Narrative Reflective Practice (NRP) is a process that helps medical students become better listeners and physicians. We hypothesized that NRP would enhance students’ performance on multiple-choice question exams (MCQs), on objective structured clinical examinations (OSCEs), and on subjective clinical evaluations (SCEs).The MCQs, OSCEs and SCEs test scores from 139 third year University of Alberta medical students from the same class doing their Internal Medicine rotation were collected over a 12 month period. All preceptors followed the same one-hour clinical teaching format, except for the single preceptor who incorporated 2 weeks of NRP in the usual clinical teaching of 16 students. The testing was done at the end of each 8-week rotation, and all students within each cohort received the same MCQs, OSCE and SCEsIndependent t-tests were used to assess group differences in the mean MCQ, OSCE and SCE scores. The group receiving NRP training scored 4.7% higher on the MCQ component than those who did not. The mean differences for OSCE and SCE scores were non-significant.Two weeks NRP exposure produced an absolute increase in students’ MCQ score. Longer periods of NRP exposure may also increase the OSCE and SCE scores. This promising pilot project needs to be confirmed using several trained preceptors and trainees at different levels of their clinical experience. Professionals with years of experience know more than do novices to the profession, but what they know is not just in textbooks or journals. Experience generates knowledge that is narrative, tacit, expressed in practice, and formed in storied contexts. The nature of this knowledge is that it is difficult to teach in traditional pedagogical settings. However, reflection on practice, through the telling of stories of experience, enables professionals to construct storied accounts of their tacit knowledge. In this way, professional practice emerges as a reflective practice. The idea of reflective knowing-in-action that emerges from reflection on practice owes a great deal to the ideas of Dewey and his concept of experience and knowledge grounded in experience.5These theoretical underpinnings have resulted in a pedagogical approach called Narrative Reflective Practice (NRP). The central purpose of NRP in medicine is to improve the clinical skills of physicians and physicians in training, particularly their skills in communicating with, and listening to patients. NRP in medicine is focused on: physicians listening to and reflecting upon, patients’ stories; listening to physicians’ stories which include their medical agendas; hearing physicians’ stories of experience in order to hone those experiences, and, thereby, develop their personal professional knowledge and clinical expertise.Other medical educators approached reflection indirectly. Henderson and Johnson describe a course for medical students designed to encourage the development of professional identity, both within a workshop experience and later in a course evaluation and email communication with group facilitators.Other interventions draw on more narrative notions of reflective practice. Instead of expecting learners to volunteer their experiences at the outset, they suggest that reflecting on the expression of others’ experiences in the humanities can trigger reflection. Charon encourages the use of literature as a way to encourage reflection.11There is general acceptance that medical trainees learn from preparing the history and physical (H & P) report on recently admitted patients who will be under their care. However, it is not clear if the enrichment of the process through formative feedback provides superior outcomes in terms of professional knowledge. It was decided to use a narrative reflective practice pedagogical strategy to ascertain if there was improvement in clinical skills and knowledge. A description of the strategy is provided below.Student Interns  working in teams in Internal Medicine at the University of Alberta (U of A) rotate for eight weeks through one of four hospitals: the University of Alberta Hospital (UAH), the Royal Alexandra Hospital (RAH), the Grey Nuns Hospital (GNH), and the Misericordia Hospital (MIS). The training at these four Edmonton hospitals is on clinical teaching units (CTUs), in which there is a staff physician, one senior and several junior residents, as well as several third-year medical students.There is no information available as to whether the objective outcome of the training such as multiple-choice questions is influenced by NRP. There are a number of outcomes that could be assessed. However, in order for administrators, clinician teachers and student trainees to accept the potential benefit of narrative reflective medicine, the evaluations needed to be in a form that is already in place or considered to be suitable and measurable within the context of the historical approaches to medical examination. We proposed firstly to use the anonymous results of the trainees’ OSCE , and the multiple-choice questions (MCQs) taken at the end of their internal medicine rotation to compare the group which did, and the groups which did not, have NRP during their Internal Medicine rotation on the CTUs at UAH, RAH, GNH and MIS. Finally, the standard evaluation and feedback forms prepared regularly by the CTU preceptors on each medical student during their rotation were used to compare the preceptors’ clinical performance.The purpose of this study was to use the standard assessment tools for clinical training of third year medical students to determine the effect of narrative medicine on the trainee’s performance. The Null Hypothesis of this study was: “there is no effect of Narrative and Reflective Practice on medical student test scores on the end of rotation multiple-choice questions (MCQs), Observed Standardized Clinical Examinations (OSCEs), and the student rotation evaluations”.In the third year of their medical education curriculum, all University of Alberta (U of A) medical students requested which clinical teaching unit (CTU) of the four teaching hospitals they wished to be assigned; whenever possible these requests were honoured. With their preceptor, students interact with patients, learn to take a medical history, examine the patient, record the interaction, and present their findings orally and in writing. Under the direct supervision of a resident and the staff preceptor, the student assists in the care of 2–5 patients on the CTU.At the UAH, the one NRP preceptor, over a time span of two weeks, met with 6–10 medical students for one hour each morning for 8 mornings. For the remaining 6 weeks of their CTU exposure at the UAH, students met with other preceptors. There was one preceptor for 6–10 students. This represents the standard teaching model, without the intervention of NRP. At the end of the students’ clinical experience, the “Narrative Reflective Practice” preceptor asked the students to write a brief account of their reflection on a patient’s experience of disease and illness, and how this experience affected the student. The task was for the students to hear the patient’s story. This usually included more details about the way in which the illness affected the lives of their patients, the beliefs of the patients about the cause and nature of the disease, their lives outside the domain of their medical history, their families, or their social history. The student then wrote a narrative account of his/her experience of how they were affected by the patient. The students volunteered to read their narratives aloud to the group. They were encouraged to explore themes such as their own response to these stories, the ways to deal with these feelings, the effect of these factors on the patient’s choice of, or response to, treatment. The student group members discussed each shared experience, and reflected upon similar experiences to which they had been exposed, and their own thoughts and feelings.The study ran over 54 consecutive weeks. Each rotation was eight weeks in duration. The lead author at one institution (UAH) provided the Narrative and Reflective Practice (NRP). Some students rotating at UAH did not have the author as a preceptor and did not have NRP.The student’s confidential “PIN” was used to ensure that the students