Lifting COVID-19 mitigation measures in Spain (May-June 2020).

Introduction: The state of alarm was declared in Spain due to the COVID-19 epidemic on March 14, 2020, and established population confinement measures. The objective is to describe the process of lifting these mitigation measures. Methods: The Plan for the Transition to a New Normality, approved on April 28, contained four sequential phases with progressive increase in socio-economic activities and population mobility. In parallel, a new strategy for early diagnosis, surveillance and control was implemented. A bilateral decision mechanism was established between the Spanish Government and the autonomous communities (AC), guided by a set of qualitative and quantitative indicators capturing the epidemiological situation and core capacities. The territorial units were established ad-hoc and could be from Basic Health Zones to entire AC. Results: The process run from May 4 to June 21, 2020. AC implemented plans for reinforcement of core capacities. Incidence decreased from a median (50% of territories) of 7.4 per 100,000 in 7 days at the beginning to 2.5 at the end. Median PCR testing increased from 53% to 89% of suspected cases and PCR total capacity from 4.5 to 9.8 per 1000 inhabitants weekly; positivity rate decreased from 3.5% to 1.8%. Median proportion of cases with traced contacts increased from 82% to 100%. Conclusion: Systematic data collection, analysis, and interterritorial dialogue allowed adequate process control. The epidemiological situation improved but, mostly, the process entailed a great reinforcement of core response capacities nation-wide, under common criteria. Maintaining and further reinforcing capacities remained crucial for responding to future waves.

Introducción: El 14 de marzo de 2020 España declaró el estado de alarma por la pandemia por COVID-19 incluyendo medidas de confinamiento. El objetivo es describir el proceso de desescalada de estas medidas. Métodos: Un plan de transición hacia una nueva normalidad, del 28 de abril, incluía 4 fases secuenciales incrementando progresivamente las actividades socioeconómicas y la movilidad. Concomitantemente, se implementó una nueva estrategia de diagnóstico precoz, vigilancia y control. Se estableció un mecanismo de decisión bilateral entre Gobierno central y comunidades autónomas (CCAA), guiado por un panel de indicadores cualitativos y cuantitativos de la situación epidemiológica y las capacidades básicas. Las unidades territoriales evaluadas comprendían desde zonas básicas de salud hasta CCAA. Resultados: El proceso se extendió del 4 de mayo al 21 de junio y se asoció a planes de refuerzo de las capacidades en las CCAA. La incidencia disminuyó de una mediana inicial de 7,4 por 100.000 en 7 días a 2,5 al final del proceso. La mediana de pruebas PCR aumentó del 53% al 89% de los casos sospechosos, y la capacidad total de 4,5 a 9,8 pruebas semanales por 1.000 habitantes; la positividad disminuyó del 3,5% al 1,8%. La mediana de casos con contactos trazados aumentó del 82% al 100%. Conclusión: La recogida y análisis sistemático de información y el diálogo interterritorial logaron un adecuado control del proceso. La situación epidemiológica mejoró, pero sobre todo, se aumentaron las capacidades, en todo el país y con criterios comunes, cuyo mantenimiento y refuerzo fue clave en olas sucesivas.

Lifting COVID-19 mitigation measures in Spain (May-June 2020).

INTRODUCTION: The state of alarm was declared in Spain due to the COVID-19 epidemic on March 14, 2020, and established population confinement measures. The objective is to describe the process of lifting these mitigation measures. METHODS: The Plan for the Transition to a New Normality, approved on April 28, contained four sequential phases with progressive increase in socio-economic activities and population mobility. In parallel, a new strategy for early diagnosis, surveillance and control was implemented. A bilateral decision mechanism was established between the Spanish Government and the autonomous communities (AC), guided by a set of qualitative and quantitative indicators capturing the epidemiological situation and core capacities. The territorial units were established ad-hoc and could be from Basic Health Zones to entire AC. RESULTS: The process run from May 4 to June 21, 2020. AC implemented plans for reinforcement of core capacities. Incidence decreased from a median (50% of territories) of 7.4 per 100,000 in 7 days at the beginning to 2.5 at the end. Median PCR testing increased from 53% to 89% of suspected cases and PCR total capacity from 4.5 to 9.8 per 1000 inhabitants weekly; positivity rate decreased from 3.5% to 1.8%. Median proportion of cases with traced contacts increased from 82% to 100%. CONCLUSION: Systematic data collection, analysis, and interterritorial dialogue allowed adequate process control. The epidemiological situation improved but, mostly, the process entailed a great reinforcement of core response capacities nation-wide, under common criteria. Maintaining and further reinforcing capacities remained crucial for responding to future waves.

