Improving the Management of Children with Fevers by Healers in Native Rural Areas in the South of Ecuador

BACKGROUND

Indigenous populations are represented among the poor and disadvantaged in rural areas. High rates of infectious diseases are observed in indigenous child populations, and fever as a general symptom is common.

OBJECTIVE

We aim to improve the skills of healers in rural indigenous areas in the South of Ecuador for managing children with fevers.

METHOD

We performed participatory action research (PAR) for this study with 65 healers.

RESULTS

The PAR focused on the following four phases: (1) 'observation,' eight focus groups were used. (2) 'planning' phase was developed, and with culturally reflective peer group sessions, a culturally adapted flowchart was constructed titled "Management of children with fever." In phase (3): 'action', the healers were trained to manage children with fever. Phase (4): 'evaluation', 50% of the healers used the flowchart.

CONCLUSIONS

Explicit recognition of the need for traditional healers and health professionals in indigenous communities to work together to improve health indicators such as infant mortality exists. Additionally, strengthening the transfer system in rural areas is based on knowledge and cooperation between the community and the biomedical system.

[Evolutionary psychiatry applied to autism spectrum disorder]

BACKGROUND

Considering an evolutionary perspective, psychiatric conditions present us with a paradox. How can the high prevalence of those conditions be explained, given the importance of genetic factors in many of them? Evolutionary principles predict that traits with an adverse effect on reproduction undergo negative selection.

AIM

To try to formulate an answer to this paradox from the perspective of evolutionary psychiatry by integrating different disciplines.

METHOD

We describe some important evolutionary models: the adaptive and maladaptive model, the mismatch model, the trade-off model and the balance model. By way of illustration, we have searched the literature for evolutionary perspectives on autism spectrum disorder.

RESULTS

In this narrative review we describe several evolutionary hypotheses about autism spectrum disorder with a framing within the different evolutionary models. We discuss, among others, evolutionary hypotheses regarding gender differences in social skills, the link with more recent evolutionary cognitive development, and autism spectrum disorder as an extreme cognitive outlier.

CONCLUSION

We conclude that evolutionary psychiatry offers a complementary point of view on psychiatric conditions and specifically on autism spectrum disorder. A link to neurodiversity and an impetus to clinical translation is made.

Culturally adapted flowcharts in obstetric emergencies: a participatory action research study

INTRODUCTION

Maternal mortality is a health problem in developing countries and is the result of several factors such as sociodemographic and economic inequalities and difficulties in accessing the health services. In addition, training strategies in obstetric emergencies targeting the non-medical personnel such as traditional midwives are scarce. The focus of this study is to develop learning and communication bridges on the management of obstetric emergencies and on policies of patients' referral to the biomedical health system in rural areas.

METHODOLOGY

A Participant Action Research (PAR) study with a mixed methods approach was set up to elaborate culturally adapted flowcharts. The project lasted approximately 3,5 years, from September 2016 to January 2021.

RESULTS

The study was conducted with 94 traditional midwives from southern Ecuador and is divided into 4 phases, namely: 1) Exploration: focus groups and interviews were conducted to document the management of obstetric emergencies through the presentation of "clinical case" scenarios in three important topics, namely: pre-eclampsia, shoulder dystocia and postpartum hemorrhage, 2) Planning: a number of reflective sessions were conducted between the researchers and the healers/midwives to elaborate flowcharts. 3) Action: the training was conducted in rooms dedicated to proficiency in the aforementioned topics and using the flowcharts, 4) Evaluation: 90% of the participants reported having used the flowcharts during the first year after the training. The most frequently used flowchart was that of pre-eclampsia for the recognition of warning signs during pregnancy control.

CONCLUSION

This study documents common practices of pregnancy and delivery management by traditional midwives. Furthermore, cultural flowcharts were developed for and together with midwives to improve the clinical response to obstetric emergencies. The preliminary evaluation was favorable; the most frequently used flowchart concerned preeclampsia. In this process, establishing a partnership was crucial for successful intercultural collaboration.

Perceptions of Ecuadorian indigenous healers on their relationship with the formal health care system: barriers and opportunities

BACKGROUND

The new paradigm of intercultural policies focuses on rethinking the common public culture. In Ecuador, the "Buen Vivir" plan seeks to incorporate the ancestral medical knowledge, experience and beliefs of traditional healers into the formal health services. This study explores views on the formal health system from the perspective of the healers belonging to the Kichwa and Shuar ethnicities in the South of Ecuador.

