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1.  The emergence of community health worker programmes in the late apartheid era in South Africa: An historical analysis 
Social Science & Medicine (1982)  2010;71(6-3):1110-1118.
There is re-emerging interest in community health workers (CHWs) as part of wider policies regarding task-shifting within human resources for health. This paper examines the history of CHW programmes established in South Africa in the later apartheid years (1970s–1994) – a time of innovative initiatives. After 1994, the new democratic government embraced primary healthcare (PHC), however CHW initiatives were not included in their health plan and most of these programmes subsequently collapsed. Since then a wide array of disease-focused CHW projects have emerged, particularly within HIV care.
Thirteen oral history interviews and eight witness seminars were conducted in South Africa in April 2008 with founders and CHWs from these earlier programmes. These data were triangulated with written primary sources and analysed using thematic content analysis. The study suggests that 1970s–1990s CHW programmes were seen as innovative, responsive, comprehensive and empowering for staff and communities, a focus which respondents felt was lost within current programmes. The growth of these earlier projects was underpinned by the struggle against apartheid. Respondents felt that the more technical focus of current CHW programmes under-utilise a valuable human resource which previously had a much wider social and health impact. These prior experiences and lessons learned could usefully inform policy-making frameworks for CHWs in South Africa today.
doi:10.1016/j.socscimed.2010.06.009
PMCID: PMC2941026  PMID: 20638169
Community health workers; Community health worker (CHW) policy; South Africa; Oral history; Apartheid; Task-shifting; Community participation
2.  A case study of haemoglobinopathy screening in the Netherlands: witnessing the past, lessons for the future 
Ethnicity & Health  2011;17(3):217-239.
Objectives. In 2007 neonatal screening (NNS) was expanded to include screening for sickle cell disease (SCD) and beta-thalassaemia. Up until that year no formal recommendations for haemoglobinopathy (carrier) screening existed in the Netherlands. Although it has been subject to debate in the past, preconceptional and prenatal haemoglobinopathy carrier screening are not part of routine healthcare in the Netherlands. This study aimed to explore the decision-making process of the past: why was the introduction of a screening programme for haemoglobinopathy considered to be untimely, and did ethnicity play a role given the history in other countries surrounding the introduction of haemoglobinopathy screening?
Design. A witness seminar was organised, inviting key figures to discuss the decision-making process concerning haemoglobinopathy screening in the Netherlands, thereby adding new perspectives on past events. The transcript was content-analysed.
Results. The subject of haemoglobinopathy screening first appeared in the 1970s. As opposed to a long history of neglect of African-American health in the United States, the heritage of the Second World War influenced the decision-making process in the Netherlands. As a consequence, registration of ethnicity surfaced as an impeding factor. However, overall, official Dutch screening policy was restrained regarding reproductive issues caused by fear of eugenics. In the 1990s haemoglobinopathy screening was found to be ‘not opportune’ due to low prevalence, lack of knowledge and fear of stigmatisation. Currently the registration of ethnicity remains on the political agenda, but still proves to be a sensitive subject.
Discussion. Carrier screening in general never appeared high on the policy agenda. Registration of ethnicity remains sensitive caused by the current political climate. Complexities related to carrier screening are a challenge in Dutch healthcare. Whether carrier screening will be considered a valuable complementary strategy in the Netherlands, depends partly on participation of representatives of high-risk groups in policy making.
doi:10.1080/13557858.2011.604126
PMCID: PMC3396381  PMID: 21819310
screening; haemoglobinopathy; sickle cell; ethnicity; reproductive choice; eugenics
3.  Current Concepts in the Neurophysiologic Basis of Sleep; a Review 
Background:
Sleep is a very vital physiological mechanism, which involves complex interactions in the nervous system. These interactions are not well understood and have been a subject of controversy in contemporary medical practice.
Objectives:
To review of the neurophysiological factors in the subject of sleep, and recent research findings that forms the basis for the current knowledge on sleep.
Methods:
Information sources consulted included, published works of past researchers, current articles on sleep in conference papers, recent editions of textbooks on neuroscience, articles in seminar papers, reports extracted from newspaper and magazine articles on sleep, reports accessed from the Internet using Google Search Engines and lecture notes.
Results:
It was noted that emphasis has now shifted from the concept that sleep was predominantly the product of activities in the neural systems in phylogenetically old reticular core of the brain through withdrawal of sensory input, to emphasis on the role of neurotransmitter systems, especially - Ach, serotonin and GABA. This review also noted that, among others, emphasis is further shifting to the PGO waves which is fast gaining prominence as the mechanism involved in the production of REM sleep and dreams in particular.
