Training medical students to conduct motivational interviewing: a randomized controlled trial.

OBJECTIVE: To examine the effectiveness of motivational interviewing (MI) training among medical students. METHODS: All students (n=131) (year 5) at Lausanne Medical School, Switzerland were randomized into an experimental or a control group. After a training in basic communication skills (control condition), an 8-h MI training was completed by 84.8% students in the exprimental group. One week later, students in both groups were invited to meet with two standardized patients. MI skills were coded by blinded research assistants using the Motivational Interviewing Treatment Integrity 3.0. RESULTS: Superior MI performance was shown for trained versus control students, as demonstrated by higher scores for "Empathy" [p<0.001] and "MI Spirit" [p<0.001]. Scores were similar between groups for "Direction", indicating that students in both groups invited the patient to talk about behavior change. Behavior counts assessment demonstrated better performance in MI in trained versus untrained students regarding occurences of MI-adherent behavior [p<0.001], MI non-adherent behavior [p<0.001], Closed questions [p<0.001], Open questions [p=0.001], simple reflections [p=0.03], and Complex reflections [p<0.001]. Occurrences were similar between groups regarding "Giving information". CONCLUSION: An 8-h training workshop was associated with improved MI performance. PRACTICE IMPLICATIONS: These findings lend support for the implementation of MI training in medical schools.

Reforms of the pre-graduate curriculum for medical students: the Bologna process and beyond.

For several years, all five medical faculties of Switzerland have embarked on a reform of their training curricula for two reasons: first, according to a new federal act issued in 2006 by the administration of the confederation, faculties needed to meet international standards in terms of content and pedagogic approaches; second, all Swiss universities and thus all medical faculties had to adapt the structure of their curriculum to the frame and principles which govern the Bologna process. This process is the result of the Bologna Declaration of June 1999 which proposes and requires a series of reforms to make European Higher Education more compatible and comparable, more competitive and more attractive for Europeans students. The present paper reviews some of the results achieved in the field, focusing on several issues such as the shortage of physicians and primary care practitioners, the importance of public health, community medicine and medical humanities, and the implementation of new training approaches including e-learning and simulation. In the future, faculties should work on several specific challenges such as: students' mobility, the improvement of students' autonomy and critical thinking as well as their generic and specific skills and finally a reflection on how to improve the attractiveness of the academic career, for physicians of both sexes.

Emotional intelligence: On definitions, neuroscience, and marshmallows

In his timely article, Cherniss offers his vision for the future of "Emotional Intelligence" (EI). However, his goal of clarifying the concept by distinguishing definitions from models and his support for "Emotional and Social Competence" (ESC) models will, in our opinion, not make the field advance. To be upfront, we agree that emotions are important for effective decision-making, leadership, performance and the like; however, at this time, EI and ESC have not yet demonstrated incremental validity over and above IQ and personality tests in meta-analyses (Harms & Credé, 2009; Van Rooy & Viswesvaran, 2004). If there is a future for EI, we see it in the ability model of Mayer, Salovey and associates (e.g, Mayer, Caruso, & Salovey, 2000), which detractors and supporters agree holds the most promise (Antonakis, Ashkanasy, & Dasborough, 2009; Zeidner, Roberts, & Matthews, 2008). With their use of quasi-objective scoring measures, the ability model grounds EI in existing frameworks of intelligence, thus differentiating itself from ESC models and their self-rated trait inventories. In fact, we do not see the value of ESC models: They overlap too much with current personality models to offer anything new for science and practice (Zeidner, et al., 2008). In this commentary we raise three concerns we have with Cherniss's suggestions for ESC models: (1) there are important conceptual problems in both the definition of ESC and the distinction of ESC from EI; (2) Cherniss's interpretation of neuroscience findings as supporting the constructs of EI and ESC is outdated, and (3) his interpretation of the famous marshmallow experiment as indicating the existence of ESCs is flawed. Building on the promise of ability models, we conclude by providing suggestions to improve research in EI.

