Assessment of medical students' integrated clinical communication skills: development of a tailor-made assessment tool.

BACKGROUND: Since patient-centered communication is directly connected to clinical performance, it should be integrated with medical knowledge and clinical skills. Therefore, clinical communication skills should be trained and assessed as an integral part of the student's clinical performance. We were unable to identify a tool, which helps when assessing patient-centered communication skills as an integrated component of medical history taking ('the integrated medical interview'). Therefore, we decided to design a new tailor-made assessment tool, the BOCC (BeOordeling Communicatie en Consultvoering (Dutch), Assessment of Communication and Consultation (English) to help raters assess students' integrated clinical communication skills with the emphasis on patient-centred communication combined with the correct medical content. This is a first initiative to develop such a tool, and this paper describes the first steps in this process. METHODS: We investigated the tool in a group of third-year medical students (n = 672) interviewing simulated patients. Internal structure and internal consistency were assessed. Regression analysis was conducted to investigate the relationship between scores on the instrument and general grading. Applicability to another context was tested in a group of fourth-year medical students (n = 374). RESULTS: PCA showed five components (Communication skills, Problem clarification, Specific History, Problem influence and Integration Skills) with various Cronbach's alpha scores. The component Problem Clarification made the strongest unique contribution to the grade prediction. Applicability was good when investigated in another context. CONCLUSIONS: The BOCC is designed to help raters assess students' integrated communication skills. It was assessed on internal structure and internal consistency. This tool is the first step in the assessment of the integrated medical interview and a basis for further investigation to reform it into a true measurement instrument on clinical communication skills.

Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study.

BACKGROUND: Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice. METHODS: We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers' fieldwork reports, were coded and thematically analysed by each team using NPT. RESULTS: In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants' needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP's diagnoses and GPs reported a clearer understanding of migrants' symptoms. CONCLUSIONS: Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

[Paediatric Rehabilitation by the German Pension Insurance - Status Quo and Future Developments]. / Kinder- und Jugendlichen-Rehabilitation ­ Stand und Perspektiven aus Sicht der Deutschen Rentenversicherung.

In Germany inpatient rehabilitation plays a major role for the treatment of children and adolescents with chronic health conditions. The German Pension Insurance carries out the rehabilitation of children and adolescents with high commitment. Paediatric rehabilitation enables children to go to kindergarten and school without interruption and participate in later professional life. The article specifies the basics of paediatric rehabilitation, describes the disease structure, defines the therapeutic care and explicates survey results.

Molecular characterisation of Porcine rubulavirus (PorPV) isolates from different outbreaks in Mexico.

Since the report of the initial outbreak of Porcine rubulavirus (PorPV) infection in pigs, only one full-length genome from 1984 (PorPV-LPMV/1984) has been characterised. To investigate the overall genetic variation, full-length gene nucleotide sequences of current PorPV isolates were obtained from different clinical cases of infected swine. Genome organisation and sequence analysis of the encoded proteins (NP, P, F, M, HN and L) revealed high sequence conservation of the NP protein and the expression of the P and V proteins in all PorPV isolates. The V protein of one isolate displayed a mutation that has been implicated to antagonise the antiviral immune responses of the host. The M protein indicated a variation in a short region that could affect the electrostatic charge and the interaction with the membrane. One PorPV isolate recovered from the lungs showed a mutation at the cleavage site (HRKKR) of the F protein that could represent an important factor to determine the tissue tropism and pathogenicity of this virus. The HN protein showed high sequence identity through the years (up to 2013). Additionally, a number of sequence motifs of very high amino acid conservation among the PorPV isolates important for polymerase activity of the L protein have been identified. In summary, genetic comparisons and phylogenetic analyses indicated that three different genetic variants of PorPV are currently spreading within the swine population, and a new generation of circulating virus with different characteristics has begun to emerge.

[Liquid ecstasy in general psychiatry: a case series]. / Liquid ecstasy in der allgemeinpsychiatrie: eine fallserie.

