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This case study demonstrates how the Osborne-Parnes Creative Problem-solving Model (CPS) can be used to enhance teacher creativity through the collaborative and inviting processes found within Invitational Education, which counter the individualistic and product-oriented enterprises often associated with creative endeavors. Conclusions indicate that the model’s three stages guided, via sequenced divergent and convergent thinking strategies, teacher curricular decision-making and, ultimately, the learning opportunities provided to students. The CPS framework encouraged participants to engage in and experience optimism, trust, respect, care, and intentionality, which are the five value-based assumptions of Invitational Education.

Study Objectives To elicit the trade-offs patients are willing to make between benefits and risks of medications for chronic insomnia, with the purpose of allowing a patient-centric interpretation of clinical trial data. Methods A discrete choice experiment (DCE) was included in the two placebo-controlled phase III trials that evaluated the efficacy and safety of daridorexant. The DCE design was informed by a two-phase qualitative study, followed by qualitative and quantitative pilot testing before fielding. Relative attribute importance (RAI) and acceptable trade-offs between benefits and risks were obtained using a mixed logit model. Results Preferences were elicited from 602 trial participants (68.1% female, aged 58.6 ± 14.5 years). Preferences were most affected by daytime functioning (RAI = 33.7%) as a treatment benefit and withdrawal symptoms (RAI = 27.5%) as a risk. Patients also valued shorter sleep onset (RAI = 6.4%), longer sleep maintenance (RAI = 5.4%), reduced likelihood of abnormal thoughts and behavioral changes (RAI = 11.3%), reduced likelihood of dizziness/grogginess (RAI = 9.2%), and reduced likelihood of falls at night (RAI = 6.5%). Patients were willing to make trade-offs between these attributes. For example, they would accept an additional 18.8% risk of abnormal thoughts and behavioral changes to improve their daytime functioning from difficult to restricted and an additional 8.1% risk of abnormal thoughts and behavioral changes to avoid moderate withdrawal effects. Conclusions Patients with insomnia were willing to make trade-offs between multiple benefits and risks of pharmacological treatments. Because patients valued daytime functioning more than sleep latency and duration, we recommend that functional outcomes and sleep quality be considered in treatment development and evaluation.

The authors provide a case-study related to a recent project using program logic models as a primary component in the implementation of a formal quality assurance process in a local juvenile court. Program logic models illustrate the evolution of court personnel’s thoughts about how best to conceptualize programming. Juvenile court officials are developing and implementing formal “quality assurance” procedures to allow for ongoing planning and program development. The authors argue that quality assurance procedures hold great promise for assuring that juvenile court programming is efficient and effective and serves the needs of local communities.

Aims To understand patient preferences for once‐daily oral versus once‐weekly injectable type 2 diabetes mellitus (T2DM) medication administration profiles, and reasons for their preferences. Materials and methods The REVISE study, a cross‐sectional online survey of 600 participants with T2DM (United Kingdom, n = 300; United States, n = 300), elicited general preferences for once‐daily oral versus once‐weekly injectable diabetes medications, and reasons for the preference. Participants then viewed two videos describing the administration procedures for injectable dulaglutide and oral semaglutide, based on the product instructions for use. Thereafter, participants indicated their preference for a once‐weekly injectable or a once‐daily oral medication based on the video descriptions. Participants who switched preferences were asked to identify the reasons influencing their decision. Results The participants were predominantly male (n = 349; 58.2%), with a mean (SD) age of 64 (11.3) years. Nearly all (n = 557; 92.8%) were taking an oral T2DM medication, and 158 (26.3%) were using an injectable. Initially, 76.5% (n = 459; 95% confidence interval [CI] 73.1–79.9) preferred a once‐daily oral and 23.5% a once‐weekly injectable (n = 141; 95% CI 20.1–26.9; P

