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Objective To analyse the concordance of original utterances by healthcare providers (HCP) and patients with the corresponding translations by interpreters using the Roter Interaction Analysis System (RIAS). Methods Video recordings of interpreted consultations were transcribed. Transcription was performed by professional interpreters, who first transcribed consultations in both languages, then provided a translation of what was said in the foreign language. Based on the translations, the videos were coded and analysed using RIAS. Results Overall, 19 consultations with a total recording time of 865 min were analysed. The main finding is the large difference in the number of utterances in the original language compared to the number of utterances in the target language: about one third of the HCPs’ and the patients’ utterances were not translated. In no instance were omissions explained to HCP or patient. Conclusion Interpreters in this sample did not always translate what had been said precisely; they omitted utterances by both HCPs and patients. Practice implications All participants of an interpreted consultation must be made aware of potential omissions in the process of translation. Further understanding of the causes and consequences of omissions is needed.

Background: The preanesthetic visit influences patient satisfaction and medical outcome. Providing relevant information may reduce anxiety. This study aimed to evaluate whether training for a structured interview technique improves communication skills, resulting in increased patient satisfaction and reduced patient’s anxiety and fear of anesthesia. Methods: Randomized controlled observational study, comparing patients (n=47) interviewed by anesthesiologists having obtained training to optimize structured communication (TA) or by anesthesiologists without such training (CA). Patient anxiety and fear was recorded before and after the preoperative interview. Interview duration and satisfaction with the anesthesiologist were also recorded. Data were analysed to test for superiority of the structured interview approach. Results: Mean preoperative anxiety was 1.2 VAS points lower in TA vs. CA group (95% CI-2.39; -0.03, P=0.082). Structured interviews significantly reduced preoperative anxiety in younger (

To examine published models of health care interpretation and associated roles, expectations, and outcomes.A literature search was conducted using the key words interpreter/translator, communication, and role and their combinations in PubMed, CINAHL, PsycINFO, and PSYNDEXPlus. References mentioned in articles identified with these search terms were then checked by hand in corresponding publications and books. We excluded articles if they were dealing with concepts of interpretation, role definitions, etc., without presenting any empirical evidence to support their recommendations. Thirty-four of 1,121 references that investigated the role of professional interpreters in health care were found to meet inclusion criteria.Out of 34 articles, only 2 recommend strict adherence to the conduit model in which interpreters are faithfully and exclusively transmitting information; the interpreter's role is in 32 studies defined in broader terms as the role of a cultural broker (n = 18), a manager or clarifier (n = 22), a patient advocate (n = 13), or a mediator (n = 6).There are no commonly accepted understandings of the interpreters' role; empirical data are lacking.The interpreter's function must be explicitly clarified before a health care encounter is conducted. There should be an agreement of some basic rules.

Ziel war die Ubersetzung des englischsprachigen Patient-Provider Orientation Scale (PPOS) ins Deutsche und die Untersuchung der Patientenorientierung in 2 Kohorten von Medizinstudierenden in Freiburg (DE) und Basel (CH). Die deutsche Ubersetzung des PPOS wurde bei 259 Medizinstudierenden in Freiburg und bei 137 Medizinstudierenden in Basel eingesetzt. Die Konstruktvaliditat wurde faktorenanalytisch uberpruft. Durch Faktorenanalyse und Uberprufen der internen Konsistenz wurde eine deutsche Version (PPOS-D12) erstellt, die fur die Subskalen „Partizipation“ und „Zuwendung & Interesse“ je 6 Items umfasst. Mit dem PPOS-D12 steht ein Instrument zur Verfugung, das es erlaubt, das Ausmas der Patientenorientierung bei Medizinstudierenden zu messen.

This article evaluates the suitability of low frequency (LF) heart rate variability (HRV) as an index of sympathetic cardiac control and the LF/high frequency (HF) ratio as an index of autonomic balance. It includes a comprehensive literature review and a reanalysis of some previous studies on autonomic cardiovascular regulation. The following sources of evidence are addressed: effects of manipulations affecting sympathetic and vagal activity on HRV, predictions of group differences in cardiac autonomic regulation from HRV, relationships between HRV and other cardiac parameters, and the theoretical and mathematical bases of the concept of autonomic balance. Available data challenge the interpretation of the LF and LF/HF ratio as indices of sympathetic cardiac control and autonomic balance, respectively, and suggest that the HRV power spectrum, including its LF component, is mainly determined by the parasympathetic system.

Die psychosomatische Perspektive kommt meist ins Spiel, wenn Schwindel ohne nachweisbares organisches oder funktionelles Korrelat auftritt. Diagnostisch lassen sich die so definierten Beschwerden unter die somatoformen Störungen einordnen (ICD-10 F45). Ätiologisch hilft diese Einordnung nicht weiter, da die Erklärungskonzepte somatoformer Störungen uneinheitlich sind. Diese ätiologische Unsicherheit widerspiegelt sich im Fehlen eindeutig belegter wirksamer Therapieoptionen, die medikamentöse Behandlung mit SSRI und Benzodiazepinen sowie kognitiv behaviorale Psychotherapie umfassen. Im zweiten Teil des Artikels wird an Hand von Fallbeispielen versucht, über das Konzept einer Unterscheidung leiblicher von körperlichen Phänomenen Schwindel in seinen Auswirkungen auf das leibliche Befinden von Patienten zu verstehen und daraus therapeutische Interventionen abzuleiten. Betont wird die Abhängigkeit der Inzidenz von Schwindel als ängstigendes Symptom vom Zeitgeist einer Epoche, der darüber entscheidet, welche Wahrnehmungen Krankheitswert erhalten. Schwindel als leibliche Regung kann Orientierungslosigkeit bedeuten, oder abgeleitet sein aus Zuständen des sich Verlierens in die Weite der Schläfrigkeit; beides wird an Fallbeispielen erläutert.

This article examines the extent to which structuring Emergency Department discharge information improves the ability to recall that information, and whether such benefits interact with relevant prior knowledge. Using three samples of students with different levels of prior medical knowledge, we investigated the amount of information recalled after structured vs. non-structured presentation of information. Across all student samples, the structured discharge information led to a relative increase in recalled items of 17% compared to non-structured discharge information (M = 9.70, SD = 4.96 vs. M = 8.31, SD = 4.93). In the sample with least medical knowledge, however, the structured discharge information resulted in a relative increase in recall by 42% (M = 8.12 vs. M = 5.71). These results suggest that structuring discharge information can be a useful tool to improve recall of information and is likely to be most beneficial for patient populations with lower levels of medical knowledge.

