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To investigate how clinicians correct patient misconceptions, we analyzed 23 video recordings of primary care visits. Analysis focused on operationalizing, identifying, and characterizing clinician corrections, integrating two inductive approaches: microanalysis of clinical interaction and conversation analysis. According to our definition, patient misconception-clinician correction episodes met three essential criteria: (1) the clinician refuted something the patient had said, (2) which the patient had presented without uncertainty, and (3) which contained a proposition that was factually incorrect. We identified 59 such episodes; the patient misconceptions most commonly related to medication issues; fewer than half had foreseeable implications for patients' future actions. We identified seven clinician correction practices: Three direct practices (displaying surprise, marking disagreement, contradicting the patient) and four indirect practices (presenting the correct proposition, providing explanations, invoking an outside authority, demonstrating with evidence). We found an almost equal distribution of these direct and indirect practices.

Background: Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse., Objective: Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population., Methods: This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up., Results: Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants., Conclusions: We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults., Trial Registration: ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn., (©Maria Torheim Bjelkarøy, Tone Breines Simonsen, Tahreem Ghazal Siddiqui, Sigrid Halset, Socheat Cheng, Ramune Grambaite, Jūratė Šaltytė Benth, Jennifer Gerwing, Espen Saxhaug Kristoffersen, Christofer Lundqvist. Originally published in JMIR Formative Research (https://formative.jmir.org), 08.02.2024.)

miR-Blood is a high-quality, small RNA expression atlas for the major components of human peripheral blood (plasma, erythrocytes, thrombocytes, monocytes, neutrophils, eosinophils, basophils, natural killer cells, CD4+ T cells, CD8+ T cells, and B cells). Based on the purified blood components from 52 individuals, the dataset provides a comprehensive repository for the expression of 4971 small RNAs from eight non-coding RNA classes., (© 2024. The Author(s).)

Although medical information is essential for all patients, information needs and information processing capacities vary between individual patients and over time and context, within patients. Therefore, it is often recommended to "tailor" medical information to individual patients during clinic visits. However, there is a lack of consensus on what "tailoring" in clinical interactions represents since the definitions provided in the literature thus far generally regard tailoring of written text, rather than in dialogue during face-to-face interactions. To provide clinicians with guidance on how to tailor information to individual patients and to allow researchers to assess the effectiveness thereof, clarity is urgently needed regarding what "tailoring" actually means and what it entails in practice. In this paper we outline the current challenges of applying the concept of "tailoring" to the clinical setting and present existing definitions. Importantly, we introduce a new working definition of the concept that encompasses essential informational and dialogic components. We believe this provisional definition promotes much-needed conceptual precision in how communication researchers and educators define and assess tailored information provision in clinical consultations., Competing Interests: Declaration of Competing Interest All authors (E. Smets, J. Menichetti, H. Lie and J. Gerwing) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don't like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians' information-sharing praxis., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Lung cancer remains the deadliest cancer in the world, and lung cancer survival is heavily dependent on tumor stage at the time of detection. Low-dose computed tomography screening can reduce mortality; however, annual screening is limited by low adherence in the United States of America and still not broadly implemented in Europe. As a result, less than 10% of lung cancers are detected through existing programs. Thus, there is a great need for additional screening tests, such as a blood test, that could be deployed in the primary care setting., Methods: We prospectively recruited 1384 individuals meeting the National Lung Screening Trial demographic eligibility criteria for lung cancer and collected stabilized whole blood to enable the pipetting-free collection of material, thus minimizing preanalytical noise. Ultra-deep small RNA sequencing (20 million reads per sample) was performed with the addition of a method to remove highly abundant erythroid RNAs, and thus open bandwidth for the detection of less abundant species originating from the plasma or the immune cellular compartment. We used 100 random data splits to train and evaluate an ensemble of logistic regression classifiers using small RNA expression of 943 individuals, discovered an 18-small RNA feature consensus signature (miLung), and validated this signature in an independent cohort (441 individuals). Blood cell sorting and tumor tissue sequencing were performed to deconvolve small RNAs into their source of origin., Results: We generated diagnostic models and report a median receiver-operating characteristic area under the curve of 0.86 (95% confidence interval [CI]: 0.84-0.86) in the discovery cohort and generalized performance of 0.83 in the validation cohort. Diagnostic performance increased in a stage-dependent manner ranging from 0.73 (95% CI: 0.71-0.76) for stage I to 0.90 (95% CI: 0.89-0.90) for stage IV in the discovery cohort and from 0.76 to 0.86 in the validation cohort. We identified a tumor-shed, plasma-bound ribosomal RNA fragment of the L1 stalk as a dominant predictor of lung cancer. The fragment is decreased after surgery with curative intent. In additional experiments, results of dried blood spot collection and sequencing revealed that small RNA analysis could potentially be conducted through home sampling., Conclusions: These data suggest the potential of a small RNA-based blood test as a viable alternative to low-dose computed tomography screening for early detection of smoking-associated lung cancer., (Copyright © 2023 International Association for the Study of Lung Cancer. Published by Elsevier Inc. All rights reserved.)