Implementation of recommendations in rheumatic and musculoskeletal diseases: considerations for development and uptake.

A clinical guideline is a document with the aim of guiding decisions based on evidence regarding diagnosis, management and treatment in specific areas of healthcare. Specific to rheumatic and musculoskeletal diseases (RMDs), adherence to clinical guidelines recommendations impacts the outcomes of people with these diseases. However, currently, the implementation of recommendations is less than optimal in rheumatology.The WHO has described the implementation of evidence-based recommendations as one of the greatest challenges facing the global health community and has identified the importance of scaling up these recommendations. But closing the evidence-to-practice gap is often complex, time-consuming and difficult. In this context, the implementation science offers a framework to overcome this scenario.This article describes the principles of implementation science to facilitate and optimise the implementation of clinical recommendations in RMDs. Embedding implementation science methods and techniques into recommendation development and daily practice can help maximise the likelihood that implementation is successful in improving the quality of healthcare and healthcare services.

Coping with intimate partner violence and the COVID-19 lockdown: The perspectives of service professionals in Spain.

Socioeconomic crisis and humanitarian disasters can cause increased stress for women who experience inter-partner violence (IPV). This study analyzed the impact of the COVID-19 lockdown on this important issue, their related health and social services and working conditions from the perspectives of professionals in different sectors. Forty-three semi-structured interviews were carried out with 47 professionals (44 women and 3 men) from 40 different entities (September 2020-April 2021). This content analysis suggests that the pandemic and its associated prevention measures have had a negative impact on women exposed to IPV and their children, which affected their social wellbeing. Professionals described burnout, difficult and slow administrative processes, and problems with coordination and access to information. These negative impacts were mitigated, in part, by the work of professionals, but this suggests that a series of key strategies are needed to improve the response capacity of the service sector to IPV in situations of crisis. These improvements are related to the availability of human and material resources; an efficient coordination network between the professionals from different sectors; existence of informal support networks in the community; protocols/procedures and prior training for better implementation; and greater flexibility and accessibility of basic services that benefit women who experience IPV.

Lifting COVID-19 mitigation measures in Spain (May-June 2020).

INTRODUCTION: The state of alarm was declared in Spain due to the COVID-19 epidemic on March 14, 2020, and established population confinement measures. The objective is to describe the process of lifting these mitigation measures. METHODS: The Plan for the Transition to a New Normality, approved on April 28, contained four sequential phases with progressive increase in socio-economic activities and population mobility. In parallel, a new strategy for early diagnosis, surveillance and control was implemented. A bilateral decision mechanism was established between the Spanish Government and the autonomous communities (AC), guided by a set of qualitative and quantitative indicators capturing the epidemiological situation and core capacities. The territorial units were established ad-hoc and could be from Basic Health Zones to entire AC. RESULTS: The process run from May 4 to June 21, 2020. AC implemented plans for reinforcement of core capacities. Incidence decreased from a median (50% of territories) of 7.4 per 100,000 in 7 days at the beginning to 2.5 at the end. Median PCR testing increased from 53% to 89% of suspected cases and PCR total capacity from 4.5 to 9.8 per 1000 inhabitants weekly; positivity rate decreased from 3.5% to 1.8%. Median proportion of cases with traced contacts increased from 82% to 100%. CONCLUSION: Systematic data collection, analysis, and interterritorial dialogue allowed adequate process control. The epidemiological situation improved but, mostly, the process entailed a great reinforcement of core response capacities nation-wide, under common criteria. Maintaining and further reinforcing capacities remained crucial for responding to future waves.

A Reliable and Valid Parent Self-Report Tool to Assess Children's Global Health Needs.