In an emergency department (ED), discharge communication represents a crucial step in medical care. In theory, it fosters patient satisfaction and adherence to medication, reduces anxiety, and ultimately promotes better outcomes. In practice, little is known about the extent to which patients receiving discharge information understand their medical condition and are able to memorize and retrieve instructions. Even less is known about the ideal content of these instructions. Focusing on patients with chest pain, we systematically assessed physicians' and patients' informational preferences and created a memory aid to support both the provision of information (physicians) and its retrieval (patients). In an iterative process, physicians of different specialties (N = 47) first chose which of 81 items to include in an ED discharge communication for patients with acute chest pain. A condensed list of 34 items was then presented to 51 such patients to gauge patients' preferences. Patients' and physicians' ratings of importance converged in 32 of the 34 items. Finally, three experts grouped the 34 items into five categories: (1) information on diagnosis; (2) follow-up suggestions; (3) advice on self-care; (4) red flags; and (5) complete treatment, from which we generated the mnemonic acronym "InFARcT." Defining and structuring the content of discharge information seems especially important for ED physicians and patients, as stress and time constraints jeopardize effective communication in this context. Chest pain accounts for up to 10% of all patient presentations in emergency departments (EDs) (Konkelberg & Esterman, 2003). The majority of these patients will usually be discharged within hours, after exclusion of serious conditions such as myocardial infarction (Goodacre et al., 2011). A comprehensive workup of low- to intermediate-risk patients is not feasible in the ED (Reichlin et al., 2009). Yet many of these patients go on to suffer from repeated episodes of chest pain, associated with anxiety and uncertainty about diagnosis and outcome (Jones & Mountain, 2009). Effective discharge communication, empowering patients to understand and memorize medical information, should therefore be an integral part of patient care. It is a likely contributor to better outcomes (Bishop, Barlow, Hartley, & William, 1997; Kessels, 2003), higher patient satisfaction (Kessels, 2003), better adherence to medication (Cameron, 1996; Kessels, 2003), more adequate disease management, and reduced anxiety (Galloway et al., 1997; Mossman, Boudioni, & Slevin, 1999).

Objective To present the V e r ona Co ding D efinitions of E motional S equences (VR-CoDES CC), a consensus based system for coding patient expressions of emotional distress in medical consultations, defined as C ues or C oncerns. Methods The system was developed by an international group of communication researchers. First, consensus was reached in different steps. Second, a reliability study was conducted on 20 psychiatric consultations. Results A Cue is defined as a verbal or non-verbal hint which suggests an underlying unpleasant emotion that lacks clarity. A Concern is defined as a clear and unambiguous expression of an unpleasant current or recent emotion that is explicitly verbalized with or without a stated issue of importance. The conceptual framework sets precise criteria for cues and concerns and for whom (health provider or patient) elicits the cue/concern. Inter-rater reliability proved satisfactory (agreement 81.5%, Cohen's Kappa 0.70). Conclusion The VR-CoDES CC will facilitate comparative research on provider–patient communication sequences in which patients express emotional distress. Practice implications The VR-CoDES CC may be used to help clinicians in recognizing or facilitating cues and concerns, thereby improving the recognition of patients' emotional distress, the therapeutic alliance and quality of care for these patients.

Objective: To propose a comprehensive set of competencies and educational objectives for communication and social competencies in undergraduate medical education and to support the nationwide implementation of these issues in all medical schools. Methods: Thirty experts from different medical and psychosocial disciplines participated in a 2-day workshop using the Nominal Group Technique (NGT) to develop an initial set of educational objectives. These were refined, structured, and rated according to their importance by means of a two-step Delphi Survey involving additional experts in medical education. Results: The initial workshop resulted in 188 educational objectives assigned to 26 different topics. After the Delphi Survey, 131 objectives remained, assigned to 19 different topics. Some objectives that could be assigned to more than one topic were subsumed under a new more general category. Conclusion: The described consensus process proved successful as one method to develop a set of educational objectives. Practical implications: The Basel consensus statement can be used to orientate curriculum reform and development in medical education.

This paper is a report of an evaluation of the effectiveness of a communication skills training programme for oncology nurses.

Psychosomatic Medicine is aiming at a comprehensive understanding of patient's requests. This requires patient-centred communication. During the two-year course for "Psychosomatic Medicine"of the Lower-Austrian Medical Chamber at the Danube-University Krems relevant techniques are trained. This paper reports on the analysis of 120 video-consultations with simulated patients (30 participants, two per participant before and after the training) using a modified version of the Roter Interaction Analysis System (RIAS). Results show a considerable increase in participant's ability to respond to emotional utterances and to use techniques of patient-centred communication: percentage of appropriate utterances related to the sum of all utterances: from 9.78 ± 3.5 to 13.56 ± 4.7 (ANOVA with repeated measures: p

Objectives An increasing number of consultations are delivered in group practices, where a stable 1:1 relationship between patient and physician cannot be guaranteed. Therefore, correct documentation of the content of a consultation is crucial to hand over information from one health care professional to the next. Methods We randomly selected 20 interviews from a series of 56 videotaped consultations with patients requesting a general check-up exam in the outpatient department of Internal Medicine at the University Hospital Basel. All patients actively denied having any symptoms or specific health concerns at the time they made their appointment. Videotapes were analysed with the Roter Interaction Analysis System (RIAS). Corresponding physician notes were analysed with a category check-list that contained the information related items from RIAS. Results Interviews contained a total of 9.002 utterances and lasted between 15 and 53 min (mean duration: 37 min). Patient-centred communication (Waiting, Echoing, Mirroring, Summarising) in the videos significantly correlated with the amount of information presented by patients: medical information ( r = .57; p = .009), therapeutic information ( r = .50; p = .03), psychosocial information ( r = .41; p = .07), life style information ( r = .52; p = .02), and with the sum of patient information ( r = .64; p = .003). Even though there was a significant correlation between the amount of information from the video and information in physician's notes in some categories (patient gives medical information; Pearson's r = .45; p = .05, patient gives psychosocial information; Pearson's r = .49; p = .03), an inspection of the regression lines shows that a large extent of patient information is omitted from the charts. Physicians never discussed with patients whether information should be documented in the charts or omitted. Conclusions The use of typical patient-centred techniques increases information gathered from patients. Physicians document only a small percentage of patient information in the charts, their ‘condensing heuristic’ is not shared with patients. Practice implications Patient involvement should be advocated not only to medical decision making but also to the way physicians document the content of a consultation. It is a joint responsibility of patient and health care professional to decide, which information should be kept and thus be communicated to another health care professional in future consultations.

