An Online Survey of Australian Medical Students' Perspectives on Spiritual History Taking and Spiritual Care.

It is reported that little spiritual care communication skills training occurs in Australian medical schools. This survey explored the experience of final year students in this domain in order to inform the construction of a new curriculum. Medical students in their final year at four Australian medical schools were invited to participate in an online survey, which included questions about demographic details, exposure to spiritual history taking, perceived learning needs, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being 12 item Non-Illness score. Two-hundred and sixty students from a cohort of 766 responded (34%). One in nine students had witnessed spiritual history taking, and one in ten students had been given the opportunity to do so. Barriers and enablers were identified. Two-thirds of the students reported no recollection of any training in spiritual care. When it did occur, it was limited in scope and structure. Final year medical students recognise that spiritual care deserves a place in the modern, broad-based medical school curriculum. This supports the argument for inclusion of spiritual care training as part of all medical student curricula in Australia.

Teaching spirituality to Canadian medical students: students' perceptions of a spiritual history taking clinical skills session.

Spirituality involves one's sense of purpose, connection with others, and ability to find meaning in life. We implemented a three-year pilot of a spiritual history taking (SHT) clinical skills session. In small groups, medical students discussed and practiced SHT with clinical scenarios and the FICA framework and received preceptor and peer feedback. Post-session focus groups and interviews demonstrated student perceptions of improved comfort, knowledge, and awareness of discussing spirituality with patients. This innovation may support improved clinical skills teaching across other health professions institutions to better prepare students to recognize patients' spiritual needs and provide more holistic, culturally competent care.

La spiritualité touche au sentiment d'avoir une raison d'être, à la relation à l'autre et à la capacité de trouver un sens à la vie1. Nous avons mis en place, comme projet pilote de trois ans, une séance visant l'acquisition de compétences cliniques portant sur l'anamnèse spirituelle (AS). En petits groupes, les étudiants discutaient de l'anamnèse spirituelle et la mettaient en pratique au moyen de scénarios cliniques et du questionnaire d'anamnèse spirituelle FICA2, puis recevaient des commentaires de la part de leur précepteur et de leurs pairs. Les groupes de discussion et les entretiens après les séances ont montré que les étudiants se sentaient mieux informés, plus à l'aise et plus conscients de la nécessité de parler de spiritualité avec les patients. Cette innovation peut contribuer à améliorer l'enseignement des compétences cliniques dans d'autres professions de la santé pour mieux préparer les étudiants à reconnaître les besoins spirituels des patients et à fournir des soins plus holistiques et culturellement adaptés.

Experiences of German health care professionals with spiritual history taking in primary care: a mixed-methods process evaluation of the HoPES3 intervention.

BACKGROUND: Spiritual needs gain importance in old age but are often ignored in health care. Within the 'Holistic care program for elderly patients to integrate spiritual needs, social activity and self-care into disease management in primary care (HoPES3)' a complex intervention was evaluated in a cluster-randomized trial. The aim of this study was to explore the acceptability, feasibility, benefits, and harms of a spiritual history taken by general practitioners (GPs) as part of the complex intervention. METHODS: In this mixed-methods study telephone interviews with 11 German GPs and 12 medical assistants (MAs) of the HoPES3 intervention group were conducted and analysed using a content-analytical approach. Furthermore, GPs were asked to complete a questionnaire after each spiritual history. One hundred and forty-one questionnaires from 14 GPs were analysed descriptively. RESULTS: GPs considered the spiritual history very/quite helpful for the patient in 27% (n= 38) and very/quite stressful in 2% (n = 3) of the cases. Interviews indicated that GPs found discussing spiritual history easier than anticipated. GPs and MAs saw a difficulty in that many patients associated spirituality with religion or church and reacted with surprise or rejection. Benefits for patients were seen in the opportunity to talk about non-medical topics, and increased awareness of their own resources. Benefits for GPs mainly related to information gain and an intensified patient-physician relationship. CONCLUSIONS: A spiritual history in general practice has the potential to reveal important information about patients' lives and to improve the patient-physician relationship. Implementation barriers identified in this study have to be considered and addressed.

