Mandatory communication skills training for oncologists: enforcement does not substantially impact satisfaction.

PURPOSE Even though there is evidence that both patients and oncology clinicians are affected by the quality of communication and that communication skills can be effectively trained, so-called Communication Skills Trainings (CSTs) remain heterogeneously implemented. METHODS A systematic evaluation of the level of satisfaction of oncologists with the Swiss CST before (2000-2005) and after (2006-2012) it became mandatory. RESULTS Levels of satisfaction with the CST were high, and satisfaction of physicians participating on a voluntary or mandatory basis did not significantly differ for the majority of the items. CONCLUSIONS The evaluation of physicians' satisfaction over the years and after introduction of mandatory training supports recommendations for generalized implementation of CST and mandatory training for medical oncologists.

Neural change following different memory training approaches in very preterm born children - A pilot study.

OBJECTIVE There is mixed evidence regarding neural change following cognitive training. Brain activation increase, decrease, or a combination of both may occur. We investigated training-induced neural change using two different memory training approaches. METHODS Very preterm born children (aged 7-12 years) were randomly allocated to a memory strategy training, an intensive working memory practice or a waiting control group. Before and immediately after the trainings and the waiting period, brain activation during a visual working memory task was measured using fMRI and cognitive performance was assessed. RESULTS Following both memory trainings, there was a significant decrease of fronto-parietal brain activation and a significant increase of memory performance. In the control group, no neural or performance change occurred after the waiting period. CONCLUSION These pilot data point towards a training-related decrease of brain activation, independent of the training approach. Our data highlight the high training-induced plasticity of the child's brain during development.

Effects of two different memory training approaches in very preterm-born children

Background: Little research has been conducted to assess the effect of using memory training with school-aged children who were born very preterm. This study aimed to determine whether two types of memory training approaches resulted in an improvement of trained functions and/or a generalization of the training effect to non-trained cognitive domains. Methods: Sixty-eight children born very preterm (7¬-12 years) were randomly allocated to a group undertaking memory strategy training (n=23), working memory training (n=22), or a waiting control group (n=23). Neuropsychological assessment was performed before and immediately after the training or waiting period, and at a six-month follow-up. Results: In both training groups, significant improvement of different memory domains occurred immediately after training (near transfer). Improvement of non-trained arithmetic performance was observed after strategy training (far transfer). At a six-month follow-up assessment, children in both training groups demonstrated better working memory, and their parents rated their memory functions to be better than controls. Performance level before the training was negatively associated with the training gain. Conclusions: These results highlight the importance of cognitive interventions, in particular the teaching of memory strategies, in very preterm-born children at early school age to strengthen cognitive performance and prevent problems at school.

Feasibility of cardiopulmonary exercise testing and training using a robotics-assisted tilt table in dependent-ambulatory stroke patients

BACKGROUND: We evaluated the feasibility of an augmented robotics-assisted tilt table (RATT) for incremental cardiopulmonary exercise testing (CPET) and exercise training in dependent-ambulatory stroke patients. METHODS: Stroke patients (Functional Ambulation Category ≤ 3) underwent familiarization, an incremental exercise test (IET) and a constant load test (CLT) on separate days. A RATT equipped with force sensors in the thigh cuffs, a work rate estimation algorithm and real-time visual feedback to guide the exercise work rate was used. Feasibility assessment considered technical feasibility, patient tolerability, and cardiopulmonary responsiveness. RESULTS: Eight patients (4 female) aged 58.3 ± 9.2 years (mean ± SD) were recruited and all completed the study. For IETs, peak oxygen uptake (V'O2peak), peak heart rate (HRpeak) and peak work rate (WRpeak) were 11.9 ± 4.0 ml/kg/min (45 % of predicted V'O2max), 117 ± 32 beats/min (72 % of predicted HRmax) and 22.5 ± 13.0 W, respectively. Peak ratings of perceived exertion (RPE) were on the range "hard" to "very hard". All 8 patients reached their limit of functional capacity in terms of either their cardiopulmonary or neuromuscular performance. A ventilatory threshold (VT) was identified in 7 patients and a respiratory compensation point (RCP) in 6 patients: mean V'O2 at VT and RCP was 8.9 and 10.7 ml/kg/min, respectively, which represent 75 % (VT) and 85 % (RCP) of mean V'O2peak. Incremental CPET provided sufficient information to satisfy the responsiveness criteria and identification of key outcomes in all 8 patients. For CLTs, mean steady-state V'O2 was 6.9 ml/kg/min (49 % of V'O2 reserve), mean HR was 90 beats/min (56 % of HRmax), RPEs were > 2, and all patients maintained the active work rate for 10 min: these values meet recommended intensity levels for bouts of training. CONCLUSIONS: The augmented RATT is deemed feasible for incremental cardiopulmonary exercise testing and exercise training in dependent-ambulatory stroke patients: the approach was found to be technically implementable, acceptable to the patients, and it showed substantial cardiopulmonary responsiveness. This work has clinical implications for patients with severe disability who otherwise are not able to be tested.

