Seasonal impact on the outcome of multidisciplinary pain therapy.

Multidisciplinary pain treatment programs (MPTP) have been considered to be the most effective treatment of chronic pain. In this study, we analyzed the influence of seasons on the outcome of chronic pain patients undergoing MPTP. Therefore, a prospective, observational trial was conducted in patients with chronic pain undergoing a 5-week interdisciplinary treatment program. Psychological stabilization (measured by ADS - Allgemeine Depressionsskala) and pain levels (measured by NRS - numeric rating scale) were considered as primary endpoints. As a result of this study, we could show that chronic pain patients (exempt patients with chronic headache) showed a highly significant better improvement in terms of ADS after MPTP when participating in autumn (coefficient: -11.67, p = .004). Patients treated during winter showed a tendency towards a better improvement in ADS scores (coefficient: -6.89, p = .051). These effects were not found in patients suffering from chronic headache. Finally, patients participating in MPTPs during summer, autumn, and winter presented a tendency of higher reduction in pain scores when compared to patients participating in spring. In conclusion, the effect of MPTPs in terms of psychological stabilization is considered to be best during autumn. This should be therefore considered in planning an MPTP in all patients who do not need immediate psychological stabilization. The treatment effect of MPTP on pain seems not being dependent on a specific season.

Personality disorders and outcome after multidisciplinary pain therapy.

OBJECTIVES: Interdisciplinary treatment programmes are the gold standard for patients suffering from chronic pain. However, several patient-related factors seem to influence the patients' outcome. The aim of our study was to inquire whether patients with personality disorders (PD) might benefit less from an interdisciplinary treatment programme compared to patients without PD. METHODS: A prospective, observational study with chronic pain patients attending a 5-week interdisciplinary treatment programme was performed. Main outcome parameters were psychological stabilization and pain intensity before and after the programme. RESULTS: Out of the 104 included patients, 71 (68.3%) showed personality accentuations and 16 (15.4%) were diagnosed with PDs. PDs were mostly classified as histrionic, followed by borderline and narcistic personality. Patients diagnosed with histrionic accentuation showed a significantly better treatment response in terms of pain. Reduction in ADS (Allgemeine Depressionsskala - depression scale) was 3.4 in patients with PD and 11.1 in those without PD. Borderline patients showed a significant increase of ADS (by 2.0; p < 0.05) after programme completion. DISCUSSION: Patients with chronic pain and personality accentuations or disorder only showed a slightly different outcome after interdisciplinary treatment programme and should therefore not be excluded from these programmes. Registered at German Clinical Trials Register (DRKS-ID: DRKS00015141).

EuroScore and IL-6 predict the course in ICU after cardiac surgery.

BACKGROUND: Despite modern advances in intensive care medicine and surgical techniques, mortality rates in cardiac surgical patients are still about 3%. Considerable efforts were made to predict morbidity and mortality after cardiac surgery. In this study, we analysed the predictive properties of EuroScore and IL-6 for mortality in ICU, prolonged postoperative mechanical ventilation, and prolonged stay in ICU. METHODS: We enrolled 2972 patients undergoing cardiac surgery. The patients either underwent aortic valve surgery (AV), mitral valve surgery (MV), coronary artery bypass grafting (CABG), and combined operations of aortic valve and coronary artery bypass grafting (AV + CABG) or of mitral and tricuspid valve (MV + TV). Different laboratory and clinical parameters were analysed. RESULTS: EuroScore as well as IL-6 were associated with increased mortality after cardiac surgery. Furthermore, a higher EuroScore and elevated levels of IL-6 were predictors for prolonged mechanical ventilation and a longer stay in ICU. Especially, highly significant elevated IL-6 levels and an increased EuroScore showed a strong association. Statistics suggested superiority when both parameters were combined in a single model. CONCLUSION: Our results suggest that EuroScore and IL-6 are helpful in predicting the course in ICU after cardiac surgery, and therefore, the use of intensive care resources. Especially, the combination of highly elevated levels of IL-6 and EuroScore may prove to be excellent predictors for an unfortunate postoperative course in ICU.

Bilirubin and lactate: easy to determine and valuable to predict outcome in cardiac surgery.

