The quality of care in nursing homes is weakly defined, and has traditionally focused on quantify nursing homes outputs and on comparison of nursing homes’ resources. Rarely the point of view of clients has been taken into account. The aim of this study was to ascertain what means “quality of care” for residents of nursing homes.Grounded theory was used to design and analyze a qualitative study based on in-depth interviews with a theoretical sampling including 20 persons aged over 65 years with no cognitive impairment and eight proxy informants of residents with cognitive impairment, institutionalized at a public nursing home in Spain.Our analysis revealed that participants perceived the quality of care in two ways, as aspects related to the persons providing care and as institutional aspects of the care’s process. All participants agreed that aspects related to the persons providing care was a pillar of quality, something that, in turn, embodied a series of emotional and technical professional competences. Regarding the institutional aspects of the care’s process, participants laid emphasis on round-the-clock access to health care services and on professional’s job stability.This paper includes perspectives of the nursing homes residents, which are largely absent. Incorporating residents’ standpoints as a complement to traditional institutional criteria would furnish health providers and funding agencies with key information when it came to designing action plans and interventions aimed at achieving excellence in health care. Nursing homes are an alternative to private homes for persons who need long-term care but do not wish or are not able to live at home. Since the 60’s, there is growing interest in improving the quality of care in nursing homes, and to attain this goal it is known that measures of quality must be targeted at achieving safe, effective, efficient, person-centered care -3. AnalyIn the last decade, the understanding of what quality means from the nursing homes’ client perspective has become a growing focus of interest ,6,7, sucQuality of care in nursing homes has been traditionally assessed through the Donabedian approach, using the indicators of structure, process and outcome in the majority of studies ,10. MostTraditionally, the point of view of residents has been measured by using questionnaires that monitor the satisfaction with the care received ,13; neveTo our knowledge, studies that incorporate the voice of residents to clarify what is quality of care in nursing homes are scarce ,16-18, aAccordingly, this study sought to ascertain what quality of care meant to residents in nursing homes.We used in-depth interviews and grounded theory dimensional analysis to collect and analyze the data -23. ThisData of this study come from a broader research project  that analyzes the phenomenon of institutionalization of older persons. The participants and methods have been described extensively elsewhere . In brieInclusion criteria for informants were persons aged 65 years and over, living at the nursing home for at least three months, the minimal estimated time to get an accurate picture of facilities, services and staff. Residents admitted on a temporary-stay basis were not considered eligible because short-term residents may have different needs and characteristics . In the Interviews were held by appointment and were conducted into the nursing home in a peaceful and quiet place. Each interview started out with an open-ended question about the personal experience of care at nursing home, which elicited subjective responses about their perceptions. The interviewer, the main researcher, had a topic list that could emerge openly throughout the interviews, but not necessarily at each interview Table . This toThe study was approved by the Clinical Research Ethics Committee of Nuestra Señora del Prado Hospital, in Talavera de la Reina, Spain, and by the management of the nursing home where the study was undertaken. After a full explanation adapted to the research project, all participants were asked to give their informed consent to a sound recording of the interview and its subsequent analysis. In the case of residents with cognitive impairment, the consent of the proxy or, where applicable, the legal guardian was obtained.After transcribing the in-depth interviews, the texts were collated and sorted. Using grounded theory methods, three qualitative methodology research experts drawn from different disciplines  analyzed the transcriptions, with the aim of ascertaining participants’ perception of overall health care quality and obtaining a theoretical explanation for this.Data-collection, analysis and interpretation were simultaneously undertaken in an interactive process, thus the results of the first data analysis informed subsequent data-collections, thereby enabling key topics to be studied in depth . This imAccording to grounded theory principles, our analysis identified specific concepts that explained how informants perceived overall quality of nursing home care. These concepts were labeled and classified into categories using open, axial and selective coding processes . FirstlyWe used of the Atlas-Ti 5.0 software program as a technical aid in the coding stage, enabling to code large amounts of text and share the data among the research team.The validity and reliability of the conclusions of the analysis were ensured by the following: literal transcription of all interviews, analysis of the data in the full context of the interview during which they had surfaced, constant comparative method and triangulation methods ,29. We uThe emergent theoretical categories that explained participants’ perceptions are described in Table Two main categories emerged from the analysis of the residents’ and family members’ perceptions the quality of nursing-home care, such as aspects related to the persons providing care, or as institutional aspects of the care’s process. But in all cases participants prioritized in their discourses aspects related to the persons providing care rather than institutional aspects of the care’s process. The results are presented beginning with the categories, subcategories and codes. In the interests of achieving a better understanding of the results we have included the most representative verbalizations; the number assigned to each participant follows each quote and the word “proxy” in the case of the discourses of family members.All participants included aspects related to the persons providing care as the pillar of quality of care. This category encompassed participants’ conceptualizations of competences related to care in nursing homes. This comprised emotional and technical competences. But throughout their discourses the participants emphasized the importance of emotional competences versus technical competences.Participants agreed when it came to including good will, affection and kindness on the part of professionals as an essential ingredient of aspects related to the persons providing care:“Since they have to do things, what I most value is that they go about them with a good will” (P.20).In the case of residents, there were also differences according to gender. While women felt that, “kind and considerate care provides warmth and affection” (P.11), men talked of kindness, “quality means that people say things in a friendly way” (P. 26).The residents also included cheerfulness and a sense of humor as an essential attitude for achieving good professional care:“Laughter is the best therapy” (P.7). “Being cheerful goes a long way because, even though you may not be able to do anything in certain cases, at least you can be a little friendly at such times” (P.25).In addition, the relatives of residents with cognitive impairment included family-like and warm care:“Quality is closeness… they should treat residents with family-like familiarity” (P.2 Proxy). “You ought to care for them as if they were your mother or a person close to you” (P.3 Proxy).All participants agreed in asserting that good manners and respect for the client should be uppermost when caring for residents:“To my mind, the worst thing of all is bad manners. One of the things that old folks most appreciate is the way in which they are treated” (P.1 Proxy). “I see this as being like a small hotel where people are treated with respect and courtesy, and I feel more at ease” (P.2 Proxy).In the informants’ opinion, professionals had to provide an individualized care:“They should take the preferences of residents and family members into account” (P.2 Proxy). “Care should be personalized” (P.6 Proxy).Participants conceptualized as another pillar of aspects related to the personal providing care the professionals’ role of listening and providing support, the result of a close relationship with the residents:“It’s not that they’re going to get rid of the pain or anything, but rather that they give you encouragement” (P.25).On the other hand, residents wanted to be attended at a pace that allows them to preserve their functionality:“Care should be given with calm and lots of patience” (P.23).Furthermore, the data showed that residents do not like anonymity. All their lives, they have been called by their own names, something that gives them a personal identity in their professional or social environments, which they want to retain: “I like to be called by my name” (P.27). Residents wish that professionals and family members would put a stop to paternalistic attitudes, and cease to regard residents as mere objects and treat them as though they were children:“They shouldn’t think we’re stupid and treat us like children, because I’m already an adult” (P.23).To ensure correct interaction, and avoid misunderstandings and conflictive situations between residents with cognitive impairment and professionals, their family members insist that they be attended “with tact” and empathy providing individualized care based on knowledge of the personal needs of each resident:“It is extremely important that they know their weak points, and guide them to neutral ground” (P.3 Proxy).In their description of quality, family members attributed higher priority to a close professional-resident relationship than to knowledge:“With just a word, a smile or a look. That’s more important than the staff knowing a lot” (P.17 Proxy).Institutionalized elderly are grateful when people enquire and are attentive to them: “Being well treated is when somebody comes over to you and says: Do you need anything? Would you like this or that?… That’s what it’s about, coming and asking you” (P.18). In order for the resident-professional relationship to be satisfactory, it is also important that adequate information be received from the professionals, i.e., “that they tell you what they’re going to do to you” (P.14). This information calms residents and makes them understand that sometimes they have to wait to be attended, and that this may even have therapeutic effects:“If you call them, then they should tell you…well now we can, now we can’t…they should keep you informed” (P.25).Female relatives, particularly in the case of residents with severe cognitive impairment, considered that medical and nursing staff had the necessary skills to handle residents by virtue of their training, whereas nursing assistants ought to have better training in geriatrics, which would directly impact on improving the care of and interaction with residents, and on the individualization of care:“I’d ask for a little more in the way of qualifications” (P.6 Proxy). “I feel that to be able to give quality, professionals must have specific training in older persons” (P.17 Proxy).The second pillar of the concept of quality which emerged from our analysis of the data was institutional aspects of the care’s process according to organizational technical standards, though this always appeared in a subordinate role, coming after aspects related to the persons providing care.Unlike family members, residents were less critical and adopt a more conformist view on aspects related to organizational technical quality in nursing homes:“I’m 93 years old, what am I going to ask here? Everything seems fine” (P. 12).Among the services that a nursing home must have, family members and three male residents stressed the importance of experienced and fast provision of health care. Family members felt that such a service afforded a sense of security:“If there’s some kind of problem or something happens at night, there’s always a physician or qualified nurse on call, and that puts my mind at rest” (P.4 Proxy). “One of the important things is 24-hour care” .Moreover, family members insist on job stability among professional staff, since constant changes in personnel hinder the relationship of trust between resident and worker. This idea is in line with view that residents have of staff as being a source of support in difficult situations:“I feel