Communication skills training in oncology: it works!

While the previous chapter by L. Fallowfield and V. Jenkins focuses on different communication skills training (CST) concepts currently being utilized, this chapter reviews and comments the scientific evidence of the impact of CST on improving communication skills. The aim of this chapter is not to provide a complete review of the evidence-this has already been done in systematic reviews-but to discuss the scientific evidence and reflect on the available results and relevant topics for further investigations.

Working alliance in communication skills training for oncology clinicians: A controlled trial.

OBJECTIVE: The aim of this study was to evaluate the impact of communication skills training (CST) on working alliance and to identify specific communicational elements related to working alliance. METHODS: Pre- and post-training simulated patient interviews (6-month interval) of oncology physicians and nurses (N=56) who benefited from CST were compared to two simulated patient interviews with a 6-month interval of oncology physicians and nurses (N=57) who did not benefit from CST. The patient-clinician interaction was analyzed by means of the Roter Interaction Analysis System (RIAS). Alliance was measured by the Working Alliance Inventory - Short Revised Form. RESULTS: While working alliance did not improve with CST, generalized linear mixed effect models demonstrated that the quality of verbal communication was related to alliance. Positive talk and psychosocial counseling fostered alliance whereas negative talk, biomedical information and patient's questions diminished alliance. CONCLUSION: Patient-clinician alliance is related to specific verbal communication behaviors. PRACTICE IMPLICATIONS: Working alliance is a key element of patient-physician communication which deserves further investigation as a new marker and efficacy criterion of CST outcome.

Improving Social Understanding of Preschool Children: Evaluation of a Training Program

This study tested the effects of a training program intending to foster social understanding or the capacity which enables them to understand themselves and others in terms of intentions, beliefs, desires, and emotions in children at preschool age. A number of studies have shown that in the context of shared narratives, children are particularly likely to engage in talk about inner states

Cooking and Active Leisure TAS Program, Spain: A Program Impact Pathways (PIP) analysis

Background. The “Cooking and Active Leisure” Tu y Alícia por la Salud (CAL-TAS) Program is a schoolbased pilot that addresses healthy lifestyle needs of Spanish secondary school students with initiatives that research has proven to improve dietary and physical activity behaviors. Objective. The objectives were to perform a Program Impact Pathways (PIP) analysis to describe key activities and processes of the CAL-TAS Program, identify Critical Quality Control Points (CCPs), and identify a suite of common indicators of healthy lifestyles to be applied across participant schools. Methods. The CAL-TAS Program designers and implementation team developed this PIP analysis through an iterative process and presented the results for feedback at the seven-country Healthy Lifestyles Program Evaluation Workshop held in Granada, Spain, 13–14 September 2013, under the auspices of the Mondelēz International Foundation. Results. The team identified three PIP CCPs: teachers’ motivation and training, changes in students’ knowledge of healthy lifestyles, and changes in students’ healthy lifestyle behavior. The selected indicators of the program’s impact on healthy lifestyles are adequacy of food intake, level of knowledge of healthy lifestyles gained, and adequacy of physical activity level according to World Health Organization recommendations. A clear definition of impact indicators, as well as collection of accurate data on healthy lifestyle behaviors and knowledge, is essential to understanding the effectiveness of this program before it can be scaled up. Conclusions. CAL-TAS is an effective secondary school-based program encouraging healthy lifestyles. The PIP analysis was instrumental in identifying CCPs to sustain and improve the quality of the program. The team hopes to sustain and improve the program through these program evaluation recommendations.

Counteracting incentive sensitization in severe alcohol dependence using deep brain stimulation of the nucleus accumbens: clinical and basic science aspects

The ventral striatum / nucleus accumbens has been implicated in the craving for drugs and alcohol which is a major reason for relapse of addicted people. Craving might be induced by drug-related cues. This suggests that disruption of craving-related neural activity in the nucleus accumbens may significantly reduce craving in alcohol-dependent patients. Here we report on preliminary clinical and neurophysiological evidence in three male patients who were treated with high frequency deep brain stimulation of the nucleus accumbens bilaterally. All three had been alcohol dependent for many years, unable to abstain from drinking, and had experienced repeated relapses prior to the stimulation. After the operation, craving was greatly reduced and all three patients were able to abstain from drinking for extended periods of time. Immediately after the operation but prior to connection of the stimulation electrodes to the stimulator, local field potentials were obtained from the externalized cables in two patients while they performed cognitive tasks addressing action monitoring and incentive salience of drug related cues. LFPs in the action monitoring task provided further evidence for a role of the nucleus accumbens in goal-directed behaviors. Importantly, alcohol related cue stimuli in the incentive salience task modulated LFPs even though these cues were presented outside of the attentional focus. This implies that cue-related craving involves the nucleus accumbens and is highly automatic.

