A Philosophical Discussion of the Support of Self-Regulated Learning in Medical Education: The Treasure Hunt Approach Versus the (Dutch) "Dropping" Approach.

Issue: Many current educational approaches are intended to cultivate learners' full (learning) potential by fostering self-regulated learning (SRL), as it is expected that those learners with a high degree of SRL learn more effectively than those with a low degree of SRL. However, these attempts to foster SRL are not always successful. Evidence: We considered complexities related to fostering self-regulated learning by use of an analogy. This analogy was based on two (Dutch) children's games: the treasure hunt (children can find a "treasure" by following directions, completing assignments and/or answering questions) and the dropping (pre-teens are dropped in the woods at nighttime with the assignment to find their way back home). We formulated four interrelated philosophical questions. These questions were not formulated with the intention to provide clear-cut answers, but were instead meant to evoke contemplation about the SRL concept. During this contemplation, the implications of definitional issues regarding SRL were discussed by use of the first question: What are the consequences of the difficulties to explicate what is (not) SRL? The second question (How does SRL relate to autonomy?) touched upon the intricate relationship between SRL and autonomy, by discussing the role of social interaction and varying degrees of instruction when fostering SRL. Next, a related topic was addressed by the third question: How much risk are we willing and able to take when fostering SRL? And finally, the importance of and possibilities to assess SRL were discussed by the fourth question (Should SRL be assessed?). Implications: From our contemplations it has become clear that approaches to foster SRL are often insufficiently aligned with the experience and needs of learners. Instead these approaches are commonly defined by contextual factors, such as misconceptions about SRL and lack of leeway for learners. Consequently, we have used principles that apply to both treasure hunts and droppings, to provide guidelines on how to align one's approach to foster SRL with the educational context and experience and needs of learners.

How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts?

INTRODUCTION: Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS: A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS: Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION: Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.

Comparison of pediatric radiation dose and vessel visibility on angiographic systems using piglets as a surrogate: antiscatter grid removal vs. lower detector air kerma settings with a grid - a preclinical investigation.

The purpose of this study was to reduce pediatric doses while maintaining or improv-ing image quality scores without removing the grid from X-ray beam. This study was approved by the Institutional Animal Care and Use Committee. Three piglets (5, 14, and 20 kg) were imaged using six different selectable detector air kerma (Kair) per frame values (100%, 70%, 50%, 35%, 25%, 17.5%) with and without the grid. Number of distal branches visualized with diagnostic confidence relative to the injected vessel defined image quality score. Five pediatric interventional radiologists evaluated all images. Image quality score and piglet Kair were statistically compared using analysis of variance and receiver operating curve analysis to define the preferred dose setting and use of grid for a visibility of 2nd and 3rd order vessel branches. Grid removal reduced both dose to subject and imaging quality by 26%. Third order branches could only be visualized with the grid present; 100% detector Kair was required for smallest pig, while 70% detector Kair was adequate for the two larger pigs. Second order branches could be visualized with grid at 17.5% detector Kair for all three pig sizes. Without the grid, 50%, 35%, and 35% detector Kair were required for smallest to largest pig, respectively. Grid removal reduces both dose and image quality score. Image quality scores can be maintained with less dose to subject with the grid in the beam as opposed to removed. Smaller anatomy requires more dose to the detector to achieve the same image quality score.

[Incident-reporting electronic-based system in internal medicine]. / Déclaration et traitement des événements indésirables en médecine interne.

How to recognize, announce and analyze incidents in internal medicine units is a daily challenge that is taught to all hospital staff. It allows suggesting useful improvements for patients, as well as for the medical department and the institution. Here is presented the assessment made in the CHUV internal medicine department one year after the beginning of the institutional procedure which promotes an open process regarding communication and risk management. The department of internal medicine underlines the importance of feedback to the reporters, ensures the staff of regular follow-up concerning the measures being taken and offers to external reporters such as general practioners the possibility of using this reporting system too.

[IgG4-related disease: a possible cause of obstructive jaundice]. / La maladie liée aux IgG4: une cause possible d'ictère obstructif.