BACKGROUND: General practitioners (GPs) are often confronted with patients presenting somatic symptoms presumed to be decisively modulated by psychosocial factors. OBJECTIVES: We aimed to explore GPs' reported clinical routine in dealing with these patients according to the GPs' level of training in psychosomatic medicine. METHODS: A structured postal questionnaire survey was conducted among all Austrian GPs with a standardized training background in psychosomatic medicine (three levels of training; duration between one and six years) as well as in a random national sample of Austrian GPs without such training, resulting in four study subgroups. RESULTS: Respondents estimated that between 20% and 40% of their patients presenting somatic symptoms need psychosocial factors to be addressed. Study subgroups differed significantly concerning their reported diagnostic and therapeutic routine behavior patterns. Some diagnostic approaches such as clarification of lay etiology increased linearly with the level of training. The proportion of patients receiving corresponding treatment in the GP's own practice was also reported to increase with the level of training (no training: 35%, levels one and two: 46%, level three: 54%), although all subgroups estimated that over 20% of patients do not receive any corresponding treatment. CONCLUSIONS: Results point at the clinical relevance of a general training in psychosomatic medicine in primary care. They also suggest specific training effects that need to be substantiated in observational studies.

OBJECTIVE: Transgression of boundaries in the relationship between physician and patient is commonly studied with patient as victim and physician as transgressor. A recent survey in the U.S. reported that almost 90% of physicians face transgression by patients over one year. Incidents happened mainly through verbal abuse, disregarding privacy, and overly affectionate behavior. Since this incidence seems to be alarmingly high, we were interested to analyze how often general practitioners in Switzerland experience transgression by patients. METHODS: 24% of the members of the Swiss Society of Internal Medicine (SGIM) and of the Swiss Society of General Medicine (SGAM) (n=675/2781) responded to an internet-based survey which asked for experiences of transgression by patients and for physicians' responses to transgression in the last 12 months. RESULTS: 81% of responding physicians experienced transgression over the period of one year. Analyzing the frequency of incidents per physician per year, the most common forms of transgression were 'use of physician's first name' (7.7/y), 'asking personal questions' (1.8/y), 'being verbally abusive' (1.5/y), and 'being overly affectionate' (1.4/y). Calculated incidence of transgression was 3 per 1000 patient contacts. 39% of physicians decided to ignore the incident, 37% discussed the event openly. Transgression led to dismissal of patients in 13% of events. CONCLUSION: Transgression even in mild and modest form is a rare phenomenon in Swiss practices. PRACTICE IMPLICATION: The Swiss data do not suggest that there is a specific risk for Swiss practitioners to be exposed to major transgression for which they should specifically be prepared for example in communication skills trainings.

Objective: Basic research and careful observation of clinical practice have yielded a vast amount of empirical data on communication in health care. This research has been guided by the assumption that good communication will be better understood and easier to teach when its single constituents are identified. This paper points to the limitation of this approach. Methods: Based upon the terminology of phenomenological thinking grounded in neo-phenomenology (Hermann Schmitz) contradictory findings from the literature on patient-centred communication in Internal Medicine and Oncology are used as a starting point to elucidate different paradigms in conducting research in clinical communication. Results: The phenomenological approach of the German philosopher Hermann Schmitz ( * 1928) is briefly presented. It is based upon experiences that ‘on the average everybody can vividly access or retrieve from his memory’. Empirical research does not provide unequivocal advice how to communicate with an individual patient. Likewise, researchers note unexpected reactions from real patients—they do not behave as the expert would assume. The inclusion of the phenomenon of a certain atmosphere is proposed referring to the impression of ‘something in the air’ that sometimes can be identified during communication or upon entering a room. Even though it can be sensed with high evidence, it cannot be deduced from particular observations. Instead, the atmosphere is part of a situation in which meaning is dissolved in chaotic manifoldness. Sensing an atmosphere is a function of the lived body (Leib) as opposed to phenomena that are mediated by the senses. Conclusion: Current research and teaching models cover only part of the phenomenology of professional communication. How research and education might profit from the addition of Schmitz’ philosophical approach will be outlined in this article. Practice implications: Including perceptions of the lived body (Leib) should improve research in clinical communication and teaching courses. # 2007 Elsevier Ireland Ltd. All rights reserved.

Objective Describe the content and of mode of patient–physician–nurse interactions during ward-rounds in Internal Medicine. Methods In 267/448 patients, 13 nurses, and 8 physicians from two wards in General Internal Medicine 448 interactions on ward rounds were tape recorded by observers. After exclusion of interactions with more than three participants (N = 150), a random sample of 90 interactions was drawn. Data were analysed with a modified RIAS version that allowed for the registration of a third contributor and for the assessment of the direction of a communicative action (e.g.: nurse → patient, etc.). Furthermore, time spent per individual patient was registered with a stop-watch. Results A total of 12,078 utterances (144 per ward round) were recorded. Due to problems with the comprehensibility of some interactions the final data set contains 71 ward round interactions with 10,713 utterances (151 per ward round interaction). The average time allotted to an individual patient during ward-rounds was 7.5 min (range: 3–16 min). The exchange of medical information is the main topic in physicians (39%) and nurses (25%), second common topic in patients (28%), in whom communicative actions like agreement or checking are more common (30% patients/25% physicians/22% nurses). Physicians and patients use a substantial number of communicative actions (1397/5531 physicians; 1119/3733 patients). Patients receive about 20 bits of medical or therapeutic information per contact during ward-rounds. Conclusions If ward rounds serve as the central marketplace of information nurses’ knowledge is under-represented. Further research should try to determine whether the quality of patient care is related to a well balanced exchange of information, to which nurses, physicians, and patients contribute their specific knowledge. Practice implications Given the fact that in-patients in Interna Medicine usually present complex problems, the exchange of factual information, expectations, and concepts is of paramount importance. We hope that this paper is going to direct the attention of the scientific community to the characteristics of ward-rounds because they will remain the central marketplace of communication in hospital.

