strengths and weaknesses of a research article

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General questions that Reviewers should keep in mind when reviewing articles are the following:

• Is the article of interest to the readers of YJBM ?
• What are the strengths and weaknesses of the manuscript?
• How can the Editors work with the Authors to improve the submitted manuscripts, if the topic and scope of the manuscript is of interest to YJBM readers?

The following contains detailed descriptions as to what should be included in each particular type of article as well as points that Reviewers should keep in mind when specifically reviewing each type of article.

YJBM will ask Reviewers to Peer Review the following types of submissions:

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Frequently asked questions.

These manuscripts should present well-rounded studies reporting innovative advances that further knowledge about a topic of importance to the fields of biology or medicine. The conclusions of the Original Research Article should clearly be supported by the results. These can be submitted as either a full-length article (no more than 6,000 words, 8 figures, and 4 tables) or a brief communication (no more than 2,500 words, 3 figures, and 2 tables). Original Research Articles contain five sections: abstract, introduction, materials and methods, results and discussion.

Reviewers should consider the following questions:

• What is the overall aim of the research being presented? Is this clearly stated?
• Have the Authors clearly stated what they have identified in their research?
• Are the aims of the manuscript and the results of the data clearly and concisely stated in the abstract?
• Does the introduction provide sufficient background information to enable readers to better understand the problem being identified by the Authors?
• Have the Authors provided sufficient evidence for the claims they are making? If not, what further experiments or data needs to be included?
• Are similar claims published elsewhere? Have the Authors acknowledged these other publications? Have the Authors made it clear how the data presented in the Author’s manuscript is different or builds upon previously published data?
• Is the data presented of high quality and has it been analyzed correctly? If the analysis is incorrect, what should the Authors do to correct this?
• Do all the figures and tables help the reader better understand the manuscript? If not, which figures or tables should be removed and should anything be presented in their place?
• Is the methodology used presented in a clear and concise manner so that someone else can repeat the same experiments? If not, what further information needs to be provided?
• Do the conclusions match the data being presented?
• Have the Authors discussed the implications of their research in the discussion? Have they presented a balanced survey of the literature and information so their data is put into context?
• Is the manuscript accessible to readers who are not familiar with the topic? If not, what further information should the Authors include to improve the accessibility of their manuscript?
• Are all abbreviations used explained? Does the author use standard scientific abbreviations?

Case reports describe an unusual disease presentation, a new treatment, an unexpected drug interaction, a new diagnostic method, or a difficult diagnosis. Case reports should include relevant positive and negative findings from history, examination and investigation, and can include clinical photographs. Additionally, the Author must make it clear what the case adds to the field of medicine and include an up-to-date review of all previous cases. These articles should be no more than 5,000 words, with no more than 6 figures and 3 tables. Case Reports contain five sections: abstract; introduction; case presentation that includes clinical presentation, observations, test results, and accompanying figures; discussion; and conclusions.

• Does the abstract clearly and concisely state the aim of the case report, the findings of the report, and its implications?
• Does the introduction provide enough details for readers who are not familiar with a particular disease/treatment/drug/diagnostic method to make the report accessible to them?
• Does the manuscript clearly state what the case presentation is and what was observed so that someone can use this description to identify similar symptoms or presentations in another patient?
• Are the figures and tables presented clearly explained and annotated? Do they provide useful information to the reader or can specific figures/tables be omitted and/or replaced by another figure/table?
• Are the data presented accurately analyzed and reported in the text? If not, how can the Author improve on this?
• Do the conclusions match the data presented?
• Does the discussion include information of similar case reports and how this current report will help with treatment of a disease/presentation/use of a particular drug?

Reviews provide a reasoned survey and examination of a particular subject of research in biology or medicine. These can be submitted as a mini-review (less than 2,500 words, 3 figures, and 1 table) or a long review (no more than 6,000 words, 6 figures, and 3 tables). They should include critical assessment of the works cited, explanations of conflicts in the literature, and analysis of the field. The conclusion must discuss in detail the limitations of current knowledge, future directions to be pursued in research, and the overall importance of the topic in medicine or biology. Reviews contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Is the review accessible to readers of YJBM who are not familiar with the topic presented?
• Does the abstract accurately summarize the contents of the review?
• Does the introduction clearly state what the focus of the review will be?
• Are the facts reported in the review accurate?
• Does the Author use the most recent literature available to put together this review?
• Is the review split up under relevant subheadings to make it easier for the readers to access the article?
• Does the Author provide balanced viewpoints on a specific topic if there is debate over the topic in the literature?
• Are the figures or tables included relevant to the review and enable the readers to better understand the manuscript? Are there further figures/tables that could be included?
• Do the conclusions and outlooks outline where further research can be done on the topic?

Perspectives provide a personal view on medical or biomedical topics in a clear narrative voice. Articles can relate personal experiences, historical perspective, or profile people or topics important to medicine and biology. Long perspectives should be no more than 6,000 words and contain no more than 2 tables. Brief opinion pieces should be no more than 2,500 words and contain no more than 2 tables. Perspectives contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Does the abstract accurately and concisely summarize the main points provided in the manuscript?
• Does the introduction provide enough information so that the reader can understand the article if he or she were not familiar with the topic?
• Are there specific areas in which the Author can provide more detail to help the reader better understand the manuscript? Or are there places where the author has provided too much detail that detracts from the main point?
• If necessary, does the Author divide the article into specific topics to help the reader better access the article? If not, how should the Author break up the article under specific topics?
• Do the conclusions follow from the information provided by the Author?
• Does the Author reflect and provide lessons learned from a specific personal experience/historical event/work of a specific person?

Analyses provide an in-depth prospective and informed analysis of a policy, major advance, or historical description of a topic related to biology or medicine. These articles should be no more than 6,000 words with no more than 3 figures and 1 table. Analyses contain four sections: abstract, introduction, topics (with headings and subheadings), and conclusions and outlook.

• Does the abstract accurately summarize the contents of the manuscript?
• Does the introduction provide enough information if the readers are not familiar with the topic being addressed?
• Are there specific areas in which the Author can provide more detail to help the reader better understand the manuscript? Or are there places where the Author has provided too much detail that detracts from the main point?