that the same staff should always be there because they know the residents. They (the residents) tell them all about themselves and come to have a lot of trust in them” (P.1 Proxy). “They’re used to old people and know what has to be done in order to deal with them” (P. 17 Proxy).Within the context of institutional aspects of the care’s process, there were differences according to sex and age. Hence, only male residents included facilities and cleanliness in their perception of quality:“I’d say that a nursing home has quality on the basis of its staff, building, rooms, services and 24-hour medical care” (P.23). “Facilities are also important, but the personal touch, warmth and tenderness, is more important” (P.7). “The fact that you are well taken care of, that there’s cleanliness, to me that’s quality” (P.26).With respect to nursing home’s services, the aspect most highly prized by participants was that care was provided on the basis of residents’ needs: “quality is not a matter of great luxury, but rather having one’s needs covered” (P.24). Residents laid emphasis on food needs, putting quality before quantity: “Quantity’s not important, what’s important is the quality of the meals and the way they are presented” (P.14). Furthermore, family members valued the fact that, when it came to attending to the residents, the professional caregivers showed personalized attention to small details:“They are attentive with my mother, thus when they put her in the chair, they placed a blanket over her knees so that she wouldn’t feel the cold” (P.28 Proxy).Residents under the age of 75 years valued the fact that there were no strict rules, and that they preserved part of their independence despite their institutionalization:“The fact of the matter is that I’m neither old nor young, and I feel pretty good, with a strong will to live and fit and active, I can fend for myself, and freedom’s what I like best” (P.9). “We really value the fact that the nursing home’s open and we’re free to go out” (P.5). “If I couldn’t leave the nursing home, I’d feel suffocated; there’d be nothing left for me” (P.24).Within this view of institutional quality standards, we found that relatives of residents with advanced cognitive impairment demanded the introduction of centers specializing in these types of disorders:“My husband ought not to be here because, with the illness he has, he shouldn’t be in a nursing home: he should be in a chronic disease unit” (P.6 Proxy).Something prized as a quality criterion by relatives of residents with cognitive impairment is the fact that they allowed to become involved in decisions affecting their relative’s care:“As soon as they see me, they say, look, your mother has done this, needs that… My mother wasn’t eating properly and the doctor asked me if I wanted them to fit her with a feeding tube, but I told the doctor, better not, and that, even though she ate very little, I’d prefer it to be without a tube” (P.28 Proxy).Family members’ idea of institutional aspects of the care’s process was completed by one last component, namely, the presence of recreational activities at the nursing home:“They should have some time for leisure and recreation” (P.15 Proxy).Our study is among the few to have used in-depth interviews to ascertain the protagonists’ points of view on how quality of care in nursing homes should be conceptualized, and is the only one conducted at a nursing home in a Mediterranean cultural setting. Furthermore, our study also furnishes a simultaneous analysis of the conceptualizations of older institutionalized persons with and without cognitive impairment, with the perceptions of the former being incorporated through the agency of proxy informants.From our study emerge the following theories that explain the patterns of relationship among constructs that arise from the discourse of the participants: 1) Aspects related to the persons providing care are the pillar of quality care; 2) professional competences for geriatric care are components of quality, but emotional competences are considered more important than aspects of the care’s process; 3) the participants’ perceptions of quality of care are highly influenced by the traditional ideas about how to provide the best care for older people; and 4) conceptualizations of nursing home are different for residents than for resident’s family members.The importance of interpersonal relationships as a component of quality of care is a characteristic that tends to emerge in qualitative studies ,16,32. OIn contrast with survey-based studies ,33, our In line with previous studies , for ourNotwithstanding this, at least in Spain, most of the institutions mainly include in their quality assessment items related to technical issues, while usually the interpersonal aspects are optional items ,38. MaybAs in other studies , for ourAlthough the number of nursing professionals has been associated with quality of care ,2, our iWe consider that cultural stereotypes can influence on care conceptualizations. In contrast with other studies conducted in countries such as USA, where care is more consumer-oriented, and in which formal care systems for the elderly people are commonly viewed in a positive light ,39, famiAs a result, their perceptions about aspects related to the persons providing care includes a family-like relationship, based on closeness, person-centered care and respect for the resident’s autonomy. Similarly, in other studies, residents ,33 and pIn the opinion of family members, quality of care includes the presence of 24-hour health care as another basic pillar of quality, but they focused health care exclusively on physicians and nurses, and neglected the other components of the team. Other studies have also underscored the importance that has early care has for clients when they have a problem . HoweverPerceptions of relatives tend to resemble those clients of private health services, being more critical and demanding than residents in their assessments of quality. Conversely, and according with other studies ,41 the rThe size of our theoretical sample, albeit insufficient to ensure external validity in terms of other empirical research models , was nevAlthough the use of proxies for presenting the views of people with cognitive impairment may have some limitations, it has been considered as the best alternative to analyze care when patients cannot do by themselves ,42.Furthermore, it is important to bear in mind that data were collected at a publicly-owned nursing home, and results should be generalized to other types of nursing homes with caution, particularly to those facilities where the end-user has to pay for the entire range of services on offer, and thus feels entitled to other rights as a client.Our results are useful for practitioners and managers of nursing homes, since they analyze quality of care in nursing homes from the point of view of those for whom it is intended, and highlight that, for residents of nursing homes, less visible aspects of quality of care as emotional needs attention may be more relevant than more tangible aspects traditionally used as quality standards.Multiple viewpoints  should be taken into account in the assessments of the quality of care in nursing homes. In this way, on the basic of patient centered approach of quality, the understanding of the residents and their proxies’ viewpoints might help to individualize the care, and might be useful to analyze this quality of care from a holistic perspective.USA: United States of America.The authors of this study declare that they have no competing interests.All authors have contributed substantially to the manuscript. In particular, BRM and VMV that were the principal investigators contributed to conception, design, analysis and interpretation of data. BRM, MMA, BCM and BNP contributed to drafting of the manuscript and revising it critically. Also, VMV coordinated the study and reviewed the work done in the study. All authors provided final approval of the manuscript submitted.1. BRM Degree: PhD. MSc. Professor Assistant of Gerontology.2. MMA Degree: MSc. Professor Assistant of Sociology.3. BCM Degree: MSc.4. BNP Degree: PhD. MSc. Professor Assistant of Nursing.5. VMV Degree: MD. Professor of Nursing.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/13/65/prepub


GP training in Australia can be professionally isolating, with trainees spread across large geographic areas, leading to problems with rural workforce retention. Virtual communities of practice (VCoPs) may provide a way of improving knowledge sharing and thus reducing professional isolation.The goal of our study was to review the usefulness of a 7-step framework for implementing a VCoP for general practitioner (GP) training and then evaluated the usefulness of the resulting VCoP in facilitating knowledge sharing and reducing professional isolation.The case was set in an Australian general practice training region involving 55 first-term trainees (GPT1s), from January to July 2012. ConnectGPR was a secure, online community site that included standard community options such as discussion forums, blogs, newsletter broadcasts, webchats, and photo sharing. A mixed-methods case study methodology was used. Results are presented and interpreted for each step of the VCoP 7-step framework and then in terms of the outcomes of knowledge sharing and overcoming isolation.Step 1, Facilitation: Regular, personal facilitation by a group of GP trainers with a co-ordinating facilitator was an important factor in the success of ConnectGPR. Step 2, Champion and Support: Leadership and stakeholder engagement were vital. Further benefits are possible if the site is recognized as contributing to training time. Step 3, Clear Goals: Clear goals of facilitating knowledge sharing and improving connectedness helped to keep the site discussions focused. Step 4, A Broad Church: The ConnectGPR community was too narrow, focusing only on first-term trainees (GPT1s). Ideally there should be more involvement of senior trainees, trainers, and specialists. Step 5, A Supportive Environment: Facilitators maintained community standards and encouraged participation. Step 6, Measurement Benchmarking and Feedback: Site activity was primarily driven by centrally generated newsletter feedback. Viewing comments by other participants helped users benchmark their own knowledge, particularly around applying guidelines. Step 7, Technology and Community: All the community tools were useful, but chat was limited and users suggested webinars in future. A larger user base and more training may also be helpful. Time is a common barrier. Trust can be built online, which may have benefit for trainees that cannot attend face-to-face workshops. Knowledge sharing and isolation outcomes: 28/34 (82%) of the eligible GPT1s enrolled on ConnectGPR. Trainees shared knowledge through online chat, forums, and shared photos. In terms of knowledge needs, GPT1s rated their need for cardiovascular knowledge more highly than supervisors. Isolation was a common theme among interview respondents, and ConnectGPR users felt more supported in their general practice .The 7-step framework for implementation of an online community was useful. Overcoming isolation and improving connectedness through an online knowledge sharing community shows promise in GP training. Time and technology are barriers that may be overcome by training, technology, and valuable content. In a VCoP, trust can be built online. This has implications for course delivery, particularly in regional areas. VCoPs may also have a specific role assisting overseas trained doctors to interpret their medical knowledge in a new context. General practice, or family physician, training in Australia can be isolating . TraineeThe changes in training from hospital to general practice can contribute to the development of three types of isolation  that in Communities of Practice theory is an appropriate model for explaining medical knowledge sharing and for overcoming one type of isolation, that is, professional isolation. Communities of practice (COP) have been described as “groups of people who share a concern or a passion for something they do and learning how to do it better as they interact regularly” . The thrStudies have shown that GP trainees have the interest, ability, and necessary online access to trial a VCoP designed to enhance GP training, while acknowledging potential barriers of time, privacy, and technology ,13. A frA mixed-methods case study methodology was used to describe and examine the implementation and impact of the online community, Coastcitycountry Online Network for an Educational Community of Training for GP Registrars (ConnectGPR). Results are presented and interpreted for each step of the VCoP 7-step framework. The description of the implementation in the Methods section is brief as implementation is addressed in each of the 