Developing a European longitudinal and interprofessional curriculum for clinical reasoning

Clinical reasoning is a complex and crucial ability health professions students need to acquire during their education. Despite its importance, explicit clinical reasoning teaching is not yet implemented in most health professions educational programs. Therefore, we carried out an international and interprofessional project to plan and develop a clinical reasoning curriculum with a train-the-trainer course to support educators in teaching this curriculum to students. We developed a framework and curricular blueprint. Then we created 25 student and 7 train-the-trainer learning units and we piloted 11 of these learning units at our institutions. Learners and faculty reported high satisfaction and they also provided helpful suggestions for improvements. One of the main challenges we faced was the heterogeneous understanding of clinical reasoning within and across professions. However, we learned from each other while discussing these different views and perspectives on clinical reasoning and were able to come to a shared understanding as the basis for developing the curriculum. Our curriculum fills an important gap in the availability of explicit clinical reasoning educational materials both for students and faculty and is unique with having specialists from different countries, schools, and professions. Faculty time and time for teaching clinical reasoning in existing curricula remain important barriers for implementation of clinical reasoning teaching

Long-wave ultraviolet radiation (UVA1) and visible light : Therapeutic and adverse effects in human skin

We studied the effects of repetitive low-dose UVA1 radiation and visible light in normal sunshielded skin, using immunohistochemical staining for p53, p21WAF-1, bcl-2, Ki67 and cyclin A. An increased expression of Ki67 after UVA1 and visible light were observed as a sign of increased proliferation. By comparison to untreated skin, increased expression of p53 protein, but not p21WAF-1, in epidermis after UVA1 and only slightly increased expression after visible light were seen. These results suggested that suberythemal doses of UVA1 - and even visible light - may cause DNA damage. Single p53 positive cells from UVA1 irradiated, earlier sun-shielded, skin were therefore microdissected and thereafter PCR-amplified with p53 sequence analysis. This showed three mutations, all GgT transversion. One of the mutations was found in codon 231 of exon 7 and the other two in the intron. The average mutation was I per 8700 bases or 1 per 12 cells, correlating well with the earlier findings of ultraviolet A signature mutations in normal sunexposed human skin. The wavelength at which the dye laser operates is in the visible range commonly used in treating port-wine stains (PWS). The treatment result depends on the wavelength, pulse duration and fluence of the laser system. Twenty-two patients with PWS were treated with flashlamp-pulsed dye laser (FPDL) using wavelengths 585 and 600 nm There was significantly less lightening with 600 run than with 585 nm when equal fluences were used. When 1.5 and 2 times the 585 nm fluence were applied with 600 nm, the lightening was equal to that of 585 nm. We compared the FPDL at 0.45 msec pulse duration and spot size 5 mm with an argonpumped dye laser with a robotized scanning laser handpiece (Hexascan) at 70-190 msec pulse duration and spot size I mm. Both were tuned to 585 nm. Thirty patients with PWS were treated on test areas with both laser systems. Twelve weeks later the degree of lightening was evaluated and biopsies were taken. The skin sections were immunohistochemically stained with CD34 to count the vessels. The clinical result showed a significant better lightening using the flashlamp-pulsed dye laser. The histological result showed significantly fewer vessels of diameter larger than 20 pin in treated PWS than in untreated, but no difference between the two laser types. However, there was a tendency towards more small vessels (diameter < 10 µm ) after one treatment with the FPDL compared to untreated. Mycosis fungoides (NU) is a cutaneous T-cell lymphoma commonly treated with psoralen and ultraviolet A (PUVA). In photodynamic therapy (PDT) porphyrin-based photosensitizers are used which absorb light energy resulting in cellular damage. We used the prodrug 5aminolevulinic acid topically on MF lesions. Thereafter we exposed the lesions to red visible light. Skin biopsies were taken before treatment, after clinical improvement and after clinical remission. The expression of CD3, CD4, CD7, CD8, CD1a CD34, CD68, CD71, Ki67, bcl-2, p53 was studied inummohistochemically. There was complete clinical clearance in 7 of 9 plaque lesions but not of two tumour lesions. The biopsies confirmed a regress of the infiltrate after treatment. In the sparse remaining infiltrate a few CD4+ and CD8+ cells were found, most showing normal bcl-2. There were also fewer proliferating cells, illustrated by decrease of Ki67 and CD71. PDT has good clinical and histological effects in treating local plaque MF lesions

Topical rapamycin for angiofibromas in patients with tuberous sclerosis: how does it work in clinical practice?

Aim: Topical rapamycin for angiofibromas has been reported to be a new promising treatment. This study aims to report the outcome in clinical practice.Methods: A retrospective clinical follow-up on twenty-three patients who had been prescribed an oral solution of 0.1% rapamycin, to be applied on facial lesions once a day.Results: Seventeen of 23 patients continued the treatment. Papules and nodules were improved in 8 patients (47%) and erythema in 12 (70%). Side effects, such as stinging and redness were reported in 35% of patients. Blood samples were taken from 5 patients and no rapamycin could be detected. All patients who paused the treatment relapsed.Conclusion: Topical rapamycin has a positive effect on angiofibromas with improvement in both erythema and papules even if only applied every second to third day, but continuous treatment is needed

General practitioners perceptions of their role and their collaboration with district nurses in wound care

Aim: To explore the perceptions of general practitioners (GPs) regarding their role and their collaboration with district nurses (DNs) in the management of leg ulcers in primary healthcare. Background: Earlier research regarding the treatment of leg ulcers in a primary care context has focussed primarily on wound healing. Less is known about GPs understandings of their role and their collaboration with DNs in the management of leg ulcers. Since the structured care of patients with leg ulcers involving both GP and DN is currently rather uncommon in Swedish primary care, this study sets out to highlight these aspects from the GPs perspective. Methods: Semi-structured individual interviews with 16 GPs including both private and county council run healthcare centres. Thematic analysis was used to analyse the data. Results: Four themes were identified. The first theme: role as consultant and coordinator shows how the GPs perceived their role in wound care. In the second theme: responsibility for diagnosis the GPs views on responsibility for wound diagnosis is presented. The third theme: desire for continuity is based on the GPs desire for continuity concerning various aspects. In the fourth theme: collaboration within the organisation the importance of the organisation for collaboration between GPs and DNs is presented. Conclusions: The GPs often work on a consultation-like basis and feel that they become involved late in the patients wound treatment. This can have negative consequences for the medical diagnosis and, thereby, lead to a prolonged healing time for the patient. Shortcomings regarding collaboration are mainly attributed to organisational factors.Funding Agencies|Stockholm County Council (ALF project)Stockholm County Council</p