Profiles describe a notable person in the fields of science or medicine. These articles should contextualize the individual’s contributions to the field at large as well as provide some personal and historical background on the person being described. More specifically, this should be done by describing what was known at the time of the individual’s discovery/contribution and how that finding contributes to the field as it stands today. These pieces should be no more than 5,000 words, with up to 6 figures, and 3 tables. The article should include the following: abstract, introduction, topics (with headings and subheadings), and conclusions.

• Does the Author provide information about the person of interest’s background, i.e., where they are from, where they were educated, etc.?
• Does the Author indicate how the person focused on became interested or involved in the subject that he or she became famous for?
• Does the Author provide information on other people who may have helped the person in his or her achievements?
• Does the Author provide information on the history of the topic before the person became involved?
• Does the Author provide information on how the person’s findings affected the field being discussed?
• Does the introduction provide enough information to the readers, should they not be familiar with the topic being addressed?

Interviews may be presented as either a transcript of an interview with questions and answers or as a personal reflection. If the latter, the Author must indicate that the article is based on an interview given. These pieces should be no more than 5,000 words and contain no more than 3 figures and 2 tables. The articles should include: abstract, introduction, questions and answers clearly indicated by subheadings or topics (with heading and subheadings), and conclusions.

• Does the Author provide relevant information to describe who the person is whom they have chosen to interview?
• Does the Author explain why he or she has chosen the person being interviewed?
• Does the Author explain why he or she has decided to focus on a specific topic in the interview?
• Are the questions relevant? Are there more questions that the Author should have asked? Are there questions that the Author has asked that are not necessary?
• If necessary, does the Author divide the article into specific topics to help the reader better access the article? If not, how should the author break up the article under specific topics?
• Does the Author accurately summarize the contents of the interview as well as specific lesson learned, if relevant, in the conclusions?

How to Critically Appraise an Article

Jane M Young; Michael J Solomon

Nat Clin Pract Gastroenterol Hepatol. 2009;6(2):82-91. 

• Summary and Introduction
• Selection and Critical Appraisal of Research Literature
• Conclusions
• Sidebar: Key Points

Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article in order to assess the usefulness and validity of research findings. The most important components of a critical appraisal are an evaluation of the appropriateness of the study design for the research question and a careful assessment of the key methodological features of this design. Other factors that also should be considered include the suitability of the statistical methods used and their subsequent interpretation, potential conflicts of interest and the relevance of the research to one's own practice. This Review presents a 10-step guide to critical appraisal that aims to assist clinicians to identify the most relevant high-quality studies available to guide their clinical practice.

Introduction

To practice evidence-based medicine, clinicians need to apply the findings of scientific research to the circumstances of individual patients as part of their clinical decision-making process. Clinicians, therefore, must be able to select and appraise scientific literature that is relevant to their field, understand the implications of research findings for individual patients, elicit patients' own preferences and develop an appropriate management plan based on the combination of this information. Each of these tasks presents its own challenges, but the sheer volume of medical literature means that the first step (that of selecting and appraising scientific evidence) can be daunting. The number of new medical research articles published each year continually increases, and more than 12,000 new articles, including papers on in excess of 300 randomized controlled trials (RCTs), are added to the MEDLINE database each week. [ 1 , 2 ] One practical way that clinicians can manage this 'information overload' [ 2 ] is to develop efficient skills in critical appraisal, which enable them focus on only the highest-quality studies that will guide their clinical practice and to extrapolate information when necessary from studies of less rigorous design if high-quality trials are unavailable.

Critical appraisal has been defined as the "...application of rules of evidence to a study to assess the validity of the data, completeness of reporting, methods and procedures, conclusions, compliance with ethical standards, etc. The rules of evidence vary with circumstances." [ 3 ] Although the methodological criteria by which the validity of a study is assessed will vary according to its design, some general principles underpin the evaluation of any research study. Various guidelines and assessment tools have been developed to provide a structured approach to the process of critical appraisal for clinicians. [ 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 ]

Despite the plethora of documents available to guide the process, no 'gold-standard' instrument for critical appraisal exists. The criteria used to assess the validity and relevance of scientific literature are not static; they must evolve with improvements in understanding of the important sources of bias inherent in different study designs, and increased awareness of the potential influence of other nonmethodological factors, such as conflicts of interest. [ 15 ] A structured approach to critical appraisal could potentially improve the quality of this process, and simple checklists can be useful to screen out research that is of low quality or of little relevance. [ 16 ] This Review presents a guide to the critical-appraisal process.

Nat Clin Pract Gastroenterol Hepatol. 2009;6(2):82-91. © 2009  Nature Publishing Group

Cite this: How to Critically Appraise an Article -  Medscape  - Feb 01, 2009.

Authors and Disclosures

Jane M Young is an Associate Professor of Public Health and the Executive Director of the Surgical Outcomes Research Centre at the University of Sydney and Sydney South-West Area Health Service, Sydney, and Michael J Solomon is Head of the Surgical Outcomes Research Centre and Director of Colorectal Research at the University of Sydney and Sydney South-West Area Health Service, Sydney, Australia. Competing Interests: The authors declared no competing interests.

Critical appraisal is a systematic process used to identify the strengths and weaknesses of a research article

Critical appraisal provides a basis for decisions on whether to use the results of a study in clinical practice

Different study designs are prone to various sources of systematic bias

Design-specific, critical-appraisal checklists are useful tools to help assess study quality

Assessments of other factors, including the importance of the research question, the appropriateness of statistical analysis, the legitimacy of conclusions and potential conflicts of interest are an important part of the critical appraisal process

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Source strengths & weaknesses

Contributor: Logan Miller

With the Internet’s ever-expanding repository of information, appraising potential sources has become an increasingly important skill. Evaluating strengths and weaknesses can be a useful tactic to assess potential sources.

What is the research question?

The research question defines the population to be investigated, interventions or exposures, and outcomes.

The population is too broad, too narrow, or specific characteristics are too vague such that possible findings will be inconclusive.

Was the study design appropriate for the research question?

The researchers chose to study the data over several years to ensure accuracy of the results for the selected population.

The researchers collected observational data when experimental data could have produced stronger support for their hypothesis.

Did the study address potential sources of bias?

