Development and evaluation of a software system for medical students to teach and practice anamnestic interviews with virtual patient avatars

BACKGROUND AND OBJECTIVES

Taking a medical history is a core competence of the diagnostic process. At the beginning of their study medical students need to learn and practice the necessary techniques, initially focusing on good structuring and completeness. For this purpose, an interactive software system (ViPATalk) was developed in which the student can train to pose questions to virtual patient avatars in free conversation. At the end, the student receives feedback on the completeness of the questioning and an explanation of the essential items. The use of this software was compared to the traditional format of student role play in a randomized trial.

METHODS

The central component of ViPATalk is a chatbot based on the AI language AIML, which generates an appropriate answer based on keywords in the student's question. To enable a realistic use, the student can enter the question via microphone (speech-to-text) and the answer generated by the chatbot is presented as a short video sequence, where the avatar is generated from a real image. Here, the transition between the sequences is seamless, resulting in a continuous movement of the avatar during the conversation.

RESULTS

The learning success by practicing with ViPATalk was tested in an anamnestic interview with actors as simulated patients. The completeness of the conversation was evaluated with regard to numerous aspects and also certain behaviors during the conversation. These results were compared with those after practicing using peer role play.

CONCLUSIONS

It was found that practicing with ViPATalk was mostly equivalent to the students' role play. In the subsequent survey of the students, the wish was expressed that the ViPATalk software should also be used as an online tool for self-study and that there should be more cases for practicing.

[Using simulated patients to test competency in child protection medicine in the third section of the medical examination]

During the COVID-19 pandemic, the third section of the medical examination could be performed with simulation patients. Simulations enable standardized examinations of medical competency according to the educational objectives of the national learning objectives catalogue. The evaluation of student's medical response to child abuse and neglect seems to be an appropriate opportunity to increase attention of prospective physicians for potential child abuse. The presented case reports the simulation of a pediatric nonaccidental trauma.

Implementation of online peer feedback for student self-reflection - first steps on the development of a feedback culture at a medical faculty

Objective: Acquisition and application of professional and personal competences is accompanied by the formation and consolidation of attitudes and values and is influenced by the norms and moods (trust and feedback culture) experienced in the learning environment in question [1]. In particular, feedback and peer feedback can have a positive influence on the learning progress and personal development of students [2], [3], [4]. The promotion of a culture of teaching and ultimately of trust or feedback, plays a special role in this [5]. The aim was therefore to structurally integrate feedback into the curriculum of a model study course in order to develop a feedback culture in which students can develop personally and professionally with the help of regular and constructive feedback. Methodology: Following an initial pilot phase in 2009, (peer) feedback was gradually integrated into the curriculum at the medical faculty, in the first instance through checklists and subsequently through an online questionnaire and direct interviews. The activities were regularly analyzed on the basis of student evaluations using the EvaSys evaluation software and semi-standardized questionnaire-based interviews with six students in 2009 and 13 students each in 2012 and 2013. Results: Initially, students felt that the trust and feedback culture at their location as being in need of improvement. There were uncertainties regarding the use of constructive feedback and making criticism but also trust issues regarding the expression of personal perceptions to faculty members. It was possible to document the increase in the acceptance of the offers in the course of their establishment by an improvement in student evaluation and an increase in the number of participants in the voluntary offers amongst others. Qualitative data showed that students had a more positive perception or assessment of the location's feedback concept as well as indications of improvements in the culture of trust at the location. The proportion of constructive free-text comments increased significantly by 11% to 99.4% compared to the previous year (t(3)=-3.79, p=0.04). Thus, in terms of the objective, an increase in feedback activities and their quality at the faculty was achieved. Conclusion: Feedback, its acceptance as well as the quality, can be positively influenced at a faculty. Change measures should be tested repeatedly in discussion with users regarding practicability in order to directly pick up implementation issues and obstacles so they can be remedied in the interests of the users. This can influence the development of a culture of trust and feedback and should promote the personal and professional development of students in the long term.

