Evolución del perfil comunicacional de los médicos residentes de medicina de familia

ObjetivoConocer cómo evolucionan en los residentes de medicina de familia las habilidades de relación con los pacientes, al comienzo y al final de su tercer año de residencia, cuando atienden a problemas de salud comunes en su especialidad.DiseñoEstudio cuasi-experimental (antesdespués), multicéntrico, de ámbito nacional. Un total de 193 médicos residentes de tercer año de medicina familiar de 8 unidades docentes, que realizaron su residencia entre 1996–1999. Durante este período los residentes realizaron las actividades formativas y asistenciales habituales que marca el Programa Nacional de la Especialidad. Se valoraron 6 escenarios clínicos videograbados con pacientes estandarizados (3 al inicio del tercer año y 3 al finalizar) mediante el cuestionario GATHA-RES. Análisis estadístico descriptivo, bivariado y multivariante.ResultadosSe evaluó un total de 1.024 entrevistas. El tiempo empleado con cada paciente disminuye significativamente al finalizar la residencia; se observa una relación directamente proporcional entre el tiempo de consulta y las puntuaciones obtenidas (p < 0,05). Se detectan mejorías en los aspectos formales y organizativos de la consulta. Por el contrario, las habilidades relacionadas con la exploración de los aspectos personales y contextuales de la dolencia, así como las habilidades negociadoras, empeoran al finalizar el estudio. Las variables que mejor predicen el perfil comunicacional de los residentes fueron: edad (inversamente), duración de la entrevista, formación del tutor en entrevista clínica y unidad docente.ConclusionesLos residentes aprenden a acortar el tiempo de consulta en detrimento de habilidades de comunicación básicas para la realización de una correcta asistencia a los problemas de salud de sus pacientes. Estos resultados sugieren la necesidad de cambios sustanciales en la formación de los médicos residentes de medicina de familia en España.AimsTo study the development of patient relation skills, as used during interviews with patients for health problems that are common within their specialty, in family medicine residents during the third year of their residency program.MethodsQuasi-experimental (before-after), national-level, multicenter study. The participants were 193 third-year residents in family medicine at 8 training units who were trained between 1996 and 1999. During this period all residents participated in the usual training and clinical activities included in the National Plan for this specialty. The GATHA-RES questionnaire was used to evaluated six clinical scenarios in video recordings of encounters with standardized patients (3 at the start of the third year and 3 at the end of the third year). Descriptive, bivariate and multivariate statistical analyses were used.ResultsA total of 1,024 interviews were analyzed. The time spent with each patient decreased significantly at the end of the residency program; the duration of the visit was directly proportional to the score on the GATHA-RES questionnaire (p < 0.05). Improvements were seen in formal and organizational aspects of the interview. In contrast, skills related with the exploration of personal and contextual aspects of the problem, and negotiating skills, were worse at the end of the study. The variables that best predicted residents’ communicational profile were age (inverse relation), duration of the interview, training of the tutor in clinical interviewing, and teaching unit.ConclusionsResidents learn to shorten the duration of the visit to the detriment of communication skills that are basic to appropriate care for their patients’ health problems. These results suggest the need for substantial changes in the training of family medicine residents in Spain

Validez y fiabilidad de un instrumento para la valoración de la entrevista clínica en médicos residentes de medicina de familia: el cuestionario GATHA-RES

