Élaboration de scénarios sur le professionnalisme pour le continuum éducatif des apprenants au sein d'une communauté de pratique médicale et infirmière

Background: It is challenging to develop professionalism curricula for all members of a medical community of practice. We collected and developed professionalism vignettes for an interactive professionalism curriculum around our institutional professionalism norms following social constructivist learning theory principles. Methods: Medical students, residents, physicians, nurses and research team members provided real-life professionalism vignettes. We collected stories about professionalism framed within the categories of our Faculty’s code of conduct:  honesty; confidentiality; respect; responsibility; and excellence. Altruism was from the Nursing Code of Ethics. Two expert committees anonymously rated and then discussed vignettes on their educational value and degree of unprofessional behaviour. Through consensus, the research team finalized vignette selection. Results: Eighty cases were submitted: 22 from another study; 20 from learners and nurses; and 30 from physicians; and eight from research team members. Two expert committees reviewed 53 and 42 vignettes, respectively. The final 18 were selected based upon: educational value; diversity in professionalism ratings; and representation of the professionalism categories. Conclusion: Realistic and relevant professionalism vignettes can be systematically gathered from a community of practice and their representation of an institutional norm, educational value, and level of professional behaviour can be judged by experts with a high level of consensus.Contexte : Il est difficile de concevoir des programmes d'enseignement sur le professionnalisme pour l'ensemble des membres d'une communauté de pratique médicale. Nous avons recueilli et préparé des scénarios pour un programme interactif sur le professionnalisme, fondé sur les normes de notre établissement en la matière, selon une approche socioconstructiviste de l'apprentissage. Méthodes : Des étudiants en médecine, des résidents, des médecins, des infirmières et des membres de l'équipe de recherche ont proposé des scénarios de situations de la vie réelle sur le sujet du professionnalisme. Nous avons recueilli des témoignages sur le professionnalisme s'inscrivant dans les catégories du code de conduite de notre faculté, à savoir l'honnêteté, la confidentialité, le respect, la responsabilité et l'excellence, auxquelles s'ajoute l'altruisme, tiré du Code de déontologie des soins infirmiers. Deux comités d'experts ont examiné la valeur éducative et le degré de non-professionnalisme décrit, et ils ont évalué de façon anonyme les scénarios. L'équipe de recherche a fait la sélection finale de scénarios par consensus. Résultats : Parmi les 80 cas soumis, 22 provenaient d'une autre étude, 20 ont été proposés par des apprenants et des infirmières, 30 par des médecins et huit par des membres de l'équipe de recherche. Deux comités d'experts ont examiné 53 et 42 scénarios, respectivement. Les 18 scénarios retenus ont été choisis pour leur valeur éducative, la diversité des évaluations du professionnalisme et leur représentativité des diverses catégories de professionnalisme. Conclusion : Des scénarios réalistes et pertinents sur le sujet du professionnalisme peuvent être systématiquement recueillis auprès de communautés de pratique. Des experts peuvent déterminer, avec un degré élevé de consensus, la valeur éducative des scénarios, le niveau du comportement professionnel qu'ils décrivent et dans quelle mesure ils reflètent les normes de l'établissement concerné

the journal's role

publishersversionepub_ahead_of_prin

Real world costs and cost-effectiveness of Rituximab for diffuse large B-cell lymphoma patients: a population-based analysis.

BackgroundCurrent treatment of diffuse-large-B-cell lymphoma (DLBCL) includes rituximab, an expensive drug, combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy. Economic models have predicted rituximab plus CHOP (RCHOP) to be a cost-effective alternative to CHOP alone as first-line treatment of DLBCL, but it remains unclear what its real-world costs and cost-effectiveness are in routine clinical practice.MethodsWe performed a population-based retrospective cohort study from 1997 to 2007, using linked administrative databases in Ontario, Canada, to evaluate the costs and cost-effectiveness of RCHOP compared to CHOP alone. A historical control cohort (n = 1,099) with DLBCL who received CHOP before rituximab approval was hard-matched on age and treatment intensity and then propensity-score matched on sex, comorbidity, and histology to 1,099 RCHOP patients. All costs and outcomes were adjusted for censoring using the inverse probability weighting method. The main outcome measure was incremental cost per life-year gained (LYG).ResultsRituximab was associated with a life expectancy increase of 3.2 months over 5 years at an additional cost of $16,298, corresponding to an incremental cost-effectiveness ratio of$61,984 (95% CI $34,087-$135,890) per LYG. The probability of being cost-effective was 90% if the willingness-to-pay threshold was $100,000/LYG. The cost-effectiveness ratio was most favourable for patients less than 60 years old ($31,800/LYG) but increased to $80,600/LYG for patients 60-79 years old and$110,100/LYG for patients ≥ 80 years old. We found that post-market survival benefits of rituximab are similar to or lower than those reported in clinical trials, while the costs, incremental costs and cost-effectiveness ratios are higher than in published economic models and differ by age.ConclusionsOur results showed that the addition of rituximab to standard CHOP chemotherapy was associated with improvement in survival but at a higher cost, and was potentially cost-effective by standard thresholds for patients <60 years old. However, cost-effectiveness decreased significantly with age, suggesting that rituximab may be not as economically attractive in the very elderly on average. This has important clinical implications regarding age-related use and funding decisions on this drug