METHODS

A qualitative study with a phenomenological approach was performed. Focus groups were conducted in three locations in Southern Ecuador. Shuar, Kichwa and Mestizo ethnic groups were included in the research.

RESULTS

Eleven focus groups with a total of 110 participants belonging to the Shuar, Kichwa and Mestizo ethnic groups participated in the study. Six themes were created through analysis: 1) conflicts with health professionals, 2) acceptance of traditional healers, 3) respect, 4) work as a team, 5) environment and patient care, and 6) salary and recognition.

CONCLUSION

This study indicated the perceived barriers compromising respectful collaboration between health staff and traditional healers from an indigenous perspective. Power inequalities and a historically unidirectional relationship and, in addition, differences in health beliefs, seem to create misunderstandings regarding each other's approach when faced with health and disease. However, insight in these barriers can create opportunities towards collaboration, which will have a positive effect on patient confidence in one or both systems and support continuity between traditional healers and the formal health system.

Towards an indigenous definition of health: an explorative study to understand the indigenous Ecuadorian people's health and illness concepts

Backgrounds

An intercultural society facilitates equitable and respectful interrelations. Knowing and understanding each other’s sociocultural and linguitic contexts is a prerequisite for an intercultural society. This study explores the concepts of health and illness among healers of indigenous ethnicities in Southern Ecuador.

Methods

A qualitative observational study with eleven focus groups was conducted in three locations in Southern Ecuador; a total of 110 participants the Shuar, Kichwa and Mestizo ethnic groups were included. A phenomenological and hermeneutic analysis was conducted.

Results

Fourteen main subtopics around of two predefined themes, i.e., “Health” and “Illness” were identified: 1) four bodies, 2) religiosity, 3) health as a good diet, 4) health as god’s blessing or a gift, 5) health as balance/ harmony, 6) health as community and social welfare, 7) health as potentiality or a skill, 8) health as peacefulness, 9) heath as individual will, 10) illness as an imbalance, 11) illness as bad energy, 12) illness as a bad diet, 13) illness as suffering or worry, and 14) illness from God, Nature and People illness. By analysing all the topics’ and subtopics’ narratives, a health and illness definition was developed. The principal evidence for this new framework is the presence of interculturality as a horizontal axis in health. The indigenous perspective of health and illness focus on a balance between 4 bodies: the physical, spiritual, social and mental bodies. Additionally, “good health” is obtained through of the good diet and balanced/harmony.

Conclusion

Indigenous healers in Southern Ecuador have views on health and illness that differ from the Western biomedical model of care. These different views must be recognized and valued in order to build an intercultural (health) system that empowers both ancestral and modern medical knowledge and healing.

Culturally Competent in Medical Education - European Medical Teachers' Self-Reported Preparedness and Training Needs to Teach Cultural Competence Topics and to Teach a Diverse Class

This article was migrated. The article was marked as recommended. Background Health inequalities related to culture and ethnicity may be reduced by training future health care providers.Medical teachers therefore also need to be culturally competent. The aim of this study was to assess medical teachers' preparedness and their training needs to teach cultural competence topics and to teach a diverse class. Methods A link to an online survey was sent to medical teachers of eleven European institutions. Results were analysed through descriptive analysis and answers to open-ended questions were analysed using qualitative analysis. Results 968 respondents were included. The majority of respondents felt it was important that cultural competence topics should be incorporated into the medical curriculum. Assessment of skills in cultural competence was found important as well. Over 60% of all respondents reported to be somewhat or very prepared to teach cultural competence topics like migrant health and disparities. Most respondents felt somewhat or very prepared to teach a diverse class. A high interest in training was expressed on teaching cultural competence topics, specifically on communication-related topics. Conclusion This study emphasizes the importance of incorporating cultural issues into the medical curriculum and to train medical teachers according to their needs.

Defining a framework for medical teachers' competencies to teach ethnic and cultural diversity: Results of a European Delphi study

BACKGROUND

Medical students need to be trained in delivering diversity-responsive health care but unknown is what competencies teachers need. The aim of this study was to devise a framework of competencies for diversity teaching.

METHODS

An open-ended questionnaire about essential diversity teaching competencies was sent to a panel. This resulted in a list of 74 teaching competencies, which was sent in a second round to the panel for rating. The final framework of competencies was approved by the panel.