Référentiels des compétences et des métiers : une approche ontologique

Résumé La mondialisation des marchés, les mutations du contexte économique et enfin l'impact des nouvelles technologies de l'information ont obligé les entreprises à revoir la façon dont elles gèrent leurs capitaux intellectuel (gestion des connaissances) et humain (gestion des compétences). II est communément admis aujourd'hui que ceux-ci jouent un rôle particulièrement stratégique dans l'organisation. L'entreprise désireuse de se lancer dans une politique gestion de ces capitaux devra faire face à différents problèmes. En effet, afin de gérer ces connaissances et ces compétences, un long processus de capitalisation doit être réalisé. Celui-ci doit passer par différentes étapes comme l'identification, l'extraction et la représentation des connaissances et des compétences. Pour cela, il existe différentes méthodes de gestion des connaissances et des compétences comme MASK, CommonKADS, KOD... Malheureusement, ces différentes méthodes sont très lourdes à mettre en oeuvre, et se cantonnent à certains types de connaissances et sont, par conséquent, plus limitées dans les fonctionnalités qu'elles peuvent offrir. Enfin, la gestion des compétences et la gestion des connaissances sont deux domaines dissociés alors qu'il serait intéressant d'unifier ces deux approches en une seule. En effet, les compétences sont très proches des connaissances comme le souligne la définition de la compétence qui suit : « un ensemble de connaissances en action dans un contexte donné ». Par conséquent, nous avons choisi d'appuyer notre proposition sur le concept de compétence. En effet, la compétence est parmi les connaissances de l'entreprise l'une des plus cruciales, en particulier pour éviter la perte de savoir-faire ou pour pouvoir prévenir les besoins futurs de l'entreprise, car derrière les compétences des collaborateurs, se trouve l'efficacité de l'organisation. De plus, il est possible de décrire grâce à la compétence de nombreux autres concepts de l'organisation, comme les métiers, les missions, les projets, les formations... Malheureusement, il n'existe pas réellement de consensus sur la définition de la compétence. D'ailleurs, les différentes définitions existantes, même si elles sont pleinement satisfaisantes pour les experts, ne permettent pas de réaliser un système opérationnel. Dans notre approche; nous abordons la gestion des compétences à l'aide d'une méthode de gestion des connaissances. En effet, de par leur nature même, connaissance et compétence sont intimement liées et donc une telle méthode est parfaitement adaptée à la gestion des compétences. Afin de pouvoir exploiter ces connaissances et ces compétences nous avons dû, dans un premier temps, définir les concepts organisationnels de façon claire et computationnelle. Sur cette base, nous proposons une méthodologie de construction des différents référentiels d'entreprise (référentiel de compétences, des missions, des métiers...). Pour modéliser ces différents référentiels, nous avons choisi l'ontologie, car elle permet d'obtenir des définitions cohérentes et consensuelles aux concepts tout en supportant les diversités langagières. Ensuite, nous cartographions les connaissances de l'entreprise (formations, missions, métiers...) sur ces différentes ontologies afin de pouvoir les exploiter et les diffuser. Notre approche de la gestion des connaissances et de la gestion des compétences a permis la réalisation d'un outil offrant de nombreuses fonctionnalités comme la gestion des aires de mobilités, l'analyse stratégique, les annuaires ou encore la gestion des CV. Abstract The globalization of markets, the easing of economical regulation and finally the impact of new information and communication technologies have obliged firms to re-examine the way they manage their knowledge capital (knowledge management) and their human capital (competence management). It is commonly admitted that knowledge plays a slightly strategical role in the organization. The firms who want to establish one politic of management of these capitals will have to face with different problems. To manage that knowledge, a long process of capitalization must be done. That one has different steps like identification, extraction and representation of knowledge and competences. There are some different methods of knowledge management like MASK, CommonKADS or KOD. Unfortunately, those methods are very difficult to implement and are using only some types of knowledge and are consequently more limited in the functionalities they can offer. Knowledge management and competence management are two different domain where it could be interesting to unify those to one. Indeed, competence is very close than knowledge as underline this definition: "a set of knowledge in action in a specified context". We choose in our approach to rely on the concept of competence. Indeed, the competence is one of crucial knowledge in the company, particularly to avoid the loss of know-how or to prevent future needs. Because behind collaborator's competence, we can find company efficiency. Unfortunately, there is no real consensus on the definition of the concept of competence. Moreover, existing different definitions don't permit to develop an operational system. Among other key concept, we can find jobs, mission, project, and training... Moreover, we approach different problems of the competence management under the angle of the knowledge management. Indeed, knowledge and competence are closely linked. Then, we propose a method to build different company repositories (competence, jobs, projects repositories). To model those different repositories we choose ontology because it permits to obtain coherent and consensual definitions of the concepts with support of linguistics diversities too. This building repositories method coupled with this knowledge and competence management approach permitted the realization of a tool offering functionalities like mobility management, strategical analysis, yellow pages or CV management.

