Harmonization of training and assessment of medical specialists in physical and rehabilitation medicine across Europe - The contribution of the UEMS Board of Physical and Rehabilitation Medicine

Background.- The main goals of the European Board of Physical and Rehabili-tation Medicine (EBPRM), founded in 1991 as the third speciality board of theUnion of European Medical Specialists (UEMS), are to harmonize pre-graduate,post-graduate and continuous medical education in physical and rehabilitationmedicine (PRM) all over Europe. The harmonization of curricula of the medi-cal specialities and the assessment of medical specialists has become one of thepriorities of the UEMS and its working groups to which the EBPRM contributes.Action.- The EBPRM will continue to promote a specific minimal undergraduatecurriculum on PRM including issues like disability, participation and handicapto be taught all over Europe as a basis for general medical practice. The EBPRMwill also expand the existing EBPRM postgraduate curriculum into a detailedcatalogue of learning objectives. This catalogue will serve as a tool to boostharmonization of the national curricula across Europe as well as to structurethe content of the MCQ examination. It would be a big step forward towardsharmonization of European PRM specialist training if an important number ofcountries would use the certifying MCQ examination of the Board as a part ofthe national assessments for PRM specialists.

Educational resources offered by the European Board of Physical and Rehabilitation Medicine (EBPRM)

Background .- Physical and Rehabilitation Medicine (PRM) is a very demanding medical speciality. To ensure high standard of research and care in PRM all across Europe, it is crucial to attract gifted trainees and offer them high quality education. At undergraduate level, many medical schools in Europe omit to offer teaching on disabled persons and on basic PRM knowledge. Thus PRM is hardly known to medical students. For postgraduate trainees access to evidence-based knowledge as well as teaching of research methodology specific to PRM, rehabilitation methodology, disability management and team building also need to be strengthened to increase the visibility of PRM. Action .- To address these issues the EBPRM proposes presently a specific undergraduate curriculum in PRM including the issues of disability, participation and handicap as a basis for general medical practice and postgraduate rehabilitation training. For PRM trainees many educational documents are now available on the EBPRM website. A growing number of educational sessions for PRM trainees take place during international and national PRM Congresses which can be accessed at low cost. Educational papers published regularly in European rehabilitation journals and European PRM Schools are offered free or at very low cost to trainees.

Digital evidence, 'absence' of data and ambiguous patterns of reasoning

In this paper we discuss the use of digital data by the Swiss Federal Criminal Court in a recent case of attempted homicide. We use this case to examine drawbacks for the defense when the presentation of scientific evidence is partial, especially when the only perspective mentioned is that of the prosecution. We tackle this discussion at two distinct levels. First, we pursue an essentially non-technical presentation of the topic by drawing parallels between the court's summing up of the case and flawed patterns of reasoning commonly seen in other forensic disciplines, such as DNA and particle traces (e.g., gunshot residues). Then, we propose a formal analysis of the case, using elements of probability and graphical probability models, to justify our main claim that the partial presentation of digital evidence poses a risk to the administration of justice in that it keeps vital information from the defense. We will argue that such practice constitutes a violation of general principles of forensic interpretation as established by forensic science literature and current recommendations by forensic science interest groups (e.g., the European Network of Forensic Science Institutes). Finally, we posit that argument construction and analysis using formal methods can help replace digital evidence appropriately into context and thus support a sound evaluation of the evidence.

Evaluation of occupational and patient dose in cerebral angiography procedures

Objective The present study was aimed at estimating the doses received by physicians and patients during cerebral angiography procedures in a public hospital of Recife, PE, Brazil. Materials and Methods The study sample included 158 adult patients, and during the procedures the following parameters were evaluated: exposure parameters (kV, mAs), number of acquired images, reference air kerma value (Ka,r) and air kerma-area product (PKA). Additionally, the physicians involved in the procedures were evaluated as for absorbed dose in the eyes, thyroid, chest, hands and feet. Results The results demonstrated that the doses to the patients' eyes region were relatively close to the threshold for cataract occurrence. As regards the physicians, the average effective dose was 2.6 µSv, and the highest effective dose recorded was 16 µSv. Conclusion Depending on the number of procedures, the doses received by the physicians may exceed the annual dose limit for the crystalline lenses (20 mSv) established by national and international standards. It is important to note that the high doses received by the physicians are due to the lack of radiation protection equipment and accessories, such as leaded curtains, screens and protective goggles.

Variation in Current Management of Term and Late-preterm Neonates at Risk for Early-onset Sepsis: An International Survey and Review of Guidelines.