Psicólogas(os) no sistema educacional de Boa Vista/Roraima: concepções, práticas e desafios / Psychologists in the educational system of Boa Vista/Roraima: conceptions, practices and challenges / Psicólogas(os) en el sistema educativo de Boa Vista/Roraima: concepciones, prácticas y retos

O objeto de estudo deste trabalho é a atuação de psicólogas(os) no campo da educação básica. Tivemos como objetivo investigar as práticas de atuação e os desafios enfrentados pelas(os) psicólogas(os) que trabalham na educação em Boa Vista (RR), com intuito de conhecer a inserção desses profissionais no sistema educacional. Trata-se de pesquisa qualitativa, orientada pelo referencial teórico-metodológico da Psicologia Escolar Crítica. Realizamos o processo de levantamento dos dados entre os meses de março e abril de 2018, por meio de entrevistas semiestruturadas, audiogravadas e transcritas. Encontramos 21 psicólogas e um psicólogo trabalhando em instituições educacionais e de ensino na cidade; a maioria atuava na educação básica; metade dos entrevistados ingressou por concurso público e a outra metade era contratada e comissionada; poucos(as) foram contratados(as) como psicólogos(as) escolares. Para a análise, selecionamos dez psicólogas(os) com mais tempo no cargo. Quanto às práticas de atuação, identificamos que 60% atuavam na modalidade clínica e 40% na modalidade clínica e institucional. Como desafios, encontramos melhoria das condições de trabalho; estabelecimento de relações hierárquicas e a dificuldade de fazer compreender as especificidades desse campo de trabalho; necessidade na melhoria das condições para formação continuada; atuação da(o) psicóloga(o) escolar enquanto ação institucional. Diante do exposto, compreendemos ser necessária uma mudança de paradigma na atuação das(os) psicólogas(os) que trabalham na educação na região, e a apropriação das discussões da área, principalmente, aquelas apresentadas pela Psicologia Escolar Crítica, vez que esta contribui para uma atuação que leve em conta os determinantes sociais, políticos, culturais e pedagógicos que constituem o processo de escolarização.(AU)

This work has as object of study the role of psychologists in the field of Basic Education. We aimed to investigate practices and challenges faced by psychologists who work in education in Boa Vista/RR, to know the insertion of these professionals in the educational system. This is a qualitative research, guided by the theoretical-methodological framework of Critical School Psychology. The data collection process was carried out between March and April 2018, with semi-structured, audio-recorded, and transcribed interviews. We found 21 female psychologists and one male psychologist working in educational institutions in the municipality; most worked in Basic Education; half of the interviewees had applied to work as government employee and the other half were hired and commissioned; few were hired as school psychologists. To carry out the analysis, we selected ten psychologists with more time in the position. Regarding the practices, we have identified that 60% worked in the clinical modality and 40% in the clinical and institutional modality. As challenges, we find the improvement in working conditions; the establishment of hierarchical relationships and the difficulty of making the specificities of this field of work understood; the need to improve conditions for continuing education; the practice of the school psychologist as institutional action. In view of the above, we understand that a paradigm shift in the performance of psychologists working in education in that region is necessary, and the appropriation of discussions in the area, especially those presented by Critical School Psychology, contributes to an action that considers social, political, cultural, and pedagogical determinants that constitute the schooling process.(AU)

