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PubMed2003

Pediatric venous thromboembolic disease in one single center: congenital prothrombotic disorders and the clinical outcome.

To learn more about the frequencies of congenital prothrombotic disorders in pediatric venous thromboembolism (VTE) and the outcome of this disease, we evaluated consecutive patients from 0 to 18 years with objectively diagnosed VTE at a single tertiary center over a 12-year period. We included 100 patients, with a median age at diagnosis of 1.0 year (range 2 days to 17 years). At least one underlying clinical condition was present in 96% of the patients. Factor (F)V G1691A mutation was present in 13%, FII G20210A mutation in 3%, antithrombin deficiency in 1%, protein C deficiency in 1% and protein S deficiency in 1% of the tested patients. Combined defects were present in 2.6% of the 77 patients with a complete work-up. Positive family history appeared to be the only predictor for positive testing for congenital disorders (OR 14.9, 95% CI 1.9-113). The overall mortality rate was 20%. The cumulative recurrence-free survival was 92% after 1 year of follow-up, and 82% after 7 years. The incidence and severity of the post-thrombotic syndrome was analyzed in a subgroup of 33 patients with VTE of the lower extremities. Twenty-three (70%) patients developed PTS: moderate in three and mild in 20 patients. In conclusion, congenital prothrombotic disorders seem to play a role in the development of pediatric VTE, and the risk of complications of this disease is high.

Adolescent↗
PubMed1999

The effect of the learning curve on the outcome of laparoscopic treatment for gastroesophageal reflux.

The laparoscopic treatment for gastroesophageal reflux (GR) by partial (PF) or total (TF) fundoplication is the current surgical treatment of choice after failure of appropriate medical treatment. The overall results with fundoplication include the initial learning period, during which the rate of complications, conversions, and duration of surgery and hospitalization are assumed to be greater. The aim of this study was to compare the results of laparoscopic treatment for GR in three groups of consecutive patients to determine the effect of the learning period on outcome. One hundred and fifty-six patients (88 men and 68 women) with an average age of 52.3 years (range, 18-78) were included. Surgery was indicated for failure or early relapse after the end of medical treatment or a symptomatic sliding hernia. The preoperative workup (endoscopy, barium meal, or esophageal pH monitoring) was governed by the clinical picture. The choice between TF and PF was based on the results of pH monitoring. Three groups of patients were chronologically defined. The parameters that were examined were the type of preoperative exploration, the type of fundoplication, the operative technique, the conversion rate, the mortality and morbidity rates, the duration of surgery and hospitalization, and the results at short- and medium-term follow-up. The three groups were comparable with respect to patient characteristics and the nature of their GR. All patients had an endoscopy, 91% had a barium meal, 77.5% underwent esophageal manometry, and 67% had pH monitoring. One hundred and thirty-six patients had a TF and 20 had a PF. Rossetti type TF became the reference procedure (67% in group III) and closure of the diaphragmatic crura was performed systematically in group III (100%). The duration of surgery was significantly reduced between groups I and groups II and III (140, 100, 80 minutes, respectively). The rate of conversion, due to a variety of causes, decreased from 9.8% to 3.8%, and then to 0%. The average duration of hospitalization decreased from 5.8 to 4.2 days (p = 0.01). There was no mortality and the morbidity rate decreased from 15% to 3.8%, and then to 0%. There were seven cases of relapse (4.6%), five in group I (10%) and two in group II (4%), with no cases in group III, although the follow-up in group III was shorter. There is an effect of the learning curve on the outcome of treatment for GR, and this must be taken into account in the training of surgeons (training within experienced departments and guidance during their initial interventions) and also in publications to allow a more accurate comparison of this technique with other treatments for GR.

Adolescent↗
PubMed1992

[Effects of self-efficacy and outcome expectation on observational learning of altruistic behavior].

