Search

OBJECTIVE: Aggregation (i.e., meta-ethnography or meta-synthesis) of qualitative studies remains relatively rare and controversial. We have attempted this procedure within an investigation of patient priorities and evaluations of primary care in order to triangulate an instrument development process as well as explore associated dilemmas. METHODS: The procedures included a literature search of qualitative research on patient priorities and evaluations and creation of a framework for quality assessment of retrieved papers. The tool for the evaluation of quality in qualitative studies was piloted, refined, and applied to the retrieved literature. The articles were equally distributed between two teams in random fashion, and inter-rater agreement calculated. Finally, we formulated and applied a strategy for aggregation of data from included papers that allowed comparison to a systematic review of quantitative studies on the topic. RESULTS: Thirty-seven articles met inclusion criteria. Twenty-four of these articles were of sufficient quality to be included in the qualitative aggregation. Inter-rater agreement ranged from 0.22 to 0.77 and 0.38 to 0.60 for pair and assessor comparisons, respectively. The aggregation strategy enabled synthesis within sub-categories of the heterogeneous papers. CONCLUSIONS: We have devised a modestly reliable instrument to assess the quality of qualitative work. The procedure for quality assessment and aggregation appears to be both feasible and potentially useful, though both theoretical and practical problems underline the need for further refinement prior to widespread utilization of this approach. PRACTICE IMPLICATIONS: An instrument to assess the quality of qualitative work within the context of aggregation efforts is described. Calculating inter-rater reliability in this framework can support future quality assessments. A method of breaking a heterogeneous collection of included papers into sub-categories to enable aggregation of qualitative studies is applied and demonstrates its feasibility and potential usefulness. [ABSTRACT FROM AUTHOR]

Objectives: As coronavirus disease 2019 is a novel disease, treatment strategies continue to be debated. This provides the intensive care community with a unique opportunity as the population of coronavirus disease 2019 patients requiring invasive mechanical ventilation is relatively homogeneous compared with other ICU populations. We hypothesize that the novelty of coronavirus disease 2019 and the uncertainty over its similarity with noncoronavirus disease 2019 acute respiratory distress syndrome resulted in substantial practice variation between hospitals during the first and second waves of coronavirus disease 2019 patients., Design: Multicenter retrospective cohort study., Setting: Twenty-five hospitals in the Netherlands from February 2020 to July 2020, and 14 hospitals from August 2020 to December 2020., Patients: One thousand two hundred ninety-four critically ill intubated adult ICU patients with coronavirus disease 2019 were selected from the Dutch Data Warehouse. Patients intubated for less than 24 hours, transferred patients, and patients still admitted at the time of data extraction were excluded., Measurements and Main Results: We aimed to estimate between-ICU practice variation in selected ventilation parameters (positive end-expiratory pressure, Fio 2 , set respiratory rate, tidal volume, minute volume, and percentage of time spent in a prone position) on days 1, 2, 3, and 7 of intubation, adjusted for patient characteristics as well as severity of illness based on Pao 2 /Fio 2 ratio, pH, ventilatory ratio, and dynamic respiratory system compliance during controlled ventilation. Using multilevel linear mixed-effects modeling, we found significant ( p ≤ 0.001) variation between ICUs in all ventilation parameters on days 1, 2, 3, and 7 of intubation for both waves., Conclusions: This is the first study to clearly demonstrate significant practice variation between ICUs related to mechanical ventilation parameters that are under direct control by intensivists. Their effect on clinical outcomes for both coronavirus disease 2019 and other critically ill mechanically ventilated patients could have widespread implications for the practice of intensive care medicine and should be investigated further by causal inference models and clinical trials., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: The three-year pre-medical programme 'Becoming a Physician' focuses on different aspects of medical professionalism. Objectives are to increase awareness and sensitivity to disadvantaged populations, and practise sensitive effective communication skills., Methods: The curriculum includes: (1) Visits to treatment centres for people with special needs, mental illnesses, substance abuse issues, physically or sexually abused, and prisoners. Students tour the facility, hold discussions with residents, and discuss ethical professional interrelations to the medical world. Students then write 'reflective diaries' summarizing their thoughts and emotions. (2) Participation in a communication course that focuses on learning by practising patient-oriented communication. Qualitative data were collected from three sources: reflective diaries, students' course evaluations, and interviews with the students' tutors., Results: Data indicated that the students were very satisfied with the programme. They indicated an increase in awareness of the special needs of diverse populations, and in the sense of efficacy for conducting interviews tailored to patients' needs. Tutors reported a sense of 'personal growth' following their role as mentors., Reflections: Interactions of medical students with diverse populations, when accompanied by appropriate feedback mechanisms and strengthening of communication skills, can improve awareness and sensitivity to patients' special needs. This could help students become more sensitive and thoughtful physicians.

