Diversity in Clinical Psychology

Clinical psychology is not as diverse as society, and the generalizability of clinical psychology to diverse groups has largely been untested. Some progress has been made in increasing the number of ethnic minorities receiving PhD degrees in clinical psychology and in increasing ethnic minority representation in clinical trials. Nevertheless, clinical psychologists and clinical psychology research are not diverse. A stages of change model may be useful in motivating clinical psychologists to diversify. A future scenario involving inertia and a second involving change are offered.     

一种面向诊疗协议的知识表达及转化方法

基于最佳循证依据来规范医疗行为,能够有效提高医疗质量和保障医疗安全。而各类循证医学诊疗协议（如标准医嘱集和临床路径）,在临床实践中并未得到普遍认可和广泛利用,其中一个重要原因是诊疗协议在临床信息环境中被简化为套餐式的医嘱集,缺乏对于个体的适应性和复杂知识的执行力,因此被临床工作者称为“菜谱医疗”。本论文提出一种诊疗协议的知识表达和转化方法,在支持传统规范化表达的临床诊疗协议的同时,能够管理、调用和集成各类个性化的临床决策支持应用,以支持个性化执行和完成复杂医学知识的转化。基于此方法设计和实现了一个临床知识转化平台,通过与临床信息系统的集成可以智能推荐诊疗方案,并提供可扩展的个性化执行环境,允许以插件的形式转化复杂临床循证知识,为个性化和精细化的循证医疗提供了一种技术解决方案。     

The meanings and measurement of clinical significance.

The previous articles in this special section make the case for the importance of evaluating the clinical significance of therapeutic change, present key measures and innovative ways in which they are applied, and more generally provide important guidelines for evaluating therapeutic change. Fundamental issues raised by the concept of clinical significance and the methods discussed in the previous articles serve as the basis of the present comments. Salient among these issues are ambiguities regarding the meaning of current measures of clinical significance, the importance of relating assessment of clinical significance to the goals of therapy, and evaluation of the construct(s) that clinical significance reflects. Research directions that are discussed include developing a typology of therapy goals, evaluating cutoff scores and thresholds for clinical significance, and attending to social as well as clinical impact of treatment.     

Allergen-specific immunotherapy: which outcome measures are useful in monitoring clinical trials?

Various clinical outcome measures are commonly applied in clinical trials on specific immunotherapy for allergic rhinoconjunctivitis with or without asthma to provide evidence of its clinical efficacy. These "primary endpoints" measure clinical symptoms as well as the use for concomitant medication. "Secondary outcome endpoints" are represented by health-related quality of life (HRQoL), "well-days," provocation-tests, in vitro tests and others. This article reviews different methods assessing the clinical outcome of trials on both subcutaneous and sublingual immunotherapy, and highlights potential advantages and drawbacks of each method.     

Lectins and their application to clinical microbiology.

Lectins are generally associated with plant or animal components, selectively bind carbohydrates, and interact with procaryotic and eucaryotic cells. Lectins have various specificities that are associated with their ability to interact with acetylaminocarbohydrates, aminocarbohydrates, sialic acids, hexoses, pentoses, and as other carbohydrates. Microbial surfaces generally contain many of the sugar residues that react with lectins. Lectins are presently used in the clinical laboratory to type blood cells and are used in a wide spectrum of applications, including, in part, as carriers of chemotherapeutic agents, as mitogens, for fractionation of animal cells, and for investigations of cellular surfaces. Numerous studies have shown that lectins can be used to identify rapidly certain microorganisms isolated from a clinical specimen or directly in a clinical specimen. Lectins have been demonstrated to be important diagnostic reagents in the major realms of clinical microbiology. Thus, they have been applied in bacteriology, mycology, mycobacteriology, and virology for the identification and/or differentiation of various microorganisms. Lectins have been used successfully as epidemiologic as well as taxonomic markers of specific microorganisms. Lectins provide the clinical microbiologist with cost-effective and potential diagnostic reagents. This review describes the applications of lectins in clinical microbiology.     

