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PubMedDate not supplied

In search of the neurobiological underpinnings of the differential outcomes effect.

Correlating unique rewards with to-be-remembered events (the Differential Outcomes Procedure [DOP]) enhances learning and memory performance in a range of species. Recently, we have demonstrated that the DOP can be used to reduce or eliminate the learning and memory impairments associated with animal models of amnesia and dementia. This powerful phenomenon, the Differential Outcomes Effect (DOE), has led to the question: How does such a simple manipulation exert such dramatic influence on learning and memory performance? A revised two-process account of the DOE states that using the DOP results in the activation of reward expectancies through Pavlovian mechanisms. The use of unique reward expectancies alters the nature of cognitive processing used to solve discrimination tasks. The change in cognitive processing is represented by utilization of a different memory system than that commonly used to acquire and remember information when a Nondifferential Outcomes Procedure (NOP) is used. Using neurochemical manipulations, it has been demonstrated that different, potentially independent, brain systems modulate memory performance when subjects are trained with a NOP versus a DOP. This memory-based DOP/NOP distinction resembles other dissociative memory theories in which two psychological processes are purportedly served by distinct neurobiological mechanisms. In addition, such results have important ramifications for the treatment of memory disorders because they demonstrate that stimulus and behavioral manipulations, like drugs, can influence neurotransmitter functioning.

Aging↗
PubMed2005

Accreditation for learning and change: quality and improvement as the outcome.

Increased accountability for facilitating and demonstrating the continued competence of physicians and improvements in the quality of health care are being called for by government, the public, and organized medicine. Areas of critical skills have been identified by the Institute of Medicine, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties. These "competencies" serve as the framework around which medical school curricula, residency programs, and continuing medical education (CME) can be built. Much discussion revolves around the reform of CME, and the organizations most involved have developed innovative plans and initiatives to ensure that CME is optimally positioned to support physicians in learning and change. The Accreditation Council for Continuing Medical Education (ACCME) supports a new and expanded role for the CME provider in physicians' lifelong learning, including periodic self-assessment and practice performance improvement. CME providers can assist in the determination of need (self-assessment) by the physician, the delivery of education to meet that need, and the evaluation of education used to meet the need, especially as it relates to the practice performance of the physician. The ACCME, working with accredited providers, has embraced these expectations and believes that CME can meet these challenges with an approach that also expects independence from commercial interests and freedom from commercial bias. The CME enterprise is uniquely positioned to deliver effective education for learning and change.

Accreditation↗
PubMed2005

Working collaboratively in health care contexts: the influence of bioscientific knowledge on patient outcomes.

This paper explores work-based learning and collaborative working in health care by drawing on the findings of a completed study about the influence of nursing knowledge on patient outcomes. A qualitative research approach was used to explore the experiences of nurses in critical care settings. Interviews and analysis produced a descriptive and interpretive account of everyday working and learning for these specialist nurses. Findings showed that nursing knowledge influenced patient outcomes in a number of ways. Nurses draw on bio-scientific knowledge and experience in order to achieve patient outcomes. Moreover, they collaborated with other health professionals in everyday working and learning. The study findings are explored with reference to the literature about situated knowledge, clinical problem solving and work-based learning. The significance of the findings is that the kind of 'collaborative competence' identified here contributes to the achievement of the aims of the NHS plan and ' Working Together, Learning Together' [Department of Health, 2001. Working Together, Learning Together. Department of Health, London]. Despite the centrality of team working and the trend for more work-based learning in NHS contexts, there is a limited evidence base to date about the influence of team working or work-based learning on patient outcomes. The analysis and discussion in this paper adds to this body of knowledge.

Attitude of Health Personnel↗
PubMedDate not supplied

Teaching baccalaureate nursing students to project outcomes to nursing interventions.

PURPOSE: To develop an innovative method of teaching baccalaureate nursing students to plan for and recognize outcomes to specific nursing interventions. METHODS: A case study design that measured the effectiveness of a teaching innovation. Tools for students (N = 8) to use during clinical practice included an Intervention-Outcome Analysis Tool and a Nursing Clinical Outcomes Tool. FINDINGS: Quantitative and qualitative evaluation data were presented that showed growth in the ability to set and meet patient outcomes during the semester. CONCLUSIONS: Thinking in terms of outcomes moved student beyond problem solving in their clinical thinking and assisted them to learn to develop individualized outcome statements for their patients.

