Critical Incident Technique

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The Critical Incident Technique (or CIT) is a set of procedures used for collecting direct observations of human behavior that have critical significance and meet methodically defined criteria. These observations are then kept track of as incidents, which are then used to solve practical problems and develop broad psychological principles. A critical incident can be described as one that makes a contributioneither positively or negativelyto an activity or phenomenon. Critical incidents can be gathered in various ways, but typically respondents are asked to tell a story about an experience they have had. CIT is a flexible method that usually relies on five major areas. The first is determining and reviewing the incident, then fact-finding, which involves collecting the details of the incident from the participants. When all of the facts are collected, the next step is to identify the issues. Afterwards a decision can be made on how to resolve the issues based on various possible solutions. The final and most important aspect is the evaluation, which will determine if the solution that was selected will solve the root cause of the situation and will cause no further problems.

History
The studies of Sir Francis Galton (circa 1930) are said to have laid the foundation for the Critical Incident Technique, but it is the work of Colonel John C. Flanagan, that resulted in the present form of CIT (described in Psychological Bulletin, Vol. 51, No. 4, July 1954). Flanagan defined the Critical Incident Technique as: [A] set of procedures for collecting direct observations of human behaviour in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles . . . By an incident is meant any specifiable human activity that is sufficiently complete in itself to permit inferences and predictions to be made about the person performing the act. To be critical the incident must occur in a situation where the purpose or intent of the act seems fairly clear to the observer and where its consequences are sufficiently definite to leave little doubt concerning its effects. (Flanagan, 1954:327) Flanagan's work was carried out as part of the Aviation Psychology Program of the United States Army Air Forces during World War II, where Flanagan conducted a series of studies focused on differentiating effective and ineffective work behaviors. Since then CIT has spread as a method to identify job requirements, develop recommendations for effective practices, and determine competencies for a vast number of professionals in various disciplines. In particular, it has been used in service research.

Principal uses
CIT can be used in a wide variety of areas. In general it is most useful in the early stages of development of large scale tasks and activity analysis within existing

projects. This is mainly due to the method's ability to quickly separate out major problem areas that reside in a system. In healthcare CIT is used in situations where direct examination of clinical staff and researchers can help them better understand their roles and help them solve practical problems. CIT allows clinical staff to better understand their roles in the clinical setting. Another advantage is that it helps them gain better knowledge about their interactions with patients and other clinicians. It also helps clinical staff better understand their practice from a variety of roles (e.g.,physician, nurse, clinical educator, nurse informatician, faculty member). In healthcare research, CIT can be a good resource in identifying the experiences of a patient in the healthcare setting, exploring the dimensions of patientprovider interactions and determining patient responses to illnesses and treatments. CIT is also widely used in organizational development as a research technique for identification of organizational problems. CIT is used as an interview technique, where the informants are encouraged to talk about unusual organizational incidents instead of answering direct questions. Using CIT deemphasizes the inclusion of general opinions about management and working procedures, instead focusing on specific incidents. In market research, CIT has been used more frequently in the last ten years. Although the CIT method first appeared in the marketing literature thirty years ago, the major catalyst for use of the CIT method in service research appears to have been a Journal of Marketing study conducted by Bitner, Booms, and Tetreault (1990) that investigated sources of satisfaction and dissatisfaction in service encounters. Since the Bitner et al. article, nearly 200 CIT studies have appeared in marketing-related literature. For a useful overview, see Gremler's article in Journal of Service Research, Vol. 7, No. 1, August 2004. CIT has also been used in studies of information-seeking behavior. See e.g. "How senior managers acquire and use information in environmental scanning" by Ethel Auster and Chun Wei Choo (1996); "Information sources used by lawyers in problem-solving: An empirical exploration" by Margaret Ann Wilkinson (2001); or "When Is 'Enough' Enough? Modeling the Information-Seeking and Stopping Behavior of Senior Arts Administrators" by Lisl Zach (2004). The employment of CIT may also allow construction of typical scenarios of user behavior when they interact with various technologies including information systems. For this, researchers should solicit: 1. the cause, description and outcome of a critical incident 2. users' feelings and perceptions of the situation 3. actions taken during the incident 4. changes (if any) in their future behavior. The typical scenarios may be presented visually as a diagram or a causal model. E.g., see the study "The use of interface agents for email notification in critical incidents" by Serenko 2006 published in the International Journal of Human Computer Studies 64 (11), pp. 10841098.

Advantages and disadvantages

By identifying possible problems associated with major usersystem or product complications, CIT recommendations try to ensure that the same type of situations do not result in a similar loss. There are both advantages and disadvantages to using this method, as shown below. In all, however, CIT has been demonstrated to be a sound method since first presented in 1954. Relatively few modifications have been suggested to the method in the more than 50 years since it was introduced, and only minor changes have been made to Flanagan's original approach. This indicates a certain robustness.

