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.

Digital patient-centred learning in medical education: A national learning platform with virtual patients as part of the DigiPaL project

Background: Due to the coronavirus pandemic, the medical faculties in the Federal Republic of Germany converted their curricula to digital formats on a large scale and very quickly in spring 2020 as an emergency measure. At the same time, a start was made on the nationwide exchange of digital teaching/learning materials via the online platform "LOOOP share" in order to save local resources. Among other things, virtual patient cases (VP) were shared across faculties for case-based learning, through which students can acquire clinical decision-making skills. Objectives: Within the framework of the cooperation project "National Learning Platforms for Digital Patient-Related Learning in Medical Studies" (DigiPaL), the usability of VPs for students and teachers should be improved, and the spectrum of disease patterns that are covered by VPs should be systematically expanded. Results: With the participation of many locations, a total of 150 VPs were developed by 96 case authors from 16 faculties, in addition to the existing 403 VPs. The thematic selection was made on the basis of criteria oriented to the National Competence Based Catalogue of Learning Objectives for Undergraduate Medical Education (NKLM). After completion, these VPs were also made available to all faculties for free use via "LOOOP share" and the CASUS learning platform. Discussion: Even after the pandemic, these developed VPs should be available to the faculties and thus make a lasting contribution to improve medical training in Germany - especially in light of digital teaching formats being expressly advocated on the basis of the adapted current Medical Licensure Act (ÄApprO). A possible application is interdisciplinary learning of clinical decision-making with the help of blended learning formats within the framework of a longitudinal curriculum. The large number of involved colleagues and faculties shows that the nationally coordinated development of VPs across faculties was commonly seen as useful.

[Inhaled marijuana and the lung, a toxic cocktail?]

Unlike the well-documented effects of tobacco smoke on the lung, the effects of cannabis smoke remain controversial, the main bias consisting in co-consumption of tobacco. That said, the composition of joint smoke is close to that of cigarettes, containing many compounds that are carcinogenic and/or alter the respiratory epithelium. Confirmed respiratory effects in chronic cannabis smokers include aggravated chronic bronchitis symptoms, a cumulative effect with tobacco on COPD and emphysema occurrence, an increased risk of bullous emphysema, and pneumothorax with heightened risk of recurrence after pleural symphysis. Recent prospective studies have shown a negative impact on lung function, with not only damage to the airways, but also DLCO alteration and an accelerated drop in FEV1. Finally, cannabis smoking is very common among young patients with lung cancer. Its consumption could lead to a different lung cancer profile, potentially more undifferentiated and less accessible to targeted therapy. Questioning about cannabis consumption must be systematic and targeted medical care should be offered.

Implementing Remote Collaboration in a Virtual Patient Platform: Usability Study

BACKGROUND

Learning with virtual patients is highly popular for fostering clinical reasoning in medical education. However, little learning with virtual patients is done collaboratively, despite the potential learning benefits of collaborative versus individual learning.

OBJECTIVE

This paper describes the implementation of student collaboration in a virtual patient platform. Our aim was to allow pairs of students to communicate remotely with each other during virtual patient learning sessions. We hypothesized that we could provide a collaborative tool that did not impair the usability of the system compared to individual learning and that this would lead to better diagnostic accuracy for the pairs of students.

METHODS

Implementing the collaboration tool had five steps: (1) searching for a suitable software library, (2) implementing the application programming interface, (3) performing technical adaptations to ensure high-quality connections for the users, (4) designing and developing the user interface, and (5) testing the usability of the tool in 270 virtual patient sessions. We compared dyad to individual diagnostic accuracy and usability with the 10-item System Usability Scale.