Cultural competency of health-care providers in a Swiss University Hospital: self-assessed cross-cultural skillfulness in a cross-sectional study.

BACKGROUND: As the diversity of the European population evolves, measuring providers' skillfulness in cross-cultural care and understanding what contextual factors may influence this is increasingly necessary. Given limited information about differences in cultural competency by provider role, we compared cross-cultural skillfulness between physicians and nurses working at a Swiss university hospital. METHODS: A survey on cross-cultural care was mailed in November 2010 to front-line providers in Lausanne, Switzerland. This questionnaire included some questions from the previously validated Cross-Cultural Care Survey. We compared physicians' and nurses' mean composite scores and proportion of "3-good/4-very good" responses, for nine perceived skillfulness items (4-point Likert-scale) using the validated tool. We used linear regression to examine how provider role (physician vs. nurse) was associated with composite skillfulness scores, adjusting for demographics (gender, non-French dominant language), workplace (time at institution, work-unit "sensitized" to cultural-care), reported cultural-competence training, and cross-cultural care problem-awareness. RESULTS: Of 885 questionnaires, 368 (41.2%) returned the survey: 124 (33.6%) physicians and 244 (66.4%) nurses, reflecting institutional distribution of providers. Physicians had better mean composite scores for perceived skillfulness than nurses (2.7 vs. 2.5, p < 0.005), and significantly higher proportion of "good/very good" responses for 4/9 items. After adjusting for explanatory variables, physicians remained more likely to have higher skillfulness (&#946; = 0.13, p = 0.05). Among all, higher skillfulness was associated with perception/awareness of problems in the following areas: inadequate cross-cultural training (&#946; = 0.14, p = 0.01) and lack of practical experience caring for diverse populations (&#946; = 0.11, p = 0.04). In stratified analyses among physicians alone, having French as a dominant language (&#946; = -0.34, p < 0.005) was negatively correlated with skillfulness. CONCLUSIONS: Overall, there is much room for cultural competency improvement among providers. These results support the need for cross-cultural skills training with an inter-professional focus on nurses, education that attunes provider awareness to the local issues in cross-cultural care, and increased diversity efforts in the work force, particularly among physicians.

Advanced trauma life support, 8th edition, the evidence for change.

The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Inexperienced sonographers can successfully visualize and assess a three-dimensional image of the fetal face using a standardized ultrasound protocol

