Quarantining From Professional Identity: How Did COVID-19 Impact Professional Identity Formation in Undergraduate Medical Education?

Introduction: Professional Identity Formation (PIF) entails the integration of a profession's core values and beliefs with an individual's existing identity and values. Within undergraduate medical education (UGME), the cultivation of PIF is a key objective. The COVID-19 pandemic brought about substantial sociocultural challenges to UGME. Existing explorations into the repercussions of COVID-19 on PIF in UGME have predominantly adopted an individualistic approach. We sought to examine how the COVID-19 pandemic influenced PIF in UGME from a sociocultural perspective. This study aims to provide valuable insights for effectively nurturing PIF in future disruptive scenarios. Methods: Semi structured interviews were conducted with medical students from the graduating class of 2022 (n = 7) and class of 2023 (n = 13) on their medical education experiences during the pandemic and its impact on their PIF. We used the Transformation in Medical Education (TIME) framework to develop the interview guide. Direct content analysis was used for data analysis. Results: The COVID-19 pandemic significantly impacted the UGME experience, causing disruptions such as an abrupt shift to online learning, increased social isolation, and limited in-person opportunities. Medical students felt disconnected from peers, educators, and the clinical setting. In the clerkship stage, students recognized knowledge gaps, producing a "late blooming" effect. There was increased awareness for self-care and burnout prevention. Discussion: Our study suggests that pandemic disruptors delayed PIF owing largely to slower acquisition of skills/knowledge and impaired socialization with the medical community. This highlights the crucial role of sociocultural experiences in developing PIF in UGME. PIF is a dynamic and adaptable process that was preserved during the COVID-19 pandemic.

Systemic Arterial and Venous Thrombotic Events Associated With Anti-Vascular Endothelial Growth Factor Injections: A Meta-Analysis.

PURPOSE: To compare the risk of systemic arteriovenous thrombotic events between intravitreal anti-vascular endothelial growth factor (anti-VEGF) and sham injections. DESIGN: Random-effects meta-analysis. METHODS: A systematic search was performed on OVID MEDLINE, Embase, and Cochrane Library from January 2005 to August 2023. Our inclusion criteria were randomized controlled trials (RCTs) reporting on systemic arteriovenous events for standard dose intravitreal anti-VEGF agents for any indication. RESULTS: A total of 20 RCTs reporting on 12,833 eyes were included. There was no significant difference in the risk of any thrombotic event between bevacizumab 1.25 mg and ranibizumab 0.5 mg (Risk ratio (RR) = 0.96, 95% CI = 0.52-1.75, P = .89). There was no significant difference between bevacizumab and ranibizumab when restricting to arterial thrombotic events (RR= 0.88, 95% CI = 0.60-1.30, P = .53) or venous thrombotic events (RR = 1.99, 95% CI =86 0.68-5.82], P = .21). The risk of arterial thrombotic events was similar between aflibercept and bevacizumab (RR = 1.11, 95% CI = 0.60-2.07, P = .74), between aflibercept and ranibizumab (RR= 0.77, 95% CI = 0.49-1.21, P = .26), between brolucizumab and aflibercept (RR= 0.67, 95% CI = 0.32-1.38, P = .27), and between aflibercept and faricimab (RR = 0.96, 95% CI = 0.43-2.17, P = .93). Compared to sham, neither dose of ranibizumab (0.5 mg or 0.3 mg) showed a higher risk of arterial thrombotic events. CONCLUSIONS: There was a similar risk of systemic arteriovenous thrombotic adverse events between anti-VEGF agents and between ranibizumab and sham injections.

Evaluation of Continuing Professional Development for Physicians - Time for Change: A Scoping Review.

Introduction: Evaluation of education interventions is essential for continuous improvement as it provides insights into how and why outcomes occur. Specifically, for physicians' continuing professional development (CPD) programs, which aim to upskill physicians in a range of practice-essential domains, evaluations are crucial to assure physicians' continuous development, enhanced patient care and safety. However, evaluations of health professions education (HPE) interventions tend to be outcomes focused, failing to capture how and why outcomes occur. This scoping review aimed to identify evaluation techniques used to evaluate CPD programs for physicians, and to determine how these techniques are being implemented as well as the their quality. Methods: We searched PubMed, Embase, Web of Science, among others for English publications on evaluation of CPD programs for physicians, in the past decade. We used a data charting template to extract study details regarding the evaluation techniques and produced a checklist to assess the quality of the evaluations. Results: 101 studies were included; of which 91 studies did not use an evaluation framework. Our findings revealed shortcomings in the evaluations of CPD programs including lack of attention to: intervention processes; unintended outcomes and contextual factors; use of theory; evaluation framework use; and rationale for chosen evaluation method. Discussion: Our findings highlighted major gaps in the evaluation techniques employed in physicians' CPD. Attention needs to be paid to evaluating both program processes and outcomes to illuminate how and why impacts are or are not occurring.