BACKGROUND: Uncertainty about the presence of infection results in unnecessary and prolonged empiric antibiotic treatment of newborns at risk for early-onset sepsis (EOS). This study evaluates the impact of this uncertainty on the diversity in management. METHODS: A web-based survey with questions addressing management of infection risk-adjusted scenarios was performed in Europe, North America, and Australia. Published national guidelines (n = 5) were reviewed and compared with the results of the survey. RESULTS: 439 Clinicians (68% were neonatologists) from 16 countries completed the survey. In the low-risk scenario, 29% would start antibiotic therapy and 26% would not, both groups without laboratory investigations; 45% would start if laboratory markers were abnormal. In the high-risk scenario, 99% would start antibiotic therapy. In the low-risk scenario, 89% would discontinue antibiotic therapy before 72 hours. In the high-risk scenario, 35% would discontinue therapy before 72 hours, 56% would continue therapy for 5-7 days, and 9% for more than 7 days. Laboratory investigations were used in 31% of scenarios for the decision to start, and in 72% for the decision to discontinue antibiotic treatment. National guidelines differ considerably regarding the decision to start in low-risk and regarding the decision to continue therapy in higher risk situations. CONCLUSIONS: There is a broad diversity of clinical practice in management of EOS and a lack of agreement between current guidelines. The results of the survey reflect the diversity of national guidelines. Prospective studies regarding management of neonates at risk of EOS with safety endpoints are needed.

Ultrasound scan as a potential source of nosocomial and cross-infection: a literature review

AbstractThe authors review the main concepts regarding the importance of cleaning/disinfection of ultrasonography probes, aiming a better comprehension by practitioners and thus enabling strategies to establish a safe practice without compromising the quality of the examination and the operator productivity. In the context of biosafety, it is imperative to assume that contact with blood or body fluids represents a potential source of infection. Thus, in order to implement cleaning/disinfection practice, it is necessary to understand the principles of infection control, to consider the cost/benefit ratio of the measures to be implemented, and most importantly, to comprehend that such measures will not only benefit the health professional and the patient, but the society as a whole.

The Influence of Education and Depression on Autonomy of Women with Chronic Pelvic Pain: A Cross-sectional Study

Objective Patient autonomy has great importance for a valid informed consent in clinical practice. Our objectives were to quantify thedomains of patient autonomy and to evaluate the variables that can affect patient autonomy in women with chronic pelvic pain. Methods This study is a cross sectional survey performed in a tertiary care University Hospital. Fifty-two consecutive women scheduled for laparoscopic management of chronic pelvic were included. Three major components of autonomy (competence, information or freedom) were evaluated using a Likert scale with 24 validated affirmatives. Results Competence scores (0.85 vs 0.92; p = 0.006) and information scores (0.90 vs 0.93; p = 0.02) were low for women with less than eight years of school attendance. Information scores were low in the presence of anxiety (0.91 vs 0.93; p = 0.05) or depression (0.90 vs 0.93; p = 0.01). Conclusions Our data show that systematic evaluation of patient autonomy can provide clinical relevant information in gynecology. Low educational level, anxiety and depression might reduce the patient autonomy in women with chronic pelvic pain.

Distributed document migration between ERP systems by means of messaging and event sourcing

This bachelor’s thesis, written for Lappeenranta University of Technology and implemented in a medium-sized enterprise (SME), examines a distributed document migration system. The system was created to migrate a large number of electronic documents, along with their metadata, from one document management system to another, so as to enable a rapid switchover of an enterprise resource planning systems inside the company. The paper examines, through theoretical analysis, messaging as a possible enabler of distributing applications and how it naturally fits an event based model, whereby system transitions and states are expressed through recorded behaviours. This is put into practice by analysing the implemented migration systems and how the core components, MassTransit, RabbitMQ and MongoDB, were orchestrated together to realize such a system. As a result, the paper presents an architecture for a scalable and distributed system that could migrate hundreds of thousands of documents over weekend, serving its goals in enabling a rapid system switchover.