RESULTS

Thirty-four experts participated. The final framework consisted of 10 competencies that were seen as essential for all medical teachers: (1) ability to critically reflect on own values and beliefs; (2) ability to communicate about individuals in a nondiscriminatory, nonstereotyping way; (3) empathy for patients regardless of ethnicity, race or nationality; (4) awareness of intersectionality; (5) awareness of own ethnic and cultural background; (6) knowledge of ethnic and social determinants of physical and mental health of migrants; (7) ability to reflect with students on the social or cultural context of the patient relevant to the medical encounter; (8) awareness that teachers are role models in the way they talk about patients from different ethnic, cultural and social backgrounds; (9) empathy for students of diverse ethnic, cultural and social background; (10) ability to engage, motivate and let all students participate.

CONCLUSIONS

This framework of teaching competencies can be used in faculty development programs to adequately train all medical teachers.

Consensus study to define appropriate inaction and inappropriate inertia in the management of patients with hypertension in primary care

OBJECTIVES

To elaborate and validate operational definitions for appropriate inaction and for inappropriate inertia in the management of patients with hypertension in primary care.

DESIGN

A two-step approach was used to reach a definition consensus. First, nominal groups provided practice-based information on the two concepts. Second, a Delphi procedure was used to modify and validate the two definitions created from the nominal groups results.

PARTICIPANTS

14 French practicing general practitioners participated in each of the two nominal groups, held in two different areas in France. For the Delphi procedure, 30 academics, international experts in the field, were contacted; 20 agreed to participate and 19 completed the procedure.

RESULTS

Inappropriate inertia was defined as: to not initiate or intensify an antihypertensive treatment for a patient who is not at the blood pressure goals defined for this patient in the guidelines when all following conditions are fulfilled: (1) elevated blood pressure has been confirmed by self-measurement or ambulatory blood pressure monitoring, (2) there is no legitimate doubt on the reliability of the measurements, (3) there is no observance issue regarding pharmacological treatment, (4) there is no specific iatrogenic risk (which alters the risk-benefit balance of treatment for this patient), in particular orthostatic hypotension in the elderly, (5) there is no other medical priority more important and more urgent, and (6) access to treatment is not difficult. Appropriate inaction was defined as the exact mirror, that is, when at least one of the above conditions is not met.

CONCLUSION

Definitions of appropriate inaction and inappropriate inertia in the management of patients with hypertension have been established from empirical practice-based data and validated by an international panel of academics as useful for practice and research.

Investigating empathy in interpreter-mediated simulated consultations: An explorative study

OBJECTIVE

To explore i) the ways in which empathic communication is expressed in interpreter-mediated consultations; ii) the interpreter's effect on the expression of empathic communication.

METHODS

We coded 9 video-recorded interpreter-mediated simulated consultations by using the Empathic Communication Coding System (ECCS) which we used for each interaction during interpreter-mediated consultations. We compared patients' empathic opportunities and doctors' responses as expressed by the patients and doctors and as rendered by the interpreters.

RESULTS

In 44 of the 70 empathic opportunities there was a match between the empathic opportunities as expressed by the patients and as rendered by the interpreters. In 26 of the 70 empathic opportunities, we identified 5 shift categories (reduced emotion, omitted emotion, emotion transformed into challenge, increased challenge/progress, twisted challenge) in the interpreter's rendition to the doctor. These were accompanied by changes in the level of empathy and in the content of the doctors' empathic responses.

CONCLUSION

The interpreters' renditions had an impact on the patients' empathic opportunities and on the doctors' empathic responses in one third of the coded interactions.

PRACTICE IMPLICATIONS

Curricula with a focus on intercultural communication and/or empathy should consider the complexity of interpreter-mediated interaction and the interpreter's impact on the co-construction of empathy.

General practitioners' justifications for therapeutic inertia in cardiovascular prevention: an empirically grounded typology

OBJECTIVE

To construct a typology of general practitioners' (GPs) responses regarding their justification of therapeutic inertia in cardiovascular primary prevention for high-risk patients with hypertension.

DESIGN

Empirically grounded construction of typology. Types were defined by attributes derived from the qualitative analysis of GPs' reported reasons for inaction.

PARTICIPANTS

256 GPs randomised in the intervention group of a cluster randomised controlled trial.

SETTING

GPs members of 23 French Regional Colleges of Teachers in General Practice, included in the EffectS of a multifaceted intervention on CArdiovascular risk factors in high-risk hyPErtensive patients (ESCAPE) trial.

DATA COLLECTION AND ANALYSIS

The database consisted of 2638 written responses given by the GPs to an open-ended question asking for the reasons why drug treatment was not changed as suggested by the national guidelines. All answers were coded using constant comparison analysis. A matrix analysis of codes per GP allowed the construction of a response typology, where types were defined by codes as attributes. Initial coding and definition of types were performed independently by two teams.