Challenges facing standardised patients representing equity-deserving groups: Insights from health care educators.

INTRODUCTION: Health professions training programmes increasingly rely on standardised patient (SP) programmes to integrate equity-deserving groups into learning and assessment opportunities. However, little is known about the optimal approach, and many SP programmes struggle to meet these growing needs. This study explored insights from health care educators working with SP programmes to deliver curricular content around equity-deserving groups. METHODS: We interviewed 14 key informants in 2021 who were involved in creating or managing SP-based education. Verbatim transcripts were analysed in an iterative coding process, anchored by qualitative content analysis methodology and informed by two theoretical frameworks: sociologic translation and simulation design. Repeated cycles of data collection and analyses continued until themes could be constructed, aligned with existing theories and grounded in empirical data, with sufficient relevance and robustness to inform educators and curricular leads. RESULTS: Three themes were constructed: (i) creating safety for SPs paid to be vulnerable, (ii) fidelity as an issue broader than who plays the role and (iii) engaging equity-deserving groups. SP work involving traditionally marginalised groups risk re-traumatization, highlighting the importance of (i) informed consent in recruiting SPs, (ii) separating role portrayal from lived experiences, (iii) adequately preparing learners and facilitators, (iv) creating time-outs and escapes for SPs and (v) building opportunity for de-roling with community support. CONCLUSIONS: SP programmes are well positioned to be allies and advocates to equity-deserving groups and to collaborate and share governance of the educational development process from its outset. SP programmes can support the delivery of curricular content around equity-deserving groups by advocating with curricular leadership, building relationships with community partners, facilitating co-creation and co-delivery of educational content and building safety into simulation.

Guidelines: The Do's, Don'ts and Don't Knows of Creating Open Educational Resources.

Background: In medical education, there is a growing global demand for Open Educational Resources (OERs). However, OER creators are challenged by a lack of uniform standards. In this guideline, the authors curated the literature on how to produce OERs for medical education with practical guidance on the Do's, Don'ts and Don't Knows for OER creation in order to improve the impact and quality of OERs in medical education. Methods: We conducted a rapid literature review by searching OVID MEDLINE, EMBASE, and Cochrane Central database using keywords "open educational resources" and "OER". The search was supplemented by hand searching the identified articles' references. We organized included articles by theme and extracted relevant content. Lastly, we developed recommendations via an iterative process of peer review and discussion: evidence-based best practices were designated Do's and Don'ts while gaps were designated Don't Knows. We used a consensus process to quantify evidentiary strength. Results: The authors performed full text analysis of 81 eligible studies. A total of 15 Do's, Don't, and Don't Knows guidelines were compiled and presented alongside relevant evidence about OERs. Discussion: OERs can add value for medical educators and their learners, both as tools for expanding teaching opportunities and for promoting medical education scholarship. This summary should guide OER creators in producing high-quality resources and pursuing future research where best practices are lacking.

Convalescent plasma therapy for coronavirus disease 2019 in ambulatory versus hospitalized patients: Efficacy and risk of thromboembolism.