The purpose of the present study was to examined the hypothesis that the effects of observational learning of altruistic behavior are related to personal viewpoint, self-efficacy, outcome expectation, and other factors. One hundred and fifty-five fourth-grade school children were assigned randomly to four conditions; distress viewpoint, outcome expectation, altruistic behavior, or non-observational control. After observational learning, the students were immediately administered the generalization test of altruistic behavior, empathy, reward and punishment expectations, and rating tests of self-efficacy belief. It was found that; (a) altruistic behavior and outcome expectation conditions had significant learning effects, (b) self-efficacy was able to predict altruistic response in the altruistic behavior viewpoint condition, and (c) from an outcome expectation viewpoint, altruistic behavior toward peers and adults related to punishment expectation, whereas social sharing was related to reward expectation. According to these findings, an observational learning model of altruistic behavior was proposed.

Altruism↗
PubMed1991

The Emanuel Miller Memorial Lecture 1990. Cooperative learning in classrooms: processes and outcomes.

This article focuses on the description and analysis of our research on cooperative grouping over the last 8 years. This research effort has moved through three interconnected phases--from description of classroom practice, to experimentation, to implementation. Descriptions of typical classroom practice have established the paucity of cooperation. Groups tend to be no more than collections of children sitting together but engaged on individual work. In such groups the level of cooperation, frequency of explanations and knowledge exchange is low. Thus, in order to gain an understanding of the nature and process of cooperation in groups on normal curriculum tasks required the setting up of within-classroom experiments. These revealed, among others, that group composition is important to learning outcomes, and that pupil involvement substantially improves in cooperative group endeavours. Missing, however, were data on the successful implementation of cooperative groups. Yet successful implementation has great contemporary relevance because of the demand for assessed skills in collaboration in the national curriculum. Our current work therefore addresses the impact of changing grouping practices on group processes, classroom management, the teacher's role and children's learning. Preliminary findings from this study are presented together with a wider analysis of the state of the research field and possible ways forward.

Child↗
PubMed2004

Comparison of machine learning techniques with classical statistical models in predicting health outcomes.

Several machine learning techniques (multilayer and single layer perceptron, logistic regression, least square linear separation and support vector machines) are applied to calculate the risk of death from two biomedical data sets, one from patient care records, and another from a population survey. Each dataset contained multiple sources of information: history of related symptoms and other illnesses, physical examination findings, laboratory tests, medications (patient records dataset), health attitudes, and disabilities in activities of daily living (survey dataset). Each technique showed very good mortality prediction in the acute patients data sample (AUC up to 0.89) and fair prediction accuracy for six year mortality (AUC from 0.70 to 0.76) in individuals from epidemiological database surveys. The results suggest that the nature of data is of primary importance rather than the learning technique. However, the consistently superior performance of the artificial neural network (multi-layer perceptron) indicates that nonlinear relationships (which cannot be discerned by linear separation techniques) can provide additional improvement in correctly predicting health outcomes.

Aged↗
PubMed2003

Do alcohol expectancies become intoxicated outcomes? A test of social-learning theory in a naturalistic bar setting.

According to social-learning theory, alcohol outcome expectancies (AOEs) are important motivators of drinking behavior that are reinforced, in part, as a result of one's direct experience with alcohol's intoxicating effects. To date, limited research has been conducted in naturalistic bar settings to examine the congruency between AOEs held prior to drinking and individuals' subjective perceptions of post-drinking outcomes. The present study was designed to fill this void. Fifty regular bar patrons (30 males and 20 females) participated. Prior to the initiation of the drinking episode, expected alcohol effects and associated valences were assessed using the Comprehensive Effects of Alcohol (CEOA) questionnaire [Fromme, Stroot, and Kaplan, (1993) 19]. At the conclusion of the drinking episode, all individuals completed the CEOA that was modified in order to assess their subjective alcohol-related outcomes. Overall, while individuals' intoxicated outcomes generally mirrored their pre-drinking AOEs, a lack of congruency was observed with respect to alcohol-related risk and aggression, such that participants reported feeling less aggressive and more disinclined to engage in risky behavior than they had expected as a result of consuming alcohol. As well, two presumably negative (i.e., behavioral impairment and self-perception) and one positive (i.e., liquid courage) alcohol-related outcomes were rated more favorably at the end of the drinking episode. Finally, a main effect for gender was found for specific AOEs. The implications of these findings for social-learning explanations of drinking behavior are discussed.

Adult↗
PubMed2005

Carotid artery stenting with neuroprotection: assessing the learning curve and treatment outcome.