The study asserts that the members of the sample were chosen randomly, ensuring they are representative of the population.

The study design contains a potential for the above selection bias, but the researchers didn’t address this potential in the study.

Was the study performed according to the original design?

The study followed the design and reported this how they followed the design. 

The researchers were unable to recruit the desired number of participants, reducing their ability to produce significant findings or answer the research question.

Do the data justify the conclusions?

The study accurately reports the statistical significance of the data without suggesting a cause and effect relationship between exposures and outcomes.

The researchers misinterpret a statistically significant correlation between the exposures and outcomes as a cause and effect relationship.

Are there any conflicts of interest?

While a party that might want to see specific findings funded the study, the researchers disclose that the party had no input into the study.

The researchers offer no disclosure on what input the funding party did or didn’t have into the study.

How to Critique a Journal Article

Most scholars and practitioners are passionate about learning how to critique a journal article. Journal article critique is a formal evaluation of a journal article or any type of literary or scientific content. As a careful, complete examination of a study, journal article critique judges the strengths, weaknesses, logical links, meanings and significance of the content presented in an article. The core aim of performing a journal article critique is to show whether or not the arguments and facts that the author provided are reasonable to support their main points. A writer of a journal article critique is expected to identify a scientific article and subject it to a critical discussion based on their point of view, but following a set of conventional guidelines.

Features of a Good Article Critique

When doing a journal article, you are expected to do the following for each section of a research article :

• Explain what was done right with evidence from the journal article being critiqued.
• Explain what was not done right, possible reasons, and what ought to have been done.
• Explain what you think could have been done or what you could do to make it better.
• Given a brief recommendation for future researchers.

What this means is that you must first of all know exactly the nature of structure and content that you expect from a journal article. Without this knowledge, it will be difficult to critique a journal article and write a quality piece of writing from it. Having done these, your journal article critique will reflect the following characteristics.

i). It should have a unique opinion discussion

Article critique does not represent a simple summary of an article. Most students make a mistake of writing a mere summary of the research article after they read it. It is worth noting that journal articles already have summaries and that is not what readers actually want, but a unique opinion and discussion is what counts as a quality journal article critique.  

ii). Evidence

As a writer, you are not expected to provide just your impressions of the article, but also evidence that sets expressions as well. Of course you are not asked to write a new content, but as you write your viewpoint of it, it is critical to support them with evidence.

iii). Identification of the Main Idea

Ensure that you identify the main idea of the article. Each journal article is published to transmit a specific idea that gives it a purpose. Furthermore, remember to clarify the background and significance.

iv). Dual Direction

Do not focus only on the issues that a given article has raised, but also give attention to the important issues that it has left out. There could some content or explanations that you could expect a journal article to present, but that was left out. Explain it and tell the difference it could have caused.

Areas of Journal Article Critique

Article critique fundamentally focuses on evaluating all the sections of a an article to determine its consistency with the scientific research and writing standards. Thus, each section of an article is subjected to critique as follows:

Introduction

• Check the extent to which the title of the article interest and allow you to have an immediate idea of the content of the research.
• Identify the authors of the research article and/or parties that conducted the research is published.
• Identify and apprise the journal in which the article the article is published.
• Evaluate the introduction in terms of how it describes the purpose and background of the study.
• Explain if the research question is consistent with the purpose of the study.
• Recognize the potential effect of the research article to your current practice.

Literature Review

• Find out if the sources of literature review in the article are current (i.e published within the last 5-10 years).
• Evaluate the theories used in relation to relevance to the independent and dependent variables. Ask yourself if the theories explain the phenomenon under investigation.
• Check whether if the literature reviewed is relevant to the research (some content of the literature may be pulled randomly and may not reflect the variables of the study.  

Methodology

• Identify and explain the research design that enabled the creation of a journal article being critiqued.
• Check the research method that was adopted and evaluate its appropriateness to the research question and context. For example, questionnaires may not be appropriate among illiterate populations.
• Evaluate the method of sampling and explain if it is appropriate to the topic and population characteristics.
• Check the possibility of biases in the sample. If biased, explain the reason and what could be done to prevent biases from occurring.
• Appraise the size of the sample in relation to the population and desired significance levels.
• Identify and critique the tools that were used to collect data, procedures through which data was collected, and their validity, reliability and accuracy.
• Find out if the researchers got ethical approval to conduct the study and if not, why.
• Overall, explain if the methods of research have been explained adequately.

Results and Findings

• Check how data was analyzed.
• Briefly explain the main findings of the research.
• Evaluate the way in which results are displayed (Is it done in a clear and understandable manner?)
• Check if the authors have discussed the results in relation to the original problem they identified in the introduction section.
• Find out if the findings have been related to the literature review and consistencies/inconsistencies identified and explained. (Have the authors cited only the pertinent literature?)
• Check if the conclusion captures all aspects of the study from introduction to the end.
• Analyze the nature of conclusions presented and if they answer the research question.
• Analyze and explain the main strengths and weaknesses of the study.
• Identify what you think is the main limitations of the study and if they were identified by the authors.
• Check if the author(s) provided suggestions for future research.
• Go through the references and check if they consistently adhere to a given referencing style.

From the above discussion, it is evident that journal article critique is an involving activity that require active reading, developing an outline, questioning authors’ main points, identifying contradictions, writing down the content of the critique, and revising it to make it perfect. You can now practice by downloading a few articles and trying to critique them.  This will give you a good opportunity to learn from experience and perfect your article critique skills.

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A simplified approach to critically appraising research evidence

Affiliation.

• 1 School of Health and Life Sciences, Teesside University, Middlesbrough, England.
• PMID: 33660465
• DOI: 10.7748/nr.2021.e1760

Background Evidence-based practice is embedded in all aspects of nursing and care. Understanding research evidence and being able to identify the strengths, weaknesses and limitations of published primary research is an essential skill of the evidence-based practitioner. However, it can be daunting and seem overly complex.

Aim: To provide a single framework that researchers can use when reading, understanding and critically assessing published research.

Discussion: To make sense of published research papers, it is helpful to understand some key concepts and how they relate to either quantitative or qualitative designs. Internal and external validity, reliability and trustworthiness are discussed. An illustration of how to apply these concepts in a practical way using a standardised framework to systematically assess a paper is provided.