Background: Although early evidence concluded a lack of clinical benefit of convalescent plasma therapy (CPT) in COVID-19 management, recent trials have demonstrated the therapeutic potential of CPT in ambulatory care. CPT may also potentiate thromboembolic events, given the presence of coagulation factors and the prothrombotic state of COVID-19. Objectives: The present study aimed to assess and compare the clinical efficacy and the risk of venous thromboembolism (VTE)/arterial thromboembolism (ATE) of CPT in ambulatory versus hospitalized patients with COVID-19. Methods: MEDLINE, Embase, and Cochrane CENTRAL were searched from December 2019 to December 2022 for randomized controlled trials that investigated the use of CPT against placebo or standard of care in adult patients with COVID-19. The primary outcome was nonmortality disease progression. Secondary outcomes include VTE, ATE, 28-day mortality, clinical improvement, length of hospitalization, sepsis/fever, and major adverse cardiovascular events. Results: Twenty randomized controlled trials, with 21,340 patients, were included. CPT significantly reduced nonmortality disease progression in ambulatory patients (odds ratio [OR], 0.72; 95% CI, 0.56-0.92; P = .009) but not in hospitalized patients (OR, 1.03; 95% CI, 0.94-1.12; P = .58). The risk of VTE and ATE did not differ between the CPT and the control group (OR, 1.16; 95% CI, 0.82-1.66; P = .40; and OR, 1.01; 95% CI, 0.37-2.79; P = .98, respectively). No conclusive differences between CPT and control groups were noted in 28-day mortality, clinical improvement, length of hospitalization, risk of sepsis/fever, and major adverse cardiovascular events. Conclusion: In conclusion, treatment of COVID-19 with CPT prevents the progression of COVID-19 in the ambulatory care. It is not associated with an increased risk of VTE, ATE, or other adverse events.

Antiviral drug treatment for nonsevere COVID-19: a systematic review and network meta-analysis.

BACKGROUND: Randomized trial evidence suggests that some antiviral drugs are effective in patients with COVID-19. However, the comparative effectiveness of antiviral drugs in nonsevere COVID-19 is unclear. METHODS: We searched the Epistemonikos COVID-19 L·OVE (Living Overview of Evidence) database for randomized trials comparing antiviral treatments, standard care or placebo in adult patients with nonsevere COVID-19 up to Apr. 25, 2022. Reviewers extracted data and assessed risk of bias. We performed a frequentist network meta-analysis and assessed the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS: We identified 41 trials, which included 18 568 patients. Compared with standard care or placebo, molnupiravir and nirmatrelvir-ritonavir each reduced risk of death with moderate certainty (10.9 fewer deaths per 1000, 95% confidence interval [CI] 12.6 to 4.5 fewer for molnupiravir; 11.7 fewer deaths per 1000, 95% CI 13.1 fewer to 2.6 more). Compared with molnupiravir, nirmatrelvir-ritonavir probably reduced risk of hospital admission (27.8 fewer admissions per 1000, 95% CI 32.8 to 18.3 fewer; moderate certainty). Remdesivir probably has no effect on risk of death, but may reduce hospital admissions (39.1 fewer admissions per 1000, 95% CI 48.7 to 13.7 fewer; low certainty). INTERPRETATION: Molnupiravir and nirmatrelvir-ritonavir probably reduce risk of hospital admissions and death among patients with nonsevere COVID-19. Nirmatrelvir-ritonavir is probably more effective than molnupiravir for reducing risk of hospital admissions. Most trials were conducted with unvaccinated patients, before the emergence of the Omicron variant; the effectiveness of these drugs must thus be tested among vaccinated patients and against newer variants.

Consistency of covid-19 trial preprints with published reports and impact for decision making: retrospective review.

Objective: To assess the trustworthiness (ie, complete and consistent reporting of key methods and results between preprint and published trial reports) and impact (ie, effects of preprints on meta-analytic estimates and the certainty of evidence) of preprint trial reports during the covid-19 pandemic. Design: Retrospective review. Data sources: World Health Organization covid-19 database and the Living Overview of the Evidence (L-OVE) covid-19 platform by the Epistemonikos Foundation (up to 3 August 2021). Main outcome measures: Comparison of characteristics of covid-19 trials with and without preprints, estimates of time to publication of covid-19 preprints, and description of differences in reporting of key methods and results between preprints and their later publications. For the effects of eight treatments on mortality and mechanical ventilation, the study comprised meta-analyses including preprints and excluding preprints at one, three, and six months after the first trial addressing the treatment became available either as a preprint or publication (120 meta-analyses in total, 60 of which included preprints and 60 of which excluded preprints) and assessed the certainty of evidence using the GRADE framework. Results: Of 356 trials included in the study, 101 were only available as preprints, 181 as journal publications, and 74 as preprints first and subsequently published in journals. The median time to publication of preprints was about six months. Key methods and results showed few important differences between trial preprints and their subsequent published reports. Apart from two (3.3%) of 60 comparisons, point estimates were consistent between meta-analyses including preprints versus those excluding preprints as to whether they indicated benefit, no appreciable effect, or harm. For nine (15%) of 60 comparisons, the rating of the certainty of evidence was different when preprints were included versus being excluded-the certainty of evidence including preprints was higher in four comparisons and lower in five comparisons. Conclusion: No compelling evidence indicates that preprints provide results that are inconsistent with published papers. Preprints remain the only source of findings of many trials for several months-an unsuitable length of time in a health emergency that is not conducive to treating patients with timely evidence. The inclusion of preprints could affect the results of meta-analyses and the certainty of evidence. Evidence users should be encouraged to consider data from preprints.

