Co-creation using crowdsourcing to promote PrEP adherence in China: study protocol for a stepped-wedge randomized controlled trial.

BACKGROUND: Adherent pre-exposure prophylaxis (PrEP) uptake can prevent HIV infections. Despite the high HIV incidence, Chinese key populations have low PrEP uptake and adherence. New interventions are needed to increase PrEP adherence among key populations in China. Co-creation methods are helpful to solicit ideas from the community to solve public health problems. The study protocol aims to describe the design of a stepped-wedge trial and to evaluate the efficacy of co-created interventions to facilitate PrEP adherence among key populations in China. METHODS: The study will develop intervention packages to facilitate PrEP adherence among Chinese key populations using co-creation methods. The study will then evaluate the efficacy of the co-created intervention packages using a stepped-wedge randomized controlled trial. This four-phased closed cohort stepped-wedge design will have four clusters. Each cluster will start intervention at three-month intervals. Seven hundred participants who initiated PrEP will be recruited. Participants will be randomized to the clusters using block randomization. The intervention condition includes receiving co-created interventions in addition to standard of care. The control condition is the standard of care that includes routine clinical assessment every 3 months. All participants will also receive an online follow-up survey every 3 months to record medication adherence and will be encouraged to use a WeChat mini-app for sexual and mental health education throughout the study. The primary outcomes are PrEP adherence and retention in PrEP care throughout the study period. We will examine a hypothesis that a co-created intervention can facilitate PrEP adherence. Generalized linear mixed models will be used for the primary outcome analysis. DISCUSSION: Developing PrEP adherence interventions in China faces barriers including suboptimal PrEP uptake among key populations, the lack of effective PrEP service delivery models, and insufficient community engagement in PrEP initiatives. Our study design addresses these obstacles by using co-creation to generate social media-based intervention materials and embedding the study design in the local healthcare system. The study outcomes may have implications for policy and intervention practices among CBOs and the medical system to facilitate PrEP adherence among key populations. TRIAL REGISTRATION: The study is registered in Clinical Trial databases in China (ChiCTR2100048981, July 19, 2021) and the US (NCT04754139, February 11, 2021).

Patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology: a qualitative systematic review.

OBJECTIVES: We aimed to describe patients' attitudes and experiences of transition from paediatric to adult healthcare in rheumatology to inform patient-centred transitional care programmes. METHODS: We searched MEDLINE, EMBASE, PsycINFO and CINAHL to August 2019 and used thematic synthesis to analyse the findings. RESULTS: From 26 studies involving 451 people with juvenile-onset rheumatic conditions we identified six themes: a sense of belonging (comfort in familiarity, connectedness in shared experiences, reassurance in being with others of a similar age, desire for normality and acceptance); preparedness for sudden changes (confidence through guided introductions to the adult environment, rapport from continuity of care, security in a reliable point of contact, minimizing lifestyle disruptions); abandonment and fear of the unknown (abrupt and forced independence, ill-equipped to hand over medical information, shocked by meeting adults with visible damage and disability, vulnerability in the loss of privacy); anonymous and dismissed in adult care (deprived of human focus, sterile and uninviting environment, disregard of debilitating pain and fatigue); quest for autonomy (controlled and patronized in the paediatric environment, liberated from the authority of others, freedom to communicate openly); and tensions in parental involvement (overshadowed by parental presence, guilt of excluding parents, reluctant withdrawal of parental support). CONCLUSION: Young people feel dismissed, abandoned, ill-prepared and out of control during transition. However, successful transition can be supported by preparing for changes, creating a sense of belonging and negotiating parental involvement and autonomy. Incorporating patient-identified priorities into transitional services may improve satisfaction and outcomes in young people with juvenile-onset rheumatic conditions.

Evaluation of geriatrics education at a Chinese University: A survey of attitudes and knowledge among undergraduate medical students.

