Autonomic nervous system activity as risk predictor in the medical emergency department: a prospective cohort study.

OBJECTIVES: To evaluate heart rate deceleration capacity, an electrocardiogram-based marker of autonomic nervous system activity, as risk predictor in a medical emergency department and to test its incremental predictive value to the modified early warning score. DESIGN: Prospective cohort study. SETTING: Medical emergency department of a large university hospital. PATIENTS: Five thousand seven hundred thirty consecutive patients of either sex in sinus rhythm, who were admitted to the medical emergency department of the University of Tübingen, Germany, between November 2010 and March 2012. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Deceleration capacity of heart rate was calculated within the first minutes after emergency department admission. The modified early warning score was assessed from respiratory rate, heart rate, systolic blood pressure, body temperature, and level of consciousness as previously described. Primary endpoint was intrahospital mortality; secondary endpoints included transfer to the ICU as well as 30-day and 180-day mortality. One hundred forty-two patients (2.5%) reached the primary endpoint. Deceleration capacity was highly significantly lower in nonsurvivors than survivors (2.9 ± 2.1 ms vs 5.6 ± 2.9 ms; p < 0.001) and yielded an area under the receiver-operator characteristic curve of 0.780 (95% CI, 0.745-0.813). The modified early warning score model yielded an area under the receiver-operator characteristic curve of 0.706 (0.667-0.750). Implementing deceleration capacity into the modified early warning score model led to a highly significant increase of the area under the receiver-operator characteristic curve to 0.804 (0.770-0.835; p < 0.001 for difference). Deceleration capacity was also a highly significant predictor of 30-day and 180-day mortality as well as transfer to the ICU. CONCLUSIONS: Deceleration capacity is a strong and independent predictor of short-term mortality among patients admitted to a medical emergency department.

Urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) and proteinuria predict severity of acute kidney injury in Puumala virus infection.

BACKGROUND: Nephropathia epidemica (NE) is a mild form of hemorrhagic fever with renal syndrome (HFRS) that is caused by the Puumala virus. Periodic outbreaks have been described in endemic areas, with a substantial number of previously healthy individuals developing acute kidney injury (AKI). There is a considerable diversity in the clinical course of the disease, and few patients require renal replacement therapy. METHODS: We tested whether urinary neutrophil gelatinase associated lipocalin (uNGAL), urine albumin/creatinine ratio (uACR), urine protein/creatinine ratio (uPCR), urine dipstick protein, C-reactive protein, procalcitonin, leukocyte and platelet count, determined on admission to the hospital, can predict the severity of AKI. Sixty-one patients were analyzed during admission in the emergency department. RESULTS: The variables most strongly associated with peak plasma creatinine concentration were uNGAL (ß = 0.70, p <0.0001), uPCR (ß = 0.64, p = 0.001), uACR (ß = 0.61, p = 0.002), and dipstick proteinuria (ß = 0.34, p = 0.008). The highest AUC-ROC to predict stage 3 AKI according to the acute kidney injury network's (AKIN) classification was seen for uNGAL (0.81, p = 0.001). CONCLUSION: uNGAL accurately predicts the severity of AKI in NE. This could help emergency room physicians predict disease severity and allow for initial risk stratification.

The benefit of repetitive skills training and frequency of expert feedback in the early acquisition of procedural skills.

