Verbal Probability Terms for Communicating Clinical Risk - a Systematic Review.

Verbal probability expressions such as 'likely' and 'possible' are commonly used to communicate uncertainty in diagnosis, treatment effectiveness as well as the risk of adverse events. Probability terms that are interpreted consistently can be used to standardize risk communication. A systematic review was conducted. Research studies that evaluated numeric meanings of probability terms were reviewed. Terms with consistent numeric interpretation across studies were selected and were used to construct a Visual Risk Scale. Five probability terms showed reliable interpretation by laypersons and healthcare professionals in empirical studies. 'Very Likely' was interpreted as 90% chance (range 80 to 95%); 'Likely/Probable,' 70% (60 to 80%); 'Possible,' 40% (30 to 60%); 'Unlikely,' 20% (10 to 30%); and 'Very Unlikely' with 10% chance (5% to 15%). The corresponding frequency terms were: Very Frequently, Frequently, Often, Infrequently, and Rarely, respectively. Probability terms should be presented with their corresponding numeric ranges during discussions with patients. Numeric values should be presented as X-in-100 natural frequency statements, even for low values; and not as percentages, X-in-1000, X-in-Y, odds, fractions, 1-in-X, or as number needed to treat (NNT). A Visual Risk Scale was developed for use in clinical shared decision making.

Global Epidemiology of Urticaria: Increasing Burden among Children, Females and Low-income Regions.

Urticaria has a high socioeconomic burden worldwide. However, the global epidemiology of urticaria and its geographical and temporal trends are not well studied. Using the Global Burden of Disease dataset, the aim of this study was to analyse the age-standardized prevalence, incidence, years lived with disability, and mean duration of urticaria in 195 countries from 1990 to 2017. In addition, the relationship between socioeconomic development and urticaria was evaluat-ed. The global prevalence of urticaria in 2017 was 86 million people. Females and children aged 1-4 years were more commonly affected than males and adults, respectively: these differences were outside the 95% uncertainty intervals. Regression analyses show-ed that a lower gross domestic product per capita was associated with a higher prevalence and incidence of urticaria (p < 0.001). The global prevalence of urticaria, incidence, and years lived with disability have remained stable from 1990 to 2017.

Relationships and boundaries: Learning needs and preferences in clerkship medical environments.

PURPOSE: Relationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries. MATERIALS AND METHODS: This was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used. RESULTS: The survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (p<0.001), and a physician's social responsibilities (p = 0.001). CONCLUSION: Medical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries.

Informed consent learning: Needs and preferences in medical clerkship environments.

PURPOSE: Limited information exists regarding students' routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments. MATERIALS AND METHODS: A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks. RESULTS: 84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item "being treated in professional manner" and "endorsement of educational needs for care of adolescents" (p = 0.05). CONCLUSION: There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education.

A Definition of Family Medicine and General Practice.

Definitions of general practice and family medicine have tended to be difficult to understand. We propose a new definition that is brief and clear. General practice / family medicine is defined as the medical specialty that manages common and long-term illnesses in children and adults, focusing on overall health and well-being. The definition should be followed by local examples of diseases within the scope of primary care such as asthma, diabetes as well as end-of-life care. This definition is based on the concept of common illnesses, reflecting the reality that family physicians manage most health conditions in a community. Unlike 'comprehensive care', common illnesses is a scope of practice that is familiar and credible to laypersons. The new definition focuses on a unique and enduring attribute of the specialty: holistic care. This core characteristic of general practice encompasses patient-centred care and continuity across the family lifecycle. By being sharply focused, the definition can guide the nature of clinical care in general practice as well as the content of undergraduate and postgraduate training in family medicine.

Burden of Breast Cancer in the Arab World: Findings from Global Burden of Disease, 2016.

Epidemiology of breast cancer in the Arab region is understudied as compared with Western countries. We aimed to examine breast cancer epidemiology in Arab countries from 1990 to 2016. We analyzed the Global Burden of Disease, 2016 data for breast cancer among women in 22 Arab countries. Epidemiological measures including incidence, mortality, and disability adjusted life years (DALYs) were analyzed for breast cancer in women from 1990 to 2016. We also measured the burden of breast cancer stratified by the sociodemographic index (SDI). Our analysis indicates that the incidence of breast cancer in Arab women has risen over the past 26 years, but is still lower than global averages. In 2016, there were 45,980 new cases (28/100,000) and 20,063 deaths (11/100,000) in the region. The burden of breast cancer as estimated by DALYs was also lower than the global rates and tended to increase with increasing SDI. Although some studies have reported that Arab women present with breast cancer at a younger age, our analysis of age-specific rates, indicates that this is not statistically significant. Our findings indicate that a comprehensive plan to improve public awareness, screening, diagnosis, and treatment is required to reduce the growing burden of breast cancer in the Arab world.