Este trabajo tiene como objeto de estudio la actuación profesional de las(os) psicólogas(os) en la educación básica. Su objetivo es investigar las prácticas y retos que enfrentan las(os) psicólogas(os) que trabajan en la educación en Boa Vista, en Roraima (Brasil), con la intención de conocer la inserción de estos profesionales en el sistema educativo. Esta es una investigación cualitativa que se guía por el marco teórico-metodológico de la Psicología Escolar Crítica. Se recopilaron los datos entre los meses de marzo y abril de 2018, mediante entrevistas semiestructuradas, grabadas en audio y después transcritas. Las 21 psicólogas y un psicólogo trabajan en instituciones educativas de la ciudad; la mayoría trabajaba en la educación básica; la mitad de los entrevistados ingresaron mediante concurso público y la otra mitad era contratada y de puesto comisionado; pocos fueron contratados como psicólogos escolares. Para el análisis, se seleccionaron diez psicólogas(os) con más tiempo en el cargo. Con respecto a las prácticas, el 60% trabajaba en la modalidad clínica; y el 40%, en la modalidad clínica e institucional. Los retos son mejora de las condiciones laborales; establecimiento de relaciones jerárquicas y dificultad para comprender las especificidades de este campo de trabajo; necesidad de mejorar las condiciones para la educación continua; y actuación dela (del) psicóloga(o) escolar como acción institucional. En vista de lo anterior, es necesario el cambio de paradigma en la práctica profesional de las(os) psicólogas(os) que trabajan en la educación de la región y la apropiación de las discusiones del área, especialmente las presentadas por la Psicología Escolar Crítica, que contribuye a una acción que tiene en cuenta los determinantes sociales, políticos, culturales y pedagógicos que constituyen el proceso de escolarización.(AU)

Sexual history taking by doctors in primary care in North West province, South Africa: Patients at risk of sexual dysfunction overlooked.

BACKGROUND:  Sexual history taking seldom occurs during a chronic care consultation and this research focussed on consultation interaction factors contributing to failure of screening for sexual dysfunction. AIM:  This study aimed to quantify the most important barriers a patient and doctor experienced in discussing sexual challenges during the consultation and to assess the nature of communication and holistic practice of doctors in these consultations. SETTING:  The study was done in 10 primary care clinics in North West province which is a mix of rural and urban areas. METHODS:  One-hundred and fifty-five consultation recordings were qualitatively analysed in this grounded theory research. Doctors and patients completed self-administered questionnaires. A structured workplace-based assessment tool was used to assess the communication skills and holistic practice doctors. Template analysis and descriptive statistics were used for analysis. The quantitative component of the study was to strengthen the study by triangulating the data. RESULTS:  Twenty-one doctors participated in video-recorded routine consultations with 151 adult patients living with hypertension and diabetes, who were at risk of sexual dysfunction. No history taking for sexual dysfunction occurred. Consultations were characterised by poor communication skills and the lack of holistic practice. Patients identified rude doctors, shyness and lack of privacy as barriers to sexual history taking, whilst doctors thought that they had more important things to do with their limited consultation time. CONCLUSION:  Consultations were doctor-centred and sexual dysfunction in patients was entirely overlooked, which could have a negative effect on biopsychosocial well-being and potentially led to poor patient care.

Prevenção Quaternária: da medicalização social à atenção integral na Atenção Primária à Saúde / Prevención Cuaternaria: de la medicalización social a la atención integral en Atención Primaria de Salud / Quaternary Prevention: from social medicalization to integral care on the Primary Health Care

Resumo Objetivo conhecer as percepções e perspectivas dos profissionais da saúde para o desenvolvimento da Prevenção Quaternária na Atenção Primária à Saúde. Método Pesquisa Apreciativa, que aplicou as fases do "ciclo 4-D", na língua inglesa: discovery, dream, design e destiny. Este artigo analisa os resultados referentes à fase discovery (descoberta), de cujos dois encontros correspondentes participaram nove profissionais da Atenção Primária. Realizou-se análise de conteúdo, seguindo as etapas de pré-análise, exploração do material e tratamento dos dados. Resultados a Prevenção Quaternária representa uma potencialidade na inovação da atenção, com possibilidade de reduzir a medicalização social, que ocorre mediante a sobremedicalização, sobrediagnósticos e sobretratamentos. Como perspectivas, é apresentada a necessidade de conscientização da sociedade e dos profissionais sobre esses excessos e de (re) posicionamento da indústria, do mercado e da mídia sobre o significado de "estar saudável". Conclusão e implicações para prática é necessário atentar para a ética na prestação de cuidados quanto ao rastreio, diagnóstico e tratamento de doenças. A Prevenção Quaternária tem potencial para reverter um modelo hegemônico em relação ao cuidado de indivíduos e famílias ao fomentar a integralidade. A Enfermagem, como prestadora do cuidado, junto com a equipe multiprofissional, deve incorporar ações de Prevenção Quaternária em suas práticas.