who had been part of this procedure did not have their identity released to the academic authorities. To ensure this, the administrator of the Division of Studies in Medical Education was responsible for coding the students’ identity, and providing the test results. At the end of each CTU rotation, each of the students’ preceptors provided a Subjective Clinical Evaluation (SCE) using a common evaluation form. The SCEs have not been validated. Students also took the same multiple-choice question (MCQ) examination, as well as the same Observed Standardized Clinical Examination (OSCE).Descriptive statistics were calculated for the entire cohort as well as for each group individually. Differences across the three groups of students were tested for significance using a one-way analysis of variance (ANOVA). Differences between the intervention and the remaining cohort were tested using an independent t-test. All computations were done using SPSS and EXCEL.The student’s SCE mark was not included in the analysis because there were numerous different preceptors at the four teaching hospitals, each group of students had different combinations of preceptors, and this method of evaluation had not been validated.The MCQs covered a wide range of areas related to the diagnosis and treatment of disorders in, for example, the heart, lung and kidneys. These MCQs were drawn from a department bank that reflected the type of questions used in a final national examination. The OSCEs were also drawn from departmental/national questions.The process of the OSCEs is uniform throughout Canada: the trainee is tested on 8 to 12 “stations”, each of which represents the testing of a clinical skill. For example, “examine the patient for liver disease.” This request is posted on the door of clinic examining room. The student reads the request; when a bell rings, she/he knocks on the door, enters the room, and introduces themselves to the patient or patient-actor. The student washes their hands, briefly explains what they plan to do, and then proceeds to perform inspection, palpation, percussion and auscultation of the appropriate body component relevant to the question/request.During this process, an examiner sits quietly in the room, carefully watching the process, notes the student’s performance, and marks off predefined components of the clinical examination on a checklist. In this way, all students have the same question, same “patient”, same examiner, and same marking outline.The MCQ and the OSCE tests were validated, and were identical for each eight-week group of students. These questions were drawn from the department’s bank of validated questions. The group means and standard deviations for the MCQ and OSCE measures are shown in The analysis compared the mean MCQ and OSCE scores among three groups of students: the NRP Intervention group, U of A - non-intervention groups, and students from the remaining three sites as a whole, who also represented a non-intervention group. A one-way ANOVA  revealedA correlation coefficient of 0.26 existed between the students’ OSCE and MCQ scores. This correlation is considered to be small (in terms of strength) but it suggests that the measures were assessing different knowledge/skill sets.The study was designed to use a new pedagogical strategy (NRP) to better help medical trainees learn from preparing the history and physical (H & P) report on recently admitted patients who will be under their supervised care. Our purpose was to learn if such an approach would provide superior outcomes in terms of professional knowledge or skills.We suggest that NRP is a way to develop the clinical skills of caring, compassion, and listening. The SCE did not assess these considerations. We did not assess patient satisfaction in this study. We wished to determine if NRP improves student performance scores on the two objective evaluation tools currently in use in the Faculty of Medicine, MCQs and OSCEs. NRP was found to improve the MCQ by 4.9%. We propose that the magnitude of this objective improvement is sufficient evidence to justify a larger study involving the training of teaching staff at each of the four teaching hospitals, and the provision of resources to introduce NRP into all clinical training experiences.The time commitment for NRP training is approximately four hours, and a group of 12 preceptors can be instructed by a single trainer. For the preceptors who take the faculty development workshop, there will likely be an improvement in their own clinical skills as well as skill in using a new pedagogical approach. For the students, they gain increased skills in talking and listening to patients, in understanding the relationship of disease to other aspects of patient’s lives, and a way of adapting to the stress and personal emotional distress associated with patient care and becoming a physician.We acknowledge that there are limitations to this study. This was a pilot project. Encouraged by the meaningful increase in the scores of students exposed to NRP (4.9%), we would wish to undertake a larger study using several preceptors trained in NRP. A longer duration of NRP training might demonstrate improvement in the student score in another objective measure, the OSCE. A follow-up of the NRP-exposed students from their third to fourth year would be useful to establish the durability of the NRP effect, and the undertaking of a multicentre study would help to establish the generalizability of the NRP improvement. Finally, in a future study we would wish to undertake a patient-focused inquiry into their satisfaction with the care provided by students with NRP versus without NRP.We do not foresee any adverse effects of the introduction of NRP. The results from third year students on CTUs may also be generalizable to other forms and levels of medical student teaching. For example, for the last three years, the NRP preceptor involved in this pilot study used NRP with second year medical students’ clinical skills teaching. The students receiving NRP for 15 hours did very much better on their OSCE examination, and on their final history and physical assignment.


One of the main features, in the follow-up of a patient with a chronic disorder is severity. Definition in severity is quite difficult since the disease manifests with various clinical and laboratory features. On the other hand, there have been many articles reported in literature about the lack of consistency between currently used severity scores such as Mor, Pras and Tel Hashomer criteria.The aim of this study was to develop and validate a new set of criteria for the assessment of disease severity for FMF patients by a multicenter study.After three rounds of Delphi survey, an elite expert panel that consisted of ten rheumatologists and one facilitator gathered in a consensus meeting in November 2012. The candidate criteria which were defined after Delphi rounds were discussed in the consensus meeting, potential criteria set were purified and the description of each item was ascertained. In order to evaluate the validity of criteria set, each expert brought together the data of clinical, laboratory manifestations and physician's global assessments of 10-50 patients from their center. Logistic regression analysis was used to evaluate predictable value of each item and ROC curve analysis was performed to demonstrate the success of the criteria set.In expert panel nine items were selected as the identifiers of severity. Area under the curve (AUC) was calculated as 0,825 for this criteria set. When each item was evaluated individually, renal failure, nephrotic proteinuria and mean duration of episodes had the least contribution to prediction of severity. Besides, in logistic regression analysis these criteria were eliminated from the terminal modal. After reducing the criteria set, AUC was calculated as 0,808. Additional analysis demonstrated that the reduced model was as successful as full model. AUC was higher than 0,75 in both pediatric and adult patient groups and the results were better in adult group.Initial validation analysis showed that the scale could be used in assessing severity in FMF patients. The validation of the criteria should be performed on FMF patients attending outpatient clinics in routine visits.None declared.