Immunoglobulin G4 related disease (IgG4-RD) has been recognized since early 2000s as an entity comprising a set of inflammatory diseases with common histopathological features. The disease may affect almost all organs and tissues, and often occurs in a subacute fashion in males over 50 years as a mass or diffuse enlargement of affected organs. The histopathological appearance is characterized by a lymphoplasmacytic infiltration with predominantly IgG4-positive plasma cells and progressive fibrosis. Its clinical and radiological features can make the distinction with a malignancy difficult. The disease responds well to systemic glucocorticoids however with a high rate of recurrence after treatment discontinuation.

[Giant cell arteritis: guidelines of the University Hospital of Lausanne]. / Artérite de Horton: recommandations Lausannoises de prise en charge.

Giant cell arteritis (GCA) is a subacute/chronic vasculitis and represents the most common form of systemic vasculitis in people over the age of 50 years. The absence of clear and specific diagnostic criteria with the highly variable clinical presentation is a diagnostic challenge requesting a multidisciplinary approach. Yet, GCA is an emergency and the treatment must be initiated very rapidly due to the risk of blindness. This article presents a review of GCA as well as the diagnostic and therapeutic institutional guidelines of the University Hospital of Lausanne.

[Biomarkers in clinical immunology]. / Biomarqueurs en immunologie générale.

In a current perspective of individualized medicine, biomarkers appear as a simple and readily available aid to assist clinicians in the identification and monitoring of diseases whose diagnosis is difficult. Basically, we know the limited performance of medical history and of clinical examination; therefore, the use of laboratory tests is often seen as the panacea to solve the clinical enigma. The purpose of this article is to analyze a few biomarkers commonly processed in the immunology laboratory (AAN, ANCA, anti-tTG, rheumatoid factor and anti-CCP) and to review the principle, the usefulness and the performance of these tests in specific clinical situations. We will see that, far from supplanting history and physical examination, these immunological biomarkers take their full value as a supplement to clinical information!

[What is new in 2012 for the specialist in hospital internal medicine?]. / L'année 2012 de la perspective de l'interniste hospitalier.

The knowledge in internal medicine is constantly and so rapidly evolving that practices have to be updated and adjusted to recent scientific rules, in order to improve quality and efficiency in the day to day activities. Residents in the Service of internal medicine of the Lausanne University present several relevant papers published in 2012, whose results are susceptible to change the daily hospital practices. From modest impacts to real revolution, a variety of subjects are discussed in the perspective of evidence based medicine.

[Allergy to beta-lactam antibiotics]. / Allergie aux beta-lactamines.

Beta-lactam antibiotics allergies are common. Up to 10% of the population describe a former allergy to penicillins. However only 10 to 15% of these individuals are actually allergic. In most cases, beta-lactam antibiotics will be avoided and replaced by other antibiotics such as quinolones. This fear of a serious allergic reaction has an economic impact and may lead to the emergence of antibiotic resistance. A thorough allergic work-up can accurately determine true allergic patients. Most of the patients with a proven allergy will be able to tolerate other antibiotics belonging to the beta-lactam family. This article focuses on the management of beta-lactam allergic patients.

[Sjögren's syndrome: a new approach to treatment]. / Syndrome de Sjögren: enfin une nouvelle approche de traitement.

Södgren's syndrome treatment has essentially been based on symptomatic approach and has been of limited efficacy. Novel biological therapies targeting B cells, a key player in the pathophysiology of the syndrome, have recently been tested in controlled clinical trials and raise the hope of improving glandular and extraglandular manifestations of Söigren's syndrome.

[Common variable immune deficiency: what you need to know]. / Immunodéficience commune variable: ce qu'il faut savoir.

Common variable immune deficiency is the most frequent primary immune deficiency, characterized mainly by a disorder of B lymphocytes differentiation and a deficit in immunoglobulins. The clinical manifestations include recurrent infections, non-infectious lung and digestive involvements, autoimmune diseases, and an increased susceptibility to cancers. Recent breakthroughs have been made in the understanding of some genetic mechanisms of the disease. Replacement therapy with intravenous immunoglobulins remains the treatment of choice, which allows significant improvement in the survival and quality of life. However progress should be made in the understanding of the pathophysiology and in the early detection of this disease, since a delay in the diagnosis may have harmful consequences in terms of morbidity and mortality.

[Hymenoptera venom allergy: new diagnostic tools and management]. / Allergie aux venins d'hyménopteres: nouveautés diagnostiques et prise en charge.

