Development of a framework with tools to support the selection and implementation of patient-reported outcome measures.

BACKGROUND: Patient reported outcomes (PROs) provide information on a patient's health status coming directly from the patient. Measuring PROs with patient reported outcome measures (PROMs) has gained wide interest in clinical practice for individual patient care, as well as in quality improvement, and for providing transparency of outcomes to stakeholders through public reporting. However, current knowledge of selecting and implementing PROMs for these purposes is scattered, and not readily available for clinicians and quality managers in healthcare organizations. The objective of this study is to develop a framework with tools to support the systematic selection, implementation and evaluation of PROs and PROMs in individual patient care, for quality improvement and public reporting. METHODS: We developed the framework in a national project in the Netherlands following a user-centered design. The development process of the framework contained five iterative components: (a) identification of existing tools, (b) identification of user requirements and designing steps for selection and implementation of PROs and PROMs, (c) discussing a prototype of the framework during a national workshop, (d) developing a web version, (e) pre-testing of the framework. A total of 40 users with different perspectives (clinicians, patient representatives, quality managers, purchasers, researchers) have been consulted. RESULTS: The final framework is presented as the PROM-cycle that consists of eight steps in four phases: (1) goal setting, (2) selecting PROs and PROMs, (3) developing and testing of quality indicator(s), (4) implementing and evaluating the PROM(s) and indicator(s). Users emphasized that the first step is the key element in which the why, for whom and setting of the PROM has to be defined. This information is decisive for the following steps. For each step the PROM-cycle provides guidance and tools, with instruments, checklists, methods, handbooks, and standards supporting the process. CONCLUSION: We developed a framework to support the selection and implementation of PROs and PROMs. Each step provides guidance and tools to support the process. The PROM-cycle and its tools are publicly available and can be used by clinicians, quality managers, patient representatives and other experts involved in using PROMS. Through periodic evaluation and updates, tools will be added for national and international use of the PROM-cycle.

Bridging the Gap between Health and Social Care for Rare Diseases: Key Issues and Innovative Solutions.

Bridging the gaps between health and social care for rare diseases is not only necessary but crucial to increase the life expectancy, quality of life and autonomy of people living with a rare disease, supporting them in the full realisation of their fundamental human rights.The complexity of rare diseases, their strong relation to disability and the current unmet social and daily life needs of people living with a rare disease must not be underestimated and require urgent attention from all stakeholders involved in care provision, from healthcare to social and community services.The Commission Expert Group Recommendations to Support the Incorporation of Rare Diseases into Social Services and Policies, adopted unanimously in April 2016, by the representatives of European Member States and the other rare disease stakeholders, clearly set the tone for the need to promote measures that facilitate multidisciplinary, holistic, continuous, person-centred and participative care provision to people living with rare diseases.These recommendations, sided by other recent policy developments at European and national levels, represent an important policy step into approaching rare diseases' complex challenges in regards to holistic care provision.Innovative approaches aiming at bridging the gap between health, social and community service and support providers are currently being developed and tested in different European countries: standards of care, networks of expertise, case management services, one-stop-shop services, amongst others.These ongoing pilot approaches, presented in this chapter, have the power to inspire future policies and the effective and efficient implementation of holistic care pathways for people living with a rare disease, bringing about significant changes for patients, carers, care providers, competent authorities and the society at large.Nonetheless, the challenges to fully address this issue remain numerous and other key issues will also need to be taken into account when moving forward with the implementation of measures that aim at bridging the gaps between care providers and providing holistic care to people living with a rare disease.

Low-frequency stimulation induces stable transitions in stereotypical activity in cortical networks.

Reverberating spontaneous synchronized brain activity is believed to play an important role in neural information processing. Whether and how external stimuli can influence this spontaneous activity is poorly understood. Because periodic synchronized network activity is also prominent in in vitro neuronal cultures, we used cortical cultures grown on multielectrode arrays to examine how spontaneous activity is affected by external stimuli. Spontaneous network activity before and after low-frequency electrical stimulation was quantified in several ways. Our results show that the initially stable pattern of stereotypical spontaneous activity was transformed into another activity pattern that remained stable for at least 1 h. The transformations consisted of changes in single site and culture-wide network activity as well as in the spatiotemporal dynamics of network bursting. We show for the first time that low-frequency electrical stimulation can induce long-lasting alterations in spontaneous activity of cortical neuronal networks. We discuss whether the observed transformations in network activity could represent a switch in attractor state.

Temporal interactions in direction-selective complex cells of area 18 and the posteromedial lateral suprasylvian cortex (PMLS) of the cat.

Temporal interactions in direction-sensitive complex cells in area 18 and the posteromedial lateral suprasylvian cortex (PMLS) were studied using a reverse correlation method. Reverse correlograms to combinations of two temporally separated motion directions were examined and compared in the two areas. A comparison to the first-order reverse correlograms allowed us to identify nonlinear suppression or facilitation due to pairwise combinations of motion directions. Results for area 18 and PMLS were very different. Area 18 showed a single type of nonlinear behavior: similar directions facilitated and opposite directions suppressed spike probability. This effect was most pronounced for motion steps that followed each other immediately and decreased with increasing delay between steps. In PMLS, the picture was much more diverse. Some cells exhibited nonlinear interactions, that were opposite to those in area 18 (facilitation for opposite directions and suppression for similar ones), while the majority did not show a systematic interaction profile. We conclude that nonlinear second-order reverse correlation characteristics reveal different functional properties, despite similarities in the first-order reverse correlation profiles. Directional interactions in time revealed optimal integration of similar directions in area 18, but motion opponency--at least in some cells--in PMLS.

Spatio-temporal requirements for direction selectivity in area 18 and PMLS complex cells.

