What Impact Does Participation in a Communication Skills Training Program Have on Health Professionals' Communication Behaviors: Findings from a Qualitative Study.

Communication skills training can enhance health professionals' knowledge and repertoire of effective communication practices. This paper describes the conceptual model underlying a 3-day retreat communication skills training program, methods used for training, and participant perception of outcomes from the training using qualitative interviews. Repeated qualitative telephone interviews (approximately 6 months apart) with participants of a 3-day Clinical Consultation Skills Retreat. Fourteen participants (70% response, 57% doctors) took part at Time 1, with 12 participating at Time 2. Semi-structured interviews were recorded and transcribed, and directional content analysis was conducted to assess themes in areas of key learnings, implementation of skills, and barriers. The training was received very positively with participants valuing the small group learning, role play, and facilitator skills. Key learnings were grouped into two themes: (i) tips and strategies to use in clinical practice and (ii) communication frameworks/methods, with the second theme reflecting an awareness of different communication styles. Most participants had tried to implement their new skills, with implementation reported as a more deliberate activity at T1 than at T2. Those implementing the new skills noted more open conversations with patients. Practical barriers of lack of time and expectations of others were mentioned more often at T2. A 3-day retreat-based communication training program was positively received and had a positive impact on the use of new communication skills. While further work is needed to determine whether effects of training are evidenced in objective clinical behaviors, the positive longer-term benefits found suggest this work would be worthwhile.

A possible social relative reward effect: Influences of outcome inequity between rats during operant responding.

Social interactions/situations have dramatic influences on motivation. Creating animal models examining these influences promotes a better understanding of the psychological and biological underpinnings of social motivation. Rodents are sensitive to social history/experience during associative conditioning and food-sharing tasks. Would reward-oriented operant behavior be sensitive to social influences by showing a negative contrast-like effect when another organism obtains a greater value outcome? We used a side-by-side arrangement of operant response chambers wherein one animal obtained consistently high reward signaled by a discrete cue. The neighboring, experimental rat experienced different combinations of high and low reward trial sequences. Control conditions included distraction from a conspecific in the neighboring chamber (rat distractor) or cue/food dispenser operating without a conspecific (program distractor) in addition to testing subjects alone. Results support an influence of the other animal actively performing the task on the experimental subject's behavior. Primarily, responding was significantly slower for the low reward trials while the neighboring rat was receiving the higher magnitude reward. The lever-press and not food-cup retrieval latency was significantly slower during exposure to a conspecific neighbor performing the operant task. The effect was not obtained in all session sequences and was more pronounced using longer series of consecutive low reward trials. The slowing effect was also obtained with the program-distractor experience in a different trial sequence. These findings suggest a social-induced negative incentive contrast effect in rats possibly mediated by an outcome inequity process that could have key similarities to complex situational-affective effects on motivation involving frustration or jealously.

Relative reward effects on operant behavior: Incentive contrast, induction and variety effects.

Comparing different rewards automatically produces dynamic relative outcome effects on behavior. Each new outcome exposure is to an updated version evaluated relative to alternatives. Relative reward effects include incentive contrast, positive induction and variety effects. The present study utilized a novel behavioral design to examine relative reward effects on a chain of operant behavior using auditory cues. Incentive contrast is the most often examined effect and focuses on increases or decreases in behavioral performance after value upshifts (positive) or downshifts (negative) relative to another outcome. We examined the impact of comparing two reward outcomes in a repeated measures design with three sessions: a single outcome and a mixed outcome and a final single outcome session. Relative reward effects should be apparent when comparing trials for the identical outcome between the single and mixed session types. An auditory cue triggered a series of operant responses (nosepoke-leverpress-food retrieval), and we measured possible contrast effects for different reward magnitude combinations. We found positive contrast for trials with the greatest magnitude differential but positive induction or variety effects in other combinations. This behavioral task could be useful for analyzing environmental or neurobiological factors involved in reward comparisons, decision-making and choice during instrumental, goal-directed action.

Attitudes and perceptions of pediatric residents on transitioning to CPOE.