7 steps within the Results section. When using a case study format, only a selection of the overall results can be presented from the array of available data. For completeness, a full description of the methods for survey and interview data collection follows, then a discussion of the case itself.Strongly Disagree (1) to Strongly Agree (7). Knowledge questions were based on stems “GPT1s need help KNOWING…” or “GPT1s need help IMPLEMENTING…” finishing with a range of topics such as asthma. These topics were drawn from the GPT1 first 6 months support guide, GP-Start. Preference questions included “I would prefer the network to be led by…”.Surveys were developed to collect data from general practice trainees, term 1 (GPT1s), and supervisors before and after the intervention. Respondents were categorized into three subgroups: (1) supervisors, (2) GPT1s who did not participate in the online trial (the non-implementation group), and (3) GPT1s who participated in the trial (the implementation group). Instrument development was informed by both the literature review and previous stages of the project. Included in the questions was the UCLA  Loneliness Scale . Six items were taken from the measure by Russell, Peplau, and Ferguson (1978). The remaining seven were modified to include questions on isolation within Coast City Country GP Training and within the GP practice where respondents were based. Responses were measured on a 7-point Likert scale ranging from The surveys were formatted to use online with SurveyMonkey . An emaiData were checked for missing values or data entry errors. Participants with missing demographic data were excluded from the study. Participants who did not complete the majority of the survey were excluded from the survey. The data were analyzed using SPSS version 17. Frequencies and descriptive analysis were used to produce summary statistics on the data as shown in the results section.t tests were used to compare means of scale data such as need for knowledge support compared with implementation support within a group, and independent sample t tests were used to compare means of scale data between groups such as knowledge support in GPT1s compared with supervisors. All statistical comparisons were two-tailed and statistical significance was set at P<.05.Paired-samples At the end of the intervention, the 28 GPT1 members of the online community were stratified into non-users (5), passive users who log in but do not post (6), intermittent users (10), and regularly active users (7). A random selection from each group was invited for semistructured telephone interviews. There were 11 interviews, comprising active users (5), intermittent (3), non-user (1), medical educator (1), and topic expert (1). There were 3 male and 8 female participants. The average length of interview was 35 minutes.The semistructured interviews were designed to explore the themes of the Health Framework for Implementation of Virtual Communities of Practice , along wThe case was set in Coast City Country General Practice Training (CCCGPT), from January to July 2012. CCCGPT is a regional GP training provider in southern NSW, Australia, covering a region of 160,000 square kilometres. It includes rural and regional areas, incorporating the urban centres of Wollongong and Canberra see .During the case study period, CCCGPT had 135 trainees in its program, with 55 in their first term, or GPT1, divided among three regional local training groups (LTGs). Previous studies in CCCGPT identified that, while there was general support for an online network for GP training, the highest interest came from the most junior training stage (GPT1). This GPT1 group is also the most vulnerable group, as they leave the support of a large hospital and are thrust into more independent practice in the community setting for the first time. The 34 GPT1s in two of the three LTGs were invited to participate in the Coast City Country Online Network of an Educational Community of Training for GP registrars (trainees)—ConnectGPR. These two LTGs were chosen for practical reasons as two of the authors  were GP trainers in these regions and had good relationships with the training provider, trainees, and online communities. The 21 GPT1s in the third LTG were included as a passive group to provide further survey data and provided some between-group comparisons in the “post” survey. Due to low numbers in the LTGs, this comparison was within the context of a case study, rather than as a case-control study.ConnectGPR was a secure, online community site, using Ning online social software. Ning was chosen for several reasons. In a previous survey of this study group (unpublished data), respondents had ranked the most important features as the ability to document share and use forums, within a private network. Ning was able to supply forums and document sharing within a private network and was therefore chosen as a technology that was simple to set up and administer. The Davis Technology Acceptance Model  also desConfiguration and technical support was provided by the University of Wollongong educational technology team. ConnectGPR included standard community options such as discussion forums, blogs, newsletter broadcasts, webchats, and photo sharing. The process of running the site included, ideally, posting a case on the forum on a Sunday night, adding some resources or photos to the site, running a webchat mid-week, and answering questions on the forum during the week. One of the authors (SB) maintained the role of central facilitator, co-ordinating the roster, sending out the weekly newsletter, and acting as support for other facilitators. This role required an average of 3 hours per week.Access was via password, and users were identified by their full name. Data included website usage using Google analytics, Ning reporting, and manual counts of total posts and manual review of website posts by the authors .Consent was obtained in keeping with the ethics approval granted by the University of Wollongong human research ethics committee.Over the 26 weeks from January to July 2012, 82% (28/34) of GPT1s enrolled in the VCoP. The case study results are presented in two sections. The first section describes the implementation of a VCoP for GP training, while the second section discusses its usefulness for GP training. In addition, the response rates of the surveys with their differing question types are presented in “Facilitators promote engagement and maintain community standards” . In OctoThe literature indicated that facilitation needs to be ongoing and ideally done by a group that understands the participants . As GP tThe use of active, clinically relevant facilitators was key to the success of the site as indicated by both pre- and post-intervention feedback. In the pre-intervention survey, all GPT1s agreed that it was important that the network had formal facilitation .The majority of post-intervention interviewees acknowledged the value of facilitation. There were a number of comments on facilitators being helpful and supportive, particularly by being personal in their responses and being organized and useful:I was really impressed…(the facilitators were) highlighting new points and always replying to questions that were asked, or acknowledging when people put new stuff up and that sort of thing. And then saying—replying but not just replying, personally replying but actually being really useful with professional guidelines and that sort of thing to guide you in the right direction.GPT11Another participant indicated that it was good to have a facilitator who was senior, so that there was feedback to prevent “chaos in the system…There should be an authority otherwise there is unlimited fighting” [GPT1]. Regular, personal facilitation by a group of GP trainers, with a lead facilitator to co-ordinate the other facilitators, was an important factor in the success of ConnectGPR.“The network needs to have an initial stakeholder champion, with stakeholder support” . The devThe importance of CCCGPT’s involvement was also supported by GPT1s. In the pre-intervention survey, on a 5-point Likert item, GPT1s agreed that it was important that the network was formally sponsored by CCCGPT .In the interviews, one GPT1 commented that having CCCGPT engaged was important, as without its endorsement, GPT1s may not give projects serious consideration. In fact, this GPT1 was supportive of further integration, an opinion supported by the facilitator group at the end of the study. While receiving formal support from CCCGPT, the program was not a required component of the training program. Thus, it was seen as a good, but an optional educational activity. Further benefit may have been obtained if ConnectGPR had been officially recognized as contributing to training time. Leadership and stakeholder engagement were vital in this project.“Clear objectives provide members with responsibilities and motivate them to contribute more actively” . In the At the GPT1 orientation workshop, facilitators gave a short presentation on ConnectGPR, in which the goals of the site were outlined. The case study authors (SB and TC) summarized the focus of the site for trainees, which was to improve connectedness, overcome isolation, and provide support by improving knowledge sharing.During the first 6 months of GP training in CCCGPT, GTP1s worked through a curriculum of 15 topics. These include practical topics such as billing, administration, and consultation management, along with clinical topics such as cardiovascular medicine. These topics formed the basis of the knowledge sharing topics. A roster of topics was developed, running through the 15 topics over 26 weeks, divided between the 5 facilitators.The ConnectGPR project established clear goals around knowledge sharing and improving connectedness. These goals were reflective of the goals expressed by GPT1s. A clear focus on these goals and on the curriculum made planning the roster simpler and helped to keep the site discussions focused.“Consider involving different, overlapping but not competing, professional groups, different organizations and external experts. However make sure the church is not too broad...” . The ConDuring the post-intervention interviews, GPT1s commented on potential benefits and areas of concern in having a broader community. For example, one GPT1 said that a broad community, including more urban-based subspecialties, would be useful when working in a rural area, particularly in guiding appropriate referrals and pre-referral “workups”: “down here in [rural town] it is mostly general surgery so anything more complicated, it’s a bit hard to decide what to do and where to send” [GPT19]. Two other GPT1s were keen to have speciality colleagues online, but one had some concerns about allied health, citing lack of relevance, and “because of the breadth of information—it could get a bit out of control and overwhelm everything” [GPT11].A “broad church” of users is desirable for an online GP training community. In the ConnectGPR study, the community was too narrow, focusing only on GPT1s. Involvement of more senior trainees, trainers, and specialists would have been good, but not so broad as to be overwhelming. Some GPT1s said that including allied health might make the site too broad.“Health VCOPs should promote a supportive and positive culture that is both safe for members, and encouraging of participation” . The facIn the post-intervention survey, GPT1s in the intervention group responded that facilitators were helpful in maintaining community standards  and in encouraging participation . Facilitators were also seen as being an important factor in encouraging ongoing use of the site  but were less important than the value of the content . The majority of GPT1s  also agreed that the culture of ConnectGPR was supportive.ConnectGPR provided a supportive environment, with facilitators maintaining community standards and encouraging participation. GPT1s were also supportive of each other, maintaining a respectful tone throughout the study. While this encouraged participation, the value of the content was the primary motivator.