Clinical trial: a clinician's perspective

As a result of my participation in several clinical trials at The University of Iowa, I have now redrawn what I perceive to be the algorithm for conduct of a clinical trial. Of note, I have excluded the development of the new device, in vitro device testing, in vivo animal experimentation, clinical protocol development, granting of an Investigational Device Exemption, and the process by which clinical sites are selected. Following my algorithm I have made no mention of the commercialization of an experimental device, including the Pre-Market Approval process and FDA panel meetings. In summary, I believe there are a variety of reasons why a principal investigator would choose to participate in a clinical trial. With tongue in cheek, I would offer fame and fortune as two possible motivating factors. Obviously, both are double-edged swords. Should a trial not turn out as hoped, celebrity can instantly turn to notoriety. With respect to fortune, administrative and clinical activity performed by the principal investigator on behalf of the clinical trial does not generate income, and, in fact, can place a considerable financial drain on the investigator's department. I believe that investigators are strongly driven by intellectual curiosity, but it is important to maintain perspective when participating in a clinical trial. The real reason we seek clinical trial site designation is to allow us to offer new, innovative therapeutic modalities to our patients. By so doing, it is imperative that we conduct the clinical trial in as thoughtful and as safe a manner as possible, with our patients' well being always foremost in our minds.     

Clinician to frontline soldier: a look at the roles and challenges of army clinical psychologists in Iraq

Psychologists have a long and respected history of service during wartime that dates back to World War I. From the early days of scientific personnel selection, clinical psychologists have made a number of wartime contributions. Today, Army clinical psychologists serving in Iraq are providing behavioral health services as both clinicians and prevention specialists in order to meet the psychological and emotional needs of service members abroad. They are also performing as Army officers and soldiers contributing to the success of military operations as a whole. The authors, two clinical psychologists and Army officers currently deployed to Iraq, provide a small glimpse into the clinical and personal opportunities and challenges faced by wartime Army clinical psychologists.     

Clinical guidelines: their implementation in general practice.

In recent years the development of clinical guidelines has received increasing attention from medical educators and those involved in standard setting, and has been initiated at both central and local levels. This review article outlines the current state of knowledge with regard to clinical guideline implementation in medical practice. It deals with the main aspects of the current guideline debate, such as, clinical freedom and doctor autonomy, the importance of ownership in guideline implementation, the effectiveness of guidelines in changing practice and, in particular, the strategies needed to implement clinical guidelines in general practice. Mechanisms of behavioural change that have been recognized as being important for implementation are also discussed. If implementation strategies are not treated as an integral part of the development process then clinical guidelines may fail to achieve their potential in changing clinical practice.     

Subtypes, dimensions, levels, and mental states in narcissism and narcissistic personality disorder

Various conceptualizations of subtypes, levels, and dimensions of narcissism and narcissistic personality disorder (NPD) are considered with a particular focus on overt grandiose presentations and covert vulnerable presentations. Evidence supporting this distinction and clinical vignettes to illustrate it are presented as well as their implications for clinical work with NPD patients. The research and clinical evidence points to the conclusion that these broad categorical subtypes are better conceptualized as dimensions on which individual patients vary on relative levels, thus suggesting that grandiose and vulnerable presentations represent two sides of the same coin. A case example and clinical implications are provided and discussed.     

A critical appraisal of 'evidence-based medicine' in allergy and asthma

 Clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They may offer concise instructions on which diagnostic or screening tests to order, stipulate how medical services should be provided, how long patients should stay in hospital, or many other details relevant to clinical practice. This paper argues that guidelines should be simple, adapted to the clinical setting they inform and to treatment availability in their respective geographic context and that they should not be viewed as a yardstick but as support for physicians. The benefits of evidence-based-medicine (EBM), which defines the value of medical interventions in terms of empiric evidence from clinical trials, are growing in many contexts and are well described. Not sufficiently acknowledged, however, are the limits of EBM. A gap still exists between clinical research and clinical practice which should be better recognized and assessed.     

Predicting treatment process steps from events

MotivationThe primary economy-driven documentation of patient-specific information in clinical information systems leads to drawbacks in the use of these systems in daily clinical routine. Missing meta-data regarding underlying clinical workflows within the stored information is crucial for intelligent support systems. Unfortunately, there is still a lack of primary clinical needs-driven electronic patient documentation. Hence, physicians and surgeons must search hundreds of documents to find necessary patient data rather than accessing relevant information directly from the current process step. In this work, a completely new approach has been developed to enrich the existing information in clinical information systems with additional meta-data, such as the actual treatment phase from which the information entity originates.MethodsStochastic models based on Hidden Markov Models (HMMs) are used to create a mathematical representation of the underlying clinical workflow. These models are created from real-world anonymized patient data and are tailored to therapy processes for patients with head and neck cancer. Additionally, two methodologies to extend the models to improve the workflow recognition rates are presented in this work.ResultsA leave-one-out cross validation study was performed and achieved promising recognition rates of up to 90% with a standard deviation of 6.4%.ConclusionsThe method presented in this paper demonstrates the feasibility of predicting clinical workflow steps from patient-specific information as the basis for clinical workflow support, as well as for the analysis and improvement of clinical pathways.     