Advantages
Flexible method that can be used to improve multi-user systems. Data is collected from the respondent's perspective and in his or her own words. Does not force the respondents into any given framework. Identifies even rare events that might be missed by other methods which only focus on common and everyday events. Useful when problems occur but the cause and severity are not known. Inexpensive and provides rich information. Emphasizes the features that will make a system particularly vulnerable and can bring major benefits (e.g. safety). Can be applied using questionnaires or interviews.

Disadvantages
A first problem comes from the type of the reported incidents. The Critical Incident Technique will rely on events being remembered by users and will also require the accurate and truthful reporting of them. Since critical incidents often rely on memory, incidents may be imprecise or may even go unreported. The method has a built-in bias towards incidents that happened recently, since these are easier to recall. Respondents may not be accustomed to or willing to take the time to tell (or write) a complete story when describing a critical incident. Since this method is based on incidents it does not say anything about the everyday situation so it is not very representative.

Journal of Nucleic Acids Volume 2013 (2013), Article ID 194858, 7 pages http://dx.doi.org/10.1155/2013/194858

Review Article

Mesenchymal Stem Cell Therapy in Diabetes Mellitus: Progress and Challenges

Nagwa El-Badri1 and Mohamed A. Ghoneim2 1Zewail University of Science and Technology, 6th of October City, Giza 12588, Egypt 2Urology and Nephrology Center, Mansoura 35516, Egypt Received 13 March 2013; Accepted 18 April 2013 Academic Editor: Sherif F. El-Khamisy Copyright 2013 Nagwa El-Badri and Mohamed A. Ghoneim. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Conclusions and Future Perspectives

Replacement of diseased pancreatic islets by healthy functioning ones from cadaveric donors is a highly effective approach to treat insulin dependent diabetes. Careful usage of combined therapies of immune suppressive regimens prolongs graft survival and improves insulin levels and norm glycemic outcome. However, this therapy is hampered by shortage of donors, the need for fresh graft, usually within 8 hours after death, the need for tissues from more than one donor for one recipient, and the incidence of graft rejection. Stem cell therapy, especially using adult MSCs as a source for engineered insulin secreting cells, is considered the next frontier for diabetes treatment. The key to an impressive outcome with stem therapy is to use high quality, well differentiated cells, with evidence of insulin production in

vivo and sustained normoglycemia. The clinical feasibility of using autologous MSCs along with minimum or no immune suppressive regimens improves the outcome substantially, since most fatal complications in stem transplant recipients are caused by the use of immunosuppression. Therapeutic applications in the clinical setting using MSCs depend on their safety and efficacy, both of which have not been yet optimized for type 2 diabetic patients. Safety issues are related to the potential pathogenicity of the cell inoculum. MSCs are currently cultured using fetal bovine serum, which can induce xenogeneic and allergic reactions in transplanted patients, in addition to transmission of xenogeneic pathogens that may contaminate the serum. The immune characteristics of MSCs have been generally encouraging for transplantation purposes; however, there are some reports on the increased tumor formation in animals due to the immune suppressive effects of MSC transplants, particularly in the allogeneic setting [59, 60]. Furthermore, frequent in vitro passaging and the long time required for effective differentiation into insulin producing cells can induce mutations and transformations and render the graft unsafe for clinical usage [61]. Safety studies must go hand in hand with efficacy studies to ensure safe long term effects of the MSC transplant. Increasing the number of insulin producing cells and their sustained survival is a high priority in stem cell research. If surrogate cells could be obtained in sufficient numbers, two additional questions have to be addressedas follows. For how long can these cells maintain their active function in vivo? And what is the optimal site for their transplantation? Information regarding the duration of active function is limited by the observation period following transplantation in experimental models, the longest of which is in order of three months before the animals are sacrificed [16]. It is abundantly clear that experiments with larger animal models and for more extended periods are required. It is reasonable to assume that experiences with possible sites for pancreatic islet transplantation can be also applied to insulin producing cells derived from MSCs. The liver is currently the site of choice for clinical islet transplantation. However, it is now recognized that it may not provide the optimal microenvironment due to immunologic, anatomic, and physiologic factors that contribute to early loss of the islet mass after its infusion [44]. Alternative sites are currently under investigation and are well summarized in some recent reviews [45, 62, 63]. An interesting approach is transplantation into striated muscles [64]. Striated muscles are easily accessible and have been used for autotransplantation of the parathyroid glands. Moreover, it is almost the only tissue in the adult where physiologic angiogenesis occurs [65]. In their animal experiment, Svensson and colleagues provided evidence that islets grafted into muscle have 3 times more blood vessels than islets at the renal subcapsular site at 2 months aftertransplant [66]. They concluded that the intramuscular site can provide an excellent condition for

engraftment. Additional tools may also be needed to improve early graft survival: bioengineered matrices, oxygen carriers, and growth factors. The potential role of MSCs in the management of several diabetic complications has also been explored. These include their benefit in promotion of healing of diabetic foot [67], control of the onset and/or progression of diabetic nephropathy [68, 69], and attenuation of symptoms of painful diabetic neuropathy [70, 71].

