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Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis
Neeltje Vermunt ORCID: orcid.org/0000-0001-9607-84161,2,
Glyn Elwyn1,3,4,
Gert Westert1,
Mirjam Harmsen1,
Marcel Olde Rikkert5,6 &
Marjan Meinders1
Multimorbidity poses a challenge for decision-making processes and requires that more attention is paid to patient goals, preferences and needs; however, goal setting is not yet widely recognised as a core aspect of the shared decision-making (SDM) approach. This study aims to analyse clinician perceptions of the concept of goal setting within the context of SDM with older patients with multimorbidity.
Semi-structured interviews with general practitioners (GPs) and clinical geriatricians (CGs) were analysed using a framework analysis. The integrative model of SDM was used to develop a categorisation matrix, including goal setting as an additional component.
Sixteen of the 33 clinicians mentioned explicit Goal setting as an integrated component of their definition of SDM, which was comparable to the number of clinicians who listed Patient values and preferences (n = 16), Doctor knowledge and recommendations (n = 19) and Make or explicitly defer a decision (n = 19), elements which are commonly considered to be important aspects of SDM. The other 17 clinicians (6 CGs and 11 GPs) did not mention Goal setting as an explicit component of SDM. Our analysis revealed two potential reasons for this observation. Besides the use of other terminology, part of clinicians viewed collaborative goal setting and SDM as separate but related processes.
Our study on clinician perspectives highlighted goal setting as component of a SDM approach and could therefore be considered supportive of recent theoretical insights that SDM models that lack an explicit goal-setting component appear to be deficient and overlook an important aspect of engaging patients in decision-making, particularly for patients with complex multimorbidities. We therefore call for the further development of a comprehensive SDM approach for older patients with multimorbidity to include explicit and unequivocal goal setting elements to sufficiently meet the expectations and needs of clinicians and their patients.
Goal setting has emerged as a critical aspect of the care of patients with two or more long-term conditions, yet little attention had been paid to patient goals in the approach known as shared decision-making (SDM). Is this an oversight or was it deliberate? Where there is multimorbidity, defined as the co-existence of two or more chronic diseases or conditions, clinical priorities can compete with one another, and patients can bring additional perspectives and priorities into consideration [1,2,3,4,5,6,7,8,9,10]. To address these challenges, many have advocated paying attention to patient goals, preferences and needs [11,12,13,14]. Tinetti et al. recommended a healthcare shift from a disease orientation to a patient goal orientation [7], which requires that patient priorities and goals are ascertained and the problems impeding these goals are identified. Explicit goal setting might improve the process and outcomes of decision-making in complex cases. In the context of ageing populations, a goal-oriented approach to healthcare could be beneficial at many levels [7, 8, 15,16,17].
Shared decision-making (SDM) would seem highly compatible with taking a goal-oriented approach to care, yet the role of goals and goal setting were not explicitly described in these models [18,19,20,21]. Based on their 2006 analysis of five prominently cited SDM models, Makoul and Clayman [18] identified the most frequently invoked elements and qualities of these approaches and presented an integrative model for SDM. This integrative model is restricted to the essential elements, as presented in Table 1, and is intended to encompass different clinical contexts, types of decisions and levels of involvement.
Table 1 Essential elements, ideal elements and general qualities of SDM
Bodenheimer and Handley defined the term collaborative goal setting (CGS) as 'a process by which healthcare professionals and patients agree on a health-related goal' [22]. This enables the acknowledgment of health-related goals and goal setting in the context of behaviour change and action planning for chronic conditions in primary care settings, without necessarily relating them to SDM. CGS has been evaluated in various rehabilitation settings [23,24,25,26]. In a 2014 Commonwealth Fund Survey of adults aged 65 or older with at least one chronic condition, the number of patients who stated that they shared their health goals with a healthcare professional ranged from 23% (Sweden) to 59% (UK), with 9 of the 11 countries having rates below 50% [27]. Furthermore, relatively few studies have explored the processes used by clinicians to set goals in the presence of complex multimorbidity, resulting in little evidence to support the best practices for goal setting with these patients [28]. In a recent systematic review, we concluded that CGS is often a component of complex multifactorial interventions [29]; however, the use of CGS in the daily practice of caring for older patients with multimorbidity is still evolving.
Increasing numbers of researchers have noted the absence of goal setting in SDM models [27,28,29,30,31,32,33,34,35], and changes are being introduced to try to address this deficit. In 2012, Elwyn et al. developed a SDM model consisting of a Choice Talk, an Option Talk and a Decision Talk, which were later updated to Team Talk, Option Talk and Decision Talk [21, 36]. In 2017, this three-talk model was revised to incorporate goal setting as an element of the first step of the SDM process, the Team Talk [35]. Van de Pol et al. [31] proposed a SDM model particularly suited for use with older patients with multimorbidity that built on this three-step model by adding a fourth term, Goal Talk. The conceptual link between CGS and SDM is not self-evident however; for example, Rose et al. [37] conducted a systematic review on SDM within CGS in rehabilitation settings.
It is clear that a coherent description of how best to accomplish SDM with older patients who have complex multimorbidities has not yet been fully established. Although absent from early models of SDM, integrating goal setting and goal attainment in a SDM approach might improve the accomplishment of care plans for patients who need to juggle the burden of illness against the burden of treatments; however, it is currently unclear how goal setting fits into the concept of SDM. Furthermore, the potential adaptations of an approach must not lead to an unnecessary increase in the complexity of its use in daily practice. The inclusion of goal setting would imply that it is a necessary and maybe fundamental aspect of SDM that would be expected to improve the suitability of SDM for use with complex cases, a benefit that will likely outweigh the potential risks of making such a change.
General practitioners (GPs) and clinical geriatricians (CGs) may be able to use their experience of daily care and decision-making with older patients with multimorbidity to better elucidate the relationship between SDM and goal setting. The aim of the present study was therefore to examine whether clinicians view goal setting as a component of SDM and, if so, whether the care of patients might be facilitated by integrating explicit goal setting into a SDM approach. For this purpose, we conducted and analysed interviews with GPs and CGs using a framework approach [38, 40].
A qualitative study was conducted based on semi-structured interviews with expert CGs and GPs. The interviews were analysed in two phases, beginning with a thematic analysis [39] of all interview topics followed by an analysis of certain themes derived specifically for the purpose of this study using a framework approach [38, 40]. For the framework approach, the integrative model of SDM developed by Makoul and Clayman [18] with the additional component of goal setting was used as the categorisation matrix. The Consolidated Criteria for Reporting Qualitative Research (COREQ) [41] and the Guidelines for the authors and reviewers of qualitative studies [42] were used for the design, performance and reporting of these analyses. The COREQ criteria are reported in terms of our research in Additional file 1. Atlas-ti 7.1.15 software was used in the data coding and analysis. This paper reports on the framework analysis of the interviews.
A purposive and snowball method was used to recruit potential participants, all of whom were professional experts in geriatric care in hospital and community settings in the Netherlands [43]. These included GPs specialised and experienced in geriatric care, as well as experienced CGs working in an academic or non-academic teaching hospitals, performing research, teaching, developing or implementing specific innovations in the care of older patients. The sampling was targeted to ensure that a comparable number of GPs and CGs would be included. To obtain diverse perspectives, different types of practice and practice location (rural or urban) were represented in the GP sample, while CGs were recruited from different types of hospitals. For both the CGs and GPs, as many Dutch regions as possible were represented. The sampling of potential participants was initiated by interviewing a GP and a CG, both of whom were familiar to the interviewer. At the end of the interview, the interviewees were asked to suggest the names of potential interview participants, including both GPs and CGs. Recruiting potential participants while also taking into account geographical spread appeared to be easier for the CGs than the GPs, probably because the CGs were hospital-based with a regional focus. GPs were also recruited at a meeting of GPs specialised in geriatric care, which allowed for a wider regional spread of potential participants and avoided regional clustering. The potential participants were approached by email.
An interview guide was drafted based on two viewpoints about goal-oriented healthcare for older patients with chronic multimorbidity [7, 14]. The main topics were SDM, CGS and effective collaborative action. Effective collaborative action was defined as the clinicians and patient jointly deciding on and performing diagnostic and treatment steps in line with collaborative goals, which were established by the patient and their clinicians or other involved caretakers. Definitions were not provided to the interviewees. The main topics and subtopics are presented in Additional file 2.
In the introduction of the interviews, the clinicians were asked to use the context of their regular care for community-dwelling older patients (age > 75 years) with a chronic disease or multimorbidity without any further specifications. Specific questions could be altered to obtain a better understanding of certain (sub)topics. All interviews were conducted by the same interviewer (NV) and lasted approximately 60 min. Two pilot interviews were conducted with a CG and a GP. The main topics and subtopics were not changed based on the pilot interview nor during the conducting of the interviews. Five interviews were held face to face, but the others were held by telephone, as the clinicians' busy schedules and varying locations required flexibility. The face-to-face interviews were held at the interviewee's office. All interviews were audio-recorded and transcribed. Field notes were kept and analytical memos were drafted during data collection and analysis. The sample size was guided by theoretical saturation [44]. After no new data were determined to have arisen, two further interviews were conducted as a confirmation.
In the first phase, a thematic analysis was performed [39] for all interview topics, after which a framework approach was taken for the purposes of this study [38, 40]. Thematic analyses focus on identifying, analysing and reporting patterns (themes) within qualitative data and on the interpretation of aspects of the research topics. During the interviewing phase, NV and MH conducted preliminary analyses by reflecting and discussing the interviews and field notes. The interview guide was adapted to reflect their emerging insights. Open coding was applied to all topics of the first five transcripts, which was independently performed by two data coders (NV and MH). The data were conceptually interpreted and labelled accordingly, resulting in initial codes which were then compared, discussed, grouped and categorised to determine a working coding tree. The remaining interviews were coded by one researcher (MH) and checked by the other (NV). In weekly meetings, the coding of the transcripts was compared, discussed and agreed upon by the researchers (NV and MH), which included the creation of additional codes and the further refinement of the analysis taking reflexivity into account. The findings were discussed and further adjusted after review by the broader research team consisting of all co-authors. Amongst others, this thematic analysis of the interview data resulted in the themes 'SDM concept' and 'Links between the concepts of SDM and CGS'.
In the second phase of the analysis, these themes were further analysed using a framework approach. For this purpose, a SDM categorisation matrix was developed based on the essential, ideal and general elements of the integrative model of SDM developed by Makoul and Clayman [18], shown in Table 1. A new category, goals/goal setting, was added to this SDM categorisation matrix. The data were charted in this categorisation matrix and the findings were interpreted. Goals/goals setting had to be mentioned specifically before they were categorised as being 'mentioned'.
The findings were discussed in regular meetings between NV and MM and further adjusted after review by the broader research team consisting of all co-authors. Illustrative quotations were selected to highlight the findings and translated from Dutch to English by a professional translator.