RESULTS

We recruited 137 students who worked on 6 virtual patients. Out of 270 virtual patient sessions per group (45 dyads times 6 virtual patients, and 47 students working individually times 6 virtual patients minus 2 randomly selected deleted sessions) the students made successful diagnoses in 143/270 sessions (53%, SD 26%) when working alone and 192/270 sessions (71%, SD 20%) when collaborating (P=.04, η²=0.12). A usability questionnaire given to the students who used the collaboration tool showed a usability score of 82.16 (SD 1.31), representing a B+ grade.

CONCLUSIONS

The collaboration tool provides a generic approach for collaboration that can be used with most virtual patient systems. The collaboration tool helped students diagnose virtual patients and had good overall usability. More broadly, the collaboration tool will provide an array of new possibilities for researchers and medical educators alike to design courses for collaborative learning with virtual patients.

Why is it so difficult to implement a longitudinal clinical reasoning curriculum? A multicenter interview study on the barriers perceived by European health professions educators

BACKGROUND

Effective clinical reasoning is a core competency of health professionals that is necessary to assure patients' safety. Unfortunately, adoption of longitudinal clinical reasoning curricula is still infrequent. This study explores the barriers that hinder the explicit teaching of clinical reasoning from a new international perspective.

METHODS

The context of this study was a European project whose aim is to develop a longitudinal clinical reasoning curriculum. We collected data in semi-structured interviews with responders from several European countries who represent various health professions and have different backgrounds, roles and experience. We performed a qualitative content analysis of the gathered data and constructed a coding frame using a combined deductive/inductive approach. The identified themes were validated by parallel coding and in group discussions among project members.

RESULTS

A total of 29 respondents from five European countries participated in the interviews; the majority of them represent medicine and nursing sciences. We grouped the identified barriers into eight general themes: Time, Culture, Motivation, Clinical Reasoning as a Concept, Teaching, Assessment, Infrastructure and Others. Subthemes included issues with discussing errors and providing feedback, awareness of clinical reasoning teaching methods, and tensions between the groups of professionals involved.

CONCLUSIONS

This study provides an in-depth analysis of the barriers that hinder the teaching of explicit clinical reasoning. The opinions are presented from the perspective of several European higher education institutions. The identified barriers are complex and should be treated holistically due to the many interconnections between the identified barriers. Progress in implementation is hampered by the presence of reciprocal causal chains that aggravate this situation. Further research could investigate the perceptual differences between health professions regarding the barriers to clinical reasoning. The collected insights on the complexity and diversity of these barriers will help when rolling out a long-term agenda for overcoming the factors that inhibit the implementation of clinical reasoning curricula.

Transdermal nicotine in non-smokers: A systematic review to design COVID-19 clinical trials

Recent data show an interaction between COVID-19 and nicotine and indicate the need for an assessment of transdermal nicotine use in non-smokers. Assessments have been conducted into the short-term cognitive effects of nicotine and into diseases such as Parkinson's, Tourette syndrome, ADHD or ulcerative colitis.

METHODS

Analyses of nicotine administration protocols and safety were conducted after reviewing Medline and Science Direct databases performing a search using the words [transdermal nicotine] AND [non-smoker] AND selected diseases.

RESULTS

Among 298 articles identified, there were 35 reviewed publications reporting on 33 studies of non-smokers receiving transdermal nicotine for >48hours. In the 16 randomized trials, 7 crossover, 1 case/control and 9 open studies patients received an initial nicotine dose of between 2.5mg and 15mg/day. In 22 studies, daily doses increased by 2 to 7 steps in 3 to 96 days until the dose was between 5mg and 105mg/day. The target nicotine dose was 19.06±20.89mg/day. The 987 non-smokers (534 never-smokers, 326 ex-smokers and 127 classified as "non-smokers") received or did not receive nicotine. The most common side-effects were nausea and skin itching. Forty-three (7.1%) non-smokers stopped treatment because of an adverse event of nicotine. No hospitalization related to nicotine side-effects were reported.