BACKGROUND: Redundant training and feedback are crucial for successful acquisition of skills in simulation trainings. It is still unclear how or how much feedback should best be delivered to maximize its effect, and how learners' activity and feedback are optimally blended. To determine the influence of high- versus low-frequency expert feedback on the learning curve of students' clinical procedural skill acquisition in a prospective randomized study. METHODS: N = 47 medical students were trained to insert a nasogastric tube in a mannequin, including structured feedback in the initial instruction phase at the beginning of the training (T1), and either additional repetitive feedback after each of their five subsequent repetitions (high-frequency feedback group, HFF group; N = 23) or additional feedback on just one occasion, after the fifth repetition only (low-frequency feedback group, LFF group; N = 24). We assessed a) task-specific clinical skill performance and b) global procedural performance (five items of the Integrated Procedural Performance Instrument (IPPI); on the basis of expert-rated videotapes at the beginning of the training (T1) and during the final, sixth trial (T2). RESULTS: The two study groups did not differ regarding their baseline data. The calculated ANOVA for task-specific clinical skill performance with the between-subject factor 'Group' (HFF vs. LFF) and within-subject factors 'Time' (T1 vs. T2) turned out not to be significant (p < .147). An exploratory post-hoc analyses revealed a trend towards a superior performance of HFF compared to LFF after the training (T2; p < .093), whereas both groups did not differ at the beginning (T1; p < .851). The smoothness of the procedure assessed as global procedural performance, was superior in HFF compared to LFF after the training (T2; p < .004), whereas groups did not differ at the beginning (T1; p < .941). CONCLUSION: Deliberate practice with both high- and low-frequency intermittent feedback results in a strong improvement of students' early procedural skill acquisition. High-frequency intermittent feedback, however, results in even better and smoother performance. We discuss the potential role of the cognitive workload on the results. We advocate a thoughtful allocation of tutor resources to future skills training.

Voluntary undergraduate technical skills training course to prepare students for clerkship assignment: tutees' and tutors' perspectives.

BACKGROUND: Skills lab training has become a widespread tool in medical education, and nowadays, skills labs are ubiquitous among medical faculties across the world. An increasingly prevalent didactic approach in skills lab teaching is peer-assisted learning (PAL), which has been shown to be not only effective, but can be considered to be on a par with faculty staff-led training. The aim of the study is to determine whether voluntary preclinical skills teaching by peer tutors is a feasible method for preparing medical students for effective workplace learning in clerkships and to investigate both tutees' and tutors' attitudes towards such an intervention. METHODS: A voluntary clerkship preparation skills course was designed and delivered. N = 135 pre-clinical medical students visited the training sessions. N = 10 tutors were trained as skills-lab peer tutors. Voluntary clerkship preparation skills courses as well as tutor training were evaluated by acceptance ratings and pre-post self-assessment ratings. Furthermore, qualitative analyses of skills lab tutors' attitudes towards the course were conducted following principles of grounded theory. RESULTS: Results show that a voluntary clerkship preparation skills course is in high demand, is highly accepted and leads to significant changes in self-assessment ratings. Regarding qualitative analysis of tutor statements, clerkship preparation skills courses were considered to be a helpful and necessary asset to preclinical medical education, which benefits from the tutors' own clerkship experiences and a high standardization of training. Tutor training is also highly accepted and regarded as an indispensable tool for peer tutors. CONCLUSIONS: Our study shows that the demand for voluntary competence-oriented clerkship preparation is high, and a peer tutor-led skills course as well as tutor training is well accepted. The focused didactic approach for tutor training is perceived to be effective in preparing tutors for their teaching activity in this context. A prospective study design would be needed to substantiate the results objectively and confirm the effectiveness.

Communication training for advanced medical students improves information recall of medical laypersons in simulated informed consent talks--a randomized controlled trial.

BACKGROUND: Informed consent talks are mandatory before invasive interventions. However, the patients' information recall has been shown to be rather poor. We investigated, whether medical laypersons recalled more information items from a simulated informed consent talk after advanced medical students participated in a communication training aiming to reduce a layperson's cognitive load. METHODS: Using a randomized, controlled, prospective cross-over-design, 30 5th and 6th year medical students were randomized into two groups. One group received communication training, followed by a comparison intervention (early intervention group, EI); the other group first received the comparison intervention and then communication training (late intervention group, LI). Before and after the interventions, the 30 medical students performed simulated informed consent talks with 30 blinded medical laypersons using a standardized set of information. We then recorded the number of information items the medical laypersons recalled. RESULTS: After the communication training both groups of medical laypersons recalled significantly more information items (EI: 41 ± 9% vs. 23 ± 9%, p < .0001, LI 49 ± 10% vs. 35 ± 6%, p < .0001). After the comparison intervention the improvement was modest and significant only in the LI (EI: 42 ± 9% vs. 40 ± 9%, p = .41, LI 35 ± 6% vs. 29 ± 9%, p = .016). CONCLUSION: Short communication training for advanced medical students improves information recall of medical laypersons in simulated informed consent talks.

