British journal of anaesthesia
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Preoperative frailty may predispose patients to poorer outcomes in cardiac surgery; however, there are limited data concerning how preoperative frailty predicts patient-centred outcomes, such as patient-reported disability. Our objective was to evaluate the association between preoperative frailty and postoperative disability. ⋯ Disability burden in frail patients improves continuously postoperatively, whereas in non-frail patients, it worsens at 1 month before improving at 3 months postoperatively. This positive trajectory of patient-centred outcomes in frail patients should be considered in preoperative decision-making.
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Programmatic assessment is a concept to support learning through continuously providing information about learner progress to trainees and supervisors. Central to the concept are multiple low-stakes workplace-based assessments and meaningful feedback opportunities. Mobile technology may facilitate frequent and concise workplace-based assessments and trigger meaningful feedback. We designed a mobile application (app) for real-time use at the workplace utilising the concept of entrustable professional activities. As the primary outcome, we analysed completion times and as the secondary outcome the quality of documented learning goals. ⋯ The prEPAred mobile app enabled frequent and concise documentation of workplace-based assessments. Disagreement in level of supervision rating stimulated documentation of specific learning goals indicating more meaningful feedback. Thus, the tool could advance workplace-based assessments towards programmatic assessment.
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Patients with COVID-19 can require critical care for prolonged periods. Patients with persistent critical Illness can have complex recovery trajectories, but this has not been studied for patients with COVID-19. We examined the prevalence, risk factors, and long-term outcomes of critically ill patients with COVID-19 and persistent critical illness. ⋯ Almost half of all patients with COVID-19 admitted to critical care developed persistent critical illness, with high resource use in critical care and beyond. However, persistent critical illness was not associated with significantly worse long-term outcomes compared with patients who were critically ill for shorter periods.
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Clinical practice guidelines are increasingly important to guide clinical care. However, they can vary widely in quality, and many recommendations are based on low-level evidence. The COVID-19 pandemic highlighted the need for new flexible formats for rigorously developed guidelines. Future guideline development should be standardised, graded, registered, and updated to ensure that they are 'living' works in progress.
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Editorial Comment
The drug titration paradox: something obvious finally understood.
The drug titration paradox is an emerging concept in clinical pharmacology. The paradox refers to the observation that when drug is titrated to a specified level of effect in a population of patients, the expected positive correlation between dose and effect is reversed. That is, when titration rather than fixed dosing is used, greater drug exposure is associated with lesser effect, and vice versa. The drug titration paradox may have important implications for study design and data interpretation in anaesthesiology investigations, particularly in big data studies.