Resumen Objetivo conocer las percepciones y perspectivas de los profesionales de la salud para el desarrollo de la Prevención Cuaternaria en Atención Primaria de Salud. Método Investigación Apreciativa, que aplicó las fases del "ciclo 4-D", en inglés: discovery, dream, design y destiny Este artículo analiza los resultados de la fase discovery (descubrimiento), en cuyos dos encuentros correspondientes participaron nueve profesionales de Atención Primaria. Se realizó análisis de contenido, siguiendo los pasos de pre-análisis, exploración de material y procesamiento de datos. Resultados la Prevención Cuaternaria representa un potencial en la innovación asistencial, con posibilidad de reducir la medicalización social, que se produce por sobremedicalización, sobrediagnóstico y sobretratamiento. Como perspectivas, se presenta la necesidad de concienciar a la sociedad y los profesionales sobre estos excesos y de (re) posicionar a la industria, el mercado y los medios de comunicación sobre el significado de "estar sano". Conclusión e implicaciones para la práctica es necesario prestar atención a la ética en la prestación de cuidados en cuanto al cribado, diagnóstico y tratamiento de enfermedades. La Prevención Cuaternaria tiene el potencial de revertir un modelo hegemónico en relación al cuidado de las personas y familias al promover la integralidad. La Enfermería, como proveedora de cuidados, junto con el equipo multidisciplinario, deben incorporar las acciones de Prevención Cuaternaria en sus prácticas.

Abstract Objective to know the perceptions and perspectives of health professionals for the development of Quaternary Prevention in Primary Health Care. Method an Appreciative Research, which applied the phases of the "4-D cycle": discovery, dream, design and destiny. This article analyzes the results referring to the discovery phase (discovery), in which nine professionals from Primary Care participated in two corresponding meetings. Content analysis was performed, following the steps of pre-analysis, material exploration and data treatment. Results the Quaternary Prevention represents a potentiality in care innovation, with the possibility of reducing social medicalization, which occurs through over-medicalization, over-diagnosis and overtreatment. As perspectives, it is presented the need for society and professionals to be aware of these excesses and the (re) positioning of the industry, market and media about the meaning of "being healthy". Conclusion and implications for the practice it is necessary to pay attention to ethics in care provision regarding screening, diagnosis and treatment of diseases. Quaternary Prevention has potential to revert a hegemonic model in relation to the care of individuals and families by promoting integrality. Nursing, as a care provider, together with the multi-professional team, must incorporate Quaternary Prevention actions in its practices.

Top-down, bottom-up, and history-driven processing of multisensory attentional cues in intellectual disability: An experimental study in virtual reality.