PURPOSE: This study aimed to develop and validate a parent self-report questionnaire to explore global health needs in 2- to 6-year-old children. DESIGN AND METHODS: The development of the tool started with a conceptualization phase, followed by the design, pilot testing and psychometric validation of the questionnaire. The construct validity was assessed. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were carried out to explore the construct validity of the questionnaire. The normed fit index (NFI), root mean square error of approximation (RMSEA), chi square test and comparative fit index (CFI) were used to test the goodness-of-fit. Reliability was explored through Cronbach's alpha for internal consistency. RESULTS: A total of 973 parents completed the 119 items of the Necesidades de salud de la Población Infantil (NPI) questionnaire for the psychometric validation stage. The EFA identified seven factors: Lifestyles, Promotion of healthy lifestyles and influence of significant persons, Children's socioemotional aspects, Parents' socioemotional aspects, Parental self-efficacy, Situational influences, Professional advice. All the factors showed good internal consistency (Cronbach's alpha >0.7). The CFA showed good adjustment to the model (RMSEA = 0.048). The values of NFI and CFI were 0.741 and 0.779 respectively. CONCLUSIONS: The NPI questionnaire is a reliable and valid instrument. PRACTICE IMPLICATIONS: The seven-factor questionnaire will be useful for analyzing children's global health needs, designing health promotion programs according to identified needs and assessing related interventions.

Early Impact of the 2014 World Health Assembly Resolution on Palliative Care: A Qualitative Study Using Semistructured Interviews with Key Experts.

Background: In 2014, the World Health Assembly (WHA) approved the Resolution "Strengthening of palliative care as a component of comprehensive care throughout the life course" (WHA67.19), urging national governments to carry out actions to develop palliative care. Objective: To establish the origins and assess the influence and early impact of this Resolution. Methods: Semistructured interviews conducted with key informants (n = 20). A thematic content analysis was conducted and triangulated on the transcriptions. Results: The collaborative work done by Non-State Actors, palliative care associations, individuals, Member States, and the World Health Organization (WHO) itself was crucial to the drafting and the approval of WHA67.19. Several post-Resolution actions undertaken by the WHO were highlighted (e.g., appointment of a dedicated officer and the creation of advisory working groups) and its role was identified as a key element in the implementation. Inadequate funding, lack of resources, and cultural factors were the most relevant barriers to implementation. The wide network of NGOs and palliative care associations was identified as the main facilitator. The key identified impact of the Resolution was its value as an advocacy tool and its contribution to raising awareness about palliative care around the world. Conclusions: Despite the lack of indicators to monitor the implementation of Resolution WHA67.19, key experts evaluate its effects in the short term as positive. Policy potential and its use in championing palliative care are its main early successes. The role of Non-State Actors, the WHO, and Member States working together is crucial to achieving its goals.

Design and Evaluation of a Novel Mobile Phone Application to Improve Palliative Home-Care in Resource-Limited Settings.

CONTEXT: Mobile health (mHealth) provides an opportunity to use internet coverage in low- and middle-income countries to improve palliative care access and quality. OBJECTIVES: This study aimed to design a mobile phone application (app) to enable or improve communication between family caregivers, community caregivers, and palliative care teams; to evaluate its acceptability, processes, and mechanisms of action; and to propose refinements. METHODS: A codesign process entailed collaboration between a Project Advisory Group and collaborators in India, Uganda, and Zimbabwe. We then trained community and family caregivers to use an app to communicate patient-reported outcomes to their palliative care providers each week on a data dashboard. App activity was monitored, and qualitative in-depth interviews explored experience with the app and its mechanisms and impact. RESULTS: N = 149 caregivers participated and uploaded n = 837 assessments of patient-reported outcomes. These data were displayed to the palliative care team on an outcomes dashboard on n = 355 occasions. Qualitative data identified: 1) high acceptability and data usage; 2) improved understanding by team members of patient symptoms and concerns; 3) a need for better feedback to caregivers, for better prioritisation of patients according to need, for enhanced training and support to use the app, and for user-led recommendations for ongoing improvement. CONCLUSION: An outcomes-focused app and data dashboard are acceptable to caregivers and health-care professionals. They are beneficial in identifying, monitoring, and communicating patient outcomes and in allocating staff resource to those most in need.

Representations of palliative care, euthanasia and assisted dying within advocacy declarations.

