Do patients respect the line? Transgression of boundaries reported by Swiss general practitioners

OBJECTIVE: Transgression of boundaries in the relationship between physician and patient is commonly studied with patient as victim and physician as transgressor. A recent survey in the U.S. reported that almost 90% of physicians face transgression by patients over one year. Incidents happened mainly through verbal abuse, disregarding privacy, and overly affectionate behavior. Since this incidence seems to be alarmingly high, we were interested to analyze how often general practitioners in Switzerland experience transgression by patients. METHODS: 24% of the members of the Swiss Society of Internal Medicine (SGIM) and of the Swiss Society of General Medicine (SGAM) (n=675/2781) responded to an internet-based survey which asked for experiences of transgression by patients and for physicians' responses to transgression in the last 12 months. RESULTS: 81% of responding physicians experienced transgression over the period of one year. Analyzing the frequency of incidents per physician per year, the most common forms of transgression were 'use of physician's first name' (7.7/y), 'asking personal questions' (1.8/y), 'being verbally abusive' (1.5/y), and 'being overly affectionate' (1.4/y). Calculated incidence of transgression was 3 per 1000 patient contacts. 39% of physicians decided to ignore the incident, 37% discussed the event openly. Transgression led to dismissal of patients in 13% of events. CONCLUSION: Transgression even in mild and modest form is a rare phenomenon in Swiss practices. PRACTICE IMPLICATION: The Swiss data do not suggest that there is a specific risk for Swiss practitioners to be exposed to major transgression for which they should specifically be prepared for example in communication skills trainings.

Interpretation of primary care physicians' attitude regarding rotavirus immunisation using diffusion of innovation theories

To evaluate primary care physicians' attitude towards implementation of rotavirus (RV) immunisation into the Swiss immunisation schedule, an eight-question internet-based questionnaire was sent to the 3799 subscribers of InfoVac, a nationwide web-based expert network on immunisation issues, which reaches >95% of paediatricians and smaller proportions of other primary care physicians. Five demographic variables were also inquired. Descriptive statistics and multivariate analyses for the main outcome "acceptance of routine RV immunisation" and other variables were performed. Diffusion of innovation theory was used for data assessment. Nine-hundred seventy-seven questionnaires were returned (26%). Fifty percent of participants were paediatricians. Routine RV immunisation was supported by 146 participants (15%; so called early adopters), dismissed by 620 (64%), leaving 211 (21%) undecided. However, when asked whether they would recommend RV vaccination to parents if it were officially recommended by the federal authorities and reimbursed, 467 (48.5%; so called early majority) agreed to recommend RV immunisation. Multivariate analysis revealed that physicians who would immunise their own child (OR: 5.1; 95% CI: 4.1-6.3), hospital-based physicians (OR: 1.6; 95% CI: 1.1-2.3) and physicians from the French (OR: 1.6; 95% CI: 1.2-2.3) and Italian speaking areas of Switzerland (OR: 2.5; 95% CI: 1.1-5.8) were more likely to support RV immunisation. Diffusion of innovation theory predicts a >80% implementation if approximately 50% of a given population support an innovation. Introduction of RV immunisation in Switzerland is likely to be successful, if (i) the federal authorities issue an official recommendation and (ii) costs are covered by basic health care insurance.

Using Dynamic Programming Decomposition for Revenue Management with Opaque Products

Opaque products enable service providers to hide specific characteristics of their service fulfillment from the customer until after purchase. Prominent examples include internet-based service providers selling airline tickets without defining details, such as departure time or operating airline, until the booking has been made. Owing to the resulting flexibility in resource utilization, the traditional revenue management process needs to be modified. In this paper, we extend dynamic programming decomposition techniques widely used for traditional revenue management to develop an intuitive capacity control approach that allows for the incorporation of opaque products. In a simulation study, we show that the developed approach significantly outperforms other well-known capacity control approaches adapted to the opaque product setting. Based on the approach, we also provide computational examples of how the share of opaque products as well as the degree of opacity can influence the results.

Fuzzy Online Reputation Analysis Framework

The fuzzy online reputation analysis framework, or “foRa” (plural of forum, the Latin word for marketplace) framework, is a method for searching the Social Web to find meaningful information about reputation. Based on an automatic, fuzzy-built ontology, this framework queries the social marketplaces of the Web for reputation, combines the retrieved results, and generates navigable Topic Maps. Using these interactive maps, communications operatives can zero in on precisely what they are looking for and discover unforeseen relationships between topics and tags. Thus, using this framework, it is possible to scan the Social Web for a name, product, brand, or combination thereof and determine query-related topic classes with related terms and thus identify hidden sources. This chapter also briefly describes the youReputation prototype (www.youreputation.org), a free web-based application for reputation analysis. In the course of this, a small example will explain the benefits of the prototype.