Anaphylactic reactions to hymenoptera venoms are common and, in our latitudes, mainly concern wasps and bees. Recently, molecular biology techniques have contributed to identifying and to sequencing the major allergens of insect venoms and led to the production of recombinant allergens. Assays for specific IgE directed against these recombinant allergens have recently been made available in clinical practice. They provide considerable assistance in identifying the insect responsible for an anaphylactic reaction, in particular when standard tests are positive for both wasp and bee. This article focuses on these new laboratory tests and also reviews the management of patients experiencing an anaphylactic reaction after hymenoptera sting.

[Allergen specific immunotherapy: review of new perspectives]. / Désensibilisation: vers de nouvelles perspectives.

Allergic diseases constitute a health problem worldwide. More than just a treatment option, the classical desensitization (SIT--Specific immunotherapy) by subcutaneous injection has profiled over time as a unique approach, able to attenuate the immune response to allergic stimuli proved. For a long time conservative, desensitization has now progressed in the knowledge of allergens, in the understanding of the mechanisms involved in immune response and in production techniques. From recombinants to alternative routes of allergen delivery, this article gives an overview of new perspectives and assesses SIT in order to provide guidance to the general physician before choosing to initiate such treatment or not in patients with respiratory allergy.

[What to expect from allergy tests?]. / Qu'attendre du futur du diagnostic en allergologie?

Diagnosis in allergology is facing novel challenges because of the availability not only of purified or recombinant allergens, but also of multitests such as allergen micro-arrays. These new diagnostic opportunities contribute to a better understanding of crossreactivities between respiratory and food allergens. In comparison to current diagnosis based on whole allergen extracts, this novel generation of specific IgE tests is expected to provide better information on the risk of reaction to allergens as well as on its severity. However these new technologies are expensive, and will have to be carefully analyzed in terms of medical usefulness and public health costs.

[Hiking and useful advices to patients (part 1)]. / Randonnée: conseils utites aux patients (1re partie).

The attraction of walking as a pastime has grown enormously in Switzerland over the past few years. Synonym of health and well-being, this activity carries some risks which more and more patients are questioning; answering these questions is not always obvious, so we wanted to tackle the subject. Risks linked to certain animals will be covered. One of these risks is insect stings, particularly wasps and bees. This is a major problem which affects the whole population and more seriously those who are allergic, accounting for around 5% of the population. Another problem: snake bites. In Switzerland, there are about 20-25 bites each year. Poisoning from these can be divided into two categories: local or systemic. The effects are multiple and diverse, ranging from renal failure to discrasia to hypovolemic shock. Pre-hospitalisation measures are of paramount importance in the treatment.

[Eosinophilic esophagitis]. / OEsophagite à éosinophiles.

Eosinophilic esophagitis is a recent diagnosis, of growing interest and prevalence. It has to be considered by every physician when facing any adult or pediatric case of dysphagia, food impaction, and symptoms of GERD (gastroesophageal reflux disease) resistant to proton-pump inhibitor treatment. The diagnosis is made by combining clinical symptoms and endoscopic signs, supported by biopsies of the mucosa, which should show more than 15 eosinophils per high power field. The etiology seems to be of allergic origin, and a full immuno-allergic testing should be made. Recommendations for the treatment are to calm down the inflammatory process by proton-pump inhibitors, and to give topical steroids, keeping the systemic treatment for acute severe cases. In cases of esophageal stenoses, dilations can be undertaken, but with a high risk of recurrence.

[Cardiac involvement in connective tissue disease: the example of systemic lupus erythematosus]. / Atteintes cardiaques dans les connectivites: l'exemple du lupus érythémateux systémique.

When we think of cardiac affection in the context of systemic lupus erythematosus (SLE), we usually refer to pericarditis first. As frequent as this affection is, it is actually not the only cardio-vascular problem that occurs with this systemic inflammatory disease. Are the cardiac events--ranging from multiple heart valve involvements to increased cardiovascular risks--clinically significant? And are they involving a specific follow-up, treatment or support? We are therefore trying to evaluate these questions in order to give some recommendations to any practitioners following up a lupus patient, or a patient suffering from any other inflammatory systemic disease.

Spirometry expert support in family practice: a cluster-randomised trial.

AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.