This paper is based on a videotaped diabetes consultation involving a German-speaking physician, a Turkish-speaking diabetes patient and a TurkishGerman interpreter who has been working in medical settings for a number of years. In the course of the consultation, the physician focuses several times on the importance of the patient carefully maintaining a balance of food intake and insulin supply in order to control his diabetes. The discourse-based analysis indicates the cognitive task load of the interpreter in this encounter when confronted with medication instructions. The data indicate that the interaction could have been more efficient if the interpreter had acquired the necessary knowledge about diabetes prior to the consultation or if she had recognised the elements structuring the discourse. In fact, the interpreter cannot establish a successful communication pertaining to the blood glucose-insulin mechanism between the doctor and the patient. The patient himself seems to have more in-depth knowledge about diabetes as a result of his personal experience than the interpreter has. In this paper, we therefore argue that interpreters need a sound understanding of the specific medical situation (top-down process) in order to interpret interactions adequately in a complex case such as diabetes. If interpreters lack sufficient medical knowledge in one of their varied assignments, they could use their textual competence and their capacity for formal, logical reasoning to infer connections between propositions (bottom-up process). Thus, interpreters’ cognitive-linguistic competence could to some extent compensate for their lack of domain-specific understanding. Nevertheless, the data shows that interpreters need specialized training not only in analysis of linguistic discourse but also in domain-specific knowledge and terminology.

Objective Patient-centered communication is a key element for improving the quality of care in terms of therapeutic relationship, patient participation, and treatment process. Postgraduate trainings provide an essential way of promoting patient centeredness on the job where learning opportunities are often limited by time, patient volume, and economic pressure. In the present study, changes in patient centeredness during clinical routines of postgraduate physicians (internal medicine) after a three-day communication training were assessed. Methods A randomized controlled trial was conducted in a primary care clinic. The intervention consisted of a communication training that aimed to enhance patient centeredness in postgraduate physicians. The training was based on a need assessment and the principles of deliberate practice. Workplace-based assessment of physicians' communication behavior was obtained using the Roter Interaction Analysis System. Results Three months after the intervention, trained physicians showed significantly increased patient centeredness ( F =5.36, p =.04; d =0.42). Conclusion The communication training significantly improved patient centeredness during routine clinical practice. Thus, this training provides a structured and theory-based concept to foster patient centeredness. Practice implications The results support the implementation of communication trainings as a part of faculty development and medical specialization training.

Fragestellung: Die Dolmetscherrolle im Behandlungssetting ist in der Literatur nicht klar definiert. Ziel dieser Studie ist es, zu untersuchen, welche Rolle Dolmetscher sich im Gespräch selbst zuschreiben und welche Rolle sie in der Praxis tatsächlich einnehmen. Methode: Im quantitativen Teil der Studie haben sich Dolmetscher im Gesundheitswesen in einem Fragebogen zu ihrem Rollenverständnis geäussert. Im qualitativen Teil wurde anhand von gedolmetschten Videoaufnahmen die Rolle der Dolmetscher in der Praxis analysiert. Ergebnisse: 373 Fragebögen und 19 gedolmetschte Konsultationen wurden analysiert und verglichen. Während im Fragebogen eine neutrale Dolmetscherrolle bevorzugt wurde, ist in der Praxis ein aktives Verständnis der Dolmetscherrolle zu beobachten. Schlussfolgerung: Da Selbst-Beschreibung und beobachtetes Verhalten stark divergieren, müssen Fachpersonen und Dolmetscher vor jedem Gespräch miteinander klären, was sie voneinander erwarten. Objectives: In the literature the role of an interpreter in the clinical setting is not yet clearly defined. The aim of the study is to explore, which role the interpreters assign to themselves and which role they actually take in the clinical setting. Methods: In the quantitative part of the study, the interpreters evaluated their role in the clinical encounter through a questionnaire, whereas in the qualitative part the interpreters’ role was assessed by analysing videotapes of the clinical encounters. Results: 373 questionnaires and 19 videotapes were collated and analysed. According to the results of the questionnaire interpreters seem to prefer a neutral role in the clinical encounter. This was in contrast to what was observed in practice, as seen in the videotapes. In reality, they take in an active role while interpreting. Conclusions: It is important that medical professionals and interpreters discuss their roles and expectations before every clinical consultation.

Sympathetic nervous system (SNS) activity at the time of acquisition is associated with human memory. However, rather than SNS activity per se, it may be afferent baroreflex feedback that is responsible for this effect. A pharmacological design was employed to unload (SNP, sodium nitro-prusside) and load (norepinephrine) baroreceptors. In addition to two placebo periods, epinephrine and esmolol (a peripherally acting β1-blocker) served as control conditions for altered cardiac perception. During drug infusion blood pressure, heart rate, and perception of heartbeat were tested. Twenty-four healthy men were participated. The participants viewed emotional slides while their electromyographic eye blink responses to random noise bursts were measured (affective startle modulation paradigm) to determine potential drug impact on emotional processing. Subjects were not informed that memory testing would take place after 4 weeks. Drugs did not impact startle, thus indicating unbiased emotional processing at the time of acquisition. Norepinephrine had no effect on heartbeat perception, but improved ( p = .002) recognition memory. SNP ( p = .0001) increased heartbeat perception but impaired ( p = .038) recognition memory. Epinephrine, on the other hand, increased heartbeat perception ( p = .0001) yet did not impair but partially improve memory (effect on high arousing pictures only: p = .05). Heartbeat perception in the placebo condition did not correlate with recognition memory ( p ’s > .5). We suggest that baroreflex unloading, with subsequent feedback activation of the SNS, impairs long-term incidental visual recognition memory in humans while baroreflex loading enhances it. Further, we propose that these memory effects are neither secondary to cardiac sensations that accompany SNS activation nor to altered emotional picture processing at the time of acquisition.