BACKGROUND: In emergency medicine and anesthaesiology liquid ecstasy (LE), the street name for GHB, GBL or 1,4-B, has become infamous for causing severe intoxications and withdrawal. In general psychiatry, however, it is little known. Therefore, we set out to gather data about the role of LE in general psychiatry, typical users and common clinical problems associated with the use of LE. METHODS: We retrospectively identified and studied all patients with a reported the use of LE seen at the Department of Psychiatry, University of Ulm, Germany, between 1998 and 2011. RESULTS: In 14 years, 19 users of LE were identified, the first dating from 2005. The majority reported a use of GBL (63 %), GHB was less common, and 1,4-B was not reported. Patients were predominantly young men (median age 25 years, 79 % men) with a history of multiple substance abuse. Ten patients had only a former use of LE, the other nine patients used it at the time of presentation. Of these, every third patient had to be transiently treated in an intermediate care unit, usually because of very severe and sudden withdrawal symptoms. Otherwise, detoxification was possible in psychiatry, but often required high doses of benzodiazepines. Three patients met the criteria for dependence from GBL. CONCLUSIONS: In recent years, a small number of users of LE is seen also in general psychiatry, The problem is rather the severity of withdrawal than the number of cases. Close cooperation with intermediate care units is needed. In any case of coma of unknown origin or delirium with sudden onset LE use or withdrawal has to be taken into consideration, respectively. Many clinical problems result from the fact that LE cannot be detected in routine drug screenings. According to our experience, withdrawal from LE can be controlled with benzodiazepines.

Challenges in communication during clerkships: a case report.

Patient-centered communication skills training is an integral part of the medical training of students of the Radboud University Nijmegen Medical Centre. During their clerkships, however, students are confronted with a variety of physicians, demonstrating communication skills which differ from what they have been taught. Some physicians have difficulty with patient-centered communication themselves. This may cause students to adopt inadequate communication behaviors. To prevent this, we suggest raising awareness in students and including supervising physicians in communication skills training.

Teaching and training in breaking bad news at the Dutch medical schools: a comparison.

BACKGROUND: Physicians consider breaking bad news (BBN) a difficult task, and training is therefore necessary. There is much variety in what schools consider to be best practice and best timing for such training. This article discusses BBN-programmes at the Dutch medical schools. We studied how students value their training and offer recommendations. METHODS: We developed two questionnaires to obtain programme information from course co-ordinators and student opinions about BBN-training. We compared student opinions right after BBN-training (T1) and towards the end of the medical curriculum (T2). RESULTS: BBN-programmes in Dutch medical schools vary in timing, models used and training methods. Overall, students are satisfied with the timing. They appreciate feedback by physicians and simulated patients most. At T2, some groups of students reported that BBN-training had given them slightly less guidance than was reported by T1-students at the same institution. DISCUSSION: T2-students perhaps realised they had not received the amount of support they needed and may have shifted from being unconsciously incompetent to being consciously incompetent. RECOMMENDATIONS: We recommend: (a) longitudinal programmes with experiential skills-training sessions and clinical practice, (b) to involve simulated patients, physicians and psychologists in training programmes as well as practising physicians who supervise students during clinical work and (c) to ensure ongoing support and feedback in the clinical phase.

[Quality assurance of rehabilitation by the German pension insurance: an overview]. / Ein aktueller Überblick zur Reha-Qualitätssicherung der Rentenversicherung.

The German pension insurance has in recent years developed a comprehensive programme for quality assurance in rehabilitation, and has implemented the programme into routine practice. Different aspects of rehabilitation are evaluated with differentiated instruments. Issues dealt with inter alia include the quality of rehabilitative care in a narrower sense, the structure and organisation of the rehabilitation centres, as well as quality from the patients' perspective. On the whole, positive results predominate. Big differences in quality however have been found between the rehabilitation centres. The data collections and data evaluations carried out make a continuous process of quality assurance reporting possible for use by rehabilitation centres and pension insurance agencies. This will enable targeted initiatives for quality improvement. The methods and procedures of quality assurance are enhanced at regular intervals, and the scope of quality assurance is extended. Thus, rehab quality assurance is also expanded to cover ambulant rehabilitation or rehabilitation of children and young people.

