Calling situated: a survey among medical students supplemented by a qualitative study and a comparison with a surveyed sample of physicians.

BACKGROUND: Calling within the medical context receives growing academic attention and empirical research has started to demonstrate its beneficial effects. The purpose of this study is to investigate what motivates students to enter medical school and what role calling may play (i), to evaluate if calling influences the way in which they experience their studies (ii), and to compare medical students' experience of calling with those of physicians. METHODS: A questionnaire survey was distributed among medical students (N = 1048; response rate above 60%) of the University of Lausanne in Switzerland. It was supplemented by a group discussion between bachelor medical students (N = 8) and senior physicians (N = 4), focusing on different facets of calling. An existing data set of a survey among physicians, addressing calling with the same questionnaire, was used to compare students' and physicians' attitudes towards calling. Survey data were analyzed with the habitual statistical procedures for categorical and continuous variables. The group discussion was analyzed with thematic analysis. RESULTS: The survey showed that experiencing calling is a motivational factor for study choice and influences positively choice consistency. Students experiencing calling differed from those who did not: they attributed different definitions to calling, indicated more often prosocial motivational factors for entering medical school and perceived the learning context as less burdensome. The analysis of the group discussion revealed that the concept of calling has a fluid definition. It was conceived as having the characteristics of a double-edged sword and as originating from within or outside or from a dialectic interplay between the inner and outer world. Finally, calling is experienced less often by physicians than by medical students, with a decreasing prevalence as the immersion in the clinical years of the study of medicine progresses. CONCLUSIONS: Calling plays an important role in study choice and consistency of medical students. Given its relevance for medical students and its ramifications with the learning context, calling should become a topic of the reflexive parts of the medical curriculum. We critically discuss the role played by calling for medical students and provide some perspectives on how calling could be integrated in the reflection and teaching on physicianhood.

Spotlight on Japanese physicians: An exploration of their professional experiences elicited by means of narrative facilitators.

BACKGROUND: While investigation of physicians' work experience is often limited to issues of satisfaction or burnout, a broader view of their experiences is lacking. OBJECTIVE: To explore professional experiences, we asked Japanese physicians (N = 18, 12 men and 6 women) of a general hospital to react to so-called "narrative facilitators". METHODS: The narrative facilitators - inspired by clinical psychology, visual sociology and purpose-designed techniques - oriented physicians' narratives towards clinical practise, relationship with peers and context. Transcribed interviews were subject to thematic analysis. RESULTS: The thematic analysis of participants' narratives revealed a lonely physician with a tough job, torn between the ideal of patient-centred care and a clinical reality, which limits these aspirations. Patients emerged as anxious and burdensome consumers of medicine. Feeling neither supported by peers nor the institution, physicians also perceived the society as somewhat negligent, delegating its problem to medicine. Communication difficulties, with patients and peers, and the absence of joyful aspects of the profession constituted fundamental elements of their narratives. CONCLUSIONS: Comprehensive investigation of physicians' lived professional experience could become a key to conceive ways to support them.

Training in communication of oncology clinicians: a position paper based on the third consensus meeting among European experts in 2018.

Background: Since there is sound evidence that communication skills training (CST) programs modify communication behavior of oncology clinicians, they have been widely implemented over the last decades. However, more recently, certain aspects of this training have been criticized. Methods: Based on this background, a call to re-launch a discussion about the future of CST led to the third European consensus meeting on communication in cancer care, organized by the Swiss Cancer League. During this meeting, which brought together European experts in the field of clinical communication and training of communication in the oncology setting, oncology clinicians, representatives of the European Society of Medical Oncology and a member of the European Oncology Nursing Society, the recommendations of the second European consensus meeting were updated and expanded. Results: The expanded recommendations recall the guiding principles of communication in cancer care, underline the important role of clinician's self-awareness, and of relational and contextual factors in clinical communication, and provide direction for the further development of communication training. Conclusion: This third European consensus meeting defines key elements for the development of a next generation of communication training for oncology clinicians.

[Multifaceted body. 2. The lived body]. / Pluralité des corps. 2. Le corps vécu.

