psychological therapy. Health care providers (n=14) were from primary care (n=7) and gastroenterology (n=7) settings. The mean usability scores (out of 100) were 52.5 (SD 14.5) for patients and 45.6 (SD 11.6) for providers. For patients and providers, qualitative data expanded the quantitative findings for acceptability and appropriateness. Acceptability findings were the comprehensive nature of the intervention and discussion of the gut-brain interaction. For appropriateness, participants reported that the intervention provided structure, accountability, and support. Feasibility was confirmed for patients, but there was a divergence of findings between quantitative and qualitative measures for providers. Patients focused on intervention feasibility, while providers focused on implementation feasibility in the clinic. Identified usability issues to address before implementation included the intervention delivery format, length, and lack of integration into health care settings that, if not addressed, may limit the reach of the intervention.

CONCLUSIONS

Patients and health care providers found the intervention acceptable and appropriate. Several feasibility and usability issues were identified, including intervention delivery methods, length of intervention, and the best methods to implement in the clinic setting. The next steps are to refine the intervention to address the identified issues and test in a pilot study whether addressing usability issues leads to the anticipated improvements in implementation and uptake.

Digital Group-Based Intervention for Physical Activity Promotion Among Thai Adults During the COVID-19 Lockdown: Randomized Controlled Trial

BACKGROUND

The COVID-19 pandemic significantly diminished the physical activity (PA) level of Thai adults belonging to Generation Y (Gen Y). As a response to the global crisis, many individuals worldwide have turned to social community platforms, recognizing their potential in promoting PA during the pandemic. Gen Y, in particular, demonstrates exceptional proficiency in using social media platforms, showcasing a remarkable aptitude for swiftly accessing new information and knowledge. However, their proclivity for reckless behavior exposes them to various health risks, potentially leading to enduring adverse health consequences. Consequently, there arises a pressing need to develop a comprehensive model aimed at elevating the PA levels among individuals belonging to Gen Y.

OBJECTIVE

This research aimed to examine the effectiveness of a digital group-based activity in promoting PA among Gen Y in Thailand.

METHODS

This was a parallel 2-arm randomized controlled trial with single-blind allocation to experimental and control groups and pre- and posttest measurements. Measurements were administered on the web and were designed for respondents to complete by themselves. The sample comprised 100 Gen Y individuals who met the inclusion criteria. Both groups were matched for background characteristics. The two 8-week intervention activities were (1) two weeks of education and (2) six weeks of motivation by target groups that set goals for PA together (using the Zoom meeting application), with a time limit and group consensus as to when the goal was to be achieved. The intervention activities were implemented one by one at specified intervals and delivered daily through health apps and the official LINE account.

RESULTS

The intervention starts from August 22 to October 16, 2021. Of the 100 participants, 20 (20%) left the study, and the remaining 80 (80%) participated in the study (40 individuals each in the experimental and control groups). After participating in the experiment, a statistically significant difference in PA was found between the 2 groups (moderate to vigorous PA; 25/40, 63%; P=.03). Participants in the intervention group collected a higher cumulative minute of moderate to vigorous PA weekly (283 minutes) than those in the control group (164 minutes), and this was statistically significant (P=.03). For the transition to the fourth stage of behavior (ie, action), the improvement in the experimental group, after participating in the trial, was statistically significant compared to that of the control group (P=.01).

CONCLUSIONS

Digital group-based activity showed its effectiveness in improving the PA of Gen Y individuals in the intervention group. It created a process-based intervention activity that corresponds to the stages of behavior changes, from contemplation to action. The digital community can also connect individuals to comparable groups locally and globally.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20211101005; https://www.thaiclinicaltrials.org/show/TCTR20211101005.

Administrative Dashboard for Monitoring Use of a Web-Based Parent Training Intervention: Usability Study

BACKGROUND

Web-based parent training (PT) programs can strengthen parent-child relationships by equipping caregivers with knowledge and evidence-based strategies to manage behavior. Hybrid facilitation of PT includes facilitator interaction paired with self-administered and web-based PT. Web-based administrative dashboards provide users (eg, administrators, facilitators, and researchers) with an integrated platform to monitor parent progress and activities within a PT program or website. Despite the utility and prevalence of administrative dashboards for web-based behavioral interventions, to our knowledge, no research studies have explored the perspectives and insights of dashboard users to enhance user experience and program delivery.