CONCLUSION

Despite a relatively safe tolerance profile, transdermal nicotine therapy in non-smokers can only be used in clinical trials. There is a lack of formal assessment of the potential risk of developing a tobacco addiction. This review offers baseline data to set a transdermal nicotine protocol for non-smokers with a new purpose.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Adaptation of an international virtual patient collection to the COVID-19 pandemic

The COVID-19 pandemic posed new global challenges for teaching. We met these challenges as an international collaboration by adapting a collection of virtual patients for clinical reasoning training to this novel context.

Automatic analysis of summary statements in virtual patients - a pilot study evaluating a machine learning approach

BACKGROUND

The ability to compose a concise summary statement about a patient is a good indicator for the clinical reasoning abilities of healthcare students. To assess such summary statements manually a rubric based on five categories - use of semantic qualifiers, narrowing, transformation, accuracy, and global rating has been published. Our aim was to explore whether computer-based methods can be applied to automatically assess summary statements composed by learners in virtual patient scenarios based on the available rubric in real-time to serve as a basis for immediate feedback to learners.

METHODS

We randomly selected 125 summary statements in German and English composed by learners in five different virtual patient scenarios. Then we manually rated these statements based on the rubric plus an additional category for the use of the virtual patients' name. We implemented a natural language processing approach in combination with our own algorithm to automatically assess 125 randomly selected summary statements and compared the results of the manual and automatic rating in each category.

RESULTS

We found a moderate agreement of the manual and automatic rating in most of the categories. However, some further analysis and development is needed, especially for a more reliable assessment of the factual accuracy and the identification of patient names in the German statements.

CONCLUSIONS

Despite some areas of improvement we believe that our results justify a careful display of the computer-calculated assessment scores as feedback to the learners. It will be important to emphasize that the rating is an approximation and give learners the possibility to complain about supposedly incorrect assessments, which will also help us to further improve the rating algorithms.

Blended learning: ten tips on how to implement it into a curriculum in healthcare education

Blended learning is a meaningful combination of online and face-to-face teaching and learning. In this article we summarize relevant aspects of this format and provide ten tips for educators and curriculum developers on implementing a blended learning curriculum in healthcare education. These general tips are derived from our experience and the available literature and cover the planning and implementation process.

Treatment of signs and symptoms of the common cold using EPs 7630 - results of a meta-analysis

The efficacy of Pelargonium sidoides preparation EPs 7630 in the common cold (CC) was assessed by performing meta-analyses of randomized, double-blind, placebo-controlled trials. Mean differences (MD) and risk ratios (RR) with their 95% confidence intervals (CI) were computed. Five trials with a total of 833 patients were included. All trials had a treatment period of ten days with visits at days 3, 5, and 10 after baseline and used a ten-symptom Cold Intensity Score (CIS) as the primary outcome. Significant differences favoring EPs 7630 were observed for total CIS reduction (day 5: MD = -2·30; 95%CI = -4·12,-0·49; day 10: MD = -1·16; 95%CI = -2·22,-0·10), proportion of patients with substantial improvement (day 5: RR = 1·73; day 10: RR = 1·06) and complete remission (day 5: RR = 2·52; day 10: RR = 2·13). Subjects treated with EPs 7630 missed fewer days at work, used less paracetamol and had an improved sleep quality. No serious adverse reactions to EPs 7630 were reported. The results support the efficacy of EPs 7630 in adults with CC.

Maternal mood disorders and lithium exposure in utero were not associated with poor cognitive development during childhood

AIM

This study evaluated whether maternal mood disorders (MMD), particularly bipolar disorder, and lithium treatment during pregnancy influenced the neonatal health and cognition of children born from 2006 to 2010.

METHODS

Our study at Karolinska University Hospital, Stockholm, Sweden, focused on women with and without mood disorders and their children. Information on pharmacotherapy, mental health, delivery and neonatal complications was retrospectively collected from electronic patient records. Children were tested in a blinded manner at four to five years of age with the Wechsler Preschool and Primary Scale of Intelligence, 3rd edition. Maternal health, child health and social situations were evaluated.