BACKGROUND: Cardiopulmonary bypass during cardiac surgery is associated with metabolic changes after operation and results inter alia in increased levels of lactate and bilirubin. Since prediction of the course after operation has become very important for the management of an ICU and the patients themselves, we evaluated easily assessable markers (lactate and bilirubin), regarding their potential to predict mortality 90 days after surgery and the length of stay in ICU. METHODS: All patients within a period of five years undergoing cardiac surgery were enrolled in the study. Among others peak levels of lactate and bilirubin within 48 hours after operation were recorded. A Cox proportional hazard model as well as a logistic regression model were used to predict mortality or rather length of stay in ICU. RESULTS: Increased levels of bilirubin and lactate were associated with a significantly increase in mortality and length of stay in ICU (in a concentration-related manner). Interestingly, creatinine serum levels before operation showed a similar performance. CONCLUSIONS: Three easily assessable and cheap laboratory parameters (bilirubin, lactate, and creatinine) are useful to predict 90-day mortality and length of stay in ICU. These findings might be helpful to give patients a reliable prediction about short and mid-term-survival and to improve the management of an ICU.

Automatic analysis of summary statements in virtual patients - a pilot study evaluating a machine learning approach.

BACKGROUND: The ability to compose a concise summary statement about a patient is a good indicator for the clinical reasoning abilities of healthcare students. To assess such summary statements manually a rubric based on five categories - use of semantic qualifiers, narrowing, transformation, accuracy, and global rating has been published. Our aim was to explore whether computer-based methods can be applied to automatically assess summary statements composed by learners in virtual patient scenarios based on the available rubric in real-time to serve as a basis for immediate feedback to learners. METHODS: We randomly selected 125 summary statements in German and English composed by learners in five different virtual patient scenarios. Then we manually rated these statements based on the rubric plus an additional category for the use of the virtual patients' name. We implemented a natural language processing approach in combination with our own algorithm to automatically assess 125 randomly selected summary statements and compared the results of the manual and automatic rating in each category. RESULTS: We found a moderate agreement of the manual and automatic rating in most of the categories. However, some further analysis and development is needed, especially for a more reliable assessment of the factual accuracy and the identification of patient names in the German statements. CONCLUSIONS: Despite some areas of improvement we believe that our results justify a careful display of the computer-calculated assessment scores as feedback to the learners. It will be important to emphasize that the rating is an approximation and give learners the possibility to complain about supposedly incorrect assessments, which will also help us to further improve the rating algorithms.

Undergraduate medical students' behavioural intentions towards medical errors and how to handle them: a qualitative vignette study.

OBJECTIVES: In undergraduate medical education, the topics of errors in medicine and patient safety are under-represented. The aim of this study was to explore undergraduate medical students' behavioural intentions when confronted with an error. DESIGN: A qualitative case vignette survey was conducted including one of six randomly distributed case scenarios in which a hypothetical but realistic medical error occurred. The six scenarios differed regarding (1) who caused the error, (2) the presence of witnesses and (3) the consequences of the error for the patient. Participants were asked: 'What would you do?". Answers were collected as written free texts and analysed according to qualitative content analysis. SETTING: Students from German medical schools participated anonymously through an online questionnaire tool. PARTICIPANTS: Altogether, n=159 students answered a case scenario. Participants were on average 24.6 years old (SD=7.9) and 69% were female. They were undergraduate medical students in their first or second year (n=27), third, fourth or fifth year (n=107) or final year (n=21). RESULTS: During the inductive coding process, 19 categories emerged from the original data and were clustered into four themes: (1) considering communication; (2) considering reporting; (3) considering consequences; and (4) emotional responsiveness. When the student him/herself caused the error in the scenario, participants did mention communication with colleagues and taking preventive action less frequently than if someone else had caused the error. When a witness was present, participants more frequently mentioned disclosure of the error and taking actions than in the absence of a witness. When the outcome was significant to the patient, participants more often showed an emotional response than if there were no consequences. CONCLUSIONS: The study highlights the importance of coping strategies for healthcare professionals to adequately deal with errors. Educators need to introduce knowledge and skills on how to deal with errors and emotional preparedness for errors into undergraduate medical education.

How could the topic patient safety be embedded in the curriculum? A recommendation by the Committee for Patient Safety and Error Management of the GMA.

The topic of patient safety is of fundamental interest for the health care sector. In view of the realisation of the National Competence-Based Learning Objectives Catalogue for Undergraduate Medical Education (NKLM) this topic now has to be prepared for medical education. For a disciplinary and content-related orientation the GMA Committee developed the Learning Objectives Catalogue Patient Safety for Undergraduate Medical Education (GMA-LZK). To ensure an optimal implementation of the GMA-LZK we recommend a longitudinal embedding into the existing curriculum. This position paper supports the implementation of the GMA-LZK and is aimed at everyone who wants to establish teaching courses on the topic patient safety and embed them in the curriculum. In light of this, we will initially describe the key features for a structured analysis of the current situation. Based on three best-practice-examples, as seen in the faculties of Freiburg, Bonn and Munich, different approaches to the implementation of the GMA-LZK will be illustrated. Lastly, we will outline the methodical requirements regarding the curriculum development as well as the disciplinary and methodical competences that the lecturers will have to hold or develop to fulfil the requirements.