Curriculum↗
PubMedDate not supplied

Early reading instruction for children with reading difficulties: meeting the needs of diverse learners.

Several multiple-probe-across-participants design studies were employed to evaluate the effectiveness of a supplemental tutoring intervention using Read Well (Sprick, Howard, & Fidanque, 1998-2000). In Year 1, we conducted two studies with 7 first-, second-, and third-grade children (1 girl and 6 boys), who were classified as having learning disabilities, having attention-deficit disorder, or being English language learners and were identified by their teachers as poor readers. The results of the two studies indicated that 3 of the 5 children who received Read Well instruction showed improvement in passage fluency. Student performance on other measures of reading and comprehension was varied. Differences in student characteristics and in the amount of Read Well instruction received (2 to 7 weeks) seemed to account for the differences in performance. In Year 2, we implemented the same tutoring intervention for a longer duration (up to 16 weeks) and included 5 children in second and third grades (2 girls and 3 boys) with reading difficulties. Two of these children had previously participated in the Year 1 studies. The results indicated growth in reading, spelling, and comprehension for most children. Overall, the findings from Year 1 and 2 studies indicate the benefits of increased instructional intensity and duration for children who struggle with emerging reading skills.

Attention Deficit Disorder with Hyperactivity↗
PubMed1994

On the relationship between differential outcomes and differential sample responding in matching-to-sample.

Four experiments examined control over choice by differential sample responding in matching-to-sample with differential outcomes. In Experiment 1, pigeons initially learned to match with food versus no-food outcomes. Their performances later transferred to other samples to which responding versus not responding had been explicitly reinforced with a single outcome (food). In Experiment 2, pigeons initially learned to produce the comparisons by pecking one sample but not the other. Transfer was then observed to new samples associated with food versus no food (and thus often vs. seldomly pecked). Experiments 3 and 4 showed that transfer of matching required differential behavior to each sample set and did not depend on explicit conditioning of that behavior prior to acquisition. Together, these results show that differential sample behaviour provides a redundant cue for choice in differential outcome matching-to-sample.

Animals↗
PubMed2002

Diffuse large B-cell lymphoma outcome prediction by gene-expression profiling and supervised machine learning.

Diffuse large B-cell lymphoma (DLBCL), the most common lymphoid malignancy in adults, is curable in less than 50% of patients. Prognostic models based on pre-treatment characteristics, such as the International Prognostic Index (IPI), are currently used to predict outcome in DLBCL. However, clinical outcome models identify neither the molecular basis of clinical heterogeneity, nor specific therapeutic targets. We analyzed the expression of 6,817 genes in diagnostic tumor specimens from DLBCL patients who received cyclophosphamide, adriamycin, vincristine and prednisone (CHOP)-based chemotherapy, and applied a supervised learning prediction method to identify cured versus fatal or refractory disease. The algorithm classified two categories of patients with very different five-year overall survival rates (70% versus 12%). The model also effectively delineated patients within specific IPI risk categories who were likely to be cured or to die of their disease. Genes implicated in DLBCL outcome included some that regulate responses to B-cell-receptor signaling, critical serine/threonine phosphorylation pathways and apoptosis. Our data indicate that supervised learning classification techniques can predict outcome in DLBCL and identify rational targets for intervention.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed2000

Stentless freestyle aortic valve/root bioprostheses: a northern Ontario community hospital perspective.