What are the views of adults with an intellectual disability (AWID), carers and healthcare professionals on a community falls management programme for AWID: a qualitative interview study in the UK

Objectives The aim of this study was to refine a draft of the ACTiON FALLS LD programme based on the views of adults with an intellectual disability (AWID), carers and healthcare professionals (HCPs). Design, setting and participants The semistructured interview study included HCP as well as AWID and carers supporting AWID living in the community. Community settings included sheltered living, supported living, AWID living at home with family carers or independently. The interview study explored the first draft of the ACTiON FALLS LD programme as well as the wider falls management for AWID. Interviews with AWID were developed to include a range of approaches (eg, case studies, pictures) to support inclusive participation. Individual interviews were digitally recorded and transcribed. Researcher notes were used during interviews with AWID. All data were analysed using the principles of framework analysis. Results 14 HCP, 8 carers and 13 AWID took part in the interview process. Five key themes were identified: programme components, programme design, programme approach, who would use the programme and programme delivery. Conclusions The views of AWID, HCP and carers showed the need to consider the impact of risk perception, anxiety and fear of falling in the adaption of the ACTiON FALLS programme. The programme needs to be accessible and support the inclusion of AWID in managing falls and ultimately fulfil the requirement for a proactive and educational tool by all.</p

Early mobilization and recovery in mechanically ventilated patients in the ICU: a bi-national, multi-centre, prospective cohort study

Introduction: The aim of this study was to investigate current mobilization practice, strength at ICU discharge and functional recovery at 6 months among mechanically ventilated ICU patients. Method: This was a prospective, multi-centre, cohort study conducted in twelve ICUs in Australia and New Zealand. Patients were previously functionally independent and expected to be ventilated for >48 hours. We measured mobilization during invasive ventilation, sedation depth using the Richmond Agitation and Sedation Scale (RASS), co-interventions, duration of mechanical ventilation, ICU-acquired weakness (ICUAW) at ICU discharge, mortality at day 90, and 6-month functional recovery including return to work. Results: We studied 192 patients (mean age 58.1 ± 15.8 years; mean Acute Physiology and Chronic Health Evaluation (APACHE) (IQR) II score, 18.0 (14 to 24)). Mortality at day 90 was 26.6% (51/192). Over 1,351 study days, we collected information during 1,288 planned early mobilization episodes in patients on mechanical ventilation for the first 14 days or until extubation (whichever occurred first). We recorded the highest level of early mobilization. Despite the presence of dedicated physical therapy staff, no mobilization occurred in 1,079 (84%) of these episodes. Where mobilization occurred, the maximum levels of mobilization were exercises in bed (N = 94, 7%), standing at the bed side (N = 11, 0.9%) or walking (N = 26, 2%). On day three, all patients who were mobilized were mechanically ventilated via an endotracheal tube (N = 10), whereas by day five 50% of the patients mobilized were mechanically ventilated via a tracheostomy tube (N = 18). In 94 of the 156 ICU survivors, strength was assessed at ICU discharge and 48 (52%) had ICU-acquired weakness (Medical Research Council Manual Muscle Test Sum Score (MRC-SS) score <48/60). The MRC-SS score was higher in those patients who mobilized while mechanically ventilated (50.0 ± 11.2 versus 42.0 ± 10.8, P = 0.003). Patients who survived to ICU discharge but who had died by day 90 had a mean MRC score of 28.9 ± 13.2 compared with 44.9 ± 11.4 for day-90 survivors (P <0.0001). Conclusions: Early mobilization of patients receiving mechanical ventilation was uncommon. More than 50% of patients discharged from the ICU had developed ICU-acquired weakness, which was associated with death between ICU discharge and day-90

A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome

INTRODUCTION: Tidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration. METHOD: Twenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined. RESULTS: There were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups. CONCLUSIONS: This open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted. TRIAL REGISTRATION: ACTRN12607000465459

