Translational cognition for decision support in critical care environments: a review

The dynamic and distributed work environment in critical care requires a high level of collaboration among clinical team members and a sophisticated task coordination system to deliver safe, timely and effective care. A complex cognitive system underlies the decision-making process in such cooperative workplaces. This methodological review paper addresses the issues of translating cognitive research to clinical practice with a specific focus on decision-making in critical care, and the role of information and communication technology to aid in such decisions. Examples are drawn from studies of critical care in our own research laboratories. Critical care, in this paper, includes both intensive (inpatient) and emergency (outpatient) care. We define translational cognition as the research on basic and applied cognitive issues that contribute to our understanding of how information is stored, retrieved and used for problem-solving and decision-making. The methods and findings are discussed in the context of constraints on decision-making in real-world complex environments and implications for supporting the design and evaluation of decision support tools for critical care health providers.     

Digital video analysis of health professionals’ interactions with an electronic whiteboard: A longitudinal,naturalistic study of changes to user interactions

As hospital departments continue to introduce electronic whiteboards in real clinical settings a range of human factor issues have emerged and it has become clear that there is a need for improved methods for designing and testing these systems. In this study, we employed a longitudinal and naturalistic method in the usability evaluation of an electronic whiteboard system. The goal of the evaluation was to explore the extent to which usability issues experienced by users change as they gain more experience with the system. In addition, the paper explores the use of a new approach to collection and analysis of continuous digital video recordings of naturalistic “live” user interactions. The method developed and employed in the study included recording the users’ interactions with system during actual use using screen-capturing software and analyzing these recordings for usability issues. In this paper we describe and discuss both the method and the results of the evaluation. We found that the electronic whiteboard system contains system-related usability issues that did not change over time as the clinicians collectively gained more experience with the system. Furthermore, we also found user-related issues that seemed to change as the users gained more experience and we discuss the underlying reasons for these changes. We also found that the method used in the study has certain advantages over traditional usability evaluation methods, including the ability to collect analyze live user data over time. However, challenges and drawbacks to using the method (including the time taken for analysis and logistical issues in doing live recordings) should be considered before utilizing a similar approach. In conclusion we summarize our findings and call for an increased focus on longitudinal and naturalistic evaluations of health information systems and encourage others to apply and refine the method utilized in this study.     

Event Representations and Predictive Processing: The Role of the Midline Default Network Core

The human brain is tightly coupled to the world through its sensory‐motor systems—but it also spends a lot of its metabolism talking to itself. One important function of this intrinsic activity is the establishment and updating of event models—representations of the current situation that can predictively guide perception, learning, and action control. Here, we propose that event models largely depend on the default network (DN) midline core that includes the posterior cingulate and anterior medial prefrontal cortex. An increasing body of data indeed suggests that this subnetwork can facilitate stimuli processing during both naturalistic event comprehension and cognitive tasks in which mental representations of prior situations, trials, and task rules can predictively guide attention and performance. This midline core involvement in supporting predictions through event models can make sense of an otherwise complex and conflicting pattern of results regarding the possible cognitive functions subserved by the DN.     

A New Approach to the Characterization of Subtle Errors in Everyday Action: Implications for Mild Cognitive Impairment

Mild functional difficulties have been associated with early cognitive decline in older adults and increased risk for conversion to dementia in mild cognitive impairment, but our understanding of this decline has been limited by a dearth of objective methods. This study evaluated the reliability and validity of a new system to code subtle errors on an established performance-based measure of everyday action and described preliminary findings within the context of a theoretical model of action disruption. Here 45 older adults completed the Naturalistic Action Test (NAT) and neuropsychological measures. NAT performance was coded for overt errors, and subtle action difficulties were scored using a novel coding system. An inter-rater reliability coefficient was calculated. Validity of the coding system was assessed using a repeated-measures ANOVA with NAT task (simple versus complex) and error type (overt versus subtle) as within-group factors. Correlation/regression analyses were conducted among overt NAT errors, subtle NAT errors, and neuropsychological variables. The coding of subtle action errors was reliable and valid, and episodic memory breakdown predicted subtle action disruption. Results suggest that the NAT can be useful in objectively assessing subtle functional decline. Treatments targeting episodic memory may be most effective in addressing early functional impairment in older age.     