Neuromarketing is a multidisciplinary field of research whose aim is to investigate the consumers' reaction to advertisements from a neuroscientific perspective. In particular, the neuroscience field is thought to be able to reveal information about consumer preferences which are unobtainable through conventional methods, including submitting questionnaires to large samples of consumers or performing psychological personal or group interviews. In this scenario, we performed an experiment in order to investigate cognitive and emotional changes of cerebral activity evaluated by neurophysiologic indices during the observation of TV commercials. In particular, we recorded the electroencephalographic (EEG), galvanic skin response (GSR), and heart rate (HR) in a group of 28 healthy subjects during the observation of a series of TV advertisements that have been grouped by commercial categories. Comparisons of cerebral indices have been performed to highlight gender differences between commercial categories and scenes of interest of two specific commercials. Findings show how EEG methodologies, along with the measurements of autonomic variables, could be used to obtain hidden information to marketers not obtainable otherwise. Most importantly, it was suggested how these tools could help to analyse the perception of TV advertisements and differentiate their production according to the consumer's gender. In the last two decades, different techniques and devices have been developed to inspect thoughts and feelings by measuring the neuroelectric brain activity through advanced high-resolution EEG methodologies –8. SinceNowadays, researchers are attempting to investigate the signs of the brain activity correlated with an increase of attention, memory, and emotional engagement during the observation of commercial advertisements , 25. In The way in which such amount of information from neuroscience could be useful to marketing studies is suggested by the well-known fact that at least the 70% of the new products launched worldwide , tested by traditional techniques with questionnaires or psychological interviews, fail within the first six months. This happens simply because people do not say (or are not able to say) the truth when interviewed, as respect to product experience or TV commercials. Thus, the application of neuroscience-based methodologies really allows the researchers to gain information related to the unconscious and spontaneous reaction of the consumers in front of the product stimuli not available otherwise.In this scientific framework, the object of our study was to measure and analyze the brain activity and the emotional engagement that occurs during an “ecologic” observation of TV commercials by using EEG and autonomic variables such as HR e GSR. The final goal was to link variations of indicator based on these neurophysiological activities with cognitive and emotional reactions to the presented TV ads. For this purpose, different cerebral indices have been used to summarize the performed measurements at the level of subjects, later used in the statistical analysis. In particular, we performed a gender analysis to investigate and compare cerebral reactions of Men and Women during the observation of specific TV commercials falling in several categories.In fact, the experimental questions of the present study were the following: are there any particular EEG activities discriminating the levels of cognitive and emotional processing related to the observation of TV advertisements belonging to different commercial categories? Are there any particular scenes of the video clips which were differently perceived by Men and Women? Is it possible to understand which is the best perceived TV commercial between Women and Men? Such questions were answered through the application of the EEG techniques in a case study. Specifically, we recorded EEG, GSR, and HR of a group of Men and Women while watching a series of TV advertisements which have been selected for belonging to several commercial categories. Thus, we compare the percentage of spontaneous recall and appreciation of such commercial categories for Men and Women. The related neurophysiological indices measuring cognitive and emotional processing are computed and compared between the two experimental groups and within particular scenes of interest of different video clips. Finally, the comparison of two TV commercials belonging to the same category will be performed.Z-scores computed across values of the twelve TV commercials presented. Pleasantness score of each TV commercial has been standardized through Z-scores using mean and standard deviation of single subject ratings. These Z-scores related to the spontaneous recalls and pleasantness ratings will be used to select two particular TV commercials that will be presented and analyzed in the following sections.The experimental subjects enrolled in this experiment are asked to comfortably have a seat in front of a computer screen by means of which we present a documentary intermingled with several commercial breaks, the target stimuli of the experiment. During the video the electroencephalographic (EEG), electrocardiographic (ECG), and galvanic skin response (GSR) were collected from the subjects. The signals gathered during the observation of the documentary will be used to estimate the personal baseline activity for each one of the EEG, ECG, and GSR variables estimated for the analysis. During the watching of the video, subjects are not aware that an interview would be held within a couple of hours from the end of the data recording. They are simply told to pay attention to what they will watch. The video consisted in a documentary related to geography, with the aim to elicit no particular emotional engagement. After the neurophysiological recordings, an interview is performed. At this stage, the experimenter asks the subjects to recall spontaneously the commercial video clips they memorized. Then, the experimenter verbally listed the sequence of advertisements presented within the documentary asking the subjects to tell which advertisement they remember. Successively, the experimenter showed on a paper several frame sequences of each advertisement inserted in the movie. Analogously, the experimenter also showed several pictures related to an equal number of advertisements that were not inserted in the commercial break (distractors). This was done to provide the subjects with the same number of distractors when compared to the target pictures. Finally, the experimenter asked subjects to give a score ranging between 1 and 10 according to the level of appreciation they perceived during the observation of each remembered ad . Percentages of spontaneous recall have been standardized through For each subject, a two-minute EEG segment related to the observation of the documentary has been further taken into account as baseline activity. No specific question related to the documentary was asked during the interview.The whole experimental sample is formed by 28 subjects (12 Women). Written informed consent was obtained from each subject after the explanation of the study. The procedure of the experimental task consisted in observing a twenty-minute long documentary in which we inserted two commercial breaks, after five and fifteen minutes from the beginning of the movie, respectively. Each interruption was formed by six commercial video clips of 30′′ length. The TV commercials we use here for case study were unknown to the subjects and they have been showed only once during the experiment. They have been selected in order to define six commercial categories: Perfume, Consumption, Bank, Sport, Telephone, and Clothing. Randomization of the occurrence of the all commercial videos within the documentary was made to remove the sequence factor as possible confounding effect in the following analysis.The two specific advertisements that will be presented and analyzed in the following sections belong to the Perfume category and are aired by Cartier and Prada. The plots of both advertisements have two lovers dancing on a floor as main characters. To inspect the cerebral activity in particular frame segments of the two commercials, they have