Opening up a tailored tutor qualification program for medical students to other healthcare students - a mixed-method study.

BACKGROUND: Peer-led tutorials are widely used in medical education to promote practical skills acquisition and support faculty staff. Typically, student tutors are custom trained for this specific task. We investigated whether opening up an existing medical tutor qualification program to other degree programs is successful in terms of acceptance among students, acquisition of tutor-specific and interprofessional competencies, and which factors contribute to success or failure. METHODS: We developed a two-day tutor qualification program and conducted it annually from 2016 to 2020 with medical and other healthcare students. At the end of each course, we administered a written survey in which the participants rated the following items: their attitudes towards interprofessional learning (using the UWE-IP-D Interprofessional Learning Scale), the interprofessional learning setting, the teaching approach, and their competency acquisition (each on a five-point Likert scale; 1 = strongly agree, 5 = strongly disagree). Furthermore, we assessed participants' qualitative feedback in free-text fields and performed inductive content analyses. RESULTS: The study participation rate was high (response rate 97%; medical students: n = 75; healthcare students: n = 22). Participants stated high levels of competency acquisition (total M = 1.59, individual items' M's ranging from 1.20 to 2.05) and even higher satisfaction with the teaching approach (total M = 1.28, individual items' M's ranging from 1.43 to 1.05). Overall satisfaction with the training was M = 1.22; SD = 0.58. No significant differences in ratings were found between the student groups. The qualitative results showed that students appreciated the interprofessional setting and experienced it as enriching. The most positive feedback was found in didactics/teaching methods on role-plays and group work; most suggestions for improvement were found in the area of structure and organisation on breaks and time management. CONCLUSIONS: Opening up an existing medical tutor qualification program to other student groups can be seen as fruitful to teach not only tutor-related aspects but also interprofessional competencies. The results demonstrate the importance of detailed planning that considers group composition and contextual conditions and provides interactive teaching methods to promote interprofessional experiences. This study offers important information about prerequisites and methodological implementation that could be important for the interprofessional redesign of existing training programs.

Students' Perceptions on an Interprofessional Ward Round Training - A Qualitative Pilot Study.

INTRODUCTION: Ward rounds are an essential activity for interprofessional teams in hospital settings and represent complex tasks requiring not only medical knowledge but also communication skills, clinical technical skills, patient management skills and team-work skills. The present study aimed to analyse final year students', nurses' as well as physiotherapists' views on a simulation-based interprofessional ward round training. METHODS: In two successive passes a total number of 29 final year students, nursing students and physiotherapy students (16 in the first run, 13 in the second) volunteered to participate in two standardized patient ward round scenarios: (1) patient with myocardial infarction, and (2) patient with poorly controlled diabetes. Views on the interprofessional ward round training were assessed using focus groups. RESULTS: Focus group based feedback contained two main categories (A) ward round training benefits and (B) difficulties. Positive aspects enfolded course preparation, setting of the training, the involvement of the participants during training and the positive learning atmosphere. Difficulties were seen in the flawed atmosphere and realization of ward rounds in the daily clinical setting with respect to inter-professional aspects, and course benefit for the different professional groups. CONCLUSION: The presented inter-professional ward round training represents a well received and valuable model of interprofessional learning. Further research should assess its effectiveness, processes of interprofessional interplay and transfer into clinical practice.

Spiral brush cervical biopsy experience in a community clinic.

OBJECTIVE: This article seeks to demonstrate the experience of implementing the spiral brush in several community clinic locales. Before the introduction of the spiral brush cervical biopsy in 2002 there were few alternatives to colposcopy directed punch biopsy when evaluating and managing abnormal dysplastic Papanicolaou (pap) smear or a visually abnormal cervix. Subsequent investigations validated the spiral brush usage but there are limited reports for its implementation in primary care colposcopy. PATIENTS AND METHODS: Over a two year period (2004-2006) patients with internal referrals for colposcopy received the spiral brush cervical biopsy. Those that resulted in the diagnoses of high grade squamous intraepithelial lesion (HSIL) diagnoses (CIN2-3) were compared to the final pathology diagnosis from the loop excision specimen. RESULTS: 15 cases of HSIL were identified with subsequent loop excision. Comparison of the pathology diagnosis from the loop excision and the spiral brush biopsy resulted in 13.3% (n=2) of cases differing. In both cases, low grade squamous intraepithelial lesion (LSIL) diagnoses (CIN1) were found whereas the remainder had the same diagnosis of HSIL. CONCLUSIONS: These results showed acceptable rates of concordance with traditional pathology specimens which supports the use of this Food and Drug Administration (FDA) approved device within a primary care setting.