Internetbasierte psychologische Behandlung bei Depressionen

Depression ist die häufigste psychische Erkrankung, aber nur ein geringer Anteil der Betroffenen erhält eine angemessene Behandlung. Internetbasierte Interventionen stellen eine vielversprechende Ergänzung zu traditionellen Behandlungsformen dar, denn über das Internet können breite Bevölkerungsschichten mit wenig Aufwand erreicht werden. Die vorliegende Übersicht stellt den aktuellen Forschungsstand zu internetbasierten Interventionen bei Depressionen dar. Mehrere randomisierte kontrollierte Studien, Metaanalysen und Reviews legen nahe, dass mit strukturierten internetbasierten Interventionen, die regelmäßige Kontakte mit Therapeuten beinhalten (z.B. geleitete Selbsthilfeansätze, E-Mail- oder Chat-Therapien), Effekte erzielt werden können, die mit den Effekten von traditionellen Psychotherapien vergleichbar sind. Ungeleitete Selbsthilfeprogramme sind typischerweise mit hohen Abbrecherquoten und geringeren Effekten verbunden. Die zukünftige Forschung sollte sich vermehrt mit der Frage beschäftigen, wie internetbasierte Interventionen bei Depressionen optimal in die psychosoziale Versorgung integriert werden können. Mögliche Einsatzbereiche und die Einbettung internetbasierter Interventionen in das Versorgungssystem werden dargestellt und diskutiert.

Development, implementation, and evaluation of a structured reporting web tool for abdominal aortic aneurysms

BACKGROUND The majority of radiological reports are lacking a standard structure. Even within a specialized area of radiology, each report has its individual structure with regards to details and order, often containing too much of non-relevant information the referring physician is not interested in. For gathering relevant clinical key parameters in an efficient way or to support long-term therapy monitoring, structured reporting might be advantageous. OBJECTIVE Despite of new technologies in medical information systems, medical reporting is still not dynamic. To improve the quality of communication in radiology reports, a new structured reporting system was developed for abdominal aortic aneurysms (AAA), intended to enhance professional communication by providing the pertinent clinical information in a predefined standard. METHODS Actual state analysis was performed within the departments of radiology and vascular surgery by developing a Technology Acceptance Model. The SWOT (strengths, weaknesses, opportunities, and threats) analysis focused on optimization of the radiology reporting of patients with AAA. Definition of clinical parameters was achieved by interviewing experienced clinicians in radiology and vascular surgery. For evaluation, a focus group (4 radiologists) looked at the reports of 16 patients. The usability and reliability of the method was validated in a real-world test environment in the field of radiology. RESULTS A Web-based application for radiological "structured reporting" (SR) was successfully standardized for AAA. Its organization comprises three main categories: characteristics of pathology and adjacent anatomy, measurements, and additional findings. Using different graphical widgets (eg, drop-down menus) in each category facilitate predefined data entries. Measurement parameters shown in a diagram can be defined for clinical monitoring and be adducted for quick adjudications. Figures for optional use to guide and standardize the reporting are embedded. Analysis of variance shows decreased average time required with SR to obtain a radiological report compared to free-text reporting (P=.0001). Questionnaire responses confirm a high acceptance rate by the user. CONCLUSIONS The new SR system may support efficient radiological reporting for initial diagnosis and follow-up for AAA. Perceived advantages of our SR platform are ease of use, which may lead to more accurate decision support. The new system is open to communicate not only with clinical partners but also with Radiology Information and Hospital Information Systems.

Quality Control for SP Performance Regarding Patient Portrayal in a High-Stakes OSCE