Background: Many people suffer from hay fever symptoms. Hypnosis has proved to be a useful adjunct in the treatment of conditions where allergic phenomena have an important role. Methods: Randomised parallel group study over an observation period of two consecutive pollen seasons. Outcome data include nasal flow under hypnosis, pollinosis symptoms from diaries and retrospective assessments, restrictions in well-being and use of anti-allergic medication. We investigated 79 patients with a mean age of 34 years (range 19–54 years; 41 males), with moderate to severe allergic rhinitis to grass or birch pollen of at least 2 years duration and mild allergic asthma. The intervention consisted of teaching self-hypnosis during a mean of 2.4 sessions (SD 1.7; range 2–5 sessions) and continuation of standard anti-allergic pharmacological treatment. Results: Of 79 randomised patients, 66 completed one, and 52 completed two seasons. Retrospective VAS scores yielded significant improvements in year 1 in patients who had learned self-hypnosis: pollinosis symptoms –29.2 (VAS score, range 0–100; SD 25.4; p < 0.001), restriction of well-being –26.2 (VAS score, range 0–100; SD 28.7; p < 0.001. In year 2, the control group improved significantly having learned self-hypnosis as well: pollinosis symptoms –24.8 (SD 29.1; p < 0.001), restriction of well-being –23.7 (SD 30.0; p < 0.001). Daily self-reports of subjects who learnt self-hypnosis do not show a significant improvement. The hazard ratio of reaching a critical flow of 70% in nasal provocation tests was 0.333 (95% CI 0.157–0.741) after having learnt and applied self-hypnosis.

Coronary artery disease (CAD) as well as depression are both highly prevalent diseases. Both cause a significant decrease in quality of life for the patient and impose a significant economic burden on society. There are several factors that seem to link depression with the development of CAD and with a worse outcome in patients with established CAD: worse adherence to prescribed medication and life style modifications in depressive patients, as well as higher rates in abnormal platelet function, endothelial dysfunction and lowered heart rate variability. The evidence is growing that depression per se is an independent risk factor for cardiac events in a patient population without known CAD and also in patients with established diagnosis of CAD, particularly after myocardial infarction. Treatment of depression has been shown to improve patients' quality of life. However, it did not improve cardiovascular prognosis in depressed patients even though there is open discussion about the trend to better outcome in treated patients. Large scale clinical trials are needed to answer this question. Selective serotonin reuptake inhibitors seem to be preferable to tricyclic antidepressants for treatment of depressive patients with comorbid CAD because of their good tolerability and absence of significant cardiovascular side effects. Hypericum perforatum (St. John's wort), an increasingly used herbal antidepressant drug should be used with caution due to severe and possibly dangerous interaction with cardioactive drugs.

We present a new paradigm to investigate cognitive processing of food cues. The study assessed if pictures of food induce prepulse inhibition (PPI) of startle eye blink, and if any such effect is sensitive to food deprivation. In a balanced cross-over design, 16 healthy male volunteers (mean age: 29 years) were tested on 2 days 1 week apart, either after a period of normal food intake (NFI) or after a 24 h period of food restriction (RFI). On each experimental day, 80 control and 20 food pictures (slides) were displayed. Noise stimuli were presented 250 ms after slide onset. Startle responses were assessed by EMG recordings of the right M. orbicularis oculi. Startle elicited during dark inter-slide periods served as control responses to calculate PPI effects. The arousing content of each picture was rated by all subjects at the end of the session. The perceived arousal effect of control slides was strongly related to their PPI effect; no impact of food access status on this association was detectable. After NFI, food slides significantly induced PPI of startle (mean: -14.5%). After RFI, arousal ratings for food pictures increased but PPI did not. These results are evidence for a pre-attentive mechanism operative in the processing of visual food cues.

Measures to improve quality of care in hospitals should best be based upon the results of patient surveys. The present paper reports in the validation of a questionnaire originally developed in the US in 658 patients from two Swiss hospitals in a tertiary care setting. Questionnaires were sent out two weeks after release from hospital, more than 75 percent of questionnaires were returned. Based upon the experience that feedback of many single items rarely results in distinct actions to improve quality of care a factor analysis followed by an analysis of reliability was undertaken to validate the instrument and to reduce the amount of information, to help hospital officials to deal with the data, and finally to reduce the number of items in the questionnaire. Factor analysis revealed a 3-factor-solution based upon 25 out of 37 deficit-oriented questions, explaining 34.4 % of total variance. The factors can be described as: 1. Patient information (9 items; explained variance: 13.0 %); 2. Patient involvement and shared decision making (11 items; explained variance: 11.2 %); 3. Nursing quality (5 items; explained variance: 10.2 %). Cronbach's alpha values of these scales are 0.75, 0.72, and 0.69, respectively. As further analyses show, reducing the item pool does not lead to the loss of relevant information. Single wards show substantial differences in scores based on these factors (e.g. between 10 and 27 percent deficit in factor 2). The sensitivity of the factors in describing specific profiles of single wards will help to target measures to improve quality of care to those wards where improvement is most utterly needed.

Assess the amount of medical information laypeople recall, investigate the impact of structured presentation on recall.105 first-year psychology students (mean age 21.5±3.8 years; 85% female) were randomised to two information-presentation conditions: structured (S group) and nonstructured (NS group). Students watched a video of a physician discharging a patient from the emergency department. In the S Group, content (28 items of information) was divided into explicit "chapters" with "chapter headings" preceding new information. Afterwards, participants wrote down all information they recalled on an empty sheet of paper.The S group (N=57) recalled significantly more items than NS group (N=41) (8.12±4.31 vs. 5.71±3.73; p=0.005), rated information as easier to understand (8.0±1.9 vs. 6.1±2.2; p0.001) and better structured (8.5±1.5 vs. 5.5±2.7; p0.001); they rather recommended the physician to friends (7.1±2.7 vs. 5.8±2.6; p0.01).University students recalled around 7/28 items of information presented. Explicit structure improved recall.Practitioners must reduce the amount of information conveyed and structure information to improve recall.

Clomethiazole, a sedative-hypnotic and anticonvulsant drug, has been successfully administered orally and intravenously, but in cases where either of these methods presents complications, rectal administration may represent a practical alternative. We sought to compare the single-dose pharmacokinetics and pharmacodynamics of clomethiazole after oral and rectal administration. Ten healthy adult volunteers were given 600 mg clomethiazole edisylate (corresponding to 390 mg clomethiazole base) in 2 capsules as a single oral or rectal dose in a double-masked, double-dummy, crossover fashion. Serum concentrations were measured up to 10 hours after administration using a specific high-performance liquid chromatography method. Computerized reaction-time measurement and visual analogue scales (VAS) were used to assess drug effects. Peak serum concentrations were significantly higher after oral administration (mean +/- SEM, oral 1.76 +/- 0.47 microg/mL vs rectal 0.48 +/- 0.14 microg/mL; P = 0.03) and appeared earlier (55 +/- 12 vs 89 +/- 11 min; P = 0.04). Area under the concentration-time curve values were similar after administration by both routes (oral 116 +/- 20.6 vs rectal 105 +/- 36.0 microg x min/mL), with a relative rectal bioavailability of 90% compared with oral administration. The objective pharmacodynamic effects on reaction time (increase of 104 +/- 26 vs 66 +/- 22 ms, oral vs rectal) and working speed (decrease of 132 +/- 38 vs 97 +/- 32 ms, oral vs rectal) were not significantly different. Subjective pharmacodynamic effects, as measured on the VAS, were comparable with both routes of administration. Clomethiazole was well tolerated, with a similar adverse effect profile for both routes of administration. The effects of rectal dosing of clomethiazole were similar to those of oral dosing but appeared to occur later. Our results suggest that rectal administration of a single 600-mg clomethiazole edisylate dose bears no safety risk. Therefore, rectal administration could be considered when neither oral nor parenteral administration is possible and a later onset of effect is not critical.