been properly segmented to define the following scenes: Intro, Dance, Final, Product, and Brand as it is illustrated in Figures  http://www.youtube.com/watch?v=D9yVNKEYlDUCartier:  http://www.youtube.com/watch?v=S_7fBn9enDE.Prada: The TV commercials can be observed at the following links:The cerebral activities have been computed in and compared between the defined frame segments of the two TV commercials.x, where IAF is the individual alpha frequency, in Hertz, and x is an integer displacement in the frequency domain which is employed to define the band ranges. In particular, we focused the present analysis on the following frequency bands: theta , that is, in the frequency band between IAF-6 and IAF-2 Hz, alpha .The cerebral activity was recorded by means of the Digital Brain Electric Activity Mapping KT88-2400 device . Informed consent was obtained from each subject after explanation of the study, which was approved by the local institutional ethics committee. Electrodes were arranged according to the 10–20 International System. Recordings were initially extracerebrally referred to and then converted to an average reference offline. We collected the EEG activity at a sampling rate of 256 Hz and the impedances were kept below 5 kΩ. Each EEG trace was then converted into the EEGlab format in order to perform signal preprocessing such as artefacts detection, filtering, and segmentation. The EEG signals have been band pass filtered at 2–30 Hz and depurated of ocular artefacts by using the independent component analysis (ICA). The EEG data have been rereferenced by computing the common average reference (CAR). Individual alpha frequency (IAF) has been calculated for each subject in order to define four bands of interest according to the method suggested in the literature . Such baThese EEG traces were then segmented to obtain the cerebral activity during the observation of the TV commercials and that associated with the documentary (baseline period).We recorded the electrical cardiac activity from the left wrist of all subjects in order to extract the heart rate signal. The recorded signal has been processed in order to compute the peak-to-peak distance from the R-waveform visible on the ECG signal. From this information, we calculated the heart rate tachogram (HR) by computing the reciprocal of the previously defined peak-to-peak distance with in-house MATLAB software. The HR signals of each subject have been averaged to obtain a mean waveform to be compared between experimental conditions.The galvanic skin response (GSR) has been recorded with the Neurobit Optima 4 system  with a sampling rate of 10 Hz. Skin conductance was recorded by the constant voltage method (0.5 V). Ag-AgCl electrodes were attached to the palmar side of the middle phalanges of the second and third fingers of the subject's nondominant hand by means of a velcro fastener. Before applying the sensors, subjects' skin has been cleaned by the following procedures and suggestions published in the literature –35. GSR Z-score variables. These variables have been computed for each TV spot analysed and subject recorded. Specifically, the Z-score variables have been computed for the tonic component of the GSR and for the HR signal.As explained in the previous section, besides the autonomic activity of the subjects during the observations of the video clips we used a part of the documentary to estimate the mean and standard deviation of the electrodermal activity and the cardiac frequency rate signal in order to compute their xθi represents the ith EEG channel in the theta band that has been recorded from the left frontal lobe. In addition, Q is the set of left channels and NQ represents its cardinality. In such a way, an increase of MI is related to an increase of Memorization. In the following, we will refer to the Memorization Index as Memorization.The EEG signal is filtered in the theta band and, for the subsequent computation, only the left frontal channels have been selected. From the neuroscientific point of view, there is evidence that trace for successful encoding of novel information can be detected by measuring an increase of EEG theta power from the left frontal cerebral regions , 37, 38.xαi and yαi represent the ith EEG channel in the alpha band that have been recorded from the right and left frontal lobes, respectively. In addition, P and Q are the sets of right channels and left channels and NP and NQ represent their cardinality. In such a way, an increase of AW will be related to an increase of interest and vice versa. In such a way, an increase of AW will be related to an increase of interest and vice versa. The AW signal of each subject has been Z-score transformed and then averaged to obtain an average waveform. In the following, we will refer to the Approach-Withdrawal Index as Interest.In order to define an Approach-Withdrawal Index (AW) according to the theory related to the earlier introduced EEG frontal asymmetry theory , we compThe Emotional Index is defined by taking into account the GSR and HR signals. As far as the construction of such variable is concerned, we refer to effects plane  where thZ, HRZ represent the Z-score variables of GSR and HR respectively; ϑ, in radians, is measured as arctang. Therefore, the angle β is defined in order to obtain the EI varying between . According to (Z < 0) and positive (HRZ > 0) values of the EI are related to negative and positive emotions, respectively, spanning the whole effect plane. In the following, we will refer to the Emotional Index as Emotion.In order to have a monodimensional variable, we describe the emotional state of a subject by defining the following Emotional Index (EI):EI=1−βπ,Such cerebral indices take into account that the strong involvement of frontal and prefrontal areas has been already experienced in previous studies performed with high resolution EEG, functional connectivity, and graph theory tools –47 as weZ-score values of percentage of spontaneous recalls and appreciation have been computed for each subject and TV commercial and averaged into the six categories of analysis. Z-score between Women and Men for spontaneous recall and appreciation.The recording of the neurometric response included the detection of the EEG signals and HR and GSR parameters on a sample of 28 subjects . The experimental group has been divided and analyzed by gender. Particularly, we took into account the groups of Women (21 ± 1.7 years) and Men (21.67 ± 1.61 years). The Z-score. From the bar graph, we can notice that the largest difference between the two genders is related to the observation of TV commercials belonging to the Perfume category, both for spontaneous recalls and appreciation. Particularly, the result is a higher percentage for Women for both spontaneous recalls and appreciation in this category .The picture shows the differences related to the percentages of spontaneous recall and appreciation between the groups of Women and Men. Values are represented in In the following, we will analyze the cerebral variables related to the memorization, interest, and emotion for the Perfume category and for the two commercial videos comprising it, Cartier and Prada, by performing a comparison between gender and between video clips, respectively.By analysing the cerebral indices of Memorization, Interest, and Emotion for the two commercial advertisements Cartier and Prada belonging to the Perfume category, we observed a different pattern of activation between the two experimental groups, as reported in Z-score analysis for Cartier and Prada video clips and a between spot Z-score comparison for the two genders. All the cerebral variables of Memorization, Emotion, and Interest have been taken into account.In order to deeper investigate the gender difference during the observation of commercials related to perfumes, we will show a between gender Zwomen = 1.91, Zmen = −0.06). The second TV commercial, Prada, returned higher values of Memorization and Emotion for Men, although the increment of Interest still regards Women.By analysing the variations of the cerebral indices for the two commercials separately, we can observe that the two groups react differently to the observation of the video