The spatio-temporal requirements for direction selectivity were studied in two extrastriate motion processing areas in the cat, area 18 and the posteromedial lateral suprasylvian cortex (PMLS). Direction, velocity and pixel size of random pixel arrays (RPA) were adjusted for each neuron and direction selectivity was measured as a function of step size and delay for a given optimal velocity. A subset of direction selective complex cells in area 18 was tuned to intermediate step size and delay combinations rather than the smoothest motion (band-pass cells). Other area 18 complex cells responded best to the smallest value of step size and delay (low-pass cells). Tuning varied with the pixel size of the RPA. Cells with tuning for smaller pixels favoured a preference for non-smooth motion. Area 18 cells with lower spatial resolution showed larger optimal and maximal step sizes. For a subset of the cells in area 18, we measured direction selectivity for extensive step-delay combinations, covering multiple velocities. Results showed that most cells were tuned to narrow range of step-delay combinations, and that the optimal step size was independent of temporal delay. Direction selective complex cells in PMLS were tuned to larger pixel sizes than those in area 18, although the distributions did overlap. In contrast to area 18, PMLS cells preferred the smoothest motion, irrespective of RPA pixel size.

Dynamics and plasticity in developing neuronal networks in vitro.

When dissociated cortical tissue is brought into culture, neurons readily grow out by forming axonal and dendritic arborizations and synaptic connections. These developing neuronal networks in vitro display spontaneous firing activity from about the end of the first week in vitro. When cultured on multielectrode arrays firing activity can be recorded from many neurons simultaneously over long periods of time. These experimental approaches provide valuable data for studying firing dynamics in neuronal networks in relation to an ongoing development of neurons and synaptic connectivity in the network. This chapter summarizes recent findings on the characteristics and developmental changes in the spontaneous firing dynamics. These changes include long-lasting transient periods of increased firing at individual sites on a time scale of days to weeks, and an age-specific repetitive pattern of synchronous network firing (network bursts) on a time scale of seconds. Especially the spatio-temporal organization of firing within network bursts showed great stability over many hours. In addition, a progressive day-to-day evolution was observed, with an initial broadening of the burst firing rate profile during the 3rd week in vitro (WIV) and a pattern of abrupt onset and precise spike timing from the 5th WIV onwards. These developmental changes are discussed in the light of structural changes in the network and activity-dependent plasticity mechanisms. Preliminary findings are presented on the pattern of spike sequences within network burst, as well as the effect of external stimulation on the spatio-temporal organization within network bursts.

Dynamics of directional selectivity in area 18 and PMLS of the cat.

Visual latencies and temporal dynamics of area 18 and PMLS direction-selective complex cells were defined with a reverse correlation method. The method allowed us to analyze the time course of responses to motion steps, without confounding temporal integration effects. Several measures of response latency and direction tuning dynamics were quantified: optimal latency (OL), latency of first and last significant responses (FSR, LSR), the increase and decrease of direction sensitivity in time, and the change of direction tuning in time. FSR, OL and LSR values for PMLS and area 18 largely overlapped. The small differences in mean latencies (3-4 ms for FSR and OL and 11.9 ms for the LSR) were not statistically significant. All cells in area 18 and the vast majority of cells in PMLS showed no systematic changes in preferred direction (monophasic neurons). In PMLS 5 out of 41 cells showed a reversal of preferred direction after approximately 56 ms relative to their OL (biphasic neurons). Monophasic cells showed no systematic changes in direction tuning width during the interval from FSR to LSR. In both areas, development of direction sensitivity was significantly faster than return to the non-direction sensitive state, but no significant difference was found between the two areas. We conclude that, for the monophasic type of direction-selective complex cells, the dynamics of primary motion processing are highly comparable for area 18 and PMLS. This suggests that motion information is predominantly processed in parallel, presumably based on input from the fast conducting thalamocortical Y-pathway.

The motion reverse correlation (MRC) method: a linear systems approach in the motion domain.

We introduce the motion reverse correlation method (MRC), a novel stimulus paradigm based on a random sequence of motion impulses. The method is tailored to investigate the spatio-temporal dynamics of motion selectivity in cells responding to moving random dot patterns. Effectiveness of the MRC method is illustrated with results obtained from recordings in both anesthetized cats and an awake, fixating macaque monkey. Motion tuning functions are computed by reverse correlating the response of single cells with a rapid sequence of displacements of a random pixel array (RPA). Significant correlations between the cell's responses and various aspects of stimulus motion are obtained at high temporal resolution. These correlations provide a detailed description of the temporal dynamics of, for example, direction tuning and velocity tuning. In addition, with a spatial array of independently moving RPAs, the MRC method can be used to measure spatial as well as temporal receptive field properties. We demonstrate that MRC serves as a powerful and time-efficient tool for quantifying receptive field properties of motion selective cells that yields temporal information that cannot be derived from existing methods.

On the velocity tuning of area 18 complex cell responses to moving textures.

Unlike simple cells, complex cells of area 18 give a directionally selective response to motion of random textures, indicating that they may play a special role in motion detection. We therefore investigated how texture motion, and especially its velocity, is represented by area 18 complex cells. Do these cells have separable spatial and temporal tunings or are these nonseparable? To answer this question, we measured responses to moving random pixel arrays as a function of both pixel size and velocity, for a set of 63 directionally selective complex cells. Complex cells generally responded to a fairly wide range of pixel sizes and velocities. Variations in pixel size of the random pixel array only caused minor changes in the cells' preferred velocity. For nearly all cells the data much better fitted a model in which pixel size and velocity act separately, than a model in which pixel size and velocity interact so as to keep temporal-frequency sensitivity constant. Our conclusion is that the studied population of special complex cells in area 18 are true motion detectors, rather than temporal-frequency tuned neurons.