Disentangling pain and fatigue in chronic fatigue syndrome: a resting state connectivity study before and after cognitive behavioral therapy.

BACKGROUND: Fatigue is a central feature of myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), but many ME/CFS patients also report comorbid pain symptoms. It remains unclear whether these symptoms are related to similar or dissociable brain networks. This study used resting-state fMRI to disentangle networks associated with fatigue and pain symptoms in ME/CFS patients, and to link changes in those networks to clinical improvements following cognitive behavioral therapy (CBT). METHODS: Relationships between pain and fatigue symptoms and cortico-cortical connectivity were assessed within ME/CFS patients at baseline (N = 72) and after CBT (N = 33) and waiting list (WL, N = 18) and compared to healthy controls (HC, N = 29). The analyses focused on four networks previously associated with pain and/or fatigue, i.e. the fronto-parietal network (FPN), premotor network (PMN), somatomotor network (SMN), and default mode network (DMN). RESULTS: At baseline, variation in pain and fatigue symptoms related to partially dissociable brain networks. Fatigue was associated with higher SMN-PMN connectivity and lower SMN-DMN connectivity. Pain was associated with lower PMN-DMN connectivity. CBT improved SMN-DMN connectivity, compared to WL. Larger clinical improvements were associated with larger increases in frontal SMN-DMN connectivity. No CBT effects were observed for PMN-DMN or SMN-PMN connectivity. CONCLUSIONS: These results provide insight into the dissociable neural mechanisms underlying fatigue and pain symptoms in ME/CFS and how they are affected by CBT in successfully treated patients. Further investigation of how and in whom behavioral and biomedical treatments affect these networks is warranted to improve and individualize existing or new treatments for ME/CFS.

The effects of gaze-display feedback on medical students' self-monitoring and learning in radiology.

Self-monitoring is essential for effectively regulating learning, but difficult in visual diagnostic tasks such as radiograph interpretation. Eye-tracking technology can visualize viewing behavior in gaze displays, thereby providing information about visual search and decision-making. We hypothesized that individually adaptive gaze-display feedback improves posttest performance and self-monitoring of medical students who learn to detect nodules in radiographs. We investigated the effects of: (1) Search displays, showing which part of the image was searched by the participant; and (2) Decision displays, showing which parts of the image received prolonged attention in 78 medical students. After a pretest and instruction, participants practiced identifying nodules in 16 cases under search-display, decision-display, or no feedback conditions (n = 26 per condition). A 10-case posttest, without feedback, was administered to assess learning outcomes. After each case, participants provided self-monitoring and confidence judgments. Afterward, participants reported on self-efficacy, perceived competence, feedback use, and perceived usefulness of the feedback. Bayesian analyses showed no benefits of gaze displays for post-test performance, monitoring accuracy (absolute difference between participants' estimated and their actual test performance), completeness of viewing behavior, self-efficacy, and perceived competence. Participants receiving search-displays reported greater feedback utilization than participants receiving decision-displays, and also found the feedback more useful when the gaze data displayed was precise and accurate. As the completeness of search was not related to posttest performance, search displays might not have been sufficiently informative to improve self-monitoring. Information from decision displays was rarely used to inform self-monitoring. Further research should address if and when gaze displays can support learning.

Connecting Biochemistry Knowledge to Patient Care in the Clinical Workplace: Senior Medical Students' Perceptions about Facilitators and Barriers.