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal., (Copyright © 2023.)

Background: Poor health among immigrants has been associated with longer duration of residence in the host country, poor host language proficiency and low education. However, the interplay among these factors is under-studied., Objective: To assess health among immigrants in Norway by combinations of duration of residence, Norwegian language proficiency and education., Methods: In 2015/2016 Statistics Norway carried out two cross-sectional Living Conditions Surveys in the general adult population ( N =5703, response rate 59%) and among immigrants from 12 countries, with ⩾2 years of residence ( N =3993, response rate 54%). Health outcomes (poor self-reported health, diabetes, cardiovascular disease, hypertension, obesity, mental health problems, back/neck pain) were assessed with logistic regressions according to combinations of duration of residence, Norwegian language proficiency and education., Results: Negative health conditions were more common among immigrants than in the general population, and varied by duration of residence, proficiency in the Norwegian language and education. In age- and sex-adjusted regressions, immigrants had higher odds of all negative health conditions, except hypertension, regardless of their duration of residence, proficiency of the Norwegian language and educational level. Immigrants with a long duration of residence and poor proficiency in the Norwegian language had the highest odds of negative health conditions., Conclusions: Special attention is warranted towards health among immigrants who have lived in Norway the longest without acquiring good Norwegian language proficiency.

Background: Migration presents numerous significant changes in a person's life, physically, emotionally and socially. How health develops in the host country depends on a range of factors, including language proficiency. We aimed to investigate associations between language proficiency and health., Methods: Statistics Norway carried out the Living Conditions Survey for Immigrants (2016), conducting telephone (82%) or face-to-face (18%) interviews with immigrants (two or more years of residence) from 12 countries. The survey collected data on self-reported proficiency in the Norwegian language, health and socio-economic variables, and included 4077 people aged 16-66 years., Results: In logistic regression models adjusted for age, sex and duration of residence, poor or medium self-reported Norwegian proficiency, as compared to good, was associated with poorer health outcomes, including lower odds of self-rated health (odds ratio (OR)=0.46; 95% confidence interval (CI) 0.39-0.54) and higher odds of hypertension (OR=1.74; 95% CI 1.34-2.26), back or neck pain (OR=1.52; 95% CI 1.28-1.80), mental health problems (OR=1.34; 95% CI 1.09-1.65), sleep disturbances (OR=1.51; 95% CI 1.23-1.86) and being overweight (OR=1.20; 95% CI 1.03-1.40). Adjustment for socio-economic status attenuated the associations, but further adjustments for perceived discrimination and lifestyle (smoking and physical activity) did not further alter the estimates., Conclusions: Host language proficiency has implications for health among immigrants. Equitable access to health services and quality of care requires adjustment to the language level needs of patients. Facilitating language learning for immigrants may be vital in providing access to health services and supporting newcomers in being more active participants in managing their health.

Pancreatic ductal adenocarcinoma (PDAC) frequently metastasizes into the peritoneum, which contributes to poor prognosis. Metastatic spreading is promoted by cancer cell plasticity, yet its regulation by the microenvironment is incompletely understood. Here, we show that the presence of hyaluronan and proteoglycan link protein-1 (HAPLN1) in the extracellular matrix enhances tumor cell plasticity and PDAC metastasis. Bioinformatic analysis showed that HAPLN1 expression is enriched in the basal PDAC subtype and associated with worse overall patient survival. In a mouse model for peritoneal carcinomatosis, HAPLN1-induced immunomodulation favors a more permissive microenvironment, which accelerates the peritoneal spread of tumor cells. Mechanistically, HAPLN1, via upregulation of tumor necrosis factor receptor 2 (TNFR2), promotes TNF-mediated upregulation of Hyaluronan (HA) production, facilitating EMT, stemness, invasion and immunomodulation. Extracellular HAPLN1 modifies cancer cells and fibroblasts, rendering them more immunomodulatory. As such, we identify HAPLN1 as a prognostic marker and as a driver for peritoneal metastasis in PDAC., (© 2023. The Author(s).)

