Although women at all career stages are more likely to leave academia than men, early-career women are a particularly high-risk group. Research supports that women are less likely than men to receive ...research funding; however, whether funding success rates vary based on research content is unknown. We addressed gender differences in funding success rates for applications directed to one or more of 13 institutes, representing research communities, over a 15-year period.
We retrospectively reviewed 55,700 grant and 4,087 personnel award applications submitted to the Canadian Institutes of Health Research. We analyzed application success rates according to gender and the primary institute selected by applicants, pooled gender differences in success rates using random effects models, and fitted Poisson regression models to assess the effects of gender, time, and institute. We noted variable success rates among grant applications directed to selected institutes and declining success rates over time. Women submitted 31.1% and 44.7% of grant and personnel award applications, respectively. In the pooled estimate, women had significantly lower grant success (risk ratio RR 0.89, 95% confidence interval CI 0.84-0.94; p < 0.001; absolute difference 3.2%) compared with men, with substantial heterogeneity (I2 = 58%). Compared with men, women who directed grants to the Institutes of Cancer Research (RR 0.86, 95% CI 0.78-0.96), Circulatory and Respiratory Health (RR 0.74, 95% CI 0.66-0.84), Health Services and Policy Research (RR 0.78, 95% CI 0.68-0.90), and Musculoskeletal Health and Arthritis (RR 0.80, 95% CI 0.69-0.93) were significantly less likely to be funded, and those who directed grants to the Institute of Aboriginal People's Health (RR 1.67, 95% CI 1.0-2.7) were more likely to be funded. Overall, women also had significantly lower personnel award success (RR 0.75, 95% CI 0.65-0.86; p < 0.001; absolute difference 6.6%). Regression modelling identified that the effect of gender on grant success rates differed by institute and not time. Study limitations include use of institutes as a surrogate identifier, variability in designation of primary institute, and lack of access to metrics reflecting applicants, coapplicants, peer reviewers, and the peer-review process.
Gender disparity existed overall in grant and personnel award success rates, especially for grants directed to selected research communities. Funding agencies should monitor for gender differences in grant success rates overall and by research content.
A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological ...phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (V
) is a standard of care, further individualization of V
may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust V
and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.
Although most critically ill patients receive invasive mechanical ventilation (IMV), few studies have characterized how IMV is discontinued in practice.
To describe practice variation in IMV ...discontinuation internationally, associations between initial discontinuation events and outcomes, and factors associated with the use of select discontinuation strategies and failed initial spontaneous breathing trials (SBTs).
Prospective, multinational, observational study of critically ill adults who received IMV for at least 24 hours from 142 intensive care units (ICUs) in 19 countries within 6 regions (27 in Canada, 23 in India, 22 in the UK, 26 in Europe, 21 in Australia/New Zealand, and 23 in the US).
Receiving IMV.
Primary analyses characterized types of initial IMV discontinuation events (extubation, SBT, or tracheostomy) and associations with clinical outcomes (including duration of ventilation, ICU and hospital mortality, and ICU and hospital length of stay). Secondary analyses examined the associations between SBT outcome and SBT timing and clinical outcomes.
Among 1868 patients (median interquartile range age, 61.8 48.9-73.1 years; 1173 62.8% men) 424 (22.7%) underwent direct extubation, 930 (49.8%) had an initial SBT (761 81.8% successful), 150 (8.0%) underwent direct tracheostomy, and 364 (19.5%) died before a weaning attempt. Across regions, there was variation in the use of written directives to guide care, daily screening, SBT techniques, ventilator modes, and the roles played by clinicians involved in weaning. Compared with initial direct extubation, patients who had an initial SBT had higher ICU mortality (20 4.7% vs 96 10.3%; absolute difference, 5.6% 95% CI, 2.6%-8.6%), longer duration of ventilation (median of 2.9 vs 4.1 days; absolute difference, 1.2 days 95% CI, 0.7-1.6), and longer ICU stay (median of 6.7 vs 8.1 days; absolute difference, 1.4 days 95% CI, 0.8-2.4). Patients whose initial SBT failed (vs passed) had higher ICU mortality (29 17.2% vs 67 8.8%; absolute difference, 8.4% 95% CI, 2.0%-14.7%), longer duration of ventilation (median of 6.1 vs 3.5 days; absolute difference, 2.6 days 95% CI, 1.6-3.6), and longer ICU stay (median of 10.6 vs 7.7 days; absolute difference, 2.8 days 95% CI, 1.1-5.2). Compared with patients who underwent early initial SBTs, patients who underwent late initial SBTs (>2.3 days after intubation) had longer duration of ventilation (median of 2.1 vs 6.1 days; absolute difference, 4.0 days 95% CI, 3.7-4.5), longer ICU stay (median of 5.9 vs 10.8 days; absolute difference, 4.9 days 95% CI, 4.0-6.3), and longer hospital stay (median of 14.3 vs 22.8 days; absolute difference, 8.5 days 95% CI, 6.0-11.0).