Patients’ Expectations of Physiotherapy Treatment for Musculoskeletal Conditions

Relevance Research shows that the expectations a patient brings to treatment have important influences on the clinical relationship, experiences of treatment, the treatment process, outcomes and satisfaction with care. This influence means that patients’ expectations are important for physiotherapists, service providers and researchers to take into account in approaches to care and treatment evaluations. Research highlights the need for a better understanding of expectations of physiotherapy treatment for Msk problems to enable more effective, high quality and cost-beneficial care. Purpose The aim of this qualitative study was to explore prospective responses to an open comment item on patients’ expectations of their physiotherapy treatment that was nested within a larger research project developing and validating the Brighton musculoskeletal Patient Reported Outcome Measure (BmPROM). Methods/Analysis The BmPROM is a generic patient self-report outcome measure developed to evaluate the effectiveness of physiotherapy treatment for musculoskeletal conditions. A validity and reliability study was undertaken with patients newly referred into five NHS physiotherapy outpatient departments in SE England. The outcome tool has open-comment items, which included a pre-treatment invitation to provide expectations of their physiotherapy treatment. A thematic analysis was undertaken of the expectations expressed to gain insights for physiotherapy practice and patient care. Results Analysis was undertaken of 563 expectations of physiotherapy treatment expressed from 224 participants (mean 50.7yrs [17-88yrs]; 60% female) experiencing a range of Msk conditions (Lower limb:30%, Upper limb:25%, Spine:28%, Other/multiple sites:17%). Five key themes were identified. Three themes were outcome-related and desired effects of treatment; Relieving symptoms, predominately pain relief; Regaining and maintaining physical abilities and function; and Improving psychological well-being by enabling coping, confidence and control. Theme four was process-related; Explanation, advice and education, where physiotherapy was seen as a resource to acquire better knowledge, skills and strategies to support resolution, management or prevention. The final theme involved recovery expectations conveyed within responses; Problem resolution and responsibility, where responses implied an expectation of a cure or one of problem management and control. Discussion and conclusions The findings provide an understanding of domains considered important or appropriate by patients when seeking care for Msk problems. The themes show overlap with studies using retrospective explorations and surveys of treatment expectations, and research on outcomes considered important to evaluate within Msk PROMs. The study has also shown that a written method of eliciting expectations can be a valuable clinical tool for use to support discussions concerning treatment aims, strategies, desired outcomes and responsibilities. These communication processes are also likely to be integral to achieving the qualities in the therapist and clinical encounters considered important to patients, of feeling listened to, consulted with and respected, and associated with satisfaction with physiotherapy and features of patient-centred care. Impact and implications Healthcare is changing as evidence-informed practice and cost-benefit drivers influence what and how care is provided. Shifts from traditional understandings about Msk problems and their management makes exploring and addressing patients’ expectations particularly important. Developing ways to support appropriate expectations of physiotherapy treatment remains an important endeavour that is integral to its effectiveness and demonstrating its value

Adaptation and Validation of the ICU Mobility Scale in Spain

Objetivo: adaptar la ICU Mobility Scale (IMS) al ámbito de las unidades de cuidados intensivos (UCI) de España y evaluar las propiedades métricas de la IMS versión española (IMS-Es). Método: estudio descriptivo de carácter métrico desarrollado en dos fases. Fase 1: adaptación al español de la IMS mediante equipo de enfermeras y fisioterapeutas (traducción, piloto, retrotraducción y acuerdo). Fase 2: análisis de propiedades métricas (validez convergente, divergente y predictiva, fiabilidad interobservador, sensibilidad y diferencia mínima importante) de la IMS-Es. Se registraron características de los pacientes (Barthel, Charlson, IMC, sexo), nivel de sedación/agitación (RASS), estancias en UCI y hospital, supervivencia, calidad de vida (SF-12), debilidad muscular (MRC-SS) y movilidad (IMS-Es) en los pacientes del estudio multicéntrico nacional MOviPre. Resultados: tras obtener la IMS-Es, se implementó en 645 pacientes de 80UCI españolas entre abril y junio de 2017. Validez convergente: moderada correlación entre IMS-Es y MRC-SS (r=0,389; p<0,001) y comparación significativa entre grupos con y sin debilidad adquirida en la UCI (p<0,001). Validez divergente: no correlación entre IMS-Es e IMC (r [IC95%]: −0,112 [−0,232 a 0,011]), peso (r [IC95%]: −0,098 [−0,219 a 0,026]), Charlson (r [IC95%]: −0,122 [−0,242 a 0,001]) y Barthel (r [IC95%]: −0,037 [−0,160 a 0,087]) y sin diferencias entre sexos (p=0,587) ni categorías de IMC (p=0,412). Validez predictiva: moderadas y significativas correlaciones con estancia en hospital post-UCI (r [IC95%]: −0,442 [−0,502 a −0,377]) y componente físico del SF-12 (PCS) (r [IC95%]: 0,318 [0,063 a 0,534]); pacientes sin movilización activa en UCI mayor riesgo de mortalidad hospitalaria (OR [IC95%]: 3,769 [1,428 a 9,947]). Fiabilidad interobservador: muy buena concordancia entre enfermeras (CCI [IC95%]: 0,987 [0,983 a 0,990]) y entre enfermera-fisioterapeuta (CCI [IC95%]: 0,963 [0,948 a 0,974]). Sensibilidad al cambio: efecto pequeño al alta de UCI (d=0,273) y moderado a los 3meses del alta hospitalaria (d=0,709). Diferencia mínima importante: punto de corte de la diferencia de 2puntos, sensibilidad del 91,1% y especificidad del 100,0%. Conclusiones: la IMS-Es es útil, válida y fiable para ser implementada por enfermeras de UCI y por fisioterapeutas al valorar la movilidad de los pacientes críticos