Working memory training in children: Effectiveness depends on temperament

Studies revealing transfer effects of working memory (WM) training on non-trained cognitive performance of children hold promising implications for scholastic learning. However, the results of existing training studies are not consistent and provoke debates about the potential and limitations of cognitive enhancement. To examine the influence of individual differences on training outcomes is a promising approach for finding causes for such inconsistencies. In this study, we implemented WM training in an elementary school setting. The aim was to investigate near and far transfer effects on cognitive abilities and academic achievement and to examine the moderating effects of a dispositional and a regulative temperament factor, neuroticism and effortful control. Ninetynine second-graders were randomly assigned to 20 sessions of computer-based adaptiveWMtraining, computer-based reading training, or a no-contact control group. For the WM training group, our analyses reveal near transfer on a visual WM task, far transfer on a vocabulary task as a proxy for crystallized intelligence, and increased academic achievement in reading and math by trend. Considering individual differences in temperament, we found that effortful control predicts larger training mean and gain scores and that there is a moderation effect of both temperament factors on post-training improvement: WM training condition predicted higher post-training gains compared to both control conditions only in children with high effortful control or low neuroticism. Our results suggest that a short but intensive WM training program can enhance cognitive abilities in children, but that sufficient selfregulative abilities and emotional stability are necessary for WM training to be effective.

Lamb Temporal Bone as a Surgical Training Model of Round Window Cochlear Implant Electrode Insertion

OBJECTIVE The preservation of residual hearing in cochlear implantation opens the door for optimal functional results. This atraumatic surgical technique requires training; however, the traditional human cadaveric temporal bones have become less available or unattainable in some institutions. This study investigates the suitability of an alternative model, using cadaveric lamb temporal bone, for surgical training of atraumatic round window electrode insertion. INTERVENTION A total of 14 lamb temporal bones were dissected for cochlear implantation by four surgeons. After mastoidectomy, visualization, and drilling of the round window niche, an atraumatic round window insertion of a Medel Flex24 electrode was performed. Electrode insertion depth and position were verified by computed tomography scans. MAIN OUTCOME MEASURE All cochleas were successfully implanted using the atraumatic round window approach; however, surgical access through the mastoid was substantially different when compared human anatomy. The mean number of intracochlear electrode contacts was 6.5 (range, 4-11) and the mean insertion depth 10.4 mm (range, 4-20 mm), which corresponds to a mean angular perimodiolar insertion depth of 229 degrees (range 67-540°). Full insertion of the electrode was not possible because of the smaller size of the lamb cochlea in comparison to that of the human. CONCLUSION The lamb temporal bone model is well suited as a training model for atraumatic cochlear implantation at the level of the round window. The minimally pneumatized mastoid as well as the smaller cochlea can help prepare a surgeon for difficult cochlear implantations. Because of substantial differences to human anatomy, it is not an adequate training model for other surgical techniques such as mastoidectomy and posterior tympanotomy as well as full electrode insertion.

Team training to establish a safety culture in dialysis access surgery.

Operating room (OR) team safety training and learning in the field of dialysis access is well suited for the use of simulators, simulated case learning and root cause analysis of adverse outcomes. The objectives of OR team training are to improve communication and leadership skills, to use checklists and to prevent errors. Other objectives are to promote a change in the attitudes towards vascular access from learning through mistakes in a nonpunitive environment, to positively impact the employee performance and to increase staff retention by making the workplace safer, more efficient and user friendly.