Phenomenon: Medical students have difficulties applying knowledge about biomedical mechanisms learned before clerkships to patient care activities. Many studies frame this challenge as a problem of basic science knowledge transfer predominantly influenced by students' individual cognitive processes. Social cognitive theory would support extending this framing to the interplay between the individual's cognition, the environment, and their behaviors. This study investigates senior medical students' experiences of biochemistry knowledge use during workplace learning and examines how their experiences were influenced by interactions with people and other elements of the clinical learning environment. Approach: The authors used a qualitative approach with a constructivist orientation. From September to November 2020 they conducted semi-structured interviews with 11 fourth-year medical students at one institution who had completed the pre-clerkship curriculum, core clinical clerkships, and the United States Medical Licensing Exam Step 1. The authors identified themes using thematic analysis. Findings: Participants reported that they infrequently used or connected to biochemistry knowledge in workplace patient care activities, yet all had examples of such connections that they found valuable to learning. Most participants felt the responsibility for making connections between biochemistry knowledge and activities in the clinical workplace should be shared between themselves and supervisors, but connections were often recognized and acted on only by the student. Connections that participants described prompted their effort to retrieve knowledge or fill a perceived learning gap. Participants identified multiple barriers and facilitators to connecting, including supervisors' behaviors and perceived knowledge, and "patients seen" in clerkships. Participants also reported learning biochemistry during USMLE Step 1 study that did not connect to patient care activities, underscoring a perception of disconnect. Insights: This study identifies specific personal, social, and physical environmental elements that influence students' perceived use of biochemistry during patient care activities. Though these findings may be most significant for biochemistry, they likely extend to other basic science disciplines. Students' self-directed efforts to connect to their biochemistry knowledge could be augmented by increased social support from clinical supervisors, which in turn likely requires faculty development. Opportunities for connection could be enhanced by embedding into the environment instructional strategies or technologies that build on known authentic connections between biochemistry and "patients seen" in clerkships. These efforts could strengthen student learning, improve clinical supervisors' self-efficacy, and better inform curriculum design.

Coping with Administrative Workload: a Pilot Study in the Usefulness of a Workshop for Psychiatric Trainees.

OBJECTIVE: Administrative workload may have detrimental effects on medical postgraduate trainee satisfaction, capacity, and quality of care. Best-practice guidelines to help trainees cope have yet to be developed. This study explores perceptions of factors that influence the experience or amount of administrative workload at the personal and workplace level and evaluates the usefulness of a workshop on coping with this workload. METHODS: A workshop was developed based on the Job Demands-Resources model, including a survey on perceptions of administrative workload; presentation on coping at personal (e.g., time management) and workplace (e.g., dealing with institutional rules) levels; personal plan of change during a group discussion; and reflective questionnaire after the session and again after 2 months. Perceptions of psychiatry trainee participants (N = 48) were collected. RESULTS: Trainees estimated they spent half their time on administration (average 50%, SD = 15%). They wanted to spend less time (average 23%, SD = 11%) on most administrative duties, except for health record keeping. Personal factors that trainees experienced as helpful to cope included time management and analytical skills. Perfectionism was perceived as impeding. Supportive job factors included helpful supervisors, competent administrative staff, trust in a team, allocated timeslots, and information technology support. High workload and cumbersome procedures were mentioned as impeding. On average, trainees rated the workshop quality and the likelihood of bringing change to their practice with a 7 out of 10. CONCLUSION: Psychiatry trainees' participation in a workshop on coping with administrative load during their training may be a worthwhile investment in the long term.

Professionals' adaptive expertise and adaptive performance in educational and workplace settings: an overview of reviews.

Professionals will increasingly be confronted with new insights and changes. This raises questions as to what kind of expertise professionals need, and how development of this expertise can be influenced within the contexts of both education and work. The terms adaptive expertise and adaptive performance are well-known concepts in the domains of education and Human Resource Development respectively. The literature, however, lacks a conceptual overview. Our research seeks to provide an overview on how adaptive expertise and adaptive performance are conceptualized. In addition we looked for what individual, task and organizational characteristics relate to adaptive expertise. We mined information drawn from existing reviews in an overview of reviews. Nine reviews met the inclusion criteria. Adaptive performance is best referred to as the visible expression of an adaptive expert and this is triggered by 'change'. The scope of this 'change' lies somewhere between change that is 'new for the learner' and change that is 'new for everyone in the whole world'. The extent to and way in which a learner or professional is able to deal with this change depends on the maturity of the learner or professional. We found numerous individual, task and environmental characteristics related to adaptive expertise and adaptive performance. The nature and relation of these characteristics, and their specificity in relation to adaptive expertise and adaptive performance are visualized in a figure, but also provide several suggestions for future research.

Developing entrustable professional activities for university teachers in the health professions.