It is well known that there are disagreements between the proponents of palliative care and of euthanasia or assisted dying, often with little common ground,shaping the end of life discourse internationally. Advocacy documents or 'declarations'constitute a significant feature of this discourse. The aim of this study was to explore the content of such declarations and to focus on what they can tell us about palliative care and assisted dying and their dispositions towards one another. 104 declarations were identified and included in the study, covering the period 1974 to 2017. These declarations were analysed following the principles of thematic content analysis. We classified them based on their primary purpose: those with the goal of advocating for palliative care services, education and research were grouped under 'palliative care declarations'; those with the primary objective of advocating for or against euthanasia/assisted dying were classified as "euthanasia/assisted dying declarations". Our analysis revealed that the content of the declarations could be broadly categorised into three dimensions: framing, claiming and demanding. We demonstrate that these declarations reveal a struggle over the construction of meanings relating to palliative care and assisted dying and constitute a valuable resource for the analysis of an unfolding debate.

Social representation of palliative care in the Spanish printed media: A qualitative analysis.

BACKGROUND: Lack of social awareness is a major barrier to the development of palliative care. Mass media influences public opinion, and frequently deal with palliative care contributing to its image and public understanding. AIM: To analyse how palliative care is portrayed in Spanish newspapers, as well as the contribution made by the press to its social representation. DESIGN: Based on criteria of scope and editorial plurality, four print newspapers were selected. Using the newspaper archive MyNews (www.mynews.es), articles published between 2009 and 2014 containing the words "palliative care" or "palliative medicine" were identified. Sociological discourse analysis was performed on the identified texts on two levels: a) contextual analysis, focusing on the message as a statement; b) interpretative analysis, considering the discourse as a social product. RESULTS: We examined 262 articles. Politician and healthcare professionals were the main representatives transmitting messages on palliative care. The discourses identified were characterised by: strong ideological and moral content focusing on social debate, strong ties linking palliative care and death and, to a lesser degree, as a healthcare service. The messages transmitted by representatives with direct experience in palliative care (professionals, patients and families) contributed the most to building a positive image of this healthcare practice. Overall, media reflect different interests in framing public understanding about palliative care. CONCLUSION: The knowledge generated about how palliative care is reflected in the printed media may help to understand better one of the main barriers to its development not only in Spain, but also in other contexts.

Metodología para el desarrollo de un resumen de evidencia para políticas en salud pública / Methodology for the development of policy brief in public health

El resumen de evidencia para políticas es un documento de referencia en la toma de decisiones políticas. De forma breve y directa, se define un problema, se realiza una síntesis de la evidencia disponible en torno al mismo, se identifican posibles líneas de actuación y se proponen recomendaciones. El objetivo de esta nota es describir su metodología, partiendo del modelo propuesto por Eugene Bardach y nuestra propia experiencia. Se describe la metodología en seis pasos: 1) identificación de la audiencia a la que se dirige el documento; 2) delimitación del problema; 3) recopilación de información y evidencias; 4) consideración de alternativas; 5) proyección de resultados y diseño de recomendaciones o mensajes clave; y 6) descripción de la historia. Se presenta también el resumen de evidencia para políticas como parte de una estrategia de comunicación más amplia que puede generar puntos de encuentro entre equipos de investigación y grupos de interés

A policy brief is a document that summarizes research to inform policy. In a brief and succinct way, it defines a policy problem, presents a synthesis of relevant evidence, identifies possible courses of action and makes recommendations or key points. The objective of this note is to describe the methodology used to produce a policy brief for communicating public health research. This note is based on the model presented by Eugene Bardach in addition to the authors’ own experiences. We describe six steps: 1) identifying the audience; 2) defining the problem; 3) gathering information and evidence; 4) consideration of policy alternatives; 5) projecting results and designing recommendations; and 6) telling the story. We make a case for the use of policy briefs as a part of an overall communications strategy for research that aims to bring together research teams and stakeholders

[Methodology for the development of policy brief in public health]. / Metodología para el desarrollo de un resumen de evidencia para políticas en salud pública.

A policy brief is a document that summarizes research to inform policy. In a brief and succinct way, it defines a policy problem, presents a synthesis of relevant evidence, identifies possible courses of action and makes recommendations or key points. The objective of this note is to describe the methodology used to produce a policy brief for communicating public health research. This note is based on the model presented by Eugene Bardach in addition to the authors' own experiences. We describe six steps: 1) identifying the audience; 2) defining the problem; 3) gathering information and evidence; 4) consideration of policy alternatives; 5) projecting results and designing recommendations; and 6) telling the story. We make a case for the use of policy briefs as a part of an overall communications strategy for research that aims to bring together research teams and stakeholders.

