Emotional and physiological responses to normative and idiographic positive stimuli in bipolar disorder

Background

Few studies have examined differences in emotional responding among distinct types of positive stimuli. This is important to understand both for individuals characterized by extreme positive mood (i.e., bipolar disorder) and healthy adults.

Methods

Using a multi-method within-subjects design, the current study examined physiological, behavioral, and self-reported responses to normative (film) and idiographic (memory) happy stimuli in bipolar (BD; n = 25) and healthy control groups (CTL; n = 23).

Results

For both groups, the happy films were associated with greater self-reported and behavioral displays of positive emotion compared to the happy memory. Furthermore, the BD group displayed greater cardiac vagal tone - a putative marker of positive emotion - across both the film and memory.

Conclusion

Normative stimuli were more potent elicitors of positive emotion compared to idiographic stimuli. The study provided further evidence for cardiac vagal tone as a potential biomarker of extreme positive emotion in BD.     

Exploring the community pharmacist's role in palliative care: focusing on the person not just the prescription

Objective

Changes in health care provision have led to an emphasis on providing end of life care within the home. community pharmacists are well positioned to provide services to community-based palliative care patients and carers.

Methods

A multiple qualitative case study design was adopted. A total of 16 focus groups and 19 interviews with pharmacists, nurses, general practitioners and carers were undertaken across metropolitan and regional settings in Western Australia, New South Wales, Queensland and Victoria. Data were analysed thematically using a framework that allowed similarities and differences across stakeholder groups and locations to be examined and compared.

Results

Three main themes emerged: effective communication; challenges to effective communication; and: towards best practice, which comprised two themes: community pharmacists’ skills and community pharmacists’ needs.

Discussion

A key component of the provision of palliative care was having effective communication skills. Although community pharmacists saw an opportunity to provide interpersonal support, they suggested that they would need to develop more effective communication skills to fulfil this role.

Conclusion

There is clear need for continuing professional development in this area - particularly in communicating effectively and managing strong emotions.

Practice implications

Community pharmacists are willing to support palliative care patients and carers but need education, support and resources.     

Impact of patient obesity on the patient-provider relationship

Objective

Health professionals’ weight bias may impair obese patients’ interactions with providers. However, few studies have examined how negative provider attitudes affect the patient-provider relationship for obese patients. We hypothesized that higher patient body mass index (BMI) would be negatively associated with patient-provider relationship quality.

Methods

We analyzed data from the 2007 Health Tracking Household Survey. BMI was the independent variable, and patient-perceived quality of the patient-provider relationship was the outcome. We performed log-binominal regression analyses accounting for complex survey design to examine the association of BMI with the patient-provider relationship.

Results

Of the 15,197 adult survey respondents, the 6427 who answered the quality of care questions were eligible for analysis. Overall, 29% had a normal range BMI, 34% were overweight, and 37% were obese. We found few differences in ratings of the patient-provider relationship for overweight and obese respondents when compared to respondents with a normal range BMI.

Conclusion

These unexpected findings may have occurred due to patients’ inability to perceive providers’ weight bias, measurement error in questionnaire items, or decreasing weight bias among health professionals.

Practice implications

Patient's positive perceptions of providers may indicate promise for health professionals acting as motivators of behavior change in obese patients.     

Shared decision making in medicine: The influence of situational treatment factors

Objective

Although shared decision making (SDM) has become increasingly important in bioethical discussions and clinical practice, it is not clear in which treatment situations SDM is suitable. We address this question by investigating social norms on the appropriateness of SDM in different situations.

Methods

We conducted qualitative expert interviews with patients, general practitioners, and health administration and research professionals.

Results

SDM was considered to be most important in severe illness and chronic condition. Furthermore, SDM was indicated to be required if there is more than one therapeutic option, especially if it is not clear which option is best. Interviewees classified end-of-life decisions and decisions about prevention as those that primarily should be made by informed patients. On the other hand a paternalistic decision was considered most appropriate in emergency situations and when the patient does not want to participate in decision making.

Conclusion

This study demonstrates that multiple situational factors and their interactions must be considered regarding the scope of SDM in medical consultation.