RESULTS

Initial coding resulted in a list of 69 codes in the final codebook, representing 4764 coded references in the question responses. A typology including seven types was constructed. 100 GPs were allocated to one and only one of these types, while 25 GPs did not provide enough data to allow classification. Types (numbers of GPs allocated) were: 'optimists' (28), 'negotiators' (20), 'checkers' (15), 'contextualisers' (13), 'cautious' (11), 'rounders' (8) and 'scientists' (5). For the 36 GPs that provided 50 or more coded references, analysis of the code evolution over time and across patients showed a consistent belonging to the initial type for any given GP.

CONCLUSION

This typology could provide GPs with some insight into their general ways of considering changes in the treatment/management of cardiovascular risk factors and guide design of specific physician-centred interventions to reduce inappropriate inaction.

TRIAL REGISTRATION NUMBER

NCT00348855.

Impact of family medicine clerkships in undergraduate medical education: a systematic review

OBJECTIVE

Synthesise evidence about the impact of family medicine/general practice (FM) clerkships on undergraduate medical students, teaching general/family practitioners (FPs) and/or their patients.

DATA SOURCES

Medline, ERIC, PsycINFO, EMBASE and Web of Knowledge searched from 21 November to 17 December 2013. Primary, empirical, quantitative or qualitative studies, since 1990, with abstracts included. No country restrictions. Full text languages: English, French, Spanish, German, Dutch or Italian.

REVIEW METHODS

Independent selection and data extraction by two authors using predefined data extraction fields, including Kirkpatrick's levels for educational intervention outcomes, study quality indicators and Best Evidence Medical Education (BEME) strength of findings' grades. Descriptive narrative synthesis applied.

RESULTS

Sixty-four included articles: impact on students (48), teaching FPs (12) and patients (8). Sample sizes: 16-1095 students, 3-146 FPs and 94-2550 patients. Twenty-six studies evaluated at Kirkpatrick level 1, 26 at level 2 and 6 at level 3. Only one study achieved BEME's grade 5. The majority was assessed as grade 4 (27) and 3 (33). Students reported satisfaction with content and process of teaching as well as learning in FM clerkships. They enhanced previous learning, and provided unique learning on dealing with common acute and chronic conditions, health maintenance, disease prevention, communication and problem-solving skills. Students' attitudes towards FM were improved, but new or enhanced interest in FM careers did not persist without change after graduation. Teaching FPs reported increased job satisfaction and stimulation for professional development, but also increased workload and less productivity, depending on the setting. Overall, student's presence and participation did not have a negative impact on patients.

CONCLUSIONS

Research quality on the impact of FM clerkships is still limited, yet across different settings and countries, positive impact is reported on students, FPs and patients. Future studies should involve different stakeholders, medical schools and countries, and use standardised and validated evaluation tools.

Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador

OBJECTIVES

The aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service.

SETTING

Primary care, rural health centres in Southern Ecuador.

PARTICIPANTS

A total of 92 recent graduated medical doctors during their compulsory rural year.

PRIMARY AND SECONDARY OUTCOMES MEASURES

A web-based survey was developed with 21 obstetrical skills. The questionnaire was sent to all rural doctors who work in Loja province, Southern Ecuador, at the Ministry of Health (n=92).

WE MEASURED TWO CATEGORIES

'importance of skills in rural practice' with a five-point Likert-type scale (1= strongly disagree; 5= strongly agree); and 'clerkship experience' using a nominal scale divided in five levels: level 1 (not seen, not performed) to level 5 (performed 10 times or more). Spearman's rank correlation coefficient (r) was used to observe associations.

RESULTS

A negative correlation was found in the skills: 'episiotomy and repair', 'umbilical vein catheterisation', 'speculum examination', 'evaluation of cervical dilation during active labour', 'neonatal resuscitation' and 'vacuum-assisted vaginal delivery'. For instance 'Episiotomy and repair' is important (strongly agree and agree) to 100% of respondents, but in practice, only 38.9% of rural doctors performed the task three times and 8.3% only once during the internship, similar pattern is seen in the others.

CONCLUSIONS

In this study we have noted the gap between the medical needs of populations in rural areas and training provided during the clerkship experiences of physicians during their rural service year. It is imperative to ensure that rural doctors are appropriately trained and skilled in the performance of routine obstetrical duties. This will help to decrease perinatal morbidity and mortality in rural Ecuador.