Biodetoxification of aflatoxin-contaminated chick feed.

Two studies were done to study detoxification of aflatoxin (AF)-contaminated chick feed with Nocardia corynebacteroides (NC). In the first study, pathogenicity of the bacteria was studied; in the second, the nutritional value of detoxified feed was evaluated. Commercial corn was divided into 2 sublots, one of which was contaminated with AF. Both lots were divided into 2 parts; the first was inoculated with NC. Four corn-soybean diets were prepared from the 4 corn lots. A completely randomized design was used with 2 x 2 factorial arrangement in which the factors were AF contaminated or not and NC inoculated or not. One hundred Ross 308 chicks (1-d-old, male) were used in 4 treatments with 5 repetitions and 5 chickens per cage. Bird weight and feed consumption were recorded weekly. Each week, 1 chick per treatment repetition was killed for histopathologic analysis of liver, kidney, bursa of Fabricius, pancreas, and small intestine (duodenum, jejunum, and ileum) and for analysis by scanning electron microscopy of the 3 sections of the intestine. At 21 d (the end of both experiments), 1 chick per treatment repetition was killed, and moisture, lipid content, and residual AF in liver were detected. Results at 3 wk did not show differences between treatments (P > 0.05) in any of the variables. In the second study, the same methodology was used except that greater levels of AF were used (800 and 1,200 mug of AFB1/kg of feed). Results showed differences (P < 0.05) in body weight, lipid content, and residual AF in liver. Histopathologic studies showed statistical differences in lesion severity in liver, duodenum, and kidney. Scanning electron microscopy analysis showed severe lesions of intestinal mucosa that mainly affected tight junctions in AF treatments. It can be concluded that NC is safe for chicks and may be used to partly detoxify chicken feed contaminated with AF.

Students' experiences with a longitudinal skills training program on breaking bad news: A follow-up study.

OBJECTIVE: Breaking bad news (BBN) should be trained, preferably early and following a helical model with multiple sessions over time, including feedback on performance. It's unclear how medical students evaluate such an approach. METHODS: We gathered student opinions regarding a helical BBN training programme, the feedback and emotional support they received, and the applicability of the skills training immediately after BBN skills training (Q1) and after finishing their clinical clerkships (Q2). RESULTS: Students find a helical curriculum useful, but this declines on follow-up. At Q2 students report less satisfaction with the amount of feedback and emotional support they received and report that the skills training was less applicable in clinical practice compared to what they reported at Q1. CONCLUSION: A helical BBN training programme with early exposure seems to lead to a shift from students being unconsciously incompetent to consciously incompetent. Students would have appreciated more emotional support and feedback. PRACTICE IMPLICATIONS: We recommend more feedback and emotional support after BBN during clerkships. The gap between classroom and practice can be diminished by emphasizing real life role play and clinical role models should demonstrate continuity and agreement between the skills that are taught and those that are used in clinical practice.

Using Participatory Learning & Action (PLA) research techniques for inter-stakeholder dialogue in primary healthcare: an analysis of stakeholders' experiences.

PLAIN ENGLISH SUMMARY: It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service. ABSTRACT: Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

[Research report 'the appropriate prescribing of antidepressants in general practice': who is better served by more diagnoses and more antidepressants?]. / Onderzoeksrapport 'doelmatig voorschrijven van antidepressiva in de huisartspraktijk': wie is er gebaat bij meer diagnosen en meer antidepressiva?

Recently a report entitled 'The appropriate prescribing of antidepressants in general practice' was published. The researchers conclude that depression and anxiety are still more under-diagnosed than over-diagnosed and that antidepressants are frequently prescribed even when they are not indicated. Why this is so remains unclear. Looking for better interventions to improve treatment and increase therapy compliance, this study reports that many types of intervention could help but it is not very specific on how this could be achieved. Improving communication and knowledge about prescribing and how and when to discontinue treatment, are among the suggestions made in the report. Many questions remain: (a) is under-diagnosis a problem in a condition that often resolves spontaneously with watchful waiting?, (b) why are antidepressants so widely prescribed when their effectiveness is controversial and they have major adverse reactions?, (c) why are other treatment options such as talking therapy and a short period psychological intervention, of which the effectiveness has been established, not more frequently applied?