The human body is the object upon which medicine is acting, but also lived reality, image, symbol, representation and the object of elaboration and theory. All these elements which constitute the body influence the way medicine is treating it. In this series of three articles, we address the human body from various perspectives: medical (1), phenomenological (2), psychosomatic and socio-anthropological (3). This second article distinguishes between the body as an object of knowledge or representation and the way the body is lived. This distinction which originates in phenomenological psychiatry aims to understand how the patient experiences his body and to surpass the classical somatic and psychiatric classifications.

[Multifaceted body. I. The bodies of medicine]. / Pluralité des corps. 1. Les corps de La medicine.

The human body is the object upon which medicine is acting, but also lived reality, image, symbol, representation and the object of elaboration and theory. All these elements which constitute the body influence the way medicine is treating it. In this series of three articles, we address the human body from various perspectives: medical (1), phenomenological (2), psychosomatic and socio-anthropological (3). This first article discusses four distinct types of representation of the body within medicine, each related to a specific epistemology and shaping a distinct kind of clinical legitimacy: the body-object of anatomy, the body-machine of physiology, the cybernetic body of biology, the statistical body of epidemiology.

[Multifaceted body. 3. The contextualised body]. / Pluralité des corps. 3. Les corps liés.

The human body is the object upon which medicine is acting, but also lived reality, image, symbol, representation and the object of elaboration and theory. All these elements which constitute the body influence the way medicine is treating it. In this series of three articles, we address the human body from various perspectives: medical (1), phenomenological (2), psychosomatic and socio-anthropological (3). This third and last article focuses on the psychosomatic and socio-anthropological facets of the body and their contribution to its understanding.

The dipeptidylpeptidase-IV inhibitors sitagliptin, vildagliptin and saxagliptin do not impair innate and adaptive immune responses.

Inhibitors of dipeptidylpeptidase IV (DPP-IV) represent a novel class of frequently used anti-diabetic drugs. In addition to its function in metabolic regulation, DPP-IV also plays a role in the immune system. Whether the DPP-IV inhibitors sitagliptin, vildagliptin or saxagliptin impair immune responses is, however, currently unknown. Here, we investigated the effect of these agents on both innate and adaptive immunity. We found that the DPP-IV inhibitors did not affect the innate immune response induced by Toll-like receptor (TLR) ligands, as cytokine secretion and induction of co-stimulatory molecules by human blood mononuclear cells was not impaired. Furthermore, proliferation of T cells and suppressive function of regulatory T cells was preserved. Mice treated with vildagliptin showed normal cytokine production, immune cell activation and lymphocyte trafficking upon TLR activation. Thus, crucial immunological parameters remain unaffected upon treatment with DPP-IV inhibitors, a fact that is reassuring with respect to safety of these drugs.

Surveillance for adverse events following immunization (AEFI) in Switzerland--1991-2001.

In Switzerland, reporting of adverse events following immunization (AEFI) has been mandatory by law since 1988. The goal of this study was a detailed analysis of reported AEFI received by the Swiss Federal Office of Public Health between 1991 and 2001. Overall, 1013 AEFI were reported which translates to 2.7 reports per 100,000 vaccine doses distributed during the study period. Most AEFI were classified as general systemic reactions (47%), followed by local (26%), neurological (16%) and allergic reactions (13%). The majority of all reported AEFI (N=513; 51%) had occurred in individuals 16 years and older. Causal relationship between immunization and AEFI was probable in 91 (10%) of 909 assessable reports and very likely or certain in 194 (21%), the majority of which (88%) were local reactions. Vaccines distributed in Switzerland have proven to be generally safe. Limitations of the passive surveillance system, however, warrant improvements in the future.

[Sociolinguistics and liaison psychiatry: a particular aspect]. / La sociolinguistique en psychiatrie de liaison: un certain regard.

Verbal language is a major tool of medical communication. However, its use can be problematic, namely because the speakers of a given language do not necessarily agree on the meaning of the words they exchange. This phenomenon is usually called linguistic variability. Based on a famous political and legal case and medical examples, we will show how variability is a critical source of misunderstandings and other communicational breakdowns. In addition, we will suggest some strategies which are likely to limit the impact of variability on clinician/patient interaction.

Fc receptors are critical for autoimmune inflammatory damage to the central nervous system in experimental autoimmune encephalomyelitis.