OBJECTIVE

The purpose of this study is to evaluate the usability of the administrative dashboard (ezDashboard) for the ezParent program, a 6-module web-based PT program for parents of children aged 2-5 years.

METHODS

This study used a descriptive, single-group design with administrators who were overseeing the implementation of the ezParent program and trained facilitators for hybrid ezParent delivery. Participants spent at least 30 minutes reviewing and evaluating the ezDashboard and then completed a survey of their experience with the dashboard. The survey included the validated 10-item System Usability Scale and open-ended questions focusing on user performance, navigation ease, and overall usefulness of the ezDashboard.

RESULTS

Participants (N=15) indicated high usability of the ezDashboard with System Usability Scale scoring a total mean score of 83.5 (SD 16.3). Most participants (n=13, 87%) rated the overall user-friendliness of the ezDashboard as good (n=3, 20%), excellent (n=9, 60%), or best imaginable (n=1, 7%). Open-ended questions revealed the ezDashboard is or would be useful to monitor parent progress and trends in engagement (n=8, 53%) and for reviewing topics for discussion and communicating with parents (n=5, 33%). ezParent administrators (n=4) identified that real-time data for ezParent use helps overall management of program uptake. Suggestions for features to add to the ezDashboard included the ability to track partial progress of program modules (4/14, 29%), total time spent per module (2/14, 14%), and exportable reports (4/14, 29%). Other ideas for improvement included direct messaging capabilities, videoconferencing platform integration, and being able to modify participant account and contact information.

CONCLUSIONS

Results indicate that the ezDashboard is easy to use and provides functional information to facilitators and administrators in delivering ezParent. Qualitative results indicate that integrating suggested features into the ezDashboard may help provide a smoother experience for facilitators, administrators, and ultimately the parents using the program. Providing resources for facilitators and administrators in real time to monitor intervention participants' progress in a program can be helpful in tracking progress and providing facilitated support in tailoring program content and program completion.

Research considerations for prospective studies of patients with coma and disorders of consciousness

Disorders of consciousness are neurological conditions characterized by impaired arousal and awareness of self and environment. Behavioural responses are absent or are present but fluctuate. Disorders of consciousness are commonly encountered as a consequence of both acute and chronic brain injuries, yet reliable epidemiological estimates would require inclusive, operational definitions of the concept, as well as wider knowledge dissemination among involved professionals. Whereas several manifestations have been described, including coma, vegetative state/unresponsive wakefulness syndrome and minimally conscious state, a comprehensive neurobiological definition for disorders of consciousness is still lacking. The scientific literature is primarily observational, and studies-specific aetiologies lead to disorders of consciousness. Despite advances in these disease-related forms, there remains uncertainty about whether disorders of consciousness are a disease-agnostic unitary entity with a common mechanism, prognosis or treatment response paradigm. Our knowledge of disorders of consciousness has also been hampered by heterogeneity of study designs, variables, and outcomes, leading to results that are not comparable for evidence synthesis. The different backgrounds of professionals caring for patients with disorders of consciousness and the different goals at different stages of care could partly explain this variability. The Prospective Studies working group of the Neurocritical Care Society Curing Coma Campaign was established to create a platform for observational studies and future clinical trials on disorders of consciousness and coma across the continuum of care. In this narrative review, the author panel presents limitations of prior observational clinical research and outlines practical considerations for future investigations. A narrative review format was selected to ensure that the full breadth of study design considerations could be addressed and to facilitate a future consensus-based statement (e.g. via a modified Delphi) and series of recommendations. The panel convened weekly online meetings from October 2021 to December 2022. Research considerations addressed the nosographic status of disorders of consciousness, case ascertainment and verification, selection of dependent variables, choice of covariates and measurement and analysis of outcomes and covariates, aiming to promote more homogeneous designs and practices in future observational studies. The goal of this review is to inform a broad community of professionals with different backgrounds and clinical interests to address the methodological challenges imposed by the transition of care from acute to chronic stages and to streamline data gathering for patients with disorders of consciousness. A coordinated effort will be a key to allow reliable observational data synthesis and epidemiological estimates and ultimately inform condition-modifying clinical trials.