Comparative effectiveness of erythropoietin alpha and beta in hemodialysis patients: a single-center prospective observational study.

BACKGROUND AND OBJECTIVES: Anemia is a prevalent complication endured by patients with chronic renal disease. Renal anemia also leads to the development of cardio-vascular complications. Epoetin alpha and beta are recombinant human erythropoietin prioritized for managing anemia in hemodialysis patients. The current study aimed to compare the therapeutic efficacy of both erythropoietin alpha and erythropoietin beta in treating renal anemia. MATERIALS AND METHODS: This prospective observational study was conducted in a Renal Dialysis Centre at a tertiary care Hospital of Karachi, Pakistan for a period of 3 months. The two erythropoietin products used were human recombinant erythropoietin alpha (Tropin®) and erythropoietin beta (Recormon®). Both groups were age-matched, BMI, eGFR, gender, and comorbidities like diabetes and hypertension were indifferent. The comparative analysis was performed after the completion of 3 months. RESULTS: A total of 94 participants were included in the analysis, 54 in group A and 40 in group B. Mean albumin, urea, creatinine, ferritin, iron, and transferrin saturation at inclusion were statistically insignificant, TIBC was higher in group A (p = 0.005) and CRP levels were slightly higher in group B (p = 0.050). There was significant improvement in Hb level (p = 0.025), PCV (p = 0.001), and RBC count (p = 0.007) in group B. While in group A, there was significantly increased MCV (p = 0.005) and MCHC (p = 0.002). In intention to treat analysis, 22.2% of subjects in group A and 40.0% in group B reached desired Hb levels of ≥11 g/l after 3 months. CONCLUSION: In our assessment of hemodialysis patients, erythropoietin beta was found more effective than erythropoietin alpha.

Relationship Between Clinical Features and Body Mass Index Among Hypertensive Patients: A Cross-Sectional Study.

Objectives Hypertension is strongly related to body mass index (BMI). Obesity has been the single main contributor to hypertension. Furthermore, the clinical manifestations are normally associated with BMI in hypertensive patients. This study aimed to evaluate the relationship between clinical features and BMI among hypertensive patients in both males and females. Methodology A retrospective cross-sectional study was conducted among 296 patients having a self-reported history of hypertension and on anti-hypertensive medication. The study was conducted in the medical outpatient department of a secondary care hospital in Karachi during six months (January 2020 to June 2020). A detailed history was taken from each patient about hypertension-related symptoms, and clinical examination was performed. Blood pressure was measured using a sphygmomanometer with a stethoscope. Results Of the 296 patients, 156 (52.2%) were males and 140 (47.3%) were females; 16 (5.4%) of them were underweight, 91 (30.7%) were normal weight, 129 (43.6%) were overweight, and 60 (20.3%) were obese; in addition, 106 (35.8%) reported edema and 71 (24.0%) reported nausea and so on. As far as the association of clinical features and BMI was concerned, our study results showed that only edema (p=0.017) and nausea (p=0.044) were significantly associated with the BMI of the patients. Patients with edema were more likely to be obese than those without edema (29.2% vs. 15.3%), whereas patients with nausea were more likely to be overweight than those without nausea (57.7% vs. 39.1%). Conclusions Our study showed that among the clinical features, edema and nausea were significantly associated with the BMI of the patients, whereas the relationship with others was insignificantly related to BMI of the patients in both male and female patients.

Impact of Fasting Lipid Profile on Chronic Kidney Disease Patients Having Fatty Liver Disease.

