Clinician Motivation Research Articles

The experience sampling methodology as a digital clinical tool for more person-centered mental health care: an implementation research agenda.

This position paper by the international IMMERSE consortium reviews the evidence of a digital mental health solution based on Experience Sampling Methodology (ESM) for advancing person-centered mental health care and outlines a research agenda for implementing innovative digital mental health tools into routine clinical practice. ESM is a structured diary technique recording real-time self-report data about the current mental state using a mobile application. We will review how ESM may contribute to (1) service user engagement and empowerment, (2) self-management and recovery, (3) goal direction in clinical assessment and management of care, and (4) shared decision-making. However, despite the evidence demonstrating the value of ESM-based approaches in enhancing person-centered mental health care, it is hardly integrated into clinical practice. Therefore, we propose a global research agenda for implementing ESM in routine mental health care addressing six key challenges: (1) the motivation and ability of service users to adhere to the ESM monitoring, reporting and feedback, (2) the motivation and competence of clinicians in routine healthcare delivery settings to integrate ESM in the workflow, (3) the technical requirements and (4) governance requirements for integrating these data in the clinical workflow, (5) the financial and competence related resources related to IT-infrastructure and clinician time, and (6) implementation studies that build the evidence-base. While focused on ESM, the research agenda holds broader implications for implementing digital innovations in mental health. This paper calls for a shift in focus from developing new digital interventions to overcoming implementation barriers, essential for achieving a true transformation toward person-centered care in mental health.

Primary care perspectives on prescribing anti-obesity medication for adolescents.

Recent pediatric guidelines recommend clinicians offer anti-obesity medication (AOM) as an adjunct to intensive lifestyle intervention. To investigate pediatricians' perspectives about prescribing AOM, including barriers and facilitators. An investigator-developed survey was emailed to primary care pediatric physicians (n = 187) and advanced practice providers (n = 190) within an academic-affiliated network. The survey evaluated how willing clinicians were to prescribe AOM and their agreement with 25 statements about barriers and facilitators. Three vignettes explored AOM decision-making. Multinomial logistic regression was used to determine relative risk ratios for willingness to prescribe by agreement with each statement. Among 74 respondents (20% response rate), 24% were willing, 42% uncertain and 34% unwilling to prescribe. Most (64%) agreed that AOM should be managed only by specialists. Willingness to prescribe was associated with clinician motivation and belief in guideline practicality and applicability. Unwillingness was associated with beliefs that patients would not continue AOM long enough for benefit and that there was insufficient time or resources to implement. In vignettes, 52% were willing to prescribe AOM for a patient with severe obesity and metabolic complications, versus 11% for a patient with obesity and possible disordered eating. Willingness to prescribe AOM was low and was associated with perceived practicality and appropriateness for patients.

Telemedicine Adoption During COVID-19 Pandemic: Perspectives from Primary Care Clinicians in Safety-Net Settings.

The objective of this study is to describe the facilitators and barriers of telemedicine during the COVID-19 pandemic for primary care clinicians in safety-net settings. We selected 5 surveys fielded between September 2020 and March 2023 from the national "Quick COVID-19 Primary Care Survey" by the Larry A. Green Center, with the Primary Care Collaborative. We used an explanatory sequential mixed method approach. We compared safety-net practices (free & charitable organization, federally qualified health center (FQHC), clinics with a 50% or greater Medicaid) to all other settings. We discuss: 1) telemedicine services provided; 2) clinician motivations; 3) and telemedicine access. All clinicians were similarly motivated to implement telemedicine. Safety-net clinicians were more likely to report use of phone visits. These clinicians felt less "confident in my use of telemedicine" (covariate-adjusted OR = 0.611, 95% CI 0.43 - 0.87) and were more likely to report struggles with televisits in March 2023 (covariate-adjusted OR = 1.73, 95% CI 1.16 - 2.57), particularly with physical examinations. Safety-net clinicians were more likely to endorse reductions in no-shows (covariate-adjusted OR = 1.77, 95% CI 1.17 - 2.68). Telemedicine increased access and new patient-facing demands including portal communications. This study enhances our understanding of the use of telemedicine within the safety-net setting. Clinician perceptions are important for identifying barriers to telemedicine following the end of the Federal COVID-19 Public Health Emergency. Clinicians highlighted significant limitations to its use including clinical appropriateness, quality of physical examinations, and added patient-facing workload.