The concept and definition of therapeutic inertia in hypertension in primary care: a qualitative systematic review

BACKGROUND

Therapeutic inertia has been defined as the failure of health-care provider to initiate or intensify therapy when therapeutic goals are not reached. It is regarded as a major cause of uncontrolled hypertension. The exploration of its causes and the interventions to reduce it are plagued by unclear conceptualizations and hypothesized mechanisms. We therefore systematically searched the literature for definitions and discussions on the concept of therapeutic inertia in hypertension in primary care, to try and form an operational definition.

METHODS

A systematic review of all types of publications related to clinical inertia in hypertension was performed. Medline, EMbase, PsycInfo, the Cochrane library and databases, BDSP, CRD and NGC were searched from the start of their databases to June 2013. Articles were selected independently by two authors on the basis of their conceptual content, without other eligibility criteria or formal quality appraisal. Qualitative data were extracted independently by two teams of authors. Data were analyzed using a constant comparative qualitative method.

RESULTS

The final selection included 89 articles. 112 codes were grouped in 4 categories: terms and definitions (semantics), "who" (physician, patient or system), "how and why" (mechanisms and reasons), and "appropriateness". Regarding each of these categories, a number of contradictory assertions were found, most of them relying on little or no empirical data. Overall, the limits of what should be considered as inertia were not clear. A number of authors insisted that what was considered deleterious inertia might in fact be appropriate care, depending on the situation.

CONCLUSIONS

Our data analysis revealed a major lack of conceptualization of therapeutic inertia in hypertension and important discrepancies regarding its possible causes, mechanisms and outcomes. The concept should be split in two parts: appropriate inaction and inappropriate inertia. The development of consensual and operational definitions relying on empirical data and the exploration of the intimate mechanisms that underlie these behaviors are now needed.

HIV testing in primary care: feasibility and acceptability of provider initiated HIV testing and counseling for sub-Saharan African migrants

Provider-initiated HIV testing and counseling (PITC) is recommended to reduce late HIV diagnoses, common among Sub-Saharan African migrants (SAM) residing in Europe. Primary care represents an ideal entry point for PITC. To support Flemish general practitioners (GPs), we developed a culturally sensitive PITC tool. Over a 12-week period, 65 GPs implemented PITC to assess acceptability and feasibility of PITC. The qualitative evaluation showed high acceptability among physicians. Routine PITC was challenged by physicians' personal discomfort, assumptions of patients' sexual risk, perceived incoherence with reasons for consultation, and time pressure. The best opportunity for PITC was an indicated blood analysis for other medical reasons. Counseling skills improved during the implementation, but participants still advocated for reduced counseling requirements. PITC proved to be feasible in primary care settings, but the up-scaling requires a reformulation of counseling guidelines, a policy stipulating the role of GPs in the prevention-care continuum, and an investment in (continuous) training.

Second primary malignancies in patients with a gastrointestinal neuroendocrine tumour: a case report and review of the literature

A second primary malignancy (SPM) is frequently reported in patients with a gastrointestinal neuroendocrine tumour (NET). The majority of SPM are located in the gastrointestinal tract, but malignancies at other sites are described as well. This phenomenon might just be coincidental due to high incidence rates of asymptomatic NET lesions in patients who are operated or who undergo autopsy for another primary malignancy. However, other theories have been developed since the observed incidences rates seem to be double as high as expected. Some authors suggest a common genetic predisposition, while others report tumourigenic properties of various neuroendocrine peptides, including secretin, gastrin and cholecystokinin. This review is illustrated by a case report of a patient in whom the radiological diagnosis of a diffuse liver metastasized adenocarcinoma of the rectum changed dramatically after positron emission tomography and explorative laparoscopy to a curable adenocarcinoma of the rectum with a simultaneous well-differentiated neuroendocrine carcinoma.

Learning intimate examinations with simulated patients: the evaluation of medical students' performance

BACKGROUND

For fifth-year's undergraduates of the medical school, a project with simulated patients (Intimate Examination Associates, IEA) was implemented in 2002 at the University of Antwerp. In this project, students from the new curriculum (NC) learned uro-genital, rectal, gynaecological and breast examination in healthy, trained volunteers and received feedback focused on personal attitude, technical and communication skills. Former curriculum (FC) students however trained these skills only during internship in the sixth year after a single training on manikins.

AIMS

This study assessed the effect of learning intimate examinations with IEA's by comparing students from FC and NC on four different outcome parameters.

METHODS

Three groups were compared: FC after internships without IEA training, NC after internships with IEA training and fifth year NC immediately after the IEA training. Four assessment instruments: an OSCE using checklists and global rating scales to assess the technical skills, a score list on students attitudes and performance filled in by the IEA's, a student questionnaire on self-assessed competence and a questionnaire on the frequency of performing intimate skills during internships.