Objective: In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns., Methods: We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue., Results: We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients' existential concerns., Conclusions: Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients' existential concerns., Practice Implications: Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients' existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objective: Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns., Methods: We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue., Results: Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion., Conclusions: Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician., Practice Implications: Health professionals should be attentive to underlying existential messages embedded in the patient's questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient's needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators' communication skills for smoothing cooperation with callers., Methods: Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976)., Results: Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001)., Conclusions: This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention., (© 2021. The Author(s).)

Introduction: The assisted reproductive technology (ART) field deals with consistent and predictable gaps in knowledge. Expressing lack of knowledge with a sentence like "I don't know" can be challenging for doctors. This study examined physicians' negative epistemic disclaimer "non lo so" in Italian ART doctor-couple interactions. In particular, it aimed to reveal specific features of "non lo so": function, topic, temporality, responsibility, and interactional aspects., Methods: This was a video-based observational study. We used microanalysis of face-to-face dialogue to analyze 20 purposively selected triadic consultations from a corpus of 85. This inductive analysis focused on the function, the content (topic and temporality) and some selected interactional aspects of the "non lo so", quantifying and capturing the interaction between these qualitative features., Results: We found 82 doctors' "non lo so" in the corpus (mean = 4.4; range = 0-15). We discovered three main functions of this expression: propositional ( n = 73/82), relational ( n = 6/82), discursive ( n = 3/82). The most frequent topics raising doctors' "non lo so" were costs ( n = 11/82), treatment-related aspects ( n = 10/82), and timing issues ( n = 9/82). In more than half of the cases ( n = 44/82), present issues emerged. The majority ( n = 70/82) of "non lo so" was framed using the "I," with doctors' taking personal responsibility. Patients played a role in these expressions from doctors: Patients initiated more than one third of them, and in one fourth of the cases, patients followed up immediately., Conclusion: Our findings may be related to characteristics of the specific field of ART. Doctors in this setting must frequently express a direct lack of knowledge to their patients, and when they do, they mean it literally. Patients contribute to such disclosures, and their responses suggest that they find them acceptable, showing that they may expect limitations in their potential to conceive., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Menichetti, Gerwing, Borghi, Gulbrandsen and Vegni.)

Background: During discharge from hospital, older patients and physicians discuss the plan for managing patients' health at home. If not followed at home, it can result in poor medication management, readmissions, or other adverse events. Comorbidities, polypharmacy and cognitive impairment may create challenges for older patients. We assessed discharge conversations between older in-patients and physicians for treatment plan activities and medication information, with emphasis on the role of cognitive function in the ongoing conversation., Methods: We collected 11 videos of discharge consultations, medication lists, and self-reported demographic information from hospitalised patients ≥65 years at the Geriatric department in a general hospital. Mini Mental State Examination score < 25 was classified as low cognitive function. We used microanalysis of face-to-face dialogue to identify and characterise sequences of interaction focused on and distinguishing the treatment plan activities discussed. In addition to descriptive statistics, we used a paired-sample t-test and Mann-Whitney U test for non-parametric data., Results: Patients' median age was 85 (range: 71-90);7 were females and 4 males. Median of 17 (range: 7 to 23) treatment plan activities were discussed. The proportions of the activities, grouped from a patient perspective, were: 0.40 my medications, 0.21 something the hospital will do for me, 0.18 someone I visit away from home, 0.12 daily routine and 0.09 someone coming to my home. Patients spoke less (mean 190.9 words, SD 133.9) during treatment plan activities compared to other topics (mean 759 words, SD 480.4), (p = .001). Patients used on average 9.2 (SD 3.1) medications; during the conversations, an average of 4.5 (SD 3.3) were discussed, and side effects discussed on average 1.2 (SD 2.1) times. During treatment plan discussions, patients with lower cognitive function were less responsive and spoke less (mean 116.5 words, SD 40.9), compared to patients with normal cognition (mean 233.4 words, SD 152.4), (p = .089)., Conclusion: Physicians and geriatric patients discuss many activities during discharge conversations, mostly focusing on medication use without stating side effects. Cognitive function might play a role in how older patients respond. These results may be useful for an intervention to improve communication between physicians and older hospitalised patients.

