Therapeutic alliance and obesity management in primary care - a cross-sectional pilot using the Working Alliance Inventory.

Therapeutic alliance is a well-recognized predictor of patient outcomes within psychological therapy. It has not been applied to obesity interventions, and Bordin's theoretical framework shows particular relevance to the management of obesity in primary health care. This cross-sectional study of a weight management programme in general practice aimed to determine if therapeutic alliance was associated with patient outcomes. The Working Alliance Inventory short revised version (WAI-SR) was administered to 23 patients and 11 general practitioners (GPs) at the end of a 6-month weight management programme. Use of the WAI-SR indicated that the strength of therapeutic alliance varied between different patient-GP relationships in this pilot intervention. A robust therapeutic alliance was strongly associated with patient engagement in the weight management programme indicated by number of appointments. It was also associated with some general health and quality of life outcomes. These are promising results that require confirmation with larger studies in primary health care. The measurement of therapeutic alliance using the WAI-SR may predict patient attendance and outcomes in obesity interventions in primary healthcare settings.

An Internet-based program to enhance motivation to change in females with symptoms of an eating disorder: a randomized controlled trial.

BACKGROUND: Previous research has demonstrated an association between low motivation to change and an unfavorable treatment outcome in patients with an eating disorder. Consequently, various studies have examined the effects of motivational enhancement therapy (MET) on motivation to change and treatment outcome in eating disorders. In each of these studies, MET was administered in a face-to-face setting. However, because of its anonymity and ease of access, the internet provides several advantages as the format for such an intervention. Therefore, the current study investigated the effects of an internet-based program ('ESS-KIMO') to enhance motivation to change in eating disorders. METHOD: In total, 212 females were accepted for participation and assigned randomly to the intervention condition (n = 103) or waiting-list control condition (n = 109). The intervention consisted of six online MET sessions. Before and after the intervention or waiting period respectively, participants completed the Eating Disorder Examination Questionnaire (EDE-Q), the Stages of Change Questionnaire for Eating Disorders (SOCQ-ED), the Pros and Cons of Eating Disorders Scale (P-CED), the Self-Efficacy Scale (SES), and the Rosenberg Self-Esteem Scale (RSES). A total of 125 participants completed the assessment post-treatment. Completer analyses and intent-to-treat analyses were performed. RESULTS: Significant time × group interactions were found, indicating a stronger increase in motivational aspects and self-esteem, in addition to a stronger symptom reduction on some measures from pre- to post-treatment in the intervention group compared to the control group. CONCLUSIONS: Internet-based approaches can be considered as useful for enhancing motivation to change in eating disorders and for yielding initial symptomatic improvement.

A qualitative investigation of obese women's experiences of effective and ineffective social support for weight management.

An obese individual's social context influences the extent to which they engage in weight control behaviors. Although the available literature acknowledges the importance of social support for weight management, detailed analyses of obese individuals' experiences of social support for weight loss and/or weight loss maintenance have not been undertaken. Using a qualitative approach, this study presents 22 Australian obese women's perspectives of the availability and effectiveness of social support for weight control. Three superordinate categories, namely, ineffective support, effective support and personal barriers to accessing support, and 12 subcategories were identified. Participants reported minimal access to quality support for weight management, while also suggesting ways in which obese women themselves may hamper significant others' provision of effective support. The results support the investigation of interventions designed to enhance the skills of significant others in assisting obese individuals with weight management.

The effectiveness of including support people in a cognitive behavioural weight loss maintenance programme for obese adults: study rationale and design.

The well-documented finding that obese adults have a high likelihood of weight regain following participation in behavioural weight loss programmes highlights the importance of developing more effective approaches for weight loss maintenance. One promising approach is to improve the quality of social support for effective weight control available to an obese individual by including support people in behavioural weight loss programmes. This paper describes the rationale and design of a randomized controlled trial that evaluates the effectiveness of training support people to assist obese adults in their weight management. The study entails a two-arm randomized controlled trial in which obese participants take part in a 1-year (26-session) cognitive behaviour therapy group weight management programme, including motivational interviewing strategies (CBT-MI). In one arm, participants receive CBT-MI alone, while in the second arm (CBT-MI-SP), participants also have a support person who attends 10 group sessions designed to teach effective skills for supporting an individual in healthy weight control. More specifically, support people will be trained in skills that aim to promote self-motivation for weight management. Assessments of anthropometric, medical, behavioural, motivational, psychological and social functioning take place at pre-treatment, post-treatment and a 1-year follow-up. By helping obese participants to increase and sustain their motivation and skills for weight control both during treatment and in the crucial period after treatment cessation through the ongoing input of support people, the CBT-MI-SP approach of the current study has the potential to effectively help patients to achieve sustained weight loss while minimizing the patient's need for ongoing, intensive weight control treatment with its attendant costs.

[ORION®: a simple and effective method for systemic analysis of clinical events and precursors occurring in hospital practice]. / Méthode Orion(®) : analyse systémique simple et efficace des événements cliniques et des précurseurs survenant en pratique médicale hospitalière.

PURPOSE: Morbimortality review is now recommended by the French Health Authority (Haute Autorité de santé [HAS]) in all hospital settings. It could be completed by Comités de retour d'expérience (CREX), making systemic analysis of event precursors which may potentially result in