Effectiveness of training general practitioners to improve the implementation of brief stop-smoking advice in German primary care: study protocol of a pragmatic, 2-arm cluster randomised controlled trial (the ABCII trial)

Background

The German clinical guideline on tobacco addiction recommends that general practitioners (GPs) provide brief stop-smoking advice to their patients according to the “5A” or the much briefer “ABC” method, but its implementation is insufficient. A lack of training is one barrier for GPs to provide such advice. Moreover, the respective effectiveness of a 5A or ABC training regarding subsequent delivery of stop-smoking advice has not been investigated. We developed a training for GPs according to both methods, and conducted a pilot study with process evaluation to optimize the trainings according to the needs of GPs. This study aims at evaluating the effectiveness of both trainings.

Methods

A pragmatic 2-arm cluster randomised controlled trial with a pre-post data collection will be conducted in 48 GP practices in North Rhine-Westphalia (Germany). GPs will be randomised to receive a 3.5-h-training in delivering either 5A or ABC, including peer coaching and intensive role plays with professional actors. The patient-reported primary outcome (receipt of GP advice to quit: yes/no) and secondary outcomes (recommendation rates of smoking cessation treatments, group comparison (5A versus ABC): receipt of GP advice to quit) will be collected in smoking patients routinely consulting their GP within 4 weeks prior, and 4 weeks following the training. Additional secondary outcomes will be collected at 4, 12 and 26 weeks following the consultation: use of cessation treatments during the last quit attempt (if so) since the GP consultation, and point-prevalence abstinence rates. The primary data analysis will be conducted using a mixed-effects logistic regression model with random effects for the cluster variable.

Discussion

If the training increases the rates of delivery of stop-smoking advice, it would offer a low-threshold strategy for the guideline implementation in German primary care. Should one method prove superior, a more specific guideline recommendation can be proposed.

Trial registration

German Clinical Trials Register (DRKS00012786); registered on 22th August 2017, prior to the first patient in.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0986-8) contains supplementary material, which is available to authorized users.

Cultural Competence and Global Health: Perspectives for Medical Education - Position paper of the GMA Committee on Cultural Competence and Global Health

Introduction: Routine medical care in Germany, Austria and Switzerland is being increasingly impacted by the cultural and linguistic diversity of an ever more complex world. Both at home and as part of international student exchanges, medical students are confronted with different ways of thinking and acting in relation to health and disease. Despite an increasing number of courses on cultural competence and global health at German-speaking medical schools, systematic approaches are lacking on how to integrate this topic into medical curricula. Methodological approach: This paper is based on a structured consensus-building process by a multidisciplinary committee composed of faculty and students. In a first step, a qualitative online survey was carried out in order to establish an inventory of definitions and concepts. After the second step, in which a literature search was conducted and definitions of global health and transcultural and intercultural competence were clarified, recommendations were formulated regarding content, teaching and institutional infrastructure. Based on small-group work and large-group discussions, different perspectives and critical issues were compiled using multiple feedback loops that served to ensure quality. Results: An inventory on the national and international level showed that great heterogeneity exists in regard to definitions, teaching strategies, teaching formats and faculty qualification. Definitions and central aspects considered essential to medical education were thus established for the use of the terms "cultural competence" and "global health". Recommendations are given for implementation, ranging from practical realization to qualification of teaching staff and education research. Outlook: High-quality healthcare as a goal calls for the systematic internationalization of undergraduate medical education. In addition to offering specific courses on cultural competence and global health, synergies would be created through the integration of cultural competence and global health content into the curricula of already existing subject areas. The NKLM (the national competence-based catalogue of learning objectives for undergraduate medical education) would serve as a basis for this.