Conclusion:
It became obvious from this review, that full knowledge of the neurophysiological processes involved in sleep production appear generally to still be more of speculative, and are yet far from full understanding.
PMCID: PMC3507109  PMID: 23209972
Current concepts; neurophysiological basis; sleep
4.  Teachers’ perceptions of aspects affecting seminar learning: a qualitative study 
BMC Medical Education  2013;13:22.
Background
Many medical schools have embraced small group learning methods in their undergraduate curricula. Given increasing financial constraints on universities, active learning groups like seminars (with 25 students a group) are gaining popularity. To enhance the understanding of seminar learning and to determine how seminar learning can be optimised it is important to investigate stakeholders’ views. In this study, we qualitatively explored the views of teachers on aspects affecting seminar learning.
Methods
Twenty-four teachers with experience in facilitating seminars in a three-year bachelor curriculum participated in semi-structured focus group interviews. Three focus groups met twice with an interval of two weeks led by one moderator. Sessions were audio taped, transcribed verbatim and independently coded by two researchers using thematic analysis. An iterative process of data reduction resulted in emerging aspects that influence seminar learning.
Results
Teachers identified seven key aspects affecting seminar learning: the seminar teacher, students, preparation, group functioning, seminar goals and content, course coherence and schedule and facilities. Important components of these aspects were: the teachers’ role in developing seminars (‘ownership’), the amount and quality of preparation materials, a non-threatening learning climate, continuity of group composition, suitability of subjects for seminar teaching, the number and quality of seminar questions, and alignment of different course activities.
Conclusions
The results of this study contribute to the unravelling of the ‘the black box’ of seminar learning. Suggestions for ways to optimise active learning in seminars are made regarding curriculum development, seminar content, quality assurance and faculty development.
doi:10.1186/1472-6920-13-22
PMCID: PMC3576232  PMID: 23399475
Seminar learning; Undergraduate (veterinary) medical education; Focus groups; Faculty development
5.  The Relationship between Media Consumption and Health-Related Anxieties after the Fukushima Daiichi Nuclear Disaster 
PLoS ONE  2013;8(8):e65331.
Background
The Fukushima Daiichi nuclear disaster caused a global panic by a release of harmful radionuclides. In a disaster setting, misusage of contemporary media sources available today can lead to disseminated incorrect information and panic. The study aims to build a scale which examines associations between media and individual anxieties, and to propose effective media usages for future disaster management.
Methods
The University of Tokyo collaborated with the Fukushima local government to conduct a radiation-health-seminar for a total of 1560 residents, at 12 different locations in Fukushima. A 13 item questionnaire collected once before and after a radiation-seminar was used on factor analysis to develop sub-scales for multiple regression models, to determine relationships between the sub-scales and media type consumed. A paired t–test was used to examine any changes in sub-scale of pre- and post-seminar scores.
Results
Three sub-scales were revealed and were associated with different media types: was with rumors, while concern for the future was positively associated with regional-newspapers and negatively with national-newspapers. Anxiety about social-disruption was associated with radio. The seminar had a significant effect on anxiety reduction for all the three sub-scales.
Conclusion
Different media types were associated with various heightened concerns, and that a radiation seminar was helpful to reduce anxieties in the post-disaster setting. By tailoring post-disaster messages via specific media types, i.e., radio, it may be possible to effectively convey important information, as well as to calm fears about particular elements of post-disaster recovery and to combat rumors.
doi:10.1371/journal.pone.0065331
PMCID: PMC3743804  PMID: 23967046
6.  A model for offering an International Medicine Seminar Course for US medical students: the 13-year experience of the New Jersey Medical School. 
An International Medicine Elective Seminar Course at the New Jersey Medical School (NJMS) was designed in 1985 to present a description of medical education, medical care systems, major global health problems, and intervention programs in other countries. Seminars are scheduled for nine weeks in the fall semester. At the end of each course, the medical students complete evaluations. Almost all (97%) students in 1997-1998 evaluated the course as either good (55%) or excellent (45%). Enrollment in the International Medicine Seminar Course increased from 12 medical students in 1985-1986 to 62 students in 1997-1998. An increasing number of students have applied for a fourth-year overseas International Medicine Elective. This and students' evaluations indicated that they have been motivated toward international medicine. The atmosphere of informal seminars and faculty interaction with students has characterized the course. It has made this model of teaching an ideal forum for medical students' professional growth. This course offers students the opportunity and insight to explore facets of their professional role not explicitly covered in the formal medical curriculum. The International Medicine Seminar Course is a self-supported model and can be adopted readily by other medical schools.
