"It's What We Can Do Right Now": Professional Identity Formation Among Internal Medicine Residents During the COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic represents a consequential moment of disruption for medical training that has far-reaching implications for professional identity formation (PIF). To date, this has not been studied. As medical education grapples with a postpandemic era, it is essential to gain insight into how the pandemic has influenced PIF to better support its positive influences and mitigate its more detrimental effects. This study examined how PIF occurred during the COVID-19 pandemic to better adapt future medical training. METHOD: Constructivist grounded theory guided the iterative data collection and analyses. The authors conducted semistructured group interviews with 24 Ontario internal medicine residents in postgraduate years (PGYs) 1 to 3 between November 2020 and July 2021. Participants were asked to reflect on their day-to-day clinical and learning experiences during the pandemic. RESULTS: Twenty-four internal medicine residents were interviewed (12 PGY-1 [50.0%], 9 PGY-2 [37.5%], and 3 PGY-3 [12.5%]). Participants described how navigating patient care and residency training through the pandemic consistently drew their attention to various system problems. How participants responded to these problems was shaped by an interplay among their personal values, their level of personal wellness or burnout, self-efficacy, institutional values, and the values of their supervisors and work community. As they were influenced by these factors, some were led toward acting on the problem(s) they identified, whereas others had a sense of resignation and deferred action. These interactions were evident in participants' experiences with communication, advocacy, and learning. CONCLUSIONS: Residents' professional identities are continuously shaped by how they perceive, reconcile, and address various challenges. As residents navigate tensions between personally held values and apparent system values, individuals in supervisory positions should be mindful of their influence as role models who empower values and practices that are recognized by participants to be important aspects of physician identity.

Exploring and reconciling discordance between documented and preferred resuscitation preferences for hospitalized patients: a quality improvement study.

PURPOSE: A discordance, predominantly towards overtreatment, exists between patients' expressed preferences for life-sustaining interventions and those documented at hospital admission. This quality improvement study sought to assess this discordance at our institution. Secondary objectives were to explore if internal medicine (IM) teams could identify patients who might benefit from further conversations and if the discordance can be reconciled in real-time. METHODS: Two registered nurses were incorporated into IM teams at a tertiary hospital to conduct resuscitation preference conversations with inpatients either specifically referred to them (group I, n = 165) or randomly selected (group II, n = 164) from 1 August 2016 to 31 August 2018. Resuscitation preferences were documented and communicated to teams prompting revised resuscitation orders where appropriate. Multivariable logistic regression was used to determine potential risk factors for discordance. RESULTS: Three hundred and twenty-nine patients were evaluated with a mean (standard deviation) age of 80 (12) and Charlson Comorbidity Index Score of 6.8 (2.6). Discordance was identified in 63/165 (38%) and 27/164 (16%) patients in groups I and II respectively. 42/194 patients (21%) did not want cardiopulmonary resuscitation (CPR) and 15/36 (41%) did not prefer intensive care unit (ICU) admission, despite these having been indicated in their initial preferences. 93% (84/90) of patients with discordance preferred de-escalation of care. Discordance was reconciled in 77% (69/90) of patients. CONCLUSION: Hospitalized patients may have preferences documented for CPR and ICU interventions contrary to their preferences. Trained nurses can identify inpatients who would benefit from further in-depth resuscitation preference conversations. Once identified, discordance can be reconciled during the index admission.