PURPOSE: There is a widely recognized need to improve teacher professional development as well as recognition of teaching expertise in health professions education (HPE). This study aimed to develop Entrustable Professional Activities (EPAs) for university teachers in HPE as foundations for systems of training, certification, and career opportunities. METHOD: A local expert consultation using a two-round Delphi study at a Dutch academic medical center (round 1: n = 23; round 2: n = 13) was conducted to reach a consensus on an initial set of EPAs developed by the researchers. Subsequently, an international expert consultation was conducted using a survey (n = 21) and a focus group discussion (n = 7) to explore their international value. RESULTS: Local consensus for all nine EPAs was reached in the second round of the Delphi study. The international survey showed a consensus for relevance and usefulness of all but one EPA but not for clarity and comprehensiveness of the EPAs. The international expert consultation revealed a need to tailor the EPA specifications to local contexts. CONCLUSION: We found international consensus for the relevance and usefulness of EPAs for university teachers in HPE but local tailoring for each EPA is needed to acknowledge contextual differences.

Expertise development in volumetric image interpretation of radiology residents: what do longitudinal scroll data reveal?

The current study used theories on expertise development (the holistic model of image perception and the information reduction hypothesis) as a starting point to identify and explore potentially relevant process measures to monitor and evaluate expertise development in radiology residency training. It is the first to examine expertise development in volumetric image interpretation (i.e., CT scans) within radiology residents using scroll data collected longitudinally over five years of residency training. Consistent with the holistic model of image perception, the percentage of time spent on full runs, i.e. scrolling through more than 50% of the CT-scan slices (global search), decreased within residents over residency training years. Furthermore, the percentage of time spent on question-relevant areas in the CT scans increased within residents over residency training years, consistent with the information reduction hypothesis. Second, we examined if scroll patterns can predict diagnostic accuracy. The percentage of time spent on full runs and the percentage of time spent on question-relevant areas did not predict diagnostic accuracy. Thus, although scroll patterns over training years are consistent with visual expertise theories, they could not be used as predictors of diagnostic accuracy in the current study. Therefore, the relation between scroll patterns and performance needs to be further examined, before process measures can be used to monitor and evaluate expertise development in radiology residency training.

EPA-based assessment: Clinical teachers' challenges when transitioning to a prospective entrustment-supervision scale.

BACKGROUND: This study explores the challenges clinical teachers face when first using a prospective entrustment-supervision (ES) scale in a curriculum based on Entrustable Professional Activities (EPAs). A prospective ES scale has the purpose to estimate at which level of supervision a student will be ready to perform an activity in subsequent encounters. METHODS: We studied the transition to prospective assessment of medical students in clerkships via semi-structured interviews with twelve purposefully sampled clinical teachers, shortly after the introduction of a new undergraduate EPA-based curriculum and EPA-based assessment employing a prospective ES scale. RESULTS: While some clinical teachers showed a correct interpretation, rating strategies also appeared to be affected by the target supervision level for completion of the clerkship. Instructions to estimate readiness for a supervision level in the future were not always understood. Further, teachers' interpretation of the scale anchors relied heavily on the phrasing. DISCUSSION: Prospective assessment asks clinical teachers to make an extra inference step in their judgement process from reporting observed performance to estimating future level of supervision. This requires a change in mindset when coming from a retrospective, performance-oriented assessment method, i.e., reporting what was observed. Our findings suggest optimizing the ES-scale wordings and improving faculty development.

Speaking up, support, control and work engagement of medical residents. A structural equation modelling analysis.

OBJECTIVES: Medical residents can play key roles in improving health care quality by speaking up and giving suggestions for improvements. However, previous research on speaking up by medical residents has shown that speaking up is difficult for residents. This study explored: (i) whether two main aspects of medical residents' work context (job control and supervisor support) are associated with speaking up by medical residents, and (ii) whether these associations differ between in-hospital and out-of-hospital settings. METHODS: Speaking up was operationalised and measured as voice behaviour. Structural equation modelling using a cross-sectional survey design was used to identify and test factors pertaining to speaking up and to compare hospital settings. RESULTS: A total of 499 medical residents in the Netherlands participated in the study. Correlational analysis showed significant positive associations between each of support and control, and voice behaviour. The authors assumed that the associations between support and control, and voice behaviour would be partially mediated by engagement. This partial mediation model fitted the data best, but showed no association between support and voice. However, multi-group analysis showed that for residents in hospital settings, support is associated with voice behaviour. For residents outside hospital settings, control is more important. Engagement mediated the effects of control and support outside hospital settings, but not within the hospital. CONCLUSIONS: This study shows that in order to enable medical residents to share their suggestions for improvement, it is beneficial to invest in supportive supervision and to increase their sense of control. Boosting medical residents' support would be most effective in hospital settings, whereas in other health care organisations it would be more effective to focus on job control.