Introduction: A standardized three-dimensional ultrasonographic (3DUS) protocol is described that allows fetal face reconstruction. Ability to identify cleft lip with 3DUS using this protocol was assessed by operators with minimal 3DUS experience. Material and Methods: 260 stored volumes of fetal face were analyzed using a standardized protocol by operators with different levels of competence in 3DUS. The outcomes studied were: (1) the performance of post-processing 3D face volumes for the detection of facial clefts; (2) the ability of a resident with minimal 3DUS experience to reconstruct the acquired facial volumes, and (3) the time needed to reconstruct each plane to allow proper diagnosis of a cleft. Results: The three orthogonal planes of the fetal face (axial, sagittal and coronal) were adequately reconstructed with similar performance when acquired by a maternal-fetal medicine specialist or by residents with minimal experience (72 vs. 76%, p = 0.629). The learning curve for manipulation of 3DUS volumes of the fetal face corresponds to 30 cases and is independent of the operator's level of experience. Discussion: The learning curve for the standardized protocol we describe is short, even for inexperienced sonographers. This technique might decrease the length of anatomy ultrasounds and improve the ability to visualize fetal face anomalies.

Reducing the learning curve for the treatment of morphoeic (sclerosing) basal cell carcinoma of the face.

The treatment of morphoeic (or sclerosing) basal cell carcinoma (mBCC) of the face is associated with high rates of incomplete excision and recurrence. A principal risk factor for incomplete resection is the grade of surgeon. We did a prospective, randomised study of 40 consecutive patients with mBCC of the face. The extent of the tumour was assessed under standard conditions by consultant surgeons and compared with assessments by resident surgeons with the help of the Varioscope, a combination of microscope and loupe glasses with strong illumination and a maximal magnification of 7x. The data from a former retrospective study of all excisions of mBCC of the face during a five-year period at the hospital served as control. Residents with the support of the Varioscope achieved a rate of incomplete excisions similar to that of consultants under standard conditions. There was a significant reduction of the rate of incomplete resections by resident surgeons thanks to high magnification and good lighting (p=0.02). High magnification and good lighting were useful in learning how to recognise skin changes associated with mBCC of the face and achieving a low rate of incomplete excisions.

Higher memory responses in HIV-infected and kidney transplanted patients than in healthy subjects following priming with the pandemic vaccine.

BACKGROUND: Memory responses require immune competence. We assessed the influence of priming with AS03-adjuvanted pandemic vaccine (Pandemrix®) on memory responses of HIV patients, kidney recipients (SOT) and healthy controls (HC). METHOD: Participants (HIV: 197, SOT: 53; HC: 156) were enrolled in a prospective study and 390/406 (96%) completed it. All had been primed in 2009/2010 with 1 (HC) or 2 (patients) doses of Pandemrix®, and were boosted with the 2010/2011 seasonal influenza vaccine. Geometric mean titres and seroprotection rates were measured 12 months after priming and 4 weeks after boosting. Primary and memory responses were directly compared in 191 participants (HCW: 69, HIV: 71, SOT: 51) followed during 2 consecutive seasons. RESULTS: Most participants (HC: 77.8%, HIV: 77.6%, SOT: 66%) remained seroprotected at 12 months post-priming. Persisting A/09/H1N1 titers were high in HIV (100.2) and HC (120.1), but lower in SOT (61.4) patients. Memory responses reached higher titers in HIV (507.8) than in HC (253.5) and SOT (136.9) patients. Increasing age and lack of HAART reduced persisting and memory responses, mainly influenced by residual antibody titers. Comparing 2009/2010 and 2010/2011 titers in 191 participants followed for 2 seasons indicated lower post-2010/2011 titers in HC (240.2 vs 313.9), but higher titers in HIV (435.7 vs 338.0) and SOT (136 vs 90.3) patients. CONCLUSIONS: Priming with 2 doses of Pandemrix® elicited persistent antibody responses and even stronger memory responses to non-adjuvanted seasonal vaccine in HIV patients than 1 dose in healthy subjects. Adjuvanted influenza vaccines may improve memory responses of immunocompromised patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT01022905.