Interaction between interleukin 10 and interleukin 6 in human B-cell differentiation

Contrary to their opposing action on human T-lymphocytes and monocytes, both Interleukin (IL-)10 and IL-6 are potent differentiation factors of human B-cells. Both are known to induce immunoglobulin (Ig) production. The precise mechanism of this converging effect of IL-6 and IL-10 remains elusive, however. Here we investigated the role of IL-6 in the IL-10 dependent B-cell differentiation into Ig secreting cells. We found that co-stimulation of SAC-stimulated human peripheral B-lymphocytes with IL-10 and IL-6 exhibited no additive effect on Ig production over stimulation with IL-10 alone, and that IL-6 receptor blockade only mildly inhibited IL-10 induced Ig synthesis. In fact, we could show that stimulation of B-cells with IL-10 somewhat suppressed SAC induced autocrine IL-6 production. Despite this suppression IL-6 levels remained sufficiently high to stimulate its receptor, and IL-6 binding to the B-cell surface was not affected. The failure of IL-6 to exert an additional effect on SAC+IL-10 induced Ig production suggests that IL-10 may recruit components of the IL-6 intracellular pathway for Ig induction. In conclusion we could demonstrate that IL-10 acts on B-cell differentiation independently of autocrine IL-6 and that it had a considerably mild effect on B lymphocytic autocrine IL-6 secretion. This still allows an IL-6 effect in the presence of IL-10 which appears adaptive with a view to the converging effects of these two cytokines on human B lymphocytes. Our study thus adds to the appreciation of the complex cytokine regulation of the immune system.

Complete recovery of renal function in a Wilms' tumor patient after acute renal failure caused by autologous bone marrow transplantation (ABMT)

An autologous bone marrow transplantation (ABMT) was carried out on a 4-year-old boy following the second pulmonary relapse of a nephroblastoma. Glomerular and tubular function of the remaining kidney before ABMT was normal. Etoposide, carboplatin, and melphalan were used in the conditioning regimen. The patient developed acute renal failure (ARF), and hemodialysis was required for 3 weeks. The situation was further complicated by his requiring mechanical ventilation for 12 days. Today, the patient is in good general health and in stable remission 32 months after bone marrow transplantation. This report shows that even serious tubular and glomerular dysfunction may be completely reversible in children. The background for high-dose chemotherapy with ABMT or stem cell rescue is discussed.

High interleukin-10 serum levels are associated with fatal outcome in patients after bone marrow transplantation

IL-10 plays an important role in the control of immune reactions during systemic infection. Here, IL-10 serum levels were investigated in patients after BMT. The IL-10 levels correlated with the clinical course of the patients and with serum levels of C-reactive protein (CRP) and neopterin (NP). A total of 26 patients with AML (7), ALL (12), CML (2), NHL (3) and multifocal Ewing's sarcoma (2) had received autologous (10) or allogeneic (16) BMT from related (9) or unrelated donors (7). Routine serum samples were obtained prior to BMT and at days 46 and 100 after BMT. However, in patients with severe complications additional samples were drawn at individual points in time. Prior to BMT, IL-10 serum levels were not detectable in 24/24 patients. Post-BMT, 11 patients developed elevated IL-10 levels, of these eight died of complications (DOC), whereas only one of 15 patients with undetectable IL-10 died of complications, indicating that high IL-10 levels were significantly correlated with severe life-threatening complications (chi2, P < 0.01). To determine the pathomechanism and role of the increased IL-10 levels, they were correlated to the respective NP and CRP serum concentrations. CRP and NP concentrations were found significantly elevated in patients with detectable IL-10, indicating a severe acute phase reaction associated with macrophage activation. In conclusion, high IL-10 serum levels in patients after BMT were significantly associated with fatal outcome. Since IL-10 is a strong suppressor of T cell immunity, high IL-10 production in patients with severe complications such as septic shock or GVHD > grade II after BMT might lead to functional immunodeficiency contributing to the poor prognosis of these patients.

Decreased interleukin 10 and increased interferon-gamma production in patients with chronic graft-versus-host disease after allogeneic bone marrow transplantation