RéSUMé: OBJECTIF: Il existe une discordance, qui tend surtout vers un sur-traitement, entre les préférences exprimées par les patients pour les interventions de maintien de la vie et celles documentées lors de l'admission à l'hôpital. Cette étude d'amélioration de la qualité avait pour objectif d'évaluer cette discordance au sein de notre institution. Les objectifs secondaires de notre étude étaient d'explorer la possibilité que les équipes de médecine interne (MI) identifient les patients qui pourraient bénéficier de conversations approfondies et de voir si la discordance pouvait être corrigée en temps réel. MéTHODE: Deux infirmières ont intégré des équipes de MI dans un hôpital tertiaire pour discuter avec les patients hospitalisés de leurs préférences en matière de réanimation entre le 1er août 2016 et le 31 août 2018; les patients leur étaient soit spécifiquement référés (groupe I, n = 165), ou sélectionnés au hasard (groupe II, n = 164). Les préférences en matière de réanimation ont été documentées et communiquées aux équipes, entraînant une révision des ordonnances de réanimation, le cas échéant. La régression logistique multivariée a été utilisée afin de déterminer les facteurs de risque potentiels de discordance. RéSULTATS: Trois cent vingt-neuf patients ont été évalués, d'un âge moyen (écart type) de 80 ans (12) et avec un score de 6,8 (2,6) à l'Indice de comorbidité de Charlson. Une discordance a été identifiée chez 63/165 (38 %) et 27/164 (16 %) patients dans les groupes I et II, respectivement. Au total, 42/194 patients (21 %) ne souhaitaient pas de réanimation cardiorespiratoire (RCR) et 15/36 (41 %) préféraient ne pas être admis à l'unité de soins intensifs (USI), malgré une mention dans leurs préférences initiales. Parmi les patients chez lesquels une discordance a été notée, 93 % (84/90) ont préféré une désescalade des soins. La discordance a pu être corrigée pour 77 % (69/90) des patients. CONCLUSION: La documentation des patients hospitalisés pourrait indiquer des préférences pour des interventions de RCR et d'admission à l'USI contraires aux véritables préférences. Des infirmières formées à cet effet peuvent identifier les patients hospitalisés qui bénéficieraient d'une conversation approfondie sur leurs préférences en matière de réanimation. Une fois identifiée, une discordance peut être corrigée lors de l'admission initiale.

Clinical Importance of Incidental Homogeneous Renal Masses That Measure 10-40 mm and 21-39 HU at Portal Venous Phase CT: A 12-Institution Retrospective Cohort Study.

BACKGROUND. Incidental homogeneous renal masses are frequently encountered at portal venous phase CT. The American College of Radiology Incidental Findings Committee's white paper on renal masses recommends additional imaging for incidental homogeneous renal masses greater than 20 HU, but single-center data and the Bosniak classification version 2019 suggest the optimal attenuation threshold for detecting solid masses should be higher. OBJECTIVE. The purpose of this article is to determine the clinical importance of small (10-40 mm) incidentally detected homogeneous renal masses measuring 21-39 HU at portal venous phase CT. METHODS. We performed a 12-institution retrospective cohort study of adult patients who underwent portal venous phase CT for a nonrenal indication. The date of the first CT at each institution ranged from January 1, 2008, to January 1, 2014. Consecutive reports from 12,167 portal venous phase CT examinations were evaluated. Images were reviewed for 4529 CT examinations whose report described a focal renal mass. Eligible masses were 10-40 mm, well-defined, subjectively homogeneous, and 21-39 HU. Of these, masses that were shown to be solid without macroscopic fat; classified as Bosniak IIF, III, or IV; or confirmed to be malignant were considered clinically important. The reference standard was renal mass protocol CT or MRI, ultrasound of definitively benign cysts or solid masses, single-phase contrast-enhanced CT or unenhanced MRI showing no growth or morphologic change for 5 years or more, or clinical follow-up 5 years or greater. A reference standard was available for 346 masses in 300 patients. The 95% CIs were calculated using the binomial exact method. RESULTS. Eligible masses were identified in 4.2% of patients (514/12,167; 95% CI, 3.9-4.6%). Of 346 masses with a reference standard, none were clinically important (0%; 95% CI, 0-0.9%). Mean mass size was 17 mm; 72% (248/346) measured 21-30 HU, and 28% (98/346) measured 31-39 HU. CONCLUSION. Incidental small homogeneous renal masses measuring 21-39 HU at portal venous phase CT are common and highly likely benign. CLINICAL IMPACT. The change in attenuation threshold signifying the need for additional imaging from greater than 20 HU to greater than 30 HU proposed by the Bosniak classification version 2019 is supported.

Similar photosynthetic response to elevated carbon dioxide concentration in species with different phloem loading strategies.