Low-dose natural interleukin-2 and recombinant interferon-gamma following autologous bone marrow grafts in pediatric patients with high-risk acute leukemia.

Twenty-two patients with high risk hematologic malignancies (13 c-ALL, two B-ALL/NHL, four T-ALL, two AML M2, one pre-pre B-ALL) entered a phase I/II trial with cyclic administration of low dose natural interleukin-2/recombinant interferon-gamma (nIL-2/rIFN-gamma) following autologous bone marrow transplantation (ABMT), in order to induce a cytotoxic antileukemic effect. Eighteen patients subsequently relapsed, corresponding to a Kaplan-Meier estimate of disease-free survival (DFS) of 18%. Compared with a historical group of autologous bone marrow recipients who have not received immunotherapy, there is no significant difference according to DFS. Immunophenotyping of peripheral lymphocytes at the onset and end of therapy cycles revealed the most significant mean increase among the NK cell population (262/microliters +/- 51 vs. 354/microliters +/- 36, p = 0.004). However, even CD3 positive T cells rose significantly (591/microliters vs. 689/microliters, p = 0.04). In vitro NK cell activity tested against the NK sensitive myeloid leukemic cell line K562, and LAK cell activity tested against the LAK sensitive Burkitt lymphoma cell line Raji, was only low. An additional in vitro stimulus with nIL2, however, led to a therapy-dependent increase of cytotoxicity which was significant against Raji cells (25% +/- 4 vs. 41% +/- 5, p = 0.0124) indicating that low dose nIL2/rIFN-gamma enhances precursors of potentially cytotoxic cells in vivo.

[The practice guideline 'Anxiety disorders' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Angststoornissen' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The recommendations provided by the revised guideline 'Anxiety disorders' are well suited to every-day practice. The multidisciplinary approach reflects the increasing cooperation between primary and secondary care in the management of mental-health problems. The description of the various anxiety disorders and the questions that can be asked to elicit the symptoms will facilitate recognition. The indications for treatment with medication are clear: a limited number of antidepressants should be used. Although it is agreed that patient education is an important part of treatment, the guidelines could have described in more detail how this should be done. Cognitive-behavioural techniques may be used but this requires extra training; its effectiveness when used by general practitioners needs further study. This guideline will add to existing knowledge and improve the skills of general practitioners in dealing with anxiety.

Dystrophinopathy in a boy with Chediak-Higashi syndrome.

Chediak-Higashi syndrome (CHS) is a hereditary, biphasic immunodeficiency syndrome which usually leads to early death, during the first decade. The second phase is characterized by a lymphoproliferative syndrome with histiocytic infiltrations in various tissues. Recently the gene has been identified on chromosome 1q43. In the patient presented here, a mutation within codon 3197 was found, resulting in a frame-shift. Additionally, Duchenne muscular dystrophy (DMD) was diagnosed by immunostaining of the muscle. Unusual for both CHS and DMD muscle weakness and hypotonia became evident during the first months of life. Compared to typical DMD cases we found an increased histiocytic infiltration in the muscle. The underlying muscular dystrophy probably predisposes to the affection of muscle in the second phase of CHS. This patient is presented as an example of modification of the phenotype by a second genetic disease.

Fractionated total body irradiation and high-dose VP-16 with purged autologous bone marrow rescue for children with high risk relapsed acute lymphoblastic leukemia.