Enhancing human security through crisis management : opportunities and challenges for learning

Inhimilliseen turvallisuuteen kriisinhallinnan kautta – oppimisen mahdollisuuksia ja haasteita Kylmän sodan jälkeen aseelliset konfliktit ovat yleensä alkaneet niin sanotuissa hauraissa valtioissa ja köyhissä maissa, ne ovat olleet valtioiden sisäisiä ja niihin on osallistunut ei-valtiollisia aseellisia ryhmittymiä. Usein ne johtavat konfliktikierteeseen, jossa sota ja vakaammat olot vaihtelevat. Koska kuolleisuus konflikteissa voi jäädä alle kansainvälisen määritelmän (1000 kuollutta vuodessa), kutsun tällaisia konflikteja ”uusiksi konflikteiksi”. Kansainvälinen yhteisö on pyrkinyt kehittämään kriisinhallinnan ja rauhanrakentamisen malleja, jotta pysyvä rauhantila saataisiin aikaiseksi. Inhimillinen turvallisuus perustuu näkemykseen, jossa kunnioitetaan jokaisen yksilön ihmisoikeuksia ja jolla on vaikutusta myös kriisinhallinnan ja rauhanrakentamisen toteuttamiseen. Tutkimukseen kuuluu kaksi empiiristä osaa: Delfoi tulevaisuuspaneeliprosessin sekä kriisinhallintahenkilöstön haastattelut. Viisitoista eri alojen kriisinhallinta-asiantuntijaa osallistui paneeliin, joka toteutettiin vuonna 2008. Paneelin tulosten mukaan tulevat konfliktit usein ovat uusien konfliktien kaltaisia. Lisäksi kriisinhallintahenkilöstöltä edellytetään vuorovaikutus- ja kommunikaatiokykyä ja luonnollisesti myös varsinaisia ammatillisia valmiuksia. Tulevaisuuspaneeli korosti vuorovaikutus- ja kommunikaatiotaitoja erityisesti siviilikriisinhallintahenkilöstön kompetensseissa, mutta samat taidot painottuivat sotilaallisen kriisinhallinnan henkilöstön kompetensseissakin. Kriisinhallinnassa tarvitaan myös selvää työnjakoa eri toimijoiden kesken. Kosovossa työskennelleen henkilöstön haastatteluaineisto koostui yhteensä 27 teemahaastattelusta. Haastateltavista 9 oli ammattiupseeria, 10 reservistä rekrytoitua rauhanturvaajaa ja 8 siviilikriisinhallinnassa työskennellyttä henkilöä. Haastattelut toteutettiin helmi- ja kesäkuun välisenä aikana vuonna 2008. Haastattelutuloksissa korostui vuorovaikutus- ja kommunikaatiotaitojen merkitys, sillä monissa käytännön tilanteissa haastateltavat olivat ratkoneet ongelmia yhteistyössä muun kriisinhallintahenkilöstön tai paikallisten asukkaiden kanssa. Kriisinhallinnassa toteutui oppimisprosesseja, jotka usein olivat luonteeltaan myönteisiä ja informaalisia. Tällaisten onnistumisten vaikutus yksilön minäkuvaan oli myönteinen. Tällaisia prosesseja voidaan kuvata ”itseä koskeviksi oivalluksiksi”. Kriisinhallintatehtävissä oppimisella on erityinen merkitys, jos halutaan kehittää toimintoja inhimillisen turvallisuuden edistämiseksi. Siksi on tärkeää, että kriisinhallintakoulutusta ja kriisinhallintatyössä oppimista kehitetään ottamaan huomioon oppimisen eri tasot ja ulottuvuudet sekä niiden merkitys. Informaaliset oppimisen muodot olisi otettava paremmin huomioon kriisinhallintakoulutusta ja kriisinhallintatehtävissä oppimista kehitettäessä. Palautejärjestelmää olisi kehitettävä eri tavoin. Koko kriisinhallintaoperaation on saatava tarvittaessa myös kriittistä palautetta onnistumisista ja epäonnistumisista. Monet kriisinhallinnassa työskennelleet kaipaavat kunnollista palautetta työrupeamastaan. Liian rutiininomaiseksi koettu palaute ei edistä yksilön oppimista. Spontaanisti monet haastatellut pitivät tärkeänä, että kriisinhallinnassa työskennelleillä olisi mahdollisuus debriefing- tyyppiseen kotiinpaluukeskusteluun. Pelkkä tällainen mahdollisuus ilmeisesti voisi olla monelle myönteinen uutinen, vaikka tilaisuutta ei hyödynnettäisikään. Paluu kriisinhallintatehtävistä Suomeen on monelle haasteellisempaa kuin näissä tehtävissä työskentelyn aloittaminen ulkomailla. Tutkimuksen tulokset kannustavat tutkimaan kriisinhallintaa oppimisen näkökulmasta. On myös olennaista, että kriisinhallinnan palautejärjestelmiä kehitetään mahdollisimman hyvin edistämään sekä yksilöllistä että organisatorista oppimista kriisinhallinnassa. Kriisinhallintaoperaatio on oppimisympäristö. Kriisinhallintahenkilöstön kommunikaatio- ja vuorovaikutustaitojen kehittäminen on olennaista tavoiteltaessa kestävää rauhanprosessia, jossa konfliktialueen asukkaatkin ovat mukana.