In this observational study of invasive mechanical ventilation discontinuation in 142 ICUs in Canada, India, the UK, Europe, Australia/New Zealand, and the US from 2013 to 2016, weaning practices varied internationally.
ClinicalTrials.gov Identifier: NCT03955874.
Efforts to mitigate the global spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing Corona Virus Disease-19 (COVID-19) have largely relied on broad compliance with ...public health recommendations yet navigating the high volume of evolving information can be challenging. We assessed self-reported public perceptions related to COVID-19 including, beliefs (e.g., severity, concerns, health), knowledge (e.g., transmission, information sources), and behaviors (e.g., physical distancing) to understand perspectives in Canada and to inform future public health initiatives.
We administered a national online survey aiming to obtain responses from 2000 adults in Canada. Respondent sampling was stratified by age, sex, and region. We used descriptive statistics to summarize responses and tested for regional differences using chi-squared tests, followed by weighted logistic regression.
We collected 1,996 eligible questionnaires between April 26th and May 1st, 2020. One-fifth (20%) of respondents knew someone diagnosed with COVID-19, but few had tested positive themselves (0.6%). Negative impacts of pandemic conditions were evidenced in several areas, including concerns about healthcare (e.g. sufficient equipment, 52%), pandemic stress (45%), and worsening social (49%) and mental/emotional (39%) health. Most respondents (88%) felt they had good to excellent knowledge of virus transmission, and predominantly accessed (74%) and trusted (60%) Canadian news television, newspapers/magazines, or non-government news websites for COVID-19 information. We found high compliance with distancing measures (80% reported self-isolating or always physical distancing). We identified associations between region and self-reported beliefs, knowledge, and behaviors related to COVID-19.
We found that information about COVID-19 is largely acquired through domestic news sources, which may explain high self-reported compliance with prevention measures. The results highlight the broader impact of a pandemic on the general public's overall health and wellbeing, outside of personal infection. The study findings should be used to inform public health communications during COVID-19 and future pandemics.
Physician wellness is vital to career satisfaction, provision of high quality patient care, and the successful education of the next generation of physicians. Despite this, the number of physicians ...experience symptoms of burnout is rising. To assess the impact of organizational culture on physicians' professional fulfillment and burnout, we surveyed full-time Department of Medicine members at the University of Toronto. A cross-sectional survey assessed: physician factors (age, gender, minority status, disability, desire to reduce clinical workload); workplace culture (efforts to create a collegial environment, respectful/civil interactions, confidence to address unprofessionalism without reprisal, witnessed and/or personally experienced unprofessionalism); professional fulfillment and burnout using the Stanford Professional Fulfillment Index. We used multivariable linear regression to examine the relationship of measures of workplace culture on professional fulfillment and burnout (scores 0-10), controlling for physician factors. Of 419 respondents (52.0% response rate), we included 400 with complete professional fulfillment and burnout data in analyses (60% less than or equal to age 50, 45% female). Mean scores for professional fulfillment and burnout were 6.7±1.9 and 2.8±1.9, respectively. Controlling for physician factors, professional fulfillment was associated with satisfaction with efforts to create a collegial environment (adjusted beta 0.45, 95% CI 0.21 to 0.70) and agreement that colleagues were respectful/civil (adjusted beta 0.85, 95% CI 0.53 to 1.17). Lower professional fulfillment was associated with higher burnout scores. Controlling for professional fulfillment and physician factors, lower confidence in taking action to address unprofessionalism (adjusted beta -0.22, 95% CI -0.40 to -0.03) was associated with burnout. Organizational culture and physician factors had an impact on professional fulfillment and burnout. Professional fulfillment partially mediated the relationship between organizational culture and burnout. Strategies that promote inclusion, respect and civility, and safe ways to report workplace unprofessionalism are needed in academic medicine.
Purpose
We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence ...regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products.
Source
Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv.
Review 1
: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure.
Review 2:
we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology.
Principal findings
No eligible studies included COVID-19 patients.
