Non-simulator-based techniques in teaching direct ophthalmoscopy for medical students: a systematic review

Non-simulator-based examination methods of the fundal examination have shown to be cost-effective.We reviewed different non-simulator-based direct fundoscopy examination methods used in undergraduate curricula and their outcomes.PubMed(MEDLINE) and Cochrane Database of Systematic Reviews were searched using standard Medical Subject Heading(MeSH) terms ophthalmoscopy,medical education,undergraduate medical education,medical student,educational assessment and learning.The search included publications until 28^(th)February 2019.We obtained 34 articles after screening abstracts;of them,12 articles were included in the qualitative synthesis.The studies were comprised of diverse teaching methods which included fundal photograph matching with corresponding eye,continuous education using community-based eye clinics,formal instructions and demonstrations prior to skills training,ophthalmoscopy skills practice using eye pathologies,teaching versus conventional ophthalmoscopy and group-based teaching.We concluded that non-simulator-based techniques such as use of fundal photograph matching of an eye of a volunteer,introduction to eye pathologies,smaller student groups and formal instructions with video demonstrations prior to skills training were highly effective in teaching direct ophthalmoscopy for undergraduate medical students.

Preferences for pre-exposure prophylaxis among U.S. military men who have sex with men:results of an adaptive choice based conjoint analysis study

Background: Pre-exposure prophylaxis(PrEP) prevents human immunodeficiency virus(HIV) infection, but its use remains low among U.S. military men who have sex with men(MSM), likely due to mis-matching with personal preferences. We conducted a study to characterize preferences to PrEP measures within this population.Methods: HIV-negative military MSM were recruited through a closed, Lesbian, Gay, Bisexual, and Transgendered(LGBT) military social media group. The survey was anonymous, and consisted of five experimentally varied attributes in service delivery: dosing method, provider type, visit location, lab work evaluation location, and dispensing venue.Relative importance and part-worth utility scores were generated using hierarchical bayes(HB) estimation, and the randomized first choice model was used to examine participation interest across eight possible PrEP program scenarios.Results: A total of 429 participants completed the survey. Among the eight scenarios with varying attributes, the most preferred scenario featured a daily tablet, PrEP injection or implant, along with a military provider, smartphone/telehealth visit, and on-base locations for lab evaluation and medication pick-up. The results also emphasized the importance for providers to be familiar with PrEP prescription knowledge, and to provide interactions sensitive to sexual identity and mental health.Conclusions: A PrEP program consisting of daily tablet is preferred in military healthcare settings is preferred. Longacting implants and injections are also desired.

Human Factors for Clinical Engineering – The Realization of a Guidance Text

Industries such as aviation and nuclear power have greatly improved their safety performance through the application of human factors methods to the design, development, selection and deployment of a range of technologies and work processes. Health care safety performance generally lags behind these industries and would benefit from a similar application of human factors methods. Clinical engineers are in an ideal position to acquire and apply this human factors knowledge, and lead its adoption in health care. This paper describes a text that has been written specifically for clinical engineers and others who design, develop, select and support the use of health care technologies, to enable them to learn the key methods of human factors and adopt them as part of their ongoing work. Early indications are that these approaches help to ensure that health care technologies are used more safely and effectively, and it is hoped that large-scale adoption will result in a noticeable and worthwhile improvement in overall health care safety. The described text is now ready and has been published in English on the IFMBE website. It is available as a free download in PDF format. Clinical engineers and others working around the world in the area of health technology are encouraged to learn and adopt these methods, and use them as appropriate in their local setting. At time of writing, plans are underway for a translation of this book into Spanish. Once completed, this version will also be made available online at no charge. The authors encourage readers to contact them with their experiences, and the aim is to build a worldwide community that gradually adopts these methods and helps to drive safety improvements in health care.

Quality of Health Care in Resource Limited Settings-Patients’ Satisfaction Survey at a Mission Hospital in South East, Nigeria

Introduction: Quality healthcare is a major contributor to health disparities and inequalities in resource limited settings. Patient satisfaction remains an important and valuable method of assessing the quality of care. Aim: This study assessed patients’ satisfaction with quality of inpatient clinical care in a mission hospital in a semi urban setting. Methods: The study was a cross-sectional study carried out on 140 inpatients at a mission hospital in Afikpo, South East Nigeria. Data was collected using pretested structured questionnaires designed on a five-point likert scale with 1 indicating the lowest and 5 indicating the highest scale. Knowledge of factors contributing to quality of care and satisfaction in the following domains: patient-staff relationship, patient-staff (doctors/nurses) communication, facility convenience, technical aspect of care (availability of equipment, drugs and adequacy of staff) and overall general satisfaction were measured. Operationally, patients who rated 3 points and above were considered satisfied while ratings less than 3 points were considered dissatisfied. Results: Knowledge of factors contributing to quality of care was 4.65 ± 0.48. General satisfaction rated 4.22 ± 0.52. Specifically, the different domains had the following scores: inter personal relationship 4.28 ± 0.81, technical aspect of care (availability of drugs, equipment and medical personnel) 4.29 ± 0.57 and facility convenience 4.21 ± 0.51. Conclusions: Knowledge of factors contributing to quality of care and overall patients’ satisfaction with inpatient care were good and comparable with patients’ satisfaction with tertiary health institutions in Nigeria. Mission hospitals may serve as excellent alternatives to government hospitals in resource limited settings to promote health equity across populations.