Studies recommend randomising the order of attributes in discrete choice experiments (DCEs) to avoid bias; however, in a benefit–risk setting, this may increase the cognitive burden of respondents who compare the benefits and risks of treatments, or may affect their decision-making process. Based on these concerns, this paper explored attribute ordering effects in a benefit–risk DCE. Attribute ordering effects were explored in a large pilot DCE relating to the medical treatment of insomnia. Participants were randomised to one of three presentation orders: (1) benefits were presented before risks (BR); (2) risks were presented before benefits (RB); (3) all attributes were randomised (RN). For the RB and BR presentation orders, attributes were randomised within benefits and risks. Responses were assessed in three ways. First, variations in respondents’ self-reported choice certainty were obtained. Second, variations in failure rates of stability and dominance tests were calculated. Third, a heteroscedastic error component model tested for differences in choice consistency across the three attribute orderings. The final analysis included 156 respondents (RN: 54; BR: 49; RB: 53). No differences were found between the presentation orders with respect to stated choice certainty, or the proportion of respondents failing either the dominance or stability test. However, deterministic attribute grouping was associated with higher choice consistency. To increase choice consistency, DCE attributes should be randomised within logical groups that may be further randomised to reduce the risk of ordering effects.

The Asthma Impairment and Risk Questionnaire (AIRQ) is a 10-item, equally weighted, yes/no control tool validated in patients with asthma aged 12 years and older.To evaluate AIRQ's ability to predict patient-reported exacerbations over 12 months.Patients completed a baseline AIRQ during an in-person enrollment visit and reported exacerbations (ie, asthma-related courses of oral corticosteroids, emergency department/urgent care visits, and hospitalizations) via monthly online surveys. Logistic regressions were performed using AIRQ control level (well-controlled [WC], not well-controlled [NWC], very poorly controlled [VPC]), age, sex, race, and body mass index as covariates and 1 or more and 2 or more exacerbations as the dependent variables (adjusted odds ratios [OR] and 95% Wald CIs). Kaplan-Meier analyses of time to first exacerbation by AIRQ control level were performed.A total of 1,112 patients were enrolled; 1,070 completed 1 or more surveys over 12 months (mean ± SD 10.5 ± 2.8 months); 70.5% female; age 43.9 ± 19.3 years; 20.4% non-White; body mass index 30.6 ± 8.7 kg/mThe AIRQ control level predicts exacerbation risk over 12 months and probability of time to first exacerbation.

This case-based study describes an occupational adaptation– based mentoring program and outcomes for six adolescents involved in a juvenile drug court. The Occupational Adaptation Practice Guide pr...

Recurrent assessment of asthma control is essential to evaluating disease stability and intervention impacts. An assessment that can be administered between annual clinic visits is needed. The Asthma Impairment and Risk Questionnaire (AIRQ) is a cross-sectionally validated, 10-item, yes or no, composite control tool evaluating previous 2-week symptoms and previous 12-month exacerbations.To evaluate the construct validity of the AIRQ using a 3-month recall period for exacerbation-based risk questions and retaining the 2-week recall for symptom-based impairment items.At baseline, patients completed the AIRQ with 12-month recall exacerbation items, Asthma Control Test (ACT), St. George's Respiratory Questionnaire (SGRQ), and global self-assessments of asthma risk, control, and symptom severity. Patient-reported exacerbations were captured monthly. The AIRQ with 3-month recall exacerbation items, ACT, and global self-assessments was administered at months 3, 6, and 9, and SGRQ at month 6.A total of 1112 patients aged 12 years or older were enrolled (mean [SD] age, 43.9 [19.5] years). The AIRQ and each administration of the AIRQ with 3-month recall exacerbation items classified asthma control similarly to an ACT plus exacerbation validation standard. For both AIRQ versions, SGRQ scores were higher with worsening asthma control (P.001). At months 3, 6, and 9, worse AIRQ control levels were associated with higher proportions of patients with 1 or more and 2 or more exacerbations in the previous 3 months and patient global self-assessments indicating greater asthma morbidity (all P.001).The AIRQ using exacerbation risk items with a 3-month recall period exhibits construct validity for classifying current asthma control and can be administered between annual AIRQ assessments.