Introduction Since the quality of patient portrayal of standardized patients (SPs) during an Objective Structured Clinical Exam (OSCE) has a major impact on the reliability and validity of the exam, quality control should be initiated. Literature about quality control of SP’s performance focuses on feedback [1, 2] or completion of checklists [3, 4]. Since we did not find a published instrument meeting our needs for the assessment of patient portrayal, we developed such an instrument after being inspired by others [5] and used it in our high-stakes exam. Methods SP trainers from all five Swiss medical faculties collected and prioritized quality criteria for patient portrayal. Items were revised with the partners twice, based on experiences during OSCEs. The final instrument contains 14 criteria for acting (i.e. adequate verbal and non-verbal expression) and standardization (i.e. verbatim delivery of the first sentence). All partners used the instrument during a high-stakes OSCE. Both, SPs and trainers were introduced to the instrument. The tool was used in training (more than 100 observations) and during the exam (more than 250 observations). FAIR_OSCE The list of items to assess the quality of the simulation by SPs was primarily developed and used to provide formative feedback to the SPs in order to help them to improve their performance. It was therefore named “Feedbackstruckture for the Assessment of Interactive Role play in Objective Structured Clinical Exams (FAIR_OSCE). It was also used to assess the quality of patient portrayal during the exam. The results were calculated for each of the five faculties individually. Formative evaluation was given to the five faculties with individual feedback without revealing results of other faculties other than overall results. Results High quality of patient portrayal during the exam was documented. More than 90% of SP performances were rated to be completely correct or sufficient. An increase in quality of performance between training and exam was noted. In example the rate of completely correct reaction in medical tests increased from 88% to 95%. 95% completely correct reactions together with 4% sufficient reactions add up to 99% of the reactions meeting the requirements of the exam. SP educators using the instrument reported an augmentation of SPs performance induced by the use of the instrument. Disadvantages mentioned were high concentration needed to explicitly observe all criteria and cumbersome handling of the paper-based forms. Conclusion We were able to document a very high quality of SP performance in our exam. The data also indicate that our training is effective. We believe that the high concentration needed using the instrument is well invested, considering the observed augmentation of performance. The development of an iPad based application for the form is planned to address the cumbersome handling of the paper.

FAIR_OSCE – Feedback structure for assessment of interactive roleplay in Objective Structured Clinical Exams

Introduction Since the quality of patient portrayal of standardized patients (SPs) during an Objective Structured Clinical Exam (OSCE) has a major impact on the reliability and validity of the exam, quality control should be initiated. Literature about quality control of SPs’ performance focuses on feedback [1, 2] or completion of checklists [3, 4]. Since we did not find a published instrument meeting our needs for the assessment of patient portrayal, we developed such an instrument after being inspired by others [5] and used it in our high-stakes exam. Project description SP trainers from five medical faculties collected and prioritized quality criteria for patient portrayal. Items were revised twice, based on experiences during OSCEs. The final instrument contains 14 criteria for acting (i.e. adequate verbal and non-verbal expression) and standardization (i.e. verbatim delivery of the first sentence). All partners used the instrument during a high-stakes OSCE. SPs and trainers were introduced to the instrument. The tool was used in training (more than 100 observations) and during the exam (more than 250 observations). Outcome High quality of SPs’ patient portrayal during the exam was documented. More than 90% of SP performances were rated to be completely correct or sufficient. An increase in quality of performance between training and exam was noted. For example, the rate of completely correct reaction in medical tests increased from 88% to 95%. Together with 4% of sufficient performances these 95% add up to 99% of the reactions in medical tests meeting the standards of the exam. SP educators using the instrument reported an augmentation of SPs’ performance induced by the use of the instrument. Disadvantages mentioned were the high concentration needed to observe all criteria and the cumbersome handling of the paper-based forms. Discussion We were able to document a very high quality of SP performance in our exam. The data also indicates that our training is effective. We believe that the high concentration needed using the instrument is well invested, considering the observed enhancement of performance. The development of an iPad-based application for the form is planned to address the cumbersome handling of the paper.

Voting Power and Probability

Voting power is commonly measured using a probability. But what kind of probability is this? Is it a degree of belief or an objective chance or some other sort of probability? The aim of this paper is to answer this question. The answer depends on the use to which a measure of voting power is put. Some objectivist interpretations of probabilities are appropriate when we employ such a measure for descriptive purposes. By contrast, when voting power is used to normatively assess voting rules, the probabilities are best understood as classical probabilities, which count possibilities. This is so because, from a normative stance, voting power is most plausibly taken to concern rights and thus possibilities. The classical interpretation also underwrites the use of the Bernoulli model upon which the Penrose/Banzhaf measure is based.