Prepackaged central line kits reduce procedural mistakes during central line insertion: a randomized controlled prospective trial.

BACKGROUND: Central line catheter insertion is a complex procedure with a high cognitive load for novices. Providing a prepackaged all-inclusive kit is a simple measure that may reduce the cognitive load. We assessed whether the use of prepackaged all-inclusive central line insertion kits reduces procedural mistakes during central line catheter insertion by novices. METHODS: Thirty final year medical students and recently qualified physicians were randomized into two equal groups. One group used a prepackaged all-inclusive kit and the other used a standard kit containing only the central vein catheter and all other separately packaged components provided in a materials cart. The procedure was videotaped and analyzed by two blinded raters using a checklist. Both groups performed central line catheter insertion on a manikin, assisted by nursing students. RESULTS: The prepackaged kit group outperformed the standard kit group in four of the five quality indicators: procedure duration (26:26 ± 3:50 min vs. 31:27 ± 5:57 min, p = .01); major technical mistakes (3.1 ± 1.4 vs. 4.8 ± 2.6, p = .03); minor technical mistakes (5.2 ± 1.7 vs. 8.0 ± 3.2, p = .01); and correct steps (83 ± 5% vs. 75 ± 11%, p = .02). The difference for breaches of aseptic technique (1.2 ± 0.8 vs. 3.0 ± 3.6, p = .06) was not statistically significant. CONCLUSIONS: Prepackaged all-inclusive kits for novices improved the procedure quality and saved staff time resources in a controlled simulation environment. Future studies are needed to address whether central line kits also improve patient safety in hospital settings.

Isolation, bulk cultivation, and characterization of coronary microvascular pericytes: the second most frequent myocardial cell type in vitro.

Densely arranged pericytes engird the endothelial tube of all coronary microvessels. Since the experimental access to these abundant cells in situ is difficult, a prerequisite for broader investigation is the availability of sufficient numbers of fully differentiated pericytes in homogenous culture. To reach this goal, we applied strictly standardized cell isolation techniques, optimized culture methods and specific histological staining. Approximately 1,000-fold enriched pericytes were proteolytically detached from highly purified coronary microvascular networks (density gradient centrifugation) of eight mammalian species including human. Addition of species-autologous fetal or neonatal serum (10-20% vol/vol) was a precondition for longer term survival of homogenous pericyte cultures. This ensured optimal growth (doubling time <14 h) and full expression of pericyte-specific markers. In 3-mo, 10(10) pericytes (15 g) could be cultivated from 1 bovine heart. Pericytes could be stored in liquid N(2), recultured, and passaged repeatedly without loss of typical features. In cocultures with EC or vascular smooth muscle cells, pericytes transferred fluorescent calcein to each other and to EC via their antler-like extensions, organized angiogenetic sprouting of vessels, and rapidly activated coagulation factors X and II via tissue factor and prothrombinase. The interconnected pericytes of the coronary system are functionally closely correlated with the vascular endothelium and may play key roles in the adjustment of local blood flow, the regulation of angiogenic processes, and the induction of procoagulatory processes. Their successful bulk cultivation enables direct experimental access under defined in vitro conditions and the isolation of pericyte specific antigens for the production of specific antibodies.

Does doctors' workload impact supervision and ward activities of final-year students? A prospective study.