Multiple sclerosis (MS) is simulated by various forms of experimental autoimmune encephalomyelitis, in which T cells, antibodies, cytokines and complementary factors interact with the central nervous system (CNS) myelin proteins and lead to inflammatory damage. We investigated the role of Fc receptors (FcRs), which link the cellular and humoral branches of the immune system, in myelin oligodendrocyte glycoprotein (MOG)-induced experimental autoimmune encephalomyelitis (EAE), using two different FcRgamma knockout DBA/1 mice. The first knockout were the FcRgamma chain-deficient mice, which lack FcgammaRI, FcgammaRIII and Fc(epsilon)RI, while the second knockout mice lack only FcgammaRII. The lack of FcgammaRII enhanced the disease susceptibility with associated increased CNS demyelination. While FcRgamma+/+ DBA/1 mice also developed pronounced CNS infiltration and myelin destruction, FcRgamma-/- littermates were protected despite initial peripheral autoimmune responses to MOG. In vitro analyses revealed equivalent potentials of fluid phase phagocytosis of myelin and MOG in bone-marrow macrophages derived from both FcRgamma+/+ and FcRgamma-/- mice, while MOG-immunoglobulin (Ig)G immune complexes were only internalized by FcRgamma+/+ macrophages. This was associated with cellular activation in FcRgamma+/+ but not FcRgamma-/- macrophages, as assessed by the activation of intracellular mitogen activated protein (MAP)-kinase signalling elements. We propose that protection from EAE in FcRgamma-deficient mice is due to the inefficient antigen processing/presentation of myelin proteins during the induction of secondary immune responses locally in the CNS, which leads to demyelination. This demonstrates the importance of FcR in the promotion of autoimmune inflammation of the CNS and highlights the therapeutic possibility of treatment of MS with FcR-directed modalities.

Anti-titin antibodies in myasthenia gravis: tight association with thymoma and heterogeneity of nonthymoma patients.

BACKGROUND: Titin is the major autoantigen recognized by anti-striated muscle antibodies, which are characteristic of generalized myasthenia gravis (MG). OBJECTIVE: To seek a correlation between anti-titin antibodies and other features of MG patients, including histopathology, age at diagnosis, anti-acetylcholine receptor (anti-AChR), autoantibody titers, and clinical severity. METHODS: A novel, highly specific radioligand assay was performed on a large group of 398 patients with generalized MG. RESULTS: Among thymectomized patients, anti-titin antibodies were present in most patients with thymoma (56/70 [80%]), contrasting with only a minority of patients with thymus atrophy or hyperplasia (17/165 [10%]). They were also present in 64 (41%) of 155 nonthymectomized patients who had a radiologically normal thymus. In these patients and in those who had a histologically normal thymus, anti-titin antibodies were associated with a later age at onset of disease and with intermediate titers of anti-AChR antibodies. After controlling for these 2 variables, disease severity was not significantly influenced by anti-titin antibodies. CONCLUSIONS: Anti-titin antibodies are a sensitive marker of thymoma associated with MG in patients 60 years and younger, justifying the insistent search for a thymoma in MG patients of this age group who have these antibodies. In nonthymoma patients, anti-titin antibodies represent an interesting marker complementary to the anti-AChR antibody titer, identifying a restricted subset of patients. These clinical correlations should prompt further studies to examine the mechanisms leading to the production of anti-titin antibodies.

Myelin oligodendrocyte glycoprotein-DNA vaccination induces antibody-mediated autoaggression in experimental autoimmune encephalomyelitis.

One strategy to reestablish self tolerance in autoimmune diseases is based on the use of DNA vaccination to induce ectopic expression of the target autoantigen. We assessed the potential of vaccination with a DNA construct encoding the myelin oligodendrocyte glycoprotein (MOG), an important candidate autoantigen in multiple sclerosis, to induce tolerance and protect against experimental autoimmune encephalomyelitis (EAE). Unexpectedly, mice vaccinated with MOG-DNA developed an exacerbated form of EAE when challenged with either MOG or an unrelated encephalitogen, myelin proteolipid protein. We demonstrate that this is due to the inability of DNA vaccination to tolerize the MOG-specific T cell response and to the concomitant induction of a cytopathic MOG-specific autoantibody response, which is pathogenic, enhancing demyelination, inflammation and disease severity. Our data suggest that tolerogenic strategies for autoimmune diseases based on DNA vaccination should be approached with caution, as the outcome is unpredictable.