The efficacy of different torque profiles for weight compensation of the hand

Orthotic wrist supports will be beneficial for people with muscular weakness to keep their hand in a neutral rest position and prevent potential wrist contractures. Compensating the weight of the hands is complex since the level of support depends on both wrist and forearm orientations. To explore simplified approaches, two different weight compensation strategies (constant and linear) were compared to the theoretical ideal sinusoidal profile and no compensation in eight healthy subjects using a mechanical wrist support system. All three compensation strategies showed a significant reduction of 47-53% surface electromyography activity in the anti-gravity m. extensor carpi radialis. However, for the higher palmar flexion region, a significant increase of 44-61% in the m. flexor carpi radialis was found for all compensation strategies. No significant differences were observed between the various compensation strategies. Two conclusions can be drawn: (1) a simplified torque profile (e.g., constant or linear) for weight compensation can be considered as equally effective as the theoretically ideal sinusoidal profile and (2) even the theoretically ideal profile provides no perfect support as other factors than weight, such as passive joint impedance, most likely influence the required compensation torque for the wrist joint.

Fetters and the Design of Bondage Objects in Britain During the 1970s and 1980s

This article examines the development of male bondage in Britain during the 1970s and 1980s through an examination of products designed by Jim Stewart, who founded the company Fetters in 1976. Through research using primary written sources, interviews with early customers, users and business partners, and the objects themselves, this paper situates Fetters designs within the broader infrastructures that were essential for the development of the material culture of male BDSM. The research finds that the primary contacts and inspiration came from outside of the emergent gay leather scene, in particular the cult of Houdini and publications that facilitated collecting of esoteric objects. Furthermore, military culture is shown to have influenced the design and mediation of bondage objects in a way that was fundamental to their design and functioning. This analysis therefore highlights some tensions surrounding cultural aspects of sexual identity that were negotiated through the design and development of objects produced at Fetters.

A Machine Learning Approach with Human-AI Collaboration for Automated Classification of Patient Safety Event Reports: Algorithm Development and Validation Study

BACKGROUND

Adverse events refer to incidents with potential or actual harm to patients in hospitals. These events are typically documented through patient safety event (PSE) reports, which consist of detailed narratives providing contextual information on the occurrences. Accurate classification of PSE reports is crucial for patient safety monitoring. However, this process faces challenges due to inconsistencies in classifications and the sheer volume of reports. Recent advancements in text representation, particularly contextual text representation derived from transformer-based language models, offer a promising solution for more precise PSE report classification. Integrating the machine learning (ML) classifier necessitates a balance between human expertise and artificial intelligence (AI). Central to this integration is the concept of explainability, which is crucial for building trust and ensuring effective human-AI collaboration.

OBJECTIVE

This study aims to investigate the efficacy of ML classifiers trained using contextual text representation in automatically classifying PSE reports. Furthermore, the study presents an interface that integrates the ML classifier with the explainability technique to facilitate human-AI collaboration for PSE report classification.

METHODS

This study used a data set of 861 PSE reports from a large academic hospital's maternity units in the Southeastern United States. Various ML classifiers were trained with both static and contextual text representations of PSE reports. The trained ML classifiers were evaluated with multiclass classification metrics and the confusion matrix. The local interpretable model-agnostic explanations (LIME) technique was used to provide the rationale for the ML classifier's predictions. An interface that integrates the ML classifier with the LIME technique was designed for incident reporting systems.