Supplier codes of conduct: Acting responsibly in global supply chains

Nowadays the Western companies are considered responsible for the social and environmental issues in their whole supply chains. To influence the practices of their suppliers the Western companies have created suppliers codes of conduct (SCCs) which express their requirements. Suppliers’ compliance with the SCCs is checked through audits. The purpose of this thesis is to analyze SCCs as a means for Western companies to ensure socially and environmentally responsible actions in their global supply chains, and the sub-objectives are to find out 1) how well do the SCCs and their auditing work at suppliers’ production sites and 2) how can possible problems related to SCCs and their auditing be solved. This is a qualitative research carried out in the form of a case study with two case companies. In this study both primary and secondary data is used. The primary data is collected in the form of interviews of the case company representatives and three external experts. Based on a theoretical framework of previous research in the fields of corporate social responsibility and supply chain management, a model with eleven factors, which influence the success of SCC implementation and the auditing of SCC –implementation, is drafted. Also several different best-practices to help to solve and avoid possible problems related to SCC -implementation and auditing have been identified from previous research. Based on the findings of this study the theoretical model has been updated adding two new influential factors. It seems that how well the SCC and its auditing work at suppliers’ production sites depends on the joint effect of thirteen influential factors: buyer’s purchasing policy, supplier’s motivation, buyer’s commitment, the solving of agency problems, the contents of the SCC, supplier’s role and the buyer-supplier –relationship, complexity of supply chain, the limitations of the smaller buyers, cooperation through a business association or multi-stakeholder system, the role of supplier’s employees, SCC –related communication and supplier’s understanding, cheating in audits and the auditors. The possible problems related to SCCs and their auditing can be solved by adopting best-practices. Nine of the theoretical best-practices stand out from the findings of this study: 1) two-way communication and collecting feedback from suppliers, 2) the philosophy of continuous improvement, 3) long-term business relationships with the supplier, 4) informing the supplier about the advantages of SCC –compliance, 5) rewarding code-compliant suppliers, 6) building collaborative, good buyer-supplier relationships, 7) supporting and advising the supplier, 8) joining a business association or multi-stakeholder system and 9) interviewing supplier’s employees as a part of the audits.

The Concept of Betterness and Sport Competitions

It is common that people disagree on a question which athlete or team was the best in a particular sport competition. This thesis attempts to clarify these disputes by analysing the concept of betterness in the context of sport competitions. Betterness can be interpersonal, intrapersonal or a combination of the two. I focus on interpersonal betterness, that is, on superiority. For example, interpersonal betterness may be contested in a football match between the national teams of Germany and Argentina. My aim is to provide a philosophical account of interpersonal betterness. The account has two functions: descriptive and normative. It describes the shapes and forms in which superiority is instantiated in sport competitions. It also provides a consistent and accurate way to discuss superiority. The thesis consists of two parts. In the first part, I introduce, elaborate and illustrate my account, which in turn consists of three elements: (1) relations of superiority, (2) standards for the relations of superiority and (3) types of competition. I also discuss my account’s relevance to issues of sport ethics through the example of gender equity and women’s ski jumping. I conclude that this account will not end the disputes over which team or athlete was better in a particular competition. Instead, it provides tools for a more consistent discussion of the disputed issues. The second part of the thesis includes five reprinted original articles. The account presented in the first part is based on these publications.

Effect of Erythrina velutina and Erythrina mulungu in rats submitted to animal models of anxiety and depression

Erythrina velutina (EV) and Erythrina mulungu (EM), popularly used in Brazil as tranquilizing agents, were studied. The effects of acute and chronic oral treatment with a water:alcohol extract of EV (7:3, plant grounded stem bark; acute = 100, 200, 400 mg/kg; chronic = 50, 100, 200 mg/kg) were evaluated in rats (N = 11-12) submitted to the elevated T-maze (for avoidance and escape measurements) model of anxiety. This model was selected for its presumed capacity to elicit specific subtypes of anxiety disorders recognized in clinical practice: avoidance has been related to generalized anxiety and escape to panic. Additionally, animals were treated with the same doses of EV and EM (water:alcohol 7:3, inflorescence extract) and submitted to the forced swim test for the evaluation of antidepressant activity (N = 7-10). Both treatment regimens with EV impaired elevated T-maze avoidance latencies, without altering escape, in a way similar to the reference drug diazepam (avoidance 1, mean ± SEM, acute study: 131.1 ± 45.5 (control), 9.0 ± 3.3 (diazepam), 12.7 ± 2.9 (200 mg/kg), 28.8 ± 15.3 (400 mg/kg); chronic study: 131.7 ± 46.9 (control), 35.8 ± 29.7 (diazepam), 24.4 ± 10.4 (50 mg/kg), 29.7 ± 11.5 (200 mg/kg)). Neither EV nor EM altered measurements performed in the forced swim test, in contrast to the reference drug imipramine that significantly decreased immobility time after chronic treatment. These results were not due to motor alterations since no significant effects were detected in an open field. These observations suggest that EV exerts anxiolytic-like effects on a specific subset of defensive behaviors which have been associated with generalized anxiety disorder.