Ex vivo production of interleukin 10 (IL-10) and interferon-gamma (IFN-gamma) was investigated in patients with (n = 5) or without (n = 5) chronic graft-versus-host disease (cGVHD) after allogeneic BMT. Patients were matched for time after transplantation and type of transplant. Anti-CD3-induced IL-10 production in MNCs isolated from patients with cGVHD (range/median: 26-650 pg/10(6) MNC; 400 pg/10(6) MNC) was significantly reduced compared to patients without cGVHD (646-2662 pg/10(6) MNC; 1314 pg/10(6) MNC; P < 0.05) or healthy controls (679-6361 pg/10(6) MNC; 3054 pg/10(6) MNC, P < 0.01). In vitro inhibition of IL-10 by an anti-IL-10 monoclonal antibody enhanced the release of IFN-gamma by anti-CD3-stimulated MNCs from 354 +/- 34 pg/10(6) MNCs to 899 +/- 61 pg/10(6) MNCs. Thus, low IL-10 production may cause high IFN-gamma release. In anti-CD3-activated MNCs obtained from patients with cGVHD IFN-gamma production was significantly increased (324-3331 pg/10(6) MNC; 1849 pg/10(6) MNC) compared to healthy donors (127-900 pg/10(6) MNC; 305 pg/10(6) MNC P < 0.01). In addition, median IFN-gamma release by anti-CD3-activated MNCs obtained from patients without cGVHD (464 pg/10(6) MNC) was about five-fold lower than in patients with cGVHD. In contrast to cytokine production, the differential leukocyte count (percentages of monocytes, T cells and CD4/CD8 ratio) was essentially the same both in patients with or without cGVHD. Thus, a different activation of Th-1 and Th-2 cells by anti-CD3 may be responsible for the deviant cytokine productions in patients with cGVHD. In conclusion, we observed significantly decreased IL-10 production in patinets with cGVHD and an increased median IFN-gamma secretion, which may contribute to the altered cytokine production after allogeneic BMT leading to cGVHD. Thus, supplementing IL-10 may become a new strategy for preventing cGVHD.

Renal function after conditioning therapy for bone marrow transplantation in childhood

The knowledge of renal function in the course of BMT is poor. We prospectively investigated glomerular and tubular function in 42 children who underwent BMT because of malignancy. Seventeen children were transplanted autologously. Investigations were performed before and immediately after the conditioning regimen. Inulin and creatinine clearance, albuminuria, urine excretion of alpha 1-microglobulin, beta-N-acetylglucosaminidase, alanine-aminopeptidase, intestinal alkaline phosphatase, and Tamm-Horsfall-Protein as well as sodium- and phosphatreabsorption were measured. The patients were classified regarding use of total body irradiation (tTBI) in the conditioning regimen. BEFORE CR: Glomerular filtration rate (GFR) was not influenced by the underlying diagnosis or previous treatment. Mean GFR was elevated compared with the reference group. Microalbuminuria was elevated in 15% of patients, and mean levels were higher than in the reference group. Proximal tubular dysfunction was indicated by an elevated excretion of alpha 1-MG in 54%, of beta-NAG in 66%, of AAP in 40%, and of IAP in 47%. Fractional sodium excretion was abnormal in 21%, phosphate reabsorption in 5% and THP-excretion in 7% of the patients. AFTER CR: Creatinine clearance was not affected by CR. After CR alpha 1-MG, beta-NAG, FENa, AAP, and IAP were increased compared with values before CR. TP/Clcr was decreased. Excretion of THP was not altered by CR. In patients without fTBI there was a greater increase in alpha 1-MG excretion and decrease in phosphate reabsorption after CR compared with patients conditioned with fTBI. We conclude that significant proximal tubular dysfunction is present in about 50-60% of patients before and in nearly all alter CR. Distal tubular function was less severely affected. Severity of nephrotoxicity after CR did not correlate with pre-existing abnormalities.