RESULTS

The top-performing classifier using contextual representation was able to obtain an accuracy of 75.4% (95/126) compared to an accuracy of 66.7% (84/126) by the top-performing classifier trained using static text representation. A PSE reporting interface has been designed to facilitate human-AI collaboration in PSE report classification. In this design, the ML classifier recommends the top 2 most probable event types, along with the explanations for the prediction, enabling PSE reporters and patient safety analysts to choose the most suitable one. The LIME technique showed that the classifier occasionally relies on arbitrary words for classification, emphasizing the necessity of human oversight.

CONCLUSIONS

This study demonstrates that training ML classifiers with contextual text representations can significantly enhance the accuracy of PSE report classification. The interface designed in this study lays the foundation for human-AI collaboration in the classification of PSE reports. The insights gained from this research enhance the decision-making process in PSE report classification, enabling hospitals to more efficiently identify potential risks and hazards and enabling patient safety analysts to take timely actions to prevent patient harm.

Adapting to Change: A Systematic Literature Review of Environmental Flexibility in Emergency Departments

PURPOSE

This study aimed to offer a comprehensive analysis of distinct design strategies identified, evaluated, or discussed in the existing literature that promote environmental flexibility in the context of emergency departments (EDs).

BACKGROUND

EDs are subject to constant changes caused by several factors, including seasonal disease trends, the emergence of new technologies, and surges resulting from local or global disasters, such as mass casualty incidents or pandemics. Thus, integrating flexibility into ED design becomes crucial to effectively addressing these evolving needs.

METHODS

A systematic search was conducted in four databases: CINAHL, MEDLINE, PubMed, and ScienceDirect, in addition to a hand search. A two-stage review process was employed to determine the final list of included articles based on the inclusion criteria. Included studies were evaluated for quality, and findings were categorized using a hybrid deductive and inductive coding approach.

RESULTS

From the initial yield of 900 records, 22 studies met the inclusion criteria and were included in the final full-text review. The identified design strategies were organized into five categories: modifiability (n = 13 articles), versatility (n = 8 articles), tolerance (n = 6 articles), convertibility (n = 4 articles), and scalability (n = 7 articles). Specific design strategies under each category are reported in detail.

CONCLUSIONS

Our findings suggest that most flexibility design solutions are based on anecdotal evidence or descriptive studies, which carry less weight in terms of reliable support for conclusions. Therefore, more studies employing quantitative, relational, or causal designs are recommended.

Designing a Web-Based Navigation Tool to Support Access to Youth Mental Health Services: Qualitative Study

BACKGROUND

Many young people with mental health problems do not readily seek help or receive treatment and support. One way to address low help-seeking behavior is to improve access to information on mental health services and how to navigate the mental health system via a web-based tool. Seeking input from the end users (young people and parents or caregivers) on key features of the tool is imperative to ensure that it is relevant, engaging, and likely to meet their needs and expectations.

OBJECTIVE

This study aims to investigate young person and parent or caregiver views on the design, content, functioning, and user experience of a web-based mental health navigation tool to support connection to mental health services for children and young people aged up to 25 years.

METHODS

A total of 4 online focus groups were conducted: 2 with young people aged 16 years and older (total n=15) and 2 with parents or caregivers (total n=13). Focus groups were structured around a series of guiding questions to explore participants' views on content, features, user experience, and design of a mental health navigation website. Focus groups were audio recorded with detailed notes taken. In addition, 53 young people aged 16-25 years and 97 parents or caregivers completed an online survey, comprising closed- and open-ended questions; open-ended responses were included with the focus group data in the qualitative analysis. All qualitative data were analyzed using thematic analysis.

RESULTS

A total of 2 topic areas and 7 themes were developed. The first topic area covered the types of information needs of young people and parents. Identified themes concerned the scope of the navigation website, as well as the provision of up-to-date and practical information on how to navigate the whole help-seeking process. The second topic area covered website features that would be beneficial and included the consideration of the website design; search engines; supported navigation; and forums, reviews, and user accounts.

CONCLUSIONS

This study provides important insights into the navigation needs of young people and parents or caregivers in seeking mental health services. Key findings identified through this research have directly informed the development of MindMap, a web-based youth navigation tool providing a searchable database of local services, including a clear description, their location, and potential wait times. The website can be navigated independently or with support.