Background and objectives Chronic kidney disease (CKD) share a common pathophysiology with non-alcoholic fatty liver disease (NAFLD). This study aims to identify the lipid derangements in patients of CKD and to associate them with radiological evidence of NAFLD. Material and methods A cross-sectional observational study was performed in a tertiary care hospital, to include all chronic kidney disease patients (n=238) through non-probability consecutive sampling. The criteria for inclusion were baseline estimated Glomerular filtration rate (eGFR) below 60 ml/min/1.73m2 for at least three months and chronic renal parenchymal changes on ultrasound. Two study groups were identified based on ongoing hemodialysis, while two further study groups were identified based on radiological evidence of fatty liver disease. Results The mean age of the study population was 48.52 ± 9.44 years with no difference amongst hemodialysis status, females elder than males (p= 0.027), those with fatty liver were much younger (p=0.014), and the most common age group below 50 years (p=0.005) among the fatty liver group. Radiological evidence of NAFLD was found amongst two-third of the study group with the status of hemodialysis indifferent among the study population (p=0.436). The mean values amongst fatty liver versus non-fatty liver groups revealed high creatinine, alanine transaminase (ALT), high-density lipoprotein (HDL), triglycerides (TG), and very-low-density lipoprotein (VLDL) in the fatty liver group, low-density lipoprotein (LDL) and total cholesterol (TC) were indifferent amongst the groups, while LDL/HDL ratio was higher in the non-fatty liver group. Conclusion A significantly higher HDL was found in fatty liver associated with CKD as compared to the non-fatty liver group.

Correlation Between Body Mass Index and Blood Pressure Levels Among Hypertensive Patients: A Gender-Based Comparison.

Objective Blood pressure (BP) has been found to rise among populations due to the high body mass index (BMI). Overweight and persons who have high BP are prone to develop heart diseases. The objective of this study was to evaluate the correlation between BMI and BP among hypertensive patients in both males and females aged 18 years and above. Methodology A cross-sectional study was carried out among patients with a self-reported history of hypertension and anti-hypertensive medication. After taking ethical approval, a total of 337 patients aged 18 or above were selected by using convenience sampling. The duration of the study was six months. A detailed history was taken from each patient about hypertension associated symptoms with the help of a self-designed questionnaire. The BMI of the patients was assessed. Statistical Package for Social Sciences (SPSS) Version 20.0 (IBM Corp., Armonk, NY, USA) was used to analyze the collected data. Spearman correlation was used, and p-value <0.05 was considered significant. Results In a total of 337 patients, the mean age of the patients was 45.87±13.38 years. In which 176 (52.2%) were males and 161 (47.8%) were females. Their mean BMI level was 26.83±5.83 kg/m2, and the mean systolic blood pressure level was 141.78±13.00 mm Hg whereas the diastolic blood pressure was 85.21±10.03 mm Hg. The results also showed that among males the BMI had a significant negative correlation with both systolic blood pressure level (ρ = -0.212, p = 0.011) and diastolic blood pressure level (ρ = -0.208, p = 0.013), while in females the correlation was insignificant. Conclusion Our study results concluded that the BMI of the patients had a significant weak negative correlation with both systolic blood pressure level and diastolic blood pressure level in males; however, no significant correlation was found in females.

Sleep deprivation and its consequences on house officers and postgraduate trainees.

OBJECTIVE: To determine sleep deprivation and its consequences on doctors in tertiary care hospitals. METHODS: The cross-sectional study was conducted from February to May 2012 and comprised house officers and postgraduate trainees at 4 public and 1 private tertiary care hospitals in Karachi. The subjects were posted in wards, out-patient departments and emergencies. A proforma was designed with questions about duration of duty hours, sleep deprivation and its effects on quality of performance, and presence of anxiety, depression, medical errors, frequent cold and infections, accidents, weight changes, and insomnia. Duration of 1 hour was given to fill the proforma. SPSS 20 was used for data analysis. RESULT: The study comprised 364 subjects: 187 (51.37%) house officers and 177 (48.62%) postgraduate trainees. There were 274 (75.27%) females and 90 (24.72%) males. Of those who admitted to being sleep deprived (287; 78.84%), also complained of generalised weakness and poor performance (n = 115; 40%), anxiety (n = 110; 38%), frequent cold and infections (n = 107; 37%), personality changes (n = 93; 32%), depression (n = 86; 30%), risk of accidents (n = 68; 23.7%), medical errors (n = 58; 20%) and insomnia (n = 52; 18%). CONCLUSION: Having to spend 80-90 hours per week in hospitals causes sleep deprivation and negative work performance among doctors. Also, there is anxiety, depression and risk of accidents in their personal lives.