RESULTS

Both NC groups scored globally better in the OSCE (significance for male examination). Sub-scores for 'completeness' and 'systematic' approach was significantly higher in both NC groups for male and female examinations. NC students reported better self-assessed competence and performance concerning gynaecological and urological clinical and communication skills during internship. The best results were obtained after IEA training and internship was done for the four outcomes. IEA's are influenced by the 'experienced' students after internship: FC and NC after internship both scored better than the fifth year NC who only received the IEA training so far.

CONCLUSION

Learning intimate examinations with IEA's has a positive effect on the performance of medical students. This beneficial effect is on its turn reinforced during internships.

Unintentional failure to assess for experience in senior undergraduate OSCE scoring

CONTEXT

One goal of undergraduate assessment is to test students' (future) performance. In the area of skills testing, the objective structured clinical examination (OSCE) has been of great value as a tool with which to test a number of skills in a limited time, with bias reduction and improved reliability. But can OSCEs measure undergraduate internship expertise in basic clinical skills?

METHODS

Undergraduate students (n = 32) were given a questionnaire listing 182 basic clinical skills. We asked them to score the number of times they had performed each skill during their internships (a 12-month period in Year 6). We assessed the students at the end of Year 5 (before the start of their internships) and again at the start of Year 7 (undergraduate training takes 7 years in Belgium, with internships during Year 6), using a 14-station OSCE assessing basic clinical skills. Global ratings were used to score performance. The relationship between internship experience and the OSCE Year 7 score was analysed using a linear regression model, controlling for variation in OSCE scores from Year 5. A multi-level analysis was performed considering students as level-1 units and stations as level-2 units.

RESULTS

Year 7 OSCE scores (post-internships) were not affected by the number of times that students practised basic medical skills during their internships.

DISCUSSION

Scores on OSCEs do not seem to reflect clinical expertise acquired during internships. Other more integrated assessment methods may prove to be more valid for testing final undergraduate skills levels.

Correlates of safe sex behaviour among low-educated adolescents of different ethnic origin in Antwerp, Belgium

BACKGROUND

Several reports suggest that low educated adolescents of ethnic minority origin are at a higher risk of acquiring a sexually transmitted infection (STI) than autochthonous teens. On the other hand, focus group research with young Moroccan boys revealed a positive attitude towards condom use; they claim to use a condom even more frequently than their Belgian peers. The aim of this study is to document the behavioural, educational and social correlates that influence the use of condoms among low educated adolescents of different origin.

METHOD

Data from 378 questionnaires completed by 253 native Belgian and 125 ethnic minority adolescents, mostly Moslems, were analysed with the statistic software: SPSS. Results were interpreted according to the behavioural science ASE model (Attitude, Social influences, self-Efficacy).

RESULTS

Native boys discuss sexual items more frequently with their parents and sexual partner, while boys in the other group address their questions more frequently to teachers, pharmacists and doctors. In both groups the most important correlate of safe sex intention and behaviour is the self-efficacy variable 'both partners taking the initiative with regard to condom use'. This correlate refers to communication skills. Parental support and quality of general communication about sexuality with the parents are very important for both groups. A positive attitude of peers influences the intention of condom use in both groups.

CONCLUSION

There is no significant difference in sexual activity and safe sex behaviour between native boys and young males of ethnic minority. Self efficacy (correct condom use and taking the initiative) is the most prominent predictor of safe sex behaviour in both groups.

Clinical skills training in a skills lab compared with skills training in internships: comparison of skills development curricula

CONTEXT

The necessity of learning skills through "integrated skills training" at an undergraduate level has been supported by several studies. The University of Antwerp implemented undergraduate skills training in its renewed curriculum in 1998, after it was demonstrated that Flemish students did not master their medical skills as well as Dutch students who received "integrated skills training" as part of their undergraduate medical course.

AIM

The aim of this study was to compare the skill outcome levels of two different student populations: students who had been trained in basic clinical skills mainly through clinical internships in year 7 with students who had learned these skills through an integrated longitudinal programme in a special learning environment in years 1-5 prior to their internship experience.

STUDY SAMPLE

Students of the traditional curriculum learned skills through a 75 hour programme in years 4 and 5, through plenary sessions followed by a 12 month period of internships during which skills could be further practiced. We tested this group right after completion of their internships. Students from the renewed curriculum followed a 200 hour intensive small group skills training programme offered in years 1-5. This group was tested before starting their internships.

