Treatment of the elderly colorectal cancer patient: SIOG expert recommendations.

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Effect of patient age on management decisions in breast cancer: consensus from a national consultation

This qualitative study investigated the attitudes, perceptions, and practices of breast cancer specialists with reference to the effect of patient age on management decisions in breast cancer, and attempted to identify national consensus on this issue. One hundred thirty-three relevant specialists, including 75 surgeons and 43 oncologists, participated in a virtual consultation using e-mailed questionnaires and open-ended discussion documents, culminating in the development of proposed consensus statements sent to participants for validation. A strong consensus was seen in favor of incorporating minimum standards of diagnostic services, treatment, and care for older patients with breast cancer into relevant national guidance, endorsed by professional bodies. Similarly, an overwhelming majority of participants agreed that simple, evidence-based protocols or guidelines on standardizing assessment of biological and chronological age should be produced by the National Institute for Health and Clinical Excellence and the Scottish Medicines Consortium, developed in collaboration with specialist oncogeriatricians, and endorsed by professional bodies. A further recommendation that all breast cancer patient treatment and diagnostic procedures be undertaken in light of up-to-date, relevant scientific data met with majority support. This study was successful in gauging national specialist opinion regarding the effect of patient age on management decisions in breast cancer in the U.K.

System dynamics mapping of acute patient flows

Department of Health staff wished to use systems modelling to discuss acute patient flows with groups of NHS staff. The aim was to assess the usefulness of system dynamics (SD) in a healthcare context and to elicit proposals concerning ways of improving patient experience. Since time restrictions excluded simulation modelling, a hybrid approach using stock/flow symbols from SD was created. Initial interviews and hospital site visits generated a series of stock/flow maps. A ‘Conceptual Framework’ was then created to introduce the mapping symbols and to generate a series of questions about different patient paths and what might speed or slow patient flows. These materials formed the centre of three workshops for NHS staff. The participants were able to propose ideas for improving patient flows and the elicited data was subsequently employed to create a finalized suite of maps of a general acute hospital. The maps and ideas were communicated back to the Department of Health and subsequently assisted the work of the Modernization Agency.

Are clinical documents optimised for patient safety? A critical analysis of patient safety outcomes using the EDA error model

Iatrogenic errors and patient safety in clinical processes are an increasing concern. The quality of process information in hardcopy or electronic form can heavily influence clinical behaviour and decision making errors. Little work has been undertaken to assess the safety impact of clinical process planning documents guiding the clinical actions and decisions. This paper investigates the clinical process documents used in elective surgery and their impact on latent and active clinical errors. Eight clinicians from a large health trust underwent extensive semi- structured interviews to understand their use of clinical documents, and their perceived impact on errors and patient safety. Samples of the key types of document used were analysed. Theories of latent organisational and active errors from the literature were combined with the EDA semiotics model of behaviour and decision making to propose the EDA Error Model. This model enabled us to identify perceptual, evaluation, knowledge and action error types and approaches to reducing their causes. The EDA error model was then used to analyse sample documents and identify error sources and controls. Types of knowledge artefact structures used in the documents were identified and assessed in terms of safety impact. This approach was combined with analysis of the questionnaire findings using existing error knowledge from the literature. The results identified a number of document and knowledge artefact issues that give rise to latent and active errors and also issues concerning medical culture and teamwork together with recommendations for further work.

Gradient competence at the syntax-discourse interface

In this article, we present additional support of Duffield's (2003, 2005) distinction between Underlying Competence and Surface Competence. Duffield argues that a more fine-grained distinction between levels of competence and performance is warranted and necessary. While underlying competence is categorical, surface competence is more probabilistic and gradient, being sensitive to lexical and constructional contingencies, including the contextual appropriateness of a given construction. We examine a subset of results from a study comparing native and learner competence of properties at the syntax-discourse interface. Specifically, we look at the acceptability of Clitic Right Dislocation in native and L2 Spanish, in discourse-appropriate context. We argue that Duffield's distinction is a possible explanation of our results.

Disentangling sources of incomplete acquisition: an explanation for competence divergence across heritage grammars.

This article brings to light an important variable involved in explaining a type of competence divergence in an instance of bilingual acquisition: heritage speaker (HS) bilingualism. We present results of experiments with European Portuguese (EP) heritage speakers (HSs), showing that they have full morpho-syntactic and semantic competence of inflected infinitives, similar to EP monolinguals. We show this constitutes clear evidence of competence mismatches between heritage speakers of European and Brazilian Portuguese, comparing our results to Rothman’s (2007) experimental evidence that Brazilian Portuguese (BP) heritage speakers lack knowledge of inflected infinitives. These comparative results are especially relevant because inflected infinitives were argued (Pires, 2002, 2006) to have been lost in colloquial BP dialects, although educated monolinguals demonstrate target competence.

Sometimes they use it, sometimes they don’t: an epistemological discussion of L2 morphological production and its use as a competence measurement

The main goal of all approaches to adult second language acquisition (SLA) is to accurately describe and explain the overall acquisition process. To accomplish this, SLA researchers must come to agree on some key issues. In this commentary, I defend the necessity of the competence/performance distinction and how this relates to why an examination of morphological production presents challenges for SLA research. I suggest that such a methodology is meaningful only when it is dovetailed with procedures that test for related syntactic/semantic knowledge.