Utilization of online systems to promote youth participation in research:A methodological study

BACKGROUND Online surveys can align with youth’s increased use of the internet and can be a mechanism for expanding youth participation in research.This is particularly important during the coronavirus disease 2019(COVID-19)pandemic,when inperson interactions are limited.However,the advantages and drawbacks of online systems used for research need to be carefully considered before utilizing such methodologies.AIM To describe and discuss the strengths and limitations of an online system developed to recruit adolescent girls for a sexual health research study and conduct a three-month follow up survey.METHODS This methodology paper examines the use of an online system to recruit and follow participants three months after their medical visit to evaluate a mobile sexual and reproductive health application,Health-E You/Salud iTuTM,for adolescent girls attending school-based health centers(SBHCs)across the United States.SBHC staff gave adolescent girls a web link to an online eligibility and consent survey.Participants were then asked to complete two online surveys(baseline and 3-month follow-up).Surveys,reminders,and incentives to complete them were distributed through short message service(SMS)text messages.Upon completing each survey,participants were also sent an email with a link to an electronic gift card as a thank-you for their participation.Barriers to implementing this system were discussed with clinicians and staff at each participating SBHC.RESULTS This online recruitment and retention system enabled participant recruitment at 26 different SBHCs in seven states across the United States.Between September 2021 and June 2022,415 adolescent girls were screened using the Qualtrics online survey platform,and 182 were eligible to participate.Of those eligible,78.0%(n=142)completed the baseline survey.Participants were racially,geographically,and linguistically diverse.Most of the participants(89.4%)were non-White,and 40.8%spoke Spanish.A total of 62.0%(n=88)completed the 3-month follow-up survey.Limitations of this system included reliance on internet access(via Wi-Fi or cell service),which was not universally available or reliable.In addition,an individual unrelated to the study obtained the survey link,filled out multiple surveys,and received multiple gift cards before the research team discovered and stopped this activity.As a result,additional security protocols were instituted.CONCLUSION Online systems for health research can increase the reach and diversity of study participants,reduce costs for research personnel time and travel,allow for continued study operation when in-person visits are limited(such as during the COVID-19 pandemic),and connect youth with research using technology.However,there are challenges and limitations to online systems,which include limited internet access,intermittent internet connection,data security concerns,and the potential for fraudulent users.These challenges should be considered prior to using online systems for research.

Impact of COVID-19 Pandemic on Haemodialysis Care at a Tertiary Centre in South East Nigeria

COVID-19 pandemic has had a significant impact on health services for patients suffering from chronic diseases. Patients suffering from kidney failure require heamodialysis and this modality of treatment is mostly offered in the hospital. Impacts of COVID-19 pandemic on haemodialysis care at a tertiary institution in South East, Nigeria include a reduction in the number of haemodialysis cases during the period of lockdown, an increase in the cost of heamodialysis, scarcity of materials used for the procedure and minor disruption of haemodialylsis care. An improvement in infection control practice at the dialysis unit is observed as a positive effect. It is advocated that the government should assist patients with kidney disease and make the procedure free to ameliorate the health and socio-economic hardships faced by the patients during the pandemic.

Isolated sacral injuries: Postoperative length of stay, complications, and readmission

AIM: To investigate inpatient length of stay(LOS), complication rates, and readmission rates for sacral fracture patients based on operative approach.METHODS: All patients who presented to a large tertiary care center with isolated sacral fractures in an 11-year period were included in a retrospective chart review. Operative approach(open reduction internal fixation vs percutaneous) was noted, as well as age, gender, race, and American Society of Anesthesiologists' score. Complications included infection, nonunion and malunion, deep venous thrombosis, and hardware problems; 90-d readmissions were broken down into infection, surgical revision of the sacral fracture, and medical complications. LOS was collected for the initial admission and readmission visits if applicable. Fisher's exact and non-parametric t-tests(Mann-Whitney U tests) were employed to compare LOS, complications, and readmissions between open and percutaneous approaches.RESULTS: Ninety-four patients with isolated sacral fractures were identified: 31(30.4%) who underwentopen reduction and internal fixation(ORIF) vs 63(67.0%) who underwent percutaneous fixation. There was a significant difference in LOS based on operative approach: 9.1 d for ORIF patients vs 6.1 d for percutaneous patients(P = 0.043), amounting to a difference in cost of $13590. Ten patients in the study developed complications, with no significant difference in complication rates or reasons for complications between the two groups(19.4% for ORIF patients vs 6.3% for percutaneous patients). Eight patients were readmitted, with no significant difference in readmission rates or reasons for readmission between the two groups(9.5% percutaneous vs 6.5% ORIF).CONCLUSION: There is a significant difference in LOS based on operative approach for sacral fracture patients. Given similar complications and readmission rates, we recommend a percutaneous approach.