PMCID: PMC2608518  PMID: 10599189
7.  Conducting correlation seminars in basic sciences at KIST Medical College, Nepal 
KIST Medical College is a new medical school in Lalitpur, Nepal. In Nepal, six basic science subjects are taught together in an integrated organ system-based manner with early clinical exposure and community medicine. Correlation seminars are conducted at the end of covering each organ system. The topics are decided by the core academic group (consisting of members from each basic science department, the Department of Community Medicine, the academic director, and the clinical and program coordinators) considering the public health importance of the condition and its ability to include learning objectives from a maximum number of subjects. The learning objectives are decided by individual departments and finalized after the meeting of the core group. There are two student coordinators for each seminar and an evaluation group evaluates each seminar and presenter. Correlation seminars help students revise the organ system covered and understand its clinical importance, promote teamwork and organization, and supports active learning. Correlation seminars should be considered as a learning modality by other medical schools.
doi:10.3352/jeehp.2011.8.10
PMCID: PMC3208187  PMID: 22066033
Educational measurement; Learning; Medical school; Nepal; Undergraduate medical education
8.  A Brief Educational Intervention in Personal Finance for Medical Residents 
Introduction
Although medical educational debt continues to escalate, residents receive little guidance in financial planning.
Aim
To educate interns about long-term investment strategies.
Setting
University-based medicine internship program.
Program Description
An unselected cohort of interns (n = 52; 84% of all interns) underwent a 90-minute interactive seminar on personal finance, focusing on retirement savings. Participants completed a preseminar investor literacy test to assess baseline financial knowledge. Afterward, interns rated the seminar and expressed their intention to make changes to their long-term retirement accounts. After 37 interns had attended the seminar, a survey was administered to all interns to compare actual changes to these accounts between seminar attendees and nonattendees.
Measurements and Main Results
Interns’ average score on the investor literacy test was 40%, equal to the general population. Interns strongly agreed that the seminar was valuable (average 5.0 on 5-point Likert scale). Of the 46 respondents to the account allocation survey, interns who had already attended the seminar (n = 25) were more likely than interns who had not yet attended (n = 21) to have switched their investments from low to high-yield accounts at the university hospital (64 vs 19%, P = 0.003) and to enroll in the county hospital retirement plan (64 vs 33%, P = 0.07).
Conclusions
One 90-minute seminar on personal finances leads to significant changes in allocation of tax-deferred retirement savings. We calculate that these changes can lead to substantial long-term financial benefits and suggest that programs consider automatically enrolling trainees into higher yield retirement plans.
doi:10.1007/s11606-006-0078-z
PMCID: PMC1824762  PMID: 17356971
curriculum program/evaluation; financial management; medical student and residency education
9.  A Brief Educational Intervention in Personal Finance for Medical Residents 
Introduction
Although medical educational debt continues to escalate, residents receive little guidance in financial planning.
Aim
To educate interns about long-term investment strategies.
Setting
University-based medicine internship program.
Program Description
An unselected cohort of interns (n = 52; 84% of all interns) underwent a 90-minute interactive seminar on personal finance, focusing on retirement savings. Participants completed a preseminar investor literacy test to assess baseline financial knowledge. Afterward, interns rated the seminar and expressed their intention to make changes to their long-term retirement accounts. After 37 interns had attended the seminar, a survey was administered to all interns to compare actual changes to these accounts between seminar attendees and nonattendees.
Measurements and Main Results
Interns’ average score on the investor literacy test was 40%, equal to the general population. Interns strongly agreed that the seminar was valuable (average 5.0 on 5-point Likert scale). Of the 46 respondents to the account allocation survey, interns who had already attended the seminar (n = 25) were more likely than interns who had not yet attended (n = 21) to have switched their investments from low to high-yield accounts at the university hospital (64 vs 19%, P = 0.003) and to enroll in the county hospital retirement plan (64 vs 33%, P = 0.07).
