Perception, experience and use of moments of change - a qualitative investigation

Objectives: In psychotherapeutic change processes, in addition to gradual changes, specific single special moments are described as a starting point for change. We investigated the perception of these moments of change (CMs) from the patient's perspective: What does each patient perceive and experience in a CM? Methods: A qualitative, explorative study of CMs was conducted by means of semi-structured questionnaires as well as qualitative interviews with patients (n = 12). Grounded theory was used for the analysis. Results: CMs were noticed by an "explicit mode of perception" based on physical, emotional and cognitive aspects. In addition, we found a "transcending mode of experience" that involved changes in consciousness and self-experience. CMs showed a "specific transformative pattern" and were preserved as "experience anchors". Conclusions: The intensification of consciousness, transformation of self-experience, and intense prototypical experience of a change process appeared particularly impressive. With the help of CMs, access could be gained to an embodied and implicit experience, which could subsequently be symbolised and used as an "experience anchor". This could be useful especially for the treatment of psychosomatic patients.

Why context matters when changing the diet: A narrative review of placebo, nocebo, and psychosocial context effects and implications for outcome research and nutrition counselling

Placebo (PE) and nocebo effects (NE) have been subjects of systematic research in medicine and psychotherapy for many decades to distinguish between the (specific) pharmacological effect of medication and the (unspecific) effect of the context. Despite this significant research, the awareness, operationalisation, and reflection of the multiplicity of PE, NE, and psychosocial context effects (PSCE) is currently limited when researching outcomes of diet changes in studies without randomisation and placebo control. This neglection is critical as it could systematically influence outcomes by moderating and mediating them and thus reducing the validity and evidence base of these studies. Therefore, we performed a (non-systematic) narrative review (NR) on the following objectives: (1) present a concise overview about the relevance of PE, NE, and PSCE in medicine and nutrition research; (2) review the current state of research on reflecting context effects when studying diet changes; (3) provide useful theoretical foundations via consideration and integration of micro- and macro context effects; (4) operationalise as hypotheses the potential PE, NE, and PSCE which are specific for researching diet changes; and (5) derive their impact for future research as well as for nutrition counselling. The electronic search in this NR for objective (2) identified N = 5 publications and for objective (4) we found N = 61 articles retrieved in the first round of search, additional references were identified by a manual and snowball search among the cited references resulting finally in N = 37. This NR offers a synoptical basis to foster awareness and operationalisation of a variety of PE, NE, and PSCE. Interdisciplinary research teams should monitor these factors using, e.g., qualitative, mixed-method studies, process evaluation, item bank approaches, moderator and mediator analysis that might reveal substantially new insights, and outcomes of relevance to science and nutrition counselling. Nevertheless, the present NR has several limitations, especially as it is non-systematic, because it is a very heterogeneous field of research, in which the topic we are investigating is usually regarded as marginal and subordinate. Therefore, future research should conduct systematic reviews and particularly theory-based primary studies (experimental research) on hypotheses of PE, NE, and PSCE in outcome research in diet changes.

Communicative competencies anchored longitudinally - the curriculum "personal and professional development" in the model study programme in undergraduate medical education at the University of Witten/Herdecke

Background: In October 2018, the University of Witten/Herdecke (UW/H) launched the new reformed medical education programme called Medicine 2018+. A major innovation compared to the existing model programme was the introduction of thematic focuses. A longitudinal communication skills curriculum was integrated into the new thematic focus "professional and personal development - inner work" (IAP). With the start of the new programme, the IAP curriculum has been built step-by-step over time, i.e. the first four semesters have already been implemented, the following semesters are being planned. Project description: IAP aims to provide students with patient-centred medicine. Five areas of competence were defined: Doctor-patient communication, team competence, staying healthy, my paths to becoming a doctor, medicine and society. The focus of this article is on the communication curriculum. The first year of study focusses on the training of basic communication skills. In the 2^nd year of study, students practice these basic skills in small groups with simulated patients (SP), whereby the emphasis in the 3^rd semester is on history taking and in the 4^th semester is on sharing information. In the 3^rd semester, students complete a communication station in an OSCE. From the 5^th semester onwards, the focus of training is on the consolidation of basic and advanced communication skills, which can be applied in clinical clerkships, and the reflection of clinical experiences. Key didactic elements are, in addition to teaching the theoretical basics, experience-based small group work with and without SP, feedback and reflection. The evaluation of the summer semester 2020 showed high agreement ratings of the students regarding the overall satisfaction with the individual courses (83-100% agreement). Discussion: The introduction of IAP has been very positively received by the students. Challenges are the adequate handling of the increasing student workload when planning new courses, the implementation of a longitudinal e-portfolio as well as the recruitment and training of clinical teachers and SPs. Conclusion: As the evaluation results of the summer semester 2020 show, the first steps of implementing a longitudinal communication curriculum at UW/H have been successful. Helpful strategies were the orientation on published examples from other faculties as well as regular feedback and discussions with students and teachers in order to adapt and integrate educational considerations into the existing model programme in Witten.

Empathy, well-being and stressful experiences in the clinical learning environment

OBJECTIVE

This study examines whether students in the clinical phase show reduced well-being and lower empathy scores compared to preclinical students. Furthermore, it explores students' most stressful experiences.