RESULTS

Of the 39 children, 20 were exposed to lithium and MMD during pregnancy, eight were exposed to MMD but not lithium and 11 were not exposed to MMD or lithium. The children's full scale intelligence quotient (IQ), performance IQ and verbal IQ results did not differ significantly between the groups. The processing speed quotient was significantly lower in children exposed to mood disorders, but there was a high level of missing data for this subtest.

CONCLUSION

This small, clinical cohort showed no significant association between mothers' prenatal exposure to lithium or mood disorders and their offspring's IQ.

The In Vitro Association of Antihemophilic Factor and von Willebrand Factor

Considerable evidence, including results of gel chromatography, indicates that antihemophilic factor (AHF; factor VIII: C) is associated with von Willebrand factor (vWF; factor VIIIR: RC or VTIIR: Ag) in citrated plasma. The present study was undertaken to determine whether these factors are also associated in plasma with a physiologic calcium ion concentration, or in an artificial medium using purified antihemophilic factor and plasma as a source of vWF. When fresh BaS04-treated native normal plasma was passed through a column of Sepharose CL-4B that was equilibrated and eluted with fresh BaS04-treated plasma from a patient with severe von Willebrand’s disease, the AHF and vWF activities were found in the void volume. Thus, AHF remains associated with vWF on gel chromatography in the presence of physiological concentrations of all plasma constituents except the vitamin-K-dependent clotting factors. On the other hand, when to 200,000 X purified “vWF-free” AHF was chromatographed in buffered 4% albumin with 2 mM CaCl2, virtually all of it appeared in the included volume of the column with an apparent molecular weight between that of fibrinogen or factor V (340,000) and gamma globulin (160,000). The combination of the “vWF-free” AHF with the vWF in plasma was studied by adding the AHF to BaS04-treated plasma from normal subjects or patients with severe hemophilia or von Willebrand’s disease and chromatographing the mixture. The AHF activity appeared in the void volume in an amount that was inversely related to the ratio of the AHF to vWF activity. Thus, with 1-12 U of AHF per unit of vWF, virtually all of the AHF eluted in the void volume, with 30 and 500 units of AHF per unit of vWF, only about 50% and 10% of the AHF, respectively, eluted in the void volume, and in the absence of vWF, none of the AHF activity eluted in the void volume.

Effect of carbetocin, oxytocin and prostaglandin E2 and F2α on intrauterine pressure in cows in dioestrus and oestrus

Objective: To describe the physiological activity of the myometrium in oestrus and dioestrus and the induced activity after medication in cows with particular reference to segmental differences. Material and methods: Six cows were given the pharmaceuticals carbetocin, oxytocin and prostaglandin (PG) F2α (dinoprost) intramuscularly and PGE2 intravenously. The physiological myometrial activity was recorded for 15 minutes and the induced activity for 105 minutes by using a transcervically attached pressure probe containing six pressure micro-transducers. Results: Lower pressures were measured in dioestrus com pared to oestrus before (dioestrus 3.2 ± 8.88 mmHg, oestrus 12.4 ± 13.23 mmHg, p < 0.0001) and after the drug administration. Carbetocin provoked the longest lasting effect (60 minutes in dioestrus, 75 minutes in oestrus) followed by PGE2 (45 minutes in dioestrus, 60 minutes in oestrus), PGF2α (30 minutes each) and oxytocin (15 minutes in oestrus only). In contrast to the other drugs carbetocin did not cause any pressure decrease beneath the base level after the primary pressure increase in dioestrus. In dioestrus the pressure before drug administration was significantly higher in the cervix (3.6 ± 19.40 mmHg) and the uterine body (7.1 ± 36.10 mmHg) than in the uterine horn (1.1 ± 7.21 mmHg). Conversely, in oestrus the pressure in the uterine horn (16.6 ± 17.73 mmHg) was significantly higher than in the uterine body (6.2 ± 16.59 mmHg) and the cervix (10.4 ± 17.91 mmHg). Drug administration in dioestrus caused a cornual pressure increase and the pressure in the uterine body decreased, whereas in oestrus the pressure increased in all uterine segments. The physiological frequency of the pressure waves in dioestrus was 5.2 ± 3.02 in 15 minutes compared to 7.5 ± 2.89 in 15 minutes in oestrus. No traceable changes of the contraction frequency were found after medication. Conclusion and clinical relevance: Carbetocin caused the most enduring increase in intrauterine pressure in dioestrus and oestrus and may therefore be indicated best for therapeutic use. The tested drugs had the same effects on the various uterine segments and no effect on the contraction frequency.