Humoral immunodeficiency in patients after bone marrow transplantation

Ex vivo IgG production was determined in 17 children and adolescents and in 14 adult patients between 10 months and 6 years after BMT. Twenty-four patients received allogeneic transplants. Seven patients were transplanted with autografts. Seven patients received immunosuppressive therapy. B cells were purified by positive selection with a CD20 antibody. After IL-2 or IL-10 stimulation, IgG production of SAC-preactivated B cells in patients with immunosuppression (median/range: 11/4-15 ng/ml or 14210-29 ng/ml) was significantly reduced compared with patients receiving allogenic (30/3-860 ng/ml or 33/2-3431 ng/ml; P < 0.01) or autologous transplants (75/7-1431 ng/ml or 269-/7-13600 ng/ml, P < 0.01). In 14/31 patients ex vivo IgG production was defective. Investigations of B cell function in patients with defective IgG production was performed significantly earlier after BMT compared with patients with normal IgG production ex vivo (2 +/- 1 years vs 3.3 +/- 1.5 years; P < 0.05). In addition, only patients with a B cell deficiency received immunosuppression. However, patients ex vivo IgG produced by B cells was decreased, but IgG production/sIgG+ B cells was within range of healthy volunteers. The number of IgG-committed B cells in these patients was significantly reduced compared to patients without deficiency (23/19-45/microliter vs 100/14-336/microliter; P < 0.05), indicating an in vivo switching defect. Although IL-10 is known to induce IgG-isotype switching in vitro, production of IL-10 by anti-CD3 activated MNCs obtained from patients with a switching defect did not differ from patients without B cell defects (1699/400-2662 pg/ml vs 724-112-1826 pg/ml). In nine patients IgG production and IgG production/sIgG+ B cells were impaired. The number of sIgG+ B cells was not decreased compared with patients without B cell deficiency (115/18-288/microliter), indicating a defective terminal differentiation of IgG-committed B cells to plasma cells. Although autocrine IL-6 is essential for plasma cell formation of isotype-determined B cells, it was comparable in patients with a terminal deficiency and without deficiency (3838/583-5967 pg/ml vs 2423/1643-6184 pg/ml). However, IL-10 production by anti-CD3 activated MNCs in patients with a terminal B cell defect (426/54-2262 pg/ml, P < 0.05) was significantly lower than in patients without deficiency, indicating a deviant cytokine production by T cells which might in part account for the B cell defect. Defective isotype switching as well as impaired terminal differentiation of B cells were found. Further analysis of factors regulating isotype-switching in vivo as well as cytokine receptor expression or signalling processes of differentiation factors in activated B cells might help to characterize the nature of these B cell deficiencies after BMT.

[Significance of interleukin 10 for acute graft versus host disease in children and adolescents after allogenic bone marrow transplantation]

BACKGROUND

It has been shown that Interleukin 10 (IL-10) is able to inhibit alloreactivity in a mixed lymphocyte culture. Therefore, here IL-10 production in patients after allogeneic BMT was investigated and correlated with the incidence of acute GvHD.

PATIENTS

14 patients after allogeneic BMT have been investigated. Patients' age ranged from 2.6 to 22 yrs. (median 7 yrs.). Patients were diagnosed with Ewing's sarcoma (1), ALL (4), AML (3), CML (2), Wiskott-Aldrich Syndrome (WAS;1), MDS (1) and SAA (2). GvHD > II degrees occurred in 5/14 patients. As control served 20 healthy volunteers.

METHODS

Mononuclear cells (MNC's) isolated from patients and 20 healthy controls were stimulated with an anti-CD3 monoclonal antibody for 72 hr. IL-10 was detected in cell-free supernatants by ELISA.

RESULTS

Anti-CD3-induced IL-10 production in MNC's isolated from patients (range/median: 0-1579 pg/10(6) MNC; 221 pg/10(6) MNC) was significantly reduced compared to healthy controls (160-5093 pg/10(6) MNC; 1250 pg/10(6) MNC; p < 0.01). 4/5 patients with low IL-10 production, but only 1/9 with a normal IL-10 production presented with GvHD > II degrees (p < 0.05).

CONCLUSION

Ex vivo IL-10 production was decreased in about one third of patients early after allogeneic BMT. The low IL-10 production was associated with a significantly increased risk of severe GvHD. Thus, supplementation of IL-10 might become a useful therapy to prevent GvHD.