“Health VCoPs should consider measurement as a factor in their design, including benchmarking and feedback” . RegularThree GPT1s on the ConnectGPR forum posted that getting feedback through knowledge sharing with their colleagues and educators was important; in essence, the feedback effectively benchmarked their approach with that of their colleagues. One interviewee said: “It allows us to know what other trainees are doing, so that we learn from each other and from our educators” [GP9].In the post-intervention survey, the majority of users  stated that the network had helped them to benchmark their knowledge against their peers. In the interviews, one overseas-trained GPT1 described how valuable feedback can be in guiding learning, particularly in the absence of a specific guideline for a local situation. In such situations, sharing knowledge and receiving feedback can assist the learner to determine whether they are on the right track. “It looks like you are sitting in an isolated place…Once you can share your knowledge then you can understand why you are in the right track because ConnectGPR, this thing we use to discuss cases and topics all the time” [GPT1].Another user noted that participating in a forum, or even reading other people’s forum discussions, can be like speaking with a senior doctor and could help when it is hard to attend a face-to-face workshop. “If you can participate in the forum, it’s almost like you are talking to a senior. And if you can’t do that, still you can see the archive readings…it can be a good way of communicating, other than physically attending a workshop” [GPT8].Finally, one expert facilitator commented that it would be good to have more feedback on the material they had supplied for the site to make sure that the materials provided were adequate.ConnectGPR activity was primarily driven by a centrally generated newsletter that summarized activity on the site, with links to resources and feedback on usage of parts of the site. Viewing comments by other participants was a way for users to benchmark their own knowledge, particularly around applying that knowledge in a clinical situation.“Online CoPs should ensure ease of use and access, along with asynchronous communication. Other options including chat and meetings can also be considered, along with the need for training. Communities are more likely to share knowledge when there is a mixture of online and face-to-face meetings, members self-select, and both passive and active users are encouraged” .While all GPT1s were offered enrolment, enrolment was voluntary, thereby allowing self-selection. The initial launch and some follow-up occurred face-to face, but the remainder of the interactions were online.In the pre-intervention survey, there was no significant difference in GPT1s’ mean responses in terms of preferring to build trust online or through face-to-face interactions (sig=0.46). However, in the post-intervention survey, participants on ConnectGPR indicated they primarily built their trust through online interactions see .In terms of the Web tools that were offered, GPT1s found document sharing  and discussions  the most useful; however, the majority of participants found all items useful.Finally, GPT1s mostly felt that adequate training was provided  and that the site was easy to use .In the interviews, GPT1s rated forums, resource sharing, and photos of skin lesions the most useful. One GPT1 believed that GPT1s needed more training on skin lesions thus the photo section helped provide insights, while another found the forum format helpful “because you’re getting first-hand information from the very experienced medical supervisor, medical educators” [GPT8].While a small group used the webchats regularly, “I attend every week” (GPT1), most users commented that the webchat had barriers related to data entry and typing speed. However, participants found that email links in newsletter reminders were a useful reminder and easy to use: “it comes to my personal email and it’s easy to click” [GPT18].GPT1s interacted differently during the course of the study. Some used the live webchat or posted on the forum, while others found benefit from passive interaction as well, even if they did not have time to take part in the interaction. One GPT1 commented that she did not always have time during the day, but “but when I would go back and read all the things that had been discussed, it was very helpful” [GPT19]. This flexible approach with a range of options was important in engaging a range of users. The majority of GPT1s also placed a high value on the day release workshops, reinforcing that while online tools are useful, they work with, rather than replace, face-to-face opportunities.A number of barriers mentioned by interviewees included comments about technology, most often about the webchat facility, which was seen as slow and reliant on fast typing. Participants indicated that additional training may have helped some of the presenters who were unfamiliar with the technology and of what was expected of them.However, the barrier mentioned by almost all participants was time. This included allocating time, as well as finding a time slot that suited everyone, as it competed with personal time, “I’ve got to use that hour for myself” [GPT3] and patient contact time, “If you make it the evening, by 6 o’clock we have to go to the hospital and see the patient” [GPT18].Several GPT1s and a medical educator commented that more users would make the community more useful. This included the comment that with few active participants, there is less activity:I think there we’re only a fixed number of people, active participants (on ConnectGPR). I don’t know if it’s again lack of time or lack of interest. With the nature of the programs it’s very useful, but unless someone shows an interest and participates then that person can’t get a real taste of it because to start with there are less participants there.GPT8One educator also questioned the value of expending educator effort on a webchat if only a small number of GPT1s participated. One suggestion for improving the uptake was by having webinars to overcome the webchat barriers:I think it would need to grow numbers-wise and I think the format needs to change…a webinar would be ideal because you’ve got the option to speak as well as type and then you’ve got the option for some visual capacity there as wellGP EducatorGPT1s found a range of social media tools on the site useful but suggested that webinars rather than chat would be desirable in future studies. Time is a common barrier to usage, but a larger user base and more training may help uptake. Finally, while theoretically trust is built better with a mixture of online and face-to-face meetings, trust can be built primarily online, which may have benefit for GPT1s that cannot attend face-to-face workshops.ConnectGPR was set up using the 7-step framework for VCoPs. The previous section described the usefulness of the framework in implementing a VCoP. The following section discusses the usefulness of the VCoP for GP training. It focuses on ConnectGPR’s two goals of knowledge sharing and overcoming professional isolation.ConnectGPR had 28 enrolments . During the 26-week study period, knowledge was shared via webchats, forums, photo postings, videos, and shared resources. The site averaged 38 unique visitors each week. Visitors were measured by a login from a unique computer or device IDs rather than by a unique user login, so actual users per week was likely lower. There was an average of 4.4 page views per visit and a total of 4377 page views. Page views were recorded as a single view of that page by a user, but a single user could generate multiple views by revisiting the page.Discussions took place around the clinical and practical topics in the GPT1 curriculum, including discussions related to interpretation of guidelines and the cultural context of medical care. This review of the cultural context of medical care occurred particularly with overseas-trained doctors during the webchats, giving these trainees the opportunity to discuss how their medical knowledge can be applied in the Australian setting.There were 18 webchats over the 26-week intervention see . Full teA number of GPT1s benefited from discussions via webchat. In the webchat logs, one GPT1 started the diabetes lifestyle modification discussion with: “This is my daily nightmare” but finished with “I will try this” [GPT10]. Another GPT1 noted the usefulness of webchats, despite the challenge of finding time, by saying, “Time is a question , but what better option have we than this (the webchats)?” [GPT1].Photos of skin conditions were a popular trigger for using the site, gaining high views and multiple comments. The most popular item was a photo of erythema multiforme, with 68 views and 2 comments. Another topic with significant interactivity was a pediatrician hosting “Ask an Expert” with 67 views and 12 comments.One of the forum topics on the site asked for feedback on the value of the site itself and whether it should continue. The posts were all positive, with the most comprehensive one providing good insight into the value of an online community in improving knowledge sharing, overcoming isolation, and providing support:I think it should continue. It allows us to know what other trainees are doing, so that we learn from each other and from our educators. It makes me feel connected to my peers, not isolated in one practice. The links are very useful. It makes me feel supported if I have any questions or difficult cases, I know I will always get a reply from someone.GPT9In the post-implementation survey, intervention GPT1s responded that they interacted with ConnectGPR, including reading the newsletter, most commonly once or twice a week, followed by twice a month, and less than monthly see . Site usIn the post-implementation interviews, most participants commented on the benefits of knowledge sharing using ConnectGPR. These included comments on the benefit of sharing knowledge and getting feedback from colleagues, supervisors, and experts. One GPT1 commented that if they had any difficult cases, “We usually put [it] in (ConnectGPR) and then usually the educators give us the feedback answer” [GPT8]. Another noted that feedback was important as “When you get the feedback, you’ll improve your knowledge and skill so in that sense I found ConnectGPR one of the interesting websites” [GPT1].One interviewee did not use the site but instead described a functioning community of practice, with a range of learners providing views on a topic, within his own practice “[There is a] range of people in the practice so I do get different viewpoints about issues” [GPT3]. Another GPT1 also had excellent in-practice support but acknowledged the benefits of other avenues of support, including other GPT1s and “also through the website (ConnectGPR)” [GPT11].t35.4=2.054, sig 0.047, mean difference 0.523, CI 0.0064-1.04). Of the five highest ranked topics for both groups, four contained significant “practice” as opposed to pure “knowledge” components, namely work injury consultations, administration, consultation management, and fitness to drive.To investigate which topics were perceived to be most important and whether “knowing” and “implementing” were perceived as different, supervisors and GPT1s were asked in the pre-implementation survey about their perceptions of how much GPT1s needed help knowing, or implementing, the 15 GP-Start medical topics . There wThere was also no significant difference between the mean score for all “knowledge” questions pre- and post implementation for registrars.GPT1s found ConnectGPR useful for knowledge sharing, but there was no measurable difference on total knowledge scores. Photos, forums, and webchats all provided benefit and the knowledge that someone would respond to a query was important. Support around practical rather than pure medical topics was identified as a learning need for trainees.To assess the need for support, GPT1s were asked about isolation pre-implementation and post-implementation. On the modified UCLA Loneliness scale , there wIn the post-implementation interviews, a number of GPT1s mentioned isolation, though not all experienced it. Structural, social, and professional isolation were all mentioned during the interviews. Structural isolation was noted: “being a GP is a lot more isolating I guess than working in the hospital system and that was something I really realized” [GPT11]. Structural isolation is due to the nature of general practice, for example, “The fact that you’re not on a team” [GPT11]. In general practice, practitioners often work asynchronously, with a single patient in front of them and when they exit their room they often find that their colleague’s door is closed. One GPT1 commented on this as a trigger for loneliness: “When you start in general practice you’re quite isolated, even from the people in your own practice because you can get quite busy and you can get almost, sometimes I almost feel like you feel lonely because you’ve got to see the next patient and the next patient” [GPT3].Social isolation can be described as a kind of loneliness  and in tProfessional isolation is also associated with a lack of professional networking and knowledge sharing opportunities. Although it is more commonly associated with rural terms, it can be found in any practice in which the interaction with colleagues is limited. One doctor was more isolated in her second term, which was urban, than her country term. “If I started my training in this particular practice I would probably hate the GP role. Because