A Qualitative Exploration of Stakeholders' Preferences for Early-Stage Rectal Cancer Treatment.

As treatment options for patients with rectal cancer evolve, patients with early-stage rectal cancer may have a treatment choice between surgery and a trial of nonoperative management. Patients must consider the treatments' clinical tradeoffs alongside their personal goals and preferences. Shared decision-making (SDM) between patients and clinicians can improve decision quality when patients are faced with preference-sensitive care options. We interviewed 28 stakeholders (13 clinicians and 15 patients) to understand their perspectives on early-stage rectal cancer treatment decision-making. Clinicians included surgeons, medical oncologists, and radiation oncologists who treat rectal cancer. Adult patients included those diagnosed with early-stage rectal cancer in the past 5 years, recruited from an institutional database. A semi-structured interview guide was developed based on a well-established decision support framework and reviewed by the research team and stakeholders. Interviews were conducted between January 2022 and January 2023. Transcripts were coded by 2 raters and analyzed using thematic analysis. Both clinicians and patients recognized the importance of SDM to support high-quality decisions about the treatment of early-stage rectal cancer. Barriers to SDM included variable clinician motivation due to lack of training or perception of patients' desires or abilities to engage, as well as time-constrained encounters. A decision aid could help facilitate SDM for early-stage rectal cancer by providing standardized, evidence-based information about treatment options that align with clinicians' and patients' decision needs.

SAT444 Perceptions Of Endocrine Clinicians On Climate Change And Health

Abstract Disclosure: S. Steinmetz-Wood: None. K. Loomba: None. J. Hitt: None. A. Kennedy: None. M.P. Gilbert: Consulting Fee; Self; Novo Nordisk. K. Barrett: None. Introduction: Effects of climate change and pollution on the endocrine system are increasingly recognized, such as from EDCs, particulate matter, and the impact of malnutrition and unhealthy lifestyle practices. The Endocrine Society set a goal to increase awareness of the impact of climate change on endocrine health. Assessing perspectives is key in building climate change awareness, knowledge, preventative action and advocacy among health professionals. There are no existing surveys evaluating perceptions of endocrine clinicians on climate change. We aimed to 1) evaluate climate change awareness/knowledge among endocrine clinicians, 2) evaluate the motivation of endocrine clinicians to incorporate climate change concepts into practice, and 3) demonstrate the need for climate change curricula in endocrine training. Methods: We designed an online questionnaire including questions from existing surveys to healthcare professionals about climate change and endocrine-specific questions. The survey was shared to the endocrine community through social media and email. Study data were collected 9/20/2022 - 11/06/2022 and managed using REDCap electronic data capture tools. Results: There were a total of 164 responses; 98% were physicians, of which 31% were program directors (PD) and 28.66% were fellows. The median age was 41 and 91% are employed in the US. The majority (95%) think that climate change is happening, and 52% are very worried about climate change. Responses were variable regarding knowledge level on climate change and health (6.7% very, 40% moderately, 35% modestly, and 17.7% not at all) and concern of effects on patient health (12.8% a great deal, 36% a moderate amount, 26% only a little, 8% not at all, 17% don’t know). The top 3 endocrine climate-health concerns were reduced exercise from motorized transport, malnutrition from food prices, and disruptions to healthcare services during weather events. The majority of respondents agree teaching about climate change and health impacts should be integrated into medical education (72.8% strongly agree or agree) and 82.7% of the PDs and fellows indicated their program does not cover this topic. The majority feel motivated to take action in their personal or professional life for climate change (68.88% strongly agree or agree). The 3 resources perceived most helpful were CME, patient education materials, and policy statements. Conclusion: The majority of endocrine clinicians surveyed are aware and worried about climate change, with varying levels of knowledge and concern about climate change and its health effects. Most respondents agree teaching about climate change and health effects should be integrated into medical education and most feel motivated to take action in some way for climate change. The results also reflect an untapped interest for a curriculum on climate change and endocrine health in fellowship programs and in CME. Presentation: Saturday, June 17, 2023

Implementation of evidence-based primary cancer prevention interventions in MA community health centers: an explanatory sequential mixed methods study