Capillary growth, ultrastructure remodelling and exercise training in skeletal muscle of essential hypertensive patients

AIM The aim was to elucidate whether essential hypertension is associated with altered capillary morphology and density and to what extent exercise training can normalize these parameters. METHODS To investigate angiogenesis and capillary morphology in essential hypertension, muscle biopsies were obtained from m. vastus lateralis in subjects with essential hypertension (n = 10) and normotensive controls (n = 11) before and after 8 weeks of aerobic exercise training. Morphometry was performed after transmission electron microscopy, and protein levels of several angioregulatory factors were determined. RESULTS At baseline, capillary density and capillary-to-fibre ratio were not different between the two groups. However, the hypertensive subjects had 9% lower capillary area (12.7 ± 0.4 vs. 13.9 ± 0.2 μm(2)) and tended to have thicker capillary basement membranes (399 ± 16 vs. 358 ± 13 nm; P = 0.094) than controls. Protein expression of vascular endothelial growth factor (VEGF), VEGF receptor-2 and thrombospondin-1 were similar in normotensive and hypertensive subjects, but tissue inhibitor of matrix metalloproteinase was 69% lower in the hypertensive group. After training, angiogenesis was evident by 15% increased capillary-to-fibre ratio in the hypertensive subjects only. Capillary area and capillary lumen area were increased by 7 and 15% in the hypertensive patients, whereas capillary basement membrane thickness was decreased by 17% (P < 0.05). VEGF expression after training was increased in both groups, whereas VEGF receptor-2 was decreased by 25% in the hypertensive patients(P < 0.05). CONCLUSION Essential hypertension is associated with decreased lumen area and a tendency for increased basement membrane thickening in capillaries of skeletal muscle. Exercise training may improve the diffusion conditions in essential hypertension by altering capillary structure and capillary number.

Evaluation of Medical Students’ Attitudes and Performance of Basic Surgery Skills in a Training Program Using Fresh Human skin, Excised During Body Contouring Surgeries

BACKGROUND: Learning surgical skills in the operating room may be a challenge for medical students. Therefore, more approaches using simulation to enable students to develop their practical skills are required. OBJECTIVES: We hypothesized that (1) there would be a need for additional surgical training for medical students in the pre-final year, and (2) our basic surgery skills training program using fresh human skin would improve medical students' surgical skills. DESIGN: We conducted a preliminary survey of medical students to clarify the need for further training in basic surgery procedures. A new approach using simulation to teach surgical skills on human skin was set up. The procedural skills of 15 randomly selected students were assessed in the operating room before and after participation in the simulation, using Objective Structured Assessment of Technical Skills. Furthermore, subjective assessment was performed based on students' self-evaluation. The data were analyzed using SPSS, version 21 (SPSS, Inc., Chicago, IL). SETTING: The study took place at the Inselspital, Bern University Hospital. PARTICIPANTS: A total of 186 pre-final-year medical students were enrolled into the preliminary survey; 15 randomly selected medical students participated in the basic surgical skills training course on the fresh human skin operating room. RESULTS: The preliminary survey revealed the need for a surgical skills curriculum. The simulation approach we developed showed significant (p < 0.001) improvement for all 12 surgical skills, with mean cumulative precourse and postcourse values of 31.25 ± 5.013 and 45.38 ± 3.557, respectively. The self-evaluation contained positive feedback as well. CONCLUSION: Simulation of surgery using human tissue samples could help medical students become more proficient in handling surgical instruments before stepping into a real surgical situation. We suggest further studies evaluating our proposed teaching method and the possibility of integrating this simulation approach into the medical school curriculum.

Simulation in vascular access surgery training.

Rapidly growing technical developments and working time constraints call for changes in trainee formation. In reality, trainees spend fewer hours in the hospital and face more difficulties in acquiring the required qualifications in order to work independently as a specialist. Simulation-based training is a potential solution. It offers the possibility to learn basic technical skills, repeatedly perform key steps in procedures and simulate challenging scenarios in team training. Patients are not at risk and learning curves can be shortened. Advanced learners are able to train rare complications. Senior faculty member's presence is key to assess and debrief effective simulation training. In the field of vascular access surgery, simulation models are available for open as well as endovascular procedures. In this narrative review, we describe the theory of simulation, present simulation models in vascular (access) surgery, discuss the possible benefits for patient safety and the difficulties of implementing simulation in training.

Simple training tool is insufficient for appropriate diagnosis and treatment of malnutrition: A pre-post intervention study in a tertiary center.