Role of Bacterial and Fungal Epidemiological Cutoff Values for Antimicrobial Susceptibility Testing in the Microbiology Laboratory

Epidemiological cutoff values (ECVs) are increasingly used in clinical microbiology and public health laboratories. Breakpoint-setting organizations have developed ECVs for bacteria and fungi. ECVs separate organism populations into wild type (WT) and non-wild type (NWT) and are defined according to species. They differ from clinical breakpoints in that clinical outcome and pharmacokinetic/pharmacodynamic data are not taken into account during their development. Thus, ECVs are not predictors of clinical success (or failure) in the patient. Laboratories should never report WT organisms as “susceptible” or NWT organisms as “resistant.” Microbiologists must be aware of the limitations and differences of ECVs as compared to breakpoints, and if ECVs are applied for individual patient care, discussions between the microbiology laboratory and other key health care providers should take place. Clinical report comments aid in interpretation of ECVs.     

A laboratory medicine residency training program that includes clinical consultation and research

We describe a laboratory medicine residency training program that includes ongoing interaction with both clinical laboratories and clinical services as well as significant research experience. Laboratory medicine residents serve as on-call consultants in the interpretation of test results, design of testing strategies, and assurance of test quality. The consultative on-call beeper system was evaluated and is presented as an effective method of clinical pathology training that is well accepted by the clinical staff. The research component of the residency program is also described. Together, these components provide training in real-time clinical problem solving and prepare residents for the changing technological environment of the clinical laboratory. At the completion of the residency, the majority of the residents are qualified laboratory subspecialists and are also capable of running an independent research program.     

Challenges in the application of NGS in the clinical laboratory

Next-generation sequencing (NGS), also known as massively parallel sequencing, has revolutionized genomic research. The current advances in NGS technology make it possible to provide high resolution, high throughput HLA typing in clinical laboratories. The focus of this review is on the recent development and implementation of NGS in clinical laboratories. Here, we examine the critical role of NGS technologies in clinical immunology for HLA genotyping. Two major NGS platforms (Illumina and Ion Torrent) are characterized including NGS library preparation, data analysis, and validation. Challenges of NGS implementation in the clinical laboratory are also discussed, including sequencing error rate, bioinformatics, result interpretation, analytic sensitivity, as well as large data storage. This review aims to promote the broader applications of NGS technology in clinical laboratories and advocate for the novel applications of NGS to drive future research.     

Array-Based Genomics in Glioma Research

Over the years, several relevant biomarkers with a potential clinical interest have been identified in gliomas using various techniques, such as karyotype, microsatellite analysis, fluorescent in situ hybridization and chromosome comparative genomic hybridization. Despite their pivotal contribution to our understanding of gliomas biology, clinical application of these approaches has been limited by technological and clinical complexities. In contrast, genomic arrays (array-based comparative genomic hybridization and single nucleotide polymorphisms array) have emerged as promising technologies for clinical use in the setting of gliomas. Indeed, their feasibility and reliability have been rigorously assessed in gliomas and are discussed in this review. The well-known genomic biomarkers in gliomas are in fact readily and reliably identified using genomic arrays. Moreover, it detects a multitude of new cryptic genomic markers, with potential biological and/or clinical significances. The main studies dedicated to genomic characterization of gliomas using genomic arrays are reviewed here. Interestingly, several recurrent genomic signatures have been reported by different teams, suggesting the validity of these genomic patterns. In light of this, genomic arrays are relatively simple and cost-effective techniques whose implementation in molecular diagnostic laboratories should be encouraged as a valuable clinical tool for management of glioma patients.     

Integrating clinical communication with clinical reasoning and the broader medical curriculum

Objective

The objectives of this paper are to discuss the results of a workshop conducted at EACH 2012. Specifically, we will (1) examine the link between communication, clinical reasoning, and medical problem solving, (2) explore strategies for (a) integrating clinical reasoning, medical problem solving, and content from the broader curriculum into clinical communication teaching and (b) integrating communication into the broader curriculum, and (3) discuss benefits gained from such integration.