METHODS

A cross-sectional mixed-methods study was conducted among medical students of the revised patient- and student-centred curriculum at Witten/Herdecke University (Germany). An online survey included questions regarding empathy (JSPE-S), well-being (WHO-5), distressing factors in the learning and clinical environments, mistreatment and thoughts of dropping out.

RESULTS

176 (34 %) of 517 medical students completed the questionnaire, 73 being preclinical and 103 clinical students. Despite lower well-being, clinical student did not demonstrate lower empathy levels. Main stressors during the clinical phase were negative physician role models and financially focussed care rather than challenging patient encounters. Compared to preclinical students, clinical students showed more mistreatment experiences and higher ratings towards thoughts of dropping out.

CONCLUSION

Our results illustrate contemporary challenges to establishing a learner-centred clinical environment that nurtures well-being and empathy of medical students. The sustainment of empathy despite more stressful experiences and lower well-being may be due to protective factors.

PRACTICE IMPLICATIONS

The paper suggests activities to support clinical students to find ways to adapt the clinical learning environment to students' needs.

History and development of medical studies at the University of Witten/Herdecke - an example of "continuous reform"

Introduction: The University of Witten/Herdecke (UW/H) was founded in 1982 as the first privately run German university. In addition to economics, dentistry, a center for life sciences and the institute for general studies, the main focus from the inception of the University was the development of a model course in medical studies. Methodology: A description of the history of the development of medical studies in relation to the reasons for its founding, its founding ideals and their implementation; phases of development, transformations and influencing factors are presented in detail. External assessments are also used for this purpose. Result: The "Herdecke Model" was first implemented with the initial group of medical students in 1983. In the past 36 years the curriculum for medical education in Witten/Herdecke has evolved to meet internal and external requirements. The goals of the founders for a reform of medical studies and the founding ideals of the UW/H have continued to lead the University through a continuous reform process of medical training. From the first model of a reform degree course at UW/H 1983 to the current Model Study Course/Modellstudiengang (MSG 2018^plus), these reforms have manifested themselves in four major phases spanning a 15 year period. Landmarks of the reforms include the first systematic introduction of problem-oriented learning in Germany, and clinical and practical training with real patients in both clinical and general medical elective blocks that far surpass the Medical Licensure Act's requirements. Additionally noteworthy are the introduction of PY training wards and the active participation and co-design role students may hold. Discussion: Due to the small size of UW/H, reforms can be tested quickly and implemented with ease and flexibility. This facilitates a "laboratory setting" for the testing of future-oriented innovations. The small size has allowed various concepts to be able to be used as models, thus serving as stimuli for larger change in medical studies in Germany.

Is your mind set? - how are intra- and interpersonal competences dealt with in medical education? A multi-professional qualitative study

BACKGROUND

Professional intrapersonal and interpersonal competences (IICs) form an important part of medical expertise but are given little attention during clinical training. In other professional fields such as psychotherapy, education and aviation, training in IICs is an integral part of education and practice. In medicine, IICs tend to actually decline during studies. To date it is unclear why IICs are given less attention in medicine, despite evidence for their importance in the treatment process. In view of this, the study examined the role of IICs in the treatment process, the current situation of IIC training in medicine and, most importantly, the reasons for the comparatively low focus on IICs in the clinical training of medical students.

METHODS

Semi-structured interviews were carried out with 21 experts from a variety of medical specialties and non-medical professions that provide a training with a stronger focus on IIC development. The interviews were evaluated using grounded theory.

RESULTS

The experts confirmed the idea that IICs are an equally important component in the treatment process, along with medical knowledge and technical skills. They also described large differences between the IICs possessed by physicians but noted a general developmental need. The key shortcoming was perceived to be a deep-seated defensiveness towards learning from mistakes and deficits e.g. through reflection and feedback. The interaction of different factors that seem to be reasons for this defensiveness and perpetuate it were identified: lack of support in dealing with insecurities in the face of responsibility; the notion of medicine as a science with the categories of right and wrong answers; and a range of pressures arising from the setting, such as hierarchical, economic and competition pressures.

CONCLUSION

Our study showed, that the defensive attitude towards learning from mistakes and deficits especially in the field of IICs appears to be a subtle but powerful obstacle for implementing IICs in medical training, in contrast to other professional fields. This obstacle is sustained by various underlying barrier factors. We therefore propose that changes should be made within a cultural transformation targeting this defensive mindset and culture and its presumed reasons.

History and development of medical studies at the University of Witten/Herdecke - an example of "continuous reform"

Introduction: The University of Witten/Herdecke (UW/H) was founded in 1982 as the first privately run German university. In addition to economics, dentistry, a center for life sciences and the institute for general studies, the main focus from the inception of the University was the development of a model course in medical studies. Methodology: A description of the history of the development of medical studies in relation to the reasons for its founding, its founding ideals and their implementation; phases of development, transformations and influencing factors are presented in detail. External assessments are also used for this purpose. Result: The "Herdecke Model" was first implemented with the initial group of medical students in 1983. In the past 36 years the curriculum for medical education in Witten/Herdecke has evolved to meet internal and external requirements. The goals of the founders for a reform of medical studies and the founding ideals of the UW/H have continued to lead the University through a continuous reform process of medical training. From the first model of a reform degree course at UW/H 1983 to the current Model Study Course/Modellstudiengang (MSG 2018^plus), these reforms have manifested themselves in four major phases spanning a 15 year period. Landmarks of the reforms include the first systematic introduction of problem-oriented learning in Germany, and clinical and practical training with real patients in both clinical and general medical elective blocks that far surpass the Medical Licensure Act's requirements. Additionally noteworthy are the introduction of PY training wards and the active participation and co-design role students may hold. Discussion: Due to the small size of UW/H, reforms can be tested quickly and implemented with ease and flexibility. This facilitates a "laboratory setting" for the testing of future-oriented innovations. The small size has allowed various concepts to be able to be used as models, thus serving as stimuli for larger change in medical studies in Germany.