Models of attention demonstrated the existence of top-down, bottom-up, and history-driven attentional mechanisms, controlled by partially segregated networks of brain areas. However, few studies have examined the specific deficits in those attentional mechanisms in intellectual disability within the same experimental setting. The aim of the current study was to specify the attentional deficits in intellectual disability in top-down, bottom-up, and history-driven processing of multisensory stimuli, and gain insight into effective attentional cues that could be utilized in cognitive training programs for intellectual disability. The performance of adults with mild to moderate intellectual disability (n = 20) was compared with that of typically developing controls (n = 20) in a virtual reality visual search task. The type of a spatial cue that could aid search performance was manipulated to be either endogenous or exogenous in different sensory modalities (visual, auditory, tactile). The results identified that attentional deficits in intellectual disability are overall more pronounced in top-down rather than in bottom-up processing, but with different magnitudes across cue types: The auditory or tactile endogenous cues were much less effective than the visual endogenous cue in the intellectual disability group. Moreover, the history-driven processing in intellectual disability was altered, such that a reversed priming effect was observed for immediate repetitions of the same cue type. These results suggest that the impact of intellectual disability on attentional processing is specific to attentional mechanisms and cue types, which has theoretical as well as practical implications for developing effective cognitive training programs for the target population.

Etiopatogenia de las uñas frágiles / Etiopathogenesis of brittle nails

Las uñas frágiles se caracterizan por ser quebradizas, de superficie áspera y descamativa, es una entidad que predomina en mujeres y afecta principalmente las uñas de las manos. En condiciones normales las uñas estás compuestas por agua, cuya concentración oscila entre 7 % al 18 %, lípidos entre 0,1 % y 5%, siendo el colesterol su principal componente, además están compuesta por células queratinizadas sin descamación, dando origen a tres capas histológicas llamadas dorsal, media y ventral. Estas también contienen trazas de elementos como hierro y zinc. La alteración y disminución de estos componentes favorecen está condición. La causa puede ser idiopática o secundaria a enfermedades sistémicas, pueden estar presentes en algunas patologías dermatológicas. Una correcta anamnesis e historia clínica son necesarias para un correcto abordaje terapéutico. Su implicación cosmética nos obliga a tener un conocimiento claro de su etiopatogenia para así poder establecer un tratamiento efectivo y oportuno(AU)

Brittle nails are characterized by being brittle, witha rough and scaly surface, it is an entity that predominates inwomen and mainly affects the fingernails. In normal conditions the nails are made up of water, whose concentration ranges from7% to 18%, lipids between 0.1% and 5%, with cholesterol beingits main component, they are also composed of keratinized cellswithout desquamation, giving rise to three histological layerscalled dorsal, middle and ventral. These also contain traces ofelements such as iron, and zinc. The alteration and decreaseof these components favor this condition. Yhe cause may beidiopathic or secondary to systemic diseases, they may be presentin some dermatological pathologies. A correct anamnesis andmedical history are necessary for a correct therapeutic approach.Its cosmetic involvement forces us to have a clear understandingof its pathogenesis in order to establish an effective and timelytreatment(AU)

Hereditary Cancer Risk Using a Genetic Chatbot Before Routine Care Visits.

OBJECTIVE: To examine user uptake and experience with a clinical chatbot that automates hereditary cancer risk triage by collecting personal and family cancer history in routine women's health care settings. METHODS: We conducted a multicenter, retrospective observational study of patients who used a web-based chatbot before routine care appointments to assess their risk for hereditary breast and ovarian cancer, Lynch syndrome, and adenomatous polyposis syndromes. Outcome measures included uptake and completion of the risk-assessment and educational section of the chatbot interaction and identification of hereditary cancer risk as evaluated against National Comprehensive Cancer Network criteria. RESULTS: Of the 95,166 patients invited, 61,070 (64.2%) engaged with the clinical chatbot. The vast majority completed the cancer risk assessment (89.4%), and most completed the genetic testing education section (71.4%), indicating high acceptability among those who opted to engage. The mean duration of use was 15.4 minutes (SD 2 hours, 56.2 minutes) when gaps of inactivity longer than 5 minutes were excluded. A personal history of cancer was reported by 19.1% (10,849/56,656) and a family history of cancer was reported by 66.7% (36,469/54,652) of patients who provided the relevant information. One in four patients (14,850/54,547) screened with the chatbot before routine care appointments met National Comprehensive Cancer Network criteria for genetic testing. Among those who were tested, 5.6% (73/1,313) had a disease-causing pathogenic variant. CONCLUSION: A chatbot digital health tool can help identify patients at high risk for hereditary cancer syndromes before routine care appointments. This scalable intervention can effectively provide cancer risk assessment, engage patients with educational information, and facilitate a path toward preventive genetic testing. FUNDING SOURCE: Implementation of the chatbot in clinics was funded by industry support from commercial genetic testing laboratories Ambry, Invitae, and Progenity.