RESULTS

On global OSCE-scores, renewed curriculum students had significantly higher overall scores (p<0.001) and they scored significantly higher at 6 of 15 stations. There was no significant difference at 8 stations, while traditional curriculum students scored better at station 1.

DISCUSSION

5 years and 200 hours of integrated undergraduate skills training is more effective as a method of learning basic clinical skills, compared to learning these skills through 75 hours of traditional skill training and reinforcement of these skills in 12 month clinical internships, when measured by means of an OSCE.

Intimate examination teaching with volunteers: implementation and assessment at the University of Antwerp

OBJECTIVES

Teaching intimate physical examinations in medical schools generates practical, didactical and ethical problems. At the University of Antwerp, a unique program with intimate examination assistants (IEA) was implemented for fifth year's undergraduate students. They learn gynaecological and urological skills in healthy volunteers. Technical, communicative and attitude aspects are taken into account.

METHODS

Description of the implementation of the project. Assessment of the project by questionnaires, written reflections and round table conferences.

RESULTS

The results provide detailed information about the student's perceptions of each component of the program as well as the perceptions of the IEA's and the teachers.

CONCLUSION

The multilevel evaluation of the program supports the surplus value of working with IEA's in medical education. The eye-catcher in this program is the integration of clinical skills with communicative skills and attention for students' attitude.

PRACTICE IMPLICATIONS

Working with IEA's for intimate examinations represents a benefit in medical education by lowering the student's threshold to perform the intimate physical examination on both men and women during their fulltime clerkships.

Sexual behaviour of second generation Moroccan immigrants balancing between traditional attitudes and safe sex

Young Moroccan Islamic immigrants are balancing the challenges of modern society and the influences of their cultural and social backgrounds. Prevention and information programs need insights into their knowledge, attitudes and behaviour concerning choice of partner, sexuality, contraception, STD and AIDS prevention. In a qualitative research project, Moroccan adolescents were invited to focus groups. The results show the specific influence of family, religion and tradition, the importance of virginity at marriage for girls, and the "almost evidence" of premarital coitus for boys. These adolescents have limited knowledge of contraceptives, STD and AIDS. Some boys pretend to perform safe sex in certain "unfixed" circumstances but show no concern about the possible risks for future virgin spouses. Most of the girls do not consider safe sex before or after marriage. There is a taboo on homosexuality.

Proximal segment position after distraction with the MD-DOS device

We investigated cephalometrically the movement of the proximal segment in the sagittal plane in patients treated with distraction (MD-DOS device) for mandibular lengthening. The proximal segment was anteriorly rotated, whilst the distal segment was posteriorly rotated after the lengthening procedure. Thus the angle of the jaw was advanced half the distance of the advancement of the distal segment. One possible reason for the anterior rotation of 3.3 degrees on average is the repositioning of the proximal segment during application of the anterior fixation unit in the cases where mobilization was complete. Another more plausible reason is the anterior pull by the masticatory muscles and elastic bands being greater than the reactive distraction vector component in concert with a flexible telescopic distraction module and a single posterior screw anchorage. The positional movements of both distal and proximal segments were similar to those observed after mandibular advancement with bilateral sagittal split osteotomies.

Cloning and characterization of Manduca sexta and Plutella xylostella midgut aminopeptidase N enzymes related to Bacillus thuringiensis toxin-binding proteins

We report the purification, cloning and characterization of an aminopeptidase N from the midgut epithelium of Manduca sexta that binds Cry1Ab5, an insecticidal crystal protein [ICP] from Bacillus thuringiensis. Sequence information derived from this M. sexta aminopeptidase N was used for the cloning of an aminopeptidase N from the midgut brush-border membrane of Plutella xylostella, an insect species of which some populations acquired resistance against Cry1Ab5. Affinity chromatography on a Cry1Ab5 matrix was used to isolate a 120-kDa glycoprotein from the larval midgut of the lepidopteran M. sexta. On ligand blots the purified 120-kDa protein discriminates between the lepidopteran-specific Cry1Ab5 and the coleopteran-specific Cry3A delta-endotoxin. Internal amino acid sequences from the 120-kDa protein were used for the design of degenerate oligonucleotides. From a nested PCR with M. sexta midgut cDNA as template, a DNA fragment was obtained which shows similarity to prokaryotic and eukaryotic aminopeptidase N genes. This PCR fragment was used to screen cDNA libraries of larval midguts from M. sexta and P. xylostella. From the M. sexta midgut cDNA library a 2973-bp nucleotide sequence was cloned. The ORF of the sequence encodes a 942-residue aminopeptidase N (M. sexta Apn2) containing two hydrophobic regions. The NH2-terminal hydrophobic region corresponds to a secretory signal sequence and the COOH-terminal hydrophobic region is typical of glycosylphosphatidylinositol (glycosyl-PtdIns)-anchored proteins. Low-stringency hybridization of the P. xylostella midgut cDNA library with M. sexta apn2 probes enabled the isolation of a 3118-bp sequence with an ORF encoding a 946-residue preproprotein. This aminopeptidase N (P. xylostella Apn1) displays 61% amino acid identity to M. sexta Apn2 and contains a COOH-terminal signal peptide for glycosyl-PtdIns anchor addition. Both M. sexta Apn2 and P. xylostella Apn1 contain four Cys residues, which are highly conserved among eukaryotic aminopeptidase N molecules. Treatment of Sf9 cells expressing the P. xylostella apn1 gene with PtdIns-specific phospholipase C demonstrated that P. xylostella Apn1 is attached to the insect cell membrane by a glycosyl-PtdIns anchor.