BackgroundMore than half of cancers could be prevented by employing evidence-based interventions (EBIs), including prevention interventions targeting nutrition, physical activity, and tobacco. Federally qualified health centers (FQHCs) are the primary source of patient care for over 30 million Americans — making them an optimal setting for ensuring evidence-based prevention that advances health equity. The aims of this study are to (1) determine the degree to which primary cancer prevention EBIs are being implemented within Massachusetts FQHCs and (2) describe how these EBIs are implemented internally and via community partnerships.MethodsWe used an explanatory sequential mixed methods design to assess the implementation of cancer prevention EBIs. First, we collected 34 quantitative surveys from staff at 16 FQHCs across Massachusetts to determine the frequency of EBI implementation. We followed up with 12 qualitative one-on-one interviews among a sample of staff to understand how the EBIs selected on the survey were implemented. Exploration of contextual influences on implementation and use of partnerships was guided by the Consolidated Framework for Implementation Research (CFIR). Quantitative data were summarized descriptively, and qualitative analyses used reflexive, thematic approaches, beginning deductively with codes from CFIR, then inductively coding additional categories.ResultsAll FQHCs indicated they offered clinic-based tobacco interventions, such as clinician-delivered screening practices and prescription of tobacco cessation medications. Quitline interventions and some diet/physical activity EBIs were available at all FQHCs, but staff perceptions of penetration were low. Only 38% of FQHCs offered group tobacco cessation counseling and 63% referred patients to mobile phone-based cessation interventions. We found multilevel factors influenced implementation across intervention types — including the complexity of intervention trainings, available time and staffing, motivation of clinicians, funding, and external policies and incentives. While partnerships were described as valuable, only one FQHC reported using clinical-community linkages for primary cancer prevention EBIs.ConclusionsAdoption of primary prevention EBIs in Massachusetts FQHCs is relatively high, but stable staffing and funding are required to successfully reach all eligible patients. FQHC staff are enthusiastic about the potential of community partnerships to foster improved implementation—providing training and support to build these relationships will be key to fulfilling that promise.

Physical therapist perceptions and use of clinical pain mechanism assessment in the musculoskeletal setting: a survey analysis

BackgroundA mechanism-based approach to the evaluation and management of pain has been suggested across disciplines in contemporary research. However, the translation of pain mechanism assessment strategies in research to clinical practice is unclear. This study sought to explore perceptions and use of clinical pain mechanism assessment by physical therapists managing musculoskeletal pain.MethodsThis was an electronic cross-sectional survey. After initial development, refinement, and piloting for comprehensiveness, comprehensibility and relevance, the survey was disseminated to members of the Academy of Orthopaedic Physical Therapy via email listserv. Data was maintained anonymously using the online database REDCap. Descriptive statistics and Spearman’s correlations for non-parametric data were analyzed for frequencies and associations across variables.ResultsIn total, 148 respondents completed all aspects of the survey. Respondent age ranged from 26 to 73 years, with a mean (SD) of 43.9 (12.0). Most respondents (70.8%) reported performing clinical pain mechanism assessments at least ‘sometimes’. A majority (80.4%) believed clinical pain mechanism assessments are useful in guiding management strategies while 79.8% reported specifically choosing interventions to alter aberrant pain mechanisms. The most commonly used pain severity, physical examination testing and questionnaires were the numeric pain rating scale, pressure pain thresholds and pain diagrams, respectively. However, the vast majority of instruments to clinically assess pain mechanisms were performed by a small proportion of respondents (< 30%). There were no significant correlations between age, years of experience, highest earned degree, completion of advanced training or specialist certification and testing frequency.ConclusionThe evaluation of pain mechanisms involved in the pain experience is becoming common in research. The clinical application of pain mechanism assessment is unclear. Based on the results of this survey, physical therapists in the orthopedic setting believe pain mechanism assessment is useful, but data suggests it is infrequently performed. Additional research to uncover clinician motivation related to pain mechanism assessment is warranted.

Barriers and facilitators to implementing self-directed therapy activities in inpatient rehabilitation settings.