A Clinical Reasoning Tool for Virtual Patients: Design-Based Research Study

BACKGROUND

Clinical reasoning is a fundamental process medical students have to learn during and after medical school. Virtual patients (VP) are a technology-enhanced learning method to teach clinical reasoning. However, VP systems do not exploit their full potential concerning the clinical reasoning process; for example, most systems focus on the outcome and less on the process of clinical reasoning.

OBJECTIVES

Keeping our concept grounded in a former qualitative study, we aimed to design and implement a tool to enhance VPs with activities and feedback, which specifically foster the acquisition of clinical reasoning skills.

METHODS

We designed the tool by translating elements of a conceptual clinical reasoning learning framework into software requirements. The resulting clinical reasoning tool enables learners to build their patient's illness script as a concept map when they are working on a VP scenario. The student's map is compared with the experts' reasoning at each stage of the VP, which is technically enabled by using Medical Subject Headings, which is a comprehensive controlled vocabulary published by the US National Library of Medicine. The tool is implemented using Web technologies, has an open architecture that enables its integration into various systems through an open application program interface, and is available under a Massachusetts Institute of Technology license.

RESULTS

We conducted usability tests following a think-aloud protocol and a pilot field study with maps created by 64 medical students. The results show that learners interact with the tool but create less nodes and connections in the concept map than an expert. Further research and usability tests are required to analyze the reasons.

CONCLUSIONS

The presented tool is a versatile, systematically developed software component that specifically supports the clinical reasoning skills acquisition. It can be plugged into VP systems or used as stand-alone software in other teaching scenarios. The modular design allows an extension with new feedback mechanisms and learning analytics algorithms.

Impact of Virtual Patients as Optional Learning Material in Veterinary Biochemistry Education

Biochemistry and physiology teachers from veterinary faculties in Hannover, Budapest, and Lublin prepared innovative, computer-based, integrative clinical case scenarios as optional learning materials for teaching and learning in basic sciences. These learning materials were designed to enhance attention and increase interest and intrinsic motivation for learning, thus strengthening autonomous, active, and self-directed learning. We investigated learning progress and success by administering a pre-test before exposure to the virtual patients (vetVIP) cases, offered vetVIP cases alongside regular biochemistry courses, and then administered a complementary post-test. We analyzed improvement in cohort performance and level of confidence in rating questions. Results of the performance in biochemistry examinations in 2014, 2015, and 2016 were correlated with the use of and performance in vetVIP cases throughout biochemistry courses in Hannover. Surveys of students reflected that interactive cases helped them understand the relevance of basic sciences in veterinary education. Differences between identical pre- and post-tests revealed knowledge improvement (correct answers: +28% in Hannover, +9% in Lublin) and enhanced confidence in decision making ("I don't know" answers: -20% in Hannover, -7.5% in Lublin). High case usage and voluntary participation (use of vetVIP cases in Hannover and Lublin >70%, Budapest <1%; response rates in pre-test 72% and post-test 48%) indicated a good increase in motivation for the subject of biochemistry. Despite increased motivation, there was only a weak correlation between performance in final exams and performance in the vetVIP cases. Case-based e-learning could be extended and generated cases should be shared across veterinary faculties.