OBJECTIVE: To examine the controversial issues of postoperative aortic insufficiency (AI), operative mortality and length of hospital stay (LOS) following stentless Freestyle aortic valve replacement (AVR). SETTING: All surgeries were performed in a small northern community hospital (Sudbury Regional Hospital, Sudbury, Ontario). DESIGN: Retrospective study of all stentless AVRs and all stented AVRs from May 1996 to December 1998, and isolated coronary artey bypasses (CABGs) done in 1996/97. PATIENTS: Patients were not selected. All consecutive patients requiring bioprosthetic AVR during this period, regardless of risk, complexity or urgency, were included. In total, 112 stentless AVRs, 138 stented AVRs and 432 isolated CABGs were examined. MAIN RESULTS: AI was rare following stentless AVRs: no significant valvular AI and only 0.9% significant paravalvular AI occurred. The incidence of AI was significantly greater with continuous than with interrupted proximal suturing (P=0. 016). No valve thromboses, thromboemboli or structural failure occurred during 3.8 years of follow-up of the stentless AVRs. The LOS for stentless AVRs was no longer than for stented AVRs or for isolated CABGs. No significant difference was found in the operative mortality following stentless and stented AVRs. The early mortality rate of 1.8% for stentless AVRs was not affected by preoperative risk strata, complexity or urgency. CONCLUSIONS: Early morbidity with stentless AVRs was comparable and LOS was no longer than with stented AVRs. The use of Freestyle bioprosthesis in itself did not result in greater operative mortality, regardless of risk, complexity or urgency of the procedure. Consistent reproducible techniques and experience improve postoperative outcome. It is essential that potential users carefully learn safe and effective surgical techniques to avoid adverse outcomes during the learning curve.

Adult↗
PubMed2006

Effects of donepezil on memory and cognition in multiple sclerosis.

Acetylcholinesterase inhibitors are used to treat dementia associated with Alzheimer's disease, but their cognitive benefits may extend to additional disorders such as multiple sclerosis (MS). A single-center double-blind placebo-controlled randomized clinical trial evaluated the effectiveness of donepezil in a sample of 69 MS persons selected for initial memory difficulties. Subjects received neuropsychological assessment at baseline and after 24 weeks of treatment. The primary outcome was change in total recall on the Selective Reminding Test, a measure of verbal learning and memory. Secondary outcomes included other neuropsychological tests from the Brief Repeatable Battery, patient-reported change in memory, and physician-reported impression of cognitive change. Donepezil improved memory performance on the SRT compared to placebo. This benefit remained significant after controlling for various covariates including Expanded Disability Status Scale (EDSS), MS subtype, interferon beta use, treatment group beliefs, gender, baseline selected reminding test (SRT) score, and reading ability. Subjects on donepezil were more likely to report memory improvement (65.7%) than those on placebo (32.4%). The clinician also reported cognitive improvement in more donepezil (54.3%) than placebo (29.4%) subjects. No serious adverse events related to study medication occurred. However, more donepezil (34.3%) than placebo (8.8%) subjects reported unusual/abnormal dreams. Donepezil improved learning and memory in MS patients with initial cognitive difficulties in a single-center clinical trial. Replication of results in a larger multi-center investigation is warranted in order to more definitively assess the efficacy of this intervention.

Adult↗
PubMed2001

Learning curve of the Inoue technique of percutaneous mitral balloon valvuloplasty.

There is controversy as to whether the double-balloon or the Inoue technique of percutaneous mitral balloon valvuloplasty (PMBV) provides superior immediate and long-term results. This study was undertaken to analyze the effect of the learning curve of the Inoue technique of PMBV in the immediate and long-term outcome of PMBV. The learning curve of Inoue PMBV was analyzed in 233 Inoue PMBVs divided into 2 groups: "early experience" (n = 100) and "late experience" (n = 133). The results of the overall Inoue technique were compared with those of 659 PMBVs performed with the double-balloon technique. Baseline clinical and morphologic characteristics between early and late experience Inoue groups were similar. Post-PMBV mitral valve area (1.89 +/- 0.56 vs 1.69 +/- 0.57 cm(2); p = 0.008) and success rate (60% vs 75.9%; p = 0.009) were significantly higher in the late experience Inoue group. Furthermore, there was a trend for less incidence of severe post-PMBV mitral regurgitation > or = 3+ in the late experience group (6.8% vs 12%; p = 0.16). Although the post-PMBV mitral valve area was larger with the double-balloon technique (1.94 +/- 0.72 vs 1.81 +/- 0.58 cm(2); p = 0.01), the success rate (71.3% vs 69.1%; p = NS), incidence of > or = 3+ mitral regurgitation (9% vs 9%), in-hospital complications, and long-term and event-free survival were similar with both techniques. In conclusion, there is a significant learning curve of the Inoue technique of PMBV. Both the Inoue and the double-balloon techniques are equally effective techniques of PMBV because they resulted in similar immediate success, in-hospital adverse events, and long-term and event-free survival.