As replications of individual studies are resource intensive, techniques for predicting the replicability are required. We introduce the repliCATS (Collaborative Assessments for Trustworthy Science) process, a new method for eliciting expert predictions about the replicability of research. This process is a structured expert elicitation approach based on a modified Delphi technique applied to the evaluation of research claims in social and behavioural sciences. The utility of processes to predict replicability is their capacity to test scientific claims without the costs of full replication. Experimental data supports the validity of this process, with a validation study producing a classification accuracy of 84% and an Area Under the Curve of 0.94, meeting or exceeding the accuracy of other techniques used to predict replicability. The repliCATS process provides other benefits. It is highly scalable, able to be deployed for both rapid assessment of small numbers of claims, and assessment of high volumes of claims over an extended period through an online elicitation platform, having been used to assess 3000 research claims over an 18 month period. It is available to be implemented in a range of ways and we describe one such implementation. An important advantage of the repliCATS process is that it collects qualitative data that has the potential to provide insight in understanding the limits of generalizability of scientific claims. The primary limitation of the repliCATS process is its reliance on human-derived predictions with consequent costs in terms of participant fatigue although careful design can minimise these costs. The repliCATS process has potential applications in alternative peer review and in the allocation of effort for replication studies.

This study provides a formal review of eight of the most commonly cited models, frameworks, and approaches to translational research in public health. Translational research is defined as the process of moving scientific and other innovations into widespread use, and the authors suggest that such activities culminate in the use of proven practices to solve societal problems. Three critical subprocesses inherent in translational research are described: (a) knowledge generation, (b) translation, and (c) widespread implementation of proven practices. Implications for translational research professionals and organizations, mostly related to public health innovation and promotion of evidence-based practices, are discussed.

Background: Patients and healthcare providers overestimate asthma control. Aim: To evaluate US asthma patients’ and their specialty physicians’ subjective assessment of control compared to the symptom-based Asthma Control Test (ACT™) and composite Asthma Impairment and Risk Questionnaire (AIRQ™). Methods: 1113 specialist-treated patients of all severity levels aged ≥12 yrs were enrolled in a validation study of AIRQ™. AIRQ™ is a 10-item, equally weighted, yes/no tool assessing symptom impairment and risk of exacerbations with score ranges indicating well-, not well-, or very poorly controlled asthma. At entry, ACT™ and AIRQ™ were given during a comprehensive visit, and prior-year, chart-documented, severe exacerbations recorded. Patients and physicians rated control on a 5-item Likert scale (completely, well, somewhat, poorly, not controlled). Results: Mean(SD) age 44(20) yrs; 15% 12-17 yrs; 30% male, 78% white. Physicians rated 54% of patients as completely/well-controlled; 62% of evaluable patients rated themselves similarly. 49% were well-controlled per ACT™ (score ≥20) and 35% per AIRQ™ (0 or 1 yes responses). 30% of physician-rated completely/well-controlled patients and 33% of similarly self-assessed patients had ≥1 prior-year exacerbation. 30% of patients well-controlled per ACT™ and 15% per AIRQ™ had prior-year exacerbations. Thus, for patients whose scores indicated well-controlled asthma, 85% of AIRQ™ vs only 70% of ACT™ assessments correctly identified exacerbation risk. Conclusion: AIRQ™ includes impairment and risk items and provides a more comprehensive assessment of asthma control than patient and physician ratings or symptom-based tools.