PURPOSE: Carotid artery stenting (CAS) has emerged as an acceptable treatment alternative in high-risk patients with carotid stenosis. The purpose of this study was to assess the effect of the learning curve on treatment complications and the clinical outcomes of CAS. METHODS: Clinical variables and treatment outcomes of 200 consecutive CAS procedures in 182 patients (mean age 72 years) with carotid stenosis > or = 70% during a 40-month period were analyzed. Four sequential groups (groups I, II, III, and IV) of 50 consecutive interventions were compared with regard to technical success, periprocedural complications, and treatment outcomes. RESULTS: Treatment indications and relevant risk factors were similar among the 4 groups. The overall technical success and combined 30-day stroke and death rates were 98% and 2.5%, respectively. An increase in the technical success rate was noted in the latter 3 groups compared with group I (P < .05). Total procedural time and contrast volume were significantly higher in group I compared with the latter 3 groups (P < .05). The intraoperative anticoagulation regimen was changed from intravenous heparin combination to bivalirudin after the first 54 patients, which resulted in decreased bleeding complications in groups III and IV (P = 0.03) compared with the first group. The 30-day stroke and death rate in groups I and II were 8% and 2%, respectively, and was decreased significantly in groups III and IV (0% and 0%, respectively, P < .05). A Cox regression model identified procedural volume (P = .03) as a predictor of decreased complication rate. CONCLUSIONS: CAS with neuroprotection can provide excellent treatment outcomes. Our experience demonstrates a procedure-associated learning curve as evidenced by decreased procedure-related complications, fluoroscopic time, and contrast volume occurring with increased physician experience. Procedural success was also enhanced partly by endovascular device refinement and an improved anticoagulation regimen. Successful CAS outcomes can be achieved once physicians overcome the initial procedure-related learning curve.

Aged↗
PubMedDate not supplied

[Early recognition of partial learning disorders].

The long-term outcome of learning disabilities (lower school performance, higher rates of unemployment and unskilled jobs, secondary psychic disorders and juvenile delinquency) requires their early recognition even at pre-school age. The concept of learning disabilities should be adapted to the concept of specific developmental disorders (ICD-10, F80-F83). The diagnosis of specific developmental disorders at pre-school age shows many difficulties due to the drawbacks of the available psychological tests. A highly economic and reliable battery of tests is presented as an alternative, which enables us to diagnose general intelligence and specific developmental disorders. The diagnostic procedure was standardised on 657 children of four and five years of age.

Adolescent↗
PubMed2000

The impact of chemotherapy dose density and dose intensity on breast cancer outcome: what have we learned?

Optimising chemotherapy dose density and dose intensity are strategies aimed at improving outcomes in adjuvant therapy for patients with breast cancer. There are, in theory, at least five models allowing the delivery of a higher overall drug dose intensity. These are reviewed in this article and vary according to three main variables: the dose per course, the interval between doses and the total cumulative dose. Cyclophosphamide, anthracyclines and taxanes are among the most active agents for the treatment of breast cancer and, as such, they have been or are currently the focus of prospective, randomised clinical trials testing some of these dose-intensity models in the adjuvant setting. The results of recent trials suggest that anthracyclines, but not cyclophosphamide, are associated with better outcomes if used at higher doses per course and at higher cumulative doses. However, care has to be taken with premenopausal women where an increased dose of anthracycline per course but a reduced cumulative dose appears to produce a worse outcome. Moreover, decreasing the interval between doses, for anthracyclines and cyclophosphamide, does not seem to provide, so far, additional benefits for women with locally advanced breast cancer. This approach is not feasible with docetaxel, since an increase in dose density induces unwanted side-effects. These results represent our current state of knowledge, but clinical trials are being performed to evaluate further the effect of dose intensity, dose density and cumulative dose of key therapeutic agents on patient outcomes.

Anthracyclines↗
PubMed2006

The effect of learning curve on the outcome of caesarean section.