ObjetivoComprobar la validez de contenido, la consistencia interna y la fiabilidad intraobservador de un cuestionario para la evaluación de la comunicación médico-paciente de los residentes de medicina de familia.DiseñoEstudio observacional, de validación de un instrumento de medida.EmplazamientoNivel de atención primaria. Unidades docentes de medicina de familia y comunitaria.Población de estudioPara el análisis de validez, 25 médicos residentes de medicina familiar y comunitaria. Para el análisis de fiabilidad, 48 médicos de la misma especialidad.Mediciones e intervencionesPara la construcción del cuestionario, se partió de una versión (GATHA-BASE), compuesta por 42 ítems seleccionados por un panel compuesto por 60 médicos de familia. Para la validez de contenido, se utilizaron 68 encuentros clínicos con pacientes simulados, que fueron videograbados y evaluados. La validez de contenido del cuestionario se estudió mediante un análisis factorial, y para medir su consistencia interna se calcularon los coeficientes alfa de Cronbach. La fiabilidad intraobservador de la versión GATHA-RES fue evaluada mediante los índices kappa y los coeficientes de correlación intraclase.ResultadosObtuvimos una versión del GATHA-RES con 27 ítems. El análisis factorial reveló la existencia de 9 factores: «empatía», «anamnesis», «bidireccionalidad», «negociación», «información», «miscelánea 1», «miscelánea 2» y «centrado en el paciente», que mostraron una buena correlación con los contenidos teóricos y formales del cuestionario original (inicialmente agrupados en 3 secciones: actitudes, tareas comunicacionales y habilidades). Todos los coeficientes de correlación intraclase presentaron cifras ≥ 0,90.ConclusionesEl cuestionario GATHA-RES es un instrumento válido y fiable que puede ser usado para la evaluación de las habilidades comunicacionales de los médicos de familia en formación.ObjectiveTo check the validity of content, the internal consistency and the intra-observer reliability of a questionnaire to evaluate the doctor-patient communication of family medicine residents.DesignObservation study, to validate a measurement instrument.SettingPrimary care. Family and community medicine teaching units.Study populationFor the validity analysis: 25 family and community medicine residents. For the reliability analysis: 48 doctors in the same speciality.Measurements and interventionsThe questionnaire was constructed on the basis of a version (GATHABASE) composed of 42 items selected by a panel of 60 general practitioners. For content validity, 68 clinical encounters with simulated patients, video-recorded and evaluated, were used. The questionnaire's validity content was studied through a factorial analysis. To measure its internal consistency, Cronbach's alpha coefficients were calculated. Intra-observer reliability of the GATHA-RES version was evaluated through the kappa indexes and the intra-class correlation coefficients.ResultsWe obtained a version of the GATHA-RES with 27 items. The factorial analysis revealed that there were 9 factors («empathy», «anamnesis», «two-way communication», «negotiation», «information», «miscellaneous 1», «miscellaneous 2» and «patient-focused») which showed close correlation with the theoretical and formal contents of the original questionnaire (originally grouped in three sections: attitudes, communication tasks and skills). All the intraclass correlation coefficients had figures ≥ 0.90.ConclusionsThe GATHA-RES questionnaire is a valid and reliable instrument that can be used for evaluating the communication skills of general practitioners in training

Evaluación de la competencia clínica de tutores de residentes de medicina familiar y comunitaria

ObjetivoDescribir la primera experiencia de una evaluación clínica objetiva y estructurada (ECOE) a tutores de residentes realizada en la comunidad autónoma de AndalucíaDiseñoObservacional descriptivoEmplazamientoUnidad Docente de Medicina Familiar y Comunitaria de HuelvaParticipantesTutores de residentes de medicina familiar y comunitariaMediciones principalesLos componentes competenciales que se consensuaron y ponderaron fueron los siguientes: anamnesis, exploración física, comunicación,habilidades técnicas, manejo, atención a la familia y actividades preventivas. La selección de las 10 situaciones clínicas de las que constaba la prueba se realizó utilizando unos criterios de priorización según la prevalencia, gravedad clínica, importancia de la prevención y del diagnóstico precoz, complejidad del caso, evaluación de la capacidad resolutiva del médico y simplicidad evaluativaResultadosRealizaron la ECOE 13 tutores. La edad media ± desviación estándar de los participantes fue de 42,8 ± 3,64 años. La prueba tuvo un coeficiente de fiabilidad (alfa de Cronbach) de 0,73. Por lo que se refiere a los resultados por participantes, la media global fue de 73 ± 6,2. Al analizar los resultados para los diferentes componentes competenciales, los mejores resultados se obtuvieron en la atención a la familia, la comunicación y las habilidades técnicasConclusionesLas pruebas de evaluación clínica objetiva y estructurada pueden ser útiles para la valoración de los tutores, con el objetivo de orientar su formación en los puntos débiles e incluso para, en un futuro no muy lejano, servir como instrumento para acreditar y reacreditar a los tutores de residentes de medicina familiar y comunitariaObjectivesWe show the first experience of the application of an objetive and structured clinical evaluation (OSCE) procedure to family medicine trainers, that has been carried out in Andalucia. The objective is to use a competence evaluation instrument that, in the short term, will be used not only for trainer accreditation but also for other public sanitary professionalsParticipantsTutors of family and commnity medicine residentsDesignObservational descriptiveSettingEducational unity of family medicinePrincipal measurementsThe competencial components to be assessed are the following: anamnesis, physical exploration, communication, technical skill, management, family attention y preventive activities. The clinical situations were selected using the following priority criteria: prevalence, clinical gravity, prevention and early diagnosis importance, case complexity, doctor's capacity of evaluation and simplicityResultsThirteen family medicine trainers took part in the OSCE. Their average age was 42.8±3.6 years. The test had an overall reliability coefficient (Cronbach's alpha) of 0.73. The overall mean score of the participants was 73±6.2. The best results about the competencial components were family attention, communication and technical skillConclusionsThe OSCE can be a convenient tool for family medical trainer evaluation, helping to orientate their education in the weak points and, in the near future, it can also be used as an instrument do accredit family medicine trainer