Conclusion: The ability to understand and evaluate research builds strong evidence-based practitioners, who are essential to nursing practice.

Implications for practice: This framework should help readers to identify the strengths, potential weaknesses and limitations of a paper to judge its quality and potential usefulness.

Keywords: literature review; qualitative research; quantitative research; research; systematic review.

©2021 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

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Conflict of interest statement

None declared

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Overview: Cohort Study Designs

Bernadette capili.

Heilbrun Family Center for Research Nursing, The Rockefeller University, 1230 York Avenue, Hospital, Room 106, New York, NY 10065

Joyce K. Anastasi

New York University Rory Meyers College of Nursing, 380 Second Avenue, Suite 305, New York, NY 10010

This paper continues the series on the observational study designs, focusing on the cohort design. The word ‘cohort’ was adopted from the Roman term of 300 to 600 fighting soldiers who march together ( Hood, 2009 ; Hulley, 2013 ). The epidemiology community-initiated using ‘cohort’ during the 1930s to mean a “designated group which are followed or traced over a period of time “( Hood, 2009 , p. E2). The term is currently defined as a group of people with pre-defined common characteristic(s) (i.e., smokers, exposure to lead in drinking water, ICU nurses) followed longitudinally with periodic measurements to determine the incidence of specific health outcomes or events ( Alexander, 2015 ; Hulley, 2013 ; Song & Chung, 2010 ). Since cohort studies are observational, study participants are monitored, and study interventions are not provided. This paper describes the prospective and retrospective cohort designs, examines the strengths and weaknesses, and discusses methods to report the results.

Cohort Design

The cohort study design is an excellent method to understand an outcome or the natural history of a disease or condition in an identified study population ( Mann, 2012 ; Song & Chung, 2010 ). Since participants do not have the outcome or disease at study entry, the temporal causality between exposure and outcome(s) can be assessed using this design ( Hulley, 2013 ; Song & Chung, 2010 ). A vital feature of a cohort study is selecting the study participants based on mutual characteristics such as geographic location, birth year, or occupation ( Song & Chung, 2010 ). Cohorts are also selected based on exposure and non-exposure status ( Setia, 2016 ). Ideally, both groups are similar except for the exposure status. Additionally, the cohort can be divided based on exposure categories at study entry.

For example, an investigator could recruit people living with HIV (PLWH) who smoke and do not smoke (never smoked) from the same community and follow them over five years to determine the relationship between smoking status and HIV and the incidence of heart disease and stroke in this population. Alternatively, at study entry, the smokers could be categorized based on the smoking pack-years (less than five pack-years or greater than five pack-years) to determine whether heart disease and stroke are associated with the amount and duration of smoking.

Prospective Cohort Design

The prospective cohort studies are also referred to as longitudinal studies. It is used to answer a specific question(s) in a selected area. Investigators recruit a sample of participants and follow them over time, from the present to the future. At pre-determined time-points, characteristics are measured (using interviews, questionnaires, biological assays, physiologic measures) to understand the relationship between the cohort and study outcome. See figure 1 .

Prospective and Retrospective Cohort Designs

During the recruitment phase, the investigator must identify potential participants who plan to move and difficult to reach during the study’s follow-up phase. The eligibility criteria should reflect this consideration. The investigator should collect contact information from the enrolled participants, telephone, email address, mailing address, and at least two friends or family members the investigator can contact if they move or die during the follow-up phase ( Hulley, 2013 ). Additionally, the study protocol should schedule periodic contact with the participants, such as telephone calls to provide assessment results, study newsletter, or study incentives (gift cards) to keep the participants engaged.

In continuing with the HIV study example, study participants are recruited from local New York City HIV primary care clinics. The study plans to evaluate participants annually for ten years to determine heart disease and stroke incidence. PLWH are eligible to join if they smoke cigarettes with well-controlled HIV (undetectable viral load). At study entry, individual exposures for smoking are determined (smoking pack-years), medical history and cardiovascular health are evaluated. Participants identified at baseline to have heart disease or a history of stroke are excluded from the study. Participants are categorized into two groups based on smoking exposure, less than five pack-years or greater than five pack-years for this study. The independent variables ((predictor variables) (smoking pack-years, blood pressure, weight, waist circumference, lipid levels), and the dependent variable ((outcome), history of heart disease, and stroke) are assessed annually. The longitudinal design allows investigators to compare changes over time (Fitzmaurice, 2008) and determine if the level of exposure (smoking pack-years) and other variables are associated with the outcome (incidence of heart disease and stroke).

Prospective Cohort Design: Strengths and Weaknesses

A primary strength of the prospective cohort design is that it allows investigators to determine the number of new cases (incidence) occurring over time. From our example, the incidence of new-onset heart disease and stroke among the study participants. Additionally, measuring the predictor variables before the onset of the outcome (heart disease and stroke) strengthens the ability to assess the sequence of events and infer the causal basis of an association between the predictor variables and the outcome ( Hulley, 2013 ).

A limitation of using this design is that it requires a large sample size. Alexander and colleagues (2015) recommend at least 100 participants. Additionally, the cost of conducting the study may be costly in terms of participant recruitment, the number of staff to conduct the research, and the collection, storage, and analysis of the outcome measurements. Moreover, some conditions (i.e., breast cancer, chronic obstructive disease), despite being relatively common, could occur at low rates in any given evaluation period and not provide meaningful results. Therefore, participants need to be followed for a longer duration, thus increasing cost and the possibility of participants withdrawing from the study or losing them during follow-ups ( Hulley, 2013 ).

Retrospective Cohort Design

Retrospective cohort studies are also called historical cohort studies. The term historical is fitting since data analysis occurs in the present time, but the participants’ baseline measurements and follow-ups happened in the past ( Hulley, 2013 ). This type of study is feasible if an investigator has access to a dataset that fits the research question. The dataset must also have adequate measurements about the predictor variables. See figure 1 .