Objective Health care decision-making for youth with mental health multimorbidity is guided by outcomes that are considered most meaningful and important. The study objective was to pilot test a best-worst scaling (BWS) instrument designed to assess trade-offs among caregiver-defined, meaningful health care outcomes. Methods A BWS was designed with continuous stakeholder involvement to elicit caregiver-defined outcomes in 4 domains: school, behavioral, social, and independence. Four attributes were identified for each outcome domain, for a total of 16 attributes. Using a balanced incomplete block design, a BWS instrument was developed with 16 choice task questions displaying 6 attributes at a time. A convenience sample was selected from Maryland caregivers of children who were 21 years old or younger and had a developmental delay and a comorbid mental health condition. Participants completed a survey that included demographics and the BWS instrument. Conditional logit was used to estimate utility scores and 95% confidence intervals (CI) for each attribute, which were ranked in order of importance. Attribute statements were refined after a respondent debriefing session. Results A total of 38 caregivers participated in the pilot study. Child safety to self was the most important outcome (1.01, CI, 0.78-1.24). This was followed by securing support for an Individualized educational plan in school (0.77, CI, 0.54-1.01) and the child being able to stay in school all day (0.53, CI, 0.29-0.77). Conclusion BWS scenarios that resemble real-life decision-making can be a useful tool to identify preferences for health care outcomes.

To evaluate whether an educational campaign on distracted driving will have an impact in a given community.Investigators were stationed in an employee parking lot of a 256-bed hospital to determine baseline distracted driving followed by a 4-week hospital-wide distracted-driving awareness campaign. The campaign included signs/posters in the hospital, a booth outside of the cafeteria with flyers, a large banner in the employee lot and an opportunity for people to sign a pledge form to drive distraction free. The same employee lot was observed at the same time of the day to re-assess distracted driving immediately following the campaign. The observations were repeated again one year later to evaluate the short and long-term impact of the campaign.A total of 485 vehicles were observed pre-campaign, identifying 170 (35%) distracted drivers at baseline. The awareness campaign resulted in 525 people pledging to drive distraction free. Following the campaign, 495 vehicles were observed and the number of distracted drivers was 64 (12.9%), showing a significant decrease in the number of distracted drivers by 22.1% (p 0.01). One year later, 530 drivers were observed with 150 (28%) displaying one form of distraction.A local distracted driving educational campaign resulted in a significant decrease in the number of distracted drivers immediately following the campaign. However, one year after the campaign, there was an increase in distracted driving. The proportion of distracted drivers was still significantly lower than the initial rate of distracted-drivers.

Context As the treatment landscape for RRMM evolves, it is becoming increasingly important to understand how treatments differ in terms of benefits, risks, and convenience, as these factors may influence patients’ preferences for treatment. Understanding these preferences can aid in shared treatment decision-making between patients and physicians. Objective To understand patients’ experiences with RRMM and their preferences related to treatment. Methods This is the qualitative interview phase of a two-part study designed to better understand the experiences and treatment preferences of patients with RRMM. Interview questions were informed by a literature review that extracted relevant attributes and clinical data of interest. Sixty-minute, semi-structured interviews were conducted with patients in the United States, United Kingdom, France, and Germany. The interview consisted of two main sections, within which patients were asked to select and rank features related to (1) disease and symptoms and (2) treatment experiences and expectations. Results A total of 19 patients participated in this study; 63% (n=12) had used 4 or more prior lines of therapy. Mean age was 56 years (range: 41–75) and 79% (n=15) of patients were female. Sixty-three percent (n=12) of patients were not working, 37% (n=7) due to disability/sick leave; 26% were retired (n=5). Forty-two percent (n=8) of patients were in remission. Disease symptoms often impacted patients’ abilities to perform daily tasks (84% [n=16]), which was also the most bothersome impact of the disease (32% [n=6]). Patients reported increased life expectancy as the most important treatment benefit (79% [n=15]). Frequent side effects after starting treatment included blood-related side effects (89%, [n=17]), fatigue (89% [n=17]), and bone pain (74% [n=14]). The side effects that patients ranked as most important to avoid included fatigue (16% [n=3]), peripheral neuropathy (16%, [n=3]), and blood-related side effects (11% [n=2]). Treatment frequency (79% [n=15]) and mode of administration (74% [n=14]) were also important to patients. Conclusions Patients reported a number of RRMM symptoms and impacts. Patients desired treatment that prolonged overall survival; whilst administration was important, this was often contingent on efficacy and risks. These results will inform a discrete choice experiment to elicit patients’ preferences for RRMM treatments. Funding GlaxoSmithKline (212408).