BACKGROUND: Hospital doctors face constantly increasing workloads. Besides caring for patients, their duties also comprise the education of future colleagues. The aim of this study was to objectively investigate whether the workload arising from increased patient care interferes with student supervision and is associated with more non-medical activities of final-year medical students. METHODS: A total of 54 final-year students were asked to keep a diary of their daily activities over a three-week period at the beginning of their internship in Internal Medicine. Students categorized their activities--both medical and non-medical--according to whether they had: (1) only watched, (2) assisted the ward resident, (3) performed the activity themselves under supervision of the ward resident, or (4) performed the activity without supervision. The activities reported on a particular day were matched with a ward specific workload-index derived from the hospital information system, including the number of patients treated on the corresponding ward on that day, a correction factor according to the patient comorbidity complexity level (PCCL), and the number of admissions and discharges. Both students and ward residents were blinded to the study question. RESULTS: A total of 32 diaries (59 %, 442 recorded working days) were handed back. Overall, the students reported 1.2 ± 1.3 supervised, 1.8 ± 1.6 medical and 3.6 ± 1.7 non-medical activities per day. The more supervised activities were reported, the more the number of reported medical activities increased (p < .0001). No relationship between the ward specific workload and number of medical activities could be shown. CONCLUSIONS: There was a significant association between ward doctors' supervision of students and the number of medical activities performed by medical students. The workload had no significant effect on supervision or the number of medical or non-medical activities of final-year students.

Student tutors for hands-on training in focused emergency echocardiography--a randomized controlled trial.

BACKGROUND: Focused emergency echocardiography performed by non-cardiologists has been shown to be feasible and effective in emergency situations. During resuscitation a short focused emergency echocardiography has been shown to narrow down potential differential diagnoses and to improve patient survival. Quite a large proportion of physicians are eligible to learn focused emergency echocardiography. Training in focused emergency echocardiography usually comprises a lecture, hands-on trainings in very small groups, and a practice phase. There is a shortage of experienced echocardiographers who can supervise the second step, the hands-on training. We thus investigated whether student tutors can perform the hands-on training for focused emergency echocardiography. METHODS: A total of 30 volunteer 4th and 5th year students were randomly assigned to a twelve-hour basic echocardiography course comprising a lecture followed by a hands-on training in small groups taught either by an expert cardiographer (EC) or by a student tutor (ST). Using a pre-post-design, the students were evaluated by an OSCE. The students had to generate two still frames with the apical five-chamber view and the parasternal long axis in five minutes and to correctly mark twelve anatomical cardiac structures. Two blinded expert cardiographers rated the students' performance using a standardized checklist. Students could achieve a maximum of 25 points. RESULTS: Both groups showed significant improvement after the training (p < .0001). In the group taught by EC the average increased from 2.3±3.4 to 17.1±3.0 points, and in the group taught by ST from 2.7±3.0 to 13.9±2.7 points. The difference in improvement between the groups was also significant (p = .03). CONCLUSIONS: Hands-on training by student tutors led to a significant gain in echocardiography skills, although inferior to teaching by an expert cardiographer.

Effects of Peyton's four-step approach on objective performance measures in technical skills training: a controlled trial.

BACKGROUND: Although skills-lab training is widely used for training undergraduates in technical procedures, the way in which clinical skills are to be used and instructed remains a matter of debate. PURPOSE: We conducted a randomized controlled trial to evaluate the learning outcome of two different instructional approaches in the context of acquiring procedural-technical skills. METHODS: Volunteer 2nd- and 3rd-year medical students were randomly assigned to an intervention group receiving instruction according to Peyton's Four-Step Approach (IG; n = 17) or to a control group receiving standard instruction (CG; n = 17). Both groups were taught gastric-tube insertion using a manikin. Following each of the two forms of instruction, participants' first independent gastric-tube insertions were video recorded and scored by two independent video assessors using binary checklists and global rating forms. The time required for each instructional approach and for the first independent performance of the skill was measured. RESULTS: A total of 34 students agreed to participate in the trial. There were no statistically significant group differences with regard to age, sex, completed education in a medical profession, or completed medical clerkships. The groups did not differ in terms of correct stepwise performance of the procedure as assessed by a binary checklist (p < .802). However, ratings based on global rating scales assessing professionalism and accompanying patient-doctor communication proved significantly better in IG (both ps < .001). The length of the different instructional approaches did not differ significantly between the two groups (IG: 605 ± 65 s; CG: 572 ± 79 s; p < .122), but the time needed for the first independent performance of gastric-tube placement on the manikin was significantly shorter in IG (IG: 168 ± 30 s; CG: 242 ± 53 s; p < .001). CONCLUSIONS: Peyton's Four-Step Approach is superior to standard instruction with respect to professionalism and accompanying doctor-patient communication and leads to faster performance when trainees perform the learned skill for the first time.

