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To identify interstage best practices associated with lower mortality, we studied National Pediatric Cardiology Quality Improvement Collaborative centres registry using a positive deviance approach.
Positive deviant and control centre team members were interviewed to identify potential interstage best practices. Subsequently, all collaborative centres were surveyed on the use of these practices to test their associations with centre mortality. Questionnaires were scored using Likert scales; the overall score was linearly transformed to a 0–100-point scale with higher scores indicating increased use of practices. Mortality was based on patients enrolled after a centre’s first year in the collaborative. Centre mortality rates were divided into tertiles. Survey scores for the low mortality tertile were compared with the other tertiles.
For this study, seven positive deviant and four control teams were interviewed. A total of 20 potential best practices were identified, including team composition, improvement practices, and parent involvement. Questionnaires were completed by 36/43 eligible centres, providing 1504 patients for analysis. Average survey score was 50.2 (SD 13.4). Average mortality was 6.1% (SD 4.1). There was no correlation between survey scores and mortality (r=0.14, p=0.41). The one practice associated with the low mortality tertile was frequency of discussion of interstage results: 58.3% of low mortality teams discussed results at least monthly versus 8.4% of the middle and high tertile centres (p=0.02).
Low-mortality centres more frequently discuss interstage results than high-mortality centres. Heightened awareness of outcomes may influence practice; however, further study is needed to understand the variation in outcomes across centres.
Secondary plant compounds have shown bioactivity against multi-drug resistant Haemonchus contortus in small ruminants. This study screened 51 strains of birdsfoot trefoil (BFT, Lotus corniculatus) crude aqueous extracts (BFT-AqE) for anti-parasitic activity in vitro against egg hatching, and of those 51 strains, 13 were selected for further testing of motility of first (L1) and third stage (L3) larvae, and exsheathment of L3. Proanthocyanidin content ranged between 1.4 and 63.8 mg PAC g−1 powder across the 51 BFT strains. When tested against egg hatching, 21 of the 51 aqueous extracts had an EC50 of 1–2 mg powder mL−1, 70% of the strains were >90% efficacious at 6 mg powder mL−1 and 11 of the strains were 100% efficacious at 3 mg powder mL−1 BFT-AqE. Across the 13 strains tested against L3, efficacy ranged from 0 to 75% exsheathment inhibition, and 17 to 92% L3 motility inhibition at a concentration of 25 mg powder mL−1 BFT-AqE. There was no correlation between the PAC content of BFT powders and the anti-parasitic activity of aqueous extracts, therefore other secondary compounds may have contributed to the observed anti-parasitic effects. Further testing of BFT using bioactivity-driven fractionation and screening of BFT populations for the identified anti-parasitic compounds is needed.
The biological domain has the potential to offer a rich source of analogies to solve engineering design problems. However, due to the complexity embedded in biological systems, adding to the lack of structured, detailed, and searchable knowledge bases, engineering designers find it hard to access the knowledge in the biological domain, which therefore poses challenges in understanding the biological concepts in order to apply these concepts to engineering design problems. In order to assist the engineering designers in problem-solving, we report, in this paper, a web-based tool called Idea-Inspire 4.0 that supports analogical design using two broad features. First, the tool provides access to a number of biological systems using a searchable knowledge base. Second, it explains each one of these biological systems using a multi-modal representation: that is, using function decomposition model, text, function model, image, video, and audio. In this paper, we report two experiments that test how well the multi-modal representation in Idea-Inspire 4.0 supports understanding and application of biological concepts in engineering design problems. In one experiment, we use Bloom's method to test “analysis” and “synthesis” levels of understanding of a biological system. In the next experiment, we provide an engineering design problem along with a biological-analogous system and examine the novelty and requirement-satisfaction (two major indicators of creativity) of resulting design solutions. In both the experiments, the biological system (analogue) was provided using Idea-Inspire 4.0 as well as using a conventional text-image representation so that the efficacy of Idea-Inspire 4.0 is tested using a benchmark.
In the product design realm, designers often use presentations to convey certain ideas about a product or a specific stage of the design process. The popular forms of presentation include verbal pitching, two-dimensional drawing, and prototyping. The clients, investigators, and other audiences rely on such presentations to evaluate an idea. Popular idea evaluation assessment tools, such as the consensual assessment technique, utilize such interactions. On the other hand, numerous pieces of literature state that the audiences are heavily influenced by the quality of presentation when evaluating the worth of the product being presented. In this study, we examine if the audience is able to discriminate between the quality of the presentation and the quality of the idea being presented. A total of 613 ideas were evaluated over a 4-year period during a specific product design class at different phases in the design process. The result shows that no matter the kind of presentation tool used, the presentation quality ratings and the idea value ratings had a very strong positive correlation despite the explicit instructions to reviewers to separate presentation quality from concept quality. Our additional analysis shows that such a pattern did not change during the different phases of the design process.