Empowerment als Informationsvermittlung entspricht den Wünschen, die Patienten und Patientinnen artikulieren. Gerade wenn es um lebensentscheidende Fakten geht, sind Ärztinnen und Ärzte aufgefordert, aufrichtig und vollständig Informationen zu vermitteln. Dies kann allerdings nicht in einem unbegrenzten Übermitteln von Fakten bestehen, sondern muss sich an den jeweils aktuellen Informationsbedürfnissen und an dem jeweils vorhandenen Auffassungsvermögen der Patientin orientieren. Bei dieser Gratwanderung helfen bestimmte kommunikative Techniken, deren mächtigster Gegenspieler die mangelnde Flexibilität einer Ärztin ist, die starr und unbeirrbar einem einmal festgelegten Skript folgt, ohne auf die Reaktionen ihrer Patienten zu achten.

This paper reviews technical, methodological and clinical aspects of ambulatory blood pressure (aBP) monitoring. It describes deficits in the evaluation of available aBP devices and in the description and interpretation of slow (e.g. seasonal or circadian) and fast blood pressure variations. The ongoing discussion about the mere existence of circadian blood pressure rhythms is reflected, referring to the most recent data. Further methodological questions considered encompass the problem of centrality (how to describe an aBP profile with one numerical measure) and the question of variability (how to describe variance within an aBP profile). Good reasons for the use of MESOR or RMSSD parameters are given. Finally, the evidence behind a broad clinical application of aBP measurements is critically reviewed; except for ‘white coat' hypertension, the clinical superiority of aBP values compared with office and home blood pressure readings is not well established on epidemiological grounds.

a b s t r a c t Aim: Prognostic uncertainty and surrogate decision-making demands associated with prolonged uncon- sciousness in out-of hospital cardiac arrest (OHCA) patients in the intensive care unit (ICU) may increase post-traumatic stress disorder (PTSD) risk in their relatives. Our aim was to study PTSD frequency and risk factors in relatives of OHCA patients. Methods: In this observational study 101 consecutive eligible adult relatives of OHCA patients were interviewed using validated questionnaires, the "Impact of Event Scale-Revised" to detect PTSD and the "Family-Satisfaction with Care in the ICU" to assess potential PTSD risk factors. Results: PTSD was detected in 40/101 relatives (40%). Multivariate logistic regression identified three significant PTSD predictors (odds ratio, 95% confidence interval): female gender (3.30, 1.08-10.11), his- tory of depression (3.63, 1.02-12.96), family perception of the patient's therapy as insufficient (18.40, 1.52-224.22). Three other predictors were not significantly associated with PTSD (hypothermia treat- ment of the patient (2.86, 0.96-8.48)), delayed delivery of prognostic information by ICU staff (2.11, 0.83-5.38), family-ICU staff conflict (3.61, 0.71-18.40)). A prediction rule including six factors (p < 0.15 each) showed high discrimination (area under the receiver-operating characteristic curve 0.74) with a stepwise increase in risk for PTSD from 0% (no risk factor) to 63% (≥3 risk factors). There was no evidence for effect modification either by survival status or neurological outcome. Conclusion: Relatives of OHCA patients treated in the ICU are at increased risk of PTSD, which can be pre- dicted based on six factors, three ICU-related and potentially at least partly modifiable. Further research is needed to validate our findings and to develop strategies to prevent PTSD in OHCA patients' relatives. © 2014 Elsevier Ireland Ltd. All rights reserved.

Summary SUMMARY OF BACKGROUND DATA: The incidence of chronic pain is higher among immigrants in Europe than among the native European population. Therapeutic interventions in this population are far less effective than in patients for whom these programmes were originally developed. OBJECTIVES: In a randomised trial, we investigated whether a cognitive behavioural treatment (CBT) programme supplemented with culturally sensitive aspects (CsCBT) improves pain intensity, pain disability and quality of life among immigrant patients, compared with a treatment of culturally sensitive exercise therapy (CsET) alone. Furthermore, we investigated whether healthcare costs would decrease. METHODS: First-generation Turkish immigrants residing in Switzerland (20–65 years of age) who suffered from chronic pain were enrolled in the trial. Patients were randomised to attend either CsCBT or CsET. The CsCBT intervention was based upon a manualised cognitive-behavioural group treatment programme for chronic pain patients and adapted to the needs of a Turkish immigrant population. The CsET intervention was based on principles of exercise therapy for treatment of nonspecific low back pain. RESULTS: A total of 116 outpatients were recruited between October 2004 and November 2006. The intervention was completed by 89 patients (77%). A total of 78 subjects (67%) completed follow-up, 12 months after the completion of the intervention programme. The intervention showed no effects in reducing pain, pain disability or quality of life. The analysis of healthcare utilisation yielded no intervention effect. CONCLUSIONS: Cognitive behavioural intervention is feasible with immigrants with chronic disabling pain, but the evidence-based CBT programme, as well as exercise therapy supplemented with culturally sensitive aspects, showed no improvement.