Identifying and prioritising unanswered research questions for people with hyperacusis: James Lind Alliance Hyperacusis Priority Setting Partnership

Objective To determine research priorities in hyperacusis that key stakeholders agree are the most important. Design/setting A priority setting partnership using two international surveys, and a UK prioritisation workshop, adhering to the six-staged methodology outlined by the James Lind Alliance. Participants People with lived experience of hyperacusis, parents/carers, family and friends, educational professionals and healthcare professionals who support and/or treat adults and children who experience hyperacusis, including but not limited to surgeons, audiologists, psychologists and hearing therapists. Methods The priority setting partnership was conducted from August 2017 to July 2018. An international identification survey asked respondents to submit any questions/uncertainties about hyperacusis. Uncertainties were categorised, refined and rephrased into representative indicative questions using thematic analysis techniques. These questions were verified as ‘unanswered’ through searches of current evidence. A second international survey asked respondents to vote for their top 10 priority questions. A shortlist of questions that represented votes from all stakeholder groups was prioritised into a top 10 at the final prioritisation workshop (UK). Results In the identification survey, 312 respondents submitted 2730 uncertainties. Of those uncertainties, 593 were removed as out of scope, and the remaining were refined into 85 indicative questions. None of the indicative questions had already been answered in research. The second survey collected votes from 327 respondents, which resulted in a shortlist of 28 representative questions for the final workshop. Consensus was reached on the top 10 priorities for future research, including identifying causes and underlying mechanisms, effective management and training for healthcare professionals. Conclusions These priorities were identified and shaped by people with lived experience, parents/carers and healthcare professionals, and as such are an essential resource for directing future research in hyperacusis. Researchers and funders should focus on addressing these priorities.Additional co-authors: Tracey Pollard, Helen Henshaw, Toto A Gronlund, Derek J Hoar

Structure of the γ-D-glutamyl-L-diamino acid endopeptidase YkfC from Bacillus cereus in complex with L-Ala-γ-D-Glu: insights into substrate recognition by NlpC/P60 cysteine peptidases.

Dipeptidyl-peptidase VI from Bacillus sphaericus and YkfC from Bacillus subtilis have both previously been characterized as highly specific γ-D-glutamyl-L-diamino acid endopeptidases. The crystal structure of a YkfC ortholog from Bacillus cereus (BcYkfC) at 1.8 Å resolution revealed that it contains two N-terminal bacterial SH3 (SH3b) domains in addition to the C-terminal catalytic NlpC/P60 domain that is ubiquitous in the very large family of cell-wall-related cysteine peptidases. A bound reaction product (L-Ala-γ-D-Glu) enabled the identification of conserved sequence and structural signatures for recognition of L-Ala and γ-D-Glu and, therefore, provides a clear framework for understanding the substrate specificity observed in dipeptidyl-peptidase VI, YkfC and other NlpC/P60 domains in general. The first SH3b domain plays an important role in defining substrate specificity by contributing to the formation of the active site, such that only murein peptides with a free N-terminal alanine are allowed. A conserved tyrosine in the SH3b domain of the YkfC subfamily is correlated with the presence of a conserved acidic residue in the NlpC/P60 domain and both residues interact with the free amine group of the alanine. This structural feature allows the definition of a subfamily of NlpC/P60 enzymes with the same N-terminal substrate requirements, including a previously characterized cyanobacterial L-alanine-γ-D-glutamate endopeptidase that contains the two key components (an NlpC/P60 domain attached to an SH3b domain) for assembly of a YkfC-like active site