Despite widespread reforms in medical education across China, nationally there has been no mandate or movement toward systemically incorporating geriatrics into curricula. To what degree medical students are trained and have exposure to geriatric topics remains unclear. We surveyed 190 medical students during their final year of medical school at a Chinese medical university, graduating from reformed and also traditional curricula. The survey was comprised of a subjective assessment of attitudes and reported knowledge, as well as an objective assessment of knowledge via a multiple choice test. Student attitudes were favorable toward geriatrics, with 91% supporting the addition of specialized clinical experiences to the curriculum. Students generally reported low exposure to geriatrics, with no statistically significant differences between reform and traditional curricula. There was a statistically significant difference in performance on the multiple choice test between curricula but at a degree unlikely to be practically significant. Students had very favorable attitudes toward geriatrics as a field and specialty; however scored poorly on competency exams, with the lowest performance around diagnosis and treatment of specific geriatric conditions. Our results suggest that there is a need and desire for increased geriatric-oriented learning at Chinese medical schools.

Twelve tips for using clinical cases to teach medical ethics.

The essential role of clinical case discussions in the teaching of medical ethics is well recognized. Based upon published literature and the authors' curricular development experience, the following 12 tips cover all major aspects of the case method for teaching clinical ethics and offer practical suggestions for designing and conducting case discussions.

Medical ethics education in China: Lessons from three schools.

BACKGROUND: Ethics teaching is a relatively new area of medical education in China, with ethics curricula at different levels of development. This study examined ethics education at three medical schools in China to understand their curricular content, teaching and learning methods, forms of assessments, changes over time, and what changes are needed for further improvement. METHODS: We used student and faculty surveys to obtain information about the ethics courses' content, teaching methods, and revisions over time. The surveys also included five realistic cases and asked participants whether each would be appropriate to use for discussion in ethics courses. Students rated the cases on a scale and gave written comments. Finally, participants were asked to indicate how much they would agree with the statement that medical professionalism is about putting the interests of patients and society above one's own. RESULTS: There were both similarities and differences among these schools with regard to course topics, teaching and assessment methods, and course faculty compositions, suggesting their courses are at different levels of development. Areas of improvement for the schools' courses were identified based on this study's findings and available literature. A model of the evolution of medical ethics education in China was proposed to guide reform in medical ethics instruction in China. Analysis identified characteristics of appropriate cases and participants' attitudes toward the ideal of professionalism. DISCUSSION: We conclude that the development of medical ethics education in China is promising while much improvement is needed. In addition, ethics education is not confined to the walls of medical schools; the society at large can have significant influence on the formation of students' professional values.

Teacher Immediacy for Effective Teaching in Medical Education.

This article introduces the concept of "teacher immediacy," defined as the teacher's communication behaviors that reduce the psychological distance between teacher and students. Though well investigated and recognized in the area of instructional communication, this concept is still new to the field of medical education. The authors first describe the origin, definition, and indicators of teacher immediacy, and then present empirical research findings on teacher immediacy's positive associations with effective teaching. The authors also introduce findings of teacher immediacy research related to the online learning environment. They recommend medical educators adopt the term "teacher immediacy" and explore it in practice.

When educators are locked down: transitioning an international faculty development program from in-person to online during the COVID-19 pandemic in China.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic forced international faculty development programs in medical education to forgo in-person activities and transition to online learning. We sought to examine changes in international medical educators' evaluations of our faculty development program as it transitioned due to the pandemic. Methods: We compared survey responses from participants in our International Medical Educators Program between 2019 (in-person) and 2020 (online). The 43-item survey addressed aspects such as program evaluation and self-assessment of curriculum development and teaching skills. We analyzed data using t-tests to compare means and chi-square test for categorical variables, and performed thematic analysis of open-ended responses. Results: We found that trainees in both cohorts rated the program highly with regard to overall program quality and self-assessed learning outcomes, but the 2019 group reported stronger relationships with peers and instructors. Some scores for self-assessed outcomes were lower for the 2020 class, but no statistically significant differences were found in pre- and post- training scores between the two cohorts. Four themes emerged from the feedback: positive program utility, IMEP as an example of good curriculum design, timing issues, and online learning environment challenges. Conclusions: Despite pandemic challenges, the transition to online faculty development was favorably evaluated, with high confidence in the applicability of learned skills. Future efforts should focus on fostering community and optimizing interaction times to enhance learning experiences. The study contributes insights for global medical education communities in pandemic circumstances.