Generally, the participants for a retrospective cohort design are generated for other purposes, such as electronic medical records or an administrative database like medicare ( Hulley, 2013 ). This design’s primary goal is to review past data (predictor variables) to examine events or outcomes. Institutional review board approval is required for this design even though actual patient interactions do not occur. For example, to ascertain the incidence of heart disease and stroke among PLWH who smoke, electronic medical records of 500 HIV patients from a local HIV primary clinic are examined over ten years, 2010–2020. For this illustration, HIV patients are categorized by their smoking exposure status: smoking less than five pack-years or greater than five pack-years. The outcome of interest is the incidence of heart disease and stroke.

Retrospective Cohort Design: Strengths and Weaknesses

A strength of the retrospective cohort design is the immediate ability to analyze the outcome since it is already assembled with collected measurements and the participants’ follow-ups. This type of design is also inexpensive to conduct. A primary limitation of this study is that the available dataset may be incomplete, inaccurate, or measurements undertaken that do not match the research question ( Hulley, 2013 ). In other words, the investigator(s) do not have control over the data collection methods and procedures.

Method to Report Results

During the scheduled evaluation periods, investigators count the incidence or the number of participants who develop the outcome of interest (i.e., heart disease and stroke). The methods to measure incidence are risks and rates ( Alexander, 2015 ). Both terms can provide additional information about the exposure of interest (smoking, nonsmoking) by calculating the risk ratio and rate ratio ( Alexander, 2015 ).

Risk and Risk Ratio

The term risk is also known as cumulative incidence . It is defined as the number of participants who develop the outcome of interest divided by the total population (participants from the cohort) at risk ( Alexander, 2015 ). For instance, investigators conduct a study to evaluate the association between smoking and heart disease and stroke among PLWH who attend an HIV primary clinic in lower Manhattan. The investigators follow a total of 1000 PLWH for ten years. Among the 1000 PLWH, 500 were smokers, and 500 were nonsmokers. Participants were evaluated annually. A total of 125 heart disease cases and stroke were diagnosed in the smoking group, while 25 heart disease cases and stroke were diagnosed in the non-smoking group. All the cases of heart disease and stroke were diagnosed at the fifth year follow-up. (See Table 1 for calculations).

Calculation Example

• a = exposed participant and acquires the outcome of interest
• b = exposed participant and does not acquires the outcome of interest
• c = unexposed participant and acquires the outcome of interest
• d = unexposed participant and does not acquire the outcome of interest
• Risk (Cumulative Incidence) of PLWH diagnosed with heart disease/stroke: (a+c)/(a+b+c+d) = 150/1000 = .15 × 100 = 15%
• Risk Ratio among PLWH who smoke for heart disease and stroke: [a/(a+b)] / [c/(c+d)] = (125/500)/(25/500) = .25/.05 = 5

Interpretation Risk Ratio or Rate Ratio

• Risk Ratio or Rate Ratio = 1 Exposure is not preventive or harmful
• Risk Ratio or Rate Ratio > 1 Exposure is harmful
• Risk Ratio or Rate Ratio < 1 Exposure is protective

Rate (Incidence Rate) of heart disease/stroke among PLWH over a ten year period: a + c/ [(a × 5 + ) + (b × 10 $ )] + [(c × 5 + ) + (d × 10 $ )] =150/9250 = 0.016 cases/Person-year

Rate Ratio (Incidence Rate Ratio (IRR)): a/[(a × 5 + ) + (b × 10 $ )] c[(c × 5 + ) + (d × 10 $ ) = 0.026/0.005= 5.2

From the above example, 150 cases of heart disease and stroke were identified from the cohort sample size of 1000. Based on the calculations, the risk for developing heart disease and stroke was 15% among the study participants. Additional analyses using the risk ratio compared the risk between participants exposed (smoker) and unexposed (nonsmoker) to provide further information about the data. The risk ratio illustrates the relative increase or decrease in the incidence between the exposed and unexposed groups ( Alexander, 2015 ). (See Table 1 for calculations).

Using the formula from table 1 , the risk ratio was 5. The results demonstrate that PLWH who smoke (exposed) were five times more likely to be diagnosed with heart disease and stroke than PLWH who were nonsmokers. To further understand the meaning of the risk ratio results, if the result was equal to 1, then the exposure (smoker) did not affect the outcome. In other words, the risk was the same for the exposed and unexposed groups. Similarly, if the risk ratio was less than 1, it indicates that the exposed (smoker) group was protective for heart disease and stroke. When the results are further away (see figure 2 )

Risk Ratio or Rate Ratio Interpretation

Rate and Rate Ratio

The term rate is also known as an incidence rate (IR). It is defined as the number of participants who develop the outcome of interest (heart disease and stroke) divided by the person-time (days, months, years) at risk during follow-up ( Alexander, 2015 ). Person-time is the sum of each participant’s total time free (no heart disease and no stroke) from the outcome of interest. This measure provides the accumulated events (cases of heart disease and stroke) and the speed at which new health outcomes transpire in a study cohort. Another analysis used to compare and understand the rate of speed (increase or decrease) of a health outcome between the exposed and unexposed groups is the rate ratio .

In continuing with the example from above, the calculated rate was 0.016 (see Table 1 ). The result indicates that 0.016 cases of heart disease and stroke per person-year occurred in the sample, with a rate ratio of 5.2. This result indicates that heart disease and stroke rates were 5.2 times greater in the exposed group than in the unexposed group. Similar to the risk ratio , if the result was equal to 1, then the smoking exposure did not affect the outcome. If the rate ratio was less than 1, smoking exposure was protective for heart disease and stroke. The greater the rate ratio is from 1 (null association, the exposure is not preventive or harmful), the exposure had more impact on the study cohort. (see figure 2 ).

Reporting Recommendations

In continuing the Step by Step Research column with the observational studies, the cohort design also has a reporting guideline to explain how a study was conducted and how the results were obtained. Like the cross-sectional study, the cohort study uses the same guideline, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) ( von Elm et al., 2014 ). The report provides specific recommendations for cohort studies in the 22-item checklist to guide investigators in what to include in their manuscript. For consumers of the research, the checklist helps the reader understand the paper better regarding study planning, conduct, findings, and conclusions ( von Elm et al., 2014 ). Additionally, the checklist contains information to allow a study to be replicated, useful to make clinical decisions, and sufficient information to be included in a systematic review ( https://www.equator-network.org/reporting-guidelines/strobe/ ).