today it’s only me in the whole building” [GPT9].In terms of protective factors for isolation, several GPT1s noted that while GP training is isolating at times, the online network provided support. One GPT1 found the weekly chat particularly supportive and felt that it helped him overcome any isolation. “I found this ConnectGPR every Wednesday (and) GP training professionally is a bit challenging because you are totally isolated. If you have this facility like weekly chat or weekly seminar, communication, so you can overcome that isolation” [GPT1].Several GPT1s commented on the benefits of sharing knowledge in overcoming isolation and building connectedness. One GPT1 described seeing a photo that another GPT1 had posted, seeing the same thing and using the lessons learned online to assist in a consultation, which in turn reduced isolation. “They would post some pictures and you might see something similar 2 days later and you say, ‘OK we talked, other people suggested we do this about those things, maybe I should do those things’. In that way it was good to connect and you don’t feel as isolated in your rooms” [GPT19]. Another GPT1 noted that in such a big training region, it is harder to physically meet on a regular basis, but the Internet can facilitate regular communication. “(Regarding ConnectGPR)…physically we are quite isolated from each other because CCCGPT covers such a big area so we can’t really see each other every day, but I think we can communicate still if we want on the Internet” [GPT12].Trainees commonly described aspects of isolation during their training. ConnectGPR helped trainees feel more connected by using technology to overcome some of the barriers to knowledge sharing.Overall, ConnectGPR was judged to be useful by those who tried it. We also found that the 7-step framework for implementation of an online community  was apprThe isolation experienced by a number of intervention GPT1s supports previous findings about structural, social, and geographic isolation. The isolation may be transitory or mild in some cases, but in other cases it can affect decisions about rural versus urban work [There are several limitations to this study. Concerning the technology choice and educational outcomes, Ning was a simple and easy-to-use online community platform; however, this simplicity had a number of limitations in terms of evaluating the learning impact. These included limited reporting, no built-in educational tools such as pre- and post-assessment, and limited learner engagement tools such as page prediction. Further intervention studies could engage more rigorous learning evaluation tools into their communities. In addition, while some knowledge sharing took place, actual changes in competency were not assessed. Larger experimental trials are needed to demonstrate this. Another limitation is that, as noted, active users were over-represented in the interview section, which could over-represent positive responses. Although one passive user was interviewed, there was no response to requests for interviews from other passive users. In addition, while some outcome data were collected, such as isolation and knowledge scores pre- and post-implementation, none of the changes were significant. This may be due to survey design limitations or small numbers, or problems with the implementation itself. Larger experimental trials are needed. Other limitations that may affect the external validity are that this is a single case study of an implementation or a VCoP in regional Australia and that two of the authors were facilitators of the study.Overcoming isolation and improving connectedness through an online knowledge sharing community shows promise in GP training ,13. InteThe second barrier to usage was time. This is in keeping with the feedback from exploratory studies on intention to use ,13 and iAnother positive feature of the online community was the trust that was built among participants. Previous studies and the responses of the control GPT1 group supported the concept that trust can be built through a mixture of face-to-face and online training ,15. In tKnowledge sharing is also most effective where there is a knowledge gradient among a range of users. This case study noted that the user base could be broader, including more trainees, supervisors, specialists, and even allied health professionals, along with a larger number of participants overall. Two further aspects of knowledge sharing were noted in this case study, which together have implications for training delivery. First, there was a mismatch between GPT1 and trainer perceptions of knowledge topics, for example, cardiovascular medicine, in which supervisors underrated the support that GPT1s felt they needed. However, there was agreement between the groups that more “practice-based” topics, such as administration and work-injury management, needed more attention during the training program. Second, while medical knowledge sharing was the goal of the site, at least one overseas trained doctor commented on the value of the cultural interpretation that came through during discussions. Taken together, these results show a need for greater alignment of expectation and curriculum between GPT1s and supervisors. These findings also support the notion of “masters and apprentices” sharing the practice of medicine, which is the premise of a CoP, whereby apprentices are helped to understand the finer details inherent in the administrative side of medicine in a busy clinical practice. Last, these VCoPs may have specific advantages for assisting overseas-trained doctors as they interpret their medical knowledge in an Australian context.


Since miRNAs of plant origin can survive digestion and cooking and enter in animal (including human) sera and tissues, their intervention in mammalian gene expression and regulation might be expected. Mouse experimental feeding, in fact, showed that a miRNA class (MIR168a) is involved in accumulation of the low-density lipoprotein (LDL), the major cholesterol-carrying lipoprotein of human plasma. Considering LDL’s role in atherosclerosis, a negative influence of miRNAs from food origin on our health may be expected. Here we concentrate on the miRNAs’ capability to cross inter-kingdom boundaries through the diet and acting as a “boundary crawler.” The boundary between plant and human is presented under a new perspective, where a new intimate relationship between two genomes – mammalian and plant – belonging to quite different kingdoms is proposed. The food’s role as molecule carrier in our health is also discussed. miRNAs, finally, are presented as an example of “bio-objects” with impact on both medical and cultural issues. In this essay in a series of articles from “Bio-Objects” research network supported by the Cooperation in Science and Technology (COST) program , we presmiRNAs have been recently detected in eukaryotic cells. They raised the attention of the scientific community and media, following the discovery that miRNAs of plant origin, introduced with the diet, have been found in the sera and tissues of various animals, including humans. Experiments of mouse feeding and an in vitro test that mimics the gastrointestinal tract environment proved that the food-derived plant miRNAs can pass through gastrointestinal tract and enter the circulation and organs. Moreover, food-derived mature plant miRNAs proved to be resistant to cooking and digestion and quite stable in the mammalian serum, blood, and tissues .In this text, the meaning of this discovery will be discussed in the framework of the concept of “bio-object” character and the feature of “boundary crawlers.”Caenorhabditis elegans, many short RNAs were thereafter isolated and nowadays thousands have been identified by random cloning and computational prediction  . They arThe capability of plant miRNAs to regulate mammalian genes, thus to cross inter-kingdom boundaries, allows to give to these nucleic acids the attribution of “boundary crawlers.” The term “boundary” has normative and non-normative senses. In its non-normative sense the term just refers to something that separates two entities from each other. However, in many contexts, boundary is also something that should not be crossed or crossing of which is somehow extraordinary.According to our understanding, in academic discussions it is sensible to distinguish between these two senses of the term, and in the context of miRNAs merely to use it in its non-normative sense. The boundary crossings of miRNAs may seem extraordinary for us, but it is not because they are unacceptable or highly uncommon, but because we have just until recently lacked knowledge of them.miRNAs question the reality of species barrier and existence of species and kingdom boundaries as natural kinds. The concept of natural kinds can be better expressed with the words by Bird and Tobin : “To sayPlant miRNA may enter into our body by food intake, may resist digestion, and may regulate genes. As a result, just through a “natural action” like eating , a piece of genetic information from plant origin is delivered into the animal/human organism and is able to regulate our gene expression with the final result to influence our health. Accordingly, we may see the boundary/relationship between plant and human/animal from a new perspective, by perceiving a new intimate relationship between two genomes – mammalian and plant – belonging to quite different kingdoms. It has been already accepted, in fact, that diet may change our health, but it has never been shown in a “direct route.”Another nucleic acid group, the xeno-nucleic acids (XNA) are the polymers constructed in laboratory and not found in nature. They are able to store and process genetic information like their “natural” DNA and RNA counterparts . We beliThis is also the case for artificial miRNAs (amiRNAs), which are designed to target one or several genes of interest and provide a new and highly specific approach for effective gene silencing in plants. The miRNAs are a sort of peculiar bio-objects which could be considered as “natural,” as they were discovered in living organisms, but also “artificial” since they have a synthetic counterpart (amiRNA). Thus, miRNAs seem to be natural when they come from food, but non-natural when they are managed via artificial vectors. Additionally, when constructed miRNA (amiRNA) shares all of the properties with another miRNA that has come into being through natural processes, should we not consider the first one as “natural” with respect to its properties and “non-natural” with respect to its origin?If one accepts the view that naturalness is not merely a question of origin, but may also refer to properties and relations , amiRNAsIf further research confirms a role of different quali-quantitative content of miRNAs in the various foodstuffs in our “health-and/or-disease-status,” a new rationale for recognizing the relevance of the diet in our lives will be provided. This fact should enrich these molecules with one of the most relevant features we recognize to bio-objects, ie, the bio-social implication.Besides availability and control of food resources, in fact, quality and style of diet are relevant topics in our sated society. Incorrect diet habits and food disorders are recognized as notable social problems. Accordingly, nutrition research shifted from epidemiology and physiology to molecular biology and genetics as exemplified by the recent progress of nutrigenomics . This laOn the other hand, the notion that to be fit and healthy we need to eat “good” food is a very ancient argument of physicians of both Occidental and Far Eastern medical cultures. Among them, worth remembering are the dictum, “Our food should be our medicine” by Hippokrates of Kos four centuries BCE and the relevance of diet in the classical texts of Chinese traditional medicine starting with Huang Di Nei Jing, two centuries BCE. Cultural, ethical, social, subjective, and psychic implications have also been recognized to food by Herodotus, five centuries BCE, who in The Histories characterized peoples through their food behavior, and by other luminaries, among them Ludwig Andreas Feuerbach (1850) with his famous expression, “der Mensch ist was er isst” (in English “Man is what he eats”). Food that one eats is today often an integral part of one’s identity and lifestyle. Religions and cultures set certain limits to diets of their members, but people also build their identity on lifestyle choices regarding food. One may consider himself as a vegan, member of the slow food movement etc. As already pointed out , food chIn conclusion, being a bio-object on the borders between natural/non-natural and plant/animal, crossing different domains, and carrying bio-social implications, miRNAs can be considered as another example of the impact of life science innovation with potential in both medical and cultural issues.