Conclusions
One 90-minute seminar on personal finances leads to significant changes in allocation of tax-deferred retirement savings. We calculate that these changes can lead to substantial long-term financial benefits and suggest that programs consider automatically enrolling trainees into higher yield retirement plans.
doi:10.1007/s11606-006-0078-z
PMCID: PMC1824762  PMID: 17356971
curriculum program/evaluation; financial management; medical student and residency education
10.  Evaluating the Impact of Pain Management (PM) Education on Physician Practice Patterns—A Continuing Medical Education (CME) Outcomes Study 
California Assembly Bill AB487 mandates that all practicing physicians are required to obtain 12 h of Continuing Medical Education in Pain Management and End of Life Care before the year 2006 in order to renew their state license to practice medicine. In order to determine the effectiveness of this bill in influencing the practice of medicine, we conducted the first of five planned annual Pain Management seminars and utilized physician questionnaires to determine possible practice changes as a result of this seminar. Eighty-one physicians representing 17 multiple specialties of medicine enrolled in this seminar. The topics included: management of malignant and non-malignant pain, pharmacology and management of side effects of opiate and non-opiate analgesics, and adjunctive therapies including depression management and spirituality issues. Physicians were asked to respond to an immediate post-seminar questionnaire and were subsequently queried 4 months following the conference. Fifty-one out of 81 physician registrants responded to an immediate post-attendance questionnaire, and 31 responded to the 4-month follow-up questionnaire. Responses included:
EarlyLateI will change/have changed my practice3428I see no need to change my practice62I will await further information71No response regarding practice change4Responses of those who changed their practices included: Increased use of known modalities for pain control21 Earlier referrals to specialists14 More attention to psychosocial aspects14 Use of new drugs/modalities of care11
This audience represents the most motivated group of practitioners electing to receive Pain Management Education long before the mandated deadline. Sixty-seven percent expressed an interest in changing their practice following this intensive educational experience. Ninety percent responding to the follow-up evaluation indicated that their practices had changed, suggesting that this seminar series is effective in altering physician practice patterns (supported by Cancer Center Support Grant CA 33572 and Sarnat Foundation).
doi:10.1007/s13187-010-0040-y
PMCID: PMC3751402  PMID: 20204577
California Assembly Bill AB487; Pain management; Practicing physicians
11.  Cardiotonic Modulation in Heart Failure 
Medicinal herbs have been used over the past centuries for restoring the body's homeostatic balance. Contemporary use of herbal supplements remains widespread in many cultures as treatment for specific ailments. Many possess cardiovascular actions, and some interact with cardiac medications. However, there is variable scientific evidence with respect to their safety and efficacy, and few have been subjected to the same rigorous evaluation processes and regulations as contemporary pharmaceuticals (1). In the field of heart failure, we have also witnessed the failure of promising naturopathic therapies like hawthorn extract in translating their potential benefits in rigorous clinical trials (2,3).
doi:10.1016/j.jacc.2013.05.028
PMCID: PMC4024708  PMID: 23747774
chronic heart failure; controlled clinical trial; qili qiangxin capsules
12.  What is the standard approach to assessment of an unprovoked seizure in an adult? 
Neurology. Clinical Practice  2012;2(4):299-300.
Since Hong Kong is highly urbanized and acute public hospitals have been established across the city, most patients with unprovoked seizures not already receiving antiepileptic drug (AED) therapy, particularly convulsive seizures, will be admitted as emergency for assessment. A thorough history is taken from the patient and any witnesses to the seizure. This includes the circumstance of the seizures, detailed symptoms and signs experienced by the patient and witnessed by others before, during, and after the seizure, any potential precipitating factors, history of previous seizures (that the patient might have overlooked), and history of previous brain insults that might have increased the risk of epilepsy later in life, including gestational and birth history, history of childhood febrile seizure, significant head trauma, any family history of epilepsy or seizures, comorbidities, current medications, drug and alcohol abuse, and social history including employment, driving, and living circumstances. A detailed physical and neurologic examination is performed.
doi:10.1212/CPJ.0b013e318279abc1
PMCID: PMC3613205  PMID: 23634374
13.  Kawasaki Disease in Mongolia: Results From 2 Nationwide Retrospective Surveys, 1996–2008 
Journal of Epidemiology  2011;21(4):293-298.
Background
Kawasaki disease (KD) has been reported in many countries. However, the incidence of KD in Mongolia is not known. This is the first report of incident cases of KD in Mongolia, which were identified using data from 2 nationwide surveys.
Methods
Two nationwide retrospective surveys were conducted: medical histories were collected from patients aged 0 to 16 years who were hospitalized countrywide between 1996 and 2008. Hospital records for these patients were also reviewed. Nationwide training seminars on KD were conducted before each survey.
