A randomised controlled trial of feedback to improve patient satisfaction and consultation skills in medical students.

BACKGROUND: The use of feedback has been integral to medical student learning, but rigorous evidence to evaluate its education effect is limited, especially in the role of patient feedback in clinical teaching and practice improvement. The aim of the Patient Teaching Associate (PTA) Feedback Study was to evaluate whether additional written consumer feedback on patient satisfaction improved consultation skills among medical students and whether multisource feedback (MSF) improved student performance. METHODS: In this single site, double-blinded randomised controlled trial, 71 eligible medical students from two universities in their first clinical year were allocated to intervention or control and followed up for one semester. They participated in five simulated student-led consultations in a teaching clinic with patient volunteers living with chronic illness. Students in the intervention group received additional written feedback on patient satisfaction combined with guided self-reflection. The control group received usual immediate formative multisource feedback from tutors, patients and peers. Student characteristics, baseline patient-rated satisfaction scores and tutor-rated consultation skills were measured. RESULTS: Follow-up assessments were complete in 70 students attending the MSF program. At the final consultation episodes, both groups improved patient-rated rapport (P = 0.002), tutor-rated patient-centeredness and tutor-rated overall consultation skills (P = 0.01). The intervention group showed significantly better tutor-rated patient-centeredness (P = 0.003) comparing with the control group. Distress relief, communication comfort, rapport reported by patients and tutor-rated clinical skills did not differ significantly between the two groups. CONCLUSIONS: The innovative multisource feedback program effectively improved consultation skills in medical students. Structured written consumer feedback combined with guided student reflection further improved patient-centred practice and effectively enhanced the benefit of an MSF model. This strategy might provide a valuable adjunct to communication skills education for medical students. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry Number ACTRN12613001055796 .

How polymer additives reduce the pour point of hydrocarbon solvents containing wax crystals.

We have investigated how four different pour point depressant (PPD) polymers affect the pour point transition in mixtures of a single pure wax in a solvent. We used either n-eicosane (C20), CH3(CH2)18CH3, n-tetracosane (C24), CH3(CH2)22CH3 or n-hexatriacontane (C36), CH3(CH2)34CH3 as the wax component with either n-heptane or toluene as the solvent component. For all wax-solvent combinations, the measured variation of wax solubility with temperature is well predicted by ideal solution theory. The variation of pour point temperature as a function of the overall wax concentration is quantitatively modelled using the idea that, for each overall wax concentration, the pour point occurs at a temperature at which a critical volume fraction ϕ* of wax crystals has precipitated. Close to the pour point temperature, extraction and examination of the wax crystals show they consist of polydisperse, irregularly-shaped platelets with axial ratios (h/d, where h is the plate thickness and d is the plate long dimension) in the range 0.005-0.05. It is found that the measured ϕ* values corresponding to the pour point transitions are weakly correlated with the wax crystal axial ratios (h/d) for all wax-solvent-PPD polymer combinations. These results indicate that the pour point transition occurs at a volume fraction larger than the value at which the volumes of rotation of the platelet crystals overlap, i.e., 2.5(h/d) < ϕ* < 11(h/d). PPD polymers work, in part, by increasing the wax crystal axial ratio (h/d), thereby increasing ϕ* and reducing the pour point temperature. Since the PPD's ability to modify the wax crystal shape relies on its adsorption to the crystal-solution surface, it is anticipated and observed experimentally that optimum PPD efficacy is correlated with the difference between the wax and the polymer solubility boundary temperatures. This finding and the mechanistic insight gained here provide the basis for a simple and rapid screening test to identify candidate species likely to be effective PPDs for particular wax systems.

Meeting report: risk assessment of tamiflu use under pandemic conditions.

On 3 October 2007, 40 participants with diverse expertise attended the workshop Tamiflu and the Environment: Implications of Use under Pandemic Conditions to assess the potential human health impact and environmental hazards associated with use of Tamiflu during an influenza pandemic. Based on the identification and risk-ranking of knowledge gaps, the consensus was that oseltamivir ethylester-phosphate (OE-P) and oseltamivir carboxylate (OC) were unlikely to pose an ecotoxicologic hazard to freshwater organisms. OC in river water might hasten the generation of OC-resistance in wildfowl, but this possibility seems less likely than the potential disruption that could be posed by OC and other pharmaceuticals to the operation of sewage treatment plants. The work-group members agreed on the following research priorities: a) available data on the ecotoxicology of OE-P and OC should be published; b) risk should be assessed for OC-contaminated river water generating OC-resistant viruses in wildfowl; c) sewage treatment plant functioning due to microbial inhibition by neuraminidase inhibitors and other antimicrobials used during a pandemic should be investigated; and d) realistic worst-case exposure scenarios should be developed. Additional modeling would be useful to identify localized areas within river catchments that might be prone to high pharmaceutical concentrations in sewage treatment plant effluent. Ongoing seasonal use of Tamiflu in Japan offers opportunities for researchers to assess how much OC enters and persists in the aquatic environment.