Ethics teaching in a medical education environment: preferences for diversity of learning and assessment methods.

BACKGROUND: Ethics and professionalism are an integral part of medical school curricula; however, medical students' views on these topics have not been assessed in many countries. OBJECTIVE:  The study aimed to examine medical students' perceptions toward ethics and professionalism teaching, and its learning and assessment methods. DESIGN: A self-administered questionnaire eliciting views on professionalism and ethics education was distributed to a total of 128 final-year medical students. RESULTS: A total of 108 students completed the survey, with an 84% response rate. Medical students reported frequently encountering ethical conflicts during training but stated only a moderate level of ethics training at medical school (mean = 5.14 ± 1.8). They noted that their education had helped somewhat to deal with ethical conflicts (mean = 5.39 ± 2.0). Students strongly affirmed the importance of ethics education (mean = 7.63 ± 1.03) and endorsed the value of positive role models (mean = 7.45 ± 1.5) as the preferred learning method. The cohort voiced interest in direct faculty supervision as an approach to assessment of knowledge and skills (mean = 7.62 ± 1.26). Female students perceived greater need for more ethics education compared to males (p = < 0.05). Students who claimed that they had experienced some unprofessional treatment had a more limited view of the importance of ethics as a subject (P = 0.001). CONCLUSION: Medical students viewed ethics education positively and preferred clinically attuned methods for learning.

Knowledge of diabetes among patients in the United Arab Emirates and trends since 2001: a study using the Michigan Diabetes Knowledge Test.

Knowledge of diabetes among patients with the disease in the United Arab Emirates is essential for effective self-management. We assessed the level of diabetes-related knowledge among patients and compared it with that found in previous studies in the same city. A cross-sectional study, using an interviewer-administered questionnaire, was conducted at two clinics in Al Ain, United Arab Emirates. The Michigan Diabetes Knowledge Test, translated into Arabic, was used to assess knowledge of diabetes. Of 165 participants with diabetes, 130 (78.8%) were women. The mean knowledge score was low at 55% (6.6 out of a maximum possible score of 12, standard deviation 1.8). This is comparable to levels found in previous studies: 55.5% in 2001 and 68.2% in 2006. Misconceptions about the diabetic diet and blood testing were common. The level of diabetes-related knowledge has remained low since 2001. These results are of concern in view of the substantial investments made in diabetes care and health education in the region.

Patient-Centered Communication: Basic Skills.

Communication skills needed for patient-centered care include eliciting the patient's agenda with open-ended questions, especially early on; not interrupting the patient; and engaging in focused active listening. Understanding the patient's perspective of the illness and expressing empathy are key features of patient-centered communication. Understanding the patient's perspective entails exploring the patient's feelings, ideas, concerns, and experience regarding the impact of the illness, as well as what the patient expects from the physician. Empathy can be expressed by naming the feeling; communicating understanding, respect, and support; and exploring the patient's illness experience and emotions. Before revealing a new diagnosis, the patient's prior knowledge and preferences for the depth of information desired should be assessed. After disclosing a diagnosis, physicians should explore the patient's emotional response. Shared decision making empowers patients by inviting them to consider the pros and cons of different treatment options, including no treatment. Instead of overwhelming the patient with medical information, small chunks of data should be provided using repeated cycles of the "ask-tell-ask" approach. Training programs on patient-centered communication for health care professionals can improve communication skills.

Knowledge of diabetes among patients in the United Arab Emirates and trends since 2001: a study using the Michigan Diabetes Knowledge Test

Knowledge of diabetes among patients with the disease in the United Arab Emirates is essential for effective self-management. We assessed the level of diabetes-related knowledge among patients and compared it with that found in previous studies in the same city. A cross-sectional study, using an interviewer-administered questionnaire, was conducted at two clinics in Al Ain, United Arab Emirates. The Michigan Diabetes Knowledge Test, translated into Arabic, was used to assess knowledge of diabetes. Of 165 participants with diabetes, 130 [78.8%] were women. The mean knowledge score was low at 55% [6.6 out of a maximum possible score of 12, standard deviation 1.8]. This is comparable to levels found in previous studies: 55.5% in 2001 and 68.2% in 2006. Misconceptions about the diabetic diet and blood testing were common. The level of diabetes-related knowledge has remained low since 2001. These results are of concern in view of the substantial investments made in diabetes care and health education in the region