Introduction The efficacy and safety of daridorexant, a dual orexin receptor antagonist intended to treat insomnia, was demonstrated in two placebo-controlled phase III trials. Both pivotal trials included instruments for eliciting treatment preferences of enrolled patients, to interpret the trial findings from their perspective using a patient-centered benefit-risk assessment (pBRA). Methods Digital ethnographies and qualitative interviews with insomnia patients informed the design of a discrete choice experiment (DCE). The DCE was pre-tested in qualitative and quantitative pilots before inclusion in the trials. Within the DCE, patients were asked to make trade-offs between seven outcomes (“time to fall asleep,” “total time asleep,” “daytime functioning,” “likelihood of daytime dizziness/grogginess,” “likelihood of abnormal thoughts and behavioural changes,” “likelihood of falls in the night,” and “treatment withdrawal”). The preference data were analysed using a mixed logit (MXL) model that accounted for preference heterogeneity. Relative attribute importance (RAI) and maximum acceptable risk (MAR) of abnormal thoughts and behavioral changes were obtained from the MXL. A pBRA combined elicited preferences with collected clinical trial data to predict preferences for daridorexant over placebo. Sensitivity analysis accounted for uncertainty in both clinical outcomes and preferences. Results Patients valued all seven outcomes (p < 0.05), but considered improving daytime functioning (RAI = 33.7%) and avoiding treatment withdrawal (RAI = 27.5%) as most important. Patients were also willing to accept an additional 18.8% risk (p-value < 0.001) of abnormal thoughts and behavioral changes for an improvement in daytime functioning from difficulty functioning to restricted functioning. The pBRA suggested that both daridorexant 50 mg and 25 mg were significantly preferred (p-value < 0.001) over placebo, and 50 mg was significantly preferred (p-value < 0.001) over 25 mg, even after accounting for uncertainty in clinical outcomes and preferences. Conclusion All seven outcomes included in the DCE were valued by patients, but improving daytime functioning and avoiding severe treatment withdrawal was considered as most important. Daridorexant 50 mg and 25 mg were found to be significantly preferred over placebo, suggesting a positive benefit-risk balance of both doses. Overall, the preference data allowed for an innovative interpretation of the trial data from patients’ perspective. Support (if any)

Objective Caregivers of a child with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability have difficult decisions regarding care management options for their child. This study aimed to pilot and refine an instrument to elicit caregivers' preferences in managing their child's care needs. Methods Subjects were 38 caregivers of a child aged 21 and younger with a coexisting cognitive/intellectual and an emotional/behavior/developmental disability. A mixed-methods design was used to develop and pilot a discrete choice experiment (DCE) to elicit care management preferences for their child. Six attributes of care management decisions were tested in the DCE: medication use, parental custody, time cost, social interactions, medication effects, and school placement. Subjects completed a paper-and-pencil survey after which a debriefing discussion was held to obtain feedback that would aid in refining the attribute descriptions. Conditional logistic regression generated mean scores for each attribute. Comments from the debriefing sessions were audio-recorded and used to modify the attribute descriptions. Results The majority (84%) of subjects were aged 40 years or older and a female caregiver. Common diagnoses of the children were autism spectrum disorder (55%) and attention-deficit/hyperactivity disorder (76%). Subjects preferred using fewer medications and maintaining decision-making authority as opposed to delegating authority to a third party. Medication effects on the child's mood were more important than effects on personality or body weight. Conclusions The DCE was sensitive to caregivers' preferences for managing their child's coexisting cognitive/intellectual and emotional/behavior/developmental disability. Findings may help providers gauge treatment in a broader context of health outcomes.