[Stability of long-term professional objectives of young physicians during postgraduate training. Results of a multicenter cohort study]. / Stabilität der beruflichen Endziele im Verlauf der fachärztlichen Weiterbildung. Ergebnisse einer multizentrischen Kohortenstudie mit zweijährigem Intervall.

INTRODUCTION: We investigated persistences and changes of career preferences of medical residents in Germany after two years of postgraduate training with regard to future working place and position. The results are compared with those forwarded at graduation from medical school in a gender comparative perspective. METHODS: The study is based on a standardized postal survey among the participants in the "KarMed" study, originally based on 1012 graduates of the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg in 2009. 2107 persons were contacted. The return rate at baseline was 48 %, and the two surveys after the baseline reached return rates of 87 % and 89 % respectively. In all samples 2/3 were women as in actual medical undergraduate education. Descriptive statistics and regression analysis were performed. RESULTS: After 2 years of residency, residents after 2 years of postgraduate training still preferred the hospital over private practice as their final workplace after postgraduate training. The attractiveness of leading positions in the hospital declined among men, whereas it was already low for women at graduation. A large proportion of those physicians preferring the ambulatory sector, especially women, wishes to work as employee instead of private practice. At the personal level, almost 60 % forwarded the same preferences as those at graduation. Gender, parenthood and region of study (East vs. West Germany) did not influence stability or change of preferences. CONCLUSION: The results demonstrate the persistence of professional preferences regarding future sector and position of medical work during postgraduate training. These preferences do neither match with principles of gender equality nor with future workforce needs (e. g. in primary care).

[Resilience in chronic heart failure]. / Resilienz bei chronischer Herzinsuffizienz.

BACKGROUND AND OBJECTIVE: The study investigated correlates of resilience in chronic heart failure (CHF) patients suffering from a high somatic symptom burden and/or a clinical relevant depression. Furthermore, the resilience of the sample was compared to a representative sample of the German general population. METHODS: 186 patients with CHF and high symptom burden (82 depressed and 104 non depressed) were investigated. Resilience was assessed using the Resilience Scale from Wagnild and Young. For the comparison of resilience, the sample of the general population (372 persons) was matched against the CHF sample regarding the variables age and gender. RESULTS: There was a significant positive association of resilience with age and social support, whereas hopelessness and the inability to understand and describe emotions in the self (alexithymia) correlated negatively with resilience. Comparison with the general population revealed a significantly lower resilience in depressed CHF patients. CONCLUSIONS: Resilience seems to be predominantly associated to psychosocial variables such as age or social support rather than to disease-specific parameters such as left ventricular ejection fraction or NYHA functional class. Our finding that resilience is especially low in depressed CHF patients underscores the clinical relevance of depression in CHF, necessitating further research regarding the improvement of resilience and depression.

[The professional and private situation of male and female physicians entering postgraduate medical education in Germany]. / Die berufliche und private Situation von Ärztinnen und Ärzten zu Beginn der fachärztlichen Weiterbildung.

AIM: This study investigated the professional and the private situation of medical interns at the onset of their postgraduate training in Germany. We analysed the contractual situation and the working hours in the hospital, the professional situation of the partner and the number of hours invested in private life with special reference to gender and children. METHOD: A standardised postal survey was conducted among all last year medical students in the medical faculties of Erlangen, Giessen, Hamburg, Heidelberg, Cologne, Leipzig and Magdeburg after entering postgraduate training. 1 009 were contacted for a first follow-up one year later and 87% responded. Descriptive statistics and regression analysis were performed. RESULTS: The analysis shows that female physicians are disadvantaged compared to males with regard to various professional and private conditions relevant for career development, especially when children are present. We found a large number of hints pointing towards a persistence of traditional role patterns within the couple relationship. These conditions differed substantially between the regions of former German Federal and former German Democratic Republic. CONCLUSIONS: A growing number of children in the study population in the course of the longitudinal analysis will show if these gender-related differences persist in the course of the training period and which influences on career development can be observed.