La connaissance du diabète parmi les patients atteints de la maladie aux Emirats arabes unis est essentielle pour une auto-prise en charge efficace. Nous avons évalué le niveau de connaissance sur le diabète parmi les patients et l'avons comparé avec celui trouvé dans les études précédentes menées dans la même ville. Une étude transversale, reposant sur un questionnaire administré par un enquêteur, a été conduite dans deux cliniques à Al Ain, aux Emirats arabes unis. Le test d'évaluation des connaissances sur le diabète du Michigan, traduit en arabe, a été utilisé pour évaluer la connaissance du diabète. Sur 165 participants diabétiques, 130 [78,8%] étaient des femmes. Le score de connaissance moyen était bas [55%, soit 6,6 sur un score maximum possible de 12, avec un écart-type de 1,8]. Ceci est comparable aux taux trouvés dans les études précédentes : 55,5% en 2001, et 68,2% en 2006. Des idées reçues sur le régime alimentaire pour diabétiques et les analyses de sang étaient courantes. Le niveau de connaissance sur le diabète reste bas depuis 2001. Ces résultats sont préoccupants compte tenu de l'investissement non négligeable réalisé dans le domaine des soins apportés aux patients diabétiques et de l'éducation sur le diabète dans la région

Basal Ganglia Calcification in Psychiatric Inpatients: A Case-Control Study.

BACKGROUND AND OBJECTIVE: Several case reports have noted basal ganglia calcification (BGC) as an incidental radiologic finding in patients presenting with psychiatric manifestations. In this study, we examined the clinical correlates of mental disorders in two groups of psychiatric patients, one with BGC and one with normal radiologic studies. METHODS: In a retrospective cross-sectional case-control study of patients admitted to the psychiatric ward in Al Ain Hospital between January 2011 and December 2013, we compared all 15 patients diagnosed with BGC and 30 control patients who had normal radiologic findings. RESULTS: The BGC group's psychiatric symptoms began when they were aged in their 30s and 40s, later than the controls' 20s and 30s (P=0.001). More of the BGC group than the controls had cognitive symptoms (60% versus 6.7%, P=0.001). The BGC group was more likely to have chronic medical comorbidities (66.7% versus 20%, P=0.003). The BGC group's mean serum calcium was lower than the controls' (P=0.003) and the C-reactive protein was higher (P=0.049). We did not find significant differences between the groups in psychiatric diagnoses; five of the 15 patients with BGC had mood disorders and four of the 15 had psychotic disorders. CONCLUSIONS: Patients with BGC tend to develop psychiatric symptoms later in life than other psychiatric patients, and have higher rates of medical comorbidities. Many patients with BGC have cognitive symptoms, which can be concurrent with a mood or psychotic disorder.

Deficiency of mitochondrial modulator MCJ promotes chemoresistance in breast cancer.

Despite major advances in early detection and prognosis, chemotherapy resistance is a major hurdle in the battle against breast cancer. Identifying predictive markers and understanding the mechanisms are key steps to overcoming chemoresistance. Methylation-controlled J protein (MCJ, also known as DNAJC15) is a negative regulator of mitochondrial respiration and has been associated with chemotherapeutic drug sensitivity in cancer cell lines. Here we show, in a retrospective study of a large cohort of breast cancer patients, that low MCJ expression in breast tumors predicts high risk of relapse in patients treated with chemotherapy; however, MCJ expression does not correlate with response to endocrine therapy. In a prospective study in breast cancer patients undergoing neoadjuvant therapy, low MCJ expression also correlates with poor clinical response to chemotherapy and decreased disease-free survival. Using MCJ-deficient mice, we demonstrate that lack of MCJ is sufficient to induce mammary tumor chemoresistance in vivo. Thus, loss of expression of this endogenous mitochondrial modulator in breast cancer promotes the development of chemoresistance.

Principles of family medicine and general practice - defining the five core values of the specialty.

