An avenue to miscarriage: a case report.

Two men were wrongfully convicted of murder in 2017 and sentenced to life imprisonment. After a physical altercation inside a flat, the victim (A) was found dead approximately 60 m away outside a residential address. He had sustained a number of injuries including a stab wound to the left side of his neck which was found to have divided the right carotid artery. The location where A was found was not regarded as a crime scene and not subjected to a specialist forensic examination by scientists as it was assumed that the fatal injury was sustained in the flat. The pathologist, who subsequently carried out the autopsy on A, was not asked to attend the scene. A review of the blood distribution at the scene in conjunction with the pathology findings indicated however that the fatal neck wound had been inflicted outside the flat, near to where the victim was found. An appeal against the convictions for murder was upheld in 2021 and a re-trial ordered. Following this second trial, both accused were acquitted of murder and released from custody. The new pathology and blood pattern evidence introduced at the second trial was a major part of the defense strategy which led to the acquittal of the accused. The case illustrates that a more inclusive and detailed crime scene strategy had been undertaken, including an assessment of the bloodstains present, in conjunction with discussion with the pathologist, then the likelihood is that the two men subsequently charged with murder would have been eliminated as suspects and a miscarriage of justice would have been avoided.

Kinetics of Plasma Cell-Free DNA and Creatine Kinase in a Canine Model of Tissue Injury.

BACKGROUND: Cell-free DNA (cfDNA) comprises short, double-stranded circulating DNA sequences released from damaged cells. In people, cfDNA concentrations correlate well with disease severity and tissue damage. No reports are available regarding cfDNA kinetics in dogs. OBJECTIVES/HYPOTHESIS: Cell-free DNA will have a short biological half-life and would be able to stratify mild, moderate, and severe tissue injury. Our study aims were to determine the kinetics and biological half-life of cfDNA and to contrast them with those of creatine kinase (CK). ANIMALS: Three groups of 10 dogs undergoing open ovariohysterectomy, surgery for cranial cruciate ligament rupture (CCLR), or hemilaminectomy. METHODS: Plasma for cfDNA and CK analysis was collected at admission, at induction of anesthesia, postsurgery (time 0) and at 6, 12, 24, 36, 48, 60, and 72 hours after surgery. RESULTS: The biological half-life of plasma cfDNA and CK were 5.64 hours (95% confidence interval [CI 95], 4.36-7.98 hours) and 28.7 hours (CI95, 25.3-33.3 hours), respectively. In the hemilaminectomy group, cfDNA concentrations differed significantly from admission at 6-12 hours after surgery. Creatine kinase activity differed among the surgical groups and reached a peak 6 hours after surgery. In the ovariohysterectomy and CCLR groups, plasma CK activity 72 hours after surgery did not differ from admission activity of the ovariohysterectomy group. In contrast, in the hemilaminectomy group, plasma CK activity after 72 hours did not return to the ovariohysterectomy group admission activity. CONCLUSIONS AND CLINICAL IMPORTANCE: Plasma CK activity has a longer biological half-life than previously thought. In contrast to plasma CK activity, cfDNA has a short half-life and could be a useful marker for peracute severe tissue injury.

Saturated mutagenesis of ketoisovalerate decarboxylase V461 enabled specific synthesis of 1-pentanol via the ketoacid elongation cycle.

Iterative ketoacid elongation has been an essential tool in engineering artificial metabolism, in particular the synthetic alcohols. However, precise control of product specificity is still greatly challenged by the substrate promiscuity of the ketoacid decarboxylase, which unselectively hijacks ketoacid intermediates from the elongation cycle along with the target ketoacid. In this work, preferential tuning of the Lactococcus lactis ketoisovalerate decarboxylase (Kivd) specificity toward 1-pentanol synthesis was achieved via saturated mutagenesis of the key residue V461 followed by screening of the resulting alcohol spectrum. Substitution of V461 with the small and polar amino acid glycine or serine significantly improved the Kivd selectivity toward the 1-pentanol precursor 2-ketocaproate by lowering its catalytic efficiency for the upstream ketoacid 2-ketobutyrate and 2-ketovalerate. Conversely, replacing V461 with bulky or charged side chains displayed severely adverse effect. Increasing supply of the iterative addition unit acetyl-CoA by acetate feeding further drove 2-ketoacid flux into the elongation cycle and enhanced 1-pentanol productivity. The Kivd V461G variant enabled a 1-pentanol production specificity around 90% of the total alcohol content with or without oleyl alcohol extraction. This work adds insight to the selectivity of Kivd active site.