Common polymorphisms within the NR4A3 locus, encoding the orphan nuclear receptor Nor-1, are associated with enhanced beta-cell function in non-diabetic subjects.

BACKGROUND: Neuron-derived orphan receptor (Nor) 1, nuclear receptor (Nur) 77, and nuclear receptor-related protein (Nurr) 1 constitute the NR4A family of orphan nuclear receptors which were recently found to modulate hepatic glucose production, insulin signalling in adipocytes, and oxidative metabolism in skeletal muscle. In this study, we assessed whether common genetic variation within the NR4A3 locus, encoding Nor-1, contributes to the development of prediabetic phenotypes, such as glucose intolerance, insulin resistance, or beta-cell dysfunction. METHODS: We genotyped 1495 non-diabetic subjects from Southern Germany for the five tagging single nucleotide polymorphisms (SNPs) rs7047636, rs1526267, rs2416879, rs12686676, and rs10819699 (minor allele frequencies >or= 0.05) covering 100% of genetic variation within the NR4A3 locus (with D' = 1.0, r2 >or= 0.9) and assessed their association with metabolic data derived from the fasting state, an oral glucose tolerance test (OGTT), and a hyperinsulinemic-euglycemic clamp (subgroup, N = 506). SNPs that revealed consistent associations with prediabetic phenotypes were subsequently genotyped in a second cohort (METSIM Study; Finland; N = 5265) for replication. RESULTS: All five SNPs were in Hardy-Weinberg equilibrium (p >or= 0.7, all). The minor alleles of three SNPs, i.e., rs1526267, rs12686676, and rs10819699, consistently tended to associate with higher insulin release as derived from plasma insulin at 30 min(OGTT), AUCC C-peptide-to-AUC Gluc ratio and the AUC Ins30-to-AUC Gluc30 ratio with rs12686676 reaching the level of significance (p

Problem-based training for medical students reduces common prescription errors: a randomised controlled trial.

CONTEXT: Avoidable drug-related problems (DRPs) cause substantial morbidity, mortality and costs. As most prescription errors are committed by recently graduated doctors, undergraduate training should specifically address DRPs. OBJECTIVES: This study set out to investigate whether a DRP teaching module can reduce prescription errors made by advanced medical students in varying clinical contexts. METHODS: A total of 74 Year 5 medical students (mean age 25 +/- 3 years; 24 men, 50 women) participated in a randomised controlled crossover study. Students filled in patients' prescription charts before and after a special DRP training module and a control intervention. The 1-week training module comprised a seminar on common prescription errors, a prescribing exercise with a standardised paper case patient, drafting of inoperative prescription charts for real patients and discussions with a lecturer. During the observation points, prescription charts for standardised patient cases in different clinical contexts had to be completed. These prescription charts were subsequently analysed by two independent raters using a checklist for common prescription errors. RESULTS: Prior to training, students committed a mean of 69 +/- 12% of the potential prescription errors. This decreased to 29 +/- 15% after DRP training (P < 0.001). CONCLUSIONS: Prescription errors can be significantly reduced in a relatively brief training time by implementing a specific DRP teaching module.

Peer-assisted versus faculty staff-led skills laboratory training: a randomised controlled trial.