Methods

Salient features from the workshop were recorded and will be presented here, as well as a case example to illustrate important connections between clinical communication and clinical reasoning.

Results

Potential links between clinical communication, clinical reasoning, and medical problem solving as well as strategies to integrate clinical communication teaching and the broader curricula in human and veterinary medicine are enumerated.

Conclusion

Participants expressed enthusiasm and keen interest in integration of clinical communication teaching and clinical reasoning during this workshop, came to the idea of the interdependence of these skills easily, and embraced the rationale immediately.

Practice implications

Valuing the importance of communication as clinical skill and embracing the interdependence between communication and thought processes related to clinical reasoning and medical problem solving will be beneficial in teaching programs.     

Beteiligung und Unterstützung klinischer Studien und anderer wissenschaftlicher Untersuchungen

Clinical studies and preclinical investigations are essential in order to test new therapies and diagnostics with the aim of sustained improvement in the treatment of patients. Fortunately, the number of clinical studies is continuously increasing and pathology and tissue-based research are included more often. The German Society for Pathology (DGP) and the pathologists it represents want to and can support this process and our clinical partners as best as possible as an equal partner. With our technologies and our specific expertise we can make a substantial contribution to the quality and the success of preclinical investigations, clinical studies and implementation of the results into clinical pathological diagnostics. In order to support this process the DGP has formulated a statement on the participation and support of clinical studies and other scientific investigations.     

The study of clinical judgment: an ecological approach

Reviews of the clinical judgment literature in psychology frequently conclude that therapists are subject to a number of biases that negatively influence the accuracy of their clinical judgments. As a consequence, therapists seem to be poor decision-makers, a finding that has serious implications for clinical training and practice. We argue that the concept of clinicians as poor decision makers requires considerable clarification. The clinical judgment literature is important, but it suffers from an inadequate framework for understanding different types of judgments and different contexts within which judgments are made. As an initial attempt to clarify some of the complexities inherent in the study of clinical judgment, we discuss a framework borrowed from cognitive psychology that is designed to provide a more comprehensive analysis of the clinical judgment ecology. The model includes: (a) characteristics of the therapist, (b) information processing strategies made available to the therapist, (c) criterial tasks that define the major focus of specific judgments, and (d) the nature of the clinical materials that provide the basis for judgments. These four factors interact to influence therapists' judgments. Implications of the model for research on clinical judgment as well as clinical practice and training are discussed.     

The applicability of experimental experience with the total artificial heart to its clinical use.

Long-term experiments with the total artificial heart (TAH) are a source of valuable knowledge for later clinical application. Our observations result from 66 long-term experiments on calves and one goat ranging from 30 to 314 days, which have shown the main possible complications in the early period (one month) and later in the experiment. Problems until the second month of pumping concern the clinical pendant of the TAH as a bridge for transplantation, i.e. surgical problems, blood coagulation disorders, infection etc. Later problems are high venous pressure or arterial hypertension, infection with septic thromboembolization, mineralization of the driving diaphragm, etc., and are more closely comparable to the conditions of permanent clinical use of the TAH. Faultless surgery, device function and the regimen of pumping are essential factors in every long-term experiment, just as in clinical application. Infection is a threat throughout any experiment, as in clinical cases. The TNS-BRNO-VII/clin/80 TAH has been implanted in six patients.     

Diagnostic accuracy would be improved by developing more categories of “non-disease”

Studies on the ways in which doctors think have shown the importance of intuitive processes in the formulation of a diagnosis. They have also suggested that intuitively generated diagnoses are used to aid the memory of relevant clinical facts during a clinical consultation. Only some symptoms and signs can be ordered into or subsumed under a diagnostic label. Others, which have not been thought of as constituting a disease, will tend to be lost from memory. If a diagnosis were to be thought of, not as the label of a disease but as a mental construct by means of which data are ordered and remembered, that is, as an invention whose utility is to be judged by the degree to which clinical thinking is facilitated, it would become reasonable to develop diagnoses to cover larger areas of clinical phenomenology. Some examples of the usefulness of such diagnoses of “non-disease” are given and it is suggested that clinical thinking might be improved by the wider use of the concept.