Factors leading to neonatal mortality due to neonatal purpura fulminans through the lens of a child death review.

A case of neonatal death due to neonatal purpura fulminans (NPF) was brought to community physicians' notice by the auxiliary nurse midwife in her catchment area as part of the routine demographic health surveillance. The community physician then conducted the child death review in the community. The neonate was born out of consanguineous marriage (mother married to her first-degree maternal cousin) with spontaneous conception. This neonate was fourth in the birth order. The second-order and third-order births had also suffered from NPF and died. The baby was delivered in a tertiary care setting, and the paediatric surgeon planned debridement of the affected part on the third day of the birth, as per the mother. However, due to inadequate counselling regarding the procedure, mother left the hospital without seeking care against medical advice, and the child died at home.

Interexaminer Agreement and Reliability of an Internationally Endorsed Screening Framework for Cervical Vascular Risks Following Manual Therapy and Exercise: The Go4Safe Project.

OBJECTIVE: Clinicians are recommended to use the clinical reasoning framework developed by the International Federation of Orthopaedic Manipulative Physical Therapists (IFOMPT) to provide guidance regarding assessment of the cervical spine and potential for cervical artery dysfunction prior to manual therapy and exercise. However, the interexaminer agreement and reliability of this framework is unknown. This study aimed to estimate the interexaminer agreement and reliability of the IFOMPT framework among physical therapists in primary care. METHODS: Ninety-six patients who consulted a physical therapist for neck pain or headache were included in the study. Each patient was tested independently by 2 physical therapists, from a group of 17 physical therapists (10 pairs) across The Netherlands. Patients and examiners were blinded to the test results. The overall interexaminer agreement, specific agreement per risk category (high-, intermediate-, and low-risk), and interexaminer reliability (weighted κ) were calculated. RESULTS: Overall agreement was 71% (specific agreement in high-risk category = 63%; specific agreement in intermediate-risk category = 38%; specific agreement in low-risk category = 84%). Overall reliability was moderate (weighted κ = 0.39; 95% CI = 0.21-0.57) and varied considerably between pairs of physical therapists (κ = 0.14-1.00). CONCLUSION: The IFOMPT framework showed an insufficient interexaminer agreement and fair interexaminer reliability among physical therapists when screening the increased risks for vascular complications following manual therapy and exercise prior to treatment. IMPACT: The IFOMPT framework contributes to the safety of manual therapy and exercise. It is widely adopted in clinical practice and educational programs, but the measurement properties are unknown. This project describes the agreement and reliability of the IFOMPT framework.

Interventions for improving medical students' interpersonal communication in medical consultations.

BACKGROUND: Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies. OBJECTIVES: To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations. SEARCH METHODS: We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE. MAIN RESULTS: We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Intensive Medical Nutrition Therapy Alone or with Added Metformin to Prevent Gestational Diabetes Mellitus among High-Risk Mexican Women: A Randomized Clinical Trial.