OBJECTIVES To improve malnutrition awareness and management in our department of general internal medicine; to assess patients' nutritional risk; and to evaluate whether an online educational program leads to an increase in basic knowledge and more frequent nutritional therapies. METHODS A prospective pre-post intervention study at a university department of general internal medicine was conducted. Nutritional screening using Nutritional Risk Score 2002 (NRS 2002) was performed, and prescriptions of nutritional therapies were assessed. The intervention included an online learning program and a pocket card for all residents, who had to fill in a multiple-choice questions (MCQ) test about basic nutritional knowledge before and after the intervention. RESULTS A total of 342 patients were included in the preintervention phase, and 300 were in the postintervention phase. In the preintervention phase, 54.1% were at nutritional risk (NRS 2002 ≥3) compared with 61.7% in the postintervention phase. There was no increase in the prescription of nutritional therapies (18.7% versus 17.0%). Forty-nine and 41 residents (response rate 58% and 48%) filled in the MCQ test before and after the intervention, respectively. The mean percentage of correct answers was 55.6% and 59.43%, respectively (which was not significant). Fifty of 84 residents completed the online program. The residents who participated in the whole program scored higher on the second MCQ test (63% versus 55% correct answers, P = 0.031). CONCLUSIONS Despite a high ratio of malnourished patients, the nutritional intervention, as assessed by nutritional prescriptions, is insufficient. However, the simple educational program via Internet and usage of NRS 2002 pocket cards did not improve either malnutrition awareness or nutritional treatment. More sophisticated educational systems to fight malnutrition are necessary.

Involuntary reflexive pelvic floor muscle training in addition to standard training versus standard training alone for women with stress urinary incontinence: study protocol for a randomized controlled trial

BACKGROUND Pelvic floor muscle training is effective and recommended as first-line therapy for female patients with stress urinary incontinence. However, standard pelvic floor physiotherapy concentrates on voluntary contractions even though the situations provoking stress urinary incontinence (for example, sneezing, coughing, running) require involuntary fast reflexive pelvic floor muscle contractions. Training procedures for involuntary reflexive muscle contractions are widely implemented in rehabilitation and sports but not yet in pelvic floor rehabilitation. Therefore, the research group developed a training protocol including standard physiotherapy and in addition focused on involuntary reflexive pelvic floor muscle contractions. METHODS/DESIGN The aim of the planned study is to compare this newly developed physiotherapy program (experimental group) and the standard physiotherapy program (control group) regarding their effect on stress urinary incontinence. The working hypothesis is that the experimental group focusing on involuntary reflexive muscle contractions will have a higher improvement of continence measured by the International Consultation on Incontinence Modular Questionnaire Urinary Incontinence (short form), and - regarding secondary and tertiary outcomes - higher pelvic floor muscle activity during stress urinary incontinence provoking activities, better pad-test results, higher quality of life scores (International Consultation on Incontinence Modular Questionnaire) and higher intravaginal muscle strength (digitally tested) from before to after the intervention phase. This study is designed as a prospective, triple-blinded (participant, investigator, outcome assessor), randomized controlled trial with two physiotherapy intervention groups with a 6-month follow-up including 48 stress urinary incontinent women per group. For both groups the intervention will last 16 weeks and will include 9 personal physiotherapy consultations and 78 short home training sessions (weeks 1-5 3x/week, 3x/day; weeks 6-16 3x/week, 1x/day). Thereafter both groups will continue with home training sessions (3x/week, 1x/day) until the 6-month follow-up. To compare the primary outcome, International Consultation on Incontinence Modular Questionnaire (short form) between and within the two groups at ten time points (before intervention, physiotherapy sessions 2-9, after intervention) ANOVA models for longitudinal data will be applied. DISCUSSION This study closes a gap, as involuntary reflexive pelvic floor muscle training has not yet been included in stress urinary incontinence physiotherapy, and if shown successful could be implemented in clinical practice immediately. TRIAL REGISTRATION NCT02318251 ; 4 December 2014 First patient randomized: 11 March 2015.

Effects of two different memory training approaches in very pretermborn children

Background: Little research has been conducted to assess the effect of using memory training with school aged children who were born very preterm. This study aimed to determine whether two types of memory training approaches resulted in an improvement of trained functions and/or a generalization of the training effect to non-trained cognitive domains. Methods: Sixty-eight children born very preterm (7-12 years) were randomly allocated to a group undertaking memory strategy training (n=23), working memory training (n=22), or a waiting control group (n=23). Neuropsychological assessment was performed before and immediately after the training or waiting period, and at a six-month follow-up. Results: In both training groups, significant improvement of different memory domains occurred immediately after training (near transfer). Improvement of non-trained arithmetic performance was observed after strategy training (far transfer). At a six-month follow-up assessment, children in both training groups demonstrated better working memory, and their parents rated their memory functions to be better than controls. Performance level before the training was negatively associated with the training gain. Conclusions: These results highlight the importance of cognitive interventions, in particular the teaching of memory strategies, in very preterm-born children at early school age to strengthen cognitive performance and prevent problems at school.