OBJECTIVES: Although peer-assisted learning (PAL) is widely employed throughout medical education, its effectiveness for training in technical procedures in skills laboratories has been subject to little systematic investigation. We conducted a prospective, randomised trial to evaluate the hypotheses that PAL is effective in technical skills training in a skills laboratory setting, and PAL is as effective as faculty staff-led training. METHODS: Volunteer Year 3 medical students were randomly assigned to one of three groups. Two of these received regular skills training from either cross-year peer tutors or experienced faculty staff. Following training, both groups were assessed using an objective structured clinical examination (OSCE) (three stations assessing various injection techniques) which was video-recorded. Two independent video assessors scored the OSCEs using binary checklists and global ranking forms. A third student group was assessed prior to training and served as a control group. RESULTS: A total of 89 students (mean age 23.0 +/- 0.2 years; 41 male, 48 female) agreed to participate in the trial. Confounding variables including prior training as a paramedic or previous experience in performing the technical procedures did not significantly differ between the three study groups. In the OSCE, PAL (58.1 +/- 1 binary points, 4.9 +/- 0.1 global ranking points) and faculty-led groups (58.3 +/- 1 binary points, 4.7 +/- 0.1 global ranking points) scored significantly higher than the control group (33.3 +/- 1 binary points, 2.7 +/- 0.1 global ranking points; all P < 0.0001). There was no significant difference between the PAL and faculty-led groups (P = 0.92 for binary checklists, P = 0.11 for global rankings). CONCLUSIONS: Peer-assisted learning is a successful method for learning technical procedures in a skills laboratory setting and can be just as effective as the training provided by experienced faculty staff.

Medical education in Germany.

Following the changes made to the medical licensing regulations of 2002, medical education in Germany has been subject to radical modification, especially at undergraduate level. The implementation of the Bologna Process is still a matter of intense political debate, whilst positive movement has occurred in developing the professionalisation of teaching staff through a Masters Degree in Medical Education. In the area of postgraduate medical education, major restructuring of programmes is occurring, whilst the debate in continuing medical education is related to the amount of practical clinical education that is required.

[Self-image, real physician's and ideal physician's image: a comparison of medical students 1981 and 2006]. / Selbstbild, Arztbild und Arztideal: Ein Vergleich Medizinstudierender 1981 und 2006.

BACKGROUND: Due to the new licensing regulations for physicians, social and communicative aspects have attained a central position within medical education. In developing self-reflexive, empathetic and communicative skills, medical students are influenced on the one hand by encounters with real physicians in the role of supervisor or colleague, and on the other by their intra-psychic ideals and role stereotypes. The present study aimed to contrast the self-evaluations of modern medical students with their role stereotypes and ideals, and to further relate these to the evaluations, stereotypes and ideals of medical students in 1981. METHODS: 696 medical students were surveyed with respect to their self-image, their image of a physician and their image of the ideal physician using Osgood and Hofstätter's polarity profile. RESULTS: Over the past 25 years, medical students' image of the ideal physician has remained surprisingly constant, comprising expectations with regard to aptitude, trustworthiness, reliability, friendliness, confidence, thoroughness and congeniality. Encountered physicians were described as negatively deviating from this ideal; self-evaluations lay predominantly in between these two extremes. Self-images were characterized by feelings of powerlessness and uncertainty. CONCLUSIONS: Medical students possess differentiated images of self, future colleagues and the ideal physician. Surveyed students appeared to develop feelings of powerlessness and uncertainty, as well as tendencies to overestimate themselves within self-evaluations. Dealing with the conflict-charged domain between idealism and realism within the occupational reality toward which medical students aspire thus appears to be complicated. These problem areas, which have so far received little attention, require urgent consideration in the development of future medical curricula, in particular in the psychosocial fields.

SIRT1 genetic variants associate with the metabolic response of Caucasians to a controlled lifestyle intervention--the TULIP Study.