Hair and salivary cortisol in a cohort of women with chronic fatigue syndrome.

Hypocortisolism has been found in CFS patients in blood, urine, and saliva. It is unclear if hypocortisolism can also be demonstrated using long-term cortisol measurements, such as cortisol in hair. In addition, the interaction between the HPA axis and the immune system, both expected to play an important role in CFS, is unclear. The objective of the current study was to compare hair and salivary cortisol concentrations in a cohort of female CFS patients to those in healthy controls, and to test the effect of an interleukin-1 receptor antagonist (anakinra) on the HPA axis. Salivary cortisol concentrations of 107 CFS patients were compared to 59 healthy controls, with CFS patients showing a decreased cortisol awakening response (4.2 nmol/L ±â€¯5.4 vs 6.1 nmol/L ±â€¯6.3, p = 0.036). Total cortisol output during the day did not differ significantly in saliva, but there was a trend to lower hair cortisol in a subset of 46 patients compared to 46 controls (3.8 pg/mg ±â€¯2.1 vs 4.3 pg/mg ±â€¯1.8, p = 0.062). After four weeks of treatment with either daily anakinra (100 mg/day) or placebo, there was a slight decrease of hair cortisol concentrations in the anakinra group compared to an increase in the placebo group (p = 0.022). This study confirms the altered dynamics of the HPA axis in a group of CFS patients, and for the first time shows that this might also be present for long-term cortisol measures.

Dopaminergic Modulation of the Functional Ventrodorsal Architecture of the Human Striatum.

Interactions between motivational, cognitive, and motor regions of the striatum are crucial for implementing behavioral control. Work with experimental animals indicates that such interactions are sensitive to modulation by dopamine. Using systematic pharmacological manipulation of dopamine D2-receptors and resting-state functional imaging, we defined the functional architecture of the human striatum and quantified the effects of dopaminergic drugs on intrinsic effective connectivity between striatal subregions. We found that dopamine modulates interactions between motivational and cognitive regions, as well cognitive and motor regions of the striatum. Stimulation and blockade of the dopamine D2-receptor had opposite (increasing and decreasing) effects on the efficacy of those interactions. Furthermore, trait impulsivity was specifically associated with dopaminergic modulation of ventral-to-dorsal striatal connectivity. Individuals with high trait impulsivity exhibited greater drug-induced increases (after stimulation) and decreases (after blockade) of ventral-to-dorsal striatal connectivity than those with low trait impulsivity. These observations establish a key link between dopamine, intrinsic effective connectivity between striatal subregions, and trait impulsivity.

Volumetric image interpretation in radiology: scroll behavior and cognitive processes.

The interpretation of medical images is a primary task for radiologists. Besides two-dimensional (2D) images, current imaging technologies allow for volumetric display of medical images. Whereas current radiology practice increasingly uses volumetric images, the majority of studies on medical image interpretation is conducted on 2D images. The current study aimed to gain deeper insight into the volumetric image interpretation process by examining this process in twenty radiology trainees who all completed four volumetric image cases. Two types of data were obtained concerning scroll behaviors and think-aloud data. Types of scroll behavior concerned oscillations, half runs, full runs, image manipulations, and interruptions. Think-aloud data were coded by a framework of knowledge and skills in radiology including three cognitive processes: perception, analysis, and synthesis. Relating scroll behavior to cognitive processes showed that oscillations and half runs coincided more often with analysis and synthesis than full runs, whereas full runs coincided more often with perception than oscillations and half runs. Interruptions were characterized by synthesis and image manipulations by perception. In addition, we investigated relations between cognitive processes and found an overall bottom-up way of reasoning with dynamic interactions between cognitive processes, especially between perception and analysis. In sum, our results highlight the dynamic interactions between these processes and the grounding of cognitive processes in scroll behavior. It suggests, that the types of scroll behavior are relevant to describe how radiologists interact with and manipulate volumetric images.