Engineering efficient production of itaconic acid from diverse substrates in Escherichia coli.

Itaconic acid is an excellent polymeric precursor with wide range of industrial applications. Here, efficient production of itaconate from various renewable substrates was demonstrated by engineered Escherichia coli. Limitation in the itaconate precursor supply was revealed by feeding of the key intermediate citrate to the culture medium. Efforts of enhancing the cis-aconitate flux and preserving the isocitrate pool increased itaconate productivity by nearly 100-fold. Elimination of the isocitrate lyase lowered the itaconate production by 10-30%, suggesting the potential positive role of glyoxylate shunt. High aeration was essential for efficient synthesis of itaconate due to its inability to serve as a fermentation product. Using the best strain, we achieved by far the highest itaconate titer from xylose and glycerol individually, reaching 20-22g/L in 72h with an average yield of 0.5g/g using bench-scale flasks. Compare to the use of phosphoenolpyruvate (PEP) carboxylase, overexpression of pyruvate carboxylase consistently led to higher production of itaconate from substrates such as glucose and glycerol whose dissimilation involves PEP-dependent phosphorylation. With high density fermentation in the fed-batch bioreactor, the titer of itaconate was further pushed to 43g/L in 32h with a final yield around 0.6g/g of glycerol.

The plumbing of land surface models: is poor performance a result of methodology or data quality?

The PALS Land sUrface Model Benchmarking Evaluation pRoject (PLUMBER) illustrated the value of prescribing a priori performance targets in model intercomparisons. It showed that the performance of turbulent energy flux predictions from different land surface models, at a broad range of flux tower sites using common evaluation metrics, was on average worse than relatively simple empirical models. For sensible heat fluxes, all land surface models were outperformed by a linear regression against downward shortwave radiation. For latent heat flux, all land surface models were outperformed by a regression against downward shortwave, surface air temperature and relative humidity. These results are explored here in greater detail and possible causes are investigated. We examine whether particular metrics or sites unduly influence the collated results, whether results change according to time-scale aggregation and whether a lack of energy conservation in flux tower data gives the empirical models an unfair advantage in the intercomparison. We demonstrate that energy conservation in the observational data is not responsible for these results. We also show that the partitioning between sensible and latent heat fluxes in LSMs, rather than the calculation of available energy, is the cause of the original findings. Finally, we present evidence suggesting that the nature of this partitioning problem is likely shared among all contributing LSMs. While we do not find a single candidate explanation for why land surface models perform poorly relative to empirical benchmarks in PLUMBER, we do exclude multiple possible explanations and provide guidance on where future research should focus.

Benchmarking NLDAS-2 Soil Moisture and Evapotranspiration to Separate Uncertainty Contributions.

Model benchmarking allows us to separate uncertainty in model predictions caused by model inputs from uncertainty due to model structural error. We extend this method with a "large-sample" approach (using data from multiple field sites) to measure prediction uncertainty caused by errors in (i) forcing data, (ii) model parameters, and (iii) model structure, and use it to compare the efficiency of soil moisture state and evapotranspiration flux predictions made by the four land surface models in the North American Land Data Assimilation System Phase 2 (NLDAS-2). Parameters dominated uncertainty in soil moisture estimates and forcing data dominated uncertainty in evapotranspiration estimates; however, the models themselves used only a fraction of the information available to them. This means that there is significant potential to improve all three components of the NLDAS-2 system. In particular, continued work toward refining the parameter maps and look-up tables, the forcing data measurement and processing, and also the land surface models themselves, has potential to result in improved estimates of surface mass and energy balances.

Multicenter Australian trial of islet transplantation: improving accessibility and outcomes.