Heritage speaker competence differences, language change and input type: inflected infinitives in Heritage Brazilian Portuguese

It has been argued that colloquial dialects of Brazilian Portuguese (BP) have undergone significant linguistic change resulting in the loss of inflected infinitives (e.g., Pires, 2002, 2006). Since BP adults, at least educated ones, have complete knowledge of inflected infinitives, the implicit claim is that they are transmitted via formal education in the standard dialect. In the present article, I test one of the latent predictions of such claims; namely, the fact that heritage speakers of BP who lack formal education in the standard dialect should never develop native-like knowledge of inflected infinitives. In doing so, I highlight two significant implications (a) that heritage speaker grammars are a good source for testing dialectal variation and language change proposals and (b) incomplete acquisition and/or attrition are not the only sources of heritage language competence differences. Employing the syntactic and semantic tests of Rothman and Iverson (2007), I compare heritage speakers' knowledge to Rothman and Iverson's advanced adult L2 learners and educated native controls. Unlike the latter groups, the data for heritage speakers indicate that they do not have target knowledge of inflected infinitives, lending support to Pires' claims, suggesting that literacy plays a significant role in the acquisition of this grammatical property in BP.

Perceived competence moderates the relation between performance-approach and performance-avoidance goals

In the present research, we conducted 4 studies designed to examine the hypothesis that perceived competence moderates the relation between performance-approach and performance-avoidance goals. Each study yielded supportive data, indicating that the correlation between the 2 goals is lower when perceived competence is high. This pattern was observed at the between- and within-subject level of analysis, with correlational and experimental methods and using both standard and novel achievement goal assessments, multiple operationalizations of perceived competence, and several different types of focal tasks. The findings from this research contribute to the achievement goal literature on theoretical, applied, and methodological fronts and highlight the importance of and need for additional empirical work in this area. (PsycINFO Database Record (c) 2012 APA, all rights reserved)(journal abstract)

A conceptual framework of patient satisfaction with a pharmacy adherence service

Background Patients do not adhere to their medicines for a host of reasons which can include their underlying beliefs as well as the quality of their interactions with healthcare professionals. One way of measuring the outcome of pharmacy adherence services is to assess patient satisfaction but no questionnaire exists that truly captures patients' experiences with these relatively new services. Objective Our objective was to develop a conceptual framework specific to patient satisfaction with a community pharmacy adherence service based on criteria used by patients themselves. Setting The study was based in community pharmacies in one large geographical area of the UK (Surrey). All the work was conducted between October 2008 and September 2010. Methods This study involved qualitative non-participant observation and semi-structured interviewing. We observed the recruitment of patients to the Medicines Use Review (MUR) service and also actual MUR consultations (7). We also interviewed patients (15). Data collection continued until no new themes were identified during analysis. We analysed interviews to firstly create a comprehensive account of themes which had significance within the transcripts, then created sub-themes within super-ordinate categories. We used a structure-process-outcome approach to develop a conceptual framework relating to patient satisfaction with the MUR. Favourable ethical opinion for this study was received from the NHS Surrey Research Ethics Committee on 2nd June 2008. Results Five super-ordinate themes linked to patient satisfaction with the MUR service were identified, including relationships with healthcare providers; attitudes towards healthcare providers; patients' experience of health, healthcare and medicines; patients' views of the MUR service; the logistics of the MUR service. In the conceptual framework, structure was conceptualised as existing relationships, environment, and time; process was conceptualised as related to recruitment and consultation stages; and outcome as two concepts of immediate patient outcomes and satisfaction on reflection. Conclusion We identified and highlighted factors that can influence patient satisfaction with the MUR service and this led to the development of a conceptual framework of patient satisfaction with the MUR service. This can form the basis for developing a questionnaire for measuring patient satisfaction with this and similar pharmacy adherence services. Impact of findings on practice * Pharmacists and researchers can access the relevant ideas presented here in relation to patient satisfaction with pharmacy adherence services. * Researcher can use the conceptual framework as a basis for measuring the quality of pharmacy adherence services. * Community pharmacists can improve the quality of healthcare they provide by realizing concepts relevant to patient satisfaction with adherence services.

Exploring the paradox of competence-creating subsidiaries: balancing bandwidth and dispersion in MNEs

This paper seeks to synthesise the various contributions to the special issue of Long Range Planning on competence-creating subsidiaries (CCS), and identifies avenues for future research. Effective competence-creation through a network of subsidiaries requires an appropriate balance between internal and external embeddedness. There are multiple types of firm-specific advantages (FSAs) essential to achieve this. In addition, wide-bandwidth pathways are needed with collaborators, suppliers, customers as well as internally within the MNE. Paradoxically, there is a natural tendency for bandwidth to shrink as dispersion increases. As distances (technological, organisational, and physical) become greater, there may be decreasing returns to R&D spread. Greater resources for knowledge integration and coordination are needed as intra-MNE and inter-firm R&D cooperation becomes more intensive and extensive. MNEs need to invest in mechanisms to promote wide-bandwidth knowledge flows, without which widely dispersed and networked MNEs can suffer from internal market failures.