Ethanol in herbal medicinal products for children : Data from pediatric studies and pharmacovigilance programs

Herbal medicinal products are indispensable in children, e. g., in functional gastrointestinal diseases and coughs and colds, especially when available in liquid dosing forms for which dosing can be adapted ideally to different age groups. Despite being generally accepted as safe, the ethanol content of many of these products, necessary for Galenic reasons, has raised questions regarding their safety. Therefore, safety data from more than 50,000 children in noninterventional pediatric studies with these products, as well as data from routine clinical use in several million children, were assessed. No evidence of the involvement of the ethanol content in any adverse drug reactions was found. This allows us to conclude that these herbal medicinal products are safe in the age groups for which they are authorized or registered and that the present labeling is adequate to allow for their safe use in the pediatric population.

'Carriers of variant luteinizing hormone (V-LH) among 1593 Baltic men have significantly higher serum LH'

Luteinizing hormone (LH) is a pituitary heterodimeric glycoprotein essential in male and female reproduction. Its functional polymorphic variant (V‐LH) is determined by two missense mutations (rs1800447, A/G, Trp8Arg; rs34349826, A/G, Ile15Thr) in the LH β‐subunit encoding gene (LHB; 19q13.3; 1111 bp; 3 exons). Among women, V‐LH has been associated with higher circulating LH and reduced fertility, but the knowledge of its effect on male reproductive parameters has been inconclusive. The objective of this study was to assess the effect of V‐LH on hormonal, seminal and testicular parameters in the Baltic young men cohort (n = 986; age: 20.1 ± 2.1 years) and Estonian idiopathic infertility patients (n = 607; 35.1 ± 5.9 years). V‐LH was detected by genotyping of the underlying DNA polymorphisms using PCR‐RFLP combined with resequencing of a random subset of subjects. Genetic associations were tested using linear regression under additive model and results were combined in meta‐analysis. No significant difference was detected between young men and infertility patients for the V‐LH allele frequency (11.0 vs. 9.3%, respectively). V‐LH was associated with higher serum LH in both, the young men cohort (p = 0.022, allelic effect = 0.26 IU/L) and the idiopathic infertility group (p = 0.008, effect = 0.59 IU/L). In meta‐analysis, the statistical significance was enhanced (p = 0.0007, resistant to Bonferroni correction for multiple testing; effect = 0.33 IU/L). The detected significant association of V‐LH with increased serum LH remained unchanged after additional adjustment for the SNPs previously demonstrated to affect LH levels (FSHB ‐211G/T, FSHR Asn680Ser, FSHR ‐29A/G). Additionally, a suggestive trend for association with reduced testicular volume was observed among young men, and with lower serum FSH among infertility patients. The V‐LH carrier status did not affect sperm parameters and other circulating reproductive hormones. For the first time, we show a conclusive contribution of V‐LH to the natural variance in male serum LH levels. Its downstream clinical consequences are still to be learned.

A non-interventional phase IV Belgian survey to assess the antiviral effectiveness of pegylated interferon-alpha-2b and ribavirin treatment according to the stage of liver fibrosis in previously untreated patients with genotype 1/4/5/6 chronic hepatitis C (PRACTICE)

BACKGROUND AND STUDY AIMS

This was an observational, non-interventional, multicenter, phase IV study, in patients with genotype 1/4/5/6 chronic hepatitis C (CHC). The primary objectives were to evaluate SVR in patients with no or minimal fibrosis (METAVIR F0-F1) versus well established fibrosis (F2-F4), and to estimate response on Weeks 12, 24 and 48 on treatment in previously untreated patients with genotypes 1/4/5/6 CHC.

PATIENTS AND METHODS

538 patients treated with pegylated interferon alfa 2b 1.5 mcg/kg in combination with ribavirin 800-1200 mg/day were enrolled in 55 sites in Belgium and Luxembourg, 505 being considered for the analysis. 40% of the patients were female and 60% male, the average age was 47.5 years, 10.5% were 65 or older.