clips. Specifically, Women present higher values for all the cerebral variables to the Cartier TV spot with respect to Men. Results are illustrated in Since the presented values relate to the observation of the whole video clips, in the following figures we present the values of the cerebral variables within several scenes of interest defined in Z-score values of Memorization for Women and Men for both Cartier and Prada TV commercials. By analysing the TV spot by Cartier we can observe that Men show a decrease of Memorization for the scenes related to the Intro and Dance . Conversely, Women present low values of Z-scores, in all scene segments of interest, closer to zero. Overall, for both Men and Women, Cartier elicited values of Memorization negative or very close to zero. Instead, Prada returned high values of Memorization for Men in the Final scene , whereas Women show a decrease of Memorization in the Intro (Zintro_women = −3.29).Z-score values of Interest for Women and Men for both Cartier and Prada TV commercials. By analysing Cartier, the value of Interest for Women across the whole commercial is positive and higher than Men. However, they present particular scenes in which Interest is negative and lower than Men, such as Product and Brand exposition . By comparing Women and Men segment values within the Cartier clip, we can observe that there are several segments in which Interest is lower for Women with respect to Men, such as Intro, Product, and Brand , whereas it is higher during Dance (Zdiff_dance = 2.52). As to Prada, Men present high values of Interest for Intro and Final , whereas Women returned Interest values close to zero. By comparing the values of the segments between the two genders we find that Interest is higher for Men in Intro and Final  whereas it is higher for Women in Brand (Zdiff_brand = 2.43).Z-score values of Emotion for Women and Men for both Cartier and Prada TV commercials. As to Cartier, Emotion value for Women is higher during Intro (Zintro_women = 2.29), whereas it does not emerge any increase or decrease of fluctuation of Emotion for Men. In addition, by comparing the values of Emotion between the two groups we find that Women present higher values of Emotion, with respect to Men, for segments of Intro and Dance . As to Prada, all values of Emotion are negative or close to zero both for Women and Men. In particular, Women show a decrease of Emotion during the Intro (Zintro_women = −2.04) whereas there is no variation among scenes for Men. However, by comparing Emotion among segments we find that Women present lower values during the Dance (Zdiff_dance = −1.96).Z-score values of Memorization, Interest, and Emotion for both Women and Men between Cartier and Prada. In particular, panel A presents differences of cerebral variables between Cartier and Prada for both Women and Men. For this graph bar it is possible to observe that Cartier elicited higher level of Emotion for Women (EmoWomen: Zcartier − Zprada = 3.39) whereas there is no deviation from zero for Men in all variables. Additional panels highlight difference in the cerebral variables in the specific scenes of the two TV commercials. As to Memorization , while the Intro returned high value for Cartier only for Women (Zintro_women = 2.491). As to Interest , whereas the same commercial returns higher value for Women during Product and Brand  and the Final scene for Men . There is no increment of Interest for Cartier with respect to Prada. As to Emotion . No deviation from zero for Men between the two commercials.In rization , Prada eInterest , we can  Emotion , CartierBehavioral data in terms of spontaneous recall and appreciation returned that the highest difference between Women and Men is related to the observation of two TV advertisements belonging to the category of Perfume. In particular, Women exhibit higher percentage of spontaneous recall and level of appreciation with respect to Men.The level of Memorization of the two TV commercials analyzed is low for both Women and Men and there is no variation between the two groups. The values of Memorization for Cartier and Prada result lower that the ones of the other commercial categories. As to Emotion, we observed that Women are more engaged during some introductive scenes of the spot by Cartier but less for Prada. In particular, the Dance scene of Cartier gives more emotion for Women while the Dance scene of Prada gives more emotion to Men. The cerebral variable related to the Interest presents a variegated pattern because there are different catching scenes both for Women and Men depending on the TV commercial. By comparing the cerebral variables between the two commercials, we observed that there are no differences of emotion between the two commercials for Men, whereas Women were more engaged during the observation of Cartier video clip. Conversely, the advertisement by Prada returned higher values of Memorization and Interest for both Women and Men.Overall, the biometric EEG, HR, and GSR recordings returned neurometric indexes linked to the variation of the Memorization, Interest, and emotional involvement of the two experimental groups. Variation of such indices along with the adopted time segments returned information about the ads perception, scene by scene, on the total sample of recorded subjects and on subsamples of such group. This information may be analyzed by providing interesting indications about the efficacy of the different frame sequences or observing original insights related to cognitive and emotional variables. Also, these tools could provide a rational schema useful to guide a reduction of the ads in time, which is often implemented in advertising campaigns after the first detailed creative production, by pointing out the most (less) performing scenes which could be preserved (cut) by a possible time-frame reduction. Such time reduction could be specifically performed and differently adapted to Men and Women .Nowadays, marketers are excited about the use of brain imaging for marketing purposes. First, they hope that neuroimaging may help to refine the possibilities of marketing research improving an efficient trade-off between costs and benefits. This hope is based on the assumptions that people cannot fully articulate their preferences when asked to express them explicitly and that consumers' brains contain hidden information about their true preferences. Such hidden information could, respecting the more recent neuroscience theory, be used to better understand their buying behaviour and meet their needs. Thus, the cost of performing neuroimaging studies would be outweighed by the benefit of improved product design and increased sales. In theory, at least, brain imaging could illuminate not only what people like, but also what they will buy. Thus far, this presented approach to neuromarketing has focused on this postdesign application, in particular on measuring the effectiveness of advertising campaigns. Particularly, we showed that there are results suggesting that it is possible to differentiate the communication according to the gender of the analyzed population. Properly designing and broadcasting two different versions of marketing communication will help to enhance the efficacy and the quality of the message. Moreover, an objective method for reducing the time length of the TV commercial will help the video makers to have a rational basis for cutting ineffective scenes and, hopefully, to create new more appealing TV commercials. Thus, while the emotional and cerebral “engaging” of the video clip is preserved, the cost of airing the video clip could be reduced saving some money by getting the same efficacy (or even more) than in the 30′′ version.Moreover, neuromarketing research can be implemented even before a product exists, because the assumption that neuroimaging data would give a more accurate indication of the underlying preferences than standard market research studies may be really useful avoiding expensive mistakes. If this is indeed the case, product concepts could be tested rapidly, and those that are not promising were eliminated early in the process. This would allow more efficient allocation of resources to develop only promising products.