Human memory is limited in the number of items held in one's mind—a limit known as “Miller's magic number”. We study the emergence of such limits as a result of the statistics of large bitvectors used to represent items in memory, given two postulates: i) the Sparse Distributed Memory; and ii) chunking through averaging. Potential implications for theoretical neuroscience are discussed. Human short-term memory is severely limited. While the existence of such limits is undisputed, there is ample debate concerning their nature. Miller Miller's ‘magic number seven’ has been subject of much debate over the decades. Some cognitive scientists have modeled such limits by simply using (computer-science) “pointers”, or “slots”  a range of plausible numbers for the dimensions of the memory, ii) a minimization of a current controversy between different ‘magic number’ estimates, and iii) potential empirical tests of the chunking through averaging assumption. We should start with a brief description of our postulates: i) the SDM, and ii) chunking through averaging.address decoders. Consider the space The Sparse Distributed Memory (SDM), developed in hard locations (see below), in Kanerva's model, hold random bitstrings with equal probability of 0's and 1's—Kanerva orthogonality of random concepts, and ii) close paths between random concepts.SDM uses Hamming distance as a metric between any two Orthogonality of random concepts: the vast majority of concepts is orthogonal to all others. Consider a non-scientific survey during a cognitive science seminar, where students asked to mention ideas unrelated to the course brought up terms like birthdays, boots, dinosaurs, fever, executive order, x-rays, and so on. Not only are the items unrelated to cognitive science, the topic of the seminar, but they are also unrelated to each other.Close paths between concepts: The organization of concepts seems to present a ‘small world’ topology–for an empirical approach on words, for instance, see dinosaurs the boot”; “she ran a fever on her birthday”; “isn't it time for the Supreme Court to x-ray that executive order?” …and so forth). Robert French presents an intriguing example in which one suddenly creates a representation linking the otherwise unrelated concepts of “coffee cups” and “old elephants” Of course, for large access sphere containing around 1000 hard locations. In other words, from any point of the space, approximately 1000 hard locations lie within a 451-bit distance. All of these accessible hard locations will be used in storing and retrieving items from memory. We therefore define the function In this model, every single item is stored in several hard locations, and can, likewise, be retrieved in distributed fashion. Storage occurs by distributing the item in every hard location within a certain threshold ‘radius’ given by the Hamming distance between the item's address and the associated hard locations. Different threshold values for different numbers of dimensions are used . For A brief example of a storage and retrieval procedure in SDM is in order: to store an item Retrieval of data in SDM is also massively collective and distributed: to peek the contents of each hard location, one computes its related bit vector from its adders, assigning the All hard locations within an access radius collectively point to an address. Note also that this process is iterative. The address obtained may not have information stored on it, but it provides a new access radius to (possibly) converge to the desired original address. One particularly impressive characteristic of the model is its ability to simulate the “tip-of-tongue” phenomenon, in which one is certain about some features of the desired memory item, yet has difficulty in retrieving it (sometimes being unable to do so). If the requested address is far enough from the original item (209 bits if chunking through averaging.The model is robust against errors for at least two reasons: i) the contribution of any one hard location, in isolation, is negligible, and ii) the system can readily deal with incomplete information and still converge to a previously registered memory item. The model's sparse nature dictates that any point of the space may be used as a storage address, whether or not it corresponds to a hard location. By using about one million hard locations, the memory's distributed nature can “virtualize” the large address space. The distributed aspect of the model allows such a virtualization. Kanerva To chunk items, the majority rule is applied to each bit: given We have chosen the term ‘chunking’ to describe an averaging operation, and ‘chunk’ to describe the resulting bitstring, because, through this operation, the original components generate a new one to be written to memory. The reader should note, in SDM's family of high-dimensional vector models, called Vector Symbolic Architectures (VSA), the operation that generates composite structures is commonly known as superposition Obviously, this new chunked bitstring may be closer, in terms of Hamming distance, to the original elements, than the mean distance Let minority votes is one, and that it may occur with either 3 votes cast or two votes and a coin flip. If there are two minority votes, they may stem from either 5 votes or 4 votes and a coin flip, and so forth. We thus have that, for Note that the minimum possible number of in isolation, i.e., per dimension on the chunking process. We want to compute the number of dimensions to  store and retrieve around While we can now, given Given a number of dimensions A threshold As Given bitstrings with dimension We thus have a number of plausible thresholds and dimensions. We can now proceed to compute the plausibility range: Despite the implicit suggestion in Consider the case of information overload, when one is presented with a large set of items. Suppose one were faced with dozens, or hundreds, of distinct items. It is not psychologically plausible that a large number of elements should be retrievable. For an item below the mean. There is such a minute part of the space below With an intermediary success factor Consider the assumption of chunking through averaging. We propose that it is plausible and worthy of further investigation, for three reasons.First, it minimizes the current controversy between Miller's estimations and Cowan's. The disparity between Miller's A mainstream interpretation of the above phenomenon may be that, as with any model, SDM is a simplification; an idealized approximation of a presumed reality. Thus, one may see it as insufficiently complete to accurately replicate the details of true biological function due to, among other phenomena, inherent noise and spiking neural activity. In this case, one would interpret it as a weakness, or an inaccuracy inherent to the model. An alternative view, however improbable, may be that the model is accurate in this particular aspect, in which case, the assumption minimizes the current controversy between Miller's estimations and Cowan's.The success factors computed above show that for either 4 or 5 items, we have orthogonality between random concepts and of close paths between concepts  items, or more generally that (Numerous cognitive scientists model the limits of human short-term memory through explicit “pointers” or “slots”. In this paper we have considered the consequences of a short-term memory limit given the mechanisms of i) Kanerva's Sparse Distributed Memory, and ii) chunking through averaging. Given an appropriate choice for the number of dimensions of the binary space, we are able to model chunks that limit active memory's storage capacity, while allowing the theoretically endless recursive association of pre-registered memory items at different levels of abstraction . A 1200×1200 dots-per-inch printer holds less than Sparse Distributed Memory holds a number of biologically and psychologically plausible characteristics. It is associative, allowing for accurate retrieval given vague or incomplete information (which is relevant given the potential for asynchronous behavior


These data sets have been used to investigate different aspects of plant biology, especially at the level of transcriptome, from tissue-specific expression patterns to patterns in as little as a few cells. Such publicly available data are a boon to researchers for hypothesis generation by providing a guide for experimental work such as phenotyping or genetic analysis. More advanced computational methods can leverage these data via gene coexpression analysis, the results of which can be visualized and refined using network analysis. Other kinds of networks of, e.g., protein–protein interactions, can also be used to inform biology. These networks can be visualized and analyzed with additional information on gene expression levels, subcellular localization, etc., or with other emerging kinds information. Finally, cross-level correlation is an area that will become increasingly important. Visualizing these cross-level correlations will require new data visualization tools.New,  These methods have been used to investigate different aspects of plant biology, especially at the level of transcriptome, from tissue-specific expression patterns at the centimeter scale to those in as little as a few cells. While such publicly available data can be used on their own by researchers to generate hypothesis, one of the most powerful methods for hypothesis generation to date is gene coexpression analysis. Here, the correlation in expression pattern between pairs of genes is measured, and those exhibiting strong correlations are “joined” in a graphical representation to create a network, which can be visualized with graph network viewers. Other kinds of networks of, e.g., protein–protein interactions, a kind of biological, in vivo correlation, can also be used to inform biology. These networks can be visualized and analyzed with additional information on gene expression levels, subcellular localization, etc., or with other kinds of information just becoming available, such as patterns of positive selection along a gene, genes with similar patterns of expression in equivalent tissues in other species, etc. Finally, cross-level correlation is an area that will become more important as genome wide association studies (GWAS) could be used to link genotype to environmental factors or perturbations through changes in the transcriptome, epigenome, or other ‘omes of a plant. Visualizing these cross-level correlations will require new data visualization tools, the most promising of which will allow the plant at all levels to be an “app” on a smart phone, laptop computer, or scientific conference video wall. Such efforts will serve to make the proposed open access/open source Arabidopsis Information Portal, in which zoomable user interfaces and powerful data analysis and visualization algorithms will be an important part, an immediate resource not only for Arabidopsis researchers, but for all plant biologists worldwide.The past decade of plant research has seen an unprecedented increase in the amount of data being generated from various levels of an organism. Advances in genome