Students with an autonomous role in hospital care - patients perceptions

BACKGROUND

There have been calls to enhance clinical education by strengthening supported active participation (SAP) of medical students in patient care. This study examines perceived quality of care when final-year medical students are integrated in hospital ward teams with an autonomous relationship toward their patients.

METHODS

We established three clinical education wards (CEWs) where final-year medical students were acting as "physician under supervision". A questionnaire-based mixed-method study of discharged patients was completed in 2009-15 using the Picker Inpatient Questionnaire complemented by specific questions on the impact of SAP. Results were compared with matched pairs of the same clinical specialty from the same hospital (CG1) and from nationwide hospitals (CG2). Patients free-text feedback about their hospital stay was qualitatively evaluated.

RESULTS

Of 1136 patients surveyed, 528 (46.2%) returned the questionnaire. The CEWs were highly recommended, with good overall quality of care and patient-physician/student-interaction, all being significantly (p < 0.001) higher for the CEW group while experienced medical treatment success was similar. Patient-centeredness of students was appreciated by patients as a support to a deeper understanding of their condition and treatment.

CONCLUSION

Our study indicates that SAP of final-year medical students is appreciated by patients with high overall quality of care and patient-centeredness.

Enhancing medical students' reflectivity in mentoring groups for professional development - a qualitative analysis

BACKGROUND

Professional competence is important in delivering high quality patient care, and it can be enhanced by reflection and reflective discourse e.g. in mentoring groups. However, students are often reluctant though to engage in this discourse. A group mentoring program involving all preclinical students as well as faculty members and co-mentoring clinical students was initiated at Witten-Herdecke University. This study explores both the attitudes of those students towards such a program and factors that might hinder or enhance how students engage in reflective discourse.

METHODS

A qualitative design was applied using semi-structured focus group interviews with preclinical students and semi-structured individual interviews with mentors and co-mentors. The interview data were analyzed using thematic content analysis.

RESULTS

Students' attitudes towards reflective discourse on professional challenges were diverse. Some students valued the new program and named positive outcomes regarding several features of professional development. Enriching experiences were described. Others expressed aversive attitudes. Three reasons for these were given: unclear goals and benefits, interpersonal problems within the groups hindering development and intrapersonal issues such as insecurity and traditional views of medical education. Participants mentioned several program setup factors that could enhance how students engage in such groups: explaining the program thoroughly, setting expectations and integrating the reflective discourse in a meaningful way into the curriculum, obliging participation without coercion, developing a sense of security, trust and interest in each other within the groups, randomizing group composition and facilitating group moderators as positive peer and faculty role models and as learning group members.

CONCLUSIONS

A well-designed and empathetic setup of group mentoring programs can help raise openness towards engaging in meaningful reflective discourse. Reflection on and communication of professional challenges can, in turn, improve professional development, which is essential for high quality patient care.

Reflective practice and its role in facilitating creative responses to dilemmas within clinical communication - a qualitative analysis

BACKGROUND

Good communication is a major factor in delivering high quality in care. Research indicates that current communication skills training alone might not sufficiently enable students to find context-specific creative solutions to individual complex personal and interpersonal challenges in the clinical context. This study explores medical students' experiences with real communication dilemmas in a facilitated group setting. The aims were to gain a better understanding of whether and, if so, how reflective practice can enhance students' ability to find creative individual solutions in difficult communication situations and to identify factors within the reflective setting that foster their creative competency.

METHODS

Thematic content analysis was used to perform a secondary analysis of semi-structured interview data from a qualitative evaluation of a group reflective practice training for final-year medical students. The categories that arose from the iterative deductive-inductive approach were analyzed in light of current scientific understandings of creativity.

RESULTS

Reflection on real difficult clinical communication situations appears to increase medical students' ability to handle such situations creatively. Although group reflection on clinical dilemmas involving personal aspects can stir up emotions, participating students stated they had learned a cognitive process tool that enhanced their communicative competence in clinical practice. They also described changes in personal attitudes: they felt more able to persevere and to tolerate ambiguity, described themselves more open and self-efficient in such complex clinical communication situations and thus more motivated. Furthermore, they reported on factors that were essential in this process, such as reflection on current and real challenges, a group format with a trainer.

CONCLUSIONS

Reflective practice providing a cognitive process tool and using real clinical challenges and trainer support in communication education may provide learners with the skills and attitudes to develop creativity in practice. Implementing reflection training in clinical communication education may increase students' overall communicative competency.

[Nail diseases in routine practice]

BACKGROUND

Nail problems are common reasons for patients presenting to dermatological and general practitioners practices.

PROBLEM

Which nail diseases should be known and recognized in routine daily practice?

MATERIAL AND METHODS

This article presents the most common nail alterations experienced by the authors from clinics and routine practices with guidelines on the diagnostics, therapy and additional literature.