The aim of this study was to examine the efficacy of intensive medical nutrition therapy (MNT) plus metformin in preventing gestational diabetes mellitus (GDM) among high-risk Mexican women. An open-label randomized clinical trial was conducted. Inclusion criteria were pregnant women with three or more GDM risk factors: Latino ethnic group, maternal age >35 years, body mass index >25 kg/m2, insulin resistance, and a history of previous GDM, prediabetes, a macrosomic neonate, polycystic ovarian syndrome, or a first-degree relative with type 2 diabetes. Women before 15 weeks of gestation were assigned to group 1 (n = 45): intensive MNT-plus metformin (850 mg twice/day) or group 2 (n = 45): intensive MNT without metformin. Intensive MNT included individual dietary counseling, with ≤50% of total energy from high carbohydrates. The primary outcome was the GDM incidence according to the International Association of Diabetes Pregnancy Study Groups criteria. There were no significant differences in baseline characteristics and adverse perinatal outcomes between the groups. The GDM incidence was n = 11 (24.4%) in the MNT plus metformin group versus n = 7 (15.5%) in the MNT without metformin group: p = 0.42 (RR: 1.57 [95% CI: 0.67-3.68]). There is no benefit in adding metformin to intensive MNT to prevent GDM among high-risk Mexican women. Clinical trials registration: NCT01675310.

Obesity, Diabetes, Coffee, Tea, and Cannabis Use Alter Risk for Alcohol-Related Cirrhosis in 2 Large Cohorts of High-Risk Drinkers.

INTRODUCTION: Sustained high alcohol intake is necessary but not sufficient to produce alcohol-related cirrhosis. Identification of risk factors, apart from lifetime alcohol exposure, would assist in discovery of mechanisms and prediction of risk. METHODS: We conducted a multicenter case-control study (GenomALC) comparing 1,293 cases (with alcohol-related cirrhosis, 75.6% male) and 754 controls (with equivalent alcohol exposure but no evidence of liver disease, 73.6% male). Information confirming or excluding cirrhosis, and on alcohol intake and other potential risk factors, was obtained from clinical records and by interview. Case-control differences in risk factors discovered in the GenomALC participants were validated using similar data from 407 cases and 6,573 controls from UK Biobank. RESULTS: The GenomALC case and control groups reported similar lifetime alcohol intake (1,374 vs 1,412 kg). Cases had a higher prevalence of diabetes (20.5% (262/1,288) vs 6.5% (48/734), P = 2.27 × 10-18) and higher premorbid body mass index (26.37 ± 0.16 kg/m2) than controls (24.44 ± 0.18 kg/m2, P = 5.77 × 10-15). Controls were significantly more likely to have been wine drinkers, coffee drinkers, smokers, and cannabis users than cases. Cases reported a higher proportion of parents who died of liver disease than controls (odds ratio 2.25 95% confidence interval 1.55-3.26). Data from UK Biobank confirmed these findings for diabetes, body mass index, proportion of alcohol as wine, and coffee consumption. DISCUSSION: If these relationships are causal, measures such as weight loss, intensive treatment of diabetes or prediabetic states, and coffee consumption should reduce the risk of alcohol-related cirrhosis.

Gynecologic Considerations for the Urologic Surgeon.

While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery. An understanding of basic tests, such as a transvaginal sonogram, can help urologists provide comprehensive care.

Approach to Patients with Unintentional Weight Loss.

Unintentional weight loss is a common clinical problem with a broad differential diagnosis that is clinically important because of the associated risks of morbidity and mortality. Community-dwelling adults are often diagnosed with malignancy, nonmalignant gastrointestinal disorders, and psychiatric disorders as the cause of unintentional weight loss, whereas institutionalized older adults are diagnosed most often with psychiatric disorders. Up to a quarter of patients do not have a diagnosis after comprehensive workup, and close follow-up is warranted. Treatment involves management of underlying causes.

Family Health History-Based Cancer Prevention Training for Community Health Workers.