RESULTS

SVR was observed in 35% of the patients, EVR in 68%, of which pEVR in 33% and cEVR in 35%. SVR was observed in 43% of the low fibrosis group (F0, F1) and 30% of the high fibrosis group (F2, F3, F4) (p = 0.005). SVR rates were 34% for genotype 1, 37% for genotype 4, and 47% for genotype 5 (NS). Multivariate analysis showed that EVR and baseline METAVIR score are independent prognostic factors for SVR.

CONCLUSIONS

This trial confirms that fibrosis stage and early viral response are the most important key-factors to predict sustained response, suggesting that the earlier patients are treated, the better the outcome. Non-invasive techniques enable us to closely monitor progression of fibrosis, allowing a better selection of patients for antiviral treatment in the DAA-era.

Response of Black African patients with hepatitis C virus genotype 4 to treatment with peg-interferon and ribavirin

AIM

To compare responses to therapy of Black African (BA) and non-Black African (non- BA) patients with hepatitis C virus genotype 4 (HCV-4) residing in Belgium.

METHODS

In this retrospective multicenter study, 473 patients with HCV-4 were selected from databases at 7 Belgian centers; 209 treatment-naive patients (154 BA) had received treatment with peg-interferon (peg-IFN) plus ribavirin (RBV) and were included in the study.

RESULTS

There was a greater percentage of female patients in the BA group than in the non- BA group; BA patients were also older, had a greater body mass index, and more frequently had abnormal glucose metabolism. The route of contamination was more frequently unknown in BA than in non-BA patients and BA patients had more HCV-4 subtypes. There were no differences in other demographic factors between the groups. Sustained viral response (SVR) and complete early viral response rates were significantly lower and relapse rates significantly higher in BA than in non-BA patients. There were no differences between groups in rates of dose modification or in drug tolerance.

CONCLUSION

In our cohort, treatment-naive BA patients with HCV-4 who were treated with peg-IFN and ribavirin had a much lower SVR rate than treatment-naive non-BA patients with HCV-4 who were treated with peg-IFN and ribavirin, and a higher relapse rate, possibly related to a weaker response to interferon-based therapy. Treatment may need to be adapted in this population.

Health impact in children and adolescents

Obesity in children and adolescents is associated with multiple comorbidities, including metabolic, cardiovascular, gastrointestinal, pulmonary, orthopedic and psychological disorders. In fact, cardiovascular and metabolic impairments in childhood and adolescence constitute major risk factors for developing cardiovascular disease in adulthood. Thus, obesity in childhood and adolescence leads to a higher morbidity and mortality in adulthood. Therefore, strong emphasis must be laid on the prevention and therapy of childhood obesity. Treatment requires a multidisciplinary and multiphase approach including dietary management, physical activity, pharmacotherapy and bariatric surgery. This paper reviews the different comorbidities of childhood obesity supporting the notion of a multidisciplinary therapy concept.

Randomized clinical trials underestimate the efficacy of antidepressants in less severe depression

OBJECTIVE

  Demonstrating the superiority of antidepressants over placebo in randomized clinical trials of antidepressants (RCT-ADs) has been difficult. A recent meta-analysis of six RCT-ADs concluded that the efficacy of antidepressants was 'non-existent to negligible' in mild and moderate depression. The aim of this study was to reanalyze the same data in order to investigate whether the meta-analysis could be biased from the shortcomings of the rating scale used, the Hamilton Depression Rating Scale (HDRS).

METHOD

We got access to the primary data on item and individual level from five of the six meta-analyzed RCT-ADs (597 individuals). We reanalyzed these data by means of item response theory.

RESULTS

Each study showed rapidly decreasing reliability of measurement with diminishing depression; 38% of the combined sample at endpoint was measured with less than half the maximal reliability.