RESULTS

Nail alterations can be designated as inflammatory nail dermatoses or neoplasms. Depending on the local nail findings, clinical investigations, patient history, histology if necessary and additional procedures, concrete indications can be derived for the correct diagnosis and therapy.

CONCLUSION

Knowledge of the most commonly occurring nail diseases allows a targeted classification and additional diagnostics which can help to alleviate pain, improve aesthetics and adequately treat malignant alterations.

Microvascular retinal abnormalities in acute intracerebral haemorrhage and lacunar infarction

BACKGROUND

Retinal microvascular changes have been previously associated with cerebral MRI markers of small vessel disease (SVD). Whether retinal changes differ between patient with intracerebral haemorrhage (ICH) and patients with lacunar infarction (LI) caused by small vessel disease has been poorly investigated.

OBJECTIVE

The study aims to compare the frequency of retinal changes between patients with LI and patients with ICH at the acute stage of stroke-related SVD.

METHODS

Microvascular wall signs (arteriolar occlusion, arteriovenous nicking, focal arterial narrowing) and retinopathy lesions (microanevrysms, cotton wool spots, retinal haemorrhages, hard exudates) were assessed by retinography up to three months after stroke onset.

RESULTS

Forty-eight non-diabetic patients with acute stroke-related to SVD (26 LI, 22 ICH) were recruited prospectively in the study. Retinal wall signs (arteriovenous nicking, and focal arterial narrowing) were found in more than three quarters of subjects and most often bilaterally in both groups. Retinopathy lesions (cotton wool spots, retinal haemorrhages) were found more frequently in ICH patients than in LI patients (22.2% vs. 15.4%, 50% vs. 34% respectively, P>0.005). The frequency of bilateral cotton wool spots and of bilateral retinal haemorrhages was significantly higher in ICH patients than in LI patients (12.5% vs. 0%, P=0.012, 41.2% vs. 7.7%, P=0.029 respectively).

CONCLUSION

These results confirm the high frequency of microvascular alterations in patients with hypertension-related SVD leading to LI or ICH and suggest that retinal tissue alterations are more frequent in ICH than in LI. Further investigations are needed to investigate the mechanisms underlying this difference.

A reflective practice intervention for professional development, reduced stress and improved patient care--a qualitative developmental evaluation

OBJECTIVE

Professional capabilities, such as empathy and patient-centeredness, decline during medical education. Reflective practice is advocated for teaching these capabilities. The Clinical Reflection Training (CRT) is a reflective practice intervention using the professional dilemmas faced by medical students during clinical practice. The aim of this study was to evaluate students' perceptions of the helpfulness of the CRT and its effects on their medical education.

METHODS

Eighteen semi-structured interviews were conducted with medical students who had participated in the CRT. Content analysis was used to analyze the interview data.

RESULTS

Medical students did not feel adequately prepared to manage the difficult personal and interpersonal problems frequently encountered in clinical practice. They reported that the CRT reduces stress, improves patient care and serves as a tool for professional development.

CONCLUSION

The CRT may be a useful tool for developing professionalism during medical education, reducing stress and enhancing the quality of patient care.

PRACTICE IMPLICATIONS

Providing students with reflective practice training that draws on their current personal clinical problems in order to improve their clinical work may be a productive investment in personal professional development, physician health, and quality improvement.

Integrative medical education: educational strategies and preliminary evaluation of the Integrated Curriculum for Anthroposophic Medicine (ICURAM)

OBJECTIVES

the development and preliminary evaluation of a new medical program aimed at educating students in patient-centered integrative care and developing appropriate educational strategies.

METHODS

The Integrated Curriculum for Anthroposophic Medicine (ICURAM) was developed with modules on anthroposophic medicine integrated into the full 6 years of the regular medical curriculum. The educational strategy is the ESPRI(2)T approach, combining Exploratory learning, Supported participation, Patient-based learning, Reflective practice, Integrated learning, an Integrative approach and Team-based learning. The student participation, assessed based on the number of credit points earned per year (ctp/year) through the ICURAM (1 ctp=30 h workload), served as a preliminary indicator of student interest.

RESULTS

Of the 412 55%medical students participated in the program: 16% full participation (≥ 4 ctp/year), 18% partial participation (1-3.99 ctp/year) and 22% occasional participation (0.25-0.99 ctp/year). The amount of additional workload taken on by students was between 7.8h/year for occasional participants, 33 h/year for partial participants and 84 h/year for full participants.

CONCLUSION

More than half of medical students were willing to invest a significant amount of additional time in the optional program.

PRACTICE IMPLICATIONS

An integrative medical curriculum with a student-centered educational strategy seems to be of interest to most medical students.

Investigation of the male pattern baldness major genetic susceptibility loci AR/EDA2R and 20p11 in female pattern hair loss

BACKGROUND

The aetiology of female pattern hair loss (FPHL) is largely unknown. However, it is hypothesized that FPHL and male pattern baldness (AGA) share common susceptibility alleles. The two major susceptibility loci for AGA are the androgen receptor (AR)/ectodysplasin A2 receptor (EDA2R) locus on the X-chromosome, and a locus on chromosome 20p11, for which no candidate gene has yet been identified.