[Measles, mumps and rubella: vaccination rate and seroprevalence in 8th grade students of 8 different sites in Switzerland 1995/96]. / Masern, Mumps und Röteln: Durchimpfungsrate und Seroprävalenz bei 8.-Klässlern in acht verschiedenen Orten der Schweiz 1995/96.

In 1987, the Swiss Federal Health Office (BAG) and the Swiss cantons launched the MMR-vaccination campaign. Within the frame of the SCARPOL Study, the vaccination status of 649, 8th class students was registered and serum samples were collected. The measles, mumps and rubella specific antibody levels were determined. The vaccination rate was 84% for measles, 74% for mumps, and 62% for rubella, 55% of these children had been vaccinated with the combined vaccine MMR. The vaccination rate for the different study areas varied from 70% to 95% for measles, 42% to 94% for mumps and 18% to 89% for rubella, 92% of the children tested seropositive for measles specific antibodies, 87% for mumps and 84% for rubella. The seroprevalence for measles, mumps and rubella was significantly higher for vaccinated than for unvaccinated children. Non-Swiss children had, without exception, a higher seroprevalence rate than Swiss children. Undergoing the disease did not influence the seroprevalence for measles, but it did so for mumps and rubella, for vaccinated and unvaccinated children alike. By analysis according to study site, we observed that sites with higher vaccination rates (e.g. Grabs in Rheintal) sometimes showed a lower seroprevalence than sites with lower vaccination rates (e.g. Langnau). This was the case for all three vaccines. This, together with other observations, shows that a booster is necessary for an adequate immunisation--as a wild virus infection or as a second vaccination.

Myelin oligodendrocyte glycoprotein induces experimental autoimmune encephalomyelitis in the "resistant" Brown Norway rat: disease susceptibility is determined by MHC and MHC-linked effects on the B cell response.

Experimental autoimmune encephalomyelitis (EAE) induced by active immunization with the myelin oligodendrocyte glycoprotein (MOG) is an Ab-mediated, T cell-dependent autoimmune disease that replicates the inflammatory demyelinating pathology of multiple sclerosis. We report that disease susceptibility and severity are determined by MHC and MHC-linked effects on the MOG-specific B cell response that mediate severe clinical EAE in the EAE-resistant Brown Norway (BN) rat. Immunization with the extracellular domain of MOG in CFA induced fulminant clinical disease associated with widespread demyelination and with an inflammatory infiltrate containing large numbers of polymorphonuclear cells and eosinophils within 10 days of immunization. To analyze the effects of the MHC (RT1 system) we compared BN (RT1 n) rats with Lewis (LEW) (RT1 l) and two reciprocal MHC congenic strains, LEW.1N (RT1n) and BN.1L (RT1 l). This comparison revealed that disease severity and clinical course were strongly influenced by the MHC haplotype that modulated the pathogenic MOG-specific autoantibody response. The intra-MHC recombinant congenic strain LEW.1R38 demonstrated that gene loci located both within the centromeric segment of the MHC containing classical class I and class II genes and within the telomeric RT1.M region containing the MOG gene are involved in determining Ab production and disease susceptibility. This study indicates that the current T cell-centered interpretation of MHC-mediated effects on disease susceptibility must be reassessed in multiple sclerosis and other autoimmune diseases in which autoantibody is involved in disease pathogenesis.

[Prevention of hepatitis B (excluding vaccination)]. / Prävention der Hepatitis B (exkl. Impfung).

The immunisation programme against hepatitis B should not neglect other preventive measures. The main measures are: Always use condoms with casual sexual partners, do not exchange syringes or injection material, always apply universal precautions with blood and other biological liquids as these must always be considered potentially infectious.

[Information strategy for physicians and public health regarding introduction of general hepatitis B vaccination in Switzerland]. / Informationsstrategie für Arzte und Offentlichkeit betreffend der Einführung der generellen Hepatitis-B-Impfung in der Schweiz.

Information is extremely important for immunisation programmes. The information should be clear, transparent, easily accessible and adapted to the different target populations. Parents consider the information presently available to be insufficient. This constitutes an obstacle to the introduction of universal vaccination against Hepatitis B in Switzerland. The population groups targeted by the information have to be the public health authorities, physicians, adolescents, parents and teachers. Various documents are now available or in preparation and should allow an effective discussion between these different partners.