Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Addressing Vaccine Hesitancy Through a Comprehensive Resident Vaccine Curriculum

Introduction Vaccine hesitancy can lead to incomplete vaccination, increased risk of vaccine-preventable diseases, and distrust or conflict between physicians and patients. Yet many physicians are uncomfortable navigating vaccine hesitancy and educating vaccine-hesitant patients and families. We developed a vaccine hesitancy curriculum to increase vaccine knowledge, comfort, and communication skills in pediatric residents. Methods The curriculum consisted of four interactive 40-minute sessions delivered to pediatric residents over 10 months. The first two sessions discussed recommended childhood vaccines, the third session examined common vaccine misconceptions, and the final session reviewed vaccine hesitancy–specific communication skills, incorporating practice through role-playing. Residents completed pre- and posttests assessing knowledge and comfort as well as receiving a standardized patient (SP) assessment of vaccine-specific communication skills after the curriculum. Results Thirty-five residents were in the educational intervention group and 35 in a control group. Pretest scores did not differ significantly between the groups. The mean knowledge score for the intervention group increased from 47% on the pretest to 66% on the posttest. The mean self-reported comfort score (1 = low comfort, 5 = high comfort) for the intervention group increased from 2.9 on the pretest to 3.8 on the posttest. The control group showed no difference between pre- and posttest scores for knowledge or comfort. The mean postintervention SP assessment score was significantly higher for the intervention group (78%) than the control group (52%). Discussion Implementation of a comprehensive vaccine hesitancy curriculum resulted in improved vaccine knowledge, self-reported comfort, and communication skills among pediatric residents

What Do Pediatric Subinterns Say About Their Learning and Assessment? A Qualitative Analysis of Individual Learning Plans.

OBJECTIVE: To perform a qualitative content analysis of learning and assessment strategies that pediatric sub-interns describe in Individualized Learning Plans (ILPs) and to explore barriers and facilitators to their learning. METHODS: We analyzed ILPs from medical students enrolled in pediatric sub-internships at 10 U.S. medical schools that utilized a standardized curriculum and were recruited to reflect diversity in geographic location, funding, and enrollment. Students used an ILP to record three or more selected learning objectives, rationale for selection, and reflection on learning and assessment strategies. Investigators used the constant comparative method to perform a content analysis of the ILPs, grouping codes into themes, and verifying relationships between codes within themes. RESULTS: 204 ILPs that included student reflections on 850 learning objectives were analyzed. Content was analyzed in five categories: rationale for selecting objectives, learning strategies, assessment strategies, challenges to learning, and facilitators of learning. Students showed strong commitment to individualized, self-directed learning, developed a wide range of creative learning strategies, and relied heavily on self-reflection to assess their progress. The learning environment both helped and hindered students\u27 ability to make and assess progress on their selected learning objectives. CONCLUSIONS: Through ILP-guided reflection and a formal curriculum, students can choose well-justified learning objectives and demonstrate resourcefulness and independence in developing self-directed learning and assessments strategies. The strategies that students identified in this study provide a menu of learning and assessment options for sub-interns. Identified challenges and facilitators of learning provide guidance for educators who seek to enhance the clinical learning environment

Cognitive Enhancement Drug Use Among Future Physicians: Findings from a Multi-Institutional Census of Medical Students

BACKGROUND: Nonmedical use of prescription psychostimulants such as methylphenidate and amphetamine salts for the purpose of cognitive enhancement is a growing trend, particularly in educational environments. To our knowledge, no recent studies have evaluated the use of these psychostimulants in a medical academic setting. OBJECTIVE: To conduct an online census of psychostimulant use among medical students. DESIGN: In 2011, we conducted a multi-institutional census using a 31–48 item online survey regarding use of prescription psychostimulants. PARTICIPANTS: 2,732 actively enrolled medical students at four private and public medical schools in the greater Chicago area. MAIN MEASURES: Prevalence and correlates of psychostimulant use KEY RESULTS: 1,115 (41 %) of students responded to the web-based questionnaire (range 26–47 % among schools). On average, students were 25.1 years of age (SD = 2.7, range 20–49), and single (70 %). Overall, 18 % (198/1,115) of this medical student sample had used prescription psychostimulants at least once in their lifetime, with first use most often in college. Of these, 11 % (117/1,115) of students reported use during medical school (range 7–16 % among schools). Psychostimulant use was significantly correlated with use of barbiturates, ecstasy, and tranquilizers (Pearson’s correlation r > 0.5, Student’s t-test p < 0.01); male gender (21 % male versus 15 % female, Chi squared p = 0.007); and training at a medical school which by student self-report determined class rank (68 % versus 51 %, Chi-squared p = 0.018). Non-users were more likely to be first year students (Chi-squared p = 0.048) or to have grown up outside of the United States (Chi-squared p = 0.013). CONCLUSIONS: Use of psychostimulants, including use without a prescription, is common among medical students. Further study of the side effects, medical implications, and use during post-graduate medical training and medical practice is needed to inform evidence-based policy

The globalizability of temporal discounting

Economic inequality is associated with extreme rates of temporal discounting, which is a behavioral pattern where individuals choose smaller, immediate financial gains over larger, delayed gains. Such patterns may feed into rising global inequality, yet it is unclear if they are a function of choice preferences or norms, or rather absence of sufficient resources to meet immediate needs. It is also not clear if these reflect true differences in choice patterns between income groups. We test temporal discounting and five intertemporal choice anomalies using local currencies and value standards in 61 countries. Across a diverse sample of 13,629 participants, we found highly consistent rates of choice anomalies. Individuals with lower incomes were not significantly different, but economic inequality and broader financial circumstances impact population choice patterns

The general fault in our fault lines

Pervading global narratives suggest that political polarization is increasing, yet the accuracy of such group meta-perceptions has been drawn into question. A recent US study suggests that these beliefs are inaccurate and drive polarized beliefs about out-groups. However, it also found that informing people of inaccuracies reduces those negative beliefs. In this work, we explore whether these results generalize to other countries. To achieve this, we replicate two of the original experiments with 10,207 participants across 26 countries. We focus on local group divisions, which we refer to as fault lines. We find broad generalizability for both inaccurate meta-perceptions and reduced negative motive attribution through a simple disclosure intervention. We conclude that inaccurate and negative group meta-perceptions are exhibited in myriad contexts and that informing individuals of their misperceptions can yield positive benefits for intergroup relations. Such generalizability highlights a robust phenomenon with implications for political discourse worldwide

The general fault in our fault lines

Ruggeri et al. tested perceptions of opposing political party members in 10,207 participants from 26 countries. Results show that beliefs about others are overly negative but could be more realistic with transparency about actual group beliefs. Pervading global narratives suggest that political polarization is increasing, yet the accuracy of such group meta-perceptions has been drawn into question. A recent US study suggests that these beliefs are inaccurate and drive polarized beliefs about out-groups. However, it also found that informing people of inaccuracies reduces those negative beliefs. In this work, we explore whether these results generalize to other countries. To achieve this, we replicate two of the original experiments with 10,207 participants across 26 countries. We focus on local group divisions, which we refer to as fault lines. We find broad generalizability for both inaccurate meta-perceptions and reduced negative motive attribution through a simple disclosure intervention. We conclude that inaccurate and negative group meta-perceptions are exhibited in myriad contexts and that informing individuals of their misperceptions can yield positive benefits for intergroup relations. Such generalizability highlights a robust phenomenon with implications for political discourse worldwide