OBJECTIVE: To evaluate the operative outcomes when trainees first perform caesarean sections independently. DESIGN: A retrospective study in a tertiary obstetric unit. POPULATION: Five hundred caesarean sections, which represented the first 50 caesarean sections performed independently by each of ten trainees, were studied. METHODS: The effect of learning curve on outcome was analysed. MAIN OUTCOME MEASURES: Total operative time, incision-to-delivery interval, operative blood loss, Apgar score, cord arterial pH, incidence of neonatal intensive care unit admission, postoperative complication rates and duration of hospitalisation. RESULTS: The mean operative time for the first five cases by trainees was 52.2 +/- 11.4 minutes. It progressively decreased and reached 39.6 +/- 8.4 minutes for the 46th to 50th cases. The operative time was significantly longer in the first 15 caesarean sections (P < 0.05). Moreover, the incision-to-delivery interval was also longer during the first five cases (P= 0.02). Besides the time of the operation, the trend for operative blood loss stabilised after the first ten caesarean sections (P < 0.05). Otherwise, there were no significant differences among other outcome variables. CONCLUSION: This study shows that trainees need to perform 10-15 caesarean sections before their skills become more proficient. Senior obstetricians may need to provide guidance to the trainees during their first independent 15 caesarean sections.

Apgar Score↗
PubMed2004

Learning about cues that prevent an outcome: conditioned inhibition and differential inhibition in human predictive learning.

Summation tests were used to assess whether participants in a human predictive judgement task learned that some cues (foods) prevented the occurrence of the outcome (migraine). In three experiments the preventative effect of a conditioned inhibitor, I, trained in the design, P+, PI-, I-, was stronger than that of a negative control cue, N, that had been presented alone with the same frequency and simply predicted no outcome. This control cue, N, also passed the summation test when compared to a novel control cue. Experiments 2 and 3 examined whether the latter negative control effect was attributable to differential inhibition. Manipulations designed to alter context learning and the magnitude of the negative contingency did not affect the properties of the negative control cue. Thus, these experiments did not support the possibility that a cue given simple negative training acquires differential inhibition. Regardless of the mechanism underlying the negative control effect, the consistent finding that the conditioned inhibition cue, I, reduced prediction of the outcome more than did the negative control cue, N, provides evidence for true conditioned inhibition whose acquisition requires co-occurrence of the preventative cue with a positive training cue.

Affect↗
PubMed2004

Two-year outcome audit in an adult learning disability population with refractory epilepsy.

Current evidence suggests that epilepsy outcome for people with a learning disability is poor, with the majority remaining refractory to treatment. There is very little evidence from randomised controlled trials in this population and despite the many uncontrolled variables it is suggested that an outcome audit may be one method of adding to the evidence base. This audit reports on the outcome for 37 patients with learning disability and refractory epilepsy. All patients were seen for the first time before March 2001 and the mean number of seizures for the sample was 10.4 per month. The exit audit included all patients at a date 2 years after their initial visit following a programme of medication changes. The mean seizure frequency had reduced to 5.9 per month. Ten patients had become seizure-free and 76% had experienced an improvement in seizure frequency overall. A simple questionnaire was administered to carers and relatives at the exit audit in an attempt to establish an impression of global changes in alertness, assertiveness and challenging behaviour following interventions. Sixty-five percent of patients were regarded as being more aware and interactive with their surroundings following medication changes and 49% were reported to be more assertive. Thirty percent presented with an increase in behaviours regarded as challenging and 22% were reported to present with less challenging behaviour. The results of this audit suggest that the outcome for the majority of patients with learning disability and refractory epilepsy may be better than that has been previously reported.

Anticonvulsants↗
PubMed2003

Hindsight bias, outcome knowledge and adaptive learning.

The ubiquitous nature of hindsight bias is a cause for concern for those engaged in investigations and retrospective analysis of medical error. Hindsight does not equal foresight. Investigations that are anchored to outcome knowledge run the risk of not capturing the complexities and uncertainties facing sharp end personnel and why their actions made sense at the time. Important lessons go unlearned if the exercise is simply to back track someone else's decision landmarks. Outcome knowledge can also bias our thinking on the quality of the processes that led to the outcome. This paper examines the influence of outcome knowledge in relation to reconstructive memory and legal testimony, ways for reducing the impact of outcome knowledge, and an adaptive learning framework that places hindsight bias in a broader context of rapid updating of knowledge.

Adaptation, Psychological↗
PubMed2005

ICF linking rules: an update based on lessons learned.