The A-allele of the common FTO gene variant rs9939609 complicates weight maintenance in severe obese patients.

OBJECTIVE: The A-allele of the fat mass and obesity-associated (FTO) gene variant rs9939609 has been associated with increased body weight, whereas no effect on weight loss during weight reduction programs has been observed. We questioned whether the AA-genotype interferes with weight stabilization after weight loss. DESIGN: We conducted a monocentric, longitudinal study involving obese individuals. The FTO gene variant rs9939609 was genotyped in participants attending a weight reduction program that was divided into two phases: a weight reduction period with formula diet (12 weeks) and a weight maintenance phase (40 weeks). Body weight, body mass index (BMI), blood pressure and concentrations of blood glucose, total cholesterol, low-density lipoprotein, high-density lipoprotein and triglycerides were determined in week 0 (T(0)), after 12 weeks (T(1)) and at the end in week 52 (T(2)). SUBJECTS: A total of 193 obese subjects aged between 18 and 72 years (129 female, 64 male; initial body weight: 122.4±22.3 kg, initial BMI: 41.8±6.7 kg m(-2)) were included. RESULTS: Genotyping revealed 32.1% TT-, 39.4% AT- and 28.5% AA-genotype carriers. At T (0), carriers of the AA-genotype had significantly higher body weight (P=0.04) and BMI (P=0.005) than carriers of the TT-genotype. Of the 193 participants, 68 discontinued and 125 completed the program. Dropout rate was not influenced by genotype (P=0.33). Completers with AA-genotype showed significantly lower additional weight loss during the weight maintenance phase than TT-genotype carriers (P=0.02). Furthermore, among participants facing weight regain during weight maintenance (n=52), more subjects were carrying the AA-genotype (P=0.006). No influence of genotype on weight reduction under formula diet was observed (P=0.32). CONCLUSION: In this program, the AA-genotype of rs9939609 was associated with a higher initial body weight and did influence success of weight stabilization. Thus, emphasizing the maintenance phase during a weight reduction program might result in better success for AA-genotype carriers.

[Anesthesiology education and training in Germany. Results from a representative questionnaire]. / Zur Lage der anästhesiologischen Weiter- und Fortbildung in Deutschland. Ergebnisse einer Repräsentativumfrage.

The aim of the present investigation, initiated by the German Academy of Education in Anaesthesiology (DAAF), was to obtain valid information about education and training strategies of German anaesthetists, in order to highlight weaknesses and strengths for better planning and performance of future efforts in this area. For this reason, a questionnaire with 23 items was distributed to 2000 German anaesthetists during the years 1993-1995 and of these 1290 questionnaires could then be evaluated (response rate 64.5%). The most important means of education and training were classical media such as text books and journals. Modern techniques such as videos, tapes or computer-assisted anaesthesia simulators were poorly used. Refresher courses, repetitoria and hospitations in other departments were, despite infrequent use, considered to be effective means of education and training and should be made more available. Systematic theoretical education was provided particularly seldom in most hospitals. Respondents considered anaesthetic complications and mishaps, intensive care and pain medicine to be the main top topics for continuing medical education. German anaesthetists seem highly motivated for education and training and spend on average about 5.5 h per week for personal learning and refreshing, a figure that is quite comparable to international standards. Hospital and department heads are mostly believed to have positive attitudes to education and training. Most respondents were in favour of strict rules for education and training measures, which includes the obligation to prove their certified attendance (as yet not required in Germany). On the other hand, the majority voted against making the continued recognition as a specialist in anaesthesiology dependent on completion of a performance control.

Heterogeneity of Kv2.1 mRNA expression and delayed rectifier current in single isolated myocytes from rat left ventricle.