At the start of the interview, all interviewees were informed about the study, the method of data handling and the preservation of anonymity. Permission to record audio during the interviews was obtained from all participants. In addition to their earlier consent to be interviewed, documented in the emails, all interviewees were formally asked for their consent to participate, which was audio recorded and documented by the interviewer. To preserve anonymity and confidentiality, names were replaced with codes indicating whether the participant was a GP or CG and the sequential number of the interview. Any identifying information was removed following the verbatim transcription of the recordings.
Interview and participant characteristics
The response rates of the CGs and GPs were 86 and 54%, respectively, resulting in a final sample of 33 clinicians (18 CGs and 15 GPs). The first author (NV), a former GP, conducted the interviews between November 2012 and April 2013. Five interviews were conducted face to face, while the remaining 28 were held over the telephone. All interviews lasted approximately 60 min. The mean age of the GPs was 51 (n = 15), while for the CGs (n = 18) it was 48; 60% of GPs and 50% of CGs were female. On average, the GPs had 16 years of professional experience and CGs had 10 years. Additional participant characteristics are presented in Table 2.
Table 2 Basic characteristics of the participants
Main elements of SDM according to CGs and GPs
In 2006, Makoul and Clayman [18] identified the most frequently invoked elements and qualities of SDM and developed an integrative model of this approach, which is presented in Table 1. As already has been argued, Makoul and Clayman's integrative model is intended to encompass different clinical contexts, types of decisions and levels of involvement. To investigate whether clinicians mention goal setting as an essential component of SDM, we added the component of Goal setting to the integrative model to constitute a categorisation matrix.
Table 3 provides information on which elements of the integrative model and the additional component of goal setting were mentioned by each clinician. Although not included in the original integrative SDM model, Goal setting was explicitly mentioned by half of the clinicians interviewed (n = 16). Established important components of SDM, which were also listed were: Patient values/preferences (n = 16), Doctor knowledge/recommendations (n = 19) and Make or explicitly defer decision (n = 19).
Table 3 Categorisation matrix for SDM with older patients with multimorbidity
Goal setting as a component of SDM
The clinicians who considered goals and/or goal setting to be a component of SDM emphasised several aspects of these categories in their descriptions. Goals and the goal setting process were described as providing inputs for the decision-making process, as illustrated by the following quotation:
"Once you have gained, let's say, insight into the patient's goals and the doctor's possibilities, then you can reach a decision. (...) In the process of exchanging information, the patient is already telling you about how they lead their life, about their goals, wishes and desires, etc. And (...) what they want to do with those". Clinical geriatrician 7 (CG_07)
Furthermore, goals and goal setting can be seen as core components of SDM, reflecting the essence of a SDM approach, as explained by one of the clinicians:
"If you opt for shared decision-making, I think you should start by looking at what the actual goal is: 'What is the patient's goal?' (...) I believe that is what the entire process of shared decision-making is about". Clinical geriatrician 11 (CG_11)
Similarly, one of the clinicians stated:
"I believe that you cannot make common decisions if you do not have joint goals". Clinical geriatrician 16 (CG_16)
In this sense, goals and goal setting reflect a person-centred attitude. Person-centred care is defined as healthcare that is 'respectful and responsive to individual patient preferences, needs and values, and ensures that patient values guide all clinical decisions' [45]. SDM can be seen as fundamental to patient-centred care [46], and both explicitly involve the patient in their care [47, 48].
Furthermore, the integration of the CGS and SDM processes was emphasised in our analysis. According to some of the clinicians, CGS and SDM can be viewed as a single integrated process and cannot be separated, since decision-making also involves goal setting. They stated that the patient and clinician should jointly determine which goals are relevant and which steps should be taken in pursuing those goals:
"When you ask someone: 'What do you think about your life and what do you find most important?', and it turns out that 'continue to live independently' is the most important, then it makes sense that the patient is involved in thinking about the 'smaller' goal that is linked to this (...) and that they also give the green light to this... for example, by asking 'Are you okay with this? And if you're not okay with THIS, how would you feel about THAT?'. This is all interwoven and cannot be seen separately". General practitioner 20 (GP_20)
This general practitioner seems to refer to various types of goals. Independence can be seen as a value and 'continuing to live independently' is a goal incorporating this value. This goal setting process could be interpreted as a process of setting of several related goals within a decision-making process. In the view of some clinicians, goals can actively steer the options presented to a patient, as illustrated by the following quotation:
"If someone says: 'I want to continue living independently as long as possible', well, then perhaps those treatment options must be chosen that enable the patient to do this. Very invasive options, meaning for example that a patient has to travel back and forth constantly, are then excluded. (...) It means you choose the more pragmatic option. (...) Yes, I do believe that such goals give direction to the options. So if you know those goals in advance and you know what the patient wants, it becomes easier to give better advice about what the best option is". Clinical geriatrician 3 (CG_03)
This value-driven goal of 'continue to live independently as long as possible' could be used to steer the decision-making process and enable the comparison of certain options.
Perceptions of clinicians not mentioning goal setting as a component of SDM
Seventeen clinicians did not explicitly mention goal setting as a component of a SDM approach. Of the clinicians who did not explicitly mention goal setting as part of SDM, six were CGs and 11 were GPs. This means that, in contrast to the CGs, the majority of GPs did not explicitly mention goal setting as a SDM component. Our analysis revealed some indication that the lack of an explicit mention of goals when attempting to undertake a SDM process does not automatically mean that there is a lack of awareness regarding goals. First, some clinicians who did not mention goals explicitly focused on other aspects of patient involvement, using terms such as 'agreement' or 'decision maker' in their description of the concept of SDM. They mentioned that aligning decisions with a patient's preferences is essential:
"In any case, to align our thoughts. (...) to make my plan clear to the patient or ask what they still want. (...) and check (...) whether the patient understands what I mean, as a GP, by a certain proposal". General practitioner 13 (GP_13)
We can interpret these aspects of patient involvement as elements of a person-centred attitude. In this sense, the attitudes of the clinicians who did or did not mention goal setting are not necessarily different. As was also concluded by Knight et al., the concepts of values, goals, and preferences are often used interchangeably [49], which could explain why some clinicians did not mention goals or goal setting.
Some clinicians did not mention goal setting when defining SDM but described CGS and SDM as separate but related processes. Some of them see CGS and goals as fundamental and SDM as a related, though more concrete, process of decision-making:
"[SDM and CGS] are two different stories, of course. Yes, because when you set a goal, you ask 'What is important to you?' (...) 'When you think of the next couple of years, what is it that you want or don't want?' And decision-making simply means that you involve the patient in the choices that you make. (...) And (...) that you provide the information the patient needs to oversee things and (...) that you try to reach a satisfactory result together. (...) But that is just a little bit different. (...) Yes, I think decision-making is bigger than that. (...) And (...) to reach a decision together, that also serves that joint goal, now doesn't it". General practitioner 17 (GP_17)
Although viewed as separate processes, from this perspective CGS remains a key input for a SDM process.
Goal setting is not yet widely recognised as a core component of SDM. Our interviews with experienced GPs and CGs highlight the need for SDM approaches that explicitly and unequivocally include the task of goal setting. This would be consistent with recent theoretical insights that patient goals and the process of goal setting can be regarded as a fundamental part of a SDM process, especially when patients have multiple long-term conditions which require trade-offs between treatment options.
This study has some methodological strengths. First, we worked with an interviewer who is trained as a GP, which may have encouraged the participants to speak frankly and directly from their own professional perspectives. The second coder of the first phase was experienced in interview analysis but has no medical background. The second data analyst during the second phase (MM) is an expert on SDM, but has no background in practicing medicine. These distinct professional backgrounds helped us avoid a 'medical' bias in our data interpretation. Second, this topic can be considered as early research into this topic. At the time of our interviews, goal setting in complex decision-making was only just evolving, which is why we used a purposive sampling and a snowball extension method to recruit professional experts. In the Netherlands, both GPs and CGs provide medical care to older people living at home, but they do so in different settings, namely in the community and hospitals, respectively. At this stage of theory development, we considered their work to be complementary, allowing both to contribute to the saturation of data collection on current medical thinking on these themes. The basic characteristics of the participants showed considerable variability in line with the Dutch context (e.g., in terms of practice type). Third, we chose a framework analysis method, which is well-suited for an analysis that departs from a theoretical position. In our analysis we used a SDM categorisation matrix based on the integrative SDM model of Makoul and Clayman.
This study also has some limitations. We aimed to focus the interviews on the care of a population with complex healthcare demands, which was introduced to the interviewees as a population of people over 75 years of age with multimorbidity. Ideally, in the context of condition and functioning, we would have been able to specify this potential complexity further by also including factors such as disease severity and disability [50]; however, we assumed that this might complicate the interviews too much if it was taken too literally. Patients and/or caregivers were not interviewed as part of this research, but should be included in future research on this topic because it centres on patient participation and the patient orientation of care. Furthermore, we found a difference between the proportion of GPs and CGs who mentioned goal setting. We have no reason to believe that GPs are less patient-oriented than CGs; in a qualitative focus group study of Dutch GPs, Luijks et al. [4] reported that GPs agreed to involve patient perspectives and preferences in the decision-making process. Further research is necessary to determine whether this indication of possible differences in perceptions between GPs and CGs can be confirmed and if so, what causal factors could be relevant in explaining these differences. In addition, we used spontaneous descriptions of the SDM context in our analysis of whether the clinician mentioned goal setting. Furthermore, although the interview guide started with the topic of SDM, all topics, including CGS, were mentioned in the introduction of the interviews, which could have primed the interviewees. Finally, although our findings contribute to the current academic debate on goal setting and SDM, the time span between interviewing and publishing the results could also be considered a limitation. Findings might be somewhat different nowadays, as the SDM field has evolved, including the consideration of goal setting as element of SDM, since the original study was conducted.
Although there is still a relative lack of tools and evidence regarding the effects of goal setting with older patients with chronic disease or multimorbidity [29], we would like to appeal for the integration of explicit goal setting into SDM approaches for older patients with multimorbidity for three reasons: 1. The potential relevance of the inclusion of goal setting as essential component; 2. the need for consistent terminology and 3. the need for the further development of practical goal setting within SDM. These reasons are explained in more detail below.
First, our findings are in line with recently published theoretical insights on the relevance of goal setting in a SDM approach [27,28,29,30,31,32,33,34,35]. Sixteen of the 33 clinicians interviewed mentioned Goal setting as a component of their definition of a SDM approach. The frequency of the inclusion of Goal setting as a SDM component is comparable with the mention of the other commonly accepted major elements, namely Patient values/preferences (n = 16), Doctor knowledge/recommendations (n = 19) and Make or explicitly defer decision (n = 19). Furthermore, the interpretation of the descriptions of goal setting revealed that the interviewees who mentioned goal setting considered it to be an important component.