Boston↗
PubMedDate not supplied

A synthesis of spelling and reading interventions and their effects on the spelling outcomes of students with LD.

Previous research studies examining the effects of spelling and reading interventions on the spelling outcomes of students with learning disabilities (LD) are synthesized. An extensive search of the professional literature between 1995 and 2003 yielded a total of 19 intervention studies that provided spelling and reading interventions to students with LD and measured spelling outcomes. Findings revealed that spelling outcomes were consistently improved following spelling interventions that included explicit instruction with multiple practice opportunities and immediate corrective feedback after the word was misspelled. Furthermore, evidence from spelling interventions that employed assistive technology aimed at spelling in written compositions indicated positive effects on spelling outcomes.

Child↗
PubMed2002

Prediction of outcome of physiotherapy in advanced Parkinson's disease.

OBJECTIVE: Prediction of the effect of a home physiotherapy intervention on the basis of four clinical characteristics of patients with advanced Parkinson's disease. DESIGN: A repeated measures design comparing six weeks without treatment with six weeks of physiotherapy and a follow-up of 12 weeks. SUBJECTS: Persons with Parkinson's disease without dementia and suffering from considerable functional disability. INTERVENTION: Community physiotherapists treated patients in the home situation three times a week teaching cueing and conscious movement control for walking and carrying out transfers in and out of beds and chairs. MAIN OUTCOME MEASURES: Mental status, disease severity, age and mood were included as predictor variables. A new functional scale developed as part of a previous study was used as the dependent variable administered in both the hospital and the home to determine whether the outcome generalized from the learning to a different environment. RESULTS: Only disease severity was a negative predictor of treatment outcome at home. In the hospital setting none of the factors predicted the immediate effect of treatment but cognitive ability and age were determinants of whether the treatment effects were maintained in the long term. CONCLUSIONS: Using cueing and cognitive strategies benefited younger and older patients with Parkinson's disease alike. However, the findings indicate targeting of treatment at patients with milder disease severity and providing follow-up treatment for older and cognitively less able patients.

Age Factors↗
PubMed2006

Reversal learning in Parkinson's disease depends on medication status and outcome valence.

We investigated the role of dopamine in distinct forms of reversal shifting by comparing two groups of patients with mild Parkinson's disease (PD), one ON and one OFF their normal dopaminergic medication. In accordance with our previous work, patients ON medication exhibited impaired reversal shifting relative to patients OFF medication. The present results extend previous studies by showing that the medication-induced deficit on reversal shifting was restricted to conditions where reversals were signaled by unexpected punishment. By contrast, patients ON medication performed as well as patients OFF medication and controls when the reversal was signaled by unexpected reward. The medication-induced deficit was particularly pronounced in patients on the dopamine D3 receptor agonist pramipexole. These data indicate that dopaminergic medication in PD impairs reversal shifting depending on the motivational valence of unexpected outcomes.

Aged↗
PubMed1997

Linsker-type Hebbian Learning: A Qualitative Analysis on the Parameter Space.

We developed a new method to relate the choice of system parameters to the outcomes of the unsupervised learning process in Linsker's multi-layer network model. The behavior of this model is determined by the underlying nonlinear dynamics that are parameterized by a set of parameters originating from the Hebb rule and the arbor density of the synapses. These parameters determine the presence or absence of a specific receptive field (or connection pattern) as a saturated fixed point attractor of the model. We derived a necessary and sufficient condition to test whether a given saturated weight vector is stable or not for any given set of system parameters, and used this condition to determine the whole regime in the parameter space over which the given connection pattern is stable. The parameter space approach allows us to investigate the relative stability of the major receptive fields reported in Linsker's simulation, and to demonstrate the crucial role played by the localized arbor density of synapses between adjacent layers. The method presented here can be employed to analyze other learning and retrieval models that use the limiter function as the constraint controlling the magnitude of the weight or state vectors. Copyright 1997 Elsevier Science Ltd.

Journal Article↗
PubMed1994

Evaluating the purpose and benefits of continuing education in nursing and the implications for the provision of continuing education for cancer nurses.