Basic skills for outpatient surgery in medical graduation

Medical students must have domain of basic surgery skills before starting more advanced stages of surgical learning. The authors present a practical and reproducible system of operative techniques circuit, idealized and often applied to the fourth year medical students of a private educational institution. This method has enabled accurate assessment of students' skills, improving their performance and preparing them for more advanced stages of the surgical learning.

Comparison of morning and afternoon exercise training for asthmatic children

Fitness improvement was used to compare morning with afternoon exercise periods for asthmatic children. Children with persistent moderate asthma (according to GINA criteria), 8 to 11 years old, were divided into 3 groups: morning training group (N = 23), afternoon training group (N = 23), and non-training group (N = 23). The program was based on twice a week 90-min sessions for 4 months. We measured the 9-min running distance, resting heart rate and abdominal muscle strength (sit-up number) before and after the training. All children took budesonide, 400 µg/day, and an on demand inhaled ß-agonist. The distance covered in 9 min increased (mean ± SEM) from 1344 ± 30 m by 248 ± 30 m for the morning group, from 1327 ± 30 m by 162 ± 20 m for the afternoon group, and from 1310 ± 20 m by 2 ± 20 m for the control group (P < 0.05 for the comparison of morning and afternoon groups with the control group by ANOVA and P > 0.05 for morning with afternoon comparison). The reduction of resting heart rate from 83 ± 1, 85 ± 2 and 86 ± 1 bpm was 5.1 ± 0.8 bpm in the morning group, 4.4 ± 0.8 bpm in the afternoon group, and -0.2 ± 0.7 bpm in the control group (P > 0.05 for morning with afternoon comparison and P < 0.05 versus control). The number of sit-ups in the morning, afternoon and control groups increased from 22.0 ± 1.7, 24.3 ± 1.4 and 23 ± 1.1 sit-ups by 9.8 ± 0.9, 7.7 ± 1.4, and 1.9 ± 0.7 sit-ups, respectively (P > 0.05 for morning with afternoon comparison and P < 0.05 versus control). No statistically significant differences were detected between the morning and afternoon groups in terms of physical training of asthmatic children.