BACKGROUND: Many resident physicians have experienced transitioning from traditional paper documentation and ordering to an electronic process during their training. OBJECTIVE: We sought to investigate the attitudes and perceptions of residents related to implementation of computer provider order entry (CPOE) and clinical decision support (CDS). METHODS: Pediatric residents completed web-based surveys prior to CPOE implementation and at 6 months and 12 months after implementation. The survey assessed resident attitudes and perceptions related to CPOE and the use of CDS tools. Additionally, at 6 and 12 months, residents were asked how electronic medical record (EMR) resources might impact future career decisions. RESULTS: Prior to CPOE implementation, 70% of residents were looking forward to CPOE, but 28% did not want to transition from paper ordering. At 12 months post-implementation, 80% of residents favored CPOE over paper ordering and only 3.33% wished to revert to paper ordering. Residents reported an increase in time needed to enter admission orders 6-months after CPOE implementation. By 12 months post-implementation, there was no significant difference in perceived time to complete admission orders when compared to pre-CPOE responses. Most residents (91.67%) identified that overall EMR resources were an important factor when considering future employment opportunities. The most important factors included the degree of EMR implementation, technology resources and the amount of support staff. The least important factors included patient portal access and which EMR product is used. CONCLUSIONS: Overall, residents demonstrated a preference for CPOE compared to traditional paper order entry. Many residents remained unaware of CDS tools embedded within CPOE at the 12 month follow-up, but a majority of residents did find them helpful and felt more knowledgeable about current guidelines. EMR resources, including degree of EMR implementation, technology resources and support staff are likely to be important factors as residents take future employment opportunities into consideration.

Emotion and relative reward processing: an investigation on instrumental successive negative contrast and ultrasonic vocalizations in the rat.

Incentive contrast effects include changes in behavioral responses after a reward upshift (positive contrast) or downshift (negative contrast). Proposed influences on these behavioral changes are emotional state reactions after experiencing or anticipating a change in reward outcome. Rat ultrasonic vocalizations have been shown to be indicators of emotional state during behavior and anticipatory periods. The objective of the present study was to monitor rodent ultrasounds during incentive contrast using a classical runway procedure called instrumental successive negative contrast. The procedure is one that has been used often to examine incentive relativity because of its reliability in measuring negative contrast effects. Rats were trained to run in the alleyway to receive a high (12 pellets) or low magnitude (1 pellet) outcome. The high magnitude was then shifted to the low and running speeds in the alleyway for the reward and USV emission were compared. Replicating previous work, a negative contrast effect was observed with postshift running speeds significantly slower in the shifted group compared to the unshifted group. USVs did not follow the same pattern with an apparent lack of significant differences between the groups following the reward downshift. We also tested another group of animals using a visual predictive cue in the same runway test. When visual cues predicted high or low magnitude outcome, no incentive contrast was found for the running speeds following an outcome downshift, but a weak contrast effect was observed for the USV emission. These results demonstrate a separation between USVs and behavioral indicators of incentive contrast suggesting that concomitant shifts in negative affect may not be necessary for anticipatory relative reward processes.

Conversion of a single-facility pediatric antimicrobial stewardship program to multi-facility application with computerized provider order entry and clinical decision support.

OBJECTIVE: Antimicrobial stewardship programs (ASPs) help meet quality and safety goals with regard to antimicrobial use. Prior to CPOE implementation, the ASP at our pediatric tertiary hospital developed a paper-based order set containing recommendations for optimization of dosing. In adapting our ASP for CPOE, we aimed to preserve consistency in our ASP recommendations and expand ASP expertise to other hospitals in our health system. METHODS: Nine hospitals in our health system adopted pediatric CPOE and share a common domain (Cerner Millenium). ASP clinicians developed sixty individual electronic order sets (vendor reference PowerPlans) to be used independently or as part of larger electronic order sets. Analysis of incidents reported during CPOE implementation and medication variances reports was used to determine the effectiveness of the ASP adaptation. RESULTS: 769 unique PowerPlans were used 15,889 times in the first 30 days after CPOE implementation. Of these, 43 were PowerPlans included in the ASP design and were used a total of 1149 times (7.2% of all orders). During CPOE implementation, 437 incidents were documented, 1.1% of which were associated with ASP content or workflow. Additionally, analysis of medication variance following CPOE implementation showed that ASP errors accounted for 2.9% of total medication variances. DISCUSSION: ASP content and workflow accounted for proportionally fewer incidents than expected as compared to equally complex and frequently used CPOE content. CONCLUSION: Well-defined ASP recommendations and modular design strengthened successful CPOE implementation, as well as the adoption of specialized pediatric ASP expertise with other facilities.

Selective breeding for 50 kHz ultrasonic vocalization emission produces alterations in the ontogeny and regulation of rough-and-tumble play.