Transcriptional silencing of the Dickkopfs-3 (Dkk-3) gene by CpG hypermethylation in acute lymphoblastic leukaemia

Dkk-3 is a newly characterised mortalisation-related gene and an antagonist of the Wnt oncogenic signalling pathway whose expression is decreased in a variety of cancer cell lines, suggesting that the Dkk-3 gene, located at chromosome 11p15.1, functions as a tumour suppressor gene. Although 11p15 is a ‘hot spot’ for methylation in acute lymphoblastic leukaemia (ALL), the role of Dkk-3 abnormalities has never been evaluated in this disease. We analysed CpG island methylation of the Dkk-3 promoter in six ALL cell lines and 183 ALL patients. We observed Dkk-3 hypermethylation in all cell lines and in cells from 33% (60/183) of ALL patients. Moreover, Dkk-3 methylation was associated with decreased Dkk-3 mRNA expression and this expression was restored after exposure to the demethylating agent 5-AzaC. Clinical features did not differ between hypermethylated and unmethylated patients. Estimated disease-free survival (DFS) and overall survival at 10 and 11 years, respectively, were 49.8 and 45.6% for normal patients and 10.5 and 15.1% for hypermethylated patients (P¼0.001 and 0.09). Multivariate analysis demonstrated that Dkk-3 methylation was an independent prognostic factor predicting DFS (P¼0.0009). Our data suggest that Dkk-3 methylation occurs at an early stage in ALL pathogenesis and probably influences the clinical behaviour of the disease

Promoter hypermethylation of cancer-related genes: a strong independent prognostic factor in acute lymphoblastic leukemia

Promoter hypermethylation plays an important role in the inactivation of cancerrelated genes. This abnormality occurs early in leukemogenesis and seems to be associated with poor prognosis in acute lymphoblastic leukemia (ALL). To determine the extent of hypermethylation in ALL, we analyzed the methylation status of the CDH1, p73, p16, p15, p57, NES-1, DKK-3, CDH13, p14, TMS-1, APAF-1, DAPK, PARKIN, LATS-1, and PTEN genes in 251 consecutive ALL patients.Atotal of 77.3% of samples had at least 1 gene methylated, whereas 35.9% of cases had 4 or more genes methylated. Clinical features and complete remission rate did not differ among patients without methylated genes, patients with 1 to 3 methylated genes (methylated group A), or patients with more than 3 methylated genes (methylated group B). Estimated disease-free survival (DFS) and overall survival (OS) at 11 years were 75.5% and 66.1%, respectively, for the nonmethylated group; 37.2% and 45.5% for methylated group A; and 9.4% and 7.8% for methylated group B (P < .0001 and P .0004, respectively). Multivariate analysis demonstrated that the methylation profile was an independent prognostic factor in predicting DFS (P < .0001) and OS (P .003). Our results suggest that the methylation profile may be a potential new biomarker of risk prediction in AL

Epigenetic regulation of human cancer/testis antigen gene, HAGE, in chronic myeloid leukemia

Cancer testis antigens (CTA) provide attractive targets for cancer-specific immunotherapy. Although CTA genes are expressed in some normal tissues, such as the testis, this immunologically protected site lacks MHC I expression and as such, does not present self antigens to T cells. To date, CTA genes have been shown to be expressed in a range of solid tumors via demethylation of their promoter CpG islands, but rarely in chronic myeloid leukemia (CML) or other hematologic malignancies

Methylation status of Wnt signaling pathway genes affects the clinical outcome of Philadelphia-positive acute lymphoblastic leukemia