High dose consolidation with autologous stem cell rescue (ASCR) for nephroblastoma initially treated according to the SIOP 9/GPOH trial and study

Patients with nephroblastoma have a high risk of relapse if they present with stage IV and anaplastic histology or with extraregional lymph node involvement; at time of relapse, bad prognosis is heralded by recurrence in an irradiated region, second or subsequent relapse, early first relapse (6 months after nephrectomy), relapse with adverse histology, relapse in two or more organ systems and lymph node or bone metastases at relapse. For such patients, an attempt to increase survival by high-dose chemotherapy seems to be justified. In 8 children aged 7.3 years (3.8-14.7) treated within the German Nephroblastoma Study SIOP9/GPOH, high dose chemotherapy with autologous hematopoietic rescue was instituted for the following reasons: stage IV with anaplastic histology and extra-regional lymph nodes (1), second or subsequent pulmonary relapse (3), early relapse with diffuse pleural (1) or skeletal (1) dissemination, recurrence in irradiated area (1) and lung metastases after early local relapse (1). At megatherapy, the patients were in first (1), second (2), third (2) and fourth complete (2) or in partial remission (1). The high dose regimen consisted of carboplatin, etoposide and melphalan. Treatment related toxicity, all non-lethal, included acute but reversible renal failure (1), esophagitis with need of parenteral nutrition for 6 months (1), cardiomyopathy (3; chronic in 1). After a follow-up of 2.1 years (0.5-3.7), 6/8 patients survive in complete remission; for 5 of them who are in remission since > 18 months a recurrence is unlikely. Both children with local relapse died after a further recurrence 3 and 8 months after high dose treatment.

CONCLUSION

High dose consolidation with ASCR seems to effectively ameliorate the prognosis of patients with high risk nephroblastoma.

Interleukin-10 directly inhibits the interleukin-6 production in T-cells

IL-6 is a potent regulator of T-cell activation, proliferation and differentiation. Since IL-10 inhibits cytokine production by T cells, the effect of IL-10 on IL-6 production by T cells was investigated. IL-6 production by purified monocytes or T cells was detected from cell-free culture supernatants by ELISA after stimulation of the cells with LPS or an anti-CD3 monoclonal antibody for 3 days. Although the main source of IL-6 are LPS activated monocytes (29.6 +/- 10 ng/ml), T cells secreted sufficiently high levels of IL-6 (790 +/- 200 pg/ml) to stimulate the high affinity IL-6 receptor. IL-10 decreased anti-CD3 induced IL-6 mRNA expression by up to 80%. In addition, IL-10 significantly inhibited IL-6 release from T-cells. Highly purified, anti-CD3 activated T-cells secreted 600 +/- 150 pg/ml IL-6 compared to 21 +/- 2 pg/ml IL-6 following addition of IL-10 (10 ng/ml; P < 0.001). FACS analysis revealed a monocyte contamination of the T-cell preparations of less than 0.5%. In addition, no IL-1 production was detectable. Thus, in our experiments the effect of IL-10 on IL-6 production was independent of the presence of monocytes. Finally, inhibition of IL-6 production was not reversed by IL-2 (100 U/ml). In conclusion, IL-10 suppressed the synthesis of IL-6 by T-cells via a monocyte- and IL-2-independent mechanism. These results may help to understand the complex regulation of T-cell mediated cytokine production by IL-10.

Activation of protein kinase C induces de novo synthesis of the soluble interleukin-6 receptor in human B cells

The mechanism of protein kinase C (PKC) induced release of the soluble interleukin-6 receptor (sIL-6R) from human B cells was investigated. Phorbol myristat acetat (PMA)-induced activation of PKC significantly enhanced the release of sIL-6R from the human B-cell line SKW 6.4. The PMA effect was completely blocked by cycloheximide, whereas different inhibitors of proteases had no effect. In contrast to the effect on sIL-6R release, FACS analysis did not reveal any effect of PMA on the expression of IL-6R on the surface of SKW 6.4 cells. After 6 h of stimulation with PMA, analysis of mRNA expression using a polymerase chain reaction-(PCR)-assisted mRNA amplification assay, showed increased expression of a spliced mRNA encoding for a soluble form of IL-6R. Comparable to the results in SKW 6.4 cells, activation of purified human B cells with PMA induced a significant augmentation of sIL-6R release which was also sensitive to cycloheximide. In conclusion, a novel mechanism of sIL-6R release is reported involving de novo synthesis. Thus, sIL-6R release from human B cells is completely different compared with that described in hepatocytes, which involved rapid, proteolytic cleavage of the membrane-bound receptor but not de novo synthesis. The results of this study may help to understand the molecular control of sIL-6R release from human B cells.