A need for consistency in terminology is a second reason why we believe goal setting should be incorporated in SDM approaches. As our findings indicated, clinicians seem to use different terms in their definition of SDM, which is consistent with other research showing that the concepts of values, goals, and preferences are often used interchangeably [49]. Clearly defining these concepts and their relevance within SDM will contribute to the further development of consistent theoretical models and practical approaches. In our view, special attention should be given to defining the types of goals in the goal setting process, as our results indicated that clinicians may set and use varying types of goals.
The third reason for our plea is the need for the further development of practical approaches for goal setting within SDM. Clinicians are increasingly interested in goal-oriented care, especially for patients with multimorbidity [1, 7, 8, 11, 14, 51, 52]. A goal-oriented approach in decision-making can be helpful in personalising care to accommodate patient goals, preferences and resources [13, 14]. As argued in the introduction, CGS has only recently been incorporated into the daily practice of caring for older patients with multimorbidity, and incorporating patient values, preferences and circumstances is a difficult step in the decision-making process [53]. Health-related goals arise not only from health but also from other dimensions such as social context or wellbeing [1, 13, 14, 51]. Clinicians may struggle to help people prioritise their values, define treatment goals and frame preferences in ways that are clinically relevant and personally meaningful (aligned with one's values) when faced with multiple diagnostic and treatment options [2, 54]. Based on our findings, we therefore want to make a plea for the integration of goal setting into the SDM model for use with older patients with multimorbidity as a next step to constitute a solid theoretical base for the further development of practical tools for facing these challenges. The perspectives of the interviewed clinicians reported here suggest that the explicit inclusion of goal setting as part of a SDM approach seems to be most promising to synchronise the concepts and approaches in caring for this category of patients.
Our research has several implications. Our findings seem to indicate that clinicians who want to practice SDM in the complex group of older patients with multimorbidity might be facilitated by the explicit integration of goal setting into this approach, although further research into the perceptions of patients regarding this topic is necessary. Furthermore, the potential differences in the perceptions of GPs and CGs require further elucidation. Finally, for practical tool development, the potential variation in the types of goals is an important topic for further research. Integrating explicit goal setting into a SDM approach would probably increase the use of goal setting in practice, and may lead to further tool development. These goals could enable the development of unambiguous terminology for the inclusion of patient perspectives in SDM. It might also improve inter-professional communication and collaboration by offering the possibility of exchanging explicit goals. In our view, the awareness and integration of goal setting in SDM could be beneficial for all patient categories, although the benefits may vary. We expect that the more complex the decision-making process becomes, the more beneficial explicit goal setting will be.
Our study on clinician perspectives highlighted a lack of explicit goal setting as component of a SDM approach. We conclude that a comprehensive SDM model for use with older patients with multimorbidity could be developed further by including an explicit goal setting process, which is regarded by clinicians as the key factor in aligning diagnostic and therapeutic options with patient preferences and values.
The anonymised interview transcripts (in Dutch) supporting the conclusions of this article are available upon request by contacting the first author (NV).
CG:
Clinical geriatrician
CGS:
Collaborative goal setting
GP :
SDM:
Shared decision-making
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Grudniewicz A, Nelson M, Kuluski K, Lui V, Cunningham HV, Nie JX, Colquhoun H, Wodchis WP, Taylor S, Loganathan M, Upshur RE. Treatment goal setting for complex patients: protocol for a scoping review. BMJ Open. 2016;6(5):e011869.
Vermunt NPCA, Harmsen M, Westert GP, Olde Rikkert MGM, Faber MJ. Collaborative goal-setting with elderly patients with chronic disease or multimorbidity: a systematic review. BMC Geriatr. 2017;17(1):167.
Vermunt NPCA, Westert GP, Olde Rikkert MGM, Faber MJ. Assessment of goals and priorities in patients with a chronic condition: a secondary quantitative analysis of determinants across 11 countries. Scand J Prim Health Care. 2018;36:80–8.
Van de Pol MHJ, Fluit CRMG, Lagro J, Slaats YHP, Olde Rikkert MGM, Lagro-Janssen ALM. Expert and patient consensus on a dynamic model for shared decision-making in frail older patients. Patient Educ Couns. 2016;99(6):1069–77.
Vermunt NPCA, Harmsen M, Elwyn G, Westert GP, Burgers JS, Olde Rikkert MGM, Faber MJ. A three-goal model for patients with multimorbidity: a qualitative approach. Health Expect. 2018;21:528–38.
Van der Weijden T, Post H, Brand PLP, Van Veenendaal H, Drenthen T, Van Mierlo LA, Stalmeier P, Damman OC, Stiggelbout A. Shared decision making, a buzz-word in the Netherlands, the pace quickens towards nationwide implementation…. Z Evid Fortbild Qual Gesundhwes. 2017;123-124:69–74.
Hoffmann T, Jansen J, Glasziou P. The importance and challenges of shared decision making in older people with multimorbidity. PLOS M. 2018;15:e1002530.
Elwyn G, Durand MA, Song J, Aarts J, Barr PJ, Berger Z, Cochran N, Frosch D, Galasiski D, Gulbrandsen P, Han PKJ, Härter M, Kinnersley P, Lloyd A, Mishra M, Perestelo-Perez L, Scholl I, Tomori K, Trevena L, Witteman HO, Van der Weijden T. A three-talk model for shared decision making: multistage consultation process. BMJ. 2017;359:j4891.
Elwyn G, Dehlendorf C, Epstein RM, Marrin K, White J, Frosch DL. Shared decision making and motivational interviewing: achieving patient-centered care across the Spectrum of health care problems. Ann Fam Med. 2014;12(3):270–5.
Rose A, Rosewilliam S, Soundy A. Shared decision making within goal setting in rehabilitation settings: a systematic review. Patient Educ Couns. 2017;100(1):65–75.
Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol. 2013;13:117.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.
Ritchie J, Lewis J. Qualitative research practice: a guide for social science students and researchers. London: Sage; 2013.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.
Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet. 2001;358(9280):483–8.
Barbour RS. Checklists for improving rigour in qualitative research: a case of the tail wagging the dog? BMJ. 2001;322(7294):1115–7.
Luborsky MR, Rubinstein RL. Sampling in qualitative research: rationale, issues, and methods. Res Aging. 1995;17(1):89–113.
Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington DC: National Academy Press; 2001.
Légaré F, Thompson-Leduc P. Twelve myths about shared decision making. Patient Educ Couns. 2014;96(3):281–6.
Härter M, Moumjid N, Cornuz J, Elwyn G, Van der Weijden T. Shared decision making in 2017: international accomplishments in policy, research and implementation. Z Evid Fortbild Qual Gesundhwes. 2017;123–124:1–5.
Scholl I, Zill JM, Härter M, Dirmaier J. An integrative model of patient-centeredness – a systematic review and concept analysis. PLoS One. 2014;9(9):e107828.
Knight SJ. Bridging the gap at the center of patient centeredness: individual patient preferences in health care decision making: comment on "comparing 3 techniques for eliciting patient values for decision making about prostate-specific antigen screening". JAMA Intern Med. 2013;173(5):369–70.
Zulman DM, Asch SM, Martins SB, Kerr EA, Hoffman BB, Goldstein MK. Quality of Care for Patients with multiple chronic conditions: the role of comorbidity interrelatedness. J Gen Intern Med. 2014;29(3):529–37.
Robben SHM, Perry M, Olde Rikkert MGM, Heinen MM, Melis RJF. Care-related goals of community-dwelling frail older. J Am Geriatr Soc. 2011;59(8):1552–4.
Tinetti ME, Esterson J, Ferris R, Posner P, Blaum CS. Patient priority–directed decision making and Care for Older Adults with multiple chronic conditions. Clin Geriatr Med. 2016;32(2):261–75.
Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA. 2014;312(13):1295–6.
Naik AD, Martin LA, Moye J, Karel MJ. Health values and treatment goals of older, multimorbid adults facing life-threatening illness. J Am Geriatr Soc. 2016;64(3):625–31.
The authors would like to thank Gijs Hesselink for his advice concerning methodology and the analysis plan.
This work was supported by the Dutch Council for Health and Society, a strategic advisory council for the Dutch government and the employer of the first author. They provided financial support for the conduct of this research and the preparation of this paper, but had no role in the study design; the data collection, analysis and interpretation; the writing of the report or the decision to submit the paper for publication.
Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Institute for Quality of Healthcare (IQ Healthcare), PO Box 9101, 6500, HB, Nijmegen, The Netherlands
Neeltje Vermunt
, Glyn Elwyn
, Gert Westert
, Mirjam Harmsen
& Marjan Meinders
The Dutch Council for Health and Society, (Raad voor Volksgezondheid en Samenleving, RVS), The Hague, the Netherlands
The Dartmouth Institute for Health Policy & Clinical Practice, Level 5 Williamson Translational Research Building, One Medical Center Drive, Lebanon, NH, 03756, USA
Glyn Elwyn
Cochrane Institute for Primary Care and Public Health, Cardiff University, Cardiff, UK
Radboud university Medical Center, Radboudumc Alzheimer Center, Donders Institute for Brain, Cognition and Behavior, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
Marcel Olde Rikkert
Department of Geriatrics, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, The Netherlands
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The manuscript has been read and approved by all the named authors and no other people have satisfied the criteria for authorship without being listed. The order of the authors listed in the manuscript has been approved by all authors. NV initiated the conception and design of the study, acquired the data, contributed to the analysis and interpretation of the data and drafted and wrote the article. MM contributed to the conception and design of the study and the analysis and interpretation of the data, and critically revised the manuscript several times. GW and MOR contributed to the conception and design of the study and the interpretation of the data, and critically revised the manuscript several times. GE contributed to the interpretation of the data and critically revised the manuscript several times. MH contributed to the analysis and critically revised the manuscript several times.
Correspondence to Neeltje Vermunt.
The study was carried out in the Netherlands in accordance with the applicable rules concerning the review of research ethics committees and informed consent (Research Ethics Committee, Radboud University Nijmegen Medical Centre, file number 2018–4052). At the start of the interview, all interviewees were informed about the background of the interviews, the method of data handling and the preservation of anonymity. Permission to audio record the interviews was obtained from all participants. In addition to their earlier agreement to be interviewed, which was documented in the email correspondences, all interviewees were formally asked for their consent to participate, which was audio recorded and documented by the interviewer. To preserve anonymity and confidentiality, names were replaced with codes indicating whether the interviewee was a GP or CG, along with the sequential number of the interview. Any identifying information was removed following the verbatim transcriptions of recordings.
All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare the following: For the submitted work, no support was received from any organisation.
NV received financial support from her employer, the Council of Health and Society, as described under Funding.
GE has edited and published books that provide royalties on sales by the publishers: the books include Shared Decision Making (Oxford University Press) and Groups (Radcliffe Press). He has in the past provided consultancy for organizations, including: 1) Emmi Solutions LLC who developed patient decision support tools; 2) National Quality Forum on the certification of decision support tools; 3) Washington State Health Department on the certification of decision support tools; 4) SciMentum LLC, Amsterdam (workshops for shared decision-making).
He is the Founder and Director of &think LLC which owns the registered trademark for Option Grids™ patient decision aids. Founder and Director of SHARPNETWORK LLC, a provider of training for shared decision-making. He provides advice in the domain of shared decision-making and patient decision aids to: 1) Access Community Health Network, Chicago (Federally Qualified Medical Centers); 2) EBSCO Health Option Grids™ patient decision aids; 3) Bind Insurance, 4) PatientWisdom Inc.
GE's academic interests are focused on shared decision-making and coproduction. He owns copyright in measures of shared decision-making and care integration, namely collaboRATE, integRATE, consideRATE, coopeRATE, toleRATE, Observer OPTION-5 and Observer OPTION-12.
No other relationships or activities have influenced the submitted work.
Table S1. Consolidated Criteria for Reporting Qualitative Studies (COREQ). Consolidated Criteria for Reporting Qualitative Studies (COREQ): A 32-item checklist [41]. (DOCX 30 kb)
Table S2. Main topics and subtopics of the semi-structured interview guide. (DOCX 21 kb)
Vermunt, N., Elwyn, G., Westert, G. et al. Goal setting is insufficiently recognised as an essential part of shared decision-making in the complex care of older patients: a framework analysis. BMC Fam Pract 20, 76 (2019) doi:10.1186/s12875-019-0966-z
Older patients
General clinicians
Clinical geriatricians


