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Australian Critical Care : Official... Apr 2024Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must... (Review)
Review
BACKGROUND
Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.
AIM
The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.
DESIGN
Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.
METHODS
Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.
RESULTS
Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.
CONCLUSION
Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.
PubMed: 38609749
DOI: 10.1016/j.aucc.2024.02.007 -
Journal of Clinical Medicine Feb 2024The medicinal leech has been used in plastic surgery to resolve venous congestion that can threaten the viability of tissue transfer. Within the context of breast... (Review)
Review
The medicinal leech has been used in plastic surgery to resolve venous congestion that can threaten the viability of tissue transfer. Within the context of breast surgery, venous congestion is a pertinent consideration for reconstructive and non-reconstructive breast surgery such as mammoplasty and mastopexy. However, leeching is closely associated with complications such as infection, pain, and anaemia. This is the first systematic review that examines the methodology, efficacy, and post therapeutic outcome data across all existing studies on medicinal leeching in breast surgery. A systematic search of PubMed and Embase databases from their inception to November 2023 was conducted. Inclusion criteria included studies reporting on the use of leeches to resolve venous congestion in any breast surgery. The JBI Critical Appraisal Checklist for Case Series tool was used for bias analysis. Descriptive statistics were undertaken in Microsoft Excel. A total of 18 studies with a combined sample size of 28 were examined, including 4 case series and 14 case reports. Patients mostly underwent reconstructive breast surgery (75%). The median number of leeches used was two, with a median number of three leeching sessions per day and 3 days of leeching. Medicinal leeching successfully prevented the loss of 75% of all tissue transfers. The complication rate was high at 81.14% and mainly included infection and anaemia. Medicinal leeching is an effective method to relieve venous congestion in breast surgery but must be judiciously used within the clinical context of the patient to maximise efficacy and mitigate harm from complications.
PubMed: 38592085
DOI: 10.3390/jcm13051243