Childhood leukaemia risks: from unexplained findings near nuclear installations to recommendations for future research.

Recent findings related to childhood leukaemia incidence near nuclear installations have raised questions which can be answered neither by current knowledge on radiation risk nor by other established risk factors. In 2012, a workshop was organised on this topic with two objectives: (a) review of results and discussion of methodological limitations of studies near nuclear installations; (b) identification of directions for future research into the causes and pathogenesis of childhood leukaemia. The workshop gathered 42 participants from different disciplines, extending widely outside of the radiation protection field. Regarding the proximity of nuclear installations, the need for continuous surveillance of childhood leukaemia incidence was highlighted, including a better characterisation of the local population. The creation of collaborative working groups was recommended for consistency in methodologies and the possibility of combining data for future analyses. Regarding the causes of childhood leukaemia, major fields of research were discussed (environmental risk factors, genetics, infections, immunity, stem cells, experimental research). The need for multidisciplinary collaboration in developing research activities was underlined, including the prevalence of potential predisposition markers and investigating further the infectious aetiology hypothesis. Animal studies and genetic/epigenetic approaches appear of great interest. Routes for future research were pointed out.

North-south palaeohydrological contrasts in the central Mediterranean during the Holocene: tentative synthesis and working hypotheses

On the basis of a multi-proxy approach and a strategy combining lacustrine and marine records along a north–south transect, data collected in the central Mediterranean within the framework of a collaborative project have led to reconstruction of high-resolution and well-dated palaeohydrological records and to assessment of their spatial and temporal coherency. Contrasting patterns of palaeohydrological changes have been evidenced in the central Mediterranean: south (north) of around 40° N of latitude, the middle part of the Holocene was characterised by lake-level maxima (minima), during an interval dated to ca. 10 300–4500 cal BP to the south and 9000–4500 cal BP to the north. Available data suggest that these contrasting palaeohydrological patterns operated throughout the Holocene, both on millennial and centennial scales. Regarding precipitation seasonality, maximum humidity in the central Mediterranean during the middle part of the Holocene was characterised by humid winters and dry summers north of ca. 40° N, and humid winters and summers south of ca. 40° N. This may explain an apparent conflict between palaeoclimatic records depending on the proxies used for reconstruction as well as the synchronous expansion of tree species taxa with contrasting climatic requirements. In addition, south of ca. 40° N, the first millennium of the Holocene was characterised by very dry climatic conditions not only in the eastern, but also in the central- and the western Mediterranean zones as reflected by low lake levels and delayed reforestation. These results suggest that, in addition to the influence of the Nile discharge reinforced by the African monsoon, the deposition of Sapropel 1 has been favoured (1) by an increase in winter precipitation in the northern Mediterranean borderlands, and (2) by an increase in winter and summer precipitation in the southern Mediterranean area. The climate reversal following the Holocene climate optimum appears to have been punctuated by two major climate changes around 7500 and 4500 cal BP. In the central Mediterranean, the Holocene palaeohydrological changes developed in response to a combination of orbital, ice-sheet and solar forcing factors. The maximum humidity interval in the south-central Mediterranean started ca. 10 300 cal BP, in correlation with the decline (1) of the possible blocking effects of the North Atlantic anticyclone linked to maximum insolation, and/or (2) of the influence of the remnant ice sheets and fresh water forcing in the North Atlantic Ocean. In the north-central Mediterranean, the lake-level minimum interval began only around 9000 cal BP when the Fennoscandian ice sheet disappeared and a prevailing positive NAO-(North Atlantic Oscillation) type circulation developed in the North Atlantic area. The major palaeohydrological oscillation around 4500–4000 cal BP may be a non-linear response to the gradual decrease in insolation, with additional key seasonal and interhemispheric changes. On a centennial scale, the successive climatic events which punctuated the entire Holocene in the central Mediterranean coincided with cooling events associated with deglacial outbursts in the North Atlantic area and decreases in solar activity during the interval 11 700–7000 cal BP, and to a possible combination of NAO-type circulation and solar forcing since ca. 7000 cal BP onwards. Thus, regarding the centennial-scale climatic oscillations, the Mediterranean Basin appears to have been strongly linked to the North Atlantic area and affected by solar activity over the entire Holocene. In addition to model experiments, a better understanding of forcing factors and past atmospheric circulation patterns behind the Holocene palaeohydrological changes in the Mediterranean area will require further investigation to establish additional high-resolution and well-dated records in selected locations around the Mediterranean Basin and in adjacent regions. Special attention should be paid to greater precision in the reconstruction, on millennial and centennial timescales, of changes in the latitudinal location of the limit between the northern and southern palaeohydrological Mediterranean sectors, depending on (1) the intensity and/or characteristics of climatic periods/oscillations (e.g. Holocene thermal maximum versus Neoglacial, as well as, for instance, the 8.2 ka event versus the 4 ka event or the Little Ice Age); and (2) on varying geographical conditions from the western to the eastern Mediterranean areas (longitudinal gradients). Finally, on the basis of projects using strategically located study sites, there is a need to explore possible influences of other general atmospheric circulation patterns than NAO, such as the East Atlantic–West Russian or North Sea–Caspian patterns, in explaining the apparent complexity of palaeoclimatic (palaeohydrological) Holocene records from the Mediterranean area.

The new final Clinical Skills examination in human medicine in Switzerland: Essential steps of exam development, implementation and evaluation, and central insights from the perspective of the national Working Group

Objective: Since 2011, the new national final examination in human medicine has been implemented in Switzerland, with a structured clinical-practical part in the OSCE format. From the perspective of the national Working Group, the current article describes the essential steps in the development, implementation and evaluation of the Federal Licensing Examination Clinical Skills (FLE CS) as well as the applied quality assurance measures. Finally, central insights gained from the last years are presented. Methods: Based on the principles of action research, the FLE CS is in a constant state of further development. On the foundation of systematically documented experiences from previous years, in the Working Group, unresolved questions are discussed and resulting solution approaches are substantiated (planning), implemented in the examination (implementation) and subsequently evaluated (reflection). The presented results are the product of this iterative procedure. Results: The FLE CS is created by experts from all faculties and subject areas in a multistage process. The examination is administered in German and French on a decentralised basis and consists of twelve interdisciplinary stations per candidate. As important quality assurance measures, the national Review Board (content validation) and the meetings of the standardised patient trainers (standardisation) have proven worthwhile. The statistical analyses show good measurement reliability and support the construct validity of the examination. Among the central insights of the past years, it has been established that the consistent implementation of the principles of action research contributes to the successful further development of the examination. Conclusion: The centrally coordinated, collaborative-iterative process, incorporating experts from all faculties, makes a fundamental contribution to the quality of the FLE CS. The processes and insights presented here can be useful for others planning a similar undertaking. Keywords: national final examination, licensing examination, summative assessment, OSCE, action research