Subpalpebral Antibiotic Lavage as Safe, Emergent, and Cost-Effective Management of Acute Infectious Keratitis Related to Contact Lens Overwear: Case Report and Literature Review.

PURPOSE: The aim of this study is to describe the technique of subpalpebral antibiotic lavage (SAL), which is a highly therapeutic, efficient, and cost-effective method for managing severe bacterial keratitis. METHODS: This case report describes a 26-year-old woman with severe bacterial keratitis in the right eye due to contact lens overwear, with progressive corneal thinning, a hypopyon, impending perforation, and marked visual loss to perception of light despite treatment with intensive topical antibiotics. This was managed with SAL that involves the insertion of a cannula transcutaneously into the upper conjunctival fornix to provide continuous antibiotic irrigation of the ocular surface. RESULTS: By 11 weeks after presentation, the cornea and anterior chamber appeared clinically quiescent, and visual acuity improved to 20/40 corrected in the right eye. CONCLUSIONS: Bacterial keratitis is a potentially blinding condition for which contact lens wear is an important risk factor. Most cases are successfully managed with topical medications; however, in cases of treatment failure, a second-line approach such as SAL can be sight-saving. SAL uses readily available equipment for the delivery of high concentrations of antibiotics to the ocular surface, thus increasing therapeutic efficacy and reducing nursing staff workload. Despite its advantages, the literature reveals apparent underutilization of this technique.

Some Learning Theories for Medical Educators.

Perspectives on the nature of learning influence decisions about curriculum design, teaching and learning strategies, and assessment of students. Current literature on medical education suggests that medical teachers have much interest in using theories to inform their practice. This article describes the following learning theories that have been discussed to various degrees in previous literature on medical education: cognitivism, constructivism, experiential learning, adult learning, self-directed learning, community of practice and situated learning, cognitive apprenticeship, and reflective learning. Each theory is explained in sufficient detail to help readers grasp its essence. Then, medical education literature is cited to show how the theory has been used or can be used to guide practice in medical education. Finally, this article analyzes the problem-based learning approach as an example to illustrate how the theories may be reflected in practice. Throughout the introduction of the various theories, this article aims at their application in medical education and attempts to draw connections among the theories rather than represent them as unrelated or competing ideas.

Evaluation of the initial implementation of a nationwide diabetic retinopathy screening programme in primary care: a multimethod study.

OBJECTIVES: The Australian Government funded a nationwide diabetic retinopathy screening programme to improve visual outcomes for people with diabetes. This study examined the benefits and barriers of the programme, image interpretation pathways and assessed the characteristics of people who had their fundus photos graded by a telereading service which was available as a part of the programme. DESIGN: Multimethod: survey and retrospective review of referral forms. SETTING: Twenty-two primary healthcare facilities from urban, regional, rural and remote areas of Australia, and one telereading service operated by a referral-only eye clinic in metropolitan Sydney, Australia. PARTICIPANTS: Twenty-seven primary healthcare workers out of 110 contacted completed a survey, and 145 patient referrals were reviewed. RESULTS: Manifest qualitative content analysis showed that primary healthcare workers reported that the benefits of the screening programme included improved patient outcomes and increased awareness and knowledge of diabetic retinopathy. Barriers related to staffing issues and limited referral pathways. Image grading was performed by a variety of primary healthcare workers, with one responder indicating the utilisation of a diabetic retinopathy reading service. Of the people with fundus photos graded by the reading service, 26.2% were reported to have diabetes. Overall, 12.3% of eyes were diagnosed with diabetic retinopathy. Photo quality was rated as excellent in 46.2% of photos. Referral to an optometrist for diabetic retinopathy was recommended in 4.1% of cases, and to an ophthalmologist in 6.9% of cases. CONCLUSIONS: This nationwide diabetic retinopathy screening programme was perceived to increase access to diabetic retinopathy screening in regional, rural and remote areas of Australia. The telereading service has diagnosed diabetic retinopathy and other ocular pathologies in images it has received. Key barriers, such as access to ophthalmologists and optometrists, must be overcome to improve visual outcomes.