Self-directed therapy activities are not currently part of routine care during inpatient rehabilitation. Understanding patient and clinician perspectives on self-directed therapy is key to increasing implementation. The aim of this study was to investigate barriers and facilitators to implementing a self-directed therapy programme ("My Therapy") in adult inpatient rehabilitation settings. My Therapy was recommended by physiotherapists and occupational therapists and completed by rehabilitation inpatients independently, outside of supervised therapy sessions. Physiotherapists, occupational therapists, and patients were invited to complete an online questionnaire comprising open-ended questions on barriers and facilitators to prescribing and participating in My Therapy. A directed content analysis of free-text responses was undertaken, with data coded using categories of the Capability, Opportunity, and Motivation Model of Behaviour (COM-B model). Eleven patients and 20 clinicians completed the questionnaire. Patient capability was reported to be facilitated by comprehensive education by clinicians, with mixed attitudes towards the format of the programme booklet. Clinician capability was facilitated by staff collaboration. One benefit was the better use of downtime between the supervised therapy sessions, but opportunities for patients to engage in self-directed therapy were compromised by the lack of space to complete the programme. Clinician opportunity was reported to be provided via organisational support but workload was a reported barrier. Patient motivation to engage in self-directed therapy was reported to be fostered by feeling empowered, engaged, and encouraged to participate. Clinician motivation was associated with belief in the value of the programme. Despite some barriers to rehabilitation patients independently practicing therapeutic exercises and activities outside of supervised sessions, both clinicians and patients agreed it should be considered as routine practice. To do this, patient time, ward space, and staff collaboration are required. Further research is needed to scale-up the implementation of the My Therapy programme and evaluate its effectiveness.

How patient-clinician education can strengthen partnerships and promote tangible actions to improve clinical trial diversity in breast and lung cancer trials.

6510 Background: Some of the greatest disparities in cancer care are related to clinical trial access for our patients. To address the racial/ethnic disparities in breast and lung cancer clinical trials, a tethered educational initiative was designed to empower patients, assess current clinician perceptions/practices, and improve awareness of real-world perspectives of clinical trials. Methods: Two, one-hour online, interactive, video-based programs were designed for patients, caregivers, and providers. This patient/caregiver program was hosted on CancerCoachLive and MedLive in November, 2022, while the provider program was hosted on ClinicalSeriesLive in December, 2022 and will remain on-demand until December 2023. This initiative was conducted in collaboration with TOUCH, the Black Breast Cancer Alliance, BlackDoctors.org, Moffitt Cancer Center, CancerCare, and the Lung Cancer Research Foundation. Herein, we report on an analysis from patients and providers regarding clinical trial diversity, behavioral impact, and qualitative insights. Results: As of data cut-off (02/10/23), 1,425 participants have engaged across both educational programs. Of participating patients, 46% were non-White (non-Hispanic), 36% were in remission, 36% were not on active treatment, and 29% were newly diagnosed. Following the program 81% were motivated to take one or more actions over the next two months: the most common actions being to research clinical trials (38%) or discuss clinical trials with a clinician (19%). Post-activity, 79% were confident to very confident discussing clinical trials with a clinician. Critical data related to clinician preferences was assessed and demonstrated a 23% increase in confidence from pre- to post-activity in improving diversity in clinical trial participation with preferences observed in both breast and lung cancers to offer clinical trials for newly diagnosed and second recurrence settings. Of those who are being offered clinical trials in the community setting, there was a higher likelihood for patients to be offered a clinical trial if their subtype was HER2+ breast cancer subtype or NSCLC with an actionable mutation. Data collection continues as this initiative is ongoing. Qualitative data including clinician write-in examples of behavioral impact and patient perspectives from the interviews will be shared. Conclusions: The outcomes discussed herein reveal a willingness from patients/caregivers to engage in clinical trial discussions and participate in clinical trials, if eligible. These educational programs positively impacted clinician motivation to address barriers to enrollment and clinical trial eligibility with their patients. Real-world accounts of patient experiences provide different perspectives that can help improve approaches to improve clinical trial diversity.

Complex Interventions Across Primary and Secondary Care to Optimize Population Kidney Health: A Systematic Review and Realist Synthesis to Understand Contexts, Mechanisms, and Outcomes.