Whilst initial rates of insulin independence following islet transplantation are encouraging, long-term function using the Edmonton Protocol remains a concern. The aim of this single-arm, multicenter study was to evaluate an immunosuppressive protocol of initial antithymocyte globulin (ATG), tacrolimus and mycophenolate mofetil (MMF) followed by switching to sirolimus and MMF. Islets were cultured for 24 h prior to transplantation. The primary end-point was an HbA1c of <7% and cessation of severe hypoglycemia. Seventeen recipients were followed for ≥ 12 months. Nine islet preparations were transported interstate for transplantation. Similar outcomes were achieved at all three centers. Fourteen of the 17 (82%) recipients achieved the primary end-point. Nine (53%) recipients achieved insulin independence for a median of 26 months (range 7-39 months) and 6 (35%) remain insulin independent. All recipients were C-peptide positive for at least 3 months. All subjects with unstimulated C-peptide >0.2 nmol/L had cessation of severe hypoglycemia. Nine of the 17 recipients tolerated switching from tacrolimus to sirolimus with similar graft outcomes. There was a small but significant reduction in renal function in the first 12 months. The combination of islet culture, ATG, tacrolimus and MMF is a viable alternative for islet transplantation.

Scapular notching and osteophyte formation after reverse shoulder replacement: Radiological analysis of implant position in male and female patients.

This study provides recommendations on the position of the implant in reverse shoulder replacement in order to minimise scapular notching and osteophyte formation. Radiographs from 151 patients who underwent primary reverse shoulder replacement with a single prosthesis were analysed at a mean follow-up of 28.3 months (24 to 44) for notching, osteophytes, the position of the glenoid baseplate, the overhang of the glenosphere, and the prosthesis scapular neck angle (PSNA). A total of 20 patients (13.2%) had a notch (16 Grade 1 and four Grade 2) and 47 (31.1%) had an osteophyte. In patients without either notching or an osteophyte the baseplate was found to be positioned lower on the glenoid, with greater overhang of the glenosphere and a lower PSNA than those with notching and an osteophyte. Female patients had a higher rate of notching than males (13.3% vs 13.0%) but a lower rate of osteophyte formation (22.9% vs 50.0%), even though the baseplate was positioned significantly lower on the glenoid in females (p = 0.009) and each had a similar mean overhang of the glenosphere. Based on these findings we make recommendations on the placement of the implant in both male and female patients to avoid notching and osteophyte formation.

Latent profile analysis of pelvic floor muscle pain in patients with chronic pelvic pain.

AIM: Chronic pelvic pain (CPP) is a syndrome of related diagnoses including pain originating from the muscles of the pelvic floor. The objective of this study was to evaluate which muscles are important to examine, in what manner pelvic floor muscle pain contributes to patients' pain experience, or what thresholds should be applied to identify significant pelvic floor muscle pain by comparing exam findings with outcome measures METHODS: A total of 428 patients meeting the definition for CPP were evaluated using a standardized physical examination of the abdominal wall, pelvic floor, and vestibule along with the 12 domain Patient Reported Outcome Measures Information System (PROMIS). These scores were evaluated for unidimensionality followed by latent profile analysis. The areas under the receiver operator characteristic curves were used to identify the best pain threshold for each muscle. RESULTS: The eight pelvic floor muscle sites all loaded onto a single factor, separate from other areas examined. Two latent classes were found within all the variables. Patients in the severe pelvic floor pain class had significantly worse pain related PROMIS scores. Optimal thresholds for identifying significant pelvic floor pain ranged between 3 and 5. CONCLUSION: Pain in the pelvic floor muscles is distinguishable from pain in the abdominal wall and vulva. Any of the lateral muscle sites evaluated can be used to identify patients with significant pelvic floor pain. Two latent classes of CPP patients were identified: those with limited and those with severe pain, as identified by moderate to severe pelvic floor tenderness.

Baculoviral inhibitors of apoptosis repeat containing (BIRC) proteins fine-tune TNF-induced nuclear factor κB and c-Jun N-terminal kinase signalling in mouse pancreatic beta cells.