Objectives To develop a methodological approach for selecting, validating, and prioritizing attributes for health care decision making. Methods Participants (n = 48) were recruited from community support groups if they had a child aged 26 years or younger diagnosed with a coexisting mental health condition and cognitive impairment. Six in-depth interviews eliciting care management experiences were transcribed and coded into themes following the principles of grounded theory and the constant comparative method. Six focus groups involving 42 participants assessed the relevance, priority, and meaning and inter-relationship among the themes. The positive predictive value and sensitivity assessed agreement on thematic meaning. A final list was selected from the top priorities with good agreement as candidate attributes. Attribute levels reflecting the range of experiences in care management decisions emerged from the verbatim passages within each coded theme. Results Participants were the child's mother (73%), white (77%), married (69%), and on average 48 years old. The children were on average 14 years old; 44% had an intellectual disability, 25% had autism, and more than half had anxiety or attention-deficit/hyperactivity disorder. All 14 attributes identified from the in-depth interviews were deemed relevant. The positive predictive value exceeded 90%, and the sensitivity ranged from 64% to 89%. The final set of attributes formed the framework for care management decisions consisting of six attributes (medication, behavior, services, social, treatment effects, and school) each with three levels. Conclusions A systematic approach grounded in qualitative methods produced a framework of relevant, important, and actionable attributes representing competing alternatives in clinical decisions.

OBJECTIVE To document variability among caregivers' priorities when considering medication to treat their Children's attention-deficit hyperactivity disorder (ADHD) and explore associations between these priorities and medication-related improvements. METHODS Caregivers of children, ages 4 to 14 years, diagnosed with ADHD were recruited from outpatient clinics and support groups across Maryland. A survey gathered data on caregiver-reported concerns when considering ADHD medication, demographic characteristics, and observed and desired improvements in their child's ADHD. A validated Best-Worst Scaling instrument assessed priorities among 16 concerns when considering ADHD medication. Latent class analysis identified subgroups with similar ADHD medication concerns. Differences in self-reported medication-related improvements were examined across subgroups. RESULTS The 184 participants (mean = 42 yrs) were primarily the biological mother, 68% white and 25% black. Their children were mostly male (73%) and using medication (81%). Overall, the most important ADHD medication concerns were the child becoming a successful adult (p < 0.0001), school behavior improvements (p < 0.0001), and better grades (p < 0.0001). Others thinking badly of the child was a significantly less important concern (p < 0.0001). Three subgroups were identified: short-term outcomes-oriented group (39%), long-term outcomes-oriented group (37%), and side effects/safety-oriented group (27%). Relative to the other 2 groups, a smaller proportion of the side effects/safety-oriented group desired these improvements (p < 0.2618). CONCLUSION Most caregivers prioritize short- and long-term outcomes when considering ADHD medication. However, those most concerned with long- or short-term outcomes tended to desire additional improvements in their child's ADHD.

Objective:The objective of this feasibility study was to develop and pilot an instrument to elicit caregivers’ priorities when initiating attention-deficit hyperactivity disorder (ADHD) medication for their child.Methods:A best-worst scaling experiment was used to rank competing priorities when initiating ADHD medicine. Forty-six participants were recruited for a two-phase study involving survey development (phase 1, N=21) and the survey pilot (phase 2, N=25). Best-worst scores and 95% confidence intervals indicating the relative importance of 16 concerns were determined, and t tests were used to determine the scores’ significance.Results:The significance of best-worst scores for most concerns indicated that the choices were purposeful. Concerns about helping the child become a successful adult, having a doctor who addresses caregivers’ concerns, and improving school behavior were ranked highest.Conclusions:The best-worst scaling method can elicit priorities for children’s mental health treatment. Future ...

OBJECTIVES: Few studies have examined the benefit-to-risk tradeoffs undergraduate students perceive when engaging in the nonmedical use of prescription stimulants (NPS). This study examined the variation in college students’ perceived risks and benefits for NPS. METHODS: An online survey was administered to 259 college students (ages 18-25) at six public universities who had engaged in NPS in the past year. A best-worst scaling (BWS) instrument assessed the relative importance of 12 perceived benefits and risks of NPS. Probabilities of selection of each factor and 95% confidence intervals were estimated for the aggregate sample and latent preference subgroups were derived using latent class analysis (LCA). RESULTS: For the aggregate sample, the strongest motivators for NPS were better grades (m=2.33, p