OBJECTIVES

To examine the role of the AR/EDA2R and 20p11 loci in the development of FPHL using 145 U.K. and 85 German patients with FPHL, 179 U.K. supercontrols and 150 German blood donors.

METHODS

Patients and controls were genotyped for 25 single nucleotide polymorphisms (SNPs) at the AR/EDA2R locus and five SNPs at the 20p11 locus.

RESULTS

Analysis of the AR/EDA2R locus revealed no significant association in the German sample. However, a nominally significant association for a single SNP (rs1397631) was found in the U.K. sample. Subgroup analysis of the U.K. patients revealed significant association for seven markers in patients with an early onset (P = 0·047 after adjustment for the testing of multiple SNPs by Monte Carlo simulation). No significant association was obtained for the five 20p11 variants, either in the overall samples or in the analysis of subgroups.

CONCLUSIONS

The observed association suggests that the AR/EDA2R locus confers susceptibility to early-onset FHPL. Our results do not implicate the 20p11 locus in the aetiology of FPHL.

Physician empathy: definition, outcome-relevance and its measurement in patient care and medical education

OBJECTIVE

The present study gives a brief introduction into 1. the definition of physician empathy (PE) and 2. its influence on patients' health outcomes. Furthermore 3. we present assessment instruments to measure PE from the perspective of the patient and medical student. The latter topic will be explored in detail as we conducted a pilot study on the German versions of two self-assessment instruments of empathy, which are mostly used in medical education research, namely the "Jefferson Scale of Physician Empathy, Student Version" (JSPE-S) and the "Interpersonal Reactivity Index" (IRI).

METHODS

We first present an overview of the current empirical and theoretical literature on the definition and outcome-relevance of PE. Additionally, we conducted basic psychometric analyses of the German versions of the JSPE-S and the IRI. Data for this analyses is based on a cross-sectional pilot-survey in N=44 medical students and N=63 students of other disciplines from the University of Cologne.

RESULTS

PE includes the understanding of the patient as well as verbal and non-verbal communication, which should result in a helpful therapeutic action of the physician. Patients' health outcomes in different healthcare settings can be improved considerably from a high quality empathic encounter with their clinician. Basic psychometric results of the German JSPE-S and IRI measures show first promising results.

CONCLUSION

PE as an essential and outcome-relevant element in the patient-physician relationship requires more consideration in the education of medical students and, thus, in medical education research. The German versions of the JSPE-S and IRI measures seem to be promising means to evaluate these education aims and to conduct medical education research on empathy.

Measurement of the ZZ production cross section and limits on anomalous neutral triple gauge couplings in proton-proton collisions at sqrt[s] = 7 TeV with the ATLAS detector

A measurement of the ZZ production cross section in proton-proton collisions at sqrt[s] = 7 TeV using data corresponding to an integrated luminosity of 1.02 fb(-1) recorded by the ATLAS experiment at the LHC is presented. Twelve events containing two Z boson candidates decaying to electrons and/or muons are observed, with an expected background of 0.3 ± 0.3(stat)(-0.3)(+0.4)(syst) events. The cross section measured in a phase-space region with good detector acceptance and for dilepton masses within the range 66 to 116 GeV is σ(ZZ → ℓ+ ℓ- ℓ+ ℓ-)(fid) = 19.4(-5.2)(+6.3)(stat)(-0.7)(+0.9)(syst) ± 0.7(lumi) fb. The resulting total cross section for on-shell ZZ production, σ(ZZ)(tot) = 8.5(-2.3)(+2.7)(stat)(-0.3)(+0.4)(syst) ± 0.3(lumi) pb, is consistent with the standard model expectation of 6.5(-0.2)(+0.3) pb calculated at the next-to-leading order in QCD. Limits on anomalous neutral triple gauge boson couplings are derived.

Search for sub-eV mass solar axions by the CERN Axion Solar Telescope with 3He buffer gas

The CERN Axion Solar Telescope (CAST) has extended its search for solar axions by using (3)He as a buffer gas. At T=1.8 K this allows for larger pressure settings and hence sensitivity to higher axion masses than our previous measurements with (4)He. With about 1 h of data taking at each of 252 different pressure settings we have scanned the axion mass range 0.39 eV≲m(a)≲0.64 eV. From the absence of excess x rays when the magnet was pointing to the Sun we set a typical upper limit on the axion-photon coupling of g(aγ)≲2.3×10(-10) GeV(-1) at 95% C.L., the exact value depending on the pressure setting. Kim-Shifman-Vainshtein-Zakharov axions are excluded at the upper end of our mass range, the first time ever for any solar axion search. In the future we will extend our search to m(a)≲1.15 eV, comfortably overlapping with cosmological hot dark matter bounds.

[Relevance and barriers of physician empathy in daily practice - current state of research and qualitative survey of physicians]

AIMS OF THE STUDY

The aim of this study was to investigate the relevance and the barriers of physician empathy in medical rehabilitation by conducting a narrative literature review and a qualitative survey in physicians.

METHODS

First, we described the current state of research of physician empathy in medical rehabilitation based on a narrative (non-systematic) review of the literature. Additionally, the questions of relevance and barriers of physician empathy were examined in a qualitative short survey with physicians from Rehabilitation Medicine, Internal Medicine, Pediatric and Family Medicine. The qualitative data were analyzed according to the summarizing content analysis of Mayring.