OSCAR – ein internetbasiertes Unterstützungsprogramm für Angehörige von Menschen mit einer Hirnverletzung: Pilotstudie

Erhöhte Depressivität und Ängstlichkeit sowie ein erhöhtes subjektives Belastungserleben sind bei Angehörigen von Menschen mit einer Hirnverletzung häufig. Die vorliegende Pilotuntersuchung widmet sich der Evaluation einer neuartigen Intervention, dem OSCAR Online-Coaching, einer internetbasierten Mehrkomponentenintervention. In einer randomisierten, kontrollierten Pilotstudie mit 35 TeilnehmerInnen wurde ein 16-wöchiges therapeutengeleitetes Selbsthilfeprogramm mit einer Wartekontrollgruppe verglichen. Als primäre Ergebnismasse wurde der Perceived Stress Questionnaire und das Zarit Burden Interview eingesetzt. Intention-to-treat-Analysen der unmittelbaren Effekte direkt nach der Intervention zeigten keine signifikanten Gruppenunterschiede auf den primären und auf sekundären Ergebnismassen. Im 6-Monate Follow-up, nach Zugang der Kontrollgruppe zur Intervention, wurde in der Gesamtstichprobe eine signifikante Reduktion des Caregiver Burden, depressiver Symptome, der Angst, sowie eine Zunahme positiver Emotionen gefunden. Die Zufriedenheit mit dem Programm war gut.

Técnicas de procesado digital de señal aplicadas a acelerómetros

En este proyecto se estudian y analizan las diferentes técnicas de procesado digital de señal aplicadas a acelerómetros. Se hace uso de una tarjeta de prototipado, basada en DSP, para realizar las diferentes pruebas. El proyecto se basa, principalmente, en realizar filtrado digital en señales provenientes de un acelerómetro en concreto, el 1201F, cuyo campo de aplicación es básicamente la automoción. Una vez estudiadas la teoría de procesado y las características de los filtros, diseñamos una aplicación basándonos sobre todo en el entorno en el que se desarrollaría una aplicación de este tipo. A lo largo del diseño, se explican las diferentes fases: diseño por ordenador (Matlab), diseño de los filtros en el DSP (C), pruebas sobre el DSP sin el acelerómetro, calibración del acelerómetro, pruebas finales sobre el acelerómetro... Las herramientas utilizadas son: la plataforma Kit de evaluación 21-161N de Analog Devices (equipado con el entorno de desarrollo Visual DSP 4.5++), el acelerómetro 1201F, el sistema de calibración de acelerómetros CS-18-LF de Spektra y los programas software MATLAB 7.5 y CoolEditPRO 2.0. Se realizan únicamente filtros IIR de 2º orden, de todos los tipos (Butterworth, Chebyshev I y II y Elípticos). Realizamos filtros de banda estrecha, paso-banda y banda eliminada, de varios tipos, dentro del fondo de escala que permite el acelerómetro. Una vez realizadas todas las pruebas, tanto simulaciones como físicas, se seleccionan los filtros que presentan un mejor funcionamiento y se analizan para obtener conclusiones. Como se dispone de un entorno adecuado para ello, se combinan los filtros entre sí de varias maneras, para obtener filtros de mayor orden (estructura paralelo). De esta forma, a partir de filtros paso-banda, podemos obtener otras configuraciones que nos darán mayor flexibilidad. El objetivo de este proyecto no se basa sólo en obtener buenos resultados en el filtrado, sino también de aprovechar las facilidades del entorno y las herramientas de las que disponemos para realizar el diseño más eficiente posible. In this project, we study and analize digital signal processing in order to design an accelerometer-based application. We use a hardware card of evaluation, based on DSP, to make different tests. This project is based in design digital filters for an automotion application. The accelerometer type is 1201F. First, we study digital processing theory and main parameters of real filters, to make a design based on the application environment. Along the application, we comment all the different steps: computer design (Matlab), filter design on the DSP (C language), simulation test on the DSP without the accelerometer, accelerometer calibration, final tests on the accelerometer... Hardware and software tools used are: Kit of Evaluation 21-161-N, based on DSP, of Analog Devices (equiped with software development tool Visual DSP 4.5++), 1201-F accelerometer, CS-18-LF calibration system of SPEKTRA and software tools MATLAB 7.5 and CoolEditPRO 2.0. We only perform 2nd orden IIR filters, all-type : Butterworth, Chebyshev I and II and Ellyptics. We perform bandpass and stopband filters, with very narrow band, taking advantage of the accelerometer's full scale. Once all the evidence, both simulations and physical, are finished, filters having better performance and analyzed and selected to draw conclusions. As there is a suitable environment for it, the filters are combined together in different ways to obtain higher order filters (parallel structure). Thus, from band-pass filters, we can obtain many configurations that will give us greater flexibility. The purpose of this project is not only based on good results in filtering, but also to exploit the facilities of the environment and the available tools to make the most efficient design possible.