Species have different strategies for loading sugars into the phloem, which vary in the route that sugars take to enter the phloem and the energetics of sugar accumulation. Species with passive phloem loading are hypothesized to have less flexibility in response to changes in some environmental conditions because sucrose export from mesophyll cells is dependent on fixed anatomical plasmodesmatal connections. Passive phloem loaders also have high mesophyll sugar content, and may be less likely to exhibit sugar-mediated down-regulation of photosynthetic capacity at elevated CO2 concentrations. To date, the effect of phloem loading strategy on the response of plant carbon metabolism to rising atmospheric CO2 concentrations is unclear, despite the widespread impacts of rising CO2 on plants. Over three field seasons, five species with apoplastic loading, passive loading, or polymer-trapping were grown at ambient and elevated CO2 concentration in free air concentration enrichment plots. Light-saturated rate of photosynthesis, photosynthetic capacity, leaf carbohydrate content, and anatomy were measured and compared among the species. All five species showed significant stimulation in midday photosynthetic CO2 uptake by elevated CO2 even though the two passive loading species showed significant down-regulation of maximum Rubisco carboxylation capacity at elevated CO2. There was a trend toward greater starch accumulation at elevated CO2 in all species, and was most pronounced in passive loaders. From this study, we cannot conclude that phloem loading strategy is a key determinant of plant response to elevated CO2, but compelling differences in response counter to our hypothesis were observed. A phylogenetically controlled experiment with more species may be needed to fully test the hypothesis.

A Scoping Review of Digital Gaming Research Involving Older Adults Aged 85 and Older.

BACKGROUND: Interest in the use of digital game technologies by older adults is growing across disciplines from health and gerontology to computer science and game studies. The objective of this scoping review was to examine research evidence involving the oldest old (persons 85 years of age or greater) and digital game technology. MATERIALS AND METHODS: PubMed, CINHAL, and Scopus were searched, and 46 articles were included in this review. RESULTS: Results highlighted that 60 percent of articles were published in gerontological journals, whereas only 8.7 percent were published in computer science journals. No studies focused directly on the oldest old population. Few studies included sample sizes greater than 100 participants. Seven primary and 34 secondary themes were identified, of which Hardware Technology and Assessment were the most common. CONCLUSIONS: Existing evidence demonstrates the paucity of studies engaging older adults 85 years of age and above regarding the use of digital gaming and highlights a new understudied cohort for further research focus. Recommendations for future research include intentional recruitment and proportionate representation of participants ≥85 years of age, large sample sizes, and explicit mention of specific numbers of participants ≥85 years of age, which are necessary to advance knowledge in this area. Integrating a rigorous and robust mixed-methods approach including theoretical perspectives would lend itself to further in-depth understanding and knowledge generation in this field.

Is there potential to adapt soybean (Glycine max Merr.) to future [CO2]? An analysis of the yield response of 18 genotypes in free-air CO2 enrichment.

Rising atmospheric [CO2] is a uniform, global change that increases C3 photosynthesis and could offset some of the negative effects of global climate change on crop yields. Genetic variation in yield responsiveness to rising [CO2] would provide an opportunity to breed more responsive crop genotypes. A multi-year study of 18 soybean (Glycine max Merr.) genotypes was carried out to identify variation in responsiveness to season-long elevated [CO2] (550 ppm) under fully open-air replicated field conditions. On average across 18 genotypes, elevated [CO2] stimulated total above-ground biomass by 22%, but seed yield by only 9%, in part because most genotypes showed a reduction in partitioning of energy to seeds. Over four years of study, there was consistency from year to year in the genotypes that were most and least responsive to elevated [CO2], suggesting heritability of CO2 response. Further analysis of six genotypes did not reveal a photosynthetic basis for the variation in yield response. Although partitioning to seed was decreased, cultivars with the highest partitioning coefficient in current [CO2 ] also had the highest partitioning coefficient in elevated [CO2]. The results show the existence of genetic variation in soybean response to elevated [CO2], which is needed to breed soybean to the future atmospheric environment.

A multi-biome gap in understanding of crop and ecosystem responses to elevated CO2.

A key finding from elevated [CO(2)] field experiments is that the impact of elevated [CO(2)] on plant and ecosystem function is highly dependent upon other environmental conditions, namely temperature and the availability of nutrients and soil moisture. In addition, there is significant variation in the response to elevated [CO(2)] among plant functional types, species and crop varieties. However, experimental data on plant and ecosystem responses to elevated [CO(2)] are strongly biased to economically and ecologically important systems in the temperate zone. There is a multi-biome gap in experimental data that is most severe in the tropics and subtropics, but also includes high latitudes. Physiological understanding of the environmental conditions and species found at high and low latitudes suggest they may respond differently to elevated [CO(2)] than well-studied temperate systems. Addressing this knowledge gap should be a high priority as it is vital to understanding 21st century food supply and ecosystem feedbacks on climate change.