CKD affects 850 million people worldwide and is associated with high risk of kidney failure and death. Existing, evidence-based treatments are not implemented in at least a third of eligible patients, and there is socioeconomic inequity in access to care. While interventions aiming to improve delivery of evidence-based care exist, these are often complex, with intervention mechanisms acting and interacting in specific contexts to achieve desired outcomes. We undertook realist synthesis to develop a model of these context-mechanism-outcome interactions. We included references from two existing systematic reviews and from database searches. Six reviewers produced a long list of study context-mechanism-outcome configurations based on review of individual studies. During group sessions, these were synthesized to produce an integrated model of intervention mechanisms, how they act and interact to deliver desired outcomes, and in which contexts these mechanisms work. Searches identified 3371 relevant studies, of which 60 were included, most from North America and Europe. Key intervention components included automated detection of higher-risk cases in primary care with management advice to general practitioners, educational support, and non-patient-facing nephrologist review. Where successful, these components promote clinician learning during the process of managing patients with CKD, promote clinician motivation to take steps toward evidence-based CKD management, and integrate dynamically with existing workflows. These mechanisms have the potential to result in improved population kidney disease outcomes and cardiovascular outcomes in supportive contexts (organizational buy-in, compatibility of interventions, geographical considerations). However, patient perspectives were unavailable and therefore did not contribute to our findings. This systematic review and realist synthesis describes how complex interventions work to improve delivery of CKD care, providing a framework within which future interventions can be developed. Included studies provided insight into the functioning of these interventions, but patient perspectives were lacking in available literature. This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_05_08_CJN0000000000000136.mp3.

Goal-Oriented Prevention: How to Fit a Square Peg into a Round Hole

Prevention does not fit well within our problem-oriented medical paradigm in which the focus is on curing or ameliorating existing diseases. It is easier and more satisfying to solve existing problems than it is to advise and motivate patients to implement measures to prevent future problems that may or may not occur. Clinician motivation is further diminished by the time required to help people make lifestyle changes, the low reimbursement rate, and the fact that the benefits, if any, are often not apparent for years. Typical patient panel sizes make it difficult to provide all of the recommended disease-oriented preventive services and to also address the social and lifestyle factors that can impact future health problems. One solution to this square peg-round hole mismatch is to focus on the goals, life extension and prevention of future disabilities.

Which Contributes to Clinical Performance: Academic Output or Person-Environment Fit?

BackgroundThe measures put in place by health authorities to ensure the professionalism of doctors are important. Hospitals in China have included academic outputs in the promotion criteria to incentive medical clinicians to engage in scientific research so that to improve job performance (JP). However, such practice disproportionally focuses on academic outputs but ignores the force of needs fulfilled brought by intrinsic incentive. This study aims to discuss the realistic problem regarding the promotion mechanism and the potential drivers to clinical JP.MethodsThis study was based on multi-source data collection on clinical performance from electric medical record (EMR), person-environment (P–E) fit from the survey, and academic output from personnel files of ward clinicians (n = 244) of general public hospitals who sought for career progression in Shanghai in 2020. Independent-Sample t-test and chi-square test were used for comparison of two sample means or constituent ratio between promoted and not promoted clinicians. Linear multilevel regression was conducted to examine the relationship between clinical performance and academic outputs and P–E fit.ResultsClinicians who were promoted were more productive in producing academic outputs than those who were not (t = −5.075, p < 0.001). However, there was no difference in clinical performance between the two groups (t = −1.728 to 0.167, p > 0.05). The regression showed that academic outputs were not related to clinical performance, while higher P–E fit was associated with the improvement of various clinical performances.ConclusionThis study shows that P–E fit plays a more important role in facilitating clinical performance than academic performance and highlights the importance of intrinsic motivation of clinicians in achieving clinical performance.

Stakeholder intention to engage in fidelity measurement methods in community mental health settings: A mixed methods study.