A new generation of real-time systems in the JET tokamak

Recently a new recipe for developing and deploying real-time systems has become increasingly adopted in the JET tokamak. Powered by the advent of x86 multi-core technology and the reliability of the JET’s well established Real-Time Data Network (RTDN) to handle all real-time I/O, an official Linux vanilla kernel has been demonstrated to be able to provide realtime performance to user-space applications that are required to meet stringent timing constraints. In particular, a careful rearrangement of the Interrupt ReQuests’ (IRQs) affinities together with the kernel’s CPU isolation mechanism allows to obtain either soft or hard real-time behavior depending on the synchronization mechanism adopted. Finally, the Multithreaded Application Real-Time executor (MARTe) framework is used for building applications particularly optimised for exploring multicore architectures. In the past year, four new systems based on this philosophy have been installed and are now part of the JET’s routine operation. The focus of the present work is on the configuration and interconnection of the ingredients that enable these new systems’ real-time capability and on the impact that JET’s distributed real-time architecture has on system engineering requirements, such as algorithm testing and plant commissioning. Details are given about the common real-time configuration and development path of these systems, followed by a brief description of each system together with results regarding their real-time performance. A cycle time jitter analysis of a user-space MARTe based application synchronising over a network is also presented. The goal is to compare its deterministic performance while running on a vanilla and on a Messaging Real time Grid (MRG) Linux kernel.

PREDIRCAM eHealth platform for individualized telemedical assistance for lifestyle modification in the treatment of obesity, diabetes, and cardiometabolic risk prevention: a pilot study (PREDIRCAM 1)

Background: Healthy diet and regular physical activity are powerful tools in reducing diabetes and cardiometabolic risk. Various international scientific and health organizations have advocated the use of new technologies to solve these problems. The PREDIRCAM project explores the contribution that a technological system could offer for the continuous monitoring of lifestyle habits and individualized treatment of obesity as well as cardiometabolic risk prevention. Methods: PREDIRCAM is a technological platform for patients and professionals designed to improve the effectiveness of lifestyle behavior modifications through the intensive use of the latest information and communication technologies. The platform consists of a web-based application providing communication interface with monitoring devices of physiological variables, application for monitoring dietary intake, ad hoc electronic medical records, different communication channels, and an intelligent notification system. A 2-week feasibility study was conducted in 15 volunteers to assess the viability of the platform. Results: The website received 244 visits (average time/session: 17 min 45 s). A total of 435 dietary intakes were recorded (average time for each intake registration, 4 min 42 s ± 2 min 30 s), 59 exercises were recorded in 20 heart rate monitor downloads, 43 topics were discussed through a forum, and 11 of the 15 volunteers expressed a favorable opinion toward the platform. Food intake recording was reported as the most laborious task. Ten of the volunteers considered long-term use of the platform to be feasible. Conclusions: The PREDIRCAM platform is technically ready for clinical evaluation. Training is required to use the platform and, in particular, for registration of dietary food intake.

A Structure of Problem Solving Methods for Real Time Decision Support in Traffic Control

This article describes a knowledge-based application in the domain of road traffic management that we have developed following a knowledge modeling approach and the notion of problem-solving method. The article presents first a domain-independent model for real-time decision support as a structured collection of problem solving methods. Then, it is described how this general model is used to develop an operational version for the domain of traffic management. For this purpose, a particular knowledge modeling tool, called KSM (Knowledge Structure Manager), was applied. Finally, the article shows an application developed for a traffic network of the city of Madrid and it is compared with a second application developed for a different traffic area of the city of Barcelona.

Patient-oriented computerized clinical guidelines for mobile decision support in gestational diabetes

The risks associated with gestational diabetes (GD) can be reduced with an active treatment able to improve glycemic control. Advances in mobile health can provide new patient-centric models for GD to create personalized health care services, increase patient independence and improve patients’ self-management capabilities, and potentially improve their treatment compliance. In these models, decision-support functions play an essential role. The telemedicine system MobiGuide provides personalized medical decision support for GD patients that is based on computerized clinical guidelines and adapted to a mobile environment. The patient’s access to the system is supported by a smartphone-based application that enhances the efficiency and ease of use of the system. We formalized the GD guideline into a computer-interpretable guideline (CIG). We identified several workflows that provide decision-support functionalities to patients and 4 types of personalized advice to be delivered through a mobile application at home, which is a preliminary step to providing decision-support tools in a telemedicine system: (1) therapy, to help patients to comply with medical prescriptions; (2) monitoring, to help patients to comply with monitoring instructions; (3) clinical assessment, to inform patients about their health conditions; and (4) upcoming events, to deal with patients’ personal context or special events. The whole process to specify patient-oriented decision support functionalities ensures that it is based on the knowledge contained in the GD clinical guideline and thus follows evidence-based recommendations but at the same time is patient-oriented, which could enhance clinical outcomes and patients’ acceptance of the whole system.