L-carnitine as an ergogenic aid for patients with chronic obstructive pulmonary disease submitted to whole-body and respiratory muscle training programs

The effects of adding L-carnitine to a whole-body and respiratory training program were determined in moderate-to-severe chronic obstructive pulmonary disease (COPD) patients. Sixteen COPD patients (66 ± 7 years) were randomly assigned to L-carnitine (CG) or placebo group (PG) that received either L-carnitine or saline solution (2 g/day, orally) for 6 weeks (forced expiratory volume on first second was 38 ± 16 and 36 ± 12%, respectively). Both groups participated in three weekly 30-min treadmill and threshold inspiratory muscle training sessions, with 3 sets of 10 loaded inspirations (40%) at maximal inspiratory pressure. Nutritional status, exercise tolerance on a treadmill and six-minute walking test, blood lactate, heart rate, blood pressure, and respiratory muscle strength were determined as baseline and on day 42. Maximal capacity in the incremental exercise test was significantly improved in both groups (P < 0.05). Blood lactate, blood pressure, oxygen saturation, and heart rate at identical exercise levels were lower in CG after training (P < 0.05). Inspiratory muscle strength and walking test tolerance were significantly improved in both groups, but the gains of CG were significantly higher than those of PG (40 ± 14 vs 14 ± 5 cmH2O, and 87 ± 30 vs 34 ± 29 m, respectively; P < 0.05). Blood lactate concentration was significantly lower in CG than in PG (1.6 ± 0.7 vs 2.3 ± 0.7 mM, P < 0.05). The present data suggest that carnitine can improve exercise tolerance and inspiratory muscle strength in COPD patients, as well as reduce lactate production.

The effect of an aerobic training program on the electrical remodeling of the heart: high-frequency components of the signal-averaged electrocardiogram are predictors of the maximal aerobic power

Increased heart rate variability (HRV) and high-frequency content of the terminal region of the ventricular activation of signal-averaged ECG (SAECG) have been reported in athletes. The present study investigates HRV and SAECG parameters as predictors of maximal aerobic power (VO2max) in athletes. HRV, SAECG and VO2max were determined in 18 high-performance long-distance (25 ± 6 years; 17 males) runners 24 h after a training session. Clinical visits, ECG and VO2max determination were scheduled for all athletes during thew training period. A group of 18 untrained healthy volunteers matched for age, gender, and body surface area was included as controls. SAECG was acquired in the resting supine position for 15 min and processed to extract average RR interval (Mean-RR) and root mean squared standard deviation (RMSSD) of the difference of two consecutive normal RR intervals. SAECG variables analyzed in the vector magnitude with 40-250 Hz band-pass bi-directional filtering were: total and 40-µV terminal (LAS40) duration of ventricular activation, RMS voltage of total (RMST) and of the 40-ms terminal region of ventricular activation. Linear and multivariate stepwise logistic regressions oriented by inter-group comparisons were adjusted in significant variables in order to predict VO2max, with a P < 0.05 considered to be significant. VO2max correlated significantly (P < 0.05) with RMST (r = 0.77), Mean-RR (r = 0.62), RMSSD (r = 0.47), and LAS40 (r = -0.39). RMST was the independent predictor of VO2max. In athletes, HRV and high-frequency components of the SAECG correlate with VO2max and the high-frequency content of SAECG is an independent predictor of VO2max.

Profitable opportunities around macroeconomic announcements in the U.S. Treasury market

This thesis studies the impact of macroeconomic announcements on the U.S. Treasury market and investigates profitable opportunities around macroeconomic announcements using data from the eSpeed electronic trading platform. We investigate how macroeconomic announcements affect the return predictability of trade imbalance for the 2-year, 5-year, IO-year U.S. Treasury notes and 30-year U.S. Treasury bonds. The goal of this thesis is to develop a methodology to identify informed trades and estimate the trade imbalance based on informed trades. We use the daily order book slope as a proxy for dispersion of beliefs among investors. Regression results in this thesis indicate that, on announcement days with a high dispersion of beliefs, daily trade imbalance estimated by informed trades significantly predicts returns on the following day. In addition, we develop a trade-imbalance based trading strategy conditional on dispersion of beliefs, informed trades, and announcement days. The trading strategy yields significantly positive net returns for the 2-year T-notes.