Results
For the nationwide surveys, the participation rates among all hospitals with pediatric wards were 97% and 94%. Inpatient medical histories from 1996 through 2008 were reviewed, and, among children younger than 16 years, 9 patients with KD were investigated. The age of KD patients ranged from 1.4 to 14 years; 7 of 9 patients were male. Six (67%) patients fulfilled all 6 clinical diagnostic criteria; the other 3 (33%) were defined as having KD based on the presence of 5 such criteria. Fever persisting 5 or more days, bilateral conjunctival congestion, and changes of the lips and oral cavity were the most common symptoms, and cervical lymphadenopathy was the least common symptom. Cardiac sequelae developed in 5 of the patients, 4 of whom were older than 10 years.
Conclusions
The results of these nationwide surveys reveal that KD cases do exist in Mongolia. However, knowledge of KD among Mongolian pediatricians is likely to be poor. Thus, there is a need to augment their understanding to improve management of KD patients. Further studies are crucial to clarify the epidemiologic characteristics of KD in Mongolia.
doi:10.2188/jea.JE20100144
PMCID: PMC3899422  PMID: 21691035
mucocutaneous lymph node syndrome; nationwide survey; Mongolia; children
14.  Biodistribution Mechanisms of Therapeutic Monoclonal Antibodies in Health and Disease 
The AAPS Journal  2009;12(1):33-43.
The monoclonal antibody market continues to witness an impressive rate of growth and has become the leading source of expansion in the biologic segment within the pharmaceutical industry. Currently marketed monoclonal antibodies target a diverse array of antigens. These antigens are distributed in a variety of tissues such as tumors, lungs, synovial fluid, psoriatic plaques, and lymph nodes. As the concentration of drug at the proximity of the biological receptor determines the magnitude of the observed pharmacological responses, a significant consideration in effective therapeutic application of monoclonal antibodies is a thorough understanding of the processes that regulate antibody biodistribution. Monoclonal antibody distribution is affected by factors such as molecular weight, blood flow, tissue and tumor heterogeneity, structure and porosity, target antigen density, turnover rate, and the target antigen expression profile.
doi:10.1208/s12248-009-9157-5
PMCID: PMC2811642  PMID: 19924542
biodistribution; monoclonal antibodies; pharmacokinetics and pharmacodynamics; tumor penetration
15.  Evidence-based Research in Complementary and Alternative Medicine I: History 
Contemporary Western medicine has witnessed a fragmentation of our conceptualization of the medical endeavor into ‘traditional medicine’ and ‘non-traditional medicine’. The former is meant to refer to the Western medical tradition, the latter encompasses both ‘complementary’ and ‘alternative’ medical practices. Complementary medicine complements conventional medical treatments, and alternative modes of medical interventions are meant to replace traditional Western medicine. Evidence-based research must be directed at establishing the best available evidence in complementary and alternative medicine. This paper is the first of a set of four ‘lectures’ that reviews the process of evidence-based research, and discusses its implications and applications for the early decades of the 21st century. The purpose of this paper is to introduce the series by examining some of the historical and philosophical foundations of this research endeavor.
doi:10.1093/ecam/neh106
PMCID: PMC1297495  PMID: 16322801
Evidence-based research; complementary and alternative medicine; mind-body interactions
16.  A Seminar Course on Contemporary Pharmacy Issues 
Objectives
To implement and evaluate an innovative approach to a pharmacy seminar course intended to develop students' presentation skills and encourage them to think critically about contemporary pharmacy issues.
Design
The instructor provided lectures intended to prepare students for their presentations. These lectures included tips on writing abstracts, learning objectives, use of visual aids, and presentation delivery. Pairs of students chose a pharmacy issue, researched their topic including identifying various strengths of evidence to support a perspective, wrote an abstract and learning objectives, prepared their visual aids, and delivered a pro/con perspective. Students also provided peer evaluations for these presentations. A personal response system was used to provide class input on the presentations.
Assessment
Ninety-five percent of the peer evaluations of the presentations were good to excellent. The overall course evaluations indicated achievement of course goals.
Conclusions
A pharmacy seminar course intended to develop student presentation skills and critical thinking about contemporary pharmacy issues was demonstrated to be successful. The “taking sides” format was an effective design for accomplishing these objectives.
PMCID: PMC2384205  PMID: 18483598
presentation skills; contemporary issues
17.  Evaluation of a communication skills seminar for students in a Japanese medical school: a non-randomized controlled study 
Background
Little data exist for the effectiveness of communication skills teaching for medical students in non-English speaking countries. We conducted a non-randomized controlled study to examine if a short intensive seminar for Japanese medical students had any impact on communication skills with patients.