The principles of general practice and family medicine are the defining characteristics of the speciality. The five principles are: compassionate care - a caring attitude towards patients and their families shown as kindness and a desire to help; generalist approach - a perspective on the whole person and the context of illness including family, culture and society; continuity of relationship - the interpersonal bond of trust and respect between family physicians, patients, and their families that develops over the life course; reflective mindfulness- doctors' awareness of their thoughts and emotions manifested as a sense of presence and attentiveness towards self and others; and lifelong learning - a commitment to personal and professional development by participating in learning activities and practice-based research that leads to better patient outcomes. Concepts such as care coordination, preventive care, access to care, professional competence, resource management and community-based care, are part of the principles above. The term 'comprehensive care' is should be avoided as it misinterprets the scope of family medicine.

Burden of virus-associated liver cancer in the Arab world, 1990-2010.

Hepatocellular carcinoma (HCC) is amongst the top three cancer causes of death worldwide with hepatitis B and C viruses (HBV/HCV) as the main etiological agents. An up-to-date descriptive epidemiology of the burden of HBV/HCV-associated HCC in the Arab world is lacking. We therefore determined the burden of HBV/HCV- associated HCC deaths in the Arab world using the Global Burden of Disease (GBD) 2010 dataset. GBD 2010 provides, for the first time, deaths specifically attributable to viral-associated HCC. We analyzed the data for the 22 Arab countries by age, sex and economic status from 1990 to 2010 and compared the findings to global trends. Our analysis revealed that in 2010, an estimated 752,101 deaths occurred from HCC worldwide. Of these 537,093 (71%) were from HBV/HCV-associated HCC. In the Arab world, 17,638 deaths occurred from HCC of which 13,558 (77%) were HBV/HCV-linked. From 1990 to 2010, the burden of HBV and HCV-associated HCC deaths in the Arab world increased by 137% and 216% respectively, compared to global increases of 62% and 73%. Age-standardized death rates also increased in most of the Arab countries, with the highest rates noted in Mauritania and Egypt. Male gender and low economic status correlated with higher rates. These findings indicate that the burden of HBV/HCV-associated HCC in the Arab world is rising at a much faster rate than rest of the world and urgent public health measures are necessary to abate this trend and diminish the impact on already stretched regional healthcare systems.

Role of a poison center in reducing unintentional childhood ingestion by targeting pre-event risk factors.

OBJECTIVES: Unintentional poisoning is a frequent presentation in the pediatric emergency care settings. We sought to determine the current incidence of unintentional poison ingestions in children who present to the emergency care in the city of Al Ain in United Arab Emirates, to create a profile of the products ingested, and to compare our data with a previous study conducted before the inception of a poison and drug information center. METHODS: We reviewed all cases of unintentional poisoning in children 10 years or younger, who presented at 2 tertiary level emergency care centers during January-December 2010. Two hundred cases met our inclusion criteria. Data on demographics, type and amount of noxious substance ingested, time of presentation, and outcomes were collected. Annual incidence was estimated, and data were compared with the previous study. RESULTS: The annual incidence of unintentional poisoning in the UAE is 2.35 per 1000 children 10 years or younger. The incidence is decreasing, especially for household chemical ingestions. The incidence is twice as high among native Emirati children compared with expatriate children. There was an increase in cosmetics- and synthetic hormone-related poisonings, as well as in the involvement of younger infants. CONCLUSIONS: The incidence of unintentional pediatric poisoning in the UAE is decreasing particularly in household chemical ingestions. Targeted health promotion campaigns by the poison center may have led to this drop. The sociological, environmental, and cultural factors that might be contributing to the greater use of emergency care in native children should be investigated.

Training in reference management software--a part of new medical informatics workshops in Pakistan.

BACKGROUND: Researchers in Pakistan can increase writing productivity, reduce errors in manuscripts and improve quality of their papers by hands-on workshops on bibliographic reference software. METHODS: A workshop was conducted in an interactive tutorial format using an overhead projector to show screenshots of software at each step. Our Workshop included: starting the Endnote program (www.endnote.com); manually entering a reference of a journal article; searching and importing references from PubMed; inserting a reference in Microsoft Word document in a journal-specific format; essentials of journal article formatting; and the ethics of respecting other peoples of intellectual effort by proper citations and avoiding plagiarism. RESULTS: A post-workshop test was administered to assess whether instructional objectives were attained. All the participants passed the post-workshop multiple choice questions and 85% rated the workshop as good, very good or excellent. CONCLUSION: A workshop on reference formatting in research writing is useful to promote high quality research work. We recommend holding workshops twice a year on research article formatting and reference software at medical colleges in Pakistan and other developing countries.