Exploring social movement concepts and actions in a knowledge uptake and sustainability context: A concept analysis

Objectives:To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care.Methods:We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability.Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings.Titles,abstracts and full texts were reviewed independently and in duplicate,resulting in 38 included articles.Results:Social movement action for knowledge uptake and sustainability can be defined as individuals,groups,or organizations that,as voluntary and intrinsically motivated change agents,mobilize around a common cause to improve outcomes through knowledge uptake and sustainability.The 10 defining attributes,three antecedents and three consequences that we identified are dynamic and interrelated,often mutually reinforcing each other to fortify various aspects of the social movement.Examples of defining attributes include an urgent need for action,collective action and collective identity.The concept analysis resulted in the development of the Social Movement Action Framework.Conclusions:Social movement action can provide a lens through which we view implementation science.Collective action and collective identity e concepts less frequently canvassed in implementation science literature e can lend insight into grassroots approaches to uptake and sustainability.Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for realworld change initiatives.By mobilizing individuals,groups,or organizations through social movement approaches,they can engage as powered change agents and teams that impact the individual,organizational and health systems levels to facilitate knowledge uptake and sustainability.

全子宫切除与次全子宫切除的医疗资源消耗:一项随机试验结果

OBJECTIVE: Hysterectomy is the most common major surgical procedure performed in the United States for nonobstetric reasons. Although most hysterectomies include removal of the cervix, the rate of supracervical procedures has increased in recent years. To provide evidence about the outcomes of both types of hysterectomy, we conducted a randomized clinical trial of total (TAH) or supracervical (SCH) hysterectomy (the “TOSH”trial). We report here an analysis of 24-month resource use by patients in this trial. METHODS: A randomized controlled trial was performed at 3 clinical centers to compare resources used by 120 patients who received a total or supracervical abdominal hysterectomy. Service use during a 24-month follow-up period was identified from medical and billing records and patient reports. Each service used was assigned a relative value, which was then converted into 2002 U.S. dollars. RESULTS: Overall resource use was similar in the 2 study groups in the first 12 months after randomization (TAH ＄5,870; SCH ＄6,018; 95%confidence interval for difference -＄960, ＄1,255; P <.79) and for the full 24 months (TAH ＄6,448; SCH ＄7,479; 95%confidence interval for difference -＄533, ＄2,616; P <.20). In exploratory multivariable analyses, resource use was significantly associated with baseline body mass index greater than or equal to 35 kg/m2 (＄8,440 versus ＄6,398, P = .02) and heavy bleeding (＄7,550 versus ＄5,368, P = .02). CONCLUSION: We conclude that the use of medical care resources over a 24-month period is comparable for total and supracervical hysterectomy. The association of a womans weight and bleeding pattern with subsequent resource use requires further investigation.

美国全髋置换关节负重面应用的流行情况调研

背景：硬性对硬性材料的负重面有提高全髋关节置换假体植入物生存的潜力。然而，对于使用这些先进技术的特定适应证仍然存在争议。本研究的日的是从患者、医院、地域和支付人特点几方面对美国全髋关节置换中负重面应用情况进行流行病学研究。方法：应用全国住院病例数据库资料，对从2005年10月1日至2006年12月31日，在美国进行的112095例初次全髋关节置换病例的负重面类型及其人口统计学特征进行分析。病例按照年龄、性别、普查区域、付款人类别和医院的类型进行分组，计算每种类型髋关节负重面在各组中的使用率。

医生是否应该鼓励患者将谈话内容进行录音？

“不管怎样，患者这样做是合法的，而且它会促成更好的诊疗实践和决策共享，”Glyn Elwyn说道。但是Laurence Buckman担心这样会让医生们在诊疗过程中采取防御措施，并且会损害医患关系。支持——Glyn Elwyn教授 一些患者已经用他们的智能手机记录下了临床中的所见所闻；许多并未得到许可或者是在非公开情况下进行的。

医疗卫生保健领域质量改进研究的发表指南：SQUIRE项目进展

质量改进研究（qualityimprovementstudies）的报告通常写得很差。质量改进优秀报告标准（SQUIRE）小组叙述了其指南是如何来提高这些标准的。