The cohort design is an appropriate method to determine the incidence of a health outcome or an event. This design is especially helpful in understanding the natural history of disease and conditions in an identified study population. Additionally, this design allows an investigator to examine the timing between an exposure and outcome(s).

Acknowledgments

This manuscript is supported in part by grant # UL1TR001866 from the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) program, and by the National Institutes of Health/National Institutes for Nursing Research #R01NR017917

Contributor Information

Bernadette Capili, Heilbrun Family Center for Research Nursing, The Rockefeller University, 1230 York Avenue, Hospital, Room 106, New York, NY 10065.

Joyce K. Anastasi, New York University Rory Meyers College of Nursing, 380 Second Avenue, Suite 305, New York, NY 10010.

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• Published: 12 September 2024

Evaluation of a perinatal palliative care program by SWOT analysis

• Francesca Catapano 1 ,
• Giuseppe Ramacieri 1 , 2 ,
• Giacomo Sperti 3 ,
• Luigi Tommaso Corvaglia 1 , 4 &
• Chiara Locatelli 3  

Pediatric Research ( 2024 ) Cite this article

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Perinatal Palliative Care (PPC) is individualized medical-nursing care aimed at improving the quality of life of newborns with life-limiting conditions and to support their families. This study draws on the analysis of the experience gained over ten years by a service of PPC called the “Percorso Giacomo” (PG).

We employed a SWOT analysis to identify the strengths, weaknesses, opportunities, and threats of the PG through a systematic retrospective review of 48 cases followed by the program over the course of 10 years, 21 unsolicited parents’ narrative and 27 experts’ point of view.

Main strengths of the program were communication and parents’ involvement in shared decision-making. Main weaknesses included lack of knowledge of the presence and the role of the PG and lack of resources. For opportunities, the PG proved to be an innovative choice for pregnancies with a fetal life-limiting diagnosis, however threats were identified such as lack of knowledge of PPC and delayed referrals.

The analysis by SWOT method of the 10-year experience of the PG allowed the identification of limitations and areas of improvement, however demonstrated that the PG provided beneficial services to women faced with fetal life-limiting diagnoses.

Perinatal Palliative Care (PPC) practice and literature on this subject is still limited.

This study offers features of the 10-year experience of the Percorso Giacomo (PG), a service of PPC, through a SWOT analysis.

By identifying strengths, weaknesses, opportunities and threats of the PG, the study shows limitations and areas of improvement but also benefits of a PPC service to women with fetal diagnosis of life-limiting condition and may allow replication in other institutions.

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Introduction.

First introduced in the 1960s, the concept of palliative care was developed in England by Dame Cicely Saunders. She was a social worker, a nurse and a physician, encompassing the three essential figures of palliative care and, while caring for patients at the last stage of their lives, focused above all on the alleviation of pain in all its forms – physical, emotional, and spiritual. 1

Gradually, palliative care moved from a purely adult-related field to a pediatric one, and eventually to a perinatal one, recognizing that pain and discomfort can affect newborns, regardless of gestational age. 2 , 3 , 4 Perinatal Palliative Care (PPC) addresses the entire perinatal journey, and it is offered in the case of a fetal or neonatal diagnosis of life-limiting (LLC) and life-threatening (LTC) conditions as a plan to achieve the comfort of the newborn and to support the mother and the family from a medical, emotional, psychological and spiritual points of view. 5 Recent biotechnological advances have made it possible to detect the health status of the developing fetus at an increasingly early stage. Although the absolute number of problems detected has not increased, the number of prenatal investigations has increased exponentially, leading to a growing number of families facing a diagnosis of congenital malformations including serious genetic conditions before the birth. 6 , 7 After such serious diagnostic communication, pregnancy becomes a time of apprehension and uncertainty. 8 , 9 Thus, it is essential to give parents honest and non-directive information to guide them toward an informed choice regarding the pregnancy management and the clinical care of the infant. 10 , 11

The importance of PPC has been recognized by the American College of Obstetrics and Gynecologists (ACOG) that recommends PPC as one of the options, along with termination of pregnancy and neonatal intensive care, to be offered to families facing a fetal diagnosis of LLC. 12

Although palliative care has been established as a discipline to support adult and pediatric patients, this is not true for PPC. Currently, there are no international standardized protocols for PPC, 13 and this discipline is not included in everyday clinical practice in the United States, and elsewhere, including Italy. 14 , 15 , 16 However, given the scientific evidence of the benefit derived from a PPC approach 17 , 18 , 19 , 20 , 21 and the recognition of its importance by major perinatal organizations, namely the American Academy of Pediatrics (AAP) 22 and the Italian Society of Neonatology (SIN), 23 some services of PPC have been implemented in Italian institutions. 24

This is the case of “Percorso Giacomo” (PG) or “Giacomo’s Pathway” a program of PPC created in 2013 at Sant’Orsola Hospital (SOH) in Bologna, Italy 24 following guidelines established by the Neonatal Comfort Care Program (NCCP) at the Columbia University Irving Medical Center (CUIMC) in New York, NY. 25

The aim of this research is to evaluate the 10-year experience of the PG to assess the features (strengths, weaknesses, opportunities, and threats) that may allow its replication in other institutions.

Materials and methods

This research was approved by the ethics committee of the Sant’Orsola Hospital in Bologna, Italy.

A SWOT analysis was conducted to identify external (opportunities, threats) and internal (strengths and weaknesses) components of the PG program based on a systematic retrospective review of patient medical records, parents’ narratives and experts’ point of view.

The investigation was divided in 2 phases.

First phase

Medical records of pregnant women and of their newborns followed by the PG from January 1 st 2013 to March 31 st 2024 were inspected. This is a selected population of women who elected to continue their pregnancy in the settings of a fetal LLC and to establish a postnatal plan of comfort care in case of livebirth.

Data collected included: fetal diagnosis and gestational age at the time of first encounter with the PG team and written narratives from each encounter’s debriefing, both prenatally and postnatally. A post-encounter debriefing is a critical component of the PG’s each case management – whether the pregnancy outcome is fetal demise, stillbirth, livebirth followed by neonatal death – and is aimed at pointing out what went well and potential areas for improvement. We also collected written unsolicited feedback from families. Through content analysis we obtained 16 attributes.