The level of provision of specialist palliative care services in Scotland: an international benchmarking study.

OBJECTIVES: Comparative benchmarking of specialist palliative care (SPC) services across jurisdictions can be used to assess the adequacy of provision. Published in 2016, the Scottish Atlas of Palliative Care unlocks the possibility of benchmarking Scotland's provision against other European Union (EU) countries. Our objectives were to describe the provision of SPC services in Scotland and compare this with other EU countries, assessing coverage against European norms. METHODS: We conducted a secondary analysis of data collected as part for the Scottish Atlas by structured telephone (n=33) or online (n=3) survey with informants from 14 territorial health boards and 15 hospices who provided information about SPC services in their locality. National-level Scottish data were compared with data from other EU countries allowing ranking for each service type and service coverage as calculated against European Association for Palliative Care norms. RESULTS: Scotland had a total of 23 SPC inpatient units containing 349 beds, 27 SPC hospital support teams and 38 SPC home care teams. Relative to other EU countries, Scotland ranked seventh for provision of SPC inpatient units and hospital support teams, and fifth for home care teams. Coverage for these services was 85%, 100% and 72%, respectively. CONCLUSION: Scotland is positioned among the top 10 EU countries for the level of provision of SPC services. National policy in Scotland has focused on the delivery of palliative care at home or in a homely setting. These data support a focus on developing services in community settings to meet Scotland's policy ambitions.

Investigación cualitativa en Cuidados Paliativos. Un recorrido por los enfoques más habituales / Qualitative research in palliative care. A walk through the most frequent approaches

La utilización de la investigación cualitativa en Cuidados Paliativos (CP) está en auge, quizás porque tienen muchos aspectos en común. Ambos se centran en la persona y su entorno y están especialmente interesados en la experiencia humana. El objetivo de este artículo es presentar algunos de los enfoques más frecuentemente utilizados en las ciencias de la salud, proporcionando ejemplos de estudios de CP. Esto con el fin de ayudar a quienes se están iniciando en la investigación cualitativa a explorar los posibles enfoques que podrían utilizar para realizar investigación en CP. A través del ejercicio «armchair walkthrough», se concretan los aspectos clave de un proyecto de investigación, considerando los distintos enfoques: la etnografía, la fenomenología, la narrativa y la teoría fundamentada. Familiarizarse con la metodología cualitativa y algunos de los enfoques ayudará a los profesionales de CP a plantear nuevas preguntas y retos con investigación rigurosa

The use of qualitative research in Palliative Care (PC) is increasing, probably because PC and qualitative methodology have many things in common. Both focus on the person and his or her environment, and they are particularly interested in human experience. The aim of this paper is to present some of the most often used qualitative research approaches in health science, providing examples of PC studies. The aim is to help beginners to explore the possible approaches that they could use to carry out research in PC. The armchair walk-through exercise, which helps to specify key aspects in research, is developed for each of the approaches: ethnography, phenomenology, personal narrative, and grounded theory. Becoming familiar with qualitative methodology and some of the approaches will help PC health professionals to raise new questions and address new challenges with rigorous research

What does the media say about palliative care? A descriptive study of news coverage in written media in Spain.

INTRODUCTION: The goal of palliative care (PC) is to improve the quality of life of terminal stage patients and their families. The subject frequently appears in the mass-media and this helps create a socially accepted identity. The aim of this study is to describe and analyse PC related news items appeared in the Spanish written media. METHODOLOGY: A descriptive cross-sectional study was designed. Considering diffusion, scope and the range in editorial policy criteria, four printed newspapers (PN) were selected, together with four exclusively digital media sources (DM). Through Mynews, a newspaper content depository, and the search tool for each DM website, articles published between 2009 and 2014 which included the terms "palliative care" and "palliative medicine" were sought. A questionnaire was created to characterise each article identified and a descriptive analysis was undertaken. RESULTS: A total of 627 articles were identified, of which 359 (57%) were published in PN (42% in the printed editions -PE- 16% in their online editions -OE-) and 268 (43%) in DM. In general, they appeared mainly in sections concerning Health (23%), Culture and Society (18%) and General/Home News (15%). In PE, just 2% were found in the Health section and nearly 70% in Culture and Society and General/Home News. Most of the articles were informative in nature and contained socio-political messages (90%). Statements by PC professionals were found in 35% of the articles and by politicians in 32%. The most frequent content was related to facing end of life (74%) and patient quality of life (70%). CONCLUSIONS: The Spanish written media reflects the socio-political interest aroused by PC. Nevertheless, messages circulating about PC do not describe professional practice, or the contribution of the same for patients. Content more in line with the clinical practice might help contribute to the development of this new area of medicine.