社区专业姑息治疗团队对患者临终时住院、急诊以及选择在医院内死亡的影响：一项汇总分析

目的汇总11个开展家庭医疗服务的专业姑息治疗团队效应。设计进行一项回顾性队列研究的汇总分析。地点加拿大，安大略省。参与者3109名在2009-2011年接受专业姑息治疗团队医疗服务的患者（暴露组）及3109名在此期间接受常规医疗服务的患者（非暴露组）。干预措施虽然这些姑息治疗团队所在地区和规模不同，但包含了相同的核心团队成员和角色分配，即能够为患者在其家中提供综合姑息治疗的姑息治疗专科医师、护士和家庭医生，团队任务包括全天候的管理症状、给予医疗信息和治疗措施以及协调服务。主要结局测量指标患者（a）在死亡前最后2周在医院度过；（b）死亡前最后2周有过急诊；（c）在医院内死亡。结果暴露组和非暴露组中癌症患者约占80％，且78％患者接受临终家庭医疗护理服务的平均时间相同。在所有姑息治疗团队中，暴露组中分别有970（31．2％）和896（28．9％）名患者在生命最后2周住院治疗和有急诊经历，而在非暴露组，分别为1219（39．3％）和1070（34．5％）名患者（P〈0．001）。暴露组与非暴露组患者在生命终期住院和经历急诊的汇总相对危险度分别为0．68[95％可信区间（CI，0．61～0．76）]和0．77[95％CI（0．69～0．86）]。与非暴露组相比，暴露组患者选择院内死亡的更少[503（16．2％）比887（28．6％），P〈0．01]，且在医院内濒死的汇总相对危险度为0．46（0．40-0．52）。结论尽管社区专业姑息治疗团队的组成和地区不同，但均能有效降低患者临终时急诊及选择在医院内死亡比例。

患者参与医疗卫生服务共建:质量改善的关键

仅仅关注医疗卫生的服务或产品特性的分析,往往会忽视医患关系这个核心要素。Paul Batalden分享了十年来的研究结果,提出优化提升卫生体系绩效的建议。临床医生治疗患者时都曾有过“心有余而力不足”之感1.卫生体系往往存在一些不尽如人意之处,由于行政工作压力的增加,占用了医生较多的临床工作时间,从而影响了患者健康结果。

使用临床流程图鉴别处方瀑布

药物的不良反应可能"隐藏"于常见症状中。如1997年Rochon和Gurwitz在The BMJ所阐述,处方瀑布即医务人员将药物不良事件误认为是新出现的医疗状况,而开具新的药物来处理这个不良事件。这个概念已扩展至不必要的诊断性检查、使用医疗设备和非处方药治疗等可能使患者暴露于风险和伤害的情况。目前还没有公认的方法来确定某一症状是否由一种药物所致,但是通过核查处方瀑布,临床医师可以减少不必要的药物、检查、会诊和伤害。

过度诊断：什么是，什么不是

那么，好的东西会嫌太多吗？——《皆大欢喜》（As You Likeh）莎士比亚（公元1600年）罗莎琳德在要嫁给奥兰多时提出的这个问题仅仅是一种反问——她认为不能对好东西过度享用。然而，尽管俗套，一个人有时候就是会过度享用。在医疗保健领域更是如此，目前已被称为“过度医疗”。尽管它容易和“过度用药”相混淆，更好的说法应该是“过度医疗保健”。

围手术期输注红细胞可降低心脏手术术后远期存活率

背景输注红细胞（RBC）与心脏手术后死亡率升高有关。我们分析了在住院期间接受了1或2个单位RBC输注的心脏手术患者的长期生存情况。方法将2001年至2004年期间9079例，在新英格兰北部地区8个医疗中心中接受了冠状动脉旁路移植术、瓣膜手术或同时进行了冠状动脉旁路移植术和瓣膜手术的患者纳入本研究。研究将纳入地区与2006年6月30日社会保障署死亡档案确定的死亡率进行概率性配对。调整的风险比采用Cox比例风险和倾向评分法进行计算。结果36％的患者（n=3254）接受过1或2个单位的RBC。43％的RBCs是在手术中被输注的，分别有56％和1％的RBCs是在手术后和手术前输注的。输血的患者更可能是贫血、高龄、体表面积小、女性和同时患多种疾病的患者。那些在心脏手术住院期间接受了1或2个单位RBCs的患者的存活率显著低于未接受过RBCs的患者（P〈0．001）。调整了患者和疾病特征之后，接受1或2个单位RBCs仍使远期死亡风险提高16％（调整的风险比=1．16，95％CI：1．01—1．34，P=0．035）。结论输注1或2个单位的RBCs可使心脏手术术后存活率降低的风险提高16％。