False positive immunostaining of Locusta neurosecretory cells with a variety of preimmune sera

A large number of antisera directed against vertebrate neuropeptides have been reported to yield positive staining when applied to insect brains. In most cases, the preimmune serum of the same animal in which the antiserum was developed is not available for testing in control experiments. We have experienced that a large percentage of preimmune sera, as well as a culture medium for hybridomas, stain cell populations and fibers in the central nervous system of the insect Locusta migratoria. Purification of these preimmune sera on a Protein A and Protein G support indicates that the reaction is due to preexisting antibodies of the IgG class. Western analysis of brain and nervous tissue extracts indicates the presence of two immunoreactive 27-kDa bands. These bands could also be visualized in other tissue extracts such as muscle, midgut, Malpighian tubules, and fat body of Locusta. The brain of other insect species, such as Periplaneta americana, Leucophaea maderae, and Neobellieria bullata were devoid of the false immunopositive reaction. There is no easy way to eliminate this type of immunoreaction. It follows that when affinity chromatographic purification of the antibody is not feasible, it is essential to include in the control procedure, the preimmune serum of the animal that was used for the production of the antiserum. This means that it should become common practice to sell or exchange sera together with their corresponding preimmune sera.

Effects of Bacillus thuringiensis delta-endotoxin on the permeability of brush border membrane vesicles from tobacco hornworm (Manduca sexta) midgut

1. The effect of two recombinant Bacillus thuringiensis delta-endotoxins on brush border membrane vesicles of Manduca sexta midgut was investigated using an in vitro assay system, based on ion-amino acid cotransport. 2. A CryIA(b)-toxin provoked an increase in the permeability of the vesicles. 3. A CryIB-toxin, not toxic to M. sexta larvae in vivo, had no effect in our assay. 4. In contrast to earlier reports, the increase in permeability was found to be neither selective for K+ nor specifically inhibited by Ca2+ or Ba2+. 5. Our data support the hypothesis that B. thuringiensis delta-endotoxins create non-specific pores.

[Analysis of severely injured patients admitted via an emergency service]

Data about the number and treatment of trauma-patients are, certainly in our country, very rare. In this study we showed that such a registration with grading of the severity of the injuries following the ISS-Score is feasible and useful. Further and more extensive registration seems necessary in order to obtain a better insight in epidemiology and treatment of trauma patients in our country.

Early versus late tocolytic treatment for preterm premature membrane rupture

The effect of tocolytic therapy before labor was evaluated in 33 pregnant women with preterm premature rupture of the membranes. Either intravenous magnesium sulfate or oral terbutaline was administered at the time of presentation. Intensive surveillance to detect signs of infection was carried out for all patients. In 29 of the patients in this treatment group who were seen at less than 34 weeks, a significantly longer prolongation of pregnancy was achieved when compared with 24 similar women treated after onset of labor in the hospital (169 hours versus 77 hours, p = 0.05). Duration of infant hospitalization was less for those mothers receiving tocolytic agents before labor. Maternal and infant infection were not different in the two groups; nor was the cesarean section rate. When this treatment group was compared with another control group of 96 women already in labor at presentation, the difference in time from admission to delivery was substantial, but it did not achieve statistical significance. In this group the rate of maternal infection was significantly higher, but newborn morbidity was not. Aggressive early treatment with tocolytic agents in pregnant women with preterm premature membrane rupture is more productive but not more dangerous than conservative management.