To investigate variation in caregiver preferences for their child's attention-deficit/hyperactivity disorder (ADHD) care and to determine if their stated preferences align with current care management.Caregivers of a child aged 4-14 years and in care for ADHD were recruited from pediatric outpatient clinics and advocacy groups across the state of Maryland. Participants completed a survey collecting demographics, the child's treatment, and caregiver preferences-elicited using a best-worst scaling experiment (case 2). Latent class analysis was used to identify distinct preference segments and bivariate analyses were used to compare the association between segment membership with what the child was currently receiving for their ADHD.Participants (n = 184) were predominantly White (68%) and the child's mother (84%). Most children had ADHD for 2 or more years (79%). Caregiver preferences were distinguished by two segments: continuous medication (36%) and minimal medication (64%). The two groups had very different preferences for when medication was administered (p 0.001), but they had similar preferences for provider-oriented and non-medication interventions (p0.05 for the caregiver behavior training, provider communication, provider specialty, and out-of-pocket costs). One third of the sample did not receive the preferred individualized education program and 42% of the minimal medication group reported using medication 7 days a week all year round.Although behavior management training and school accommodations aspects of an ADHD care plan are more important to caregivers than evidence-based medication, fewer families had access to educational accommodations. Further research is needed to clarify how stated preferences for care align with treatments used in actual practice settings.

Aims: This study aimed to identify methods to engage hard-to-reach patients in the research process. Materials & methods: With funding from the Patient-Centered Outcomes Research Institute (Washington, DC, USA), the University of Maryland (MD, USA) conducted 20 focus groups and one individual interview. The sample consisted of six groups of hard-to-reach patients, two groups of healthcare providers who work with hard-to-reach patients and two groups of surrogates of hard-to-reach patients. Results & conclusion: In order to make patient-centered outcomes research more meaningful to patients and their caregivers, patient-centered outcomes research should be conducted with a focus on building and maintaining trust, which is achieved via pre-engagement with communities and continuous engagement of study participants and their communities.

The purpose of this article is to explore infrastructure and functions to serve as a foundation for collaborative community problem solving. The literature reviewed in this article focuses on problem solving in the health, education, and social services arenas. However, the recommendations and perspectives would appear to apply to collaborative community problem solving focused on any complex social issue. It is imperative that as local, state, and national policies and practices evolve supporting collaborative efforts to address a variety of issues, planners be prepared to facilitate community dialogue designed to build strong partnerships at the local level.

Six species of phytoplankton recently isolated from upper San Francisco Bay were tested for their sensitivity to growth inhibition by ammonium (NH 4 +), and for differences in growth rates according to inorganic nitrogen (N) growth source. The quantum yield of photosystem II (Fv/Fm) was a sensitive indicator of NH 4 + toxicity, manifested by a suppression of Fv/Fm in a dose‐dependent manner. Two chlorophytes were the least sensitive to NH 4 + inhibition, at concentrations of >3,000 μmoles NH 4 + · L−1, followed by two estuarine diatoms that were sensitive at concentrations >1,000 μmoles NH 4 + · L−1, followed lastly by two freshwater diatoms that were sensitive at concentrations between 200 and 500 μmoles NH 4 + · L−1. At non‐inhibiting concentrations of NH 4 +, the freshwater diatom species grew fastest, followed by the estuarine diatoms, while the chlorophytes grew slowest. Variations in growth rates with N source did not follow taxonomic divisions. Of the two chlorophytes, one grew significantly faster on nitrate (NO 3 −), whereas the other grew significantly faster on NH 4 +. All four diatoms tested grew faster on NH 4 + compared with NO 3 −. We showed that in cases where growth rates were faster on NH 4 + than they were on NO 3 −, the difference was not larger for chlorophytes compared with diatoms. This holds true for comparisons across a number of culture investigations suggesting that diatoms as a group will not be at a competitive disadvantage under natural conditions when NH 4 + dominates the total N pool and they will also not have a growth advantage when NO 3 − is dominant, as long as N concentrations are sufficient.