Twenty-two children with ALL in high risk second (n = 13), third or subsequent complete remission (n = 9) were treated with high-dose VP-16 60 mg/kg and fractionated total body irradiation (fTBI) 12 Gy, 2 x 2 Gy daily followed by autologous BM rescue. Prior to transplantation all patients had been treated according to intensive German BFM front-line or BFM relapse protocols. In all cases the marrow was purged using monoclonal antibodies attached to magnetic microspheres. All patients engrafted. There was no severe toxicity related to the pre-transplant high-dose chemoradiotherapy. Two patients died in the early course of transplantation from infections (Legionella and Aspergillus). Sixteen patients relapsed within 259 days (median 109 days); 13 died from leukemia. Four patients are alive in CR at a median of 1328 days with a Karnofsky score of 100%. The Kaplan-Meier estimation shows a probability of event-free survival (EFS) of 18% and a probability of relapse of 80%. Considering the otherwise poor prognosis of these children the results are acceptable although the high relapse rate is still disappointing. We conclude that high-dose VP-16 and fTBI combined with ABMT is a curative treatment for some children and should therefore be considered for those who lack an HLA-identical sibling donor. In future better therapy concepts are needed either in pre-transplant conditioning regimens or in post-transplant treatment schedules.

Allogeneic bone marrow transplantation for a subset of children with acute lymphoblastic leukemia in third remission: a conceivable alternative?

In the BFM Relapse Study registry we retrospectively identified 136 patients with a first marrow relapse who had undergone BMT in second complete remission (CR2) (group A) and 33 patients who received transplants only after a 2nd bone marrow (BM) relapse had occurred (group B). Event-free survival (EFS) rates at 6 years after BMT were 0.49 +/- 0.05 and 0.48 +/- 0.09 for patients transplanted in CR2 and CR3, respectively. In context with the BFM chemotherapy trials for relapsed childhood ALL there is a clear benefit from BMT in 2nd CR for children with unfavorable prognostic features (isolated early BM relapse, very early BM relapse or BM relapse of T cell ALL). Similar control of leukemia can be achieved with either chemotherapy or BMT in late BM relapse of ALL. Assuming a 60% failure rate with chemotherapy for patients in second relapse, a third remission can be achieved in about 60% of patients who have received chemotherapy, rendering them eligible for BMT in 3rd CR. With this strategy 58% of these patients would survive and late sequelae of BMT be restricted to a minority. To withhold BMT in CR2 and not perform BMT before a 2nd BM relapse has occurred, may be a conceivable alternative for children with late ALL BM relapse, at least if no related donor is available.

Partial trisomy 1q, an uncommon chromosomal aberration in erythroleukemia.

A 2 years 4 months old boy with erythroleukemia (FAB-M6) and Down's syndrome is described. Chromosome analysis of bone marrow leukemic blasts revealed apart from the trisomy 21 a partial trisomy of the long arm of chromosome 1:1q23-->1qter in all cells and trisomy 8 mosaicism. To the best of our knowledge this is the first time that a partial trisomy of chromosome 1 in association with erythroleukemia has been described. Previous reports of other hematologic malignancies with aberrations of chromosome 1 indicate that the breakpoint 1q23 is nonrandom and that trisomies of chromosome 1 plays a crucial role in the course of development of hematologic malignancies. This could probably also be true for erythroleukemias.

The long-term perspective: a study of psychopathology and health status of patients with a history of depression more than 15 years after the first episode.

This article examines psychopathology, functioning, well-being, social support, and coping-behavior of family practice patients with a history of depressive illness, both with and without recurrences. Results of depressive patients were compared with each other and with those of "normal" controls. The patients belonged to the four practices of the Continuous Morbidity Registry of the University of Nijmegen, Netherlands. Their first episode of depression for each patient was more than 15 years ago. Data were collected with the Symptom Checklist (SCL-90) the RAND-36, the Social Support List (SSL-12), and the short Utrecht Coping List (UCL-k). Psychopathology scores of patients without recurrences were higher than "normal" controls and lower than patients with recurrences. The same pattern was found concerning health status. No significant differences were found between the groups in social support but patients with recurrences had a lower score of emotional coping than patients without recurrences or normal patients. That even a long time after an episode of depression, patients have higher levels of a variety of psychopathology than controls has implications for every-day practice as it calls for a longer and more critical follow-up of depression by clinicians.