The clinical significance of aberrant promoter methylation of the canonical Wnt pathway antagonist genes (sFRP1, sFRP2, sFRP4, sFRP5, Wif1, Dkk3, and Hdpr1) and also putative tumor-suppressor gene Wnt5a, belonging to the non-canonical Wnt signaling pathway, was investigated in a large series of 75 patients with Philadelphia chromosome-positive acute lymphoblastic leukemia by methylationspecific polymerase chain reaction. At least one methylated gene was observed in cells from 66% (49/75) of patients (methylated group). Disease-free survival and overall survival at 9 years were 51 and 40%, respectively, for the unmethylated group and 3 and 2%, respectively, for the methylated group (both P < 0.0001). Multivariate analysis demonstrated that the Wnt methylation profile was an independent prognostic factor predicting disease-free survival (P = 0.007) and overall survival (P = 0.039). Abnormal DNA methylation of promoter-associated CpG islands in the Wnt signaling pathway is very common in Philadelphia chromosome-positive acute lymphoblastic leukemia and potentially defines subgroups with distinct clinical characteristics

Promoter hypomethylation of the LINE-1 retrotransposable elements activates sense/antisense transcription and marks the progression of chronic myeloid leukemia

Aberrant genome-wide hypomethylation is thought to be related to tumorigenesis by promoting genomic instability. Since DNA methylation is considered an important mechanism for the silencingof retroelements, hypomethylation in human tumors may lead to their reactivation. However, the role of DNA hypomethylation in chronic myeloid leukemia (CML) remains to be elucidated. In this study, the methylation status of the LINE-1 (L1) retrotransposon promoter was analysed in CML samples from the chronicphase (CP, n¼140) and the blast crisis (BC, n¼47). L1 hypomethylation was significantly more frequent in BC (74.5%) than in CP (38%) (Po0.0001). Furthermore, L1 hypomethylation led to activation of both ORF1 sense transcription (Po0.0001) and c-MET gene antisense transcription (Po0.0001), and was significantly associated with high levels of BCR–ABL (P¼0.02) and DNMT3b4 (P¼0.001) transcripts. Interestingly, in CP-CML, extensive L1 hypomethylation was associated with poorer prognosis in terms of cytogenetic response to interferon (P¼0.004) or imatinib (P¼0.034) and progression-free survival (P¼0.005). The above results strongly suggest that activation of both sense and antisense transcriptions by aberrant promoter hypomethylation of the L1 elements plays a role in the progression and clinical behavior of the CML

Relativistic chiral representation of the πN\pi N scattering amplitude I: The Goldberger-Treiman relation

In this work we study the $\pi N$ scattering process within the Baryon Chiral Perturbation Theory framework in the covariant scheme of Extended-On-Mass-Shell (EOMS). We compare the description obtained in this scheme with the previously obtained using the Infrared Regularization scheme and show that EOMS accomplishes the best convergence, being able to extract from partial wave analyses reliable values of important quantities as the Goldberger-Treiman deviation. In regard to the latter, we solve the long-standing problem concerning to the extraction of the Goldberger-Treiman deviation with covariant ChPT that jeopardized the applicability of ChPT to the $\pi N$ system. We also show the potential of the unitarization techniques applied to the perturbative calculation in the EOMS scheme, that allow us to increase the range of validity of our description up to $\approx 200$ MeV in $\sqrt{s}$.Comment: PROCEEDINGS to the 33rd International School of Nuclear Physics "From Quarks and Gluons to Hadrons and Nuclei"- 7 Pag,, 1 Table, 4 Figures. Erice-Sicily: 16 - 24 September 201

The DNDN, πΣc\pi \Sigma_c interaction in finite volume and the Λc(2595)\Lambda_c(2595) resonance

In this work the interaction of the coupled channels $DN$ and $\pi \Sigma_c$ in an SU(4) extrapolation of the chiral unitary theory, where the $\Lambda_c(2595)$ resonance appears as dynamically generated from that interaction, is extended to produce results in finite volume. Energy levels in the finite box are evaluated and, assuming that they would correspond to lattice results, the inverse problem of determining the phase shifts in the infinite volume from the lattice results is solved. We observe that it is possible to obtain accurate $\pi \Sigma_c$ phase shifts and the position of the $\Lambda_c(2595)$ resonance, but it requires the explicit consideration of the two coupled channels. We also observe that some of the energy levels in the box are attached to the closed $DN$ channel, such that their use to induce the $\pi \Sigma_c$ phase shifts via L\"uscher's formula leads to incorrect results.Comment: 10 pages, 13 figures, accepted for publication in Eur. Phys. J.