In the light of increasing emphasis upon mandatory continuing education in nursing, the need for cancer nurses to update and improve their knowledge and skills is heightened. The challenges lie in how to keep nurses up-to-date, broaden their outlook and ensure that patients benefit. In this paper the literature on the purpose and benefits of continuing education is reviewed, and the implications of the Post-Registration Education and Practice Project (PREPP) for cancer nurses are addressed. Arguments about a definition of 'continuing learning' rather than 'continuing education' are discussed, since outcomes vary depending upon the definition adopted. Inconsistencies between the benefits claimed and those measured are highlighted. Attention is drawn to the inconclusive nature of the studies that have measured impact; some of the problems encountered in the provision of adequate education and its accessibility to nurses; and the continuing discrepancy of perceived need between nurse and manager. Specific impact evaluation studies relating to continuing education in cancer nursing are reviewed. Recommendations for providing education with measurable outcomes are drawn from the literature, while a case is made for the alternative perspective of lifelong learning where outcomes are neither specific nor measurable. In conclusion, the questions of who should be responsible for education and the need for further development of impact evaluation tools are addressed.

Education, Nursing, Continuing↗
PubMed2006

Operative time is a poor surrogate for the learning curve in laparoscopic colorectal surgery.

BACKGROUND: Previous studies have relied on conversion rate and operative time for construction of learning curves in laparoscopic colorectal surgery. The authors hypothesized that conversion rate and operative time were less important than complication and readmission rates in defining good outcomes and hence the learning curve. METHODS: A database of 287 consecutive laparoscopic colorectal resections from a single tertiary referral center was analyzed. Outcome measures included operative time, conversion rate, major and minor complications, length of hospital stay, and the 15- and 30-day hospital readmission rate. Data were analyzed both by surgeons and by quartile case numbers. RESULTS: A total of 151 right colectomies and 136 left colectomies were performed between 1995 and 2005. For both right and left colectomies, the conversion rate decreased in each of the first three quartiles, reaching a nadir of 0% for right colectomies and 3% for left colectomies in the third quartile. The conversion rates increased slightly in the fourth quartile. The operative time remained stable for three quartiles, then increased slightly in the fourth quartile. Two surgeons managed 199 of the 287 cases. Analysis of the two high-volume surgeons demonstrated that for left-sided resections, the surgeon with the shorter operative times had the higher major complication rate (13% vs 2%), overall complication rate (22% vs 2%), 30-day readmission rate (13% vs 0%), and length of stay (3.8 vs 3.1 days) (p < 0.05 for all comparisons). CONCLUSIONS: In this series, operative time failed to decrease with experience, and shorter operative times did not correlate with better clinical outcomes. The failure of operative time to decline with experience often reflects surgeons' willingness to attempt more difficult cases rather than an accurate representation of a "learning curve." Therefore, complication and readmission rates are more important than operative time and conversion rates for evaluating the learning curve and quality of laparoscopic colorectal surgery.

Adult↗
PubMed2001

Developmental outcomes of newborn encephalopathy in the term infant.

Newborn encephalopathy is a clinically defined condition of abnormal neurological behaviours in the newborn period. Though most cases have their origin in the preconceptional and antepartum period, newborn encephalopathy represents a crucial link between intrapartum events and permanent neurological problems in the child. The birth prevalence of newborn encephalopathy ranges from 1.8 to 7.7 per 1000 term live births according to the definition used and the population to which it is applied. Few studies have investigated the outcomes of newborn encephalopathy other than for cases solely attributed to intrapartum hypoxia. These adverse outcomes range from death to cerebral palsy, intellectual disability, and less severe neurological disabilities such as learning and behavioural problems. Outcomes following newborn encephalopathy may vary from country to country with 9.1% of affected babies dying in the newborn period in Western Australia and 10.1% manifesting cerebral palsy by the age of two. These compare to a case fatality of 30.5% in Kathmandu and a cerebral palsy rate of 14.5% by one year of age. The study by Robertson et al which followed children with hypoxic ischaemic encephalopathy found an incidence of impairment of 16% among survivors assessed at 8 years with 42% requiring school resource room help or special classes. This review emphasises the great need for comprehensive clinical and educational assessment as these infants approach school entry to enable appropriate educational provisions to be made.

Brain Damage, Chronic↗