A rug for all seasons. Made of superheroic polypropylene, the indoor/outdoor area rugs are terrific for high traffic areas and muddy messes. Scrubbable, bleachable and UV-treated for outdoor use, this collection of woven rugs can stand up to all that you dish out.. Due to the handmade quality of these rugs, they may vary slightly in size and/or colour.


text:
Q: Rotação de imagem não funciona corretamente no Chrome Estou tentando utilizar uma função em jQuery, e a mesma funciona bem no Firefox mas no Chrome ela simplesmente não inicia, fica parada na primeira imagem e não passa para as demais.
Alguém poderia me dar uma luz de como faço para que funcione também no Chrome?
Segue meu código jQuery:
var intervalId;
var slidetime = 3500; // milliseconds between automatic transitions

$(document).ready(function() {

  // Comment out this line to disable auto-play
    intervalID = setInterval(cycleImage, slidetime);

    $(".main_image .desc").show(); // Show Banner
    $(".main_image .block").animate({ opacity: 0.85 }, 1 ); // Set Opacity

    // Click and Hover events for thumbnail list
    $(".image_thumb ul li:first").addClass('active');
    $(".image_thumb ul li").click(function(){
        // Set Variables
        var imgAlt = $(this).find('img').attr("alt"); //  Get Alt Tag of Image
        var imgTitle = $(this).find('a').attr("href"); // Get Main Image URL
        var imgDesc = $(this).find('.block').html();    //  Get HTML of block
        var imgDescHeight = $(".main_image").find('.block').height();   // Calculate height of block

        if ($(this).is(".active")) {  // If it's already active, then...
            return false; // Don't click through
        } else {
            // Animate the Teaser
            $(".main_image .block").animate({ opacity: 0, marginBottom: -imgDescHeight }, 250 , function() {
                $(".main_image .block").html(imgDesc).animate({ opacity: 0.85,  marginBottom: "0" }, 250 );
                $(".main_image img").attr({ src: imgTitle , alt: imgAlt});
            });
        }

        $(".image_thumb ul li").removeClass('active'); // Remove class of 'active' on all lists
        $(this).addClass('active');  // add class of 'active' on this list only
        return false;