Methods
Throughout the academic year 2001–2002, a total of 105 fifth-year students (18 groups of 5 to 7 students) participated, one group at a time, in a two-day, small group seminar on medical interviewing. Half way through the year, a five-station objective structured clinical examination (OSCE) was conducted for all fifth-year students. We videotaped all the students' interaction with a standardized patient in one OSCE station that was focused on communication skills. Two independent observers rated the videotapes of 50 students who had attended the seminar and 47 who had not. Sixteen core communication skills were measured. Disagreements between raters were resolved by a third observer's rating.
Results
There was a statistically significant difference in proportions of students who were judged as 'acceptable' in one particular skill related to understanding patient's perspectives: asking how the illness or problems affected the patient's life, (53% in the experimental group and 30% in the control group, p = .02). No differences were observed in the other 15 core communication skills, although there was a trend for improvement in the skill for asking the patient's ideas about the illness or problems (60% vs. 40%, p = .054) and one of the relationship building skills; being attentive and empathic nonverbally (87% vs. 72%, p = .064).
Conclusion
The results of this study suggest that a short, intensive small group seminar for Japanese medical students may have had a short-term impact on specific communication skills, pertaining to understanding patient's perspectives.
doi:10.1186/1472-6920-4-24
PMCID: PMC534797  PMID: 15550166
18.  Warfare, genocide, and ethnic conflict: a Darwinian approach 
As the 21st century dawns, I reflect on the history of humankind with growing concern about the need to understand the underlying biological and cultural roots of ethnic conflict and warfare. In the many studies of human conflict, innate biological predispositions have been neglected. This article is the third part of a series of seminars for medical residents at the University of Texas Southwestern Medical School at Dallas (see http://adarwinstudygroup.org/). The series starts with in-depth coverage of Darwinian natural and sexual selection, with examples from the domestication of animals and plants and the crisis of antibiotic resistance. The series strives to show how biology has been neglected in the study of the we-they orientation of human behavior, with its devastating consequences. The subject material is profoundly disturbing, as it looks at “human nature” and contrasts the “dark side” of human behavior with the opposite, profoundly caring and loving side.
PMCID: PMC2900985  PMID: 21240320
19.  Immunogenetic Mechanisms Driving Norovirus GII.4 Antigenic Variation 
PLoS Pathogens  2012;8(5):e1002705.
Noroviruses are the principal cause of epidemic gastroenteritis worldwide with GII.4 strains accounting for 80% of infections. The major capsid protein of GII.4 strains is evolving rapidly, resulting in new epidemic strains with altered antigenic potentials. To test if antigenic drift may contribute to GII.4 persistence, human memory B cells were immortalized and the resulting human monoclonal antibodies (mAbs) characterized for reactivity to a panel of time-ordered GII.4 virus-like particles (VLPs). Reflecting the complex exposure history of the volunteer, human anti-GII.4 mAbs grouped into three VLP reactivity patterns; ancestral (1987–1997), contemporary (2004–2009), and broad (1987–2009). NVB 114 reacted exclusively to the earliest GII.4 VLPs by EIA and blockade. NVB 97 specifically bound and blocked only contemporary GII.4 VLPs, while NBV 111 and 43.9 exclusively reacted with and blocked variants of the GII.4.2006 Minerva strain. Three mAbs had broad GII.4 reactivity. Two, NVB 37.10 and 61.3, also detected other genogroup II VLPs by EIA but did not block any VLP interactions with carbohydrate ligands. NVB 71.4 cross-neutralized the panel of time-ordered GII.4 VLPs, as measured by VLP-carbohydrate blockade assays. Using mutant VLPs designed to alter predicted antigenic epitopes, two evolving, GII.4-specific, blockade epitopes were mapped. Amino acids 294–298 and 368–372 were required for binding NVB 114, 111 and 43.9 mAbs. Amino acids 393–395 were essential for binding NVB 97, supporting earlier correlations between antibody blockade escape and carbohydrate binding variation. These data inform VLP vaccine design, provide a strategy for expanding the cross-blockade potential of chimeric VLP vaccines, and identify an antibody with broadly neutralizing therapeutic potential for the treatment of human disease. Moreover, these data support the hypothesis that GII.4 norovirus evolution is heavily influenced by antigenic variation of neutralizing epitopes and consequently, antibody-driven receptor switching; thus, protective herd immunity is a driving force in norovirus molecular evolution.