It is well-known that creativity is crucial for sustaining a product against competition. Many factors have been proposed in the literature as indicators of creativity, among which outcome-characteristics-based factors are considered the most reliable; among these, the creativity of an outcome is often indicated by two major factors: novelty and usefulness. Only a few studies address as to how creativity assessment methods and their results can be used during the design process. To systematically address the issue of how to influence creativity of design solutions, the following questions have been framed. (1) Which factors should be used as indicators of creativity consistently across different phases of the engineering design process? (2) How can creativity be assessed in terms of these factors during the engineering design process? In this work, we consider novelty and usefulness as the necessary factors for creativity. It is found, however, that it is not possible to directly assess the usefulness of outcomes during the design process. Therefore, requirement satisfaction is used as a proxy for usefulness. We propose a creativity assessment method that uses novelty and requirement satisfaction as indicators for creativity; the method can be used for assessing not only complete products but also ideas or concepts, as they evolve through the phases of the design process. The application of the method in design is explained using a detailed example from a case study.
Analogy is a core cognition process used to produce inferences as well as new ideas using previous knowledge and experience. Ontology is a formal representation of a set of domain concepts and their relationships. The use of analogy and ontology in design activities to support design creativity have previously been explored. This paper explores an approach to construct ontologies with sufficient richness and coverage to support reasoning over real-world datasets for prompting creative idea generation. This approach has been implemented into a computational tool for assisting designers in generating creative ideas during the early stages of design. The tool, called “the Retriever”, has been developed based on ontology by embracing the aspects of analogical reasoning. A case study has indicated that the tool can be effective and useful for idea generation. The results have indicated that the tool, in its current formulation, can significantly improve the fluency and flexibility of idea generation and the usefulness of ideas, as well as slightly increase the originality of ideas, for the case study concerned.
Traditionally, design opportunities and directions are conceived based on expertise, intuition, or time-consuming user studies and marketing research at the fuzzy front end of the design process. Herein, we propose the use of the total technology space map (TSM) as a visual ideation aid for rapidly conceiving high-level design opportunities. The map is comprised of various technology domains positioned according to knowledge proximity, which is measured based on a large quantity of patent data. It provides a systematic picture of the total technology space to enable stimulated ideation beyond the designer's knowledge. Designers can browse the map and navigate various technologies to conceive new design opportunities that relate different technologies across the space. We demonstrate the process of using TSM as a rapid ideation aid and then analyze its applications in two experiments to show its effectiveness and limitations. Furthermore, we have developed a cloud-based system for computer-aided ideation, that is, InnoGPS, to integrate interactive map browsing for conceiving high-level design opportunities with domain-specific patent retrieval for stimulating concrete technical concepts, and to potentially embed machine-learning and artificial intelligence in the map-aided ideation process.
The goal of this paper is to examine meaning as a component of creativity. We take a demand-based approach for conceptualizing meaning, and propose that it emerges from user needs instead of emerging from already existing creative solutions. Meaning is proposed as a third component of creativity, alongside novelty and usefulness. We test this proposition in a pre-study, and two empirical studies. In the pre-study, designers define creativity and provide examples of solutions that they deem creative. The results of the pre-study yield a 24-item scale for assessing creativity. Then, we conduct two empirical studies, in which we utilize the created scale for measuring creativity, and for examining the components arising thereof. In the first study, we ask creators (design engineering students) to generate ideas for one of two design briefs. Afterwards, creators were asked to rate their own creations, on the 24-item creativity scale. Here, we find a four-factor solution for creative outcomes, consisting of the dimensions novelty, usefulness, cleverness, and meaning. In the second study, we ask independent evaluators (individuals with related and relevant degrees) to assess the creators’ work on the creativity scale. Here, we find a three-factor solution for creative outcomes, consisting of the dimensions novelty, usefulness, and meaning. In both studies, meaning emerged as a separate component of creativity. Additionally, in both studies, it accounted for variance that was unaccounted for by novelty and usefulness, thereby increasing the overall explanatory power of creative solutions. These findings strongly speak of meaning as a third component of creativity.
Design problems are often presented as structured briefs with detailed constraints and requirements, suggesting a fixed definition. However, past studies have identified the importance of exploring design problems for creative design outcomes. Previous protocol studies of designers has shown that problems can “co-evolve” with the development of solutions during the design process. But to date, little evidence has been provided about how designers systematically explore presented problems to create better solutions. In this study, we conducted a qualitative analysis of 252 design problems collected from publically available sources, including award-winning product designs and open-source design competitions. This database offers an independent sample of presented problems, designers’ alternative problem descriptions, and innovative solutions. We report the results of this large-scale qualitative analysis aimed at characterizing changes to problems during the design process. Inductive coding was used to identify content patterns in “discovered” problem descriptions, with qualitative codes reliably scored by two independent coders. A total of 32 distinct patterns of problem exploration were identified across designers and presented problems. Each pattern is described in the form of a generalized strategy to guide designers as they explore problem spaces. The exploration patterns identified in this study are the first empirical evidence of problem exploration in independent design problems. Further, the presence of exploration patterns in discovered problems is associated with the selection of the corresponding solution as a challenge finalist. These empirically identified strategies for problem exploration may be useful for computational tools supporting designers.
Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT).
Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership.
Five classes, namely rapid responder (7–17%), steep linear responder (14–22%), gradual responder (30–34%), non-responder (27–33%), and symptom exacerbation (7–13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT.
Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.
Although interstage mortality for infants with hypoplastic left heart syndrome has declined within the National Pediatric Cardiology Quality Improvement Collaborative, variation across centres persists. It remains unclear whether centres with lower interstage mortality have lower-risk patients or whether differences in care may explain this variation. We examined previously established risk factors across National Pediatric Cardiology Quality Improvement Collaborative centres with lower and higher interstage mortality rates.
Lower-mortality centres were defined as those with >25 consecutive interstage survivors. Higher-mortality centres were defined as those with cumulative interstage mortality rates >10%, which is a collaborative historic baseline rate. Baseline risk factors and perioperative characteristics were compared.
Seven lower-mortality centres were identified (n=331 patients) and had an interstage mortality rate of 2.7%, as compared with 13.3% in the four higher-mortality centres (n=173 patients, p<0.0001). Of all baseline risk factors examined, the only factor that differed between the lower- and higher-mortality centres was postnatal diagnosis (18.4 versus 31.8%, p=0.001). In multivariable analysis, there remained a significant mortality difference between the two groups of centres after adjusting for this variable: adjusted mortality rate was 2.8% in lower-mortality centres compared with 12.6% in higher-mortality centres, p=0.003. Secondary analyses identified multiple differences between groups in perioperative practices and other variables.
Variation in interstage mortality rates between these two groups of centres does not appear to be explained by differences in baseline risk factors. Further study is necessary to evaluate variation in care practices to identify targets for improvement efforts.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
The objective of this study was to prospectively validate the “Brief Developmental Assessment”, which is a new early recognition tool for neurodevelopmental abnormalities in children with heart disease that was developed for use by cardiac teams.
This was a prospective validation study among a representative sample of 960 pre-school children with heart disease from three United Kingdom tertiary cardiac centres who were analysed grouped into five separate age bands.
The “Brief Developmental Assessment” was successfully validated in the older four age bands, but not in the youngest representing infants under the age of 4 months, as pre-set validation thresholds were met – lower 95% confidence limit for the correlation coefficient above 0.75 – in terms of agreement of scores between two raters and with an external measure the “Mullen Scales of Early Learning”. On the basis of American Association of Pediatrics Guidelines, which state that the sensitivity and specificity of a developmental screening tool should fall between 70 and 80%, “Brief Developmental Assessment” outcome of Red meets this threshold for detection of Mullen scores >2 standard deviations below the mean.
The “Brief Developmental Assessment” may be used to improve the quality of assessment of children with heart disease. This will require a training package for users and a guide to action for abnormal results. Further research is needed to determine how best to deploy the “Brief Developmental Assessment” at different time points in children with heart disease and to determine the management strategy in infants younger than 4 months old.
Neurodevelopmental abnormalities are common in children with CHD and are the highest-priority concerns for parents and professionals following cardiac surgery in childhood. There is no additional routine monitoring of development for children with CHD in the United Kingdom; hence, neurodevelopmental concerns may be detected late, precluding early referral and intervention.
An early recognition tool – the “Brief Developmental Assessment” – was developed using quality improvement methodology involving several iterations and rounds of pilot testing. Our requirements were for a tool covering important developmental domains and practicable for use within inpatient and outpatient settings by paediatric cardiac health professionals who are non-developmental specialists, without specialised equipment and which involved direct observation, as well as parental report.
Items were included in the tool based on existing developmental measures, covering the domains of gross and fine motor skills, daily living skills, communication, socialisation, and general understanding. Items were developed for five age bands – 0–16 weeks, 17–34 weeks, 35–60 weeks, 15 months–2.9 years, and 3–4.9 years – and the final versions included a traffic light scoring system for identifying children with possible delay in any or all domains. Preliminary testing indicated excellent inter-rater reliability, an ability to detect children with a diagnosis known to be associated with developmental delay, and largely acceptable internal reliability.
We report the evolution and preliminary testing of an early recognition tool for assessing the development of children with heart disease; this was encouraging and sufficiently good to support further validation in a larger study.