Communication skills in psychiatry residents-- how do they handle patient concerns? An application of sequence analysis to interviews with simulated patients

BACKGROUND: The main focus of the training of psychiatrists is on diagnosis and treatment based on the traditional doctor-centered approach to the psychiatric interview. Less attention is given to the correct handling of patients' emotional concerns, which is crucial for the patient-physician relationship, but also for improving diagnostic and treatment decisions. The aim of this study is to assess psychiatrists' responses to patients' concerns and worries. METHOD: 118 consultations, conducted by 10 residents in psychiatry with 20 simulated patients, have been coded using the Verona Psychiatric Interview Classification System. Lag1 sequential analysis and a multinomial logit regression analysis were performed to investigate the relationship between patients' expressions of concern and psychiatrists' subsequent interventions in terms of patient-centered skills. RESULTS: Compared to doctor-centered interventions, all patients' expressions of concern increased the probability of passive listening (odds ratios between 2.4 and 4.2). They also increased the occurrence of emotion focusing interventions (odds ratios between 3.3 and 1.7), which however remained rare (4% of residents' total responses). A small although significant increase in the likelihood of active listening expressions was observed as a response to two types of patient expressions of concern: statements of feelings (odds ratio 1.4) and expression of opinions regarding problematic psychosocial issues (odds ratio of 1.7). CONCLUSIONS: Young psychiatrists are good passive listeners but need to improve active listening skills which, together with emotion focusing skills, should be a major learning target in psychiatry. These patient-centered interviewing skills should integrate those traditionally used for attributing ICD-10 and/or DSM-IV categories.     

Association of prion protein with cognitive functioning in humans

Objectives

Recent animal studies have suggested a key role for cellular prion protein (PrPc) in the pathological consequences of amyloid plaque formation, the hallmark of Alzheimer's disease. This epidemiological study investigated whether serum concentrations of PrPc are associated with cognitive functioning in humans.

Design, Setting, Participants

Cross-sectional study of 1,322 participants from the elderly general population in Germany, aged 65 + years at baseline (2000–2002).

Measurements

Cognitive functioning was assessed by the COGTEL phone interview 5 years after baseline. Serum PrPc was determined by a commercial immunoassay.

Results

In multiple linear regression adjusted for important confounders, subjects in higher PrPc quintiles appeared to have lower cognitive functioning scores than those in the lowest PrPc quintile. Spline regression suggested pronounced non-linearity with an inverse association between PrPc and cognitive functioning levelling off beyond median PrPc. Cognitive subdomain-specific models produced somewhat heterogeneous results.

Conclusion

The findings are suggestive of an independent association of PrPc with cognitive functioning in humans. Confirmatory and longitudinal studies are needed to elucidate the potential of PrPc for applications in early risk stratification for cognitive impairment.     

Systemic endotoxin activity correlates with clot formation: an observational study in patients with early systemic inflammation and sepsis

Introduction

Inflammation and coagulation are closely linked, and both can be triggered by endotoxin. Thrombelastometry and impedance aggregometry are of diagnostic and predictive value in critically ill patients. In this observational study we investigated the correlation of endotoxin activity with thrombelasometric and aggregometric variables in patients with systemic inflammation.

Methods

Based on a daily screening on a tertiary academic surgical ICU, patients, as soon as they fulfilled two or more criteria for systemic inflammatory response syndrome (SIRS), were included. In whole blood we performed endotoxin activity (EA) assay, thrombelastometry (ROTEM^®) and impendance aggregometry (Multiplate^®).

Results

In total, 49 patients were included with a broad spread of EA levels of (median (minimum to maximum)) 0.27 (0.01 to 0.72), allowing expedient correlative analysis. Clot formation time (CFT) (263 s (60 to 1,438 s)) and clotting time (CT) (1,008 s (53 to 1,481 s)) showed a significant negative correlation with EA level (r = -0.38 (P < 0.005) and r = -0.29 (P < 0.05)). Positive correlations were found for alpha-angle (50° (17 to 78°), r = 0.40 (P < 0.005)) and maximum clot firmness (MCF) (55 mm (5/76), r = 0.27 (P < 0.05)). No significant correlations were found between Lysis Index at 60 minutes (LI60) and EA levels. There was no correlation between EA level and aggregometric values, or classical coagulation parameters.

Conclusions

In patients with systemic inflammation, increasing endotoxin concentrations correlate with increased clot formation.     

Association between lifestyle factors and headache

Modification of lifestyle habits is a key preventive strategy for many diseases. The role of lifestyle for the onset of headache in general and for specific headache types, such as migraine and tension-type headache (TTH), has been discussed for many years. Most results, however, were inconsistent and data on the association between lifestyle factors and probable headache forms are completely lacking. We evaluated the cross-sectional association between different lifestyle factors and headache subtypes using data from three different German cohorts. Information was assessed by standardized face-to-face interviews. Lifestyle factors included alcohol consumption, smoking status, physical activity and body mass index. According to the 2004 diagnostic criteria, we distinguished the following headache types: migraine, TTH and their probable forms. Regional variations of lifestyle factors were observed. In the age- and gender-adjusted logistic regression models, none of the lifestyle factors was statistically significant associated with migraine, TTH, and their probable headache forms. In addition, we found no association between headache subtypes and the health index representing the sum of individual lifestyle factors. The lifestyle factors such as alcohol consumption, smoking, physical activity and overweight seem to be unrelated to migraine and TTH prevalence. For a judgement on their role in the onset of new or first attacks of migraine or TTH (incident cases), prospective cohort studies are required.     