BACKGROUND: Sirtuin1 (SIRT1) regulates gene expression in distinct metabolic pathways and mediates beneficial effects of caloric restriction in animal models. In humans, SIRT1 genetic variants associate with fasting energy expenditure. To investigate the relevance of SIRT1 for human metabolism and caloric restriction, we analyzed SIRT1 genetic variants in respect to the outcome of a controlled lifestyle intervention in Caucasians at risk for type 2 diabetes. METHODS: A total of 1013 non-diabetic Caucasians from the Tuebingen Family Study (TUEF) were genotyped for four tagging SIRT1 SNPs (rs730821, rs12413112, rs7069102, rs2273773) for cross-sectional association analyses with prediabetic traits. SNPs that associated with basal energy expenditure in the TUEF cohort were additionally analyzed in 196 individuals who underwent a controlled lifestyle intervention (Tuebingen Lifestyle Intervention Program; TULIP). Multivariate regressions analyses with adjustment for relevant covariates were performed to detect associations of SIRT1 variants with the changes in anthropometrics, weight, body fat or metabolic characteristics (blood glucose, insulin sensitivity, insulin secretion and liver fat, measured by magnetic resonance techniques) after the 9-month follow-up test in the TULIP study. RESULTS: Minor allele (X/A) carriers of rs12413112 (G/A) had a significantly lower basal energy expenditure (p = 0.04) and an increased respiratory quotient (p = 0.02). This group (rs12413112: X/A) was resistant against lifestyle-induced improvement of fasting plasma glucose (GG: -2.01%, X/A: 0.53%; p = 0.04), had less increase in insulin sensitivity (GG: 17.3%, X/A: 9.6%; p = 0.05) and an attenuated decline in liver fat (GG: -38.4%, X/A: -7.5%; p = 0.01). CONCLUSION: SIRT1 plays a role for the individual lifestyle intervention response, possibly owing to decreased basal energy expenditure and a lower lipid-oxidation rate in rs12413112 X/A allele carriers. SIRT1 genetic variants may, therefore, represent a relevant determinant for the response rate of individuals undergoing caloric restriction and increased physical activity.

Effect of genotype on success of lifestyle intervention in subjects at risk for type 2 diabetes.

Lifestyle intervention programs including increased physical activity and healthy nutrition have been proven to delay the onset of type 2 diabetes. This is achieved mainly by reducing body weight and improving insulin sensitivity. However, response to lifestyle or dietary interventions does differ between individuals, and the genetic or environmental factors that may account for these differences are not yet precisely characterized. Identification of these factors would be desirable in order to provide an individually tailored preventive strategy for patients at risk of developing diabetes. This review summarizes the so far known genetic variations, which determine responders and nonresponders to a lifestyle intervention. In addition, general methodological approaches to study gene-lifestyle interactions are described.

Undergraduate technical skills training guided by student tutors--analysis of tutors' attitudes, tutees' acceptance and learning progress in an innovative teaching model.

BACKGROUND: Skills labs provide a sheltered learning environment. As close supervision and individual feedback were proven to be important in ensuring effective skills training, we implemented a cross-year peer tutor system in our skills lab of internal medicine that allowed intense training sessions with small learning groups (3-4 students) taught by one student tutor. METHODS: The expectations, experiences and criticisms of peer tutors regarding the tutor system for undergraduate skills lab training were investigated in the context of a focus group. In addition, tutees' acceptance of this learning model and of their student tutors was evaluated by means of a pre/post web-based survey. RESULTS: 14 voluntary senior students were intensely prepared by consultants for their peer tutor activity. 127 students participated in the project, 66.9% of which responded to the web-based survey (23 topics with help of 6-point Likert scale + free comments). Acceptance was very high (5.69 +/- 0.07, mean +/- SEM), and self-confidence ratings increased significantly after the intervention for each of the trained skills (average 1.96 +/- 0.08, all p < 0.002). Tutors received high global ratings (5.50 +/- 0.07) and very positive anonymous individual feedback from participants. 82% of tutees considered the peer teaching model to be sufficient, and a mere 1% expressed the wish for skills training to be provided by faculty staff only. Focus group analyses with tutors revealed 18 different topics, including profit in personal knowledge and personal satisfaction through teaching activities. The ratio of 1:4 tutor/tutees was regarded to be very beneficial for effective feedback, and the personalized online evaluation by tutees to be a strong motivator and helpful for further improvements. The tutors ascribed great importance to the continuous availability of a contact doctor in case of uncertainties. CONCLUSION: This study demonstrates that peer teaching in undergraduate technical clinical skills training is feasible and widely accepted among tutees, provided that the tutors receive sufficient training and supervision.