What are families most grateful for after receiving palliative care? Content analysis of written documents received: a chance to improve the quality of care.

BACKGROUND: Family members are involved in the care of palliative patients at home and therefore, should be viewed as important sources of information to help clinicians better understand the quality palliative care service patients receive. The objective of the study was to analyse what is valued most by family carers undergoing bereavement of a palliative care home service in order to identify factors of quality of care. METHODS: Qualitative exploratory study based on documentary analysis. Content analysis of 77 gratitude documents received over 8 years by a palliative home service in Odivelas, near Lisbon (Portugal) was undertaken, through an inductive approach and using investigator triangulation. Frequency of distinct categories was quantitatively defined. RESULTS: Three different content categories emerged from the analysis: a) Recognition of the care received and the value of particular aspects of care within recognised difficult situations included aspects such as kindness, listening, attention to the family, empathy, closeness, affection and the therapeutic relationships established (63/77 documents); b) Family recognition of the achievements of the palliative care team (29/77) indicated as relief from suffering for the patient and family, opportunity of dying at home, help in facing difficult situations, improvement in quality of life and wellbeing, and feeling of serenity during bereavement; c) Messages of support (45/77) related to the need of resources provided. The relational component emerges as an underlying key aspect of family carers' experience with palliative care home service. CONCLUSION: Family carers show spontaneous gratitude for the professionalism and humanity found in palliative care. The relational component of care emerges as key to achieve a high quality care experience of palliative care homes service, and could be one indicator of quality of palliative care.

The Palliative Care Challenge: Analysis of Barriers and Opportunities to Integrate Palliative Care in Europe in the View of National Associations.

BACKGROUND: Palliative care (PC) development is diverse and lacks an effective integration into European healthcare systems. This article investigates levels of integrated PC in European countries. METHODS: A qualitative survey was undertaken for the 2013 EAPC Atlas of PC in Europe with boards of national associations, eliciting opinions on opportunities for, and barriers to, PC development. ANALYSIS: Barriers and opportunities directly related to PC integration were identified and analyzed thematically according (1) to the dimensions of the World Health Organization (WHO) public health model and (2) by the degree of service provision in each country. A frequency analysis of dimensions and level of provision was also conducted. RESULTS: In total, 48/53 (91%) European countries responded to the survey. A total of 43 barriers and 65 opportunities were identified as being related to PC integration. Main barriers were (1) lack of basic PC training, with a particular emphasis on the absence of teaching at the undergraduate level; (2) lack of official certification for professionals; (3) lack of coordination and continuity of care for users and providers; (4) lack of PC integration for noncancer patients; (5) absence of PC from countries' regulatory frameworks; and (6) unequal laws or regulations pertaining to PC within countries. Innovations in education and new regulatory frameworks were identified as main opportunities in some European countries, in addition to opportunities around the implementation of PC in home care, nursing home settings, and the earlier integration of PC into patients' continuum of care. With increasing provision of services, more challenges for the integration are detected (p < 0.005). CONCLUSION: A set of barriers and opportunities to PC integration has been identified across Europe, by national associations, offering a barometer against which to check the challenge of integration across countries.

Palliative Care Bedside Teaching: A Qualitative Analysis of Medical Students' Reflective Writings after Clinical Practices.