Elevated adiponectin serum levels in patients with chronic alcohol abuse rapidly decline during alcohol withdrawal

Background:  Adiponectin is a circulating protein with hepatoprotective effects.
Aims:  To study the relationship of excessive alcohol consumption and serum adiponectin levels (SAL).
Patients and Methods:  The SAL were determined in (i) heavy drinkers without advanced liver damage during the course of alcohol withdrawal, (ii) patients with chronic hepatitis C virus (HCV) infection, (iii) patients with alcohol-associated cirrhosis, and (iv) healthy volunteers that consumed excessive amounts of alcohol for only a short period of time. Further, primary human hepatocytes (PHH) and adipocytes were incubated in vitro with alcohol or serum of patients.
Results:  Patients with chronic alcohol consumption had significantly higher SAL than HCV-patients with comparable degrees of liver damage. In alcoholics, but not in HCV patients, SAL positively correlated with serum levels of aminotransferases. Further, SAL correlated with the amount of alcohol consumption but declined during the course of alcohol abstinence. After short-term excessive alcohol consumption SAL were not elevated in healthy individuals. Adiponectin mRNA was detectable in adipocytes but not in hepatocytes, and alcohol failed to induce adiponectin in both cell types. In contrast, serum of active drinkers induced adiponectin expression in adipocytes while serum from the same individuals collected after alcohol withdrawal had no effect.
Conclusions:  Alcohol exhibits a specific effect on SAL that is dose and time dependent, and correlates with the degree of hepatic damage. Alcohol does not seem to affect adiponectin expression directly in adipocytes but potentially via mediators systemically released as a result of the chronic alcohol intake.     

Multicenter clinical trials in sepsis: understanding the big picture and building a successful operation at your hospital

Only through adequately designed and adequately conducted clinical trials can new treatments be found for the benefit of the septic patient. Over the past 20 years, tens of thousands of patients have been enrolled in sepsis clinical trials with little success. These efforts, however, have not been without worth. Much has been learned and the knowledge gained has changed our approach to trial design in this very difficult field. Animal studies are better designed to match the clinical picture of severe sepsis. Phase II studies are more carefully engineered to answer questions about the most suitable target population and end points. Trial conduct likely benefits from use of CROs and a CCC. The future of clinical trials may include more standardization of sepsis management across investigative sites. Before the decision is made to become an investigative site in a multicenter industry-sponsored clinical trial in sepsis or severe sepsis, it is important to recognize what is required to succeed. Once these key-to-success elements are in place, members of the investigative team are more likely to realize the satisfaction and career growth from becoming a successful site. The most professional satisfaction comes from the knowledge of contributing to original science in the field of the sepsis.     

Risk of cardiac arrhythmias and conduction abnormalities in patients with acute myocardial infarction receiving packed red blood cell transfusions

Purpose

Although transfusion has been linked to the development of atrial fibrillation (AF) in cardiac surgical patients, this association has not been investigated in patients with acute myocardial infarction (AMI). Evidence supports an inflammatory mechanism in the development of AF, and red cell transfusions also elicit an inflammatory response. We therefore sought to evaluate whether packed red blood cell transfusion increases the risk of AF, ventricular tachycardia (VT), and other arrhythmias and conduction abnormalities in patients with AMI.

Materials and Methods

This is a retrospective study on patients with AMI and no prior history of AF, admitted to a critical care area and entered in Project Impact database from 08/2003-12/2007. Primary outcome measures were new-onset cardiac arrhythmias or conduction disturbances.

Results

Transfused patients had significantly higher incidences of AF (4.7% vs 1.3%, P = .008), cardiac arrest (9.5% vs 1.7%, P < .001) and heart block (3.4% vs 0.1%, P < .001), and a trend toward a higher incidence of VT (3.4% vs 1.3%, P = .058). Multivariate regression analysis confirmed transfusion as an independent risk factor for “non-lethal” cardiac events (AF/heart block; odds ratio [OR], 4.7 [1.9-11.9]; P = .001), “lethal” events (VT/cardiac arrest; OR, 2.4 [1.1-5]; P = .016), and all cardiac events (OR, 2.8 [1.5-65.1]; P = .001). Transfused patients had significantly longer length of stay (P < .0001) and significantly higher mortality rates than nontransfused patients (OR, 3 [1.7-5.5]; P < .001).

Conclusions

Packed red blood cell transfusion is independently associated with an increased risk of new-onset cardiac arrhythmias and conduction abnormalities in the setting of AMI, even after controlling for traditional risk factors.