    }) .hover(function(){
        $(this).addClass('hover');
        }, function() {
        $(this).removeClass('hover');
    });

    // Toggle Teaser
    $("a.collapse").click(function(){
        $(".main_image .block").slideToggle();
        $("a.collapse").toggleClass("show");
    });

    // Function to autoplay cycling of images
    // Source: http://stackoverflow.com/a/9259171/477958
    function cycleImage(){
    var onLastLi = $(".image_thumb ul li:last").hasClass("active");
    var currentImage = $(".image_thumb ul li.active");

    if(onLastLi){
      var nextImage = $(".image_thumb ul li:first");
    } else {
      var nextImage = $(".image_thumb ul li.active").next();
    }

    $(currentImage).removeClass("active");
    $(nextImage).addClass("active");

        // Duplicate code for animation
        var imgAlt = $(nextImage).find('img').attr("alt");
        var imgTitle = $(nextImage).find('a').attr("href");
        var imgDesc = $(nextImage).find('.block').html();
        var imgDescHeight = $(".main_image").find('.block').height();

        $(".main_image .block").animate({ opacity: 0, marginBottom: -imgDescHeight }, 250 , function() {
      $(".main_image .block").html(imgDesc).animate({ opacity: 0.85,    marginBottom: "0" }, 250 );
      $(".main_image img").attr({ src: imgTitle , alt: imgAlt});
        });
  };

});// Close Function

Html:

<img src="<?php bloginfo('template_url') ?>/img/load.gif" alt="- banner1" />

<?php
$paged = (get_query_var('paged')) ? get_query_var('paged') : 1;
query_posts("posts_per_page=4&category_name=novidades&paged=$paged"); ?>
<?php while (have_posts()) : the_post(); ?>

<a href=" <?php
//Pega as imagens anexadas desse post
$args = array(
    'post_type' => 'attachment',
    'post_mime_type' => 'image',
    'numberposts' => -1,
        'order' => 'ASC',
    'post_status' => null,
    'post_parent' => $post->ID
);
$attachments = get_posts($args);
if ($attachments) {
    foreach ($attachments as $attachment) {
        $img = wp_get_attachment_thumb_url( $attachment->ID );
                break;
        }
}
echo $img;
?>">

<a target="_self" href="#" OnClick="javascript:window.document.location=('<?php the_permalink() ?>');" rel="bookmark" ><?php limit_title(28); ?>

<?php ob_start(); the_excerpt(); echo dp_clean(ob_get_clean(), 110); ?> [...]

<?php endwhile; ?>
<?php wp_reset_query();?>

A: sua resposta esta aqui: http://jsfiddle.net/68964/2/
e foi respondida no seu próprio código fonte ( esta em comentário ) da uma olhada ai no seu código a linha:
// Source: https://stackoverflow.com/a/9259171/477958

e segue esse link https://stackoverflow.com/a/9259171/477958 lá tem um código exemplo que testei aqui no chrome e resolveu
Observação: Quando há problemas de incompatibilidade entre navegadores geralmente é alguma propriedade do CSS que só existe em um determinado navegador ex:
.ui-button { -moz-user-select: none; } /* PARA QUE O TEXTO DO BOTAO NAO SEJA SELECIONADO COM O MOUSE*/

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As the nation deals with their first cases of Ebola, hospitals and other healthcare facilities work to put protocols in place for isolating and treating infected patients and containing hazardous materials. Concorde Career College - Grand Prairie decided to take a proactive approach and reached out to the United States Public Health Service Department to help them properly educate their campuses in the Dallas area. Do you know everything you need to know about the Ebola virus? Are you confused by all the misinformation being shared? To continue Concorde's proactive approach, we have provided some important FAQs to help get you up to date.
Ebola is a severe, often fatal disease found in several African countries. The first Ebola species was discovered in 1976 near the Ebola River. The host of Ebola remains unknown. However, researchers believe the virus is animal born with bats being the most likely host.
Ebola can NOT be spread through air, water or food.
How do I protect myself from Ebola?
Who is at the highest risk of catching Ebola?
Where can I find more information about Ebola?
Visit the Centers for Disease Control and Prevention website to learn more.


For over six years we have been traveling America to better understand the art of barbecue. Not simple backyard grilling, but the labor-intensive process of slow-smoking meat over wood-fueled fires that is common in the area stretching between North Carolina and Texas. These twelve photos will introduce you to some of the places we've been and people we've met so far.
Barbecue is more than a way to cook brisket, pork and mutton – it is a tradition that is passed on, generation to generation, through long hours in the smoking pits. For the truly talented, barbecue transcends tradition and becomes a craft, one that all too often gets overlooked simply because its end result is edible.
In the course of our travels we've met World War II veterans, stoners, people struggling to keep their restaurants open in a down economy, future reality TV show characters, a school janitor moonlighting as a pitmaster, and modern-day cowboys working the stockyards. Each person's story is as unique as their particular method of barbecuing.
Also documented is the larger world within which these craftsmen and women labor. Beyond each smoky pit is a base of customers sitting in a lunchroom that is defined by austerity as often as it is by kitsch. From within these lunchrooms comes a sense of the community: hunting or little league trophies, photographs or awards, hand-crafted tables or mass-produced folding chairs, workers in overalls, or businesspeople in suits … each room reflects the unique qualities of its town. And yet, from region to region, a commonality persists – honest people working on a product that disappears in much less time than it takes to make.


text:
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Parsons Awarded $139.1m for Kwajalein Atoll Runway Repair
Parsons Government Services Inc., Pasadena, California, was awarded a $139,123,690 firm-fixed-price contract for runway repair at Bucholz Army Airfield, Kwajalein Atoll, Republic of the Marshall Islands. Work will be performed in Kwajalein Atoll, Republic of the Marshall Islands, with an estimated completion date of Aug. 22, 2022.
The firm fixed price project delivery contract is a new, competitive win for the company. The total contract value including base and options is approximately $229 million.
Bucholz Army Airfield is in a remote, highly corrosive, humid and salt-laden environment which presents unique challenges as Parson replaces various components of the airfield, including the major runways, taxiways and parking aprons. Additional work includes installing potable and non-potable water line systems, lined water catchment and drainage systems, airfield pavement markings, runway and taxiway lighting systems, electric vault, and an airfield electrical distribution system along with upgrading airfield navigation aids for flight operations.
"We understand the strategic significance of a fully operational Bucholz Airfield for the U.S. military in the Pacific theatre and are honored the U.S. Army Corps of Engineers has selected Parsons for this important mission," said Dave Bird, program manager for Parsons. "The company's multi-decade history of delivering thoughtful, predictable, safe and sustainably focused results represents the lowest risk, highest value option for the U.S. Army to ensure operations continue during renovation."
Bucholz Army Airfield Repair is a design-bid-build renovation project with phasing to accommodate a fully active runway throughout the entire duration of renovation. Airfield repairs will be completed in one single phase, and airfield operations will continue to function during repairs.
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Gochar Agochar books in Gujarati. Gujarati books on Aghori & world of aghori. List of Gochar Agochar books in Gujarati language. Buy Gujarati books on Gochar Agochar vishwa. Supersensible world books in Gujarati.


text:
Morning of the Earth
15 - 17 Nov 2018
The 1971 Australian surfing classic was screened with a completely new soundtrack composed and recorded by local Brisbane artists. Two new versions are produced by Tim Gaze from Tamam Shud, whose work on the original score was pivotal, and will create a new chapter in the life of this film, whose story is so essential to Australian culture.
A panel discussion after the film included guests including Tim Gaze and G. Wayne Thomas, who produced the original soundtrack album, and supplied its hit single "Open Up Your Heart".
Artists credited on both versions of the soundtrack include John Willsteed from Halfway and The Go-Betweens, Chris Perren and Nonsemble, Drawn From Bees, Big Dead, Port Royal and Andrew Taylor.
Enter Inferno, the unforgettable cyborg experience, part robotic dance party, part wake-up call from the future. Machine art is about to meet demonic, in a dynamic crash-merging of spectral mechanics and human imagination.
QUT Music Biz Forum 2018
The QUT Music Biz Forum featured the brightest ideas about the changing nature of the music industry from QUT students and industry leaders such as Triple J presenter KLP.
Studio 140, Level 1, Building Z9
Z9 Block, Kelvin Grove Rd & Musk Ave, Kelvin Grove, Brisbane
Building Z9, Cnr Kelvin Grove Rd and Musk Avenue
Kelvin Grove, Brisbane
cifadvancement@qut.edu.au