CONTEXT: A mandatory course in palliative care (PC) is organized for all final-year medical students at the University of Navarre. It consists of 24 lectures, 4 workshops, and 1 scheduled five hour clinical PC service experience at two different sites. In the 48 hours after the visit and related to the clinical experience, each student has to complete a 500-word reflective writing (RW) piece. OBJECTIVE: To investigate how a brief PC clinical experience helps equip the medical student. METHODS: Qualitative study of RW. Two researchers produced a content analysis of students' RW. They collaboratively developed themes and categories with a constant review of the classification tree and an exhaustive collection of quotes. Differences between services were analyzed (λ2). RESULTS: One hundred sixty-seven RW were analyzed from the 197 students on the course (response rate 85%). Six major themes emerged: All the students identified central aspects of PC work dynamics; students acquired specific PC knowledge (86%); the personal influence of the experience was reported (68%); students described how patients and their caregivers deal with the patients' illness (68%); students talked about the essence of PC and essential aspects of medicine (42%); students reported spontaneously having changed their assumptions about PC (15%); and they realized that the experience was relevant to all clinical practice. Categories such as teamwork, the expression of patients' and caregivers' feelings, and family devotion showed statistical differences between services (λ2 p < 0.05). CONCLUSION: A short bedside clinical experience in PC, encouraging student reflection, provides a deeper understanding of PC and even of core medicine values. The data we gather cannot explain only new skill acquisition but seems to suggest a life-changing personal experience for the student.

'Dignity therapy', a promising intervention in palliative care: A comprehensive systematic literature review.

BACKGROUND: Dignity therapy is psychotherapy to relieve psychological and existential distress in patients at the end of life. Little is known about its effect. AIM: To analyse the outcomes of dignity therapy in patients with advanced life-threatening diseases. DESIGN: Systematic review was conducted. Three authors extracted data of the articles and evaluated quality using Critical Appraisal Skills Programme. Data were synthesized, considering study objectives. DATA SOURCES: PubMed, CINAHL, Cochrane Library and PsycINFO. The years searched were 2002 (year of dignity therapy development) to January 2016. 'Dignity therapy' was used as search term. Studies with patients with advanced life-threatening diseases were included. RESULTS: Of 121 studies, 28 were included. Quality of studies is high. Results were grouped into effectiveness, satisfaction, suitability and feasibility, and adaptability to different diseases and cultures. Two of five randomized control trials applied dignity therapy to patients with high levels of baseline psychological distress. One showed statistically significant decrease on patients' anxiety and depression scores over time. The other showed statistical decrease on anxiety scores pre-post dignity therapy, not on depression. Nonrandomized studies suggested statistically significant improvements in existential and psychosocial measurements. Patients, relatives and professionals perceived it improved end-of-life experience. CONCLUSION: Evidence suggests that dignity therapy is beneficial. One randomized controlled trial with patients with high levels of psychological distress shows DT efficacy in anxiety and depression scores. Other design studies report beneficial outcomes in terms of end-of-life experience. Further research should understand how dignity therapy functions to establish a means for measuring its impact and assessing whether high level of distress patients can benefit most from this therapy.

Development of an activity disease score in patients with uveitis (UVEDAI).

To develop a disease activity index for patients with uveitis (UVEDAI) encompassing the relevant domains of disease activity considered important among experts in this field. The steps for designing UVEDAI were: (a) Defining the construct and establishing the domains through a formal judgment of experts, (b) A two-round Delphi study with a panel of 15 experts to determine the relevant items, (c) Selection of items: A logistic regression model was developed that set ocular inflammatory activity as the dependent variable. The construct "uveitis inflammatory activity" was defined as any intraocular inflammation that included external structures (cornea) in addition to uvea. Seven domains and 15 items were identified: best-corrected visual acuity, inflammation of the anterior chamber (anterior chamber cells, hypopyon, the presence of fibrin, active posterior keratic precipitates and iris nodules), intraocular pressure, inflammation of the vitreous cavity (vitreous haze, snowballs and snowbanks), central macular edema, inflammation of the posterior pole (the presence and number of choroidal/retinal lesions, vascular inflammation and papillitis), and global assessment from both (patient and physician). From all the variables studied in the multivariate model, anterior chamber cell grade, vitreous haze, central macular edema, inflammatory vessel sheathing, papillitis, choroidal/retinal lesions and patient evaluation were included in UVEDAI. UVEDAI is an index designed to assess the global ocular inflammatory activity in patients with uveitis. It might prove worthwhile to motorize the activity of this extraarticular manifestation of some rheumatic diseases.