Author Summary
Noroviruses are the principal cause of epidemic gastroenteritis worldwide with GII.4 strains accounting for 80% of infections. The major capsid protein of GII.4 strains is evolving rapidly, resulting in new epidemic strains with altered antigenic sites. To define these sites we prepared the first human monoclonal antibodies (Hu mAbs) against GII.4 noroviruses by immortalizing memory B cells and characterizing antibody reactivity and carbohydrate blockade responses across a ∼20 year panel of time-ordered GII.4 virus-like particles (VLPs). Reflecting the complex exposure history of the patient, human anti-GII.4 mAbs grouped into three VLP reactivity patterns: broad (1987–2009), contemporary (2004–2009), and ancestral (1987–2002). We also identified the location of several defined epitopes which evolve over time and drive antigenic change. Our data indicate that antibodies targeting these sites block carbohydrate binding and likely select for the emergence of new strains that escape herd immunity and recognize unique carbohydrates for entry, resulting in new outbreaks of disease in vulnerable human populations. Importantly, these studies critically inform the rational design of broadly active vaccines and immunotherapeutics for the treatment of norovirus disease.
doi:10.1371/journal.ppat.1002705
PMCID: PMC3355092  PMID: 22615565
20.  Evaluating an educational intervention to improve the accuracy of death certification among trainees from various specialties 
Background
The inaccuracy of death certification can lead to the misallocation of resources in health care programs and research. We evaluated the rate of errors in the completion of death certificates among medical residents from various specialties, before and after an educational intervention which was designed to improve the accuracy in the certification of the cause of death.
Methods
A 90-min seminar was delivered to seven mixed groups of medical trainees (n = 166) from several health care institutions in Spain. Physicians were asked to read and anonymously complete a same case-scenario of death certification before and after the seminar. We compared the rates of errors and the impact of the educational intervention before and after the seminar.
Results
A total of 332 death certificates (166 completed before and 166 completed after the intervention) were audited. Death certificates were completed with errors by 71.1% of the physicians before the educational intervention. Following the seminar, the proportion of death certificates with errors decreased to 9% (p < 0.0001). The most common error in the completion of death certificates was the listing of the mechanism of death instead of the cause of death. Before the seminar, 56.8% listed respiratory or cardiac arrest as the immediate cause of death. None of the participants listed any mechanism of death after the educational intervention (p < 0.0001).
Conclusion
Major errors in the completion of the correct cause of death on death certificates are common among medical residents. A simple educational intervention can dramatically improve the accuracy in the completion of death certificates by physicians.
doi:10.1186/1472-6963-7-183
PMCID: PMC2194687  PMID: 18005414
21.  Interactive seminars or small group tutorials in preclinical medical education: results of a randomized controlled trial 
BMC Medical Education  2010;10:79.
Background
Learning in small group tutorials is appreciated by students and effective in the acquisition of clinical problem-solving skills but poses financial and resource challenges. Interactive seminars, which accommodate large groups, might be an alternative. This study examines the educational effectiveness of small group tutorials and interactive seminars and students' preferences for and satisfaction with these formats.
Methods
Students in year three of the Leiden undergraduate medical curriculum, who agreed to participate in a randomized controlled trial (RCT, n = 107), were randomly allocated to small group tutorials (n = 53) or interactive seminars (n = 54). Students who did not agree were free to choose either format (n = 105). Educational effectiveness was measured by comparing the participants' results on the end-of-block test. Data on students' reasons and satisfaction were collected by means of questionnaires. Data was analyzed using student unpaired t test or chi-square test where appropriate.
Results
There were no significant differences between the two educational formats in students' test grades. Retention of knowledge through active participation was the most frequently cited reason for preferring small group tutorials, while a dislike of compulsory course components was mentioned more frequently by students preferring interactive seminars. Small group tutorials led to greater satisfaction.
Conclusions
We found that small group tutorials leads to greater satisfaction but not to better learning results. Interactive learning in large groups might be might be an effective alternative to small group tutorials in some cases and be offered as an option.
doi:10.1186/1472-6920-10-79
PMCID: PMC3000405  PMID: 21073744
22.  Evidence-based Health Care Continuing Education Seminars Improve Academic Staff Knowledge and Attitudes in Saudi Arabia 
Objective: To assess the influence of a monthly evidence-based health care (EBHC) seminar series on academic staff knowledge, attitudes, and barriers regarding EBHC practice.