In this issue of the Journal, Seedat (page 193) asks why the control of hypertension in sub-Saharan Africa is as bad as it is. Citing the importance of the disease as a cause of death and disability, he concludes that both the prevalence of hypertension and the failure to control it properly is driven by the poverty of the population of the region, the cost of pharmaceuticals, and a lack of medical resources. He finishes with a rousing call, echoing the late iconic President Mandela, to all of us to find African solutions to African problems.In an editorial comment, Campbell and Legoum (page 152) re-iterate the size of the problem of hypertension in the region, and remind us that this was not always the case. Mechanisms we do not always fully understand, but which are almost certainly driven by urbanisation and poverty, are probably driving the epidemic. Furthermore, they point out that recognition and acknowledgement of the size and importance of the problem is an important first step to finding a resolution. Crucially, they discuss that at recent meetings in Africa, local leaders and champions have emerged who can spearhead an offensive on this scourge. They also list a number of organisations committed to the project. All involved in treatment and control of hypertension in Africa need to read the contributions of Seedat and Campbell.In one of those happy moments of editorial serendipity, we are able to publish the literature review of Pinchevsky and co-authors in this same issue (page 188). These authors investigated the published results of the success of guideline directed control of a number of important risk factors (including blood pressure) in patients with diabetes. Only 35.2% (range 7.4–66.3%) of patients achieved a target blood pressure of 130/80 mmHg (or less), and targets for glycaemic and lipid control were not much better. It is interesting to note that even in well-resourced countries, achievement of targets in this vulnerable population were most unsatisfactory. Perhaps we need to re-think traditional methods of management and reflect on why we are so unsuccessful in our usual management strategies. It may be time for the world to look more closely at a polypill or alternative novel approach.Permanent pacemaker implantation (PPMI) is a very effective tool to treat bradyarrhythmias, particularly complete heart block. The sad fact is that many patients who should receive PPMI in many parts of Africa (and I assume other similarly poorly resourced countries) do not receive the life-saving benefit and dramatic symptomatic improvement that PPMI offers. Pacemaker implantation is simple, at least for the basic ventricular-paced, ventricular-inhibited (VVI) systems that most patients with complete heart block require. The technique can be learned in a few months, it requires basic surgical skills, which most doctors possess, and access to fluoroscopy.The challenge with pacemakers is the cost of the necessary hardware. A pacemaker generator, in its most basic form, costs US$2 500–3 000 and the leads cost US$800–1 000. The high cost of pacemakers results in limited access for deserving patients in under-resourced countries to these dramatic improvements in both quality of life and life expectancy. As outlined by Jama and colleagues (page 181), re-use of such devices is both feasible and clinically safe, provided the necessary skills for re-testing and sterilisation of the devices are available. Such programmes have been available and in place in parts of Africa for years but have not been subjected to the sort of post-implantation examination performed by Jama and co-authors, and they are to be congratulated for that.I have purposefully not addressed implantable cardioverter defibrillator (ICD) re-use, which they also discuss. I believe that we in Africa need to be able to address the relatively simple issue of pacing for complete heart block, ensure that it is relatively easily available to all who need it, and work towards simple pacemaker availability before worrying about more complex devices, which while undoubtedly effective, offer marginal benefit compared to the wonderful benefit of VVI pacing for symptomatic complete heart block.