Influenza virus susceptibility and resistance to oseltamivir.

Oseltamivir phosphate is a prodrug of oseltamivir carboxylate, a highly specific inhibitor of influenza virus neuraminidases. Given that oseltamivir carboxylate binds to highly conserved, essential amino acids in the catalytic site of the enzyme, and that the activity of neuraminidase is critical for virus release from infected cells and subsequent virus spread, the drug was expected to have a low propensity to select for viable resistant mutants. Indeed, viruses with neuraminidase (and haemagglutinin) substitutions conferring reduced susceptibility to oseltamivir have been generated with difficulty in vitro, and these mutants generally have reduced infectivity and transmissibility compared with wild-type virus in animal models. Studies of seasonal influenza isolates collected before the introduction of oseltamivir show an absence of naturally occurring resistance. Few resistant mutants have arisen during clinical trials of oseltamivir in seasonal influenza, with cumulative data from all Roche-sponsored studies indicating an incidence of resistance of 0.32% in adults (0.4%, including low-level mutants detected by genotyping alone in mixed virus populations) and 4.1% (5.4%) in children. Higher incidences of resistance were observed in two small Japanese studies, in which children received a different dosing schedule from their Western counterparts. In summary, the overall incidence of influenza virus resistance associated with the seasonal use of oseltamivir is currently low and resistant viruses might be of little clinical significance, except perhaps in immunocompromised individuals. However, continued vigilance, especially of emerging avian H5N1 strains, combined with careful, systematic laboratory-based monitoring, is essential.

Searching for a written patient feedback instrument for patient-medical student consultations.

OBJECTIVE: The Patient Teaching Associate (PTA) program at Eastern Health Clinical School uses volunteer patients with chronic illnesses in consultation-based medical student education. The PTA program aims to develop students' patient-centeredness and associated skills. Our study aims, 1) to identify key desirable characteristics of written patient feedback to doctors and/or students that focuses on patient-centeredness in consultations, and 2) to critically evaluate existing instruments to identify any suitable instrument for use for medical student teaching. METHODS: We reviewed our experience with the PTA program and explored the literature on patient-centeredness and patient feedback to identify desirable characteristics of written feedback for our program. A systematic search was conducted to identify existing patient feedback instruments. These were then evaluated in light of criteria based on desirable characteristics. RESULTS: Eight instruments met the inclusion criteria. While all were designed for patient use, none were ideal for the PTA program. The Doctors' Interpersonal Skills Questionnaire (DISQ), while not used with medical students, is the closest fit to criteria. CONCLUSION: The lack of instruments specifically designed for written patient feedback to medical students highlights a gap in the current literature. PRACTICE IMPLICATIONS: The DISQ provides a good basis for developing a new feedback instrument focused on patient-centeredness in medical students.

Clinical outcomes in a high nursing ratio ward setting for children with obstructive sleep apnea at high risk after adenotonsillectomy.