sequencing, gene expression profiling, determining all-by-all interactomes, and other areas, have allowed new, Arabidopsis thaliana and other plants have been generated in the past decade, and these can be examined to provide further understanding about one’s gene(s) or biological system of interest. One can use such data to ask questions such as: within my gene’s family, are family members uniquely expressed in specific organs/tissues or is one uniquely induced in expression by a specific stress? Such data can be explored with several easy-to-use web-based tools, such as Expression Browser 2 = 0.04, or only 4% of variance in common. This fact also often explains why a PCC value of 0.75 is commonly used as a cutoff, because then the r2 value would be 0.56, meaning that genes exhibiting such a score would have 56% of their variance in common. This seems biologically “meaningful” in the sense that this variance might be directed by cis-regulatory elements in common in the promoters of coexpressed genes. In terms of visualizing expression patterns, often it is instructive to examine heatmap outputs for all of the highly correlated genes for a given query gene, or for those matching a desired gene expression pattern, as shown in Figure 1. When the values for coexpression are significant between several of the genes in the single gene query example just mentioned, it is also useful to depict these as a graph network as shown in Figure 1.Four components are necessary for conducting a gene coexpression analysis. These are: (1) a collection of gene expression profiles across as many genes as possible from different samples and/or different perturbations; (2) a method for computing expression pattern similarity; (3) a way for assessing the degree of significance of expression pattern similarity; and (4) a tool to visualize and analyze statistically significant coexpression patterns. A recent review by Figure 1 can be generated using the ATTEDII coexpression tool (The network depicted in ion tool . Nodes tArabidopsis are CressExpress (Other useful tools for generating and visualizing gene coexpression networks in sExpress , PlaNet sExpress , and CSBsExpress . With easExpress  and AraNsExpress  permit csExpress .Table 1.Once a coexpression network has been generated, for example, using the ATTEDII database or by a custom “all-by-all” analysis, as was the case for SeedNet, it is often useful to import the network into a powerful network analysis tool, Cytoscape . This isArabidopsis thaliana, many groups have used biochemical or yeast-based methods, such as the yeast two hybrid system (in vitro or in vivo, doesn’t mean that they necessarily interact in vivo in every tissue of the plant or under every perturbation. Other factors, such as expression levels, protein degradation, and subcellular localization, are important for an interaction to occur. For instance, if two proteins can physically interact based on yeast two hybrid data, but one of these proteins is not expressed in a given tissue or organ in planta, then that interaction cannot occur in that tissue or organ. Likewise, proteins that are not localized in the same subcellular compartment would seem to have a lower likelihood of being able to interact in planta, although it is clear that proteins, especially signaling proteins, can move between compartments.Elucidating protein–protein interaction networks has proven to be useful for the identification of novel members of a biological process. In the case of d system , to deted system . An impoArabidopsis subcellular database (Figure 2. The network shows some proteins involved in vesicle trafficking, based both on literature-documented and predicted protein–protein interactions (In order to address the above caveat, it is possible to overlay subcellular localization data or gene expression data onto protein–protein interaction networks. Such data are available in the former case from SUBA, the database , and in database , the BARdatabase , Genevesdatabase  and otheractions .Figure 2, only certain members of the “supernetwork” of all possible protein–protein interactions are expressed in either seedlings or guard cells. While further experiments are necessary to show whether the nodes with higher expression levels, shown in red or orange in the figure, are actually key to vesicle trafficking in these tissues, such information can clearly be useful in terms of ordering T-DNA knockout lines of specific genes (As shown in ic genes  and idenArabidopsis thaliana. Recent work by Arabidopsis, soybean, Medicago truncatula, poplar, barley, maize, and rice – to identify equivalent tissues between these species. Based on these tissue equivalencies, the authors then computed the expression pattern similarity scores for a set of homologs from one species to a homolog from another species. The homolog exhibiting the best expression pattern similarity score is termed the “expressolog”. The authors showed that the number of instances in which the expressologs are not the best sequence similarity matches ranges from a low of 15.4% between poplar and M. truncatula, to a high of 50.7% between barley and soybean. The expression pattern and sequence similarity scores may be viewed with the Expressolog Tree Viewer tool available at http://bar.utoronto.ca. Given the complexity of plant genomes in terms of whole genome and segmental duplication events (Arabidopsis as compared to rice.The above two sections have highlighted two ways in which correlation networks can be used to guide biology in one very well studied species, n events , it is pArabidopsis is being generated by the 1001 Arabidopsis Genomes effort (It is becoming easier to produce transcriptome data for specific cell types, following the protocol initially developed in Philip Benfey’s lab . A high s effort . Correlas effort  will eass effort , will alThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A large body of literature studies on the relationship between health care expenditure (HCE) and GDP have been analyzed using data intensively from developed countries, but little is known for other regions. This paper considers a semiparametric panel data analysis for the study of the relationship between per capita HCE and per capita GDP for 42 African countries over the period 1995–2009. We found that infant mortality rate per 1,000 live births has a negative effect on per capita HCE, while the proportion of the population aged 65 is statistically insignificant in African countries. Furthermore, we found that the income elasticity is not constant but varies with income level, and health care is a necessity rather than a luxury for African countries. It is important for policymakers to know the relationship between health care expenditure and income, knowing this relationship helps them to make wise judgments, plan health reforms, and allocate resources efficiently.It is generally believed that there is a strong and positive relationship between health care expenditure and income, which is well established in the literature. However, there is no consensus on whether the income elasticity of health expenditure is greater or less than 1, Baltagi and Moscone  provide There is already a substantial literature on studying the link between HCE and GDP, but almost without exception, these studies have been limited to OECD countries or developed countries, and we will review this literature in the following section. As it can be seen, most of previous studies have been performed at OECD countries. Very little literature has been done for African countries, this maybe because of data availability. To the best of our knowledge, Gbesemete and Gerdtham  and JaunCompared with previous studies, this study contributes to the literature in the following aspects. First, as we all know, most of early studies use parametric techniques that assume a functional form, like a linear one. In fact, this may be unavoidable to obtain the estimator inconsistent, if their true relationship is nonlinear –7. ThereThe remainder of this paper is organized as follows. The next section reviews the literature. In this section, we review the existing papers and their main result about the income elasticity of health care expenditure. Since the seminal paper by Newhouse , who obsEarly studies on this topic usually used a single cross-section data, Parkin et al.  found thThe data structure is a balanced panel of 42 African countries during the period from 1995 to 2009. Some countries are excluded from this study, because it is not possible to obtain detailed corresponding statistics. Our data are gathered from the World Bank's World Development indicators 2012. The World Bank classified countries into four categories  by GNI. In this paper, we put the low-middle income and upper-middle income as middle income group. So, these 42 African countries include 22 lower income countries and 20 middle income countries. The dependent variable used in this paper is total health care expenditure per capita measured in US dollars in real prices, adjusted for purchasing power parities (PPP). To fully examine the relationship between health care expenditure and income, we include income and two nonincome variables as explanatory variables. The income is replaced by per capita GDP, The two nonincome variables are defined as follows: infant mortality rate per 1,000 live births and the percentage of population age 65 and above (POP65). All these variables are expressed in logarithm. it is logarithm of HCE per capita of country i at year t, lngdpit is logarithm of GDP per capita of country i at year t, and μi is the country fixed effects. Moreover, additional explanatory variables, like the percentage of population age 65 and above (POP65), infant mortality rate per 1,000 live births (IMR), denoted by a d × 1 vector of zit, can be added to yieldTo study the link between per capita HCE and per capita GDP, the conventional approaches assume that their relationship is linear, and the most commonly used parametric specification is the following one:m(·) is an unknown smooth function, and εit is assumed to be i.i.d. with a zero mean, finite variance. Like the parametric cases, we include some other variables in the nonparametric panel data model:Just as Yatchew  argues, yit = lnhceit and xit = lngdpit, then we can specify a partially linear panel data model as follows:it enters the unknown function m(·) and the other variables are specified parametrically. Our model permits the inclusion of other explanatory variables without suffering the curse of dimensionality. To remove the fixed effects, motivated by the first differencing method for linear panel data models, one can consider the following first-order difference model:m(xit) − m] by the following series differences:pk(x) are the first k terms of a sequence of functions (p1(x), p2,…). Then, (m′(·), where m′(·) stands for the derivative of the function m(·), we adopt the conventional local linear approach. m′(·) can be estimated by solving the following optimization problem:kh(·) is invariable kernel function satisfying the usual regularity conditions, h is the bandwidths (or smoothing parameters), and  = (m(·), m′(·)). For simplicity, we set xit − v)T] and e = T, then the local linear estimator of m′(·) is given byThe above model may consider the relationship between HCE and GDP more accurate, however, as is known to all, high dimensional nonparametric model suffers from the dimensionality curse. To remedy this shortcoming, one resolution is to follow Baltagi and Li . Let yie model:yit−yi,t−e model:yit−yi,t−residual . 