Regulation of horizontal gene transfer of the catabolic island ICEclc

ICEclc is a mobile genetic element found in two copies on the chromosome of the bacterium Pseudomonas knackmussii B13. ICEclc harbors genes encoding metabolic pathways for the degradation of chlorocatechols (CLC) and 2-aminophenol (2AP). At low frequencies, ICEclc excises from the chromosome, closes into a circular DNA molecule which can transfer to another bacterium via conjugation. Once in the recipient cell, ICEclc can reintegrate into the chromosome by site-specific recombination. This thesis aimed at identifying the regulatory network underlying the decisions for ICEclc horizontal transfer (HGT). The first chapter is an introduction on integrative and conjugative elements (ICEs) more in general, of which ICEclc is one example. In particular I emphasized the current knowledge of regulation and conjugation machineries of the different classes of ICE. In the second chapter, I describe a transcriptional analysis using microarrays and other experiments to understand expression of ICEclc in exponential and stationary phase. By overlaying transcriptomic profiles with Northern hybridizations and RT- PCR data, we established a transcription map for the entire core region of ICEclc, a region assumed to encode the ICE conjugation process. We also demonstrated how transcription of the ICEclc core is maximal in stationary phase, which correlates to expression of reporter genes fused to key ICEclc promoters. In the third chapter, I present a transcriptome analysis of ICEclc in a variety of different host species, in order to explore whether there are species-specific differences. In the fourth chapter, I focus on the role of a curious ICEclc-encoded TetR-type transcriptional repressor. We find that this gene, which we name mfsR, not only controls its own expression but that of a set of genes for a putative multi-drug efflux pump (mfsABC) as well. By using a combination of biochemical and molecular biology techniques, I could show that MfsR specifically binds to operator boxes in two ICEclc promoters (PmfsR and PmfsA), inhibiting the transcription of both the mfsR and mfsABC-orf38184 operons. Although we could not detect a clear phenotype of an mfsABC deletion, we discuss the implications of pump gene reorganizations in ICEclc and close relatives. In the fifth chapter, we find that mfsR not only controls its own expression and that of the mfsABC operon, but is also indirectly controlling ICEclc transfer. Using gene deletions, microarrays, transfer assays and microscopy-based reporter fusions, we demonstrate that mfsR actually controls a small operon of three regulatory genes. The last gene of this mfsR operon, orf17162, encodes a LysR-type activator that when deleted strongly impairs ICEclc transfer. Interestingly, deletion of mfsR leads to transfer competence in almost all cells, thereby overruling the bistability process in the wild-type. In the final sixth chapter, I discuss the relevance of the present thesis and the resulting perspectives for future studies.

Urgences préhospitalières: mieux valoriser le travail des professionnels pour prévenir les troubles mentaux

On savait déjà que la détresse psychique touchait souvent les professionnels des interventions d'urgence préhospitalières. Voici qu'une étude chez des ambulanciers suisses, qui, à l'instar des pompiers français, prennent en charge les patients avant leur admission à l'hôpital, montre que le surinvestissement dans le travail et la perception d'un travail faiblement valorisé sont des facteurs nettement associés à des troubles de la santé mentale. [Auteurs]

Envelope glycoprotein of arenaviruses.

Arenaviruses include lethal human pathogens which pose serious public health threats. So far, no FDA approved vaccines are available against arenavirus infections, and therapeutic options are limited, making the identification of novel drug targets for the development of efficacious therapeutics an urgent need. Arenaviruses are comprised of two RNA genome segments and four proteins, the polymerase L, the envelope glycoprotein GP, the matrix protein Z, and the nucleoprotein NP. A crucial step in the arenavirus life-cycle is the biosynthesis and maturation of the GP precursor (GPC) by cellular signal peptidases and the cellular enzyme Subtilisin Kexin Isozyme-1 (SKI-1)/Site-1 Protease (S1P) yielding a tripartite mature GP complex formed by GP1/GP2 and a stable signal peptide (SSP). GPC cleavage by SKI-1/S1P is crucial for fusion competence and incorporation of mature GP into nascent budding virion particles. In a first part of our review, we cover basic aspects and newer developments in the biosynthesis of arenavirus GP and its molecular interaction with SKI-1/S1P. A second part will then highlight the potential of SKI-1/S1P-mediated processing of arenavirus GPC as a novel target for therapeutic intervention to combat human pathogenic arenaviruses.