RESULTS

Only n=13 studies of physician empathy were conducted in Rehabilitation Medicine; of those, just a few were from Germany and a small number investigated the influence of empathy on patient health outcomes. The qualitative survey's results regarding the definition, patient outcomes and barriers of physician empathy are similar to other theoretical and empirical studies on those issues. Moreover, they show many new, practical aspects, particularly in the field of barriers of physician empathy.

CONCLUSION

Although physician empathy has been shown to be an outcome-relevant factor in acute health care, less attention has been paid to it in Rehabilitation research. Physicians from Rehabilitation Medicine, Internal Medicine, Pediatric and Family Medicine perceive empathic behavior also as an outcome-relevant ability, which is particularly hindered by time pressure and stress but also by personal and patient-specific factors.

Can patient-provider interaction increase the effectiveness of medical treatment or even substitute it?--an exploration on why and how to study the specific effect of the provider

OBJECTIVE

Numerous studies demonstrate the impact of high-quality patient-provider interaction (PPI) on health outcomes. However, transformation of these findings into clinical practice is still a crucial problem. One reason might be that health communication research rarely investigated whether PPI can increase the effectiveness of medical treatment and/or even substitute it. Therefore, our objective was to provide empirical and methodological background of why and how to investigate the specific effect of the provider on patients' health outcomes.

METHODS

This is a debate paper based on a narrative (non-systematic) literature review in Medline and PsycINFO without any year limitation.

RESULTS

Neurobiological evidence based on expectation and conditioning theory indicates that PPI is able to increase the effectiveness of medical treatment. Moreover, the use of creative RCT study designs described in this paper enables health communication researchers to investigate whether PPI is able to substitute medical treatment.

CONCLUSION

This paper exemplifies that there exist an evidence-based knowledge from neurobiology as well as creative RCT designs which enable researcher to investigate the specific effects of PPI.

PRACTICE IMPLICATIONS

Research on the specific effects of PPI requires intense reflection on which patient groups or types of illness are reasonable, suitable, and ethically justifiable for interventions.

[Effect of written patient information on knowledge and function of patients with acute uncomplicated back pain (PIK Study)]

BACKGROUND

If patients return early in the course of acute, uncomplicated back pain to their normal activities, their symptoms improve more quickly. Written detailed patient information can have a positive effect on knowledge and can increase physical activity. In this study the effect of a short evidence-based back pain leaflet on knowledge, function and patients' beliefs was investigated.

METHODS

A randomised controlled trial was carried out in 12 primary care practices. Patients with acute, uncomplicated back pain received either the back-pain specific information (intervention) or a leaflet without content regarding back pain (control). Participants' data were inquired before consultation of the general practitioner, as well as 1 week and 3 months later. Outcome measures were SF-36, FABQ-D, FFbH-R, knowledge concerning back pain, frequency of use of the leaflet, usefulness of the information and change of behaviour.

RESULTS

The included patients totaled 174. The response rates were 74.7% (1 week) and 67% (3 months). Patients receiving the intervention leaflet showed better knowledge at 1 week and greater improvement in function scores at 3 months. There was no effect on patients' beliefs. Patients of the intervention group reported more activity in everyday life.

CONCLUSION

Short written information may have small, in total possibly positive effects on knowledge, support of activity and function in patients with acute, uncomplicated back pain.

The TRAF1/C5 locus confers risk for familial and severe alopecia areata

BACKGROUND

Alopecia areata (AA) is a common hair loss disorder with a complex mode of inheritance. Autoimmune mechanisms are presumed to be crucial aetiologically. It is plausible that a number of autoimmune disorders may share a common genetic background. This phenomenon has been demonstrated in previous studies, which have shown an overlap of susceptibility alleles between AA and other autoimmune disorders. Recent studies have shown that genetic variants on the TRAF1/C5 (tumor necrosis factor receptor-associated factor 1, complement component 5) locus confer susceptibility to rheumatoid arthritis (RA).

OBJECTIVES

To examine the role of the TRAF1/C5 locus in the development of AA using a large sample of 1,195 patients with AA and 1280 controls.

METHODS

We genotyped the two most significant single nucleotide polymorphisms (SNPs) (rs10818488, rs2416808) from a former RA candidate gene study. After having obtained evidence for association, we performed a fine-mapping study and genotyped the locus with an additional 27 SNPs.

RESULTS

While no significant result was obtained for the overall sample, rs2416808 showed significant associations in the analysis of the subgroups with severe AA and with a positive family history. The most significant P-value for rs2416808 was in familial cases (P = 0.004, P(corr) = 0.026). The fine mapping revealed significant associations for four additional SNPs in the analysis of subgroups, with rs2416808 remaining the most significant marker.

CONCLUSIONS

Our results point to the involvement of the TRAF1/C5 locus in the aetiology of familial and severe AA, and provide further support for a shared aetiology between AA and other autoimmune disorders.

The R620W polymorphism in PTPN22 confers general susceptibility for the development of alopecia areata

BACKGROUND

The functional R620W (c.1858C>T) variant of the protein tyrosine phosphatase nonreceptor 22 gene (PTPN22) has been associated with a variety of autoimmune disorders. A recent study has suggested that R620W also contributes to the severe form of alopecia areata (AA).

OBJECTIVES

We sought to replicate the finding of an association between PTPN22 and severe AA. In addition, we wanted to study the effect of PTPN22 on the general risk to develop AA and on other subtypes of AA (mild AA, early/late age at onset, positive/negative family history).