CONCLUSION

The HDRS Scale provides unreliable primary data. Low effect sizes can be expected because of the scale's low precision and low sensitivity to change, particularly in mild and moderate depression. The conclusion of the meta-analysis by Fournier et al. is therefore unfounded. The clinical value of antidepressants cannot be evaluated from unreliable data. It is urgent that better measurement techniques for depression severity are developed.

Strong scalability indexes for a new self-rating scale for mania and depression

The Affective Self Rating Scale (AS-18) was developed in response to clinical need for a user friendly self-rating scale for simultaneous assessment of depression, mania and mixed affective states in outpatient settings. The two subscales of AS-18 have nine items each (AS-18-M and AS-18-D). There are five levels of response categories graded from 0 to 4. AS-18 has been evaluated in two samples of bipolar 1 patients, using the non-parametric Mokken method. The Mokken method was especially developed for analysis of scales of ordinal type and gives scalability indexes that are measures of the ability of items and a full scale to rank persons according to their total score on a common dimension (unidimensionality).

The AS-18 have in two samples shown scalability indexes above the generally accepted cut-offs of ≥ 0.3 for items and ≥ 0.5 for a strong full scale.

Conclusion

AS-18 has good basic psychometric properties. It takes only a few minutes for patients to perform and is suitable for routine use in outpatients with bipolar 1 disorder.

Abdominal ultrasonography by the hepato-gastroenterologist: problems, demands, solutions

This document analyzes the reasons for organizing an abdominal ultrasound training for Belgian trainees in hepatogastroenterology. The hepatogastroenterology speciality should implement, together with the radiology speciality and the national scientific and professional associations, the minimum training requirements which are proposed by the European Board of Gastroenterology and Hepatology and the European Federation of Societies for Ultrasound in Medicine and Biology. Trainees in hepatogastroenterology should acquire the same theoretical and practical training as radiologists, they should be taught and supervised by competent instructors and have their expertise evaluated.

High prevalence of advanced fibrosis in association with the metabolic syndrome in a Belgian prospective cohort of NAFLD patients with elevated ALT. Results of the Belgian NAFLD registry

INTRODUCTION

Non-alcoholic Fatty Liver Disease (NAFLD) is increasingly recognised as a source of liver related morbidity and mortality. Hard data on epidemiology and natural history are scarce.

AIM

To study demographic and metabolic characteristics of the NAFLD patients seen by Belgian hepatologists.

METHODS

Belgian hepatologists filled in a questionnaire for every newly diagnosed NAFLD patient between January 1st and December 31st 2004. Liver biopsy was advised if ALT > 1.5 x ULN and if 3/5 of the criteria for the metabolic syndrome (MS) (ATPI-II) were present, but was not mandatory. Biopsy was scored using the Brunt classification.

RESULTS

230 patients were prospectively included in 9 centres; 54% were males; mean age was 49.4 +/- 13.9 y; mean BMI was 30.6 +/- 4.6 kg/m2. The MS was present in 53%. In 16% formerly undiagnosed diabetes was discovered. 51% had a liver biopsy: 25% met the criteria, 26% did not. Grading did not differ between patients with or without MS. Staging was significantly more severe in patients with MS (2.43 +/- 1.25 vs. 1.73 +/- 1.18, p < 0.001). A subgroup of patients with GGT > 5 x ULN were significantly older (55.9 vs. 47.64 y, p = 0.02), more frequently diabetic (53% vs. 23%, p = 0.01) and had more advanced fibrosis (3.42 vs. 1.08, p = 0.008). ALT levels were variable.

CONCLUSIONS

The MS is highly prevalent in Belgian NAFLD patients and is associated with more severe disease. Mild to moderate fibrosis is frequent, and the proposed criteria for liver biopsy are not accurate in selecting these patients. Patients with elevated GGT constitute a subgroup with more advanced disease.