text:
Blockchain Integration
Blockchain Pilot
Blockchain Tokenization and ICO
Digital Identities
IMPACT TECHNOLOGIES
Decentralized Economies
December 22, 2020 | By dynaquest_admin | In Blockchain, Digital Identity, Information Technology
PHILSYS DIGITAL IDENTITIES: Integrated Identity Services
Last month, the Philippine Statistics Authority (PSA) stated that it will be rolling out the early pilot of the Philippine National ID System that is otherwise known as PHILSYS. It is a national ID program that aims to register and provide legal identities to over 109 million Filipinos living in the country. It includes both […]
September 3, 2020 | By dynaquest_admin | In Blockchain, Digital Identity
United Kingdom Charts Next Steps for Digital Identity
Digital Identity is a technology that is said to further reinforce public safety while giving citizens the stewardship of managing their self-sovereignty. The United Kingdom is charting the next step for its national use of digital identity to reinforce the individual's irrevocable identity while giving the citizens the means to instantly verify their identity claims […]
August 14, 2020 | By dynaquest_admin | In BPO, Digital Identity, Information Technology
14th International ICT Awards 2020 Winners
The International ICT Awards is the premiere awards ceremony in the Philippines and now in its 14th year of recognizing companies that excel and elevate innovation in the country's ICT sector, this year's theme was "Transcending Excellence", an apt observance of the times where the world's leading conglomerates and technology providers are doing more by […]
July 15, 2020 | By dynaquest_admin | In Digital Identity
Survey: Digital Identity Adoption Post Pandemic
The pandemic disrupted businesses and even how people live their daily lives. It created a new normal where in the world is more aware of the advantages of going digital during and after the pandemic. However, the shift from traditional to digital caused problems in logistics and verifications. The volume of transactions and delivers is […]
June 3, 2020 | By dynaquest_admin | In Digital Identity
Importance of Digital Identity Verification after the Pandemic
A report from the Federal Trade Commission noted an increase in incidents of identity theft and digital fraud. Such incidents include attacks that took advantage of the current coronavirus pandemic situation. Unfortunate events like these underscore the importance of putting in place better digital identity verification solutions sooner rather than later. It is painful […]
May 5, 2020 | By dynaquest_admin | In Blockchain, Digital Identity
ID2020 Layouts Integrity of Digital Identities
The pandemic created a new normal for the whole world. In today's situation, people are staying at home where they are both working and taking care of themselves and their loved ones at the same time. Without a choice of leaving, the procurement of goods shifted to online services and delivery. In the Philippines, the […]
April 12, 2020 | By dynaquest_admin | In Blockchain, Digital Identity
How Blockchain and Smart Contracts Can Improve the Insurance Industry
Blockchain already revolutionized the way several organizations handle their logistics, identification, and data sharing. Even whole industries now value the benefits it brings to their processes. The health industry, using blockchain, made it possible for a system wherein patients have control over their records in terms of privacy. Also, several countries used blockchain technology […]
April 5, 2020 | By dynaquest_admin | In Blockchain, Digital Identity
How Digital Identities Function in 2020
Trust will always come into play when it comes to the exchange of goods. Without it, no one is willing to take the plunge in buying from someone they know and don't know. Whether shopping online or offline, at least one participant will ask for identification to vouch that it is not a scam. Being able […]
February 28, 2020 | By dynaquest_admin | In Blockchain, Blockchain Education, Digital Identity
Blockchain in Education: Smart Contract Diplomas in South Korea
South Korea is a country known worldwide as the origin of K-Pop, the hometown K-Dramas, and a popular tourist destination. But what the country offers are not limited to that. The country is also a major force when it comes to technology, with Samsung and LG becoming trusted global brands. No matter where you look, […]
November 4, 2019 | By dynaquest_admin | In Blockchain, Digital Identity, Impact Technology
Emerging Technologies that Could Foster Economic Inclusion in Caraga
This article was first published on BitPinas: Emerging Technologies that Could Foster Economic Inclusion in Caraga The internet has made the world a smaller place. I find that belief very true as the rate of how we broadcast, receive and interpret information has accelerated to an unimaginable pace. On a regular day, most of us would […]
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text:
Opinions|Health
From beer to eternity – how yeast is revealing cancer's secrets
Tiny yeast cells are helping researchers unravel the complex networks that drive cancer.
Kat Arney
Dr Kat Arney is Science Information Manager at Cancer Research UK, the largest charitable funder of cancer research in the world.
Published On 9 Jun 20139 Jun 2013
Sir Paul Nurse was awarded a Nobel prize in 2001 for "discoveries of key regulators of the cell cycle" [Reuters]
For more than five thousand years, humans have harnessed the power of yeast to brew beer and leaven bread, even though they may have attributed the bubbles of fermentation to mysterious forces rather than fungal micro-organisms.
Over recent decades, humble baker's and brewer's yeasts have made it out of the kitchen and into the research lab. Although humans and yeast inhabit completely different branches of the evolutionary tree – animals having branched off from fungi around one and a half billion years ago – we still share strong similarities with our single-celled distant cousins. Around forty percent of human genes are also found in yeast, including the fundamental genetic instructions that tell cells when to grow and divide.
While this process of cell division is highly useful (not to mention tasty) when you use yeast to make beer or bread, it also lies at the heart of human cancer. The disease is caused by cells in our own body multiplying out of control to form solid tumours such as breast, bowel or lung cancer, or "liquid cancers" affecting immune cells in the blood, more commonly known as leukaemia. And it's not just human and yeast cells that share the same genetic drivers for division. A similar set of genes are used to control cell growth in virtually all living cells, although very simple organisms like bacteria do things differently.
Over the years, yeast has proven to be a valuable model organism to help researchers pin down these drivers, with much less mess and fuss than other life-forms. They're easy and quick to grow in the lab, reproducing in just a few hours – human and animal cells can take a day or more – and needing little more than nutrient broth or jelly and a warm incubator to keep them happy.
Inside Story – Unlocking the genetic causes of cancer
Understanding the genes that drive cell growth is essential if we're to truly get to grips with cancer and develop more effective therapies. Two people who've made a huge impact in this area are Cancer Research UK scientists Professor Sir Paul Nurse and Sir Tim Hunt, who won a Nobel prize in 2001 (along with US researcher Dr Leland Hartwell) for their discovery in the early 1980s that the genes driving cell division are the same from yeast to plants, animals to humans, and how they work together to make cells multiply.
Since then, research has continued apace, and we now have a much more detailed picture of how a huge network of genes and molecules fit together to drive the "engine" of cell division. The picture is extremely complex, but clarity is starting to come. Professor Nurse and his team recently published the first comprehensive "roadmap" of the genes that coordinate the division and growth of yeast cells, helping to provide a framework for understanding how the same genes might work in healthy – and cancerous – human cells.
To construct their map, the researchers trawled through nearly 5,000 different strains of a type of brewer's yeast known as Schizosaccharomyces pombe, each missing a single different gene, to see if the cells had problems with growth or division, or were a strange shape (usually an indicator of underlying growth problems). If cells have these problems, it's usually because the missing gene normally plays an important role in making sure everything works properly.
The search turned up more than 500 genes involved in cell division, more than half of which hadn't been discovered before. And nearly 900 more genes were implicated in growth, as yeast cells missing any these particular genes were misshapen. In total, the scientists investigated more than 95 percent of the total number of yeast genes – an impressive feat that provides a valuable resource for researchers working in this field.
The next step is to find out how many of these genes match to equivalent ones in human cells, and whether they work in the same way within our bodies as they do in single-celled yeast. But, based on research over the past few decades, there's a good chance that important discoveries will be made in the coming years, which will hopefully translate into new treatments for cancer patients. For example, there are a number of drugs currently in clinical trials aimed at blocking some of the molecules first revealed by Nurse, Hunt and Hartwell back in the 1980s.
And Professor Nurse and his team are certainly in the right place to take their ideas forward. After spending a number of years in the US, he's now returned to the UK to head up the new Francis Crick Institute, currently being built in central London. Once finished, it will house the largest biomedical research facility in Europe under one roof, bringing together scientists working on a range of challenging diseases, including cancer, stroke, immune disorders and more.
The history of scientific progress tells us that great ideas can come from collaborations across disciplines and fields. So maybe the cancer drugs of the future will come from discoveries made in tiny yeast, springing from conversations between researchers in the local pub over a pint of beer and a breadbasket.
Dr Kat Arney is Science Information Manager at Cancer Research UK – the largest charitable funder of cancer research in the world – and writes for the charity's Science Update Blog.
Follow Cancer Research UK on Twitter: @CR_UK


Happy Halloween! This animation doesn't have anything to do with Halloween though.
I got motivated to make something a bit more flashier based off the previous animation.
This entry was posted in Animations and tagged animation, heal, rpg maker. Bookmark the permalink.
Hey, great blog, I'm just getting into making an rm one myself and came across yours. You've got a lot of really cool content, so keep up the good work!


The speech delivered by Zach Wahls is very deep and impactful. His presentation techniques and speech skills are exceptional. This testimony is in support of LGBT equality and its purpose is to address the proposal of banning gay marriage in Iowa. He speaks clearly and projects his voice, using a variance of tone and volume. Many gestures are used to emphasize points and there are pauses for dramatic effect. The speaker is also able to hold the audience's attention by using connections that the audience can relate to. The structure is well laid out and the speech includes many personal thoughts and experiences. What makes this speech most effective is the conclusion. The last sentence is, "the sexual orientation of my parents has had zero effect on the content of my character." This is an allusion to Martin Luther King's famous 'I Have a Dream' speech.


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Give us a call today, or stop by the showroom to learn more about GAF Glenwood Shingles for your home.