Influence of cueing on the preparation and execution of untrained and trained complex motor responses

This study investigated the influence of cueing on the performance of untrained and trained complex motor responses. Healthy adults responded to a visual target by performing four sequential movements (complex response) or a single movement (simple response) of their middle finger. A visual cue preceded the target by an interval of 300, 1000, or 2000 ms. In Experiment 1, the complex and simple responses were not previously trained. During the testing session, the complex response pattern varied on a trial-by-trial basis following the indication provided by the visual cue. In Experiment 2, the complex response and the simple response were extensively trained beforehand. During the testing session, the trained complex response pattern was performed in all trials. The latency of the untrained and trained complex responses decreased from the short to the medium and long cue-target intervals. The latency of the complex response was longer than that of the simple response, except in the case of the trained responses and the long cue-target interval. These results suggest that the preparation of untrained complex responses cannot be completed in advance, this being possible, however, for trained complex responses when enough time is available. The duration of the 1st submovement, 1st pause and 2nd submovement of the untrained and the trained complex responses increased from the short to the long cue-target interval, suggesting that there is an increase of online programming of the response possibly related to the degree of certainty about the moment of target appearance.

Characterization of maturity and quality of Brazilian apirenic grapes in the São Francisco river Valley

The objective of this study was to characterize and correlate maturity and quality of the first varieties of Brazilian seedless grapes 'BRS Clara', 'BRS Linda', 'BRS Morena', and 'Advanced Selection 8' compared with the American variety 'Crimson Seedless' in compliance with the Brazilian Normative/2002 and export standards Advanced Selection 8' is dark reddish, has large clusters, and is a very large ellipsoid berry; 'BRS Morena' is black with medium sized clusters and large berry shaped as ellipsoid to globoid; 'BRS Linda' is light green and has large sized clusters; 'Crimson' is pink and has small clusters with berries varying from medium to large sizes and ellipsoid shaped; and 'BRS Clara' is green yellowish has medium sized clusters and small berry of elongated ellipsoid shape. All varieties evaluated meet the standard for domestic market established as berry size minimum diameter 12 mm. 'BRS Clara' does not meet the export requirements of diameter. Berries of the red grapes 'BRS Morena' and 'Crimson Seedless' are firmer. The pH, titratable acidity, and soluble solids meet the official standards. Larger clusters are less acidic and present higher soluble solids/titratable acidity ratios implying that they are the sweetest type when ripe.

University students’ regulation of learning and text processing – examples from medical and teacher education