Second phase

The SWOT (Strengths, Weaknesses, Opportunities and Threats) analysis 26 , 27 was obtained from the results of the content analysis. The SWOT categories were subsequently assessed through an anonymous questionnaire designed on a Qualtrics platform. The survey included participants’ demographic information and the SWOT categories to be assessed with quantitative Likert agreement/disagreement scale (1= strongly disagree; 2= disagree; 3= neutral; 4= agree; and 5= strongly agree). Participants, including professionals and parents were selected through purposive sampling. Inclusion criteria for health care providers were participation at least once to the care of families followed by the PG, and experience in treating infants with LLC. Inclusion criteria for parents were perinatal loss at least 5 years prior to the study period and Italian speaking. Participants received the questionnaire via email, after they had consented to participate. The results were analyzed using descriptive statistics.

Forty-eight women with fetal LLC were followed by the PG team and the first encounter for 87% occurred in the third trimester. Fetal diagnoses included Anencephaly ( N  = 7), Renal dysplasia ( N  = 8), Trisomy 18 ( N  = 9), Trisomy 21 complicated with severe hydrops ( N  = 1), Skeletal dysplasia ( N  = 1), Cystic hygroma ( N  = 1), Spinal muscular atrophy with congenital fractures ( N  = 1), Congenital heart disease with single ventricle anatomy ( N  = 8), Thanatophoric dysplasia ( N  = 1), Glioblastoma ( N  = 1), Multiple malformations ( N  = 7), Trisomy 13 ( N  = 3). Outcomes included fetal demise (8), stillbirth (7) and live birth (33). The 33 newborns were treated with comfort care according to previously published guidelines 24 and survival ranged from few hours to 127 days. Twenty-one parents submitted unsolicited written narrative commenting the experience of their newborns’ care.

Figure  1 shows the attributes summarized in SWOT categories. The strengths are characterized by the semantic field of the relationship (quote from a parent narrative: “when I met your team, I finally felt relieved […]” ), while the weaknesses concern issues relating to organization and resources (quote from a PG team member: “It was hard to dedicate plenty of time to this family along with our responsibilities in the NICU […]”) . With regard to the opportunities, the innovation and the necessity of such a pathway emerged (quote from a parent narrative: “For us, the Giacomo’s pathway was that light at the end of the tunnel, the hope that our little girl could also have the embrace of her mummy, her daddy and her brothers or whoever we wanted in our private moment”) . Threats were characterized by lack of knowledge of the subject leading to difficult integration in everyday practice (quote from a PG team member “ It was challenging to involve the primary neonatologist in the palliative plan of care, I could feel her hesitation […]”) .

Summary of Strengths, Weaknesses, Opportunities, and Threats analysis of Giacomo’s Pathway.

Thirty-eight questionnaires were sent to 30 professionals and 8 parents, and 27 answers were collected and analyzed. Table  1 shows the results of evaluation through questionnaire. The responders included 8 physicians, 13 nurses and midwives and 6 parents.

In this study we present features (strengths, weaknesses, opportunities, and threats) of a service of perinatal palliative care, the PG, by using SWOT analysis.

The main finding is that communication is a pivotal point of our program. The items “Ability to communicate the diagnosis in an understandable and transparent manner to parents” and “Willingness to listen to and involve parents in shared decision-making” were considered the most important strengths in this study. It is well recognized that the moment of the communication of a prenatal diagnosis is a delicate and critical step and determines the experience of the reminder of the pregnancy. 28 , 29 When a woman is informed of a fetal LLC diagnosis the pregnancy turns, from a time of hope and expectation to a time of apprehension, anxiety, because of difficult decisions. 30 Careful communication with the family is essential to provide all the necessary information, in a comprehensive and transparent manner to the family, facilitating decisions aligned with the family’s cultural beliefs and values. The communication method should be aimed at creating a relationship of trust between the team and the parents, essential for the safe and effective management of the entire process.

Other strengths of the study include “Ongoing training and education” and “Expertise in perinatal palliative care ”. It is essential for professionals in perinatology to be proficient in PPC in order to be able to face the complexity of the medical and non-medical care of the dyad mother/baby. In fact, despite various recommendations for training in the field of perinatal palliation, 21 , 31 gaps in knowledge and competence are still present. 32 Thus, these results suggest the importance of developing training courses and offering formal education to professionals to facilitate competence in perinatal communication. 33 , 34

Finally, the “ Presence of a multi-disciplinary team ” has been identified as a strength of the PG, mirroring what has been abundantly reported in literature. 26 , 30

A timely prenatal palliative counseling is essential in the settings of a fetal diagnosis of LLC when the parents elect to continue their pregnancy. Parents need to have a good knowledge of the wide range of prognoses associated with a specific diagnosis in order to make an informed decision regarding delivery and postnatal plan of care. The earlier the perinatal journey starts, the easier is for parents to be ready for the celebration of the birth of their baby, especially when the infant’s life is expected to be short. 25 , 29 , 35

The results of this study identified some weaknesses related to the process of prenatal counseling of the PG. The highest score went for “Lack of providers’ communication to parents about the PG pathway” and “Lack of knowledge of the presence and role of the PG in the hospital” . Narrative from families reported difficulties in coming to the knowledge of the option of PPC and of the presence of the program in our institution. “It was not easy to find it (the PG) and realise that we too could be part of it” . This aspect is certainly associated with the lack of understanding of providers about the role of palliative care, 20 especially in the perinatal field. “ Lack of standardized guidelines” obtained a relatively low score, reflecting the fact that the PG team developed its guidelines. 24 However, “ Lack of time” and “Inadequate dedicated and private space for parents” remain challenging issues, most likely associated with one of the threats: “Lack of funding to support the PG” . Team members make themselves available to the PG patients and their families in addition to their hospital responsibilities and the space in our institution is quite limited, thus, despite our best attempts, it has been difficult to assure privacy. These limitations have been mentioned by other authors. 36