AIMS/HYPOTHESIS: For beta cells, contact with TNF-α triggers signalling cascades that converge on pathways important for cell survival and inflammation, specifically nuclear factor κB (NF-κB), c-Jun N-terminal kinase (JNK) and p38 mitogen-activated protein kinase pathways. Here, we investigated the function of baculoviral inhibitors of apoptosis repeat containing (BIRC) proteins in regulating TNF signalling cascades. METHODS: TNF regulation of Birc genes was studied by mRNA expression and promoter analysis. Birc gene control of cell signalling was studied in beta cell lines, and in islets from Birc2(-/-) and Birc3(-/-) mice, and from Birc3(-/-) Birc2Δ beta cell mice that selectively lack Birc2 and Birc3 (double knockout [DKO]). Islet function was tested by intraperitoneal glucose tolerance test and transplantation. RESULTS: TNF-α selectively induced Birc3 in beta cells, which in turn was sufficient to drive and potentiate NF-κB reporter activity. Conversely, Birc3(-/-) islets exhibited delayed TNF-α-induced IκBα degradation with reduced expression of Ccl2 and Cxcl10. DKO islets showed a further delay in IκBα degradation kinetics. Surprisingly, DKO islets exhibited stimulus-independent and TNF-dependent hyperexpression of TNF target genes A20 (also known as Tnfaip3), Icam1, Ccl2 and Cxcl10. DKO islets showed hyperphosphorylation of the JNK-substrate, c-Jun, while a JNK-antagonist prevented increases of Icam1, Ccl2 and Cxcl10 expression. Proteosome blockade of MIN6 cells phenocopied DKO islets. DKO islets showed more rapid loss of glucose homeostasis when challenged with the inflammatory insult of transplantation. CONCLUSIONS/INTERPRETATION: BIRC3 provides a feed-forward loop, which, with BIRC2, is required to moderate the normal speed of NF-κB activation. Paradoxically, BIRC2 and BIRC3 act as a molecular brake to rein in activation of the JNK signalling pathway. Thus BIRC2 and BIRC3 fine-tune NF-κB and JNK signalling to ensure transcriptional responses are appropriately matched to extracellular inputs. This control is critical for the beta cell's stress response.

Phenotyping chronic pelvic pain based on latent class modeling of physical examination.

Introduction. Defining clinical phenotypes based on physical examination is required for clarifying heterogeneous disorders such as chronic pelvic pain (CPP). The objective of this study was to determine the number of classes within 4 examinable regions and then establish threshold and optimal exam criteria for the classes discovered. Methods. A total of 476 patients meeting the criteria for CPP were examined using pain pressure threshold (PPT) algometry and standardized numeric scale (NRS) pain ratings at 30 distinct sites over 4 pelvic regions. Exploratory factor analysis, latent profile analysis, and ROC curves were then used to identify classes, optimal examination points, and threshold scores. Results. Latent profile analysis produced two classes for each region: high and low pain groups. The optimal examination sites (and high pain minimum thresholds) were for the abdominal wall region: the pair at the midabdomen (PPT threshold depression of > 2); vulvar vestibule region: 10:00 position (NRS > 2); pelvic floor region: puborectalis (combined NRS > 6); vaginal apex region: uterosacral ligaments (combined NRS > 8). Conclusion. Physical examination scores of patients with CPP are best categorized into two classes: high pain and low pain. Standardization of the physical examination in CPP provides both researchers and general gynecologists with a validated technique.

Receptor for advanced glycation end-products (RAGE) provides a link between genetic susceptibility and environmental factors in type 1 diabetes.

AIMS/HYPOTHESIS: This group of studies examines human genetic susceptibility conferred by the receptor for advanced glycation end-products (RAGE) in type 1 diabetes and investigates how this may interact with a western environment. METHODS: We analysed the AGER gene, using 13 tag SNPs, in 3,624 Finnish individuals from the FinnDiane study, followed by AGER associations with a high risk HLA genotype (DR3)-DQA1*05-DQB1*02/DRB1*0401-DQB1*0302 (n = 546; HLA-DR3/DR4), matched in healthy newborn infants from the Finnish Type 1 Diabetes Prediction and Prevention (DIPP) Study (n = 373) using allelic analysis. We also studied islets and circulating RAGE in NODLt mice. RESULTS: The rs2070600 and rs17493811 polymorphisms predicted increased risk of type 1 diabetes, whereas the rs9469089 SNP was related to decreased risk, on a high risk HLA background. Children from the DIPP study also showed a decline in circulating soluble RAGE levels, at seroconversion to positivity for type 1 diabetes-associated autoantibodies. Islet RAGE and circulating soluble RAGE levels in prediabetic NODLt mice decreased over time and were prevented by the AGE lowering therapy alagebrium chloride. Alagebrium chloride also decreased the incidence of autoimmune diabetes and restored islet RAGE levels. CONCLUSIONS/INTERPRETATION: These studies suggest that inherited AGER gene polymorphisms may confer susceptibility to environmental insults. Declining circulating levels of soluble RAGE, before the development of overt diabetes, may also be predictive of clinical disease in children with high to medium risk HLA II backgrounds and this possibility warrants further investigation in a larger cohort.