Patient-clinician interactions are central to technical and interpersonal processes of medical care. Video recordings of these interactions provide a rich source of data and a stable record that allows for repeated viewing and analysis. Collecting video recordings requires navigating ethical and feasibility constraints; further, realizing the potential of video requires specialized research skills. Interdisciplinary collaborations involving practitioners, medical educators, and social scientists are needed to provide the clinical perspectives, methodological expertise, and capacity needed to make collecting video worthwhile. Such collaboration ensures that research questions will be based on scholarship from the social sciences, resonate with practice, and produce results that fit educational needs. However, the literature lacks suggested practices for building and sustaining interdisciplinary research collaborations involving video data. In this paper, we provide concrete advice based on our experience collecting and analyzing a single set of video-recorded clinical encounters and non-video data, which have so far yielded nine distinct studies. We present the research process, timeline, and advice based on our experience with interdisciplinary collaboration. We found that integrating disciplines and traditions required patience, compromise, and mutual respect; learning from each other enhanced our enjoyment of the process, our productivity, and the clinical relevance of our research., Competing Interests: Declaration of Competing Interest No authors have any conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aims: Polish migration to Norway is a relatively new phenomenon. Many Polish migrants do not speak Norwegian or have insufficient knowledge of the language, which makes it difficult or impossible to communicate with health personnel. The main aim of the study was to identify barriers and facilitators to Polish migrants' access and use of interpreter services in health care settings in Norway. Methods : Nineteen semi-structured interviews with Polish migrants were carried out in 2013 and 2014. Thematic analysis was performed to identify barriers and facilitators related to the use of interpreter services. Results : Participants often received information regarding their health condition and treatment in a language they did not fully understand. They reported that their access to interpretation services was limited or denied for a variety of reasons, such as reluctance of health personnel to book an interpreter and overestimation of patient's language skills. In many cases, using friends, relatives or bilingual staff instead of professional interpreters compromised the quality of interpretation. Conclusions : Even though migrants are entitled to free interpreter services, Polish migrants experience several barriers accessing interpreters in health care settings. A variety of practices such as selective use and use of unqualified and ad hoc interpreters reveals a failure to meet recommended standards of interpretation services. Not involving professional interpreters in language-discordant consultations constitutes a serious threat to practitioners' ability to work as competent professionals, potentially risking the quality and safety of health care for these patients.

With increasing global migration, health care providers and patients may lack a shared language. Interpreters help to secure understanding. Doctors and patients cannot evaluate how the interpreter translates their utterances; however, they can see hand movements, which can provide a window into the interpretation process. While research on natural language use has acknowledged the semiotic contribution of co-speech gestures (i.e., spontaneous hand and arm movements that are tightly synchronized with speech), their role in interpreted interactions is unstudied. We aimed to reveal whether gestures could shed light on the interpreting process and to develop a systematic methodology for investigating gesture-use in interpreted encounters. Using data from authentic, interpreted clinical interactions, we identified and analyzed gestures referring to the body (i.e., body-oriented gestures). Data were 76 min of video-recorded doctor-patient consultations at two UK inner-city general practices in 2009. Using microanalysis of face-to-face dialogue, we revealed how participants used body-oriented gestures and how interpreters transmitted them. Participants used 264 body-oriented gestures (doctors = 113, patients = 54, interpreters = 97). Gestures served an important semiotic function: On average, 70% of the doctors' and patients' gestures provided information not conveyed in speech. When interpreters repeated the primary participants' body-oriented gestures, they were highly likely to accompany the gesture with speech that retained the overall utterance meaning. Conversely, when interpreters did not repeat the gesture, their speech tended to lack that information as well. A qualitative investigation into the local effect of gesture transmission suggested a means for quality control: visible discrepancies in interpretation generated opportunities to check understanding. The findings suggest that clinical communication training could benefit from including skills to understand and attend to gestures. The analysis developed here provides a promising schema and method for future research informing clinical guidelines and training., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: Occasionally mishaps in an investigation lead to new understandings. We report how a videotaped emotional discussion among a family after they had received information about their relative's state gave us insight into the minute sources of uncertainty that fueled their confusion., Methods: Based on the themes of the family's discussion, we used a forensic approach to locate distinct sequences of interest in the video and transcript. Microanalysis of face-to-face dialogue was performed to understand the most critical sequence. The analysis was supported by questionnaire data., Results: The family's disagreement about the patient's prognosis could be traced to minor differences in how the surgeon and the anesthesiologist had framed the information. In attempting to resolve apparent contradictions, the family realized they were uncertain about the physicians' roles, which amplified the emotional expressions in the discussions. Role confusion could be traced to subtle details in the surgeon's presentation of himself and the surgery., Conclusion: Minor discrepancies in how health care professionals frame information combined with not exploring relatives' emotions may lead to major differences in relatives' perceptions. Doubt about health providers' roles decontextualizes information and reassurance, magnifying uncertainty., Practice Implications: Health providers should present themselves clearly without haste. If more than one provider is involved, joint preparation of the main messages may be necessary., (Copyright © 2017. Published by Elsevier B.V.)