Opportunities and constraints of peri-urban buffalo and dairy cattle systems in Faisalabad, Punjab, Pakistan

In the big cities of Pakistan, peri-urban dairy production plays an important role for household income generation and the supply of milk and meat to the urban population. On the other hand, milk production in general, and peri-urban dairy production in particular, faces numerous problems that have been well known for decades. Peri-urban dairy producers have been especially neglected by politicians as well as non-government-organizations (NGOs). Against this background, a study in Pakistan’s third largest city, Faisalabad (Punjab Province), was carried out with the aims of gathering basic information, determining major constraints and identifying options for improvements of the peri-urban milk production systems. For data collection, 145 peri-urban households (HH) engaged in dairy production were interviewed face to face using a structured and pretested questionnaire with an interpreter. For analyses, HH were classified into three wealth groups according to their own perception. Thus, 38 HH were poor, 95 HH well off and 12 HH rich (26.2%, 65.5% and 8.3%, respectively). The richer the respondents perceived their HH, the more frequently they were actually in possession of high value HH assets like phones, bank accounts, motorbikes, tractors and cars. Although there was no difference between the wealth groups with respect to the number of HH members (about 10, range: 1 to 23), the educational level of the HH heads differed significantly: on average, heads of poor HH had followed education for 3 years, compared to 6 years for well off HH and 8 years for rich HH. About 40% of the poor and well off HH also had off-farm incomes, while the percentage was much higher - two thirds (67%) - for the rich HH. The majority of the HH were landless (62%); the rest (55 HH) possessed agricultural land from 0.1 to 10.1 ha (average 2.8 ha), where they were growing green fodder: maize, sorghum and pearl millet in summer; berseem, sugar cane and wheat were grown in winter. Dairy animals accounted for about 60% of the herds; the number of dairy animals per HH ranged from 2 to 50 buffaloes (Nili-Ravi breed) and from 0 to 20 cows (mostly crossbred, also Sahiwal). About 37% (n=54) of the HH did not keep cattle. About three quarters of the dairy animals were lactating. The majority of the people taking care of the animals were family workers; 17.3% were hired labourers (exclusively male), employed by 11 rich and 32 well off HH; none of the poor HH employed workers, but the percentages were 33.7% for the well off and 91.7% for the rich HH. The total number of workers increased significantly with increasing wealth (poor: 2.0; well off:2.5; rich: 3.4). Overall, 69 female labourers were recorded, making up 16.8% of employed workers and one fourth of the HH’s own labourers. Apparently, their only duty was to clean the animals´ living areas; only one of them was also watering and showering the animals. Poor HH relied more on female workers than the other two groups: 27.1% of the workers of poor HH were women, but only 14.8% and 6.8% of the labour force of well off and rich HH were female. Two thirds (70%) of the HH sold milk to dhodis (middlemen) and one third (35%) to neighbours; three HH (2%) did doorstep delivery and one HH (1%) had its own shop. The 91 HH keeping both species usually sold mixed milk (97%). Clients for mixed and pure buffalo milk were dhodis (78%, respectively 59%) and neighbours (28%, respectively 47%). The highest milk prices per liter (Pakistani Rupees, 100 PKR @ 0.8 Euro) were paid by alternative clients (44 PKR; 4 HH), followed by neighbours (40 PKR, 50 HH); dhodis paid lower prices (36 PKR, 99 HH). Prices for pure buffalo and mixed milk did not differ significantly. However, HH obtaining the maximum price from the respective clients for the respective type of milk got between 20% (mixed milk, alternative clients) and 68% (mixed milk, dhodi) more than HH fetching the minimum price. Some HH (19%) reported 7% higher prices for the current summer than the preceding winter. Amount of milk sold and distance from the HH to the city center did not influence milk prices. Respondents usually named problems that directly affected their income and that were directly and constantly visible to them, such as high costs, little space and fodder shortages. Other constraints that are only influencing their income indirectly, e.g. the relatively low genetic potential of their animals due to neglected breeding as well as the short- and long-term health problems correlated with imbalanced feeding and insufficient health care, were rarely named. The same accounts for problems accompanying improper dung management (storage, disposal, burning instead of recycling) for the environment and human health. Most of the named problems are linked to each other and should be addressed within the context of the entire system. Therefore, further research should focus on systematic investigations and improvement options, taking a holistic and interdisciplinary approach instead of only working in single fields. Concerted efforts of dairy farmers, researchers, NGOs and political decision makers are necessary to create an economic, ecological and social framework that allows dairy production to serve the entire society. For this, different improvement options should be tested in terms of their impact on environment and income of the farmers, as well as feasibility and sustainability in the peri-urban zones of Faisalabad.