Restoration of angiogenic capacity of diabetes-insulted mesenchymal stem cells by oxytocin Yong Sook Kim, Jin Sook Kwon, Moon Hwa Hong, Wan Seok Kang, Hye-yun Jeong, Hye-jin Kang, Myung Ho Jeong and Youngkeun Ahn BMC Cell Biology 2013, 14:38 doi:10.1186/1471-2121-14-38 Published: 11 September 2013

Abstract (provisional)
Background
Angiogenesis is the main therapeutic mechanism of cell therapy for cardiovascular diseases, but diabetes is reported to reduce the function and number of progenitor cells. Therefore, we studied the effect of streptozotocin-induced diabetes on the bone marrow-mesenchymal stem cell (MSC) function, and examined whether diabetes-impaired MSC could be rescued by pretreatment with oxytocin.

Results
MSCs were isolated and cultured from diabetic (DM) or non-diabetic (non-DM) rat, and proliferation rate was compared. DM-MSC was pretreated with oxytocin and compared with non-DM-MSC. Angiogenic capacity was estimated by tube formation and Matrigel plug assay, and therapeutic efficacy was studied in rat myocardial infarction (MI) model. The proliferation and angiogenic activity of DM-MSC were severely impaired but significantly improved by pretreatment with oxytocin. Kruppel-like factor 2 (KLF2), a critical angiogenic factor, was dramatically reduced in DM-MSC and significantly restored by oxytocin. In the Matrigel plug assay, vessel formation of DM-BMSCs was attenuated but was recovered by oxytocin. In rat MI model, DM-MSC injection did not ameliorate cardiac injury, whereas oxytocinpretreated DM-MSC improved cardiac function and reduced fibrosis.

Conclusions
Our results show that diabetes influenced MSC by reducing angiogenic capacity and therapeutic potential. We demonstrate the striking effect of oxytocin on stem cell dysfunction and suggest the use of oxytocin as a priming reagent in autologous stem cell therapy.

Stem cell transplantation for type 1 diabetes mellitus

Jlio C Voltarelli* and Carlos Eduardo Barra Couri

*Corresponding author: Jlio C Voltarelli jcvoltar@fmrp.usp.br Department of Clinical Medicine, Ribeiro Preto School of Medicine, University of So Paulo, Brazil For all author emails, please log on. Author Affiliations 09, 1:4 doi:10.1186/1758-5996-1-4

Diabetology & Metabolic Syndrome 20

Side Effects and Results

Because we apply immunosuppressant leukemia therapy on an autoimmune disease in young patients, reports of side effects are extremely important, and the most frequent side effects are infections in general, controlled using an antibiotic scheme prophylatically or therapeutically. In three patients, we observed post-transplant autoimmune diseases due to the transplant or to diabetes. During a 7- to 58-month follow-up (mean, 29.8 months; median, 30 months), 20 patients without previous ketoacidosis and not receiving corticosteroids during the preparative regimen became insulin free. Twelve patients maintained this status for a mean 31 months (range, 14-52 months) and 8 patients relapsed and resumed insulin use at low dose (0.10.3 IU/kg). In the continuous insulin-independent group, A1c levels were less than 7.0% and mean (SE) area under the curve (AUC) of C-peptide levels increased significantly from 225.0 (75.2) ng/mL per 2 hours pretransplantation to 785.4 (90.3) ng/mL per 2 hours at 24 months posttransplantation (P < .001) and to 728.1 (144.4) ng/mL per 2 hours at 36 months (P = .001). In the transient insulin-independent group, mean (SE) AUC of C-peptide levels also increased from 148.9 (75.2) ng/mL per 2 hours pretransplantation to 546.8 (96.9) ng/mL per 2 hours at 36 months (P = .001), which was sustained at 48 months. In this group, 2 patients regained insulin independence after treatment with sitagliptin, which is a DPP-4 inhibitor, an enzyme which metabolizes GLP-1, and is thus associated with a glucose dependent increase in C-peptide levels. Two patients developed bilateral nosocomial pneumonia, 3 patients developed late endocrine dysfunction, and 9 patients developed oligospermia. There was no mortality [19,20].

Conclusion
We have concluded that there are several challenges when it comes to this type of transplant in recently diagnosed T1DM, from which the main one is to investigate the length of the clinical response (insulin independence) and relapse mechanism. Using embryonic stem cells could have better results at the long term diseases. Injecting bone marrow mononuclear cells directly into the pancreas significantly increased endogenous insulin secretion in type 2 diabetic patients, but not in persons with T1DM in studies conducted in Peru and Argentina. The use of autologous umbilical cord stem cells in children with T1DM resulted in not significant differences in daily insulin doses and in a decline in Cpeptide levels after 1 year of follow-up. This study is still being conducted at the University of Florida, in Gainesville.