Review 1:
12 RCTs (
n
= 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk RR, 0.85; 95% confidence interval CI, 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively).
Review 2
: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density.
Conclusions
High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.
Purpose
Systematic review and network meta-analysis to investigate the efficacy of noninvasive respiratory strategies, including noninvasive positive pressure ventilation (NIPPV) and high-flow nasal ...cannula (HFNC), in reducing extubation failure among critically ill adults.
Methods
We searched databases from inception through October 2021 for randomized controlled trials (RCTs) evaluating noninvasive respiratory support therapies (NIPPV, HFNC, conventional oxygen therapy, or a combination of these) following extubation in critically ill adults. Two reviewers performed screening, full text review, and extraction independently. The primary outcome of interest was reintubation. We used GRADE to rate the certainty of our findings.
Results
We included 36 RCTs (6806 patients). Compared to conventional oxygen therapy, NIPPV (OR 0.65 95% CI 0.52–0.82) and HFNC (OR 0.63 95% CI 0.45–0.87) reduced reintubation (both moderate certainty). Sensitivity analyses showed that the magnitude of the effect was highest in patients with increased baseline risk of reintubation. As compared to HFNC, no difference in incidence of reintubation was seen with NIPPV (OR 1.04 95% CI 0.78–1.38, low certainty). Compared to conventional oxygen therapy, neither NIPPV (OR 0.8 95% CI 0.61–1.04, moderate certainty) or HFNC (OR 0.9 95% CI 0.66–1.24, low certainty) reduced short-term mortality. Consistent findings were demonstrated across multiple subgroups, including high- and low-risk patients. These results were replicated when evaluating noninvasive strategies for prevention (prophylaxis), but not in rescue (application only after evidence of deterioration) situations.
Conclusions
Our findings suggest that both NIPPV and HFNC reduced reintubation in critically ill adults, compared to conventional oxygen therapy. NIPPV did not reduce incidence of reintubation when compared to HFNC. These findings support the preventative application of noninvasive respiratory support strategies to mitigate extubation failure in critically ill adults, but not in rescue conditions.
This is an update of a review last published in Issue 5, 2010, of The Cochrane Library. Reducing weaning time is desirable in minimizing potential complications from mechanical ventilation. ...Standardized weaning protocols are purported to reduce time spent on mechanical ventilation. However, evidence supporting their use in clinical practice is inconsistent.
The first objective of this review was to compare the total duration of mechanical ventilation of critically ill adults who were weaned using protocols versus usual (non-protocolized) practice.The second objective was to ascertain differences between protocolized and non-protocolized weaning in outcomes measuring weaning duration, harm (adverse events) and resource use (intensive care unit (ICU) and hospital length of stay, cost).The third objective was to explore, using subgroup analyses, variations in outcomes by type of ICU, type of protocol and approach to delivering the protocol (professional-led or computer-driven).
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2014), MEDLINE (1950 to January 2014), EMBASE (1988 to January 2014), CINAHL (1937 to January 2014), LILACS (1982 to January 2014), ISI Web of Science and ISI Conference Proceedings (1970 to February 2014), and reference lists of articles. We did not apply language restrictions. The original search was performed in January 2010 and updated in January 2014.
We included randomized controlled trials (RCTs) and quasi-RCTs of protocolized weaning versus non-protocolized weaning from mechanical ventilation in critically ill adults.
Two authors independently assessed trial quality and extracted data. We performed a priori subgroup and sensitivity analyses. We contacted study authors for additional information.
We included 17 trials (with 2434 patients) in this updated review. The original review included 11 trials. The total geometric mean duration of mechanical ventilation in the protocolized weaning group was on average reduced by 26% compared with the usual care group (N = 14 trials, 95% confidence interval (CI) 13% to 37%, P = 0.0002). Reductions were most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. Weaning duration was reduced by 70% (N = 8 trials, 95% CI 27% to 88%, P = 0.009); and ICU length of stay by 11% (N = 9 trials, 95% CI 3% to 19%, P = 0.01). There was significant heterogeneity among studies for total duration of mechanical ventilation (I(2) = 67%, P < 0.0001) and weaning duration (I(2) = 97%, P < 0.00001), which could not be explained by subgroup analyses based on type of unit or type of approach.
There is evidence of reduced duration of mechanical ventilation, weaning duration and ICU length of stay with use of standardized weaning protocols. Reductions are most likely to occur in medical, surgical and mixed ICUs, but not in neurosurgical ICUs. However, significant heterogeneity among studies indicates caution in generalizing results. Some study authors suggest that organizational context may influence outcomes, however these factors were not considered in all included studies and could not be evaluated. Future trials should consider an evaluation of the process of intervention delivery to distinguish between intervention and implementation effects. There is an important need for further development and research in the neurosurgical population.