The Neurocognitive Cost of Enhancing Cognition with Methylphenidate: Improved Distractor Resistance but Impaired Updating.

A balance has to be struck between supporting distractor-resistant representations in working memory and allowing those representations to be updated. Catecholamine, particularly dopamine, transmission has been proposed to modulate the balance between the stability and flexibility of working memory representations. However, it is unclear whether drugs that increase catecholamine transmission, such as methylphenidate, optimize this balance in a task-dependent manner or bias the system toward stability at the expense of flexibility (or vice versa). Here we demonstrate, using pharmacological fMRI, that methylphenidate improves the ability to resist distraction (cognitive stability) but impairs the ability to flexibly update items currently held in working memory (cognitive flexibility). These behavioral effects were accompanied by task-general effects in the striatum and opposite and task-specific effects on neural signal in the pFC. This suggests that methylphenidate exerts its cognitive enhancing and impairing effects through acting on the pFC, an effect likely associated with methylphenidate's action on the striatum. These findings highlight that methylphenidate acts as a double-edged sword, improving one cognitive function at the expense of another, while also elucidating the neurocognitive mechanisms underlying these paradoxical effects.

Predictors of Knowledge and Image Interpretation Skill Development in Radiology Residents.

Purpose To investigate knowledge and image interpretation skill development in residency by studying scores on knowledge and image questions on radiology tests, mediated by the training environment. Materials and Methods Ethical approval for the study was obtained from the ethical review board of the Netherlands Association for Medical Education. Longitudinal test data of 577 of 2884 radiology residents who took semiannual progress tests during 5 years were retrospectively analyzed by using a nonlinear mixed-effects model taking training length as input variable. Tests included nonimage and image questions that assessed knowledge and image interpretation skill. Hypothesized predictors were hospital type (academic or nonacademic), training hospital, enrollment age, sex, and test date. Results Scores showed a curvilinear growth during residency. Image scores increased faster during the first 3 years of residency and reached a higher maximum than knowledge scores (55.8% vs 45.1%). The slope of image score development versus knowledge question scores of 1st-year residents was 16.8% versus 12.4%, respectively. Training hospital environment appeared to be an important predictor in both knowledge and image interpretation skill development (maximum score difference between training hospitals was 23.2%; P < .001). Conclusion Expertise developed rapidly in the initial years of radiology residency and leveled off in the 3rd and 4th training year. The shape of the curve was mainly influenced by the specific training hospital. © RSNA, 2017 Online supplemental material is available for this article.

Interleukin-1 as a mediator of fatigue in disease: a narrative review.

Fatigue is commonly reported in a variety of illnesses, and it has major impact on quality of life. Previously, it was thought that fatigue originates in the skeletal muscles, leading to cessation of activity. However, more recently, it has become clear that the brain is the central regulator of fatigue perception. It has been suggested that pro-inflammatory cytokines, especially interleukin-1 alpha (IL-1α) and interleukin-1 beta (IL-1ß), play a prominent role in the development of central fatigue, and several studies have been performed to elucidate the connection between inflammation and these central processes.In this narrative review, mechanisms of action of IL-1 are described, with special attention to its effect on the central nervous system. In addition, we present a summary of studies that (i) investigated the relationship between circulating IL-1α and IL-1ß and fatigue severity and/or (ii) evaluated the effect of inhibiting IL-1 on fatigue. We aim to improve the understanding of fatigue in both inflammatory and non-inflammatory illnesses, which could help develop strategies to treat fatigue more effectively.Reviewing the studies that have been performed, it appears that there is a limited value of measuring circulating IL-1. However, inhibiting IL-1 has a positive effect on severe fatigue in most studies that have been conducted.

Building bridges: engaging medical residents in quality improvement and medical leadership.