9)u^itu^ityit h.As we all know, compared to the selection of the bandwidths, the choice of the kernel is less important for the properties of the resulting estimator. So, in this paper, we use standard univariate Gaussian kernel, and we use the least squares cross-validation method to select the bandwidths P = 0.0000) supports the fixed effect model against the random effect model. Columns 1-2 of In this section, we firstly present the results from the parametric panel data mode (2). Hausman test  and column 3) of  of 3 illIn this paper, we examined the relationship between per capita health care expenditure and per capita GDP in 42 African countries during the period 1995–2009. Our paper has several advantages. First, in research methods, we applied a semiparametric partially linear model. On the one hand, this method requires no or very limited assumptions to be made about the format of the data, and it is also very useful for dealing with unexpected, outlying observations that might be problematic with a parametric approach. On the other hand, fully nonparametric methods may be unreliable due to the so-called “curse-of-dimensionality”. Therefore, a semiparametric partially linear panel data model is more preferable.Next, we take into account the relationship between income growth and health spending growth for countries at different levels of development. Our findings indicate that IMR has a negative effect on health expenditures. However, we found that the percentage of older people has no positive effect on health expenditures in African countries.Finally, our results suggest that the elasticity of income for health spending is varied by the level of per GDP, and health care is necessary good for African countries.Based on our results, some practical suggestions are put forward to provide reference for policymakers. First, since IMR also play a key role as well as income to determine the level of HCE in African countries, an appropriate, robust, and sustainable model for improvement in health system performance is essential in order to reverse the declining trends in health and development status and break the vicious cycle of higher IMR and lower HCE in Africa. Second, our results suggest that POP65 is insignificant in African countries. Therefore, a fair health care system should be taken into account to improve life expectancy. Finally, as the income elasticity is a measure of the degree of responsiveness of health spending to changes in a country's income, our findings indicate that the income elasticity of health expending is less than one, so it is necessary for policymakers to take every aspect into consideration not only to manage the limited health funds in an effective way, but also to focus on increasing income.


Wide availability of highly palatable foods is often blamed for the rising incidence of obesity. As palatability is largely determined by the sensory properties of food, this study investigated how sensitivity to these properties affects how much we eat. Forty females were classified as either high or low in sensory sensitivity based on their scores on a self-report measure of sensory processing (the Adult Sensory Profile), and their intake of chocolate during the experiment was measured. Food intake was significantly higher for high-sensitivity compared to low-sensitivity individuals. Furthermore, individual scores of sensory sensitivity were positively correlated with self-reported emotional eating. These data could indicate that individuals who are more sensitive to the sensory properties of food have a heightened perception of palatability, which, in turn, leads to a greater food intake. The rising incidence of obesity can be attributed, in part, to the wide range of palatable foods that is available to us on a daily basis “neurons trigger more readily” to sensory input , and all were psychology students participating for course credits. The participants’ body mass index (BMI) ranged from 16.3 to 33.2 . The study was approved by the Ethics Committee of the University of Birmingham, and conformed to the principles set out in the Declaration of Helsinki.Forty female students from the University of Birmingham responded to an online advert for a ‘Mood, personality, and lifestyle’ experiment. Participants were aged between 18 and 25 years  on the table, telling participants to help themselves, and that they were an incentive to encourage participation. Minstrels are small milk chocolates encased in a crispy chocolate shell. Chocolate is a widely-liked food e.g., , and theA univariate analysis of variance (ANOVA) was used to compare the food intake of individuals with high and low sensory sensitivity, and correlational analyses were conducted to look for associations between food intake, sensory sensitivity, emotional eating, dietary restraint, and BMI. Further ANOVAs were performed to compare food intake between individuals classified as ‘emotional’ and ‘non-emotional’ eaters, and between ‘restrained’ and ‘non-restrained’ participants. Tests of normality were performed, and Spearman’s correlation coefficient was used to assess relationships involving non-normal data. All tests were carried out using SPSS Version 17.0 , and, for all analyses, statistical significance was determined with alpha set to.05.F = 5.73, p = .022; see M = 35.0 g, SD = 21.9 g) than low-sensitivity participants . In addition, a significant bivariate correlation was found between sensory sensitivity and emotional eating . No differences in food intake were found between emotional and non-emotional eaters  = 2.52, p = .120), or between restrained and non-restrained participants  = .264, p = .610), and no other significant correlations were found.The ANOVA revealed a main effect of sensory sensitivity on food intake  to deal with them. Indeed, sensory processing style has been shown to influence how individuals experience and cope with anxiety There are, however, some potential limitations to this study. The first is that the participants may not have been equally hungry at the time of the experiment. As the participants were not instructed to arrive in a hungry or satiated state, and testing times were at various times throughout the day, hunger may have influenced participants’ intake of chocolate. This is not perceived as a threat to the current findings, but is something that should be addressed in replications of this study. A further improvement to the methodology would be to take an explicit measure of liking for chocolate. Although our study advertisement indicated that participation would involve eating chocolate, so it was assumed that all of the participants did like chocolate, it may have been useful to include liking of chocolate as a covariate in our analyses. A final consideration is that, due to the original aim to manipulate stress, participants were not all doing exactly the same task. Again, this is not considered a threat to the reported findings, because the numbers of ‘low-’ and ‘high-’ sensitivity participants in each of the ‘stress’ and ‘non-stress’ groups were not significantly different; however this difference should be taken into account when considering the reported effects.The results of this study strongly suggest that food intake is influenced by sensory sensitivity; the reasons for this, however, can only speculated from the current data. In the context of previous research, it is suggested that the rewarding effect of eating palatable foods is intensified in individuals who are sensory sensitive, due to a heightened sensitivity to the sensory properties of food, which influence palatability.


Using X-ray crystallography to visualize the three-dimensional structure of an enzyme associated with regulating levels of estrogen, a team of National Institutes of Health scientists have discovered new information on how flame retardants may alter estrogen metabolism.Flame retardants are added to foam, textiles, electronics, building materials, and other items to reduce flammability.,Flame retardants come in two types: reactive agents, which are chemically bound to base materials during manufacturing, and additive agents, which are incorporated into products but not chemically bound, allowing them to escape into the surrounding environment.The new research shows how both TBBPA and 3-OH-BDE-47 can bind to an enzyme known as estrogen sulfotransferase (SULT1E1). This enzyme’s job is to bind the major endogenous estrogen 17β-estradiol and add a sulfate molecule to it; the sulfated estradiol is more readily eliminated from the body. “Basically, the flame retardants are going to compete with estradiol for binding to the sulfotransferase,” says coauthor Linda Birnbaum, director of the National Institute of Environmental Health Sciences (NIEHS). The result may be to raise levels of estradiol in the body, explains corresponding author, Lars Pedersen of the NIEHS Laboratory of Structural Biology.Endocrine disruption can take several forms—transport disruption, receptor binding, and metabolism are all processes that will affect the endocrine system, Pedersen says. This research demonstrates a potential metabolic impact on the endocrine system and shows that xenobiotic compounds don’t have to bind to the hormone receptor in order to perturb the system, Birnbaum points out.Pedersen adds that these structures only show how these chemicals inhibit the enzyme in the lab. “We need to figure out if this is what is going on in the body,” he says.Given the structural differences between 17β-estradiol and the flame retardants, Pedersen says he was surprised the exogenous molecules were able to bind SULT1E1. Craig Butt, a postdoctoral environmental chemist at Duke University’s Nicholas School of the Environment, observes, “It shows that there is a little bit of flexibility in terms of what molecules can fit into the enzyme, which explains why these foreign chemicals can inhibit the action of the enzyme.”The new research raises concerns because hormones are designed to regulate key mechanisms in our bodies, and they do this at very low levels in our bloodstream and tissues, says Heather Stapleton, an associate professor of environmental chemistry at Duke and Butt’s advisor. “Having continuous exposure to man-made chemicals that can bind with the same affinity as endogenous hormones may have very significant consequences on development and overall health,” Stapleton says.Birnbaum agrees: “We know that hormones are important in many, many aspects of our lives. … One of the important things is, it’s not a single hormone that may be critical. Often it’s the balance of multiple hormones. We all have our own balance. It’s possible you can throw one person out of balance by perturbing one system while in another person you would not.”