Respiratory sinus arrhythmia (RSA) has been used as an index of parasympathetic cardiac control. However, recent psychophysiological research casts serious doubts upon the usefulness of RSA as an index of vagal influences upon the heart in psychophysiological as well as in clinical studies. It suggests the need to look for another measure. In this exploratory study we investigated whether the baroreflex sensitivity (BRS) could serve as an alternative tool to investigate between-subject tonic parasympathetic influences on the heart. In nine healthy subjects we examined the effects of intravenous atropine (0.03 mg/kg i.v.), intravenous metoprolol (10–15 mg i.v.), and of saline as a placebo condition upon RSA, BRS, and related cardiovascular and respiratory variables, both under resting and under mental task conditions. After parasympathetic blockade, RSA and BRS display values near zero, showing their vagal origin. After beta-adrenergic blockade, when heart period is predominantly under vagal control, RSA fails to predict heart period variability. Using BRS, however, it is possible to predict more than 97% of heart period variance during beta-blockade. Finally, both the vagal and beta-adrenergic blockade show that BRS is a better predictor of parasympathetic cardiac control during blood pressure increases than during blood pressure decreases.

The classical study of Egbert et al. in the 1960s showed that a pre-operative visit by an anesthetist reduced preoperative anxiety more than a sedative premedication [1]. Since then, anesthetists routinely visit their patients preoperatively. Despite this long standing tradition and notwithstanding the fact that skillful patient–physician communication is increasingly recognised as important in anesthesia as well, little is known about the pre-operative communication between anesthetists and patients. In the present study, fiftyseven videotaped real-life anesthetic preoperative visits were observed and coded with the Roter Interaction Analysis System (RIAS; a system for coding communication units in different categories) [2] and a sequence analysis of consecutive utterances (i.e., single action units of physician or patient) was performed. Basic information on this specific type of patient–physician communication is presented in this paper. Assessing the quality of an interaction between a health care provider and his or her patient is dependent on the definition of ‘good’ or ‘desirable’ communication. Two approaches have commonly been applied: a theory driven definition of good communication or an empirically driven definition based upon the results of an explorative data analysis. In our theory-driven approach, we assumed that the affective (i.e., the non-specific information-related) quality of an interview is determined by minute sequences of communication units during which physicians react to or ignore patient clues. We further argued that the amount of patient-centredness cannot be measured appropriately by simply counting the number of RIAS categories which are typically linked to a patient-centred communication style, e.g., ‘reassurance/showing optimism (R/O-doc)’ or ‘empathy/legitimate (emp/leg-doc)’ [2]. Instead, these utterances should be used as indicating true patient-centred communication only when they occur in response to appropriate patient clues. We then defined measures of empathy and ‘reciprocity’, i.e., moments during an interview when communication sequences of patient and physician are intertwined: a patient responding to a physician having given information or counselling; a physician responding to patient’s concerns or utterances indicating anxiety or uncertainty [3]. Analysing initial interviews with patients in Patient Education and Counseling 54 (2004) 379–381

This article evaluates the suitability of low frequency (LF) heart rate variability (HRV) as an index of sympathetic cardiac control and the LF/high frequency (HF) ratio as an index of autonomic balance. It includes a comprehensive literature review and a reanalysis of some previous studies on autonomic cardiovascular regulation. The following sources of evidence are addressed: effects of manipulations affecting sympathetic and vagal activity on HRV, predictions of group differences in cardiac autonomic regulation from HRV, relationships between HRV and other cardiac parameters, and the theoretical and mathematical bases of the concept of autonomic balance. Available data challenge the interpretation of the LF and LF/HF ratio as indices of sympathetic cardiac control and autonomic balance, respectively, and suggest that the HRV power spectrum, including its LF component, is mainly determined by the parasympathetic system.

In an emergency department, discharge communication represents a key step in medical care. The efficiency of this doctor-patient interaction could be hampered by two bounds: The limited time in emergency care and patients' mind's limited capacity to encode, store and maintain information. Such limitations are the focus of this study. Specifically, we examine the number of items physicians deem crucial in a discharge communication and the necessary time estimated to present them.A vignette of a patient with chest pain was presented to 47 physicians (38 internists, 9 emergency physicians). Physicians were offered a list of 81 items possibly conveyed to patients and asked to select the important ones assuming a discharge interaction of 15 minutes. Additionally, 7 experts estimated the time required to communicate each item.Physicians' mean clinical experience was 10.1 years. From the list of 81 items, physicians selected, on average, 36 items (Range: 20-57). Experts rated the time necessary to communicate this subset to be 44.5 minutes - almost three times the preset 15 minutes. While emergency physicians, relative to internists, selected an insignificantly lower number of items (31.6 ± 6.2 vs. 37.4 ± 10.2), the time estimated for communicating the information was significantly shorter (36.9 ± 6.3 vs. 46.4 ± 13.5).Physicians in our study proved to be miscalibrated with regard to the number of items they could realistically discuss in a discharge communication. We conclude that there is an obvious need to train physicians in skills of implementing efficient discharge communication.

1. Theoretical and practical considerations suggest that in subjects complaining of fatigue, in the absence of evident organ dysfunction, an alteration in the autonomic nervous system might be present as a functional correlate. 2. Autoregressive spectral analysis of R-R interval variability from a surface ECG, was used in healthy control subjects (n = 24, age 45 ± 4 years) and in subjects complaining of unexplained fatigue (n = 53, age 46 ± 9 years) to obtain quantitative indices of the state of the sympathovagal balance, both at rest and during a mental stimulus (mental arithmetic), capable of enhancing sympathetic drive. Sympathetic and vagal modulations were inferred from the normalized powers of the low frequency and high frequency spectral components respectively. 3. We observed in patients, at rest, a prevailing low frequency component of R-R variability (patients low frequency = 73 ± 11, control subjects 51 ± 10 normalized units, P < 0.05). The responsiveness to mental arithmetic was reduced in patients as compared with controls. Systolic blood pressure variability did not differ. This suggested a selective imbalance in autonomic control of the sinoatrial node, characterized by sympathetic predominance as well as by vagal withdrawal, at rest. 4. The possibility of discriminating patients from control subjects on the basis of simple non-invasive functional markers might provide a better understanding of the mechanisms, clinical evolution and outcome of conditions such as the chronic fatigue syndrome, which lack ordinary evidence of disease, but comprise, as physiopathological correlate, a quantitative alteration of autonomic control.