Health service research: the square peg in human subjects protection regulations.

Protection of human participants is a fundamental facet of biomedical research. We report the activities of a health service research study in which there were three institutional review boards (IRBs), three legal departments and one research administration department providing recommendations and mandating changes in the study methods. Complying with IRB requirements can be challenging, but can also adversely affect study outcomes. Multiple protocol changes mandated from multiple IRBs created a research method that was not reflective of how substance use screening would be performed in a clinical setting. There was direct conflict between the IRBs' perceptions of participants' protection with the researchers' need to use research methodology that assures the clinical relevancy of results.

The hypoxia response pathway and ß-cell function.

ß-cells sense glucose and secrete appropriate amounts of insulin by coupling glucose uptake and glycolysis with quantitative ATP production via mitochondrial oxidative pathways. Therefore, oxidative phosphorylation is essential for normal ß-cell function. Multiple cell types adapt to hypoxia by inducing a transcriptional programme coordinated by the transcription factor hypoxia-inducible factor (HIF). HIF activity is regulated by the von Hippel-Lindau (Vhl) protein, which targets the HIFα subunit for proteasomal degradation in the presence of oxygen. Several recent studies have shown that Vhl deletion in ß-cells results in Hif1α activation, impaired glucose-stimulated insulin secretion (GSIS) and glucose intolerance. This was found to be because of alterations in ß-cell gene expression inducing a switch from aerobic glucose metabolism to anaerobic glycolysis, thus disrupting the GSIS triggering pathway. Situations in which islets may become hypoxic are discussed, in particular islet transplantation which has been reported to cause islet hypoxia because of an inadequate blood supply post-transplant. Aside from this principal role for HIF in negatively regulating ß-cell glucose sensing, other aspects of hypoxia signalling are discussed including ß-cell differentiation, development and vascularization. In conclusion, recent studies clearly show that hypoxia response mechanisms can negatively impact on glucose sensing mechanisms in the ß-cell and this has the potential to impair ß-cell function in a number of physiological and clinical situations.

Deficiency of Atf3, an adaptive-response gene, protects islets and ameliorates inflammation in a syngeneic mouse transplantation model.

AIMS/HYPOTHESIS: Islet transplantation is a potential therapeutic option for type 1 diabetes. However, the need for multiple donors per patient and heavy immunosuppression of the recipients limit its use. The goal of this study was to test whether the gene encoding activating transcription factor 3 (ATF3), a stress-inducible pro-apoptotic gene, plays a role in graft rejection in islet transplantation. METHODS: We compared wild-type (WT) and Atf3 knockout (KO) islets in vitro using stress paradigms relevant to islet transplantation: isolation, inflammation and hypoxia. We also compared the WT and KO islets in vivo using a syngeneic mouse transplantation model. RESULTS: ATF3 was induced in all three stress paradigms and played a deleterious role in islet survival, as evidenced by the lower viability of WT islets compared with KO islets. ATF3 upregulated various downstream target genes in a stress-dependent manner. These target genes can be classified into two functional groups: (1) apoptosis (Noxa [also known as Pmaip1] and Bnip3), and (2) immunomodulation (Tnfalpha [also known as Tnf], Il-1beta [also known as Il1b], Il-6 [also known as Il6] and Ccl2 [also known as Mcp-1]). In vivo, Atf3 KO islets performed better than WT islets after transplantation, as evidenced by better glucose homeostasis in the recipients and the reduction of the following variables in the KO grafts: caspase 3 activation, macrophage infiltration and expression of the above apoptotic and immunomodulatory genes. CONCLUSIONS/INTERPRETATION: ATF3 plays a role in islet graft rejection by contributing to islet cell death and inflammatory responses at the graft sites. Silencing the ATF3 gene may provide therapeutic benefits in islet transplantation.

Detection of two different papillomaviruses within a feline cutaneous squamous cell carcinoma: case report and review of the literature.