Methodology: All academic staff in the College of Applied Medical Sciences (CAMS), King Saud University, Saudi Arabia, were sent a validated web-based survey. The survey contained 35 items regarding 3 domains: knowledge (14 items), attitudes (11 items), and barrier factors (10 items). A 5-point Likert scale was used and descriptive statistics were generated for demographic data and participants’ responses to each item.
Results: Among academic staff at CAMS, 79 of 198 (40%) completed the survey. Among the survey respondents, 58% had attended at least one EBHC seminar. Those who had attended at least one seminar had better knowledge of 8 items compared with those who did not attend any seminars (P<.05). Academic staff members who attended at least one seminar were more likely to have a positive attitude regarding EBHC. Insufficient time was the only factor that significantly differed between the 2 groups, serving as a barrier to EBHC practice.
Conclusions: Our findings suggest that EBHC seminars may improve the abilities and skills of academic staff for using EBHC.
PMCID: PMC3809279  PMID: 24353612
Evidence-based health care; Health profession education; Academic staff
23.  The Expert Witness in Medical Malpractice Litigation 
Physicians may find serving as an expert witness to be interesting, intellectually stimulating, and financially beneficial. However, potential expert witnesses should be aware of the increased legal scrutiny being applied to expert witness testimony in medical malpractice litigation. In the past, expert witnesses received absolute immunity from civil litigation regarding their testimony. This is no longer the case. Expert witnesses may be subject to disciplinary sanctions from professional organizations and state medical boards. In addition, emerging case law is defining the legal duty owed by the expert witness to the litigating parties. Orthopaedic surgeons who serve as expert witnesses should be familiar with the relevant Standards of Professionalism issued by the American Academy of Orthopaedic Surgeons.
doi:10.1007/s11999-008-0634-4
PMCID: PMC2628518  PMID: 19052827
24.  Juggling law, ethics, and intuition: practical answers to awkward questions 
Journal of Medical Ethics  2003;29(5):281-286.
The eclectic problem solving methodology used by the British Medical Association (BMA) is described in this paper. It has grown from the daily need to respond to doctors' practical queries and incorporates reference to law, traditional professional codes, and established BMA policies—all of which must be regularly assessed against the benchmark of contemporary societal expectations. The two Jehovah's Witness scenarios are analysed, using this methodology and in both cases the four principles solution is found to concur with that of the BMA's approach. The author's overall conclusion is that although the BMA resorts to a lengthier list of thins to consider, the solutions that emerge are often likely to coincide with the four principles approach.
doi:10.1136/jme.29.5.281
PMCID: PMC1733789  PMID: 14519837
25.  Non- medical prescribing in Australasia and the UK: the case of podiatry 
Background
The last decade has witnessed a rapid transformation in the role boundaries of the allied health professions, enabled through the creation of new roles and the expansion of existing, traditional roles. A strategy of health care 'modernisation' has encompassed calls for the redrawing of professional boundaries and identities, linked with demands for greater workforce flexibility. Several tasks and roles previously within the exclusive domain of medicine have been delegated to, or assumed by, allied health professionals, as the workforce is reshaped to meet the challenges posed by changing demographic, social and political contexts. The prescribing of medicines by non-medically qualified healthcare professionals, and in particular the podiatry profession, reflects these changes.
Methods
Using a range of key primary documentary sources derived from published material in the public domain and unpublished material in private possession, this paper traces the development of contemporary UK and Australasian podiatric prescribing, access, supply and administration of medicines. Documentary sources include material from legislative, health policy, regulatory and professional bodies (including both State and Federal sources in Australia).
Results
Tracing a chronological, comparative, socio-historical account of the emergence and development of 'prescribing' in podiatry in both Australasia and the UK enables an analysis of the impact of health policy reforms on the use of, and access to, medicines by podiatrists. The advent of neo-liberal healthcare policies, coupled with demands for workforce flexibility and role transfer within a climate of demographic, economic and social change has enabled allied health professionals to undertake an expanding number of tasks involving the sale, supply, administration and prescription of medicines.
Conclusion
As a challenge to medical dominance, these changes, although driven by wider healthcare policy, have met with resistance. As anticipated in the theory of medical dominance, inter-professional jurisdictional disputes centred on the right to access, administer, supply and prescribe medicines act as obstacles to workforce change. Nevertheless, the broader policy agenda continues to ensure workforce redesign in which podiatry has assumed wider roles and responsibilities in prescribing.
doi:10.1186/1757-1146-3-1
PMCID: PMC2821370  PMID: 20051138

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