Using Quicktome for Intracerebral Surgery: Early Retrospective Study and Proof of Concept.

BACKGROUND: Neurosurgeons have limited tools in their armamentarium to visualize critical brain networks during surgical planning. Quicktome was designed using machine-learning to generate robust visualization of important brain networks that can be used with standard neuronavigation to minimize those deficits. We sought to see whether Quicktome could help localize important cerebral networks and tracts during intracerebral surgery. METHODS: We report on all patients who underwent keyhole intracranial surgery with available Quicktome-enabled neuronavigation. We retrospectively analyzed the locations of the lesions and determined functional networks at risks, including chief executive network, default mode network, salience, corticospinal/sensorimotor, language, neglect, and visual networks. We report on the postoperative neurologic outcomes of the patients and retrospectively determined whether the outcomes could be explained by Quicktome's functional localizations. RESULTS: Fifteen high-risk patients underwent craniotomies for intra-axial tumors, with the exception of one meningioma and one case of leukoencephalopathy. Eight patients were male. The median age was 49.6 years. Quicktome was readily integrated in our existing navigation system in every case. New postoperative neurologic deficits occurred in 8 patients. All new deficits, except for one resulting from a postoperative stroke, were expected and could be explained by preoperative findings by Quicktome. In addition, in those who did not have new neurologic deficits, Quicktome offered explanations for their outcomes. CONCLUSIONS: Quicktome helps to visualize complex functional connectomic networks and tracts by seamlessly integrating into existing neuronavigation platforms. The added information may assist in reducing neurological deficits and offer explanations for postsurgical outcomes.

Patient and parent perspectives on transition from paediatric to adult healthcare in rheumatic diseases: an interview study.

OBJECTIVES: To describe the experiences, priorities, and needs of patients with rheumatic disease and their parents during transition from paediatric to adult healthcare. SETTING: Face-to-face and telephone semistructured interviews were conducted from December 2018 to September 2019 recruited from five hospital centres in Australia. PARTICIPANTS: Fourteen young people and 16 parents were interviewed. Young people were included if they were English speaking, aged 14-25 years, diagnosed with an inflammatory rheumatic disease (eg, juvenile idiopathic arthritis, juvenile dermatomyositis, systemic lupus erythematosus, panniculitis, familial Mediterranean fever) before 18 years of age. Young people were not included if they were diagnosed in the adult setting. RESULTS: We identified four themes with respective subthemes: avoid repeat of past disruption (maintain disease stability, preserve adjusted personal goals, protect social inclusion); encounter a daunting adult environment (serious and sombre mood, discredited and isolated identity, fear of a rigid system); establish therapeutic alliances with adult rheumatology providers (relinquish a trusting relationship, seek person-focused care, redefine personal-professional boundaries, reassurance of alternative medical supports, transferred trust to adult doctor) and negotiate patient autonomy (confidence in formerly gained independence, alleviate burden on patients, mediate parental anxiety). CONCLUSIONS: During transition, patients want to maintain disease stability, develop a relationship with their adult provider centralised on personal goals and access support networks. Strategies to comprehensively communicate information between providers, support self-management, and negotiate individualised goals for independence during transition planning may improve satisfaction, and health and treatment outcomes.

The diagnosis and management of temporal arteritis.

Temporal arteritis (TA), or giant cell arteritis, is a systemic autoimmune vasculitis affecting patients over 50 years of age. It can cause rapid, irreversible bilateral vision loss in older adults and is therefore considered an ophthalmological emergency. Many of the symptoms and signs of TA can be vague, non-specific and gradual in onset, often leading to a delayed or inaccurate diagnosis. As such, it is important for a wide variety of primary optometrists and health practitioners to maintain a robust understanding of the clinical presentation, key investigations and time-sensitive management of this disease, as early initiation of treatment for TA can be vision- and life-saving.