METHODS

The R620W variant was genotyped in a large case-control sample of Belgian-German origin with 435 patients and 628 controls.

RESULTS

Significant results were obtained for the overall collective of patients with AA (P=0.007). Subdividing the sample according to severity of AA, family history and age at onset, we detected lowest P-values for patients with the severe form of AA (Pcorr=0.036), with a positive family history (Pcorr=0.042) and with an age at onset<or=20 years (Pcorr=0.048).

CONCLUSIONS

Our results suggest the R620W variant of PTPN22 as a general risk factor in AA with the strongest effect observed among patients with a severe type of AA, a positive family history or an early onset of disease.

Silicon drift and pixel devices for X-ray imaging and spectroscopy

Starting from the basic photon detection process in semiconductors, the function, principles and properties of sophisticated silicon detectors are discussed. These detectors are based on, or inspired by, the semiconductor drift detector. They have already shown their potential in X-ray astronomy (pn-CCD) and in X-ray spectroscopy (silicon drift diode), and further detector types (DEPFET pixel detector and macro-pixel detector) are under development for several other future experiments. The detectors seem to be very well suited for synchrotron radiation experiments.

First results from the CERN axion solar telescope

Hypothetical axionlike particles with a two-photon interaction would be produced in the sun by the Primakoff process. In a laboratory magnetic field ("axion helioscope"), they would be transformed into x-rays with energies of a few keV. Using a decommissioned Large Hadron Collider test magnet, the CERN Axion Solar Telescope ran for about 6 months during 2003. The first results from the analysis of these data are presented here. No signal above background was observed, implying an upper limit to the axion-photon coupling g(agamma)<1.16x10(-10) GeV-1 at 95% C.L. for m(a) less, similar 0.02 eV. This limit, assumption-free, is comparable to the limit from stellar energy-loss arguments and considerably more restrictive than any previous experiment over a broad range of axion masses.

Efficacy and tolerability of acetazolamide in migraine prophylaxis: a randomised placebo-controlled trial

BACKGROUND

Familial hemiplegic migraine and episodic ataxia type 2 (EA2) are allelic disorders with distinct types of mutations in the CACNA1A gene. EA2 attacks are remarkably sensitive to acetazolamide, a carbonic anhydrase inhibitor. The effectiveness of acetazolamide in migraine prophylaxis is unknown.

OBJECTIVES

To evaluate the efficacy and the tolerability of acetazolamide in migraine prophylaxis.

METHODS

We compared daily oral 500 mg acetazolamide and placebo in patients with migraine in a multicentre, double-blind, randomised trial of 12 weeks duration after a run-in period of 4 weeks without treatment. Frequency of attacks at the last trial period of 4 weeks was the primary efficacy criterion. Secondary efficacy criteria were the frequency of attacks per 4 weeks, the severity and duration of attacks, the number of hours with migraine as well as the number of responders with more than 50% reduction in attack frequency.

RESULTS

53 patients had been enrolled when the study was prematurely stopped because of a high number of withdrawals (34%), primarily linked to acetazolamide related side effects. Considering the primary and secondary efficacy criteria, among the 53 included patients (27 in the placebo group and 26 in the acetazolamide group), no difference between the 2 study groups could be demonstrated. The most frequent adverse events related to acetazolamide were paresthesias and asthenia.

CONCLUSIONS

In this trial, migraine sufferers poorly tolerated acetazolamide given in an oral dose of 500 mg daily. No obvious prophylactic beneficial effect of acetazolamide appeared on migraine attacks.

Rad54 protein stimulates heteroduplex DNA formation in the synaptic phase of DNA strand exchange via specific interactions with the presynaptic Rad51 nucleoprotein filament

RAD54 is an important member of the RAD52 group of genes that carry out recombinational repair of DNA damage in the yeast Saccharomyces cerevisiae. Rad54 protein is a member of the Snf2/Swi2 protein family of DNA-dependent/stimulated ATPases, and its ATPase activity is crucial for Rad54 protein function. Rad54 protein and Rad54-K341R, a mutant protein defective in the Walker A box ATP-binding fold, were fused to glutathione-S-transferase (GST) and purified to near homogeneity. In vivo, GST-Rad54 protein carried out the functions required for methyl methanesulfonate sulfate (MMS), UV, and DSB repair. In vitro, GST-Rad54 protein exhibited dsDNA-specific ATPase activity. Rad54 protein stimulated Rad51/Rpa-mediated DNA strand exchange by specifically increasing the kinetics of joint molecule formation. This stimulation was accompanied by a concurrent increase in the formation of heteroduplex DNA. Our results suggest that Rad54 protein interacts specifically with established Rad51 nucleoprotein filaments before homology search on the duplex DNA and heteroduplex DNA formation. Rad54 protein did not stimulate DNA strand exchange by increasing presynaptic complex formation. We conclude that Rad54 protein acts during the synaptic phase of DNA strand exchange and after the formation of presynaptic Rad51 protein-ssDNA filaments.

Transient global amnesia, migraine, thalamic infarct, dihydroergotamine, and sumatriptan

This case report describes an episode of transient global amnesia that occurred during a migraine attack, which had been treated with vasoconstrictors. Magnetic resonance imaging showed a small lesion with an ischemic appearance in the right thalamus.