Practice implications

Research addressing this question will help physicians adjust their consultation style and allow implementations of SDM and decision aids to be tailored more appropriately to complex treatment situations.     

Beyond reading alone: The relationship between aural literacy and asthma management

Objectives

To examine the relationship between literacy and asthma management with a focus on the oral exchange.

Methods

Study participants, all of whom reported asthma, were drawn from the New England Family Study (NEFS), an examination of links between education and health. NEFS data included reading, oral (speaking), and aural (listening) literacy measures. An additional survey was conducted with this group of study participants related to asthma issues, particularly asthma management. Data analysis focused on bivariate and multivariable logistic regression.

Results

In bivariate logistic regression models exploring aural literacy, there was a statistically significant association between those participants with lower aural literacy skills and less successful asthma management (OR: 4.37, 95%CI: 1.11, 17.32). In multivariable logistic regression analyses, controlling for gender, income, and race in separate models (one-at-a-time), there remained a statistically significant association between those participants with lower aural literacy skills and less successful asthma management.

Conclusion

Lower aural literacy skills seem to complicate asthma management capabilities.

Practice implications

Greater attention to the oral exchange, in particular the listening skills highlighted by aural literacy, as well as other related literacy skills may help us develop strategies for clear communication related to asthma management.     

Serum amylase in bulimia nervosa and purging disorder: differentiating the association with binge eating versus purging behavior

Objective

Elevated serum amylase levels in bulimia nervosa (BN), associated with increased salivary gland size and self-induced vomiting in some patients, provide a possible marker of symptom severity. The goal of this study was to assess whether serum hyperamylasemia in BN is more closely associated with binge eating episodes involving consumption of large amounts of food or with purging behavior.

Method

Participants included women with BN (n = 26); women with “purging disorder” (PD), a subtype of EDNOS characterized by recurrent purging in the absence of objectively large binge eating episodes (n = 14); and healthy non-eating disorder female controls (n = 32). There were no significant differences in age or body mass index (BMI) across groups. The clinical groups reported similar frequency of self-induced vomiting behavior and were free of psychotropic medications. Serum samples were obtained after overnight fast and were assayed for alpha-amylase by enzymatic method.

Results

Serum amylase levels were significantly elevated in BN (60.7 ± 25.4 international units [IU]/liter, mean ± sd) in comparison to PD (44.7 ± 17.1 IU/L, p < .02) and to Controls (49.3 ± 15.8, p < .05).

Conclusion

These findings provide evidence to suggest that it is recurrent binge eating involving large amounts of food, rather than self-induced vomiting, which contributes to elevated serum amylase values in BN.     

Understanding information and education gaps among people with type 1 diabetes: A qualitative investigation

Objective

Many patients with type 1 diabetes struggle to self-manage this chronic disease, often because they have a poor knowledge and understanding of the condition. However, little attention has been paid to examining the reasons for this poor knowledge/understanding. To inform future educational interventions, we explored patients’ accounts of the education and information they had received since diagnosis, and the reasons behind gaps in their diabetes knowledge.

Methods

Semi-structured interviews were conducted with 30 type 1 diabetes patients enrolled on a structured education programme in the UK. Data were analysed using an inductive, thematic approach.

Results

Patients’ accounts illustrated a number of knowledge deficits which were influenced by various lifecourse events. Reasons for deficits included: diagnosis at a young age and assumption of decision-making responsibility by parents; lack of engagement with information when feeling well; transitions in care; inconsistency in information provision; and, lack of awareness that knowledge was poor or incomplete.

Conclusion

Patients’ knowledge deficits can arise for different reasons, at different points in the lifecourse, and may change over time.

Practice implications

The delivery of individualised education should take account of the origins of patients’ knowledge gaps and be provided on a regular and on-going basis.     

Patient preferences for shared decisions: a systematic review

Objectives

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients’ role preferences across measures, time and patient population.

Methods

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

Results

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

Conclusion

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

Practice implications

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.     

Correlating reading comprehension and health numeracy among adults with low literacy

Objective

Using the Test of Functional Health Literacy for Adults (TOFHLA), a pilot study was conducted to assess whether reading comprehension and numeracy scores sufficiently correlate in health contexts among adults with low literacy skills.