Evaluation à l'aide d'un livre de bord des compétences cliniques acquises par des stagiaires en médecine. [Evaluation using a logbook of mastering of clinical skills by medical students]

La maîtrise des compétences cliniques est extrêmement importante pour le médecin. Leur enseignement est aujourd'hui facilité grâce à la disponibilité du «Swiss Catalogue of Learning Objectives for Undergraduate Medical Training» où sont décrits les niveaux de compétence à atteindre au terme des études de médecine. Un carnet de bord a été préparé à la Faculté de biologie et de médecine de Lausanne à partir de ce document. Il a permis de mettre en évidence chez les étudiants une très nette amélioration de la maîtrise des compétences cliniques entre le début et la fin des stages en médecine interne, chirurgie/orthopédie, pédiatrie, gynécologie/obstétrique et psychiatrie. Un tel outil devrait permettre dans l'avenir de mieux guider l'apprentissage des étudiants et de suivre leurs progrès à chaque étape du curriculum. [Abstract] The mastering of the clinical skills is of utmost importance for the physician. The teaching of the skills is nowadays made easier with the &lt;&lt;Swiss Catalogue of Learning Objectives for Undergraduate Medical Training&gt;&gt; which lists all the skills and their respective level of expected mastering at graduation. In order to do a survey on how good the students are at those skills, a logbook based on this document has been setup at the Faculty of biology and medicine of the University of Lausanne. This has shown that students went through a clear progression of the mastering of the skills during their elective year in internal medicine, surgery/orthopaedics, paediatric, obstetric and gynaecology as well as psychiatry. Such an instrument should in the future help to better guide the learning process of the clinical skills and to do a better follow-up of their progress.

Characterization of tumor reactive CD8 T cells induced by peptide vaccination in melanoma patients

ABSTRACT¦Naturally acquired tumor-specific T-cells can be detected in most advanced cancer patients.¦Yet, they often fail to control or eliminate the disease, in contrast to many virus-specific CD8¦T lymphocytes. Therapeutic vaccines aim at inducing and boosting specific T-cells mediated¦immunity to reduce tumor burden. The properties of CD8 T-cells required for protection from¦infectious disease and cancer are only partially characterized.¦The objectives of this study were to assess effector functions, stage of differentiation and¦clonotype selection of tumor-reactive T lymphocytes following peptide vaccination in¦melanoma patients over time. Results were compared to protective viral-specific T-cell¦responses found in healthy individuals. We also characterized dominant versus low/non¦dominant T-cell clonotypes with the aim to further understand the in vivo function of each set¦of frequency-based specific T-cells.¦Here we developed and applied a novel approach for molecular and functional analysis of¦single T lymphocytes ex vivo. T-cell receptor (TCR) clonotype mapping revealed rapid¦selection and expansion of co-dominant T-cell clonotypes, which made up the majority of the¦highly differentiated "effector" T-cells, but only 25% of the less differentiated "effectormemory"¦cells, mostly composed of non-dominant clonotypes. Moreover, we show that¦advanced effector cell differentiation was indeed clonotype-dependent. Surprisingly, however,¦the acquisition of effector functions (cytokine production, killing) was clonotype-independent.¦Vaccination of melanoma patients with native peptide induced competent effector function in¦both dominant and non-dominant clonotypes, suggesting that most if not all clonotypes¦participating in a T-cell response have the potential to develop equal functional competence.¦In contrast, many T-cells remained poorly functional after vaccination with analog peptide,¦despite similar clonotype-dependent differentiation. Our findings show that the type of¦peptide vaccine has a critical influence on the selection and functional activation of the¦clonotypic T-cell repertoire. They also show that systematic assessment of individual T-cells¦identifies the cellular basis of immune responses, contributing to the rational development of¦vaccines.