Psychiatric comorbidity is related to headache induced by chronic substance use in migraineurs

Headache centers have to deal with patients suffering from headache induced by chronic substance use which is a well-recognized complication of migraine treatment. The objective of this study was to compare psychiatric comorbidity between migraineurs with and without chronic substance use: 34 migrainous inpatients with chronic substance use were compared with 34 sex-matched noncomplicated migraineurs in a case-control study. The results showed a significantly higher prevalence of major depressive disorder, panic disorder, and social phobia in the patients with a history of chronic substance use. Consistently, anxious and depressive dimensions were significantly higher in these patients. Therefore, psychiatric morbidity may be linked to chronic substance use in migraineurs. This stresses the importance of psychiatric assessment and the need for appropriate treatment in such patients.

Dissociation of affect recognition and mood state from blunting in patients with schizophrenia

The present study was designed to investigate the relationships between expression, perception, and experience of emotion in schizophrenic patients with and without affective blunting. Cognitive processing speed, emotional perception, and emotional experience were assessed in 25 schizophrenic patients grouped according to scores on a measure of overt emotional expression (Rating Scale for Emotional Blunting). Results showed dissociation of emotional expression from emotional perception and emotional experience. Blunted schizophrenic patients were no more impaired in the perception of emotion (Profile of Nonverbal Sensitivity) than non-blunted schizophrenic patients. In addition, groups did not differ in intensity of emotional experience as quantified on the self-report of arousal state (Positive and Negative Affect Scales). Accuracy of perception and reported experience of emotion did not differ between groups as a function of emotional valence. Cognitive processing speed (Symbol Digit Modalities Test; SDMT) was related to blunting score and to perception accuracy, although the SDMT did not differ between groups. Results are discussed in terms of a neuropathological basis for impairment of emotional expression.

High-Resolution High-Count-Rate X-ray Spectroscopy with State-of-the-Art Silicon Detectors

For the European X-ray multi-mirror (XMM) satellite mission and the German X-ray satellite ABRIXAS, fully depleted pn-CCDs have been fabricated, enabling high-speed low-noise position-resolving X-ray spectroscopy. The detector was designed and fabricated with a homogeneously sensitive area of 36 cm(2). At 150 K it has a noise of 4 e(-) r.m.s., with a readout time of the total focal plane array of 4 ms. The maximum count rate for single-photon counting was 10(5) counts s(-1) under flat-field conditions. In the integration mode more than 10(9) counts s(-1) can be detected at 6 keV. Its position resolution is of the order of 100 micro m. The quantum efficiency is higher than 90% from carbon K X-rays (277 eV) up to 10 keV. New cylindrical silicon drift detectors have been designed, fabricated and tested. They comprise an integrated on-chip amplifier system with continuous reset, on-chip voltage divider, electron accumulation layer stabilizer, large area, homogeneous radiation entrance window and a drain for surface-generated leakage current. At count rates as high as 2 x 10(6) counts cm(-2) s(-1), they still show excellent spectroscopic behaviour at room-temperature operation in single-photon detection mode. The energy resolution at room temperature is 220 eV at 6 keV X-ray energy and 140 eV at 253 K, being achieved with Peltier coolers. These systems were operated at synchrotron light sources (ESRF, HASYLAB and NLS) as X-ray fluorescence spectrometers in scanning electron microscopes and as ultra low noise photodiodes. The operation of a multi-channel silicon drift detector system is already foreseen at synchrotron light sources for X-ray holography experiments. All systems are fabricated in planar technology having the detector and amplifiers monolithically integrated on high-resistivity silicon.

Angiotropic large-cell lymphoma with peripheral nerve and skeletal muscle involvement: early diagnosis and treatment

Angiotropic large-cell lymphoma is a disorder characterized by an intravascular proliferation of malignant lymphoid cells. We present a patient with polyradiculoneuropathy, myelopathy, and myopathy diagnosed by peripheral nerve and muscle biopsy, who was treated and remains in stable neurologic condition.

Antipsoriatic effect of fumaric acid derivatives. Results of a multicenter double-blind study in 100 patients

BACKGROUND

Psoriasis vulgaris may benefit from treatment with fumaric acid and/or its derivatives; however, because different preparations have been used, results have been contradictory and difficult to interpret.

OBJECTIVE

The purpose of this clinical trial was to evaluate the therapeutic value of fumaric acid derivatives.

METHODS

A randomized double-blind study was carried out in patients with psoriasis, comparing a well-characterized formulation of fumaric acid derivatives with placebo.

RESULTS

The results indicated statistically significant superiority of the fumaric acid derivatives over placebo. Adverse events (flush, gastrointestinal disturbances) were initially relatively frequent, but decreased thereafter.

CONCLUSION

Fumaric acid derivatives were found to be effective and safe in the treatment of psoriasis.

Effects of cyclosporin A on hair

Cyclosporin A (CSA) is an immunosuppressive agent that has provided new approaches in transplantation medicine and in the treatment of autoimmune diseases. One of the most common dermatological side effects of oral CSA is dose-dependent hypertrichosis. This stimulating effect on hair growth encouraged a number of investigators to use CSA not only in the treatment of alopecia areata (AA), but also in male pattern alopecia (MPA). While oral application proved successful, the beneficial effect of topical application was very limited in both AA and MPA.