Methods

The TOFHLA was administered to 144 adults with low literacy enrolled in a health literacy program prior to the start of coursework. Raw scores for reading and numeracy were calculated. Weighted numeracy scores were calculated and compared to raw reading comprehension scores.

Results

Among 143 participants, 20% (n = 28) had a higher numeracy score than reading comprehension score, while an additional 20% scored lower in numeracy than in reading comprehension.

Conclusion

This study found that reading comprehension and numeracy skill in the context of understanding health information do not necessarily correlate for specific disadvantaged groups. This finding calls attention to the need to further examine numeracy as a construct which is conceptually separate from reading comprehension, and highlights the importance of including a numerate component in health literacy evaluations.

Practice implications

The results of this study have important implications for medical decision-makers, health educators, and health promoters working with traditional methods of assessing health literacy.     

Neurocognitive impairment in adolescent major depressive disorder: state vs. trait illness markers

Background

Current treatment outcomes of Major Depressive Disorder (MDD) in adolescents remain suboptimal. Discriminating between state and trait markers of MDD in adolescents would help identify markers that may guide choice of appropriate interventions and help improve longer-term outcome for individuals with the illness.

Methods

We compared neurocognitive performance in executive function, sustained attention and short-term memory in 20 adolescents with MDD in acute episode (MDDa), 20 previously depressed adolescents in remission (MDDr) and 17 healthy control participants (HC).

Results

There was a group difference that emerged for executive function with increasing task difficulty (p = 0.033). MDDa showed impaired executive function, as measured by using more moves to solve 4-move problems on a forward planning task, relative to MDDr and HC (p = 0.01, d = 0.94 and p = 0.015, d = 0.77 respectively). MDDa showed more impulsivity as measured by lower response bias (B″) on a sustained attention task than both MDDr and HC (p = 0.01, d = 0.85 and p = 0.008, d = 0.49 respectively). Higher impulsivity was associated with more severe depression (r = − 0.365, p = 0.022) and earlier age of onset of depression (r = 0.402, p = 0.012) and there was a trend for a correlation between more executive dysfunction and more severe depression (r = 0.301 p = 0.059) in MDDa and MDDr combined. The three groups did not differ significantly on short-term memory or target detection on the sustained attention task.

Limitation

These results need to be replicated in the future with a larger sample size.

Conclusion

Executive dysfunction and impulsivity appear to be state-specific markers of MDD in adolescents that are related to depression severity and not present in remission.     

Emotional cues and concerns in hospital encounters with non-Western immigrants as compared with Norwegians: an exploratory study

Objective

To identify potential barriers in communication with non-Western immigrant patients by comparing the frequency and nature of emotional cues and concerns, as well as physician responses during consultations, between ethnically Norwegian patients and immigrant patients in a general hospital setting.

Methods

Consultations with 56 patients (30 non-Western immigrants and 26 ethnic Norwegians) were coded using the Verona Coding Definitions of Emotional Sequences (VR-CoDES) and the Verona Codes for Provider Responses (Verona Codes-P).

Results

There were no significant differences in frequencies of cues and concerns between immigrant and Norwegian patients. However, the immigrant patients with high language proficiency expressed more concerns compared to immigrant patients with language problems and Norwegian patients. Moreover, more concerns were expressed during consultations with female physicians than with male physicians.

Conclusion

Expression of cues and concerns in immigrant patients is dependent on the patient's language proficiency and the physician's gender.

Practice implications

Providers should recognize that immigrant patients may have many emotional cues and concerns, but that language problems may represent a barrier for the expression of these concerns.     

Auditory hallucinations and the P3a: Attention-switching to speech in schizophrenia

Background

In line with emerging research strategies focusing on specific symptoms rather than global syndromes in psychiatric disorders, we examined the functional neural correlates of auditory verbal hallucinations (AHs) in schizophrenia. Recent neuroimaging and behavioural evidence suggest altered early cognitive processes may be seen in patients with AH as a result of limited processing resources.