The current gold standard for measuring fidelity (specifically, adherence) to cognitive behavioral therapy (CBT) is direct observation, a costly, resource-intensive practice that is not feasible for many community organizations to implement regularly. Recent research indicates that behavioral rehearsal (i.e., role-play between clinician and individual with regard to session delivery) and chart-stimulated recall (i.e., brief structured interview between clinician and individual about what they did in session; clinicians use the client chart to prompt memory) may provide accurate and affordable alternatives for measuring adherence to CBT in such settings, with behavioral rehearsal yielding greater correspondence with direct observation. Drawing on established causal theories from social psychology and leading implementation science frameworks, this study evaluates stakeholders' intention to use behavioral rehearsal and chart-stimulated recall. Specifically, we measured attitudes, self-efficacy, and subjective norms toward using each, and compared these factors across the two methods. We also examined the relationship between attitudes, self-efficacy, subjective norms, and intention to use each method. Finally, using an integrated approach we asked stakeholders to discuss their perception of contextual factors that may influence beliefs about using each method. These data were collected from community-based supervisors (n = 17) and clinicians (n = 66). Quantitative analyses suggest moderately strong intention to use both methods across stakeholders. There were no differences in supervisors' or clinicians' attitudes, self-efficacy, subjective norms, or intention across methods. More positive attitudes and greater reported subjective norms were associated with greater reported intention to use either measure. Qualitative analyses identified participants' specific beliefs about using each fidelity measure in their organization, and results were organized using the Consolidated Framework for Implementation Research. Strategies are warranted to overcome or minimize potential barriers to using fidelity measurement methods and to further increase the strength of intention to use them.Plain Language Summary: The best way to measure fidelity, or how closely a clinician follows the protocol, to Cognitive Behavioral Therapy (CBT) is watching the session. This is an expensive practice that is not feasible for many community organizations to do regularly. Recent research indicates that behavioral rehearsal, or a role-play between the clinician and individual with regard to session delivery, and chart-stimulated recall, or a brief discussion between an individual and the clinician about what they did in session with the clinician having access to the chart to help them remember, may provide accurate and affordable alternatives for measuring fidelity to CBT. We just completed a study demonstrating that both methods are promising, with behavioral rehearsal offering scores that are the most similar to watching the session. Drawing on established theories from social psychology and leading implementation science frameworks, this study evaluates future supervisor and clinician motivation to use these fidelity measurement methods. Specifically, we measured supervisor (n = 17) and clinician (n = 66) attitudes, norms, self-efficacy, intentions, and anticipated barriers and facilitators to using each of these fidelity measurement tools. Quantitative and qualitative analyses suggest similar intention to use both methods, and concerns about barriers to using each method. Further research is warranted to minimize the burden associated with implementing fidelity measurement methods and deploying strategies to increase use.

Adapting to Telepractice: Views of Graduate Student Clinicians

Purpose:The purpose of this study was to investigate the initial perceptions of speech-language pathology graduate student clinicians following implementation of telepractice using survey questions.Method:The study used thematic analysis to answer three research questions: (a) How comfortable and confident are graduate student clinicians using telepractice? (b) What are the differences between in-person and telepractice service delivery? (c) What surprised graduate student clinicians about telepractice?Results:Thirty first-year graduate student clinicians completed the survey following 5 weeks of telepractice service delivery. Findings revealed that, initially, graduate student clinicians felt nervous and uncertain about administering speech-language therapy through telepractice but eventually became more comfortable and confident with the new therapy delivery model. Differences between in-person and telepractice involved more attention to clinician's facial expressions, learning technology, managing environmental distractions at home, and the necessity for caregiver involvement. Graduate student clinicians expressed mixed perceptions of treatment effectiveness through telepractice, which may be associated with the client's attention, communication severity, and clinician's motivation. In the end, graduate student clinicians shared positive reflections of this learning experience.Conclusions:As speech therapy through telepractice continues, students will require guidance about this service delivery model. This study described graduate students' perceptions of telepractice, which may be applied to academic clinical curriculum.

Глюкокортикостероиды в лечении ОРДС: за и против. Обзор литературы

Летальность при остром респираторном ди­стресс-синдроме остается высокой, несмотря на внедрение современных технологий респираторной поддержки и экстракорпоральных методов оксигенации. В значительной степени это обусловлено дизрегулированным воспалительным ответом организма на повреждающий фактор, прогрессивным повреждением альвеолярно-капиллярной мембраны, и, как следствие, критической редукцией газообмена в легких. Глюкокортикостероиды относятся к мощным противовоспалительным препаратам, что объясняет мотивацию клиницистов назначать эти препараты у больных с тяжелым течением острого респираторного дистресс-синдрома. В литературном обзоре проведен анализ научных исследований, которые как поддерживают эффективность, так и отрицают пользу от применения глюкокортикостероидов при остром респираторном дистресс-синдроме. Согласно приведенным в обзоре данным, глюкокортикостероиды могут быть эффективными, если применяются в ранней стадии заболевания (первые 5–7 дней) и в низких дозах с пролонгированным введением. Говоря о критериях выбора пациентов, такими следует считать больных со среднетяжелым и тяжелым респираторным дистресс-синдромом (PaO2/FiO2 &lt; 200), у которых, несмотря на применение адекватной стратегии искусственной вентиляции легких, происходит прогрессивное снижение оксигенации.

Scientific reasons to question teleconsultations in expert general practice.

There has been much discussion of the impact of a move to telephone consultation on both the doctor–patient relationship, and the morale and motivation of clinicians. But to date, there has been less consideration of the potential impact on the scientific practice of medicine. General practice is a scientific discipline — making use of both the knowledge (evidence) and method (reasoning) of scientific practice. So what are the implications of a move to teleconsultations? In a recent blog, Hammond considered the impact of remote consultations on her clinical reasoning in practice.1 She spoke of the need for closer listening and attention to the patient’s story, supporting deeper reflections. She recognised this as a shift from the everyday short-hand thinking of ‘pattern recognition’ back to a deeper, hypothetico-deductive thinking. But generalist medicine, expertise in whole person care, uses a different model …

Oncology Clinicians' Challenges to Providing Palliative Cancer Care-A Theoretical Domains Framework, Pan-Cancer System Survey.

Despite the known benefits, healthcare systems struggle to provide early, integrated palliative care (PC) for advanced cancer patients. Understanding the barriers to providing PC from the perspective of oncology clinicians is an important first step in improving care. A 33-item online survey was emailed to all oncology clinicians working with all cancer types in Alberta, Canada, from November 2017 to January 2018. Questions were informed by Michie’s Theoretical Domains Framework and Behaviour Change Wheel (BCW) and queried (a) PC provision in oncology clinics, (b) specialist PC consultation referrals, and (c) working with PC consultants and home care. Respondents (n = 263) were nurses (41%), physicians (25%), and allied healthcare professionals (18%). Barriers most frequently identified were “clinicians’ limited time/competing priorities” (64%), “patients’ negative perceptions of PC” (63%), and clinicians’ capability to manage patients’ social issues (63%). These factors mapped to all three BCW domains: motivation, opportunity, and capability. In contrast, the least frequently identified barriers were clinician motivation and perceived PC benefits. Oncology clinicians’ perceptions of barriers to early PC were comparable across tumour types and specialties but varied by professional role. The main challenges to early integrated PC include all three BCW domains. Notably, motivation is not a barrier for oncology clinicians; however, opportunity and capability barriers were identified. Multifaceted interventions using these findings have been developed, such as tip sheets to enhance capability, reframing PC with patients, and earlier specialist PC nursing access, to enhance clinicians’ use of and patients’ benefits from an early PC approach.

Evaluation of experimental, analytical, and computational methods to determine long-bone bending stiffness

Methods used to evaluate bone mechanical properties vary widely depending on the motivation and environment of individual researchers, clinicians, and industries. Further, the innate complexity of bone makes validation of each method difficult. Thus, the purpose of the present research was to quantify methodological error of the most common methods used to predict long-bone bending stiffness, more specifically, flexural rigidity (EI). Functional testing of a bi-material porcine bone surrogate, developed in a previous study, was conducted under four-point bending test conditions. The bone surrogate was imaged using computed tomography (CT) with an isotropic voxel resolution of 0.625 mm. Digital image correlation (DIC) of the bone surrogate was used to quantify the methodological error between experimental, analytical, and computational methods used to calculate EI. These methods include the application of Euler Bernoulli beam theory to mechanical testing and DIC data; the product of the bone surrogate composite bending modulus and second area moment of inertia; and finite element analysis (FEA) using computer-aided design (CAD) and CT-based geometric models. The methodological errors of each method were then compared. The results of this study determined that CAD-based FEA was the most accurate determinant of bone EI, with less than five percent difference in EI to that of the DIC and consistent reproducibility of the measured displacements for each load increment. CT-based FEA was most accurate for axial strains. Analytical calculations overestimated EI and mechanical testing was the least accurate, grossly underestimating flexural rigidity of long-bones.

Communication Skills of the Clinician and Patient Motivation in Dental Practice

This review examines the current literature on the importance and role of communication skills of the clinician for patient motivation. Moreover, methods for teaching communication skills to the dental students are discussed. Good relationship between the clinician and the patient is essential for not only establishing mutual trust and satisfaction but also obtaining better clinical outcomes from the periodontal treatment. Competency in communication skills for dental practitioners can be gained within the dental curriculum, and this will provide more sustainable benefits from the periodontal treatment. There is a clear need for development of specific models for gaining good communication skills within the context of periodontal treatment, and such models are to be implemented in the dental curriculum.

Severe Acute Respiratory Syndrome Coronavirus 2 is Penetrating to Dementia Research.

Severe Acute Respiratory Syndrome Coronavirus 2 is Penetrating to Dementia Research.