Opportunities

Building a new PPC program requires motivation, time, energy and funds; however, it is clear that this type of care is needed and has been proven to be beneficial 12 , 29 , 37 as an “Innovative choice available to women who elect to continue their pregnancy” . It is also crucial to point out that the PG constitutes a “Unique opportunity for families given the lack of similar pathways in the Italian context” . Unfortunately, PPC in Italy is not yet routinely integrated in the care of pregnancies with fetal LLC diagnosis, and only few centers provide a comprehensive service of PPC. 15

This study identifies several factors which threatened the success of the PG including the “ Lack of funding to support the PG” , leading to some of the weaknesses identified above. Moreover, we believe that the “Lack of knowledge about perinatal palliative care” and the “Misunderstanding of the role of palliative care” led to the “L ack of or delayed referral to the PG team” , as reported by some families’ narrative. Fruitful attempts to educate perinatal professionals to the knowledge and the role of PPC and, specifically the service of the PG, have been the organization of annual conferences and training courses led by national and international experts in this field. 38

In conclusion, the SWOT analysis of the 10-year experience of the PG showed important weaknesses and threats, mostly associated with lack of knowledge of the role of PPC, the presence of the PG in the institution, and lack of resources. However, the results demonstrated that the PG provided beneficial services to women faced with fetal LLC diagnoses. Communication and parents’ involvement in shared decision-making scored quite high in strengths. Moreover, the PG proved to be an innovative choice for women who elect to continue the pregnancy, and pretty unique in the Italian context, given the lack of similar programs. The narrative of one family sums it up: “The Percorso Giacomo for us was the light at the end of the tunnel, the hope that our little girl could enjoy the embrace of her mum, her dad and her brothers and whoever we wanted in the precious and private moment of her birth” .

Data availability

The datasets generated and analyzed during the current study are available upon request to the corresponding author.

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Acknowledgements

We would like to thank all the families who allowed us to do this work. We would also like to thank all the professionals involved in the Giacomo’s Pathway for their valuable contributions.

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Francesca Catapano, Giuseppe Ramacieri & Luigi Tommaso Corvaglia

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F.C. designed the study, collected the data, and wrote the manuscript. G.S. and G.R. managed, entered, and analyzed the data. C.L. designed the study and drafted the initial manuscript and L.T.C. drafted the initial manuscript. All authors contributed to the article and approved the submitted version.

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DOI : https://doi.org/10.1038/s41390-024-03366-2

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Predictive modeling for concrete properties under variable curing conditions using advanced machine learning approaches

• Published: 17 September 2024

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• Nischal P. Mungle 1 ,
• Dnyaneshwar M. Mate 2 ,
• Sham H. Mankar 3 ,
• Vithoba T. Tale 2 ,
• Ankita Mehta 4 ,
• Shrikrishna A. Dhale 5 &
• Vikrant S. Vairagade   ORCID: orcid.org/0000-0001-8357-5253 5  

Such is the need for this work, since accurate concrete strength prediction at different curing conditions is critical to having structures that are both strong and long-lasting. Traditional methods for the prediction of concrete strength often lack the complexity that occurs in the interaction of the different environmental factors involved, hence leading to suboptimal practices in curing with potential structural weaknesses. Current research into this area has typically focused on disparate data sources and rather naïve modeling methods, further limiting predictive accuracy and creating a general lack of comprehensive knowledge of curing dynamics. Such limitations bring out the need for a more integrated, sophisticated predictive modeling approach to explain variability in concrete strength levels. This paper proposes a novel predictive modeling framework that will be powered by advanced machine learning techniques to take up these challenges. It will adopt a multimodal data integration approach driven by a combination of sensor data related to temperature, humidity, and strain gauges; environmental data related to weather conditions and atmospheric pressure; and historical records, such as mix design and curing duration, further leveraging techniques from data fusion, including the Kalman filter and Bayesian networks. This will be further integrated into a unified, enriched dataset, encapsulating the complex interaction of factors influencing concrete strength. In the present work, this is a chosen approach: hybrid modeling with ensemble learning using XGBoost for the prediction of static features, and Long Short-Term Memory (LSTM) networks for capturing temporal dependencies. In this case, a combination of these models via weighted averaging or stacking improves the accuracy of the predictions to a very great extent: the R² increased from 0.85 to 0.92, and MAE levels by 10–15%. In addition to that, AutoML with Feature Tools implements advanced feature engineering through the generation and selection of optimal features on transformation and aggregation primitives, further refining model performance and interpretability. This process at times reduces the Root Mean Squared Error levels by 5–10%. Finally, Bayesian Neural Networks together with Sobol sensitivity analysis can be used for handling uncertainty and uncovering key factors. BNN provides probabilistic predictions, therefore 95% confidence intervals, while Sobol analysis identifies those critical features that contribute more to variability and allows an in-depth understanding of the role each factor has in driving concrete strength. Indeed, the framework propounded in this work has made great strides in predictive abilities concerning concrete strength variability and will permit more efficient curing practices, thereby making construction outcomes more secure and long-lasting.

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Acknowledgements

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The authors did not receive any funds, grants, or other support from any organization for the submitted work.

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Nischal P. Mungle

Department of Mechanical Engineering, JSPM’s Rajarshi Shahu College of Engineering, Pune, Maharashtra, 440033, India

Dnyaneshwar M. Mate & Vithoba T. Tale

Department of Mechanical Engineering, PCET’s Pimpri Chinchwad College of Engineering and Research Ravet, Pune, Maharashtra, 412101, India

Sham H. Mankar

Department of Computer Science and Application, Ramdeobaba University, Nagpur, Maharashtra, 440013, India

Ankita Mehta

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All the authors conceived of the presented idea. NPM and DMM: Material preparation, data collection and analysis, SHM & VTT; Conceptualization and formulation, AM and VSV: Drafting of the paper, result analysis and conclusion, SAD: Supervision, final correction and commented on earlier drafts. All authors have read and approved the final manuscript.

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Correspondence to Vikrant S. Vairagade .

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Mungle, N.P., Mate, D.M., Mankar, S.H. et al. Predictive modeling for concrete properties under variable curing conditions using advanced machine learning approaches. Asian J Civ Eng (2024). https://doi.org/10.1007/s42107-024-01174-x

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Received : 06 August 2024

Accepted : 08 September 2024

Published : 17 September 2024

DOI : https://doi.org/10.1007/s42107-024-01174-x

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