How to tell a patient's story? Influence of the case narrative design on the clinical reasoning process in virtual patients.

BACKGROUND: Virtual patients (VPs) are narrative-based educational activities to train clinical reasoning in a safe environment. Our aim was to explore the influence of the design of the narrative and level of difficulty on the clinical reasoning process, diagnostic accuracy and time-on-task. METHODS: In a randomized controlled trial, we analyzed the clinical reasoning process of 46 medical students with six VPs in three different variations: (1) patients showing a friendly behavior, (2) patients showing a disruptive behavior and (3) a version without a patient story. RESULTS: For easy VPs, we did not see a significant difference in diagnostic accuracy. For difficult VPs, the diagnostic accuracy was significantly higher for participants who worked on the friendly VPs compared to the other two groups. Independent from VP difficulty, participants identified significantly more problems and tests for disruptive than for friendly VPs; time on task was comparable for these two groups. The extrinsic motivation of participants working on the VPs without a patient story was significantly lower than for the students working on the friendly VPs. CONCLUSIONS: Our results indicate that the measured VP difficulty has a higher influence on the clinical reasoning process and diagnostic accuracy than the variations in the narratives.

Validation of a German short version of the Attitudes towards Patient Safety Questionnaire (G-APSQshort) for the measurement of undergraduate medical students' attitudes to and needs for patient safety.

Introduction: Topics of patient safety are being taught increasingly within medical eudcation. To date, however, there is no suitable means of measuring the status quo of medical students' attitudes towards patient safety in German-speaking Europe. The German validation of a short version of the Attitude towards Patient Safety Questionnaire (G-APSQshort) is meant to fill this gap with the aid of two validation studies. Methods: In Study 1, item and reliability analyses were used to examine internal consistency as well as factorial structure. In Study 2, the measurement sensitivity of the G-APSQshort in detecting changes in attitudes was assessed. Results: Study 1 comprised N=83 participants (M=23.16 years; 21 female). Adequate internal consistency (Cronbach's α=.722-.903) was reached in 6 of the seven subscales. The factor analysis showed that the six extracted factors matched the theoretically conceived subscales. Study 2 comprised N=21 participants (M=26 years; 11 female). A multivariate analysis of variance showed that the differences before and after a short-term intervention were significant with medium effect size (F(1;16)=6.675; p<.05; η2=.29). Discussion: In six subscales, the G-APSQshort can be considered valid in respect to measuring point and change. It is hoped that regular and concerted implementation of measuring instruments such as the G-APSQshort will help to develop a common ground for data comparison among many different German-speaking medical faculties.

Patients' perception of types of errors in palliative care - results from a qualitative interview study.

BACKGROUND: Medical errors have been recognized as a relevant public health concern and research efforts to improve patient safety have increased. In palliative care, however, studies on errors are rare and mainly focus on quantitative measures. We aimed to explore how palliative care patients perceive and think about errors in palliative care and to generate an understanding of patients' perception of errors in that specialty. METHODS: A semistructured qualitative interview study was conducted with patients who had received at least 1 week of palliative care in an inpatient or outpatient setting. All interviews were transcribed verbatim and analysed according to qualitative content analysis. RESULTS: Twelve patients from two centers were interviewed (7 women, median age 63.5 years, range 22-90 years). Eleven patients suffered from a malignancy. Days in palliative care ranged from 10 to 180 days (median 28 days). 96 categories emerged which were summed up under 11 umbrella terms definition, difference, type, cause, consequence, meaning, recognition, handling, prevention, person causing and affected person. A deductive model was developed assigning umbrella terms to error-theory-based factor levels (definition, type and process-related factors). 23 categories for type of error were identified, including 12 categories that can be considered as palliative care specific. On the level of process-related factors 3 palliative care specific categories emerged (recognition, meaning and consequence of errors). CONCLUSION: From the patients' perspective, there are some aspects of errors that could be considered as specific to palliative care. As the results of our study suggest, these palliative care-specific aspects seem to be very important from the patients' point of view and should receive further investigation. Moreover, the findings of this study can serve as a guide to further assess single aspects or categories of errors in palliative care in future research.

The Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education--A Position Statement of the Committee for Patient Safety and Error Management of the German Association for Medical Education.