Expression of the voltage-gated K(+) channel Kv2.1, a possible molecular correlate for the cardiac delayed rectifier current (I(K)), has recently been shown to vary between individual ventricular myocytes. The functional consequences of this cell-to-cell heterogeneity in Kv2.1 expression are not known. Using multiplex single-cell reverse transcriptase-polymerase chain reaction (RT-PCR), we detected Kv2.1 mRNA in 47% of isolated midmyocardial myocytes from the rat left ventricular free wall that were positive for alpha-myosin heavy chain mRNA (n=74). Whole-cell patch-clamp recordings demonstrated marked differences in the magnitude of I(K) (200 to 1450 pA at V(Pip)=40 mV) between individual myocytes of the same origin. Furthermore, the tetraethylammonium (TEA)-sensitive outward current (I(TEA)), known to be partly encoded by Kv2.1 in mice, revealed a wide range of current magnitudes between single cells (150 to 1130 pA at V(Pip)=40 mV). Combined patch-clamp recordings and multiplex single-cell RT-PCR analysis of the same myocytes, however, showed no differences in I(K) or I(TEA) magnitude or inactivation kinetics between myocytes expressing Kv2.1 mRNA and those that did not express Kv2.1 mRNA. In contrast, in all midmyocardial myocytes expressing the transient outward potassium current (I(to1)), Kv4 mRNA, which has been shown to underlie I(to1), was detected (n=10). These results indicate that I(K) heterogeneity among individual left ventricular myocytes cannot be explained by the distribution pattern of Kv2.1 mRNA. Other mechanisms besides Kv2.1 mRNA expression appear to determine magnitude and kinetics of I(K) in rat ventricular myocytes.

Regional alterations of repolarizing K+ currents among the left ventricular free wall of rats with ascending aortic stenosis.

The effect of cardiac hypertrophy on electrocardiogram (ECG), action potential duration (APD) and repolarizing K+ currents was investigated in epicardial, midmyocardial and endocardial myocytes isolated from the rat left ventricular free wall. Cardiac hypertrophy was induced by stenosis of the ascending aorta (AS), which led to an increased pressure load (+85 +/- 10 u1v1vZ mm11Z Hg) of the left ventricle; sham-operated animals served as controls. In ECG recordings from AS rats, the QTc interval was prolonged and the main vectors of the QRS complex and the T-wave pointed in opposite directions, indicating an abnormal sequence of repolarization. APD and K+ currents were recorded using the whole-cell patch-clamp technique. In the AS group, APD90 (90 % repolarization) was significantly prolonged in epicardial and midmyocardial, but not endocardial myocytes. Corresponding to the increase in APD, the magnitude of the transient outward K+ current (Ito1) was significantly smaller (-30 %) in epicardial and midmyocardial, but not endocardial myocytes. Inactivation and steady-state inactivation of Ito1 were not affected by hypertrophy. Recovery from inactivation was slightly prolonged in endocardial myocytes from AS rats. No differences in delayed rectifier currents (IK) or inwardly rectifying K+ currents (IK1) were detected between myocytes of the three regions of sham-operated or AS animals. However, both currents were reduced by AS. The present data show that cardiac hypertrophy caused by pressure overload leads to an increase in APD and a decrease in Ito1 primarily in epicardial and midmyocardial myocytes, which implies a major role of alterations in Ito1 for the reduced gradient in APD. The effects of AS on IK1 and IK may slightly counteract the decrease in APD gradient. The observed changes in APD and underlying ionic currents could well explain the alterations in repolarization observed in the ECG induced by cardiac hypertrophy.

Relationship between transient outward K+ current and Ca2+ influx in rat cardiac myocytes of endo- and epicardial origin.

1. The transient outward K+ current (Ito) is a major repolarizing ionic current in ventricular myocytes of several mammals. Recently it has been found that its magnitude depends on the origin of the myocyte and is regulated by a number of physiological and pathophysiological signals. 2. The relationship between the magnitude of Ito, action potential duration (APD) and Ca2+ influx (QCa) was studied in rat left ventricular myocytes of endo- and epicardial origin using whole-cell recordings and the action potential voltage-clamp method. 3. Under control conditions, in response to a depolarizing voltage step to +40 mV, Ito averaged 12.1 +/- 2.6 pA pF-1 in endocardial (n = 11) and 24.0 +/- 2.6 pA pF-1 in epicardial myocytes (n = 12; P < 0.01). APD90 (90 % repolarization) was twice as long in endocardial myocytes, whereas QCa inversely depended on the magnitude of Ito. L-type Ca2+ current density was similar in myocytes from both regions. 4. To determine the effects of controlled reductions of Ito on QCa, recordings were repeated in the presence of increasing concentrations of the Ito inhibitor 4-aminopyridine. 5. Inhibition of Ito by as little as 20 % more than doubled QCa in epicardial myocytes, whereas it had only a minor effect on QCa in myocytes of endocardial origin. Further inhibition of Ito led to a progressive increase in QCa in epicardial myocytes; at 90 % inhibition of Ito, QCa was four times larger than the control value. 6. We conclude that moderate changes in the magnitude of Ito strongly affect QCa primarily in epicardial regions. An alteration of Ito might therefore allow for a regional regulation of contractility during physiological and pathophysiological adaptations.