Methods

The P3a subcomponent of the P300, an event-related potential (ERP) index of early attention switching, was assessed in 12 hallucinating patients (HP), 12 non-hallucinating patients (NP) and 12 healthy controls (HC) within a passive two-tone auditory oddball paradigm using vowel phonemes. P3a amplitudes and latencies were measured in response to across-phoneme changes. Following P3a acquisition, patients indicated the duration, intensity and clarity of their auditory hallucinations during recording.

Results

Hallucinating patients exhibited smaller P3a amplitudes than non-hallucinating patients and healthy controls. In HPs, P3a amplitude was negatively correlated with AH trait scores.

Significance

These findings suggest that AHs are associated with impaired processing of speech as evidenced by altered P3a amplitudes to vowel phonemes. This finding may be due to limited cognitive resources available for incoming external stimuli due to a usurping of finite resources by AHs. The P3a may be a useful non-invasive tool for probing relationships between hallucinatory and neural states within schizophrenia and the manner in which auditory processing is altered in these afflicted patients.     

Reduced long distance gamma (28-48 Hz) coherence in euthymic patients with bipolar disorder

Background

EEG coherence represents the brain's functional connectivity. Synchronous neural gamma oscillations are critical for cortico-cortical communication and large-scale integration of distributed sets of neurons. We investigated long distance gamma (28-48 Hz) coherence in bipolar disorder.

Methods

Sensory evoked coherence (EC) and event related coherence (ERC) values for the gamma frequency band during simple light stimulation and visual odd-ball paradigm was assessed in 20 drug-free euthymic bipolar patients in comparison to healthy controls. Groups were compared for the coherence values of the left (F₃-T₃, F₃-TP₇, F₃-P₃, F₃-O₁) and right (F₄-T₄, F₄-TP₈, F₄-P₄, F₄-O₂) intra-hemispheric electrode pairs by means of a repeated measure analysis of variance (ANOVA) and t-tests.

Results

Patients showed significantly lower gamma coherence values in response to target stimuli than the healthy controls between left and right fronto-temporal, as well as between frontal and temporo-parietal electrode pairs. Coherence values for the non-target stimuli were significantly lower in the patients than the healthy controls between frontal and temporo-parietal regions on both right and left sides. EP coherence values did not differ significantly between the groups.

Limitations

A relatively small sample size is the major limitation of the study.

Conclusions

Bipolar patients present disturbance in functional long-range connectivity between the frontal and temporal as well as temporo-parietal brain structures during a cognitive paradigm requiring attention and immediate recall. The location of the connectivity disturbance corresponds to the underlying neurobiology of executive function, memory and attention impairments in bipolar disorder and raises the question of whether gamma coherence reduction may be a candidate biomarker for bipolar disorder.     

Bulimia nervosa and evidence for striatal dopamine dysregulation: a conceptual review

Objective

This article reviews concepts and evidence, based in particular on the work of Bartley G. Hoebel and colleagues, which suggest that a better understanding of the role of striatal dopamine (DA) in the initiation and/or maintenance of bulimia nervosa (BN) may result in a clearer characterization of mechanisms underlying BN.

Methods

Literature review, using PubMed search.

Results

Several lines of evidence, including the work of Bartley G. Hoebel, implicate the importance of striatal DA in feeding behavior, as well as in the disordered eating behaviors relevant to BN. Preclinical models of ‘BN-like’ eating behaviors have been associated with changes in striatal DA and DA receptor measures. Emerging clinical research also suggests that striatal DA abnormalities exist in individuals with BN.

Conclusion

Alterations in striatal DA may exist in patients with BN. While the precise relationship between these findings and the etiology and maintenance of bulimic symptomatology remains unclear, further investigation of brain DA systems is a fruitful avenue of future research in BN.     

Parotitis associated with Crimean Congo hemorrhagic fever virus

Background

Crimean Congo Hemorrhagic Fever (CCHF) is a potentially fatal tick-borne viral disease, the course of which may accompanied by various clinical findings.

Objectives

We describe a picture of non-suppurative parotitis developing in association with CCHF virus.