Ultrasonic vocalizations (USVs) are emitted by rodents and can signal either negative or positive affective states in social and nonsocial contexts. Our recent work has utilized selective breeding based upon the emission of 50 kHz USVs in response to standard cross species hand play-namely experimenters 'tickling' rats. Previous work has shown that high-tickle responsive animals (i.e., rats emitting abundant 50 kHz USVs) are gregarious and express enhanced positive emotional behaviors relative to animals exhibiting low 50 kHz USVs. The present study extends this work by examining the developmental profile of play behavior and the suppression of play behavior by predator (cat) odor in juvenile high-line and low-line animals. Results support dissociations in key play measures between these groups, with high-line animals emitting more dorsal contacts during play and low-line animals emitting more pinning behavior. For cat-odor induced play suppression, we found that high-line animals exhibit elevated suppression of play for a prolonged period compared to low-line rats. In contrast, low-line animals returned to normal levels of play just 1 day post-predator odor experience. These findings support the idea that emotional arousal may differ between these selectively bred groups, and extends previous work by demonstrating a possible influence of altered emotional learning and conditioning in these phenotypically different animals. One possibility is that high-line animals exhibit enhanced associative learning abilities leading to stronger negative contextual conditioning. These findings suggest that selection for positive or negative social-emotional phenotypes may also segregate genes that control emotional learning abilities in unanticipated ways.

Wistar-Kyoto rats as an animal model of anxiety vulnerability: support for a hypervigilance hypothesis.

Inbred Wistar-Kyoto (WKY) rats have been proposed as a model of anxiety vulnerability as they display behavioral inhibition and a constellation of learning and reactivity abnormalities relative to outbred Sprague-Dawley (SD) rats. Together, the behaviors of the WKY rat suggest a hypervigilant state that may contribute to its anxiety vulnerability. To test this hypothesis, open-field behavior, acoustic startle, pre-pulse inhibition and timing behavior were assessed in WKY and Sprague-Dawley (SD) rats. Timing behavior was evaluated using a modified version of the peak-interval timing procedure. Training and testing of timing first occurred without audio-visual (AV) interference. Following this initial test, AV interference was included on some trials. Overall, WKY rats took much longer to leave the center of the arena, made fewer line crossings, and reared less, than did SD rats. WKY rats showed much greater startle responses to acoustic stimuli and significantly greater pre-pulse inhibition than did the SD rats. During timing conditions without AV interference, timing accuracy for both strains was similar; peak times for WKY and SD rats were not different. During interference conditions, however, the timing behavior of the two strains was very different. Whereas peak times for SD rats were similar between non-interference and interference conditions, peak times for WKY rats were shorter and response rates higher in interference conditions than in non-interference conditions. The enhanced acoustic startle response, greater prepulse inhibition and altered timing behavior with audio-visual interference supports a characterization of WKY strain as hypervigilant and provides further evidence for the use of the WKY strain as a model of anxiety vulnerability.

Surgical intervention in children with Crohn's disease.

INTRODUCTION: Crohn's disease (CD) causes chronic inflammation of the gastrointestinal tract leading to extensive medical treatments and surgery with two thirds of patients having surgery over their lifetime. In this study, we reviewed the pediatric population at the British Columbia Children's Hospital diagnosed with CD and examined their demographics and treatments, in particular assessing those who ultimately underwent surgery. MATERIALS AND METHODS: Two hundred and eighty children (median age 11.9 years [CI 11.5-12.28]) diagnosed with CD from January 1994 to December 2003 were included. Demographic data were documented including age, ethnicity, duration of symptoms before diagnosis, treatment to date and surgical parameters. Comparison was made between operative and non-operative patients including involvement of disease, medical treatment, complications and recurrence of disease leading to repeat operations. RESULTS: Fifty-five (19.6%) children had surgical procedures. There was a significant increase in surgery in those patients who had not received immunomodulator therapy before surgery (odds ratio 1.95 [CI 1.02-3.73]). We also observed that those CD patients with extensive small intestinal involvement had lower likelihood of having surgery (odds ratio 0.386 [CI 0.145-1.033]). No significant difference was found between the two groups with regard to age of diagnosis (p = 0.41), duration of symptoms (p = 0.22), gender (p = 0.50) or ethnicity (p = 0.451). CONCLUSION: There was an increased incidence of surgery in those patients who were not treated with immunomodulator therapy. In addition, children with extensive as opposed to isolated small intestinal disease were less likely to have surgery in childhood.

Do rates of hospital admission for falls and hip fracture in elderly people vary by socio-economic status?