The general aim of the thesis was to study university students’ learning from the perspective of regulation of learning and text processing. The data were collected from the two academic disciplines of medical and teacher education, which share the features of highly scheduled study, a multidisciplinary character, a complex relationship between theory and practice and a professional nature. Contemporary information society poses new challenges for learning, as it is not possible to learn all the information needed in a profession during a study programme. Therefore, it is increasingly important to learn how to think and learn independently, how to recognise gaps in and update one’s knowledge and how to deal with the huge amount of constantly changing information. In other words, it is critical to regulate one’s learning and to process text effectively. The thesis comprises five sub-studies that employed cross-sectional, longitudinal and experimental designs and multiple methods, from surveys to eye tracking. Study I examined the connections between students’ study orientations and the ways they regulate their learning. In total, 410 second-, fourth- and sixth-year medical students from two Finnish medical schools participated in the study by completing a questionnaire measuring both general study orientations and regulation strategies. The students were generally deeply oriented towards their studies. However, they regulated their studying externally. Several interesting and theoretically reasonable connections between the variables were found. For instance, self-regulation was positively correlated with deep orientation and achievement orientation and was negatively correlated with non-commitment. However, external regulation was likewise positively correlated with deep orientation and achievement orientation but also with surface orientation and systematic orientation. It is argued that external regulation might function as an effective coping strategy in the cognitively loaded medical curriculum. Study II focused on medical students’ regulation of learning and their conceptions of the learning environment in an innovative medical course where traditional lectures were combined wth problem-based learning (PBL) group work. First-year medical and dental students (N = 153) completed a questionnaire assessing their regulation strategies of learning and views about the PBL group work. The results indicated that external regulation and self-regulation of the learning content were the most typical regulation strategies among the participants. In line with previous studies, self-regulation wasconnected with study success. Strictly organised PBL sessions were not considered as useful as lectures, although the students’ views of the teacher/tutor and the group were mainly positive. Therefore, developers of teaching methods are challenged to think of new solutions that facilitate reflection of one’s learning and that improve the development of self-regulation. In Study III, a person-centred approach to studying regulation strategies was employed, in contrast to the traditional variable-centred approach used in Study I and Study II. The aim of Study III was to identify different regulation strategy profiles among medical students (N = 162) across time and to examine to what extent these profiles predict study success in preclinical studies. Four regulation strategy profiles were identified, and connections with study success were found. Students with the lowest self-regulation and with an increasing lack of regulation performed worse than the other groups. As the person-centred approach enables us to individualise students with diverse regulation patterns, it could be used in supporting student learning and in facilitating the early diagnosis of learning difficulties. In Study IV, 91 student teachers participated in a pre-test/post-test design where they answered open-ended questions about a complex science concept both before and after reading either a traditional, expository science text or a refutational text that prompted the reader to change his/her beliefs according to scientific beliefs about the phenomenon. The student teachers completed a questionnaire concerning their regulation and processing strategies. The results showed that the students’ understanding improved after text reading intervention and that refutational text promoted understanding better than the traditional text. Additionally, regulation and processing strategies were found to be connected with understanding the science phenomenon. A weak trend showed that weaker learners would benefit more from the refutational text. It seems that learners with effective learning strategies are able to pick out the relevant content regardless of the text type, whereas weaker learners might benefit from refutational parts that contrast the most typical misconceptions with scientific views. The purpose of Study V was to use eye tracking to determine how third-year medical studets (n = 39) and internal medicine residents (n = 13) read and solve patient case texts. The results revealed differences between medical students and residents in processing patient case texts; compared to the students, the residents were more accurate in their diagnoses and processed the texts significantly faster and with a lower number of fixations. Different reading patterns were also found. The observed differences between medical students and residents in processing patient case texts could be used in medical education to model expert reasoning and to teach how a good medical text should be constructed. The main findings of the thesis indicate that even among very selected student populations, such as high-achieving medical students or student teachers, there seems to be a lot of variation in regulation strategies of learning and text processing. As these learning strategies are related to successful studying, students enter educational programmes with rather different chances of managing and achieving success. Further, the ways of engaging in learning seldom centre on a single strategy or approach; rather, students seem to combine several strategies to a certain degree. Sometimes, it can be a matter of perspective of which way of learning can be considered best; therefore, the reality of studying in higher education is often more complicated than the simplistic view of self-regulation as a good quality and external regulation as a harmful quality. The beginning of university studies may be stressful for many, as the gap between high school and university studies is huge and those strategies that were adequate during high school might not work as well in higher education. Therefore, it is important to map students’ learning strategies and to encourage them to engage in using high-quality learning strategies from the beginning. Instead of separate courses on learning skills, the integration of these skills into course contents should be considered. Furthermore, learning complex scientific phenomena could be facilitated by paying attention to high-quality learning materials and texts and other support from the learning environment also in the university. Eye tracking seems to have great potential in evaluating performance and growing diagnostic expertise in text processing, although more research using texts as stimulus is needed. Both medical and teacher education programmes and the professions themselves are challenging in terms of their multidisciplinary nature and increasing amounts of information and therefore require good lifelong learning skills during the study period and later in work life.

Effect of loading type on the fatigue strength of symmetric and asymmetric welded joints made of ultra high strength steel

In this study, finite element analyses and experimental tests are carried out in order to investigate the effect of loading type and symmetry on the fatigue strength of three different non-load carrying welded joints. The current codes and recommendations do not give explicit instructions how to consider degree of bending in loading and the effect of symmetry in the fatigue assessment of welded joints. The fatigue assessment is done by using effective notch stress method and linear elastic fracture mechanics. Transverse attachment and cover plate joints are analyzed by using 2D plane strain element models in FEMAP/NxNastran and Franc2D software and longitudinal gusset case is analyzed by using solid element models in Abaqus and Abaqus/XFEM software. By means of the evaluated effective notch stress range and stress intensity factor range, the nominal fatigue strength is assessed. Experimental tests consist of the fatigue tests of transverse attachment joints with total amount of 12 specimens. In the tests, the effect of both loading type and symmetry on the fatigue strength is studied. Finite element analyses showed that the fatigue strength of asymmetric joint is higher in tensile loading and the fatigue strength of symmetric joint is higher in bending loading in terms of nominal and hot spot stress methods. Linear elastic fracture mechanics indicated that bending reduces stress intensity factors when the crack size is relatively large since the normal stress decreases at the crack tip due to the stress gradient. Under tensile loading, experimental tests corresponded with finite element analyzes. Still, the fatigue tested joints subjected to bending showed the bending increased the fatigue strength of non-load carrying welded joints and the fatigue test results did not fully agree with the fatigue assessment. According to the results, it can be concluded that in tensile loading, the symmetry of joint distinctly affects on the fatigue strength. The fatigue life assessment of bending loaded joints is challenging since it depends on whether the crack initiation or propagation is predominant.