BACKGROUND: In 2012 clinical management of children having adenotonsillectomy (AT) for suspected obstructive sleep apnea (OSA) at our tertiary centre changed based on previous research: children with severe obstructive sleep apnea (OSA) at increased risk of post-operative respiratory adverse events (AE) identified using home overnight oximetry or polysomnography (PSG) were managed post-operatively in a high nurse/patient ratio unit in the ward (high acuity unit, HAU) rather than in the intensive care unit (ICU) as previously. OBJECTIVES: To examine the post-operative respiratory AE post AT in HAU. METHODS: A retrospective audit was performed of children having AT on the HAU list from Oct 2012-Sept 2014, identifying clinical information, pre-operative testing for OSA and post-operative course. RESULTS: 343 children underwent elective adenotonsillectomy at our tertiary centre in the study period, of whom 79 had surgery on the HAU list (16F; median age 4.2year (range 1.2-14.7); median weight-for-age centile 77.9% (IQR 44-98.7%)). 75 had moderate/severe OSA by oximetry (n=44) or PSG (n=31) criteria. 77 of 79 children had oxygen therapy in the recovery room (median 20min, IQR 15-40min). 18 (23%) had at least one AE outside the recovery room, which were observed (n=2) or treated with oxygen therapy (n=14) or repositioning (n=2). Obesity increased the risk of an AE (10/25 obese vs 8/54 non obese, p=0.01), as did the presence of a major comorbidity (5/9 with comorbidity vs 13/70 without, p=0.03). There were no admissions from the HAU to ICU. 63 patients (83%) stayed only one night in hospital (median 1d, range 1-5d). CONCLUSIONS: In a cohort of children with known moderate-severe OSA, post-operative AE after AT were all managed in the HAU. Post-operative care in HAU provides safe and effective care for high-risk children post-AT, minimizing admissions to ICU.

Effectiveness of patient feedback as an educational intervention to improve medical student consultation (PTA Feedback Study): study protocol for a randomized controlled trial.

BACKGROUND: Oral feedback from clinical educators is the traditional teaching method for improving clinical consultation skills in medical students. New approaches are needed to enhance this teaching model. Multisource feedback is a commonly used assessment method for learning among practising clinicians, but this assessment has not been explored rigorously in medical student education. This study seeks to evaluate if additional feedback on patient satisfaction improves medical student performance. METHODS: The Patient Teaching Associate (PTA) Feedback Study is a single site randomized controlled, double-blinded trial with two parallel groups.An after-hours general practitioner clinic in Victoria, Australia, is adapted as a teaching clinic during the day. Medical students from two universities in their first clinical year participate in six simulated clinical consultations with ambulatory patient volunteers living with chronic illness. Eligible students will be randomized in equal proportions to receive patient satisfaction score feedback with the usual multisource feedback and the usual multisource feedback alone as control. Block randomization will be performed. We will assess patient satisfaction and consultation performance outcomes at baseline and after one semester and will compare any change in mean scores at the last session from that at baseline. We will model data using regression analysis to determine any differences between intervention and control groups. Full ethical approval has been obtained for the study. This trial will comply with CONSORT guidelines and we will disseminate data at conferences and in peer-reviewed journals. DISCUSSION: This is the first proposed trial to determine whether consumer feedback enhances the use of multisource feedback in medical student education, and to assess the value of multisource feedback in teaching and learning about the management of ambulatory patients living with chronic conditions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613001055796.

Neuraminidase is important for the initiation of influenza virus infection in human airway epithelium.

Influenza virus neuraminidase (NA) plays an essential role in release and spread of progeny virions, following the intracellular viral replication cycle. To test whether NA could also facilitate virus entry into cell, we infected cultures of human airway epithelium with human and avian influenza viruses in the presence of the NA inhibitor oseltamivir carboxylate. Twenty- to 500-fold less cells became infected in drug-treated versus nontreated cultures (P < 0.0001) 7 h after virus application, indicating that the drug suppressed the initiation of infection. These data demonstrate that viral NA plays a role early in infection, and they provide further rationale for the prophylactic use of NA inhibitors.

A population-dynamic model for evaluating the potential spread of drug-resistant influenza virus infections during community-based use of antivirals.

A mathematical model of influenza transmission dynamics is used to simulate the impact of neuraminidase inhibitor therapy on infection rates and transmission of drug-resistant viral strains. The model incorporates population age structure, seasonal transmission, immunity and inclusion of elderly nursing home residents or non-residents. Key parameter values are estimated from epidemiological, clinical and experimental data. The analysis examines the factors determining the population spread of antiviral resistance, and predicts no significant transmission of neuraminidase inhibitor resistant virus. This conclusion is robust even at high therapy levels and under conservative assumptions regarding the likely frequency of transmission of resistant virus. The predicted incidence of resistance following protracted usage reflects primary drug resistance, currently estimated as approximately 2% for neuraminidase inhibitor therapy. It is also shown that until high levels of therapy are attained, early treatment of symptomatic cases is more efficient (per unit of drug) at preventing infections than prophylactic therapy.

Human and avian influenza viruses target different cell types in cultures of human airway epithelium.