We investigated two groups of men with regard to vasectomy acceptance, and subsequent erectile dysfunction. Group I was a group of 45 men chosen at random from 254 vasectomized patients. Group II was a group of 18 men who, out of 180 patients treated for erectile dysfunction, attributed their dysfunction to previous vasectomy. We analysed the social background, motivation for vasectomy and postoperative changes of sexual life or behaviour of the partners. The partnership constellation, particularly the role of a predominant female partner seems to be an important feature for vasectomy acceptance. Low acceptance might cause erectile dysfunction.Of 180 patients treated for erectile dysfunction in 1989-91 in Basel, Switzerland, 25 had previously undergone vasectomy. 18 of these latter individuals volunteered to be interviewed about their social background, motivation for vasectomy, and postoperative changes of sex life or partner behavior. All of these men attributed their sexual dysfunction to previous vasectomy. Somatic erectile dysfunction was, however, clinically excluded, thereby making the dysfunction of these men psychological in origin. For comparison, a group of 45 randomly chosen vasectomized men underwent the same psychosexual evaluation in the attempt to find a possible relationship between vasectomy and subsequent erectile dysfunction. The men were chosen from 254 vasectomized patients over the period 1986-90. The 45 controls comprise group one, while the 18 men who attribute their erectile dysfunction to previous vasectomy comprise group two. The mean age at time of vasectomy in group one was 39.1 years in the range of 23-59 years, while the mean age in group two at the time of vasectomy was 56.4 years in the range of 42-71 years. Vasectomy dated back on average 18.8 years. 98% of all patients interviewed were married or living in a steady partnership. 18% of patients in group one and 11% of patients in group two found the operation to be traumatic, while 13% of patients in group one and 17% of patients in group two reported fears of demascularization; these differences were not significant. It was significant, however, that 22% of patients in group two had the decision to undergo vasectomy imposed upon them by their partner. 4% of patients in group one and 22% of patients in group two reported a reduced libido within the first two postoperative years. Less frequent or weaker erections were reported by 2% of patients in group one and 27% of patients in group two. Decreased frequency of orgasm was reported by none of the patients in group one, but by 28% of the patients in group two. Ejaculation quality and orgasm by masturbation remained unchanged in all cases. Decreased sexual activity in the partner was reported by 7% of patients in group one and 33% of patients in group two. 4% of patients in group one and 28% of group two believed there was a connection between previous vasectomy and their own erectile dysfunction. In all patients with erectile dysfunction this occurred within two years of the vasectomy. 4% of patients in group one and 39% of patients in group two had changed their partners within the follow-up time. Generally, a patient's psychosocial environment is most important for the acceptance of vasectomy. A good acceptance of vasectomy is usually found among men living in traditional partnerships with a predominating male. Men in partnerships where the female predominates and where the female may have demanded that the male undergo vasectomy, however, may have difficulty later accepting and coping with such imposed decisions on reproduction. Patients requesting vasectomy should always be asked systematically about their motivation and the manner in which the decision was reached. A prospective study is underway to determine the characteristics of men who are predisposed to become sexually dysfunctional.

The relationship between professionals representing conventional treatment (CT) and professionals representing non-conventional therapies (alternative therapy (AT) and/or psychotherapy (PT)) is usually characterized by mutual scepticism and mistrust, the overriding fear being that either side will evoke unjustified hopes or will provide false treatment. We investigated whether patients with HIV infection had unrealistic hopes in non-conventional treatment (non-CT), to what extent they use non-CT, and whether perceived benefit and harm differ between the two modes of treatment. We examined a sample of 100 patients with documented HIV-infection in the out-patient department using a self-developed questionnaire, the Hospital Anxiety and Depression Scale (HAD) and data concerning the HIV status. Fifty-six patients used AT and/or PT. Severity of HIV disease did not differ between users and non-users of non-CT. The most important reasons for the use of AT were 'strengthening the body and resistance; supplementing conventional therapy'. Users of non-CT rated the competence of CT lower than non-users in solving medical problems (VAS-scores 0-100: 65.5 +/- 17.6 vs 76.3 +/- 17.7; p = 0.003) and in solving emotional problems (VAS scores 0-100: 35.8 +/- 21.2 vs 48.2 +/- 28.9; p = 0.02). Users of non-CT were significantly more anxious 8.4 +/- 4.8 vs 5.5 +/- 4.6; p = 0.004) and more depressive (5.7 +/- 4.5 vs 3.7 +/- 4.5; p = 0.03) than non-users. Expectations and hopes did not differ between users of AT and non-users: main hopes were a delay of disease progression (76% vs 71%) and an alleviation of symptoms (78% vs 66%).(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND It is essential that medical students are adequately trained in smoking cessation. A web based tobacco abstinence training program might supplement or replace traditional didactic methods. METHODS One hundred and forty third year medical students were all provided access to a self directed web based learning module on smoking cessation. Thereafter they were randomly allocated to attend 1 of 4 education approaches: (a) web based training using the same tool (b) lecture (c) role playing and (d) supervised interaction with real patients. RESULTS Success of the intervention was measured in an objective structured clinical examination. Scores were highest in Group 4 (35.9 ± 8.7) followed by Groups 3 (35.7 ± 6.5) 2 (33.5 ± 9.4) and 1 (28.0 ± 9.6; p = .007). Students in Groups 4 (60.7) and 3 (57.7) achieved adequate counseling skills more frequently than those in Groups 2 (34.8) and 1 (30; p = .043). There was no difference in the scores reflecting theoretical knowledge (p = .439). Self assessment of cessation skills and students' satisfaction with training was significantly better in Groups 3 and 4 as compared with 1 and 2 (p < .001 and p = .006 respectively). CONCLUSIONS Role playing and interaction with real patients are equally efficient and both more powerful learning tools than web based learning with or without a lecture.

A B S T R A C T Objective: To test the effect of patient counseling using educational tools, on rates of return for follow-up in newly diagnosed hypertensive and/or diabetic patients in a rural African context. Methods: Free screening for hypertension and elevated blood glucose was offered in primary health care centers in central Cameroon during 9 campaigns of 3 days each. Individuals with untreated hypertension and/or diabetes were divided into 2 groups: a control group receiving counseling according to routine procedures, and an intervention group receiving counseling with different educational tools to explain the diagnosis and its implications to the patient. Results: Prevalence of hypertension and/or diabetes in the screened population was 41%. At 3 months from screening, rates of return visits were higher in the intervention group than in the control group: 55/ 169 (32%) vs. 15/92 (16%), OR 2.4; 95%CI 1.3–4.7; p < 0.001. Conclusion: Screening may identify untreated individuals efficiently. Rates of return visits after screening, although low in both groups, could be doubled by a short communication intervention. Practice implications: This study suggests that modest communication interventions, e.g., the application of educational tools, may bring important benefits and increase the effectiveness of public health measures to combat chronic diseases in settings of limited resources.