CASE HISTORY: A 15-year-old, brown-and-white cat was presented to a veterinary clinic with an ulcerated, reddened 1-cm diameter lesion on the nasal planum. CLINICAL FINDINGS AND DIAGNOSIS: Histology of a biopsy sample confirmed the lesion was a squamous cell carcinoma (SCC). PCR amplified DNA sequences from two different papillomaviruses. One sequence was from FdPV-2, which has previously been amplified from feline cutaneous SCC. However, the other sequence has not previously been reported, suggesting a novel feline papillomavirus. CLINICAL RELEVANCE: There is evidence that papillomaviruses promote the development of SCC on sun-exposed skin in humans. This is the first report in a cat of a papillomavirus other than FdPV-2 and the first time that multiple papillomaviruses have been detected within a single neoplasm in this species. Whether the papillomaviruses influenced the development and behaviour of this SCC is currently uncertain, but this case provides additional evidence of the association between papillomaviruses and feline cutaneous SCC. If papillomaviruses are found to influence the development of SCC this may allow novel strategies to prevent these common neoplasms in cats.

Medical students' perceptions of their development of `soft skills' Part I : A qualitative research methodology

Background: Following the introduction of a new; integrated; problem-oriented undergraduate medical curriculum at the University of Pretoria (UP) in 1997; a research project was undertaken to study interpersonal skills; professional attitudes; teamwork; ethics and related topics - which have come to be known collectively as `soft skills'. This contribution is the first of two articles on the professional socialisation of medical students and their development of `soft skills'. It describes the particular qualitative methodology developed for; and applied to; the study of soft skills among medical students at UP. Methods: This paper describes the aim of the study; reasons for adopting a qualitative research approach to achieve this aim; the theoretical orientation underpinning the qualitative approach that we considered most suitable; the design; the sampling; the data management and analysis; and the methods that we deployed to ensure the credibility of the findings. Research Design: The aim of the study was to explore the subjective meanings that students attributed to soft skills; as they understood them. These subjective meanings involve the way students interact meaningfully with fellow students; lecturers and other individuals participating in the medical and clinical education programme; and the way they construct shared conceptualisations of soft skills and medical education in their lives and social world. A qualitative approach was considered most appropriate; as this study set out to uncover subjective and diverse meanings that do not necessarily amount to generalisable truths. The particular qualitative strategy or design used was that of an extended case study; or `casing'; within the modernist theoretical orientation of symbolic interactionism. Elements of process evaluation were incorporated into the design to account for the process of curriculum reform within which this study was embedded.We recruited participants for this study from two cohorts of students. The first group; who completed their studies in 2001; had followed the traditional curriculum; while the second group; who completed their programme in 2002; had followed the reformed curriculum. The data collection tools were face-to-face individual interviews; focused group interviews and solicited autobiographical sketches. The utilisation of more than one method or data source enabled triangulation or cross-checking of findings. We followed an inductive reasoning approach; which means that we did not search for data to test any hypotheses that had been formulated prior to commencing the study; but focused instead on building constructs that were grounded in or reflected intimate familiarity with the students' world. Conclusion:The modernist qualitative research approach enabled us to uncover; describe and illuminate the subjective points of view on soft skills as expressed by final-year medical students before and after curriculum reform. More specifically; by carrying out an extended case study we were able to perform a process evaluation of the curriculum reform in terms of soft skills and the professional socialisation of the students. This paper outlines how qualitative research methods enabled us to capture and explore aspects of the inner life (social worlds) of these students. Whether they would be the same; similar or different in another setting are questions for further exploration or research - questions prompted by our study in a manner that illuminates the qualities that may be inherent in these subjective meanings

Medical students' perceptions of their development of 'soft skills' Part II: the development of 'soft skills' through 'guiding and growing'