Most western countries are experiencing greater pressure on community care services due to increased life expectancy and changes in policy toward prioritizing independent living. This has led to a demand for change and innovation in caring practices with an expected increased use of technology. Despite numerous attempts, it has proven surprisingly difficult to implement and adopt technological innovations. The main established technological innovation in home care services for older people is the personal emergency response system (PERS), which is widely adopted and used throughout most western countries aiming to support “aging safely in place.”This integrative review examines how research literature describes use of the PERS focusing on the users’ perspective, thus exploring how different actors experience the technology in use and how it affects the complex interactions between multiple actors in caring practices.The review presents an overview of the body of research on this well-established telecare solution, indicating what is important for different actors in regard to accepting and using this technology in community care services. An integrative review, recognized by a systematic search in major databases followed by a review process, was conducted.The search resulted in 33 included studies describing different actors’ experiences with the PERS in use. The overall focus was on the end users’ experiences and the consequences of having and using the alarm, and how the technology changes caring practices and interactions between the actors.The PERS contributes to safety and independent living for users of the alarm, but there are also unforeseen consequences and possible improvements in the device and the integrated service. This rather simple and well-established telecare technology in use interacts with the actors involved, creating changes in daily living and even affecting their identities. This review argues for an approach to telecare in which the complexity of practice is accounted for and shows how the plug-and-play expectations producers tend to generate is a simplification of the reality. This calls for a recognition that place and actors matter, as does a sensitivity to technology as an integrated part of complex caring practices. Western societies have an ageing population due to increased life expectancy and large cohorts in the postwar years, presenting growing challenges to long-term care services ,2. IndepMeeting such demands through technology innovation is one suggested solution. Technological innovations in community care services are highly regarded, even though integration and adoption has proven difficult and many projects never pass the pilot stage ,7. StudyThe PERS has proved sustainable over time. Since its launch in the late 1970s, it is widely used and spread throughout most western societies  and 74,0The PERS is a technological device and an integrated service, embodying three generations of alarm devices as a result of technical development, although some characteristics remain unchanged. The first generation alarm device had a unit placed centrally in the home, with a switch or a pull cord to use in emergency. The second generation has in addition a pendant, a necklace/wristband with a button that the user can press in case of emergency. This allows open communication between the user and a responder through the main unit, enabling the responders to effect a proper response. The range of the pendant is normally inside the home and partly outside. The third and newest generation of the PERS has the potential to incorporate a range of devices , proIt is mainly the second and third generation versions that are in use today, although implementation of additional alarms, devices, and services has proven difficult and is done on a much smaller scale than expected with a slowly growing market. Thus, the PERS might be described as a foundation for further safety and monitoring telecare.The organization of the PERS as a service varies from private arrangements, where the alarm goes to a nominated contact, to small or large public or private call centers answering and effecting proper responses ,10. The Policy makers and advocates of such alarm systems often describe telecare technologies such as the PERS as ‘‘plug-n-play’’ solutions with placement of devices at home providing help in an effective way, enhancing quality of life, and reducing costs for the care service . HoweverWhen studying practice, Nicolini  argues tThree main questions exploring how technology in use is integrated in caring practices arise from what research tells us about the users’ experiences with the PERS:1. What has research focused on when studying use of the PERS over time?2. How do actors in home care practices experience, integrate, and relate to the PERS in everyday life?3. How does this established technology in use influence and affect caring practices?An integrative review was conducted, characterized by explicit, rigorous, and transparent methodology using a systematic search, but allowing the inclusion of research with diverse methodologies and a broader range of studies . EthicalInclusion criteria:Articles dealing with older people’s attitudes, experiences, interactions, feelings, use and nonuse, consequences, and effects of use of a personal emergency response system (PERS) in home carePeer-reviewed articles from academic journals describing and focusing on different aspects of the PERS in use rather than articles with a main focus on further technology innovationArticles written in the English language, no limitation in publication period, and no methodological restrictionsA systematic search of relevant terms was conducted in relevant databases and search engines. The search strategies and results are presented in A descriptive, integrative, thematic analysis as described by Whittemore and Knafl  was usedThe next steps were exploring and displaying the extracted data around different variables and subgroups looking for patterns, themes, and relationships, and then drawing a map of the essential identified themes. This was followed by abstracting and grouping themes into categories, aiming to subsume the particulars into more general findings. To ensure quality, the included articles were checked to verify for accuracy and conformability. Uncertainties throughout the process were discussed with a group of supervisors. Methodological considerations are described in A total of 33 peer-reviewed articles were included, all published between 1987 and 2014 ,22-52. Tpersonal emergency response system (PERS) is the term most commonly used in articles from the United States, Australia, Germany, the United Kingdom, and Sweden. Other common terms mainly used in the United Kingdom, Scandinavia, and Australia are variations of personal, safety, social, and community alarms.As shown in The following section will follow Nicolini's  suggestiSumming up the demographic data from the included studies, the typical PERS end user is an old, fragile woman, living alone, over 80 years of age with physical problems and in need of assistance. The articles state that the end users find the alarm easy to use. Only 2 out of 33 studies (6%) describe demands for training and information and suggest that short learning sessions are preferable to one initial, long session ,33.Even though most studies indicate the usefulness of the alarm for fragile elderly people, the alarm does not seem suitable for everybody. Roush and Teasdale  found thThe most stated reason for getting a PERS was the possibility of getting help fast in an emergency ,35,38-40The articles found that many end users were satisfied with the PERS overall, since it enabled them to summon help if necessary, and that staff were patient despite false or repeated alarms ,38,42-44Almost all included studies discussed reasons for activation of the alarm. They demonstrated quite different results regarding the frequency of activation due to emergencies. In one study, only 2.1% of alarm activations were due to emergencies whereas in another, the figure was 67%. Falling was the most common reason for emergency calls, and many users had fallen more than once. Other medical emergencies were also common ,44,46-51Despite satisfaction with the service, the studies found challenging experiences for the alarm users as well. One study describes fear and insecurity regarding whether the PERS would function when needed, especially at nighttime . The PERNyman and Victor  found thAccording to the articles, the end users had many reasons for not wearing the pendant: “forgot to put it on,” “worry it will get damaged,” “do not think they need it at the time,” “not satisfied with the PERS,” and “uncomfortable to wear” ,30,45. PIt is clear that the alarms are also used for purposes that were not foreseen or intended ,45,53,54Several studies found that some users would not activate the PERS even in emergencies ,30,34,48Economic issues were mentioned, mainly in studies from the United States and Canada. Users often paid a fee for having the PERS. Both users and responders raised concerns about the costs and felt it to be too expensive ,33,49,50The included studies focused very little on how relatives experienced the PERS. Some studies mentioned that having the alarm gave families peace of mind and reduced their burden ,38,40,43The studies described different service organizations, from directly distributing the alarm call to a nominated contact, to larger or smaller private or public response centers. Control center operators’ tasks varied according