The recent human infections caused by H5N1, H9N2, and H7N7 avian influenza viruses highlighted the continuous threat of new pathogenic influenza viruses emerging from a natural reservoir in birds. It is generally believed that replication of avian influenza viruses in humans is restricted by a poor fit of these viruses to cellular receptors and extracellular inhibitors in the human respiratory tract. However, detailed mechanisms of this restriction remain obscure. Here, using cultures of differentiated human airway epithelial cells, we demonstrated that influenza viruses enter the airway epithelium through specific target cells and that there were striking differences in this respect between human and avian viruses. During the course of a single-cycle infection, human viruses preferentially infected nonciliated cells, whereas avian viruses as well as the egg-adapted human virus variant with an avian virus-like receptor specificity mainly infected ciliated cells. This pattern correlated with the predominant localization of receptors for human viruses (2-6-linked sialic acids) on nonciliated cells and of receptors for avian viruses (2-3-linked sialic acids) on ciliated cells. These findings suggest that although avian influenza viruses can infect human airway epithelium, their replication may be limited by a nonoptimal cellular tropism. Our data throw light on the mechanisms of generation of pandemic viruses from their avian progenitors and open avenues for cell level-oriented studies on the replication and pathogenicity of influenza virus in humans.

Overexpression of the alpha-2,6-sialyltransferase in MDCK cells increases influenza virus sensitivity to neuraminidase inhibitors.

No reliable cell culture assay is currently available for monitoring human influenza virus sensitivity to neuraminidase inhibitors (NAI). This can be explained by the observation that because of a low concentration of sialyl-alpha2,6-galactose (Sia[alpha2,6]Gal)-containing virus receptors in conventional cell lines, replication of human virus isolates shows little dependency on viral neuraminidase. To test whether overexpression of Sia(alpha2,6)Gal moieties in cultured cells could make them suitable for testing human influenza virus sensitivity to NAI, we stably transfected MDCK cells with cDNA of human 2,6-sialyltransferase (SIAT1). Transfected cells expressed twofold-higher amounts of 6-linked sialic acids and twofold-lower amounts of 3-linked sialic acids than parent MDCK cells as judged by staining with Sambucus nigra agglutinin and Maackia amurensis agglutinin, respectively. After transfection, binding of a clinical human influenza virus isolate was increased, whereas binding of its egg-adapted variant which preferentially bound 3-linked receptors was decreased. The sensitivity of human influenza A and B viruses to the neuraminidase inhibitor oseltamivir carboxylate was substantially improved in the SIAT1-transfected cell line and was consistent with their sensitivity in neuraminidase enzyme assay and with the hemagglutinin (HA) receptor-binding phenotype. MDCK cells stably transfected with SIAT1 may therefore be a suitable system for testing influenza virus sensitivity to NAI.

Influenza viruses resistant to the antiviral drug oseltamivir: transmission studies in ferrets.

Three type A influenza viruses, each of which has a distinct neuraminidase-gene mutation and is resistant to the neuraminidase inhibitor oseltamivir, have been isolated. Previously, in the ferret model, an R292K mutant of a type A (H3N2) virus was not transmitted under conditions in which the wild-type virus was transmitted. This model was used to investigate whether the E119V mutant of a type A (H3N2) virus and the H274Y mutant of a type A (H1N1) virus would be transmitted under similar circumstances. Both mutant viruses were transmitted, although the H274Y mutant required a 100-fold-higher dose for infection of donor ferrets and was transmitted more slowly than was the wild type. Both the mutant and the wild-type viruses retained their genotypic characteristics.

Absence of cytomegalovirus-resistance mutations after valganciclovir prophylaxis, in a prospective multicenter study of solid-organ transplant recipients.

We investigated the emergence of cytomegalovirus (CMV) ganciclovir-resistance mutations in 301 high-risk solid-organ transplant (SOT) recipients after oral prophylaxis, for 100 days, with either valganciclovir or ganciclovir. For patients treated with ganciclovir, the incidence of CMV UL97 mutations was 1.9% (2/103) at the end of prophylaxis and 6.1% (2/33) for patients with suspected CMV disease up to 1 year after transplantation. No resistance mutations were detected in samples from valganciclovir-treated patients. Dual polymerase (UL54) and UL97 resistance mutations were not seen. Valganciclovir was associated with negligible risk of resistance and thus constitutes a useful alternative to ganciclovir prophylaxis for CMV in high-risk SOT recipients.