OBJECTIVE: To determine the relationship between hospital admissions for falls and hip fracture in elderly people and area characteristics such as socio-economic deprivation. STUDY DESIGN: Ecological study of routinely collected hospital admissions data for falls and hip fracture in people aged 75 years or over for 1992-1997, linked at electoral ward level with characteristics from census data. METHODS: In total, 42,293 and 17,390 admissions were identified for falls and hip fracture, respectively, from 858 electoral wards in Trent. Rate ratios (RRs) for hospital admissions for falls and hip fracture were calculated by the electoral wards' Townsend score divided by quintiles. RRs were estimated by negative binomial regression and adjusted for the ward characteristics of age, gender, ethnicity, rurality, proportion of elderly people living alone and distance from hospital. RESULTS: There was a small but statistically significant association at electoral ward level between hospital admissions for falls and the Townsend score, with the most deprived wards having a 10% higher admission rate for falls compared with the most affluent wards (adjusted RR 1.10, 95% CI 1.01-1.19). No association was found between hospital admission for hip fracture and deprivation (adjusted RR 1.05, 95% CI 0.95-1.16). CONCLUSION: There is some evidence of an association at electoral ward level between hospital admissions for falls and socio-economic deprivation, with higher rates in deprived areas. No such association was found for hip fracture. Further work is required to assess the impact of interventions on reducing inequalities in hospital admission rates for falls in elderly people.

NHS Direct: consistency of triage outcomes.

OBJECTIVES: To examine the consistency of triage outcomes by nurses using four types of computerised decision support software in NHS Direct. METHODS: 119 scenarios were constructed based on calls to ambulance services that had been assigned the lowest priority category by the emergency medical dispatch systems in use. These scenarios were presented to nurses working in four NHS Direct call centres using different computerised decision support software, including the NHS Clinical Assessment System. RESULTS: The overall level of agreement between the nurses using the four systems was "fair" rather than "moderate" or "good" (kappa=0.375, 95% CI: 0.34 to 0.41). For example, the proportion of calls triaged to accident and emergency departments varied from 22% (26 of 119) to 44% (53 of 119). Between 21% (25 of 119) and 31% (37 of 119) of these low priority ambulance calls were triaged back to the 999 ambulance service. No system had both high sensitivity and specificity for referral to accident and emergency services. CONCLUSIONS: There were large differences in outcome between nurses using different software systems to triage the same calls. If the variation is primarily attributable to the software then standardising on a single system will obviously eliminate this. As the calls were originally made to ambulance services and given the lowest priority, this study also suggests that if, in the future, ambulance services pass such calls to NHS Direct then at least a fifth of these may be passed back unless greater sensitivity in the selection of calls can be achieved.

Mass march of termites into the deadly trap.

Carnivorous pitcher plants of the genus Nepenthes are not usually very selective about their prey, catching anything that is careless enough to walk on their slippery peristome, but Nepenthes albomarginata is an exception. We show here that this plant uses a fringe of edible white hairs to lure and then trap its prey, which consists exclusively of termites in enormous numbers. This singular feature accounts for the specialization of N. albomarginata for one prey taxon, unique so far among carnivorous plants.

Comparative genomic hybridization detects multiple chromosomal amplifications and deletions in undifferentiated embryonal sarcoma of the liver.

Undifferentiated embryonal sarcoma (UES) is the third most common hepatic malignancy in children. Previous reports have described a broad range of complex cytogenetic abnormalities in individual cases of hepatic UES. Herein we report the cytogenetic findings of six cases of hepatic UES at our institution analyzed by conventional cytogenetic methods and comparative genomic hybridization (CGH). The CGH demonstrated several chromosomal gains and deletions in each case, but there was no specific abnormality seen in every case. Patterns of chromosomal changes included gains of chromosome 1q (four cases), 5p (four cases), 6q (four cases), 8p (three cases), and 12q (three cases), and losses of chromosome 9p (two cases), 11p (two cases), and chromosome 14 (three cases). The three cases in which CGH showed gains in the 12q region were studied specifically for amplifications of MDM2 and CDK4, two genes that have been shown to be amplified in other soft tissue sarcomas. However, Southern analysis showed no amplification of MDM2 or CDK4 in these three cases. Further analysis will be needed to determine the critical events in the pathogenesis of these malignant pediatric liver tumors.

Presentation of low anorectal malformations beyond the neonatal period.