Background: Organ failure in severe sepsis and septic shock may be caused by microcirculatory failure., Objective: The objective of this study is to test a conceptual model of microcirculatory failure by using a resuscitation strategy targeting early opening of the constricted microcirculation with active vasodilatation., Design: A randomised controlled pilot study., Setting: Single-centre mixed medical and surgical tertiary ICU., Patients: Ninety severe sepsis and septic shock patients randomised to early opening microcirculation resuscitation group or standard resuscitation group., Interventions: Standard resuscitation group: fluids, noradrenaline, dobutamine and hydrocortisone were given to achieve a mean arterial pressure (MAP) of more than 60 mmHg, cardiac index more than 2.5 l min m and ScvO2 more than 70%. Microcirculation resuscitation group: nitroglycerin, enoximone, dopamine and dexamethasone targeting a microvascular flow index (MFI), measured by sublingual side-stream dark field imaging, more than 2.5., Main Outcome Measure: A decrease in organ failure score (SOFA) on day four of ICU treatment., Results: Data from 37 microcirculation resuscitation and 28 standard resuscitation patients were analysed. In the microcirculation resuscitation group, MFI of more than 2.5 was achieved after a mean ± SD of 7.0 ± 4.6 h. The microcirculation resuscitation group received more fluids, and noradrenaline was equally prescribed in both groups. Per protocol, the decrease in SOFA score at day 4 was not different between groups (P = 0.64). There was a significant reduction in SOFA score in both groups compared with admission (1.2 and 1.6 in microcirculation resuscitation and standard resuscitation groups, respectively; P = 0.028 and P = 0.045)., Conclusion: Early opening of the microcirculation in patients with severe sepsis and septic shock using nitroglycerin, enoximone, dopamine and corticosteroids did not result in a faster reduction in organ failure than standard resuscitation., Trial Registration: Clinicaltrials.gov identifier NCT00484133.

In the light of the growing interest in professionalism and non-cognitive attributes in medical education, a focus group (FG) methodology was used to achieve a database of desired physician attributes. Ten FGs, consisting of medical faculty, service heads, residents, general practitioners, students and patients, took place, producing 169 desired attributes; further attributes were derived from a literature search, and the Mission and Vision Statement (MVS) of the authors' medical faculty. A total of 254 separate attributes finally emerged, after a process of combining and collapsing similar items. Attributes appearing with the highest frequency were: honest, empathic, patient, capacity to be an attentive listener, understanding, able to work in a team, intellectual curiosity, egalitarian. The high number of attributes generated in this study provides an indication of what the profession is wanting of itself. This database is multipotential and preliminary in nature and requires further processing before achieving full relevance.

Background: Which medical specialties do Israeli medical graduates choose? Answers to this question can serve as an essential means of evaluating both Israeli medical education and the healthcare system., Objectives: To determine the distribution of medical specialty choice, its change over time and the possible influence of the medical school on the choice; to study the graduates' gender, gender variability in specialty choice and time trends in both; and to assess the choice of family medicine as a career among the graduates as a group, by medical school, gender, and time trends., Methods: The study population comprised all graduates of the four medical schools in Israel during 16 years: 1980-1995 inclusive. Data were obtained from the four medical schools, the Israel Medical Association's Scientific Council, and the Ministry of Health. Data allowed for correct identification of two-thirds of the graduates., Results: A total of 4,578 physicians graduated during this period. There was a significant growth trend in the proportion of women graduates from 22.6% in 1980 (lowest: 20.0% in 1981) to 35.3 in 1995 (highest: 41.5% in 1991). Overall, 3,063 physicians (66.8%) started residency and 1,714 (37.4%) became specialists. The four most popular residencies were internal medicine, pediatrics, obstetrics and gynecology, and family medicine. Ten percent of Israeli graduates choose family medicine., Conclusions: The overall class size in Israel was stable at a time of considerable population change. Women's place in Israeli medicine is undergoing significant change. Family medicine is one of the four most popular residencies. A monitoring system for MSC in Israel is imperative.

Building on a body of research which confirms that psychosocial factors have an important influence on health in general and on pregnancy outcomes in particular, we carried out a prospective study of pregnant women in Israel. We hypothesized that medical pregnancy and delivery outcomes are mediated by psychosocial coping resources and risks. Resources were defined as social ties, and risks as life events self-reported as stressful. The population studied included 233 women who responded to questionnaires after the second trimester of pregnancy. Medical data on the delivery were collected from hospital archives. The questionnaire measured biomedical risks, including general medical and obstetrical history, as well as health behaviours, social ties, and perceived stress. Pregnancy outcomes were classified according to medical measures of abnormalities in mother and child at birth. Our findings show that resources such as the variety of social ties (family, friends, neighbours and colleagues) interacted significantly with biomedical risk. It was found that low scores for social ties anticipated 3.6 times higher negative medical outcome in otherwise healthy women than in those with higher scores for social ties. The findings of the study are discussed in terms of their implications for relating to social competence as a determining element in health and health behaviour.