In 2015, at the International Conference on Communication in Healthcare in New Orleans, USA, we formed a symposium panel to discuss and debate how interdisciplinary research can inform interpreter-mediated medical consultation training. In all our work, a recurring theme is not just the strengths but also the shortcomings of the guidelines proposed in the textbooks and widely used in medical education. This paper is an account of our multidisciplinary reflections on a prominent issue of the lack of attention to interaction in communications, which shed light on the limitations of these guidelines and clinical communication models. We propose that an international network be established for all stakeholders to foster interprofessional and interdisciplinary collaboration for research and clinical interventions, and to inform training and policy making., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: To explore how language barriers influence communication and collaboration between newly-employed international medical doctors and Norwegian health personnel., Methods: Interviews were conducted with 16 doctors who had recently started working in Norway and 12 Norwegian born health personnel who had extensive experience working with international medical doctors. Analyses were consistent with principles of systematic text condensation., Results: All participants experienced that language barriers caused difficulties in their everyday collaboration. Furthermore, the participants' descriptions of "language barriers" encompassed a wide range of topics, including semantics (e.g., specialized professional vocabulary, system knowledge), pragmatics (e.g., using language in doctor-patient and interprofessional interactions), and specific culturally sensitive topics. All participants described that language barriers provoked uncertainty about a doctor's competence., Conclusion: Newly employed international medical doctors and their colleagues are concerned by ineffective communication due to language barriers. Experiences of language barriers threaten professional identity as a competent and effective doctor., Practice Implications: Newly employed doctors who are non-native speakers could benefit from support in understanding and handling the array of barriers related to language., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation., Methods: From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM., Results: Though the physician did extensive interactional work to secure the patient's understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient's participation. In ratings of PCC and SDM, this case scored well above average., Conclusion: Despite the fact that this encounter displays some of the 'best actual practice' of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement., Practice Implications: When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: Physicians and patients discuss treatment plans. If tasks within plans are not described adequately, patients cannot adhere. We evaluated task descriptions, testing whether patient engagement and language barriers affected task clarity., Method: We sampled 12 videotaped hospital interactions from a corpus of 497: two encounters each from six hospital physicians, interacting with one native-speaking and one non-native-speaking patient. We used microanalysis of face-to-face dialogue to assess whether the physicians and patients achieved a complete, clear description of each task's three core information elements (who should do what and when)., Results: We conducted detailed analysis on 78 of the 90 tasks. Core information elements were complete in 62 (0.79) and clear in 37 (0.47). Language barriers had no effect on task clarity. When native-speaking patients were engaged, tasks were clearer (p<0.05). Although non-native-speaking patients were significantly more engaged (p<0.01), their engagement had no effect., Conclusion: Physicians may be pursuing patients' agreement, motivation, and commitment at the expense of working with the patient to be clear about what needs to be done., Practice Implications: Physicians need to improve how clearly they present basic task information. Previous research demonstrated that even a short course can significantly improve the clarity of instructions., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Gestures' semiotic role in clinical interactions is unexplored. Using theoretical underpinnings from basic research on gesture, our objective was to investigate the semantic contributions of physicians' gestures during interactions with patients with a different native language., Methods: We analyzed gestures-speech composites in eight videotaped interactions between physicians and patients during treatment plan discussions. Using microanalysis of face-to-face dialogue and conversation analysis, we identified physicians' gestures, decided whether they served semantic functions, and explored their relationship with the accompanying speech., Results: Using the operational definitions developed here resulted in high reliability. Physicians gestured at a mean rate of 6.5 gestures per 100 words. Approximately half of the gestures served semantic functions, with referents that were concrete (e.g., actions, body parts) and abstract (e.g., regularity, timelines). Gestures conveyed topic information, but speech conveyed information about that topic and context for interpreting gestures' meaning., Conclusion: Analyzing the semantic functions of gestures in clinical interactions is feasible. Physicians' gestures and speech formed integrated messages; the two modalities conveyed mutually dependent meanings., Practice Implications: Physicians could become aware of the semiotic potential of gestures. However, conversational gestures lack conventional meanings and rely on the accompanying speech to provide necessary context for interpreting their meaning., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To explore how physician efforts to involve patients in medical decisions align with established core elements of shared decision making (SDM)., Methods: Detailed video analysis of two hospital outpatient encounters, selected because the physicians exhibited much effort to involve the patients in decision making, and because the final decisions were not what the physicians had initially recommended. The analysis was supplied by physician, patient, and observer-rated data from a total of 497 encounters collected during the same original study. The observer-rated data confirmed that these physicians demonstrated above average patient-centred skills in this material., Results: Behaviours of these two not trained physicians demonstrated confusion about how to perform SDM. Information provided to the patients was imprecise and ambiguous. Insufficient patient involvement did not prompt the physicians to change strategy. Physician and patient reports indicated awareness of suboptimal communication., Conclusion: Inadequate SDM in hospital encounters may introduce confusion. Quantitative evaluations by patients and observers may reflect much effort rather than process quality., Practice Implications: SDM may be discredited because the medical community has not acquired the necessary skills to perform it, even if it is ethically and legally mandated. Training and supervision should follow regulations and guidelines., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Gerwing, Julia (The University of British Columbia, Vancouver, Canada), Claude E. Dolman, and David A. Arnott. Activation phenomenon of Clostridium botulinum type E toxin. J. Bacteriol. 84:302-306. 1962-Highly purified preparations of both nonactivated and trypsin-activated type E botulinus toxins have been analyzed in an ultracentrifuge. Untreated botulinus type E toxin was found to have a sedimentation constant (S(20,w)) of 5.6 Svedberg units, whereas trypsin-activated toxins would not form a boundary under identical conditions. These and other considerations indicate that the mechanism of tryptic activation involves a fragmentation process whereby more toxic sites become exposed.