"Commercialized Jungle": Pharmacists and Pharmacy Design in the Postwar United States

Pharmacists and pharmacies are key drivers in the American marketplace. They serve as an endpoint of the pharmaceutical supply chain and are the dispensers of a range of consumer goods, some nonthreatening and others potentially harmful to public health. In adding pharmacies to the roster of consumerist locales in the postwar period, scholars might draw even deeper connections about the transformation of health, corporate medicine, and American economic power. To understand the interface of consumerism, corporatism, and health in postwar America, this article holds the postwar pharmacy as a key site of commodity exchange and business and positions it within the larger American firmament, paying attention to the design of pharmacies. In particular, the article will add to the knowledge about the tangible ways that medical and health care spaces are constructed, organized, and designed to best generate profits. Besides prescription medications, alcohol, tobacco, and sugar-rich products were also vital elements of the postwar pharmacy and will be featured in this article. What is more, this article focuses on a central debate between pharmacists during the postwar period about how pharmacies were shifting from the role of healer to that of a retailer - from a "conscientious guardian" to a "commercialized jungle" - in order to highlight how the public health role of pharmacies was undermined by industry pressures for profit. Based on unused corporate guides and manuals, company records, photographs, and management documents, this article will spotlight the underexplored interiority of pharmacies - the store's insides, processes of organization, and design features related to potentially habit-changing substances.

Cluster Randomized Trials Designed to Support Generalizable Inferences

When planning a cluster randomized trial, evaluators often have access to an enumerated cohort representing the target population of clusters. Practicalities of conducting the trial, such as the need to oversample clusters with certain characteristics in order to improve trial economy or support inferences about subgroups of clusters, may preclude simple random sampling from the cohort into the trial, and thus interfere with the goal of producing generalizable inferences about the target population. We describe a nested trial design where the randomized clusters are embedded within a cohort of trial-eligible clusters from the target population and where clusters are selected for inclusion in the trial with known sampling probabilities that may depend on cluster characteristics (e.g., allowing clusters to be chosen to facilitate trial conduct or to examine hypotheses related to their characteristics). We develop and evaluate methods for analyzing data from this design to generalize causal inferences to the target population underlying the cohort. We present identification and estimation results for the expectation of the average potential outcome and for the average treatment effect, in the entire target population of clusters and in its non-randomized subset. In simulation studies, we show that all the estimators have low bias but markedly different precision. Cluster randomized trials where clusters are selected for inclusion with known sampling probabilities that depend on cluster characteristics, combined with efficient estimation methods, can precisely quantify treatment effects in the target population, while addressing objectives of trial conduct that require oversampling clusters on the basis of their characteristics.

Mapping the Cardiometabolic Patient Experience and Self-Care Behaviors to Inform Design, Implementation, and Persistent Use of Digital Health Care Solutions: Mixed Methods Study

BACKGROUND

Cardiometabolic conditions including acute coronary syndrome (ACS) and type 2 diabetes (T2D) require comprehensive care and patient engagement in self-care behaviors, and the drivers of those behaviors at the individual and health system level are still poorly understood.

OBJECTIVE

We aim to gain insights into self-care behaviors of individuals with cardiometabolic conditions.

METHODS

A convenience sample of 98 adult patients with ACS and T2D was recruited in the United States, Germany, and Taiwan to participate in a mixed methods study using ethnographic methods. All participants completed 7-day web-based diaries tracking their level of engagement, and 48 completed 90-minute web-based semistructured interviews between February 4, 2021, and March 27, 2021, focusing on themes including moments of engagement. Qualitative analysis identified factors influencing self-care practices and a Patient Mind States Model prototype.

RESULTS

Patient reports indicate that many patients feel social pressure to adhere to treatment. Patients' experience can be understood within 5 categories defined in terms of their degree of engagement and adherence ("ignoring," "struggling," "juggling," "controlling," and "reframing").

CONCLUSIONS

For people living with ACS and T2D, the self-care journey is defined by patterns of patient experiences, which can identify areas that tailored digital health care interventions may play a meaningful role.