to the service offered. Some response centers were staffed with health care workers ,47,53,55In the included studies, there was little focus on the interactions between the different actors involved in the PERS. Pekkarinen and Melkas  found inStudies described how respondents became motivated to request an alarm in different ways. Health care workers and family were the main source for suggesting a PERS. Respondents became more motivated to use a PERS if health care personnel rather than family suggested this ,45.Some articles reported that having the PERS reduced end users’ contact with family , leavingAs reflected in the name, the PERS is a technical device integrated in a service system. Many of the included articles touched on technological problems, even though this is a well-established technology. There is no connection between the technical failure reported and the age of the studies. In addition to limited and confusing alarm range, reported problems included insufficient speaker capability, battery failure, varying needs for button sensitivity, and nonreplaceable parts of the device ,52,54,55Some studies described wishes for improvement of the PERS. End users wanted longer pendant range, smaller pendants, and for the PERS to be waterproof, personalized, include global positioning system (GPS) and relevant alarms, automatic connection to the nearest health personnel, and automatic dispatching sound when in need ,42. Theytheory-method package, as described by Nicolini [The key objectives of this integrative review were to explore existing research on the PERS and to seek insight into how actors experience this technology in use in home care services, thus providing a richer and more nuanced view of how actors interact with technologies in caring practices. By following the Nicolini , the “zopersonal emergency response system indicates that the purpose is to respond to an emergency. The term safety or social alarm indicates that the alarm might include help with social issues and is there for the end user’s safety. Technologies are scripted, like a play or a film. This means that the designer and producer have context and users in mind when developing technology [The many different terms used for this technology may reflect different conceptions of the purpose of the technology. The term chnology . Oudshoochnology  argues tOudshoorn  argues tTelecare promises an opportunity to get help when needed in one’s home. Previous studies showed little reference to the shift this brings about in the redistribution of responsibility among the actors involved, with the delegation of major responsibility to care workers and the end user ,24. Use This responsibility is further extended in devices developed for the third generation of the PERS, where patients are expected to some extent to manage and monitor their own health. This is a double-edged sword: patients on the one hand gain knowledge and ownership of their own health, but often face demanding requirements to master the technology within the strict frames decided by the system and the technology. This requires that the end user develop skills in using the technology in possibly stressful situations since the caregiver is not present in the home.These changes in roles, responsibilities, and work were largely disregarded in the studies included in this review. The findings paid little attention to the changes in the role of the care personnel. However, this review reveals a diversity and complexity in health care workers’ experiences with the PERS, varying from finding that the technology enables them to give the users more privacy and freedom, to complicating the organization of the work and causing stress and failure in the caring practice.Promoters of technology innovations tend to describe resistance and nonuse of technology due to lack of technological skills and access among older people as a generational issue ,60. AkriDespite the main finding of the studies included in this review of users showing great satisfaction with the PERS, the results described how many users acquire the alarm, but hardly ever wear or activate the alarm pendant. As previously described, it seems clear that some nonuse described in the results was related to lack of ability to utilize the alarm, but that is not the whole story. Those not using the alarm often had relevant reasons for doing so. In addition to the previously mentioned reasons, many end users described how they did not feel they needed the PERS, found other solutions for being safe, did not want to bother or be bothered, or found the PERS stigmatizing. It seems that nonuse is more complex than the users’ lack of skills and access, though that is also important. This review shows that resistance and nonuse are due to factors such as the change in caring practices and the way users experience the technology as changing their lives and homes. The results also indicate how end users experience challenges related to use of the PERS, including technological failure, fear of the alarm not working, and limited alarm pendant range.Pols  affirmedTelecare implies a different kind of care with complex interactions between multiple actors and a wide variety of technology and changed roles, thus redefining how actors live, work, and even identify their lives . ResultsThis review reveals a huge diversity in the experiences and roles of the actors involved, presenting a variety of experiences, both negative and positive, from end users, care personnel, and other actors. Therefore, we cannot really talk about one type of practice related to the PERS, but rather a variety of practices as a result of the interactions between the technology and the actors involved, and how the service is organized and carried out.The history of integrating telecare in community care shows that the technology in use tends to work in unforeseen and different ways than intended . The resPols  found inThe PERS is introduced as technology that makes users safe in their homes and enables them to reach help when needed. This review shows how end users in the included studies expressed satisfaction with the technology, and experienced well-being and a sense of security. However, having the PERS did not reduce anxiety or improve their quality of life. Some of the studies included in this review found that having the PERS did reduce hospital days and medical complications due to long lies after falls. Moreover, the material described success stories involving activating the alarm. To some extent, the alarm thereby fulfilled its promise of increasing safety at home. However, what the results show is that the picture is much more complicated than the PERS simply being an easy fix for anxiety and risk experienced by frail older people living alone.This review reveals how rather simple and well-established telecare technologies such as the PERS are actually complex, integrated caring practices that interact with the different actors involved and create changes in daily living.The PERS has proven to be durable over time, while many telecare technologies tend never to leave the pilot stage. The reasons for this are complicated, but the results describe some contributing factors. Many users find the PERS to be easy to use and it makes it possible for the end users to live independently by providing help and safety when needed, giving the end users an active role in the caring practice. The PERS in many ways delivers its promises of safety and independent living.While the Results section describes how the PERS contributes to safety and independence and discusses what the PERS means for the actors involved, it also reveals unforeseen consequences of the alarm and possible improvements in both the device and the service. This review provides us with an understanding of the complexity of practice by showing how even rather simple technology interacts with actors and redefines how they live and work, and even how the technology affects their identities. The Discussion section problematizes this by “zooming out” and argues for an approach to telecare in which the complexity of practice is accounted for, where actors’ resources, attitudes, and abilities are considered when choosing technology.This paper shows how technology, involved actors, network, and context must be thought of together as part of practice. This calls for a sensitivity to what it means for involved actors when we redistribute responsibility to the end users, and change the roles and work practices of the caring personnel. Another key factor is taking into account how implementing telecare changes the idea of home and all it represents for the actors.There is a need to be sensitive to diversity in apparently homogenous groups when adopting new telecare technologies in home care practices, and to acknowledge that technology is never neutral. This review shows how understanding end users’ experiences is an important resource for understanding how technology innovations in caring practices are actants in creating new caring practices, thus acknowledging that there are many reasons for resisting and failing to use the technology.It is time to move away from thinking of telecare technologies as black boxes that can be implemented without changing the caring practice. This review shows how the plug-and-play expectations producers tend to generate is a simplification of the reality. It seems clear that “one size doesn’t fit all.” This calls for a recognition that place and actors matter, and a sensitivity for the practices in which the technology is adopted is necessary.