Gerwing, Julia (The University of British Columbia, Vancouver, British Columbia, Canada), Claude E. Dolman, M. E. Reichmann, and Hardial S. Bains. Purification and molecular weight determination of Clostridium botulinum type E toxin. J. Bacteriol. 88:216-219. 1964.-A method was developed whereby type E botulinus toxin can be obtained in a highly purified state by elution through acidified diethylaminoethyl-cellulose columns. The material thus isolated appears to be electrophoretically and ultracentrifugally homogeneous. A molecular weight of 18,600 was calculated for the toxin.

Gerwing, Julia (University of British Columbia, Vancouver, B.C., Canada), Claude E. Dolman, and Arthur Ko. Mechanism of tryptic activation of Clostridium botulinum type E toxin. J. Bacteriol. 89:1176-1179. 1965.-The toxic peptide of trypsin activated Clostridium botulinum type E toxin was purified by chromatography through columns packed with Sephadex G-75 and G-50. The molecular weight of the active peptide was estimated to lie between 10,000 and 12,000. Amino acid analyses indicated that the active peptide had lost at least 18 of the amino acid residues present in the original protein. The active peptide and the original protein were found to have different N-terminal amino acid residues. The mechanism of tryptic activation apparently involves chiefly the removal of amino acids from the N-terminus of the toxin molecule.

The synthesis and nature of the toxin of Clostridium botulinum type B were studied in growing cells. It was demonstrated that the toxin was synthesized in the latter stage of logarithmic growth and was released into the culture supernatant fluid during lysis of the cells. Studies were done on the sedimentation properties of intracellular toxin. Two components were demonstrated, one of low molecular weight and low specific activity and one of high molecular weight with specific activity similar to that isolated from culture lysates. The high molecular weight toxin was shown to be composed of an aggregate of small subunits, separable with either high ionic strength or sodium dodecyl sulfate.