OBJECTIVE: Outcome research seeks to understand the end results of health services. Researchers use a wide variety of outcome measures including technical, clinical and patient-oriented measures. The International Classification of Functioning, Disability and Health (ICF) as a common reference framework for functioning may contribute to improved outcome research. The objective of this paper is to provide an updated version of the linking rules published in 2002 and illustrate how these rules are applied to link technical and clinical measures, health-status measures and interventions to the ICF. RESULTS: Three specific linking rules have been established to link health-status measures to the ICF and one specific linking rule has been created to link technical and clinical measures and interventions. A total of 8 linking rules have been established for use with all different outcome measures and with interventions. CONCLUSION: The newly updated linking rules will allow researchers systematically to link and compare meaningful concepts contained in them. This should prove extremely useful in selecting the most appropriate outcome measures among a number of candidate measures for the applied interventions. Further possible applications are the operationalization of concrete ICF categories using specific measures or the creation of ICF category-based item bankings.

Activities of Daily Living↗
PubMed2005

First-episode psychosis, early intervention, and outcome: what have we learned?

OBJECTIVE: There has been increased interest in the potential of early intervention to positively influence outcome in first-episode psychosis (FEP) and, consequently, to influence mental health policy and practice. This study's objective was to examine the concept of early intervention and the evidence that currently exists to support such a shift in the delivery of care. METHOD: We examined the evidence for phase-specific treatment of FEP, looking for interventions that attempt to arrest the transition from a putative prodromal state to full psychosis, as well as for interventions that attempt to reduce delay in treatment. RESULTS: Some evidence supports specialized FEP interventions for short-term outcome in terms of symptom reduction, relapse rates, and greater adherence to and retention in treatment. As well, there is modest support for benefits to aspects of social and community functioning and satisfaction with life. Limited evidence supports a positive effect of community-wide case detection in terms of reduced delays in treatment and pharmacologic and psychological interventions in the prodromal phase. CONCLUSIONS: The field of early intervention in psychosis is young, with encouraging preliminary results, especially for improving outcome in established FEP. It requires further study, especially of longer-term outcome. Further studies need to examine the effects of a specialized approach on longer-term outcome and to explore cost-effective methods to reduce delays in treatment and provide interventions in the prodromal phase.

Cognitive Behavioral Therapy↗
PubMed2006

Implementation of a statewide outcome monitoring system: lessons learned from substance abuse treatment provider staff.

The authors analyze the pilot implementation of a statewide automated outcome monitoring system (OMS) in California, using the perspectives of substance abuse treatment providers responsible for its day-to-day operation. To gain a better understanding of changes experienced by staff and their perceptions of barriers and facilitators of implementation, they conducted 28 focus groups designed to inform midstream adjustments to the system prior to its possible roll-out. Qualitative analysis of the focus group data revealed five important factors influencing implementation: the treatment provider's ethos, the time-consuming nature of the OMS, staff buy-in, resources, and counselor and program discretion. Lessons learned underscored the importance of taking into consideration aspects of organizational change and institutional resources and infrastructure when implementing a major change such as an automated OMS. Findings might be useful to those designing and implementing similar systems or other large organizational change initiatives.

Confidentiality↗
PubMed1991

Assessing student outcomes in a nursing learning assistance program.

This study measured the apparent effectiveness of a Learning Assistance Program (LAP) in second-year baccalaureate nursing students using a process-outcome design. Seventy-eight students participated in LAP and 98 did not. SAT/ACT scores and freshman GPA were the cognitive "input" variables and the end-of-sophomore-year GPA the cognitive "outcome" variable. Affective variables at the beginning and end of the test year were the Study Attitudes and Methods Survey (SAMS) and the Survey of Reading and Study Efficiency (SR/SE). Statistical analysis included stepwise multiple regressions for evaluating the relationship between the process (LAP participation) and outcomes when the entry variables had been accounted for. Attending LAP improved participants' study attitudes and skills scores. There was a significant negative correlation between the degree of LAP participation by lower achieving students and their sophomore-year-ending GPA. This may be related to the fact that students who perform poorly on tests are encouraged to participate in LAP.

Adolescent↗