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Saturday hits: Whit: I'll never put on another uniform; Shaw-Zim connect; Slim salute; Coaching add
Five days after baring his soul about clarity concerning his future, left tackle Andrew Whitworth has seen the future and it is in stripes.
"I'll never put on another uniform other than a Cincinnati Bengals uniform," Whitworth said he watched Saturday morning's rookie minicamp at Paul Brown Stadium/ "The bottom line is I love this. I won't play anywhere else."
Whitworth said he and the club have talked, but he won't divulge the contents. But after working second-round pick Jake Fisher, he said he's ready to lead his team to a world's championship.
"They've always been great and loyal to me and my family. We will continue to be that way to them," Whitworth said.
SHAW-ZIM CONNECT: One of the more impressive guys this camp has been fourth-rounder Josh Shaw, the USC cornerback, who, by the way, may be the biggest cornerback in captivity with four percent body fat on 6-0, 201 pounds. And it looks like he knows what he's doing.
First, he's a football junkie as they like to say. But he's also got a leg up on the scheme. When the Bengals drafted him, Shaw's coordinator at USC in 2013, Clancy Pendergast, gave him a call and told him he'd have no problem figuring out the Bengals scheme because it's a Mike Zimmer defense.
It turns out that Pendergast coached Zimmer's secondary when Zimmer was the defensive coordinator in Dallas. When Zimmer was the secondary coach for the Cowboys for five years before he got the job. Pendergast was a quality control coach on defense and then a linebackers coach. He now coaches the 49ers inside backers.
"It looks like it's the same scheme from the one we had in '13," Shaw said.
SLIM SALUTE: The late Chris "Slim," Henry wore No. 15 for the Bengals in a star-crossed career that ended in 2009 with his death in a truck accident. The 6-4 Henry, a wide receiver from West Virginia, proved to be almost unstoppable on balls down the field. Seventh-round pick Mario Alford, a 5-8 receiver from West Virginia who burns a 4.25 40-yard dash, says it's a coincidence he's wearing No. 15, too.
He said his Twitter blew up Friday about the similarity and although he had heard Henry's name, he had never seen him play. So he spent part of Friday night watching him on video.
"He was really good," Alford said.
COACHING ADD: The Bengals have moved Robert Livingston, their southeast scout, to the coaching staff. Livingston has been with the Bengals since the end of the 2011 season, which he spent as the Vanderbilt defensive quality control coach. He's now the defensive quality control coach/special teams assistant.
Mixon Holds Second Annual Football Camp
Joe Mixon's football camp was held at his high school in California.
Camp hits: Green eyes century; Ross wreaks havoc in space; Price continues grind; TBT on line
Ced gets another say
Willow no longer just in the wind
Quick hits: Eifert question mark for camp; three-pick day; Joe all go
Record sack race underway
Carl Lawson is one of the many guys happy to see voluble and valued veteran left end Carlo Dunlap surface for this week's mandatory minicamp. Lawson, who usually sets up at right end on passing downs, nearly broke Dunlap's rookie sack record last season and he likes the competition. And on Tuesday he offered a challenge to a guy he calls "like an older brother to me."
Quick hits: Eifert not back Tuesday; Dalton finds Ross, Malone deep
Bengals 2018 Training Camp Opens Thursday, July 26
Bengals fans will get their first chance to see this year's team up close when Bengals Training Camp, presented by Fifth Third Bank, kicks off on Thursday, July 26.
On Sale Now: Bengals Introduce Jungle Pass
Fans interested in attending every Bengals home game this season have a new option. The $200 mobile-only Jungle Pass includes tickets to 10 Bengals games, eight in the regular season and two in the preseason.
Scrutiny is mandatory for offense
Just the presence of the very large Cordy Glenn at left tackle at Tuesday's start of mandatory minicamp is evidence of the effort to shore up the offense since he arrived via trade for a first-rounder. But the hopes of a little-used role player also reflect how this offense may be changed by as much philosophy as looks. Remember Ryan Hewitt, the forgotten fullback?
Hobson's Choice: Potpourri
Open Letter to Fans: Bengals Support Music Venue
The Bengals support a music venue and think it would be a great addition to the downtown area.


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USFWS Seeks Proposals from States for Annual Endangered Species Grants
Posted on Wednesday, October 31st, 2012 by aadmin | Comments Off on USFWS Seeks Proposals from States for Annual Endangered Species Grants
The U.S. Fish and Wildlife Service is seeking proposals from states and U.S. territories interested in obtaining federal financial assistance to acquire land or conduct planning efforts for endangered species conservation.
The Cooperative Endangered Species Conservation Fund (CESCF) is authorized under Section 6 of the Endangered Species Act (ESA) and provides grants to states and territories to support participation in a wide array of voluntary conservation projects for species on the Federal Lists of Endangered and Threatened Wildlife and Plants, as well as for candidate species. For fiscal year (FY) 2013, the President's budget request for the annual Cooperative Endangered Species Conservation Fund includes $60 million in grant funding for conservation activities benefitting federally protected species.
"These conservation grants are among the Service's most important tools for building strong partnerships for the conservation of threatened and endangered species," said Service Director Dan Ashe. "Local involvement is the cornerstone of conservation success and these grants allow states and territories to protect vital habitat lands and work with local communities and private landowners to conserve listed species for generations to come."
The Service is seeking proposals under the following three CESCF categories:
Recovery Land Acquisition Grants: These grants provide funds for the acquisition of threatened and endangered species habitat in support of approved and draft species recovery plans. Acquiring habitat in order to secure long-term protection is often the critical element in a comprehensive recovery effort for a listed species. Last year, the State of Hawaii was awarded a grant of $1.2 million to acquire 3,128 acres of sensitive coastal habitat, including more than a mile of coastline, on the southern coast of the island of Hawaii. These beaches are important habitat for hawksbill turtles, green turtles and Hawaiian monk seals. The property is adjacent to the largest natural area reserve in the state and will provide landscape-level protection of the area's unique ecosystems and habitats.
Habitat Conservation Planning Assistance Grants: These grants provide funds to support the development of Habitat Conservation Plans (HCPs). The purpose of an HCP is to ensure adequate protection of suitable habitat for threatened and endangered species, while at the same time providing for economic growth and development. Last year, the State of Florida was awarded a grant of $300,250 to initiate the planning of a county-wide HCP for scrub habitats in Highlands County to benefit the Florida scrub-jay, eastern indigo snake and other dry scrub species. Implementation of an HCP in Highlands County marks a significant step forward for scrub conservation in the heart of Florida's central ridge, and enhances similar efforts made in neighboring counties.
HCP Land Acquisition Grants: These grants provide funds to states and territories to acquire habitat for threatened and endangered species to complement conservation strategies of approved HCPs. Last year, the State of Washington received $3.7 million to protect 4,160 acres in southern Asotin County, including four miles of critical bull trout habitat along the Lower Grande Ronde River and three miles of riparian habitat along Cougar Creek. This project complements a larger, landscape-level conservation effort that will protect over 15 miles of streams and 13,000 acres of habitat that support federally listed gray wolf, bull trout, and steelhead as well as multiple unlisted species.
By law, the state or territory must have a current cooperative agreement with the Secretary of the Interior and contribute at least 25 percent of the total project costs, or ten percent when two or more states or territories undertake a joint project. Proposals must be submitted to the appropriate Service regional offices by January 14, 2013.
For more information about these grants and the application requirements contact: U.S. Fish and Wildlife Service, Division of Consultation, HCPs, Recovery, and State Grants, 4401 N. Fairfax Drive, Room 420, Arlington, VA 22203, 703-358-2171. The Cooperative Endangered Species Conservation Fund is identified in the Catalog of Federal Domestic Assistance as number 15.615.
The ESA provides a critical safety net for America's native fish, wildlife, and plants. The Service is working to actively engage conservation partners and the public in the search for improved and innovative ways to conserve and recover imperiled species. To learn more about the grants, visit the Endangered Species Program online at: http://www.fws.gov/endangered/grants/index.html
This press release was produced by the U.S. Fish and Wildlife Service.
« AMJV Partner Receives Interior's "Conservation" Award
Lock Haven, Nature Conservancy Protect 5,200 Acres in Conservation Effort »