真实性评估概述及其对我国聋儿康复工作的启示

真实性评估采用自然主义方法,在真实情境中收集功能性和背景性信息,从而科学评价聋儿的言语发展情况以及行为表现情况.本文介绍了真实性评估的概念、功能、特点和实施方法,并提出我国的聋儿康复工作应借鉴这一新理念.     

A prospective,multicentre, open-label study of aripiprazole in the management of patients with schizophrenia in psychiatric practice in Europe: Broad Effectiveness Trial with Aripiprazole in Europe (EU-BETA)

ABSTRACT

Objective: To examine the effectiveness of aripiprazole in schizophrenia in a naturalistic setting in 14 European countries.

Methods: This multicentre, open-label study of aripiprazole evaluated outpatients with schizophrenia for whom a medication switch was clinically reasonable or antipsychotic initiation was required. Patients (n = 833) were randomized in a 4:1 ratio to aripiprazole (recommended starting dose 15?mg/day, permitted adjustment 10–30?mg/day) (n = 680) or another antipsychotic (safety control [SC] group) (n = 153) for 8 weeks. The control group received an antipsychotic different to their recent pre-study medication. The primary effectiveness measure was the Clinical Global Impression – Improvement (CGI – I) score of aripiprazole-treated patients at Week 8 (last observation carried forward [LOCF]). Patients’ and caregivers’ medication preference was assessed using the Preference of Medication (POM) questionnaire. The Investigator Assessment Questionnaire (IAQ) was used to record investigators’ assessments of their patients’ responses to the study antipsychotic. Adverse events (AEs) were recorded.

Results: At endpoint (Week 8, LOCF), the mean CGI – I score of 3.16 (95% confidence interval, [CI]: 3.04, 3.28) demonstrated the effectiveness of aripiprazole. At endpoint, 43% of aripiprazole-treated patients showed a response (CGI – I score = 1/2). Aripiprazole was rated as slightly or much better than previous antipsychotic at endpoint by 68% of patients and 65% of caregivers. The mean CGI – I score (Week 8, LOCF) for the SC group was 3.37 (95% CI: 3.14, 3.60). No major differences in the occurrence of AEs were noted between aripiprazole- and SC-treated patients.

Limitations: As this is an open-label design, there may have been a bias. Secondly, the study was not powered to show differences between treatment groups and no statistical comparisons were planned. Thirdly, 8 weeks is too short to evaluate long-term effectiveness.

Conclusions: Aripiprazole was effective, well tolerated and well accepted by patients and caregivers in this naturalistic study.     

A cluster analysis of early onset in common anxiety disorders

Early onset is regarded as an important characteristic of anxiety disorders, associated with higher severity. However, previous findings diverge, as definitions of early onset vary and are often unsubstantiated. We objectively defined early onset in social phobia, panic disorder, agoraphobia, and generalised anxiety disorder, using cluster analysis with data gathered in the general population. Resulting cut-off ages for early onset were ≤22 (social phobia), ≤31 (panic disorder), ≤21 (agoraphobia), and ≤27 (generalised anxiety disorder). Comparison of psychiatric comorbidity and general wellbeing between subjects with early and late onset in the general population and an outpatient cohort, demonstrated that among outpatients anxiety comorbidity was more common in early onset agoraphobia, but also that anxiety- as well as mood comorbidity were more common in late onset social phobia. A major limitation was the retrospective assessment of onset. Our results encourage future studies into correlates of early onset of psychiatric disorders.     

多奈哌齐治疗阿尔茨海默病患者认知功能的自然观察研究

目的 考察记忆门诊自然观察过程中多奈哌齐对阿尔茨海默痛(AD)患者认知功能的改善作用.方法 13例在记忆门诊就诊的符合NINCDS-ADRDA很可能AD诊断标准的接受多奈哌齐(5 mg/d)治疗的轻中度AD患者纳入自然观察研究,采用认知功能筛查测验(CASI)评估患者认知功能,分别在治疗前、治疗3个月和6个月进行.结果 与基线相比,治疗6个月时思维流畅性有显著改善(4.3±3.1与6.2±2.7,P＜0.05);构图能力呈改善趋势,但差异无统计学意义(P=0.06),其余认知功能治疗前后比较差异均无统计学意义(P均＞0.05).结论 记忆门诊自然观察条件下,多奈哌齐能改善AD患者言语流畅性,并能使患者其他认知领域功能保持基本稳定.