Study design

A 48-year-old patient presenting to our hospital with lethargy, hemorrhage and pain and swelling below the left ear was diagnosed with CCHF through IgM antibody and polymerase chain reaction positivity in serum investigated for CCHF virus. A picture of non-suppurative parotitis developed on the 3rd day of admission.

Results

Other causes of parotitis were excluded with the help of serological tests, and the case was regarded as one of CCHF-associated parotitis. The patient was put on adjuvant therapy, an improvement in clinical findings was observed and he was discharged in a healthy condition on the 8th day.

Conclusions

Ours is the first case in the literature of parotitis seen during CCHF. CCHF should be considered in differential diagnosis in addition to other frequently encountered viral agents in patients from endemic regions presenting with a picture of non-suppurative parotitis.     

Desire for autonomy in health care decisions: A general population survey

Objective

To examine factors associated with desire for autonomy in health care decisions in the general population.

Methods

Mailed survey of 2348 residents of Geneva, Switzerland. Participants answered questions on a scale measuring their desire for autonomy in health care decisions. The scale was scored between 0 (lowest desire for autonomy) and 100 (highest desire for autonomy).

Results

On average the respondents favoured shared or active involvement in medical decisions (mean score 62.0, SD 20.9), but attitudes varied considerably. In the multivariate model, factors associated with a higher desire for autonomy included female gender, younger age, higher education, living alone, reporting an excellent global health and - a new observation compared to previous studies - having made several medical decisions in the past 6 months.

Conclusions

The attitudes of the general public appear to be consistent with the model of shared decision making. However, people vary considerably in their desire for autonomy.

Practice implications

An explicit assessment of each individual's desire for autonomy may improve the decision-making process. Such an assessment should be repeated regularly, as familiarity with medical decisions may increase the desire for autonomy.     

The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: The DISTANCE study

Objective

To assess the association of limited English proficiency (LEP) and physician language concordance with patient reports of clinical interactions.

Methods

Cross-sectional survey of 8638 Kaiser Permanente Northern California patients with diabetes. Patient responses were used to define English proficiency and physician language concordance. Quality of clinical interactions was based on 5 questions drawn from validated scales on communication, 2 on trust, and 3 on discrimination.

Results

Respondents included 8116 English-proficient and 522 LEP patients. Among LEP patients, 210 were language concordant and 153 were language discordant. In fully adjusted models, LEP patients were more likely than English-proficient patients to report suboptimal interactions on 3 out of 10 outcomes, including 1 communication and 2 discrimination items. In separate analyses, LEP-discordant patients were more likely than English-proficient patients to report suboptimal clinician-patient interactions on 7 out of 10 outcomes, including 2 communication, 2 trust, and 3 discrimination items. In contrast, LEP-concordant patients reported similar interactions to English-proficient patients.

Conclusions

Reports of suboptimal interactions among patients with LEP were more common among those with language-discordant physicians.

Practice implications

Expanding access to language concordant physicians may improve clinical interactions among patients with LEP. Quality and performance assessments should consider physician-patient language concordance.     

Goal difficulty and goal commitment affect adoption of a lower glycemic index diet in adults with type 2 diabetes

Objective

Few studies have examined the effect of goal difficulty on behavioral change even though goal setting is widely used in diabetes education. The effect of a goal to consume either 6 or 8 servings/day of low glycemic index (LGI) foods was evaluated in this study.

Methods

Adults 40-65 years old with type 2 diabetes were randomly assigned to the 6 or 8 serving/day treatment group following a 5-week GI intervention. Perceived goal difficulty, commitment, satisfaction, and self-efficacy were evaluated, and four day food records assessed dietary intake.

Results

Both groups increased consumption of LGI foods (P < 0.001); there were no significant differences in the change in consumption between groups. Participants who were more committed to the goal perceived the goal to be less difficult (P < 0.01). Those with greater efficacy beliefs were more committed to their goal, perceived the goal to be less difficult, and were more satisfied with their performance (all P < 0.05).

Conclusion

A specific goal regarding LGI foods can facilitate the adoption of a lower GI diet. Future research is needed to determine if goal commitment or goal difficulty mediate the process.

Practice implications

Clinicians should help clients set specific goals regarding dietary change.