OBJECTIVE: To develop an educational intervention that targets residents' beliefs and attitudes to quality Improvement (QI) and leadership in order to demonstrate proactive behaviour. DESIGN: Theory-driven, mixed methods study including document analysis, interviews, observations and open-ended questionnaires. SETTING: Six Dutch teaching hospitals. INTERVENTION: Using expertise from medicine, psychology, organizational and educational sciences we developed a situated learning programme named Ponder and IMProve (PIMP). The acronym PIMP reflects the original upbeat name in Dutch, Verwonder & Verbeter. It has a modern, positive meaning that relates to improving your current circumstances. In quarterly 1-h sessions residents are challenged to identify daily workplace frustrations and translate them into small-scale QI activities. MAIN OUTCOME MEASURES: Organizational awareness, beliefs and attitudes to QI and organizational responsibilities, resident behaviour, barriers and facilitators to successful learning and the programme's potential impact on the organization. RESULTS: Overall, 19 PIMP meetings were held over a period of 3 years. Residents defined 119 PIMP goals, resolved 37 projects and are currently working on another 39 projects. Interviews show that PIMP sessions make residents more aware of the organizational aspects of their daily work. Moreover, residents feel empowered to take up the role of change agent. Facilitators for success include a positive cost-benefit trade-off, a valuable group process and a safe learning environment. CONCLUSION: This article demonstrates the added value of multidisciplinary theory-driven research for the design, development and evaluation of educational programmes. Residents can be encouraged to develop organizational awareness and reshape their daily frustrations in QI work.

Transforming the learning outcomes of anaesthesiology training into entrustable professional activities: A Delphi study.

BACKGROUND: True competency-based medical education should produce graduates meeting fixed standards of competence. Current postgraduate programmes are usually based on a pre-determined length of time in training making them poorly suited for an individual approach. The concept of entrustable professional activities (EPAs) enables a more flexible, personalised and less time-dependent approach to training programmes. An EPA is a unit of professional practice, to be entrusted to a trainee to execute without supervision once they demonstrate sufficient competence. As EPAs relate competencies to clinical practice, they structure training and assessment more logically according to the way clinicians actually work. A first step in building an EPA-based curriculum is to identify the core EPAs of the profession. OBJECTIVES: The aim of this study was to identify EPAs for postgraduate training in anaesthesiology and to provide an example of how an existing curriculum can be transformed into an EPA-based curriculum. DESIGN: A modified Delphi method was used as a consensus approach applying three Delphi rounds. SETTING: Postgraduate specialty training in anaesthesiology in the Netherlands. PARTICIPANTS: All programme directors in anaesthesiology in the Netherlands except for a single programme director who was involved as a researcher in this study and could not participate. MAIN OUTCOME MEASURES: Agreement among participants on a list of EPAs. Agreement was specified as a consensus rate of more than 80%. RESULTS: In this study, 27 programme directors (69% overall response rate) reached consensus on a set of 45 EPAs that describe a curriculum in anaesthesiology for the Netherlands. CONCLUSION: This study is a first step toward a more contemporary curriculum in competency-based postgraduate anaesthesiology training.

Establishing the dopamine dependency of human striatal signals during reward and punishment reversal learning.

Drugs that alter dopamine transmission have opposite effects on reward and punishment learning. These opposite effects have been suggested to depend on dopamine in the striatum. Here, we establish for the first time the neurochemical specificity of such drug effects, during reward and punishment learning in humans, by adopting a coadministration design. Participants (N = 22) were scanned on 4 occasions using functional magnetic resonance imaging, following intake of placebo, bromocriptine (dopamine-receptor agonist), sulpiride (dopamine-receptor antagonist), or a combination of both drugs. A reversal-learning task was employed, in which both unexpected rewards and punishments signaled reversals. Drug effects were stratified with baseline working memory to take into account individual variations in drug response. Sulpiride induced parallel span-dependent changes on striatal blood oxygen level-dependent (BOLD) signal during unexpected rewards and punishments. These drug effects were found to be partially dopamine-dependent, as they were blocked by coadministration with bromocriptine. In contrast, sulpiride elicited opposite effects on behavioral measures of reward and punishment learning. Moreover, sulpiride-induced increases in striatal BOLD signal during both outcomes were associated with behavioral improvement in reward versus punishment learning. These results provide a strong support for current theories, suggesting that drug effects on reward and punishment learning are mediated via striatal dopamine.