Functional and molecular differences between voltage-gated K+ channels of fast-spiking interneurons and pyramidal neurons of rat hippocampus.

We have examined gating and pharmacological characteristics of somatic K+ channels in fast-spiking interneurons and regularly spiking principal neurons of hippocampal slices. In nucleated patches isolated from basket cells of the dentate gyrus, a fast delayed rectifier K+ current component that was highly sensitive to tetraethylammonium (TEA) and 4-aminopyridine (4-AP) (half-maximal inhibitory concentrations <0.1 mM) predominated, contributing an average of 58% to the total K+ current in these cells. By contrast, in pyramidal neurons of the CA1 region a rapidly inactivating A-type K+ current component that was TEA-resistant prevailed, contributing 61% to the total K+ current. Both types of neurons also showed small amounts of the K+ current component mainly found in the other type of neuron and, in addition, a slow delayed rectifier K+ current component with intermediate properties (slow inactivation, intermediate sensitivity to TEA). Single-cell RT-PCR analysis of mRNA revealed that Kv3 (Kv3.1, Kv3.2) subunit transcripts were expressed in almost all (89%) of the interneurons but only in 17% of the pyramidal neurons. In contrast, Kv4 (Kv4.2, Kv4.3) subunit mRNAs were present in 87% of pyramidal neurons but only in 55% of interneurons. Selective block of fast delayed rectifier K+ channels, presumably assembled from Kv3 subunits, by 4-AP reduced substantially the action potential frequency in interneurons. These results indicate that the differential expression of Kv3 and Kv4 subunits shapes the action potential phenotypes of principal neurons and interneurons in the cortex.

The courageous follower.

With the recent changes in the delivery of medical care in the United States, physicians are being thrust into new and unsettling roles. Many are finding themselves for the first time in the role of the follower, subject to myriad types of leadership. Leaders frequently complain that leading physicians is like "herding cats." What are the characteristics of followers? Do physicians make good followers? This article examines the role of the "cats"--what is effective followership, why physicians may fall short in followership skills, and how physicians might become better "followers."

[Dangers and risks of thoracic drainage at the accident site]. / Gefahren und Risiken der am Unfallort gelegten Thoraxdrainagen.

For several years it has been argued that a chest tube should be placed at the scene of an accident if thoracic trauma is suspected. However, during emergency treatment in hospital it has been observed that a high number of such tubes have been placed incorrectly. To validate this impression, we conducted a retrospective analysis of the clinical course of 33 trauma victims who had chest tubes placed at the scene of accident. It was found that 39.4% of the chest tubes were placed completely incorrectly and 21.2% required some correction; 39.4% were placed correctly. In two cases (6.1%) life-threatening complications developed because of the chest tube, necessitating a thoracotomy in 1 patient and repeated pericardial punction in the other. Based on the results of our study we believe that a more critical attitude should be adopted to the placement of chest tubes at the scene of the accident.

Identification of a titratable lysine residue that determines sensitivity of kidney potassium channels (ROMK) to intracellular pH.

Potassium (K+) homeostasis is controlled by the secretion of K+ ions across the apical membrane of renal collecting duct cells through a low-conductance inwardly rectifying K+ channel. The sensitivity of this channel to intracellular pH is particularly high and assumed to play a key role in K+ homeostasis. Recently, the apical K+ channel has been cloned (ROMK1,2,3 = Kir1.1a, Kir1.1b and Kir1.1c) and the pH dependence of ROMK1 was shown to resemble closely that of the native apical K+ channel. It is reported here that the steep pH dependence of ROMK channels is determined by a single amino acid residue located in the N-terminus close to the first hydrophobic segment M1. Changing lysine (K) at position 80 to methionine (M) removed the sensitivity of ROMK1 channels to intracellular pH. In pH-insensitive IRK1 channels, the reverse mutation (M84K) introduced dependence on intracellular pH similar to that of ROMK1 wild-type. A detailed mutation analysis suggests that a shift in the apparent pKalpha of K80 underlies the pH regulation of ROMK1 channels in the physiological pH range.