Background: This paper reports on medical students' views on the ways in which their `soft skills' were developed. It is the result of a study on soft skills among two groups of students before and after curriculum reform at the School of Medicine of the University of Pretoria. One of the aims of the reform was to provide more teaching and learning opportunities for the development of soft skills. Soft skills include professional interpersonal and social skills; communication skills; and professional and ethical attitudes.Methods: As symbolic interactionism was used as the theoretical framework to guide the research; qualitative methods were used to collect the data. A purposive-theoretical sample of 42 final-year medical students from the traditional curriculum and 49 from the reformed curriculum was recruited. Data were collected by means of focus groups; individual in-depth interviews and autobiographical sketches.ResultsThe same categories of comments emerged from the data collected from the study participants from both the traditional and the reformed curriculum. The students ascribed their behaviour related to soft skills to personality and innate features. They had varying opinions on whether soft skills could be taught; but there was as a strong feeling that teaching should focus on principles and guidelines for dealing with difficult situations. They believed that; in the end; they should take responsibility for their own development of soft skills. Most participants felt they could at least grow through exposure to teaching activities and the observation of role models. They also indicated that they had developed their soft skills and constructed their own identity through their interaction with others. Their definition of situations was shaped by their interactions with doctors and educators; fellow students and other health professionals. Interaction with patients was considered the most important. For both groups of students their third year was a watershed; as it is the first year of more intensive patient contact and the beginning of serious learning from interaction with patients. The views on the development of soft skills differed very little between the traditional and reformed curriculum groups; except that students who had followed the reformed curriculum felt more prepared through the increased teaching and training efforts. Further consideration needs to be given to the intention of the changed curriculum compared to the actual effect.The way in which the participants in the study described their development of soft skills could be categorised as a complex interplay between `being' and `becoming'. Instead of using the word `acquisition' of soft skills; `development' seemed to be more appropriate. The metaphor of `guiding' and `growing' also captures the development of these skills better than the terms `teaching' and `learning'. Conclusion: Teaching activities in the clinical years should be adapted with a view to facilitating the students' professional growth. New models for the development of medical educators should be created and institutional barriers should be investigated

Medical Students' Perceptions of their Development of 'Soft Skills' - Part I: A qualitative Research Methodology

Background: Following the introduction of a new; integrated; problem-oriented undergraduate medical curriculum at the University of Pretoria (UP) in 1997; a research project was undertaken to study interpersonal skills; professional attitudes; teamwork; ethics and related topics - which have come to be known collectively as 'soft skills'. This contribution is the first of two articles on the professional socialisation of medical students and their development of 'soft skills'. It describes the particular qualitative methodology developed for; and applied to; the study of soft skills among medical students at UP.Methods: This paper describes the aim of the study; reasons for adopting a qualitative research approach to achieve this aim; the theoretical orientation underpinning the qualitative approach that we considered most suitable; the design; the sampling; the data management and analysis; and the methods that we deployed to ensure the credibility of the findings.Research Design: The aim of the study was to explore the subjective meanings that students attributed to soft skills; as they understood them. These subjective meanings involve the way students interact meaningfully with fellow students; lecturers and other individuals participating in the medical and clinical education programme; and the way they construct shared conceptualisations of soft skills and medical education in their lives and social world. A qualitative approach was considered most appropriate; as this study set out to uncover subjective and diverse meanings that do not necessarily amount to generalisable truths. The particular qualitative strategy or design used was that of an extended case study; or 'casing'; within the modernist theoretical orientation of symbolic interactionism. Elements of process evaluation were incorporated into the design to account for the process of curriculum reform within which this study was embedded. We recruited participants for this study from two cohorts of students. The first group; who completed their studies in 2001; had followed the traditional curriculum; while the second group; who completed their programme in 2002; had followed the reformed curriculum. The data collection tools were face-to-face individual interviews; focused group interviews and solicited autobiographical sketches. The utilisation of more than one method or data source enabled triangulation or cross-checking of findings. We followed an inductive reasoning approach; which means that we did not search for data to test any hypotheses that had been formulated prior to commencing the study; but focused instead on building constructs that were grounded in or reflected intimate familiarity with the students' world.Conclusion: The modernist qualitative research approach enabled us to uncover; describe and illuminate the subjective points of view on soft skills as expressed by final-year medical students before and after curriculum reform. More specifically; by carrying out an extended case study we were able to perform a process evaluation of the curriculum reform in terms of soft skills and the professional socialisation of the students. This paper outlines how qualitative research methods enabled us to capture and explore aspects of the inner life (social worlds) of these students. Whether they would be the same; similar or different in another setting are questions for further exploration or research - questions prompted by our study in a manner that illuminates the qualities that may be inherent in these subjective meanings