The first organization in SE Asia to use this solution for secure, agile and business-ready networking.
Petroliam Nasional Berhad (PETRONAS) is Malaysia's national oil company. It operates in more than 20 countries and is among the largest corporations on Fortune Global 500.
PETRONAS' vision is to become the oil and gas company of choice.
PETRONAS recognizes technology as key to its ambitions - technology that enables innovations that matter, growth, and added value for stakeholders.
PETRONAS ICT delivers mission-critical, innovative and secure ICT solutions that operate across 140+ sites in 65 countries, and support more than 51,000 employees. These capabilities include workplace services, enterprise applications, business applications, ICT project services, and 24 x 7 ICT support for PETRONAS.
In an era of mobility and IoT, managing network access for users and devices in the PETRONAS network is a big challenge. There are constant changes. Meanwhile, ad-hoc manual changes to configurations lead to inconsistent security across networks and added vulnerabilities.
PETRONAS ICT wants to further limit their already low (2-3 per month) frequency of network glitches.
"The frequency of network glitches was never a matter of concern. But imagine if you have to submit a multi billion-dollar tender at a fixed time and that is exactly when the network doesn't work. We can't afford to have any downtime, and rely on time-consuming, error-prone manual fixes." said Hafizan Habeeb Rahman, Head of Business Function - Infrastructure at PETRONAS ICT.
The deployment and configuration of devices was lengthy, arduous and inefficient.
For example, it took up to 2 months to deploy and configure switches in the Twin Towers, which have 88 floors. Upgrading configurations across the company could take more than 6 months. The traditional methods used for policy administration are difficult to implement and maintain. And it is a daunting task to implement network policies based on user/device identity.
Deployment, configuration, testing and maintenance were handled manually. This meant a large pool of engineers was required at all times. Human interaction led to excessive man hours and high operational cost.
PETRONAS ICT strives to provide a high-quality communication experience to optimize staff productivity. But it was difficult and time-consuming to tailor configurations.
Changes in quality of service took several months to plan and implement. Meanwhile, the lack of implementation caused performance issues in business-critical applications.
The significant size and complexity of networks under the current network paradigm meant that when a failure occurred, pinpointing and resolving the issues could take a lot of effort and time. This was because a large amount of data collected from multiple systems was not properly correlated.
Recognizing the challenges above, the Infrastructure team began a mission to build a new network. PETRONAS ICT presented their issues and expectations to Cisco.
The Cisco team proposed the Cisco Digital Network Architecture (DNA), an open, extensible, software-driven network architecture. PETRONAS ICT was particularly interested in the Cisco Software-Defined Access (SD Access), a new network architecture built on the principles of Cisco DNA.
Find out more in the next section.
Cisco SDA makes building and managing networks faster, easier and improves business efficiency. By decoupling network functions from hardware, SD-Access ensures policy consistency, enables faster launches and significantly reduces issue resolution time and operational expense.
PETRONAS ICT seized the opportunity to adopt this technology as a networking solution for the future. The following section discusses how Cisco SDA addresses the challenges mentioned earlier.
SD-Access allows organizations to set up and enforce automated access and consistent security policies across the network. This allows users, devices, and applications to be segmented in an automated, policy-driven way. Pre-tested identity-based security policy will be applied consistently to all users and devices, irrespective of the sub-network they are connected to. This will significantly bolster the network security.
For example, if there is an unauthorized manual change to a network device in the PETRONAS network, Cisco DNA Center is able to detect this change and enforce pre-defined policy by reverting the configuration to the original one.
The tasks of configuring and provisioning network devices in a traditional network architecture are highly laborious, repetitive and prone to human error. By using artificial intelligence to automate these tasks, Cisco SD- Access minimizes the human errors, thus dramatically improves the network availability.
Configuring only needs to be done at Cisco DNA Center, a single network management and command center for the Cisco SDA solution. Using automation enabled by artificial intelligence, the configuration and the policy is then applied to tens or hundreds of network devices in minutes, instead of days.
For example, in the past, it took 60 days to complete deployment, configuration and testing in one of PETRONAS twin towers. Now it takes just 6 days with Cisco SDA.
The automation and assurance capabilities of Cisco SDA, have reduced the number of man-hours and related business costs significantly.
6 people reduced to 3, 60 days reduced to 6, and MYR 720,000 reduced to MYR 36,000.
PETRONAS ICT has been able to reduce support/maintenance staff over the years to 10 people only due to automation, assurance and intent-based networking.
Changing business needs mean users require PETRONAS ICT to be agile and build solutions that meet new needs.
"Cisco SDA has a lot more to offer than we have currently leveraged. We are now working on creating user profiles with the data and knowledge from Cisco SDA Network which allows us to cater to individual user's network needs. For example, there are various kinds of users when their day to day work may require them to work on an application from a corporate office versus a mobile user versus a user who does drawings for oil drilling locations etc.
To optimize the network we will create 5 -6 user profiles and allocate them to individuals. This, in turn, will optimize the network bandwidth," says Hafizan.
"These user profiles can be designed to manage/restrict access to various applications and users will be able to plug in from any site to work within their granted access."
Hafizan Habeeb Rahman, Head of Business Function - Infrastructure at PETRONAS ICT.


I think I have a cool idea, will it work?
I would like to see a scientific 'domino's' event. My idea is that you have a series of containers with different chemical combinations, and they all have entry and exit areas. The containers would have a starting spot, whereby a chemical would be added to the current combination, to cause a spurt to leave the exit point, and enter the next container by the entry point, this would cause another reaction, and the chain would continue to the next container. I'm wondering if the reaction could be continued for 20 containers or more. Obviously an explosion in the chain would break the next container, so each reaction would need to be thought out to produce a spurt. What's more the positioning of each container would need to be perfectly planned according to the power of the reaction. For the container's I'm thinking something like a glass watering can, with chambers inside if needed to produce the right reaction or effect. The entry point would be the filling rea, and the spout would be the exit point. I think it's a cool idea, and I would love to know if it could work.
On a basic level, a living thing can be seen as a chain of chemical reactions. I mention it because there are some interesting chains of events in biological chemistry. You might want to look into the citric-acid cycle and model it in some way. Just a thought.
There are some similarities between a Rube Goldberg machine and metabolism. But the big differences are that metabolism is usually a massively parallel and redundant operation and that it is constantly (or regularly) supplied with energy. A Rube Goldberg machine, on the other hand, is much more fragile and is typically only 'fed' once in its lifetime (i.e. it is initially set up). Now if you had a dozen interlocking Rube Goldberg machines running simultaneously, each one receiving energy input (dropped marbles, added chemical reactants) on a regular basis... that would be impressively lifelike.
Notice that I specified constant energy input from outside the machine. To compare it to metabolism: If I seal you in a box, completely cut off from the rest of the world, with a battery powered light, some plants, and a limited amount of food, is this a recipe for perpetual life?
Could you get perpetual motion? No.
Could you make people think you had perpetual motion? Very possibly, yes.
That's a great analogy. I love it. The metabolic rube-goldberg machine... hehe. Thanks that will help me next time I have to explain it.
Lemonie mentions a catalyst because you might find a catalyst that can be diluted 20 times and still work, while you will probably not find a reactant capable of that.
Say you have a bottle that is standing upright but balanced so that it can easily tip over into a depression shaped to fit the fallen bottle.
In the bottom of the bottle is vinegar.
Inside the bottle, suspended over the vinegar, is a tissue filled with baking soda.
A tube runs through the lid of the bottle.
The tube contains a piston.
You lay the first bottle into its slot.
Once horizontal, the vinegar soaks though the tissue.
The baking soda and vinegar react.
while the depression prevents the bottle from sliding in the opposite direction.
The piston tips over the next bottle.
If you need further inspiration, try watching some Rube Goldberg competitions and Pitagora Suichi.
I like the idea of involving pistons and glass containers or plastic would show the reactions but glass would require more control of the resulting effect. Thanks for the links too.
Set up a long track with a cylindrical groove down the middle.
Set many of these tubes end-to-end in the track.
Tap the first tube to activate it.
That tube sprays liquid and gas out the back and travels forward.
It strikes the next tube, activating it.
Energy tends to go downhill. If you had energetic solutions in the containers and used the out put for catalysis you might get it to work. 20 is pushing it a bit though.


Entering Bootloader mode is one of those things that most of know how to do with our eyes closed on a Nexus. It's really easy and also it's been the same on every Nexus device. But there are some people out there that are brand new to Android and thus don't know how to do things like this. So this is where we come in, to help. Today we'll be walking you through booting into Bootloader mode.
That's it, actually. Pretty easy right?
See how easy that is? Can't really get any easier than that. From there you'll use the volume buttons to navigate through the options and the power button to choose that option. If you need help, feel free to leave a comment down below.


Facebook's lead EU regulator has started an investigation into the recent cyberattack on the social networking site.
According to Reuters, the Irish Data Protection Commissioner (DPC) announced on Wednesday (Oct. 3) that it has launched an investigation into the breach that exposed the data of about 50 million Facebook users. The social media giant found that attackers were able to take control of user accounts through a function within the platform's code.
Facebook has already informed the DPC that their own investigation is ongoing, and that the company will continue to take actions to lessen the potential risk to users. And earlier this week, a company spokeswoman said the company plans to answer all of DPC's questions, as well as keep regulators informed of further developments.
In the meantime, the vulnerability that caused the breach has been fixed, and Facebook added that it reached out to authorities when the vulnerability was discovered. More than 90 million users had to log out of their accounts as a result of the breach, which has been described as a typical measure taken with comprised accounts.


All of my artwork was hand-drawn by me and cared for deeply. My mission is to create art that is meaningful and personal to you and your story. I care deeply about helping others- and I hope to do so by providing you high quality printables that can be gifted and loved.
This listing is for an Instant Download/Printable. Personalized options are available. **Please see the 'personalize' section for details.
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You will immediately be taken to a page after checkout where you will receive (4) high quality JPG files to download.
You may print as many times as you'd like! I just ask that you DON'T SHARE THE FILES WITH OTHERS, SELL THE PRINTS FOR PROFIT, OR ALTER IN ANY WAY.
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