Extracellular K+ and intracellular pH allosterically regulate renal Kir1.1 channels.

The channels that control K+ homeostasis by mediating K+ secretion across the apical membrane of renal tubular cells have recently been cloned and designated ROMK1, -2, and -3. Native apical K+ channels are indirectly regulated by the K+ concentration at the basolateral membrane through a cascade of intracellular second messengers. It is shown here that ROMK1 (Kir1.1) channels are also directly regulated by the extracellular (apical) K+ concentration, and that this K+ regulation is coupled to intracellular pH. The K+ regulation and its coupling to pH were assigned to different structural parts of the channel protein. K+ regulation is determined by the core region, which comprises the two hydrophobic segments M1 and M2 and the P region. Decoupling from pH was achieved by exchanging the N terminus of ROMK1 by that of the pH-insensitive channel IRK1 (Kir2.1). These results suggest an allosteric regulation of ROMK1 channels by extracellular K+ and intracellular pH, which may represent a novel link between K+ homeostasis and pH control.

Subunit-specific inhibition of inward-rectifier K+ channels by quinidine.

Distinct inward-rectifier K+ channel subunits were expressed in Xenopus oocytes and tested for their sensitivity to the channel blocker quinidine. The 'strong' inward-rectifier K+ channel IRK1 was inhibited by quinidine with an EC50 of 0.7 mM, while the 'weak' rectifier channel ROMK1 was only moderately inhibited. ROMK1(N171D)-IRK1C-term chimeric channels, which carry both sites for strong rectification of IRK1 channels (the negatively charged D171 in the second transmembrane domain and the IRK1-C-terminus including E224), displayed strong rectification like IRK1, but showed weak sensitivity to quinidine-like ROMK1, suggesting independence of quinidine binding and rectification mechanisms. Moreover, BIR10 and BIR11, two strong rectifier subunits originally cloned from rat brain, exerted subunit-specific sensitivity to quinidine, being much higher for BIR11. Quinidine blockade of IRK1 was not voltage-dependent, but strongly dependent on the pH in the superfusate. These results strongly suggest a subunit-specific interaction of inward-rectifier K+ channels with neutral quinidine within membrane lipid bilayers.

[Treatment of severe concomitant injuries in severely burned patients]. / Die Behandlung schwerer Begleitverletzungen beim Verbrennungspatienten.

Over a period of almost 6 years, 18 out of 320 burn patients treated in the burn centre had sustained additional severe trauma; for the most part the trauma was due to a motor vehicle accident or a fall. The risk of overlooking such additional injuries can be minimized by systematic examination and a team approach, the same as in normal multiple-trauma patients. Apart from the burn, life-threatening complications such as intra-abdominal bleeding or haemopneumothoracic injuries are to be treated immediately. In order to facilitate appropriate burn wound care and optimize mobilization, early internal or external fixation of unstable orthopaedic injuries should be performed as soon as possible. In our experience, operations carried out within 48 h after the injury have neither led to complications in wound healing nor to osteomyelitis.

[In vitro and in vivo studies of a temporary absorbable dressing]. / In-vitro- und in-vivo-Untersuchungen einer absorbierbaren temporären Wundabdeckung.

The major advantage of biodegradable synthetic wound dressings compared to other synthetic materials and biological tissue derivatives is avoidance of the necessity to change the dressing. The copolymer films used in this study were made of lactic and caproic acid. They pose no problems concerning immunology or transmission of diseases. Moreover, the substances released by degradation may possibly influence the process of wound healing. The material proved to be non-toxic and was used successfully as a carrier for cell culture with keratinocytes. The permeability for bacteria is determined by degradation. Evaluation of the bacteriological studies indicates secure protection against secondary contamination of the films for at least 15 days, however. Concerning application, dressing properties, wound healing and wound retraction, no disadvantages were found in comparison with the results of the competition's film Opsite. Based on these findings, the films are now used in a clinical study as a wound dressing for split-skin donor sites.