Entwicklung und Implementierung von Modellen für ein Skills-Training-Parcours für internistische Assistenzärzte

„Entwicklung und Implementierung von Modellen für ein Skills-Training-Parcours für internistische Assistenzärzte “ V. Maier1 - K. Schnabel2 1 Universitätslinik für Allgemeine Innere Medizin, Inselspital, Bern 2 Berner interdisziplinäres Skills- und Schauspielpatientenzentrum (BiSS), Institut für Medizinische Lehre (IML), Abteilung für Unterricht und Medien (AUM) Einleitung: Im klinischen Alltag sind praktische Fertigkeiten gefordert, um Patienten sicher zu behandeln. Auch in der Schweizer Fachgesellschaft FMH kam es zu einer stärkeren Gewichtung der praktischen Fertigkeiten und müssen jetzt ein Logbuch über Art und Zeitpunkt der Intervention führen [1]. Am Inselspital Bern wurde dafür ein Skillsparcours etabliert, da in vielen Bereichen simulationsbasierte Ausbildungen traditionellen Methoden überlegen ist [2]. Der Skillsparcours besteht aus einem Nachmittag mit 4 nicht-invasiven Prozeduren und einem Nachmittag mit 5 invasiven Prozeduren. Eigens dafür wurden drei Modelle entwickelt und deren Tauglichkeit evaluiert. Fragestellung: Bilden die selbst gefertigten Modelle die Realität ausreichend ab? Material und Methoden: Innerhalb der 9 Posten (5 invasiv und 4 nichtinvasiv) wurden für die 5 invasiven Posten zwei Modelle aus dem Skillslab (BiSS) genutzt (Lumbalpunktion (LP) und Blasenkatheter (BK)) und drei Modelle neu entwickelt (Pleura-(PP), Aszites-(AP) und Knochenmarks-Punktion (KMP)). Die Modelle wurden mit Materialien aus dem Baumarkt entwickelt (Material ca. CHF 50/Stück). Der Aufbau der Modelle soll auf der Tagung demonstriert werden. Die Teilnehmer (N=12) und Dozenten (N=5) wurden zu der Qualität mittels Fragebogen befragt. Dabei wurde die individuelle Vorerfahrung und die Einschätzung der Teilnehmer erfragt. Die Frage zur Eignung des Modells war: „Das Modell war zum Üben geeignet“. Als Skala wurde eine Likert-Skala von 0 bis 5 (1=sehr ungeeignet, 5=sehr geeignet) benutzt. Ergebnisse: Die Assistenzärzte beurteilten die Modelleignung wie folgt (Median (Min;Max)): LP: 5 (4;5) KMP: 4.5 (3;5), PP: 4 (3;5), AP: 4.5 (2;5), BK-Einlage: 4.5 (4;6). Die Oberärzte, die jeweils nur das Modell bewerteten, an welchem sie den Kurs durchführten, beurteilten die Modelleignung wie folgt: LP 5.0, KMP: 5.0, PP 5.0, AP: 4.0, BK-Einlage: 3.0. Diskussion: Alle Modelle wurden sowohl von den Oberärzten als auch von den Assistenzärzten als zum Üben tauglich eingeschätzt. Zwischen den selbst hergestellten Low-Fidelity Modellen und den High-Fidelity Modellen gab es hierein keinen signifikanten Unterschied. Als am wenigsten tauglich wurde von den Oberärzten mit der Simulation der Blasenkatheter-Einlage ein High-Fidelity-Modell bewertet. Schlussfolgerungen: Alle Modelle für die Simulation der Punktionstechniken haben gut bis sehr gut funktioniert. Die selbst hergestellten Modelle bilden die Wirklich zum Üben der Techniken hinreichend gut und nicht schlechter als die High-Fidelity-Modelle ab. Selbst gebaute Modelle mit Materialien aus dem Baumarkt können das sonst sehr materialaufwändige Training mit Simulatoren genauso effektiv aber wesentlich effizienter durchführbar machen. Literatur bei den Autoren (1) Weiterbildungsordnung FMH 2014 (letzte Revision 4. September 2014). www.fmh.ch/files/pdf15/wbo_d.pdf (2) McGaghie WC, Issenberg SB, Cohen ER, Barsuk JH, Wayne DB (2011) Does simulation-based medical education with deliberate practice yield better results than traditional clinical education? A meta-analytic comparative review of the evidence. Acad Med. 2011 Jun;86(6):706-11