BACKGROUND: Since the report "To err is human" was published by the Institute of Medicine in the year 2000, topics regarding patient safety and error management are in the focal point of interest of science and politics. Despite international attention, a structured and comprehensive medical education regarding these topics remains to be missing. GOALS: The Learning Objective Catalogue for Patient Safety described below the Committee for Patient Safety and Error Management of the German Association for Medical Education (GMA) has aimed to establish a common foundation for the structured implementation of patient safety curricula at the medical faculties in German-speaking countries. METHODS: The development the Learning Objective Catalogue resulted via the participation of 13 faculties in two committee meetings, two multi-day workshops, and additional judgments of external specialists. RESULTS: The Committee of Patient Safety and Error Management of GMA developed the present Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education, structured in three chapters: Basics, Recognize Causes as Foundation for Proactive Behavior, and Approaches for Solutions. The learning objectives within the chapters are organized on three levels with a hierarchical organization of the topics. Overall, the Learning Objective Catalogue consists of 38 learning objectives. All learning objectives are referenced with the National Competency-based Catalogue of Learning Objectives for Undergraduate Medical Education. DISCUSSION: The Learning Objective Catalogue for Patient Safety in Undergraduate Medical Education is a product that was developed through collaboration of members from 13 medical faculties. In the German-speaking countries, the Learning Objective Catalogue should advance discussion regarding the topics of patient safety and error management and help develop subsequent educational structures. The Learning Objective Catalogue for Patient Safety can serve as a common ground for an intensified, constructive, subject-specific discussion about these topics at the medical faculties, and guide the implementation of hopefully multiple patient safety curricula in undergraduate medical education.

Undergraduate education in palliative medicine in Germany: a longitudinal perspective on curricular and infrastructural development.

BACKGROUND: In 2009, palliative medicine became an integrated and compulsory part of undergraduate training in Germany by legislation. After a transitional period, all medical faculties were required to provide adequate teaching with an according examination and certification procedure. In parallel, we conducted bi-annual surveys on all medical faculties in Germany to examine for potential discrepancies between the implementation process and their intended consequences on teaching time and content. METHODS: Four consecutive bi-annual surveys (2006, 2008, 2010, 2012) of all 36 medical faculties in Germany were performed, using purposively for this study developed questionnaires. Likert scales and closed questions were analyzed descriptively. RESULTS: Medical Faculty response rate increased from 50 % in 2006 to 88.9 % in 2012. Teaching coordinators in palliative medicine primarily had an anesthesiology or internal medicine background. There was a noted increase over time of the involvement of specialized palliative care units (PCUs) as providing the setting for education. The number of faculties that were able to offer a complete 16 weeks of training in palliative medicine during the "final year" rose steadily. In addition, increased patient-centered teaching formats have been implemented over time. The faculties which offered innovative teaching formats with actors as patients (standardized patient interaction) increased, as did the total number of mandatory examinations. The number of faculties that provided compulsory teaching in a condensed manner within a single academic year increased sharply from 3 of 31 responding faculties in 2010 to 19 of 32 responding faculties in 2012. CONCLUSIONS: Until now, teaching conditions and structures in palliative medicine in Germany have proven to be extraordinarily heterogeneous. Although professorships ("Chairs") in palliative medicine proved to be particularly beneficial and supportive in curricular and structural development, only a minority of faculties provide leading academic positions in palliative medicine.

Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines.

CONTEXT: Palliative sedation therapy (PST) is increasingly used in patients at the end of life. However, consensus about medications and monitoring is lacking. OBJECTIVES: To assess published PST guidelines with regard to quality and recommendations on drugs and monitoring. METHODS: We searched CINAHL, the Cochrane Library, Embase, PsycINFO, PubMed, and references of included articles until July 2014. Search terms included "palliative sedation" or "sedation" and "guideline" or "policy" or "framework." Guideline selection was based on English or German publications that included a PST guideline. Two investigators independently assessed the quality of the guidelines according to the Appraisal of Guidelines for Research and Evaluation II instrument (AGREE II) and extracted information on drug selection and monitoring. RESULTS: Nine guidelines were eligible. Eight guidelines received high quality scores for the domain "scope and purpose" (median 69%, range 28-83%), whereas in the other domains the guidelines' quality differed considerably. The majority of guidelines suggest midazolam as drug of first choice. Recommendations on dosage and alternatives vary. The guidelines' recommendations regarding monitoring of PST show wide variation in the number and details of outcome parameters and methods of assessment. CONCLUSION: The published guidelines on PST vary considerably regarding their quality and content on drugs and monitoring. Given the need for clear guidance regarding PST in patients at the end of life, this comparative analysis may serve as a starting point for further improvement.