OBJECTIVE: Anorectal malformations are usually diagnosed at birth, but some patients have presented to this institution beyond the early newborn period without recognition of their anorectal malformations. To quantify the extent of this problem, we undertook a review of all patients presenting to this hospital with anorectal malformations. METHODS: We reviewed all new cases of anorectal malformations treated at British Columbia's Children's Hospital during the past 11 years. We looked specifically at the time of diagnosis, patient age, sex and mode of presentation, the type of anorectal malformations, and any associated anomalies. RESULTS: One hundred twenty new cases of anorectal malformations were seen here, of whom, 15 patients (9 girls and 6 boys) presented beyond the early newborn period. Of these, 1 male infant was diagnosed at 2 weeks of age and another girl at 14 years of age. The remaining 13 presented between 3 and 11 months of age because of increasing constipation, usually associated with the introduction of solid foods. All had low anorectal malformations. Nine patients had at least 1 other feature of the VACTERL complex. CONCLUSIONS: Most anorectal malformations are identified at birth, but a significant number of the milder lesions may not be recognized until later. Therefore, this condition must be considered in older infants and children presenting with constipation, particularly if they also have cardiac or genitourinary anomalies. constipation, imperforate anus, VACTERL.

Undifferentiated embryonal sarcoma of the liver: results of clinical management in one center.

PURPOSE: This study was undertaken to review the authors' clinical experience with undifferentiated embryonal sarcoma of the liver (UES) in children, focusing on the clinical presentation and results of treatment. METHODS: A retrospective analysis of all children who have undergone treatment for UES during the 15-year period from 1984 through 1998 was performed. RESULTS: Seven patients (4 boys and 3 girls) ranging in age from 20 months to 12 years at the time of diagnosis were identified. All presented with large abdominal masses and normal liver function test results. All underwent complete tumor resection; trisegmentectomy was required in 4 of these cases. All patients received postoperative chemotherapy. Two patients suffered tumor recurrence at 12 and 29 months; both of these patients died of their disease. Another patient died of complications related to chemotherapy. The other 4 patients are alive with no evidence of disease after 19 to 150 months' follow-up. CONCLUSIONS: Undifferentiated embryonal sarcoma of the liver presents as a large hepatic tumor. Operative resection is difficult, but combined with adjuvant chemotherapy offers the best hope for cure.

Laparoscopy as a cause of a false-positive Meckel's scan.

A new cause of a false-positive result of a Meckel's scan is reported. An 11-year-old girl had a 3-week history of constant right lower quadrant pain that was initially managed by laparoscopic appendectomy. A repeated laparoscopy for persistent pain was nondiagnostic. A missed Meckel's diverticulum was considered as the cause of this pain, which prompted a Meckel scan. This scan revealed a periumbilical focus of activity that was interpreted as a Meckel's diverticulum attached to the anterior abdominal wall by a band. The laparotomy showed no Meckel's diverticulum. The false-positive result of the Meckel scan may be the result of inflammation from the periumbilical laparoscopic port site.

Tumor necrosis factor primes hepatocytes for DNA replication in the rat.

Signaling through tumor necrosis factor receptor type 1 (TNFR-1) using a pathway that involves nuclear factor kappaB (NF-kappaB), interleukin-6 (IL-6), and STAT3 is required for the initiation of liver regeneration. We have proposed that TNF primes hepatocytes to respond to the mitogenic effect of growth factors, but so far, there has been no experimental demonstration that TNF enhances growth factor responses of hepatocytes. To test this hypothesis, we infused hepatocyte growth factor (HGF) and transforming growth factor (TGF-) (40 microgram/24 h) directly into the portal vein of rats for 24 hours using osmotic pumps and determined whether TNF injection (5 microgram per rat) would significantly increase hepatocyte DNA labeling in these animals. All rats received 5-bromo-2'-deoxyuridine (BrdU) by intraperitoneal delivery during a 48-hour period (i.e., BrdU infusion continued for 24 hours after the end of growth factor administration). BrdU labeling in the liver was measured by both immunohistochemistry and flow cytometry, and the results obtained by these methods showed excellent concordance. The results demonstrate that TNF transiently activates NF-kappaB and STAT3 and increases the proliferative response of hepatocytes to HGF or TGF- by fourfold. Priming effects on hepatocyte DNA replication were also obtained with injection of lipopolysaccharide (LPS) and gadolinium chloride (GdCl3), agents that release TNF in the liver. Similarly to TNF, GdCl3 injection caused the activation of NF-kappaB and STAT3, reaching a maximum 8 to 12 hours after the injection. The results show that TNF acts as a primer to sensitize hepatocytes to the proliferative effects of growth factors and offers a mechanism to explain the initiation and progression phases of liver regeneration after partial hepatectomy (PH).