Cancer is the second leading cause of death in the U.S. Utilizing family health history in cancer prevention holds promise in lessening the burden of cancer. Nevertheless, family health history is underutilized in public health and preventive medicine. Community health workers, also known as lay health educators, are ideal candidates to offer basic cancer family history-based education and services to the general public. The authors developed the first cancer family history-based genomics training program in cancer prevention tailored for community health workers. This paper details the development and pilot testing findings of the training. Specifically, a multidisciplinary research team of geneticists, genetic counselors, health educators, community health workers, and community health worker instructors developed a 7-module, 6-hour, bilingual (English and Spanish) cancer family history-based training focusing on cancer family history-based risk assessment, lifestyle recommendations, and genetic evaluation and testing. The curriculum was based on an integrated theoretical framework, the National Comprehensive Cancer Network guidelines, the community health worker core competencies, and the 4MAT instructional model. The Texas Department of State Health Services approved and certified the curriculum with 2 delivery formats: in-person/face-to-face workshops and online training. A total of 34 community health workers completed the pilot training in person (n=17) and online (n=17) in 2018 and 2019. Participating community health workers' knowledge, attitudes, self-efficacy, and intention in delivering basic cancer family history-based genomics education and services significantly increased on the immediate post-test measures compared with their pretest data. Positive ratings and feedback were also reported by the community health workers. Findings from this pilot study suggest that wider training is warranted for educating more community health workers in the U.S.

A construção de competências nas etapas iniciais da formação médica: Um relato de experiência / The building of skills in the initial stages of medical training: An experience report

Introdução: A graduação em Medicina tem passado por diversas mudanças curriculares, com transferência gradativa do ensino tradicional para metodologias ativas, as quais preconizam a aprendizagem significativa e a participação ativa dos discentes. Orientado pelas Diretrizes Curriculares Nacionais vigentes, o curso de graduação em Medicina da Universidade Federal do Pampa (UNIPAMPA), contempla essa nova perspectiva formativa. Apresenta como foco as construções de competências médicas, desenvolvidas desde etapas iniciais do curso, com ênfase no vínculo entre teoria e prática. Método: O presente estudo aborda um relato de experiência e tem por objetivo refletir acerca da implementação da disciplina "Introdução à Psicologia e Habilidades Médicas" (IPHM). Resultados: Por meio das atividades do referido componente curricular, é ofertado desde o primeiro semestre o contato dos discentes com a entrevista médica, com ênfase na construção da anamnese e na compreensão dos aspectos relacionais e comunicacionais englobados. Ainda que outras instituições desenvolvam a construção de aspectos relacionados à anamnese médica em fases iniciais, o curso de Medicina da Unipampa apresenta inovações na forma como conduz esse trabalho, com emprego de metodologias ativas associadas às situações clínicas simuladas (Role-play), com foco tanto na redação, como nas relações interpessoais e qualidade da comunicação na relação médico-paciente. Conclusões: Por meio da abordagem dos desafios e potencialidades do processo de implementação do referido componente curricular, cumpre reconhecer a adequação e a pertinência da experiência, no sentido de estabelecer um espaço de construção de competências profissionais para a entrevista médica, em momento inicial da formação acadêmica.

Introduction: Graduation in Medicine has experienced several changes in the training curriculum, by changing from the traditional way of teaching to active methodologies, providing meaningful learning and active participation by students. Guided by the National Curriculum Guidelines, the undergraduate course in Medicine, from the Federal University of Pampa (Unipampa), contemplates this new formative perspective, through curricular innovations in the methodological and organizational fields. It focuses on the construction of medical skills, developed since the initial stages of the course, with emphasis on the link between theory and practice. Method: This study is an experience report, with a qualitative approach and aims to reflect on the implementation of the IPHM discipline. Results: Through the activities of this curricular component, student´s contact with the medical interview is offered in the first semester, emphasis on the construction off the anamnesis and the knowlegment of its relational and communicational aspects. Although other academies develop the construction of aspects related to medical anamnesis in early stages, the Unipampa's Medicine course introduced a inovation in the way that conducts it's work, using active methodologies associated with simulated clinical situations (Roleplay), focusing both writing, interpersonal relationship and quality of communication between doctor and patient. Conclusions: Through addressing the challenges and potentialities of the implementation process of the said curricular component, it is important to recognize the adequacy and relevance of the experience, in order to establish a space for the construction of professional skills for the medical interview, at the beginning of academic training.