Therapeutic alliance and multiple psychotherapy in the context of therapist rotation: Experiences with OLITA

Despite a long tradition of client-centered approaches in addiction therapy, these approaches have not been broadly applied until the 90s of the last century, since treatment programs were predominantly based on behavior therapy. However, due to dissemination of and research on motivational interviewing (MI) over the last 20 years, client-centered therapy has become increasingly accepted in routine care of patients with substance use disorders. Originally, W. R. Miller and S. Rollnick did not establish MI as a brief intervention. Nevertheless, research on MI has mainly been performed within the context of brief interventions. As a consequence, empirically supported client-centered interventions that are based on long-term treatment are largely missing in addiction therapy. OLITA, the Outpatient Long-term Intensive Therapy for Alcoholics, may be one of few exceptions. OLITA is a comprehensive long-term treatment program that is fully compatible with the principles of MI and that combines elements of client-centered and behavior therapy. This review article presents a synopsis of the published literature on OLITA, focusing on aspects of therapeutic alliance and multiple psychotherapy. After a short introduction of the therapy program, we delineate how client-centered therapy is integrated in the context of therapist rotation. The most important data on process–outcome research in OLITA are summarized. Our results suggest that the therapeutic alliance is a major treatment factor that is strongly associated with the eight treatment processes of the TOPPS (Therapy Orientation by Process Prediction Score) that, in turn, is highly predictive of long-term alcohol abstinence. Based on experience of clinical care and training of OLITA therapists, we show in the practical part of this article how to implement therapist rotation and multiple psychotherapy, as well as how to apply communication and interaction skills to build a successful working alliance.     

Evaluating how electronic charting affects resident productivity

Electronic medical records (EMRs) are becoming standard to improve the communication of information and longevity of patient records. Using an EMR in the emergency department (ED) could potentially slow residents evaluating patients. We evaluated how introducing an EMR affected resident productivity in an academic ED. We retrospectively studied first year emergency medicine residents from a large, academic, tertiary care center before-and-after the institution of an EMR on July 1st, 2010. No residents from the 2009–2010 class used the EMR, while all of the 2010–2011 residents used the EMR. We performed univariate and multivariate analyses using productivity, measured in patients per hour (pt/hr), as the primary outcome. A mixed-model multivariate regression, stratified by acuity zone, was created incorporating EMR and other possible confounders: admissions, signouts, daily ED volume, and days after July 1st for each shift. The study was granted IRB waiver of informed. We reviewed 2,405 shifts: 1,259 shifts before and 1,146 shifts after EMR implementation. When using the EMR, the univariate analysis estimated a 0.084 pt/hr increase in the high acuity zone (p = 0.1317) and 0.029 pt/hr decrease (p = 0.7085) in the low acuity zone. The multivariate regression estimated a 0.038 pt/hr increase (p = 0.3413) in the high acuity zone and a 0.009 pt/hr increase (p = 0.9049) in the low acuity zone with the EMR. Despite the expectation that electronic charting is detrimental to resident productivity, our analyses do not suggest a significant relationship between resident productivity and using the EMR.     

Rapid and reliable detection of previous freezing of cerebral tissue by computed tomography and magnetic resonance imaging

Due to slowing or even inhibition of postmortem processes, freezing may make an estimation of the time-since-death very difficult. This is also true in previously frozen and subsequently thawed bodies. Knowledge of prior freezing is important, as it may lead to a different assessment of the time since death. Twelve pig heads were frozen at ?20 °C, and 6 heads were either kept at room temperature (approximately 20 °C) or in a cooling cell (approximately 5 °C). The frozen brains and cadavers were thawed at either room temperature or in a cooling cell. All specimens underwent repeated CT and MRI scanning until the brains were sampled for histological examination. Two radiologists assessed the images and two pathologists reviewed the histological slides with regard to thawing artifacts and putrefaction. All raters were blinded regarding whether the samples had been frozen, for how long and how they had been thawed. Imaging revealed distinct, tiny bubble-like artifacts only in previously frozen specimens. Histology also revealed artifacts only seen in such cases, namely very distinct, columnar bubbles in the cerebral cortex. All raters successfully identified previously unfrozen brains (100% specificity) and nearly all previously frozen brains. Our results suggest that initial post-mortem imaging can be of enormous importance in everyday forensic practice by identifying possible cases of previous freezing – cases that would therefore warrant closer scrutiny and thus raise caution regarding the time of death.     

Quantitative magnetic resonance spectroscopy at 3T based on the principle of reciprocity

Quantification of magnetic resonance spectroscopy signals using the phantom replacement method requires an adequate correction of differences between the acquisition of the reference signal in the phantom and the measurement in vivo. Applying the principle of reciprocity, sensitivity differences can be corrected at low field strength by measuring the RF transmitter gain needed to obtain a certain flip angle in the measured volume. However, at higher field strength the transmit sensitivity may vary from the reception sensitivity, which leads to wrongly estimated concentrations. To address this issue, a quantification approach based on the principle of reciprocity for use at 3T is proposed and validated thoroughly. In this approach, the RF transmitter gain is determined automatically using a volume‐selective power optimization and complemented with information from relative reception sensitivity maps derived from contrast‐minimized images to correct differences in transmission and reception sensitivity. In this way, a reliable measure of the local sensitivity was obtained. The proposed method is used to derive in vivo concentrations of brain metabolites and tissue water in two studies with different coil sets in a total of 40 healthy volunteers. Resulting molar concentrations are compared with results using internal water referencing (IWR) and Electric REference To access In vivo Concentrations (ERETIC). With the proposed method, changes in coil loading and regional sensitivity due to B₁ inhomogeneities are successfully corrected, as demonstrated in phantom and in vivo measurements. For the tissue water content, coefficients of variation between 2% and 3.5% were obtained (0.6–1.4% in a single subject). The coefficients of variation of the three major metabolites ranged from 3.4–14.5%. In general, the derived concentrations agree well with values estimated with IWR. Hence, the presented method is a valuable alternative for IWR, without the need for additional hardware such as ERETIC and with potential advantages in diseased tissue.