Although designing and conducting surveys may appear straightforward, there are important factors to consider when reading and reviewing survey research. Several guides exist on how to design and ...report surveys, but few guides exist to assist readers and peer reviewers in appraising survey methods.1-9 We have developed a guide to aid readers and reviewers to discern whether the information gathered from a survey is reliable, unbiased and from a representative sample of the population. In our guide, we pose seven broad questions and specific subquestions to assist in assessing the quality of articles reporting on self-administered surveys (Box 1). We explain the rationale for each question posed and cite literature addressing its relevance in appraising the methodologic and reporting quality of survey research. Throughout the guide, we use the term "questionnaire" to refer to the instrument administered to respondents and "survey" to define the process of administering the questionnaire. We use "readers" to encompass both readers and peer reviewers. Several types of questionnaire testing can be performed, including pilot, clinical sensibility, reliability and validity testing. Readers should assess whether the investigators conducted formal testing to identify problems that may affect how respondents interpret and respond to individual questions and to the questionnaire as a whole. At a minimum, each questionnaire should have undergone pilot testing. Readers should evaluate what process was used for pilot testing the questionnaire (e.g., investigators sought feedback in a semi-structured format), the number and type of people involved (e.g., individuals similar to those in the sampling frame) and what features (e.g., the flow, salience and acceptability of the questionnaire) were assessed. Both pretesting and pilot testing minimize the chance that respondents will misinterpret questions. Whereas pretesting focuses on the wording of the questionnaire, pilot testing assesses the flow and relevance of the entire questionnaire, as well as individual questions, to identify unusual, irrelevant, poorly worded or redundant questions and responses.18 Through testing, the authors identify problems with questions and response formats so that modifications can be made to enhance questionnaire reliability, validity and responsiveness. Types of validity assessments include face, content, construct and criterion validity. Readers should assess whether any validity testing was conducted. Although the number of validity assessments depends on current or future use of the questionnaire, investigators should have assessed at a minimum the face validity of their questionnaire during clinical sensibility testing.2 In face validity, experts in the field or a sample of respondents similar to the target population determine whether the questionnaire measures what it aims to measure.20 In content validity, experts assess whether the content of the questionnaire includes all aspects considered essential to the construct or topic. Investigators evaluate construct validity when specific criteria to define the concept of interest are unknown; they verify whether key constructs were included using content validity assessments made by experts in the field or using statistical methods (e.g., factor analysis).2 In criterion validity, investigators compare responses to items with a gold standard.2
Severe traumatic brain injury often leads to death from withdrawal of life-sustaining therapy, although prognosis is difficult to determine.
To evaluate variation in mortality following the ...withdrawal of life-sustaining therapy and hospital mortality in patients with critical illness and severe traumatic brain injury, we conducted a two-year multicentre retrospective cohort study in six Canadian level-one trauma centres. The effect of centre on hospital mortality and withdrawal of life-sustaining therapy was evaluated using multivariable logistic regression adjusted for baseline patient-level covariates (sex, age, pupillary reactivity and score on the Glasgow coma scale).
We randomly selected 720 patients with traumatic brain injury for our study. The overall hospital mortality among these patients was 228/720 (31.7%, 95% confidence interval CI 28.4%-35.2%) and ranged from 10.8% to 44.2% across centres (χ(2) test for overall difference, p < 0.001). Most deaths (70.2% 160/228, 95% CI 63.9%-75.7%) were associated with withdrawal of life-sustaining therapy, ranging from 45.0% (18/40) to 86.8% (46/53) (χ(2) test for overall difference, p < 0.001) across centres. Adjusted odd ratios (ORs) for the effect of centre on hospital mortality ranged from 0.61 to 1.55 (p < 0.001). The incidence of withdrawal of life-sustaining therapy varied by centre, with ORs ranging from 0.42 to 2.40 (p = 0.001). About one half of deaths that occurred following the withdrawal of life-sustaining therapies happened within the first three days of care.
We observed significant variation in mortality across centres. This may be explained in part by regional variations in physician, family or community approaches to the withdrawal of life-sustaining therapy. Considering the high proportion of early deaths associated with the withdrawal of life-sustaining therapy and the limited accuracy of current prognostic indicators, caution should be used regarding early withdrawal of life-sustaining therapy following severe traumatic brain injury.
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