Abstract Background Feedback is a crucial element in learning. While studies in the field of healthcare professions education have highlighted the process of educators feeding back to learners, relatively little investigation exists on learners feeding back to educators in Asian cultures. Studies show that recipients of effective feedback develop educational skills and reflective practice, but the process of giving feedback seems to have been mainly studied through surveys and questionnaires. Such research offers little to no insights on feedback providers' and recipients' experiences of feedback. To fill the gap, in the context of multi‐source feedback, we investigate medical students, residents, and nurses feedback giving to clinical educators (and their receiving of this) following a case presentation training course. We aim to understand the facilitators and inhibitors that encourage and/or prevent feedback provision alongside educators' uptake and reactions. Methods We used semi‐structured group interviews. Participants comprised five different categories of participants: year‐4 medical students (n = 6); residents (n = 5); nurses (n = 4); junior clinical educators (n = 9); senior clinical educators (n = 3). We asked them about their experiences of providing feedback to educators and educators receiving of feedback on their teaching. Group interviews were conducted in the largest healthcare institution in Taiwan. Data were analysed using thematic Framework Analysis and managed in ATLAS.ti 8.0. Results We identified two major themes with respective sub‐themes: (1) Factors affecting feedback giving (including desire for improvement, feedback content, process of feedback, feedback fears, feedback prevention and medical hierarchy); and (2) Educators' reactions to receiving feedback (including validity of feedback, face‐saving and emotional reactions to receiving feedback). Conclusions Feedback provision to educators on their teaching, and educators' receiving of this feedback in an Asian culture brings forth issues around medical hierarchy, in‐person feedback and face‐saving, which have important implications for effective and optimal delivery of feedback. Curricular developers should consider the context of feedback (e.g. anonymously online), facilitating students as active participants for the development of educational quality, and educators' mindful practice when engaging with student feedback.
Liver transplantation can prolong survival in patients with end-stage liver disease. We have proposed that the Sequential Organ Failure Assessment (SOFA) score calculated on post-transplant day 7 has a great discriminative power for predicting 1-year mortality after liver transplantation. The Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) score, a modified SOFA score, is a newly developed scoring system exclusively for patients with end-stage liver disease. This study was designed to compare the CLIF-SOFA score with other main scoring systems in outcome prediction for liver transplant patients.We retrospectively reviewed medical records of 323 patients who had received liver transplants in a tertiary care university hospital from October 2002 to December 2010. Demographic parameters and clinical characteristic variables were recorded on the first day of admission before transplantation and on post-transplantation days 1, 3, 7, and 14.The overall 1-year survival rate was 78.3% (253/323). Liver diseases were mostly attributed to hepatitis B virus infection (34%). The CLIF-SOFA score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease (MELD) score, RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria, and SOFA score. The AUROC curves were highest for CLIF-SOFA score on post-liver transplant day 7 for predicting 1-year mortality. The cumulative survival rates differed significantly for patients with a CLIF-SOFA score ≤8 and those with a CLIF-SOFA score >8 on post-liver transplant day 7.The CLIF-SOFA score can increase the prediction accuracy of prognosis after transplantation. Moreover, the CLIF-SOFA score on post-transplantation day 7 had the best discriminative power for predicting 1-year mortality after liver transplantation.
Anemia is a component of the pathological triangle in cardiorenal anemia syndrome and is a risk factor for mortality in acute respiratory distress syndrome. This study assessed the predictive value of anemia for outcomes in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) support. This retrospective study analyzed patients who received ECMO support at the cardiovascular surgery intensive care unit in the study institute between July 2003 and March 2012. Patient data, such as demographic information, etiologies of ECMO implementation, clinical parameters, and in-hospital and 6-month mortality rates, were statistically analyzed. The overall in-hospital mortality rate among the enrolled 295 patients was 55.6%. Multivariate logistical regression analysis indicated that age, albumin levels, sequential organ failure assessment (SOFA) score, and hemoglobin (Hb) level on ECMO day 1 exhibited independent prognostic significance for predicting in-hospital mortality rate. The SOFA score exhibited the highest areas under the receiver operating characteristic curve value (0.812 ± 0.025). The Hb level on ECMO day 1 exhibited satisfactory calibration and discriminatory power. The cumulative 6-month survival rates differed significantly between patients with Hb levels less than and more than 8.85 g/dL (30.6 vs. 54.0%, respectively, P < 0.001). This study indicated that old age, low albumin levels, low Hb levels, and higher SOFA scores on ECMO day 1 increased the risk of mortality. The Hb level is a readily measurable parameter and with good predictive power for critical patients on ECMO.
Abstract Background Active learning is defined as any instructional method that engages students in the learning process. Cultural differences in learning patterns can play an important role in engagement with active learning. We aimed to examine process models of active learning to understand what works, for whom and why. Methods Forty-eight sixth- and seventh-year medical students with experience of active learning methods were purposively selected to participate in ten group interviews. Interactions around active learning were analysed using a realist evaluation framework to unpack the ‘context-mechanism-outcome’ (CMO) configurations. Results Three core CMO configurations including cultural, training and individual domains were identified. In the cultural context of a strong hierarchical culture, the mechanisms of fear prompted students to be silent (outcome), daring not to share their opinions. In the training context of teacher-student familiarity alongside teachers’ guidance, the mechanisms of learning motivation, self-regulation and enthusiasm are triggered, prompting positive learning outcomes and competencies (outcome). In the individual context of learning how to learn actively at an early stage within the medical learning environment, the mechanisms of internalisation, professional identity and stress, resulted in recognised active learning and advanced preparation (outcomes). Conclusions We identified three CMO configurations of Taiwanese medical students’ active learning. The connections between hierarchical culture, fear, teachers’ guidance, motivation, the medical environment and professional identity have been shown to affect the complex interactions of learning outcomes. Fear derived from a hierarchical culture is a concern as it is a significant and specific contextual factor, often sparking fear with negative outcomes.
Background Renal dysfunction is an established predictor of all-cause mortality in intensive care units. This study analyzed the outcomes of coronary care unit (CCU) patients and evaluated several biomarkers of acute kidney injury (AKI), including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18) and cystatin C (CysC) on the first day of CCU admission. Methodology/Principal Findings Serum and urinary samples collected from 150 patients in the coronary care unit of a tertiary care university hospital between September 2009 and August 2010 were tested for NGAL, IL-18 and CysC. Prospective demographic, clinical and laboratory data were evaluated as predictors of survival in this patient group. The most common cause of CCU admission was acute myocardial infarction (80%). According to Acute Kidney Injury Network criteria, 28.7% (43/150) of CCU patients had AKI of varying severity. Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.05) between patients with AKI versus those without AKI. For predicting AKI, serum CysC displayed an excellent areas under the receiver operating characteristic curve (AUROC) (0.895±0.031, p<0.001). The overall 180-day survival rate was 88.7% (133/150). Multiple Cox logistic regression hazard analysis revealed that urinary NGAL, serum IL-18, Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) and sodium on CCU admission day one were independent risk factors for 6-month mortality. In terms of 6-month mortality, urinary NGAL had the best discriminatory power, the best Youden index, and the highest overall correctness of prediction. Conclusions Our data showed that serum CysC has the best discriminative power for predicting AKI in CCU patients. However, urinary NGAL and serum IL-18 are associated with short-term mortality in these critically ill patients.
Cirrhotic patients admitted to intensive care units (ICUs) have high mortality rates. This study evaluated specific predictors and scoring systems for hospital and 6-month mortality in critically ill cirrhotic patients. This investigation is a prospective clinical study performed in a 10-bed specialized hepatogastroenterology ICU in a tertiary care university hospital in Taiwan. Two hundred two consecutive cirrhotic patients admitted to the ICU during a 2-year period were enrolled in this study. Demographic, clinical, and laboratory variables recorded on the first day of ICU admission and scoring systems applied were prospectively recorded for post hoc analysis for predicting survival. The overall hospital mortality was 59.9%, and the 6-month mortality rate was 70.8%. The main causes of cirrhosis were hepatitis B (29%), hepatitis C (22%), and alcoholism (20%). The major cause of ICU admission was upper gastrointestinal bleeding (36%). Multiple logistic regression analysis revealed that the Acute Kidney Injury Network (AKIN) score at the 48th hour of ICU admission and the Sequential Organ Failure Assessment (SOFA) as well as the Model for End-Stage Liver Disease scores on the first day of ICU admission were independent risk factors for hospital mortality. The SOFA score had the best discriminatory power (0.872 ± 0.036), whereas the AKIN had the best Youden index (0.57) and the highest correctness of prediction (79%). Cumulative survival rates at the 6-month follow-up after hospital discharge differed significantly (P < 0.05) for AKIN stage 0 vs. stages 1, 2, and 3, and for AKIN stage 1 vs. stage 3. The AKIN, SOFA, and Model for End-stage Liver Disease (MELD) scores showed well discriminative power in predicting hospital mortality in this group of patients. The AKIN scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.
Background: Hyponatremia is common in advanced cirrhosis patients. This condition is associated with reduced survival in patients with end-stage liver disease awaiting liver transplantation. Hyponatremia has been proved as a posttransplantation outcome predictor in cirrhosis patient undergoing liver transplantation. This study assesses the prognostic value of serum sodium level, not only pre-operation but also post-operation, in liver transplant patients. Methods: One hundred forty-nine consecutive cirrhosis patients who had received liver transplants during a 7-year period were enrolled in this study. Demographic data as well as pre- and post-transplant clinical and laboratory variables were retrospectively recorded. Results: The overall 1-year mortality rate was 22.1%. Patients with pre-transplant serum sodium ≤135 mmol/L had significantly higher 1-month, 3-month, and 1-year mortality. In patients with serum sodium ≤135 mmol/L on Day 3 post-liver transplant, 1-year mortality was significantly increased, but 1-month and 3-month mortality were not. As a predictor of 3-month mortality, the discriminatory power of pre-transplant serum sodium concentration was superior to that of concentrations observed on post-transplant Day 1 and Day 3. For predicting 1-year mortality, the pre-transplant and post-transplant Day 3 serum sodium levels displayed better areas under the receiver operating characteristic curves than post-transplant Day 1 serum sodium concentration did. Finally, cumulative survival rates at 1-year follow-up differed significantly (p＜0.05) between patients with pre-transplant and post-transplant Day 3 serum sodium＞135 mmol/L and those with serum sodium ≤135 mmol/L. Conclusions: Low serum sodium level at pre-transplant and at Day 3 post-transplant is associated with poor short-term prognosis. In cirrhosis patients, low sodium level should be considered a mortality risk factor before transplantation as well as a risk factor for poor early post-transplantation outcome.
in the rightabdomen. Ultrasound study verified the existence of amassive right-side abdominal heterogenous tumour.Due to renal failure with severe metabolic acidosis,the patient underwent haemodialysis.Abdominal computed tomography (CT) withcontrast (Figure 1) and angiography (Figure 2) demon-strated a substantial right-side renal tumour, roughly28cm in size. The tumour directly invaded the rightlobe and caudate lobe of the liver, right retroperito-neum space and hepatic flexure of the colon. Closeattachment of the tumour with the duodenum andpancreatic head was noted in addition to displacement.Inferior vena cava (IVC) was effaced and the adrenalgland was encased by the huge tumour. Kidney biopsyconfirmed the diagnosis of sarcomatoid RCC.Sarcomatoid renal cell carcinoma (RCC), firstdescribed by Farrow et al. in 1968, is definedpathologically by highly pleomorphic spindle cellsand/or giant cells resembling sarcoma, with varyingdegrees of clear or granular epithelial cells thatcharacterize RCC. A sarcomatoid component isindicative of an aggressive tumour [1]. RCC cangenerate many paraneoplastic manifestations.Common paraneoplastic syndromes of RCC arecachexia, hypertension, anaemia, non-metastatichepatic dysfunction, erythrocytosis and amyloidosis.Clinically, sarcomatoid RCC is associated with poorprognosis, due to locally aggressive and potentialmetastasis [2]. Recognizing paraneoplastic syndromecan facilitate prompt diagnosis and intervention.Cytoreduction of the primary malignancy is themainstay therapy.
Aggressively applying e-interventions in the health care industry has become a global trend to improve the quality of medical care. The present retrospective study evaluated the effect of electronic information systems on the quality of medical care provide to hemodialysis (HD) patients. In total, 600 patients (300 patients each in the e-intervention and non-e-intervention groups, were matched for sex, age, HD duration, diabetes, and hypertension) receiving HD at the study institute for four years were included in this study. The e-intervention group had significantly fewer hospitalization days than the non-e-intervention group. Cox regression analysis demonstrated that the non-e-intervention group had a significantly higher mortality rate than the e-intervention group. Stratified analysis revealed significant differences between the e-intervention and non-e-intervention groups in their serum albumin levels, urea reduction ratios, and cardiothoracic ratios at 1-year follow-up. The patients in the e-intervention group had a significantly higher HD blood flow rate, fewer hospitalization days and a lower 4-year all-cause mortality rate than those in the non-e-intervention group. The implementation of the e-intervention improved patient outcomes, but additional studies are required to evaluate the cost effectiveness of such implementations.
Acute respiratory distress syndrome (ARDS) is commonly diagnosed in intensive care units (ICUs), often in association with acute kidney injury. In this study, we compared the predictive value of outcome scoring systems: Acute Physiology and Chronic Health Evaluation IV (APACHE IV), earlier APACHE models, Sequential Organ Failure Assessment (SOFA), the Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure (RIFLE) classification, and Acute Lung Injury score in critically ill patients with ARDS. We retrospectively abstracted data from the medical records of 135 critically ill ARDS patients in two medical ICUs of a tertiary care hospital from December 1999 to June 2006. Overall mortality rate was 65% (88/135). Forward conditional logistic regression identified APACHE IV, alveolar-arterial O2 tension difference, age, sepsis, and maximum RIFLE (RIFLEmax) score on ICU days 1 and 3 to be independent predictors of hospital mortality. The area under the receiver operating characteristic curve for the APACHE IV score revealed good fit (Hosmer and Lemeshow goodness-of-fit test results) and discriminative power (area under the receiver operating characteristic curve, 0.792 ± 0.038; P < 0.001). The cumulative survival rates at 6-month follow-up after hospital discharge were significantly (P < 0.001) different among ARDS patients with APACHE IV mortality rate 35% or less and APACHE IV mortality rate higher than 35%. The APACHE IV score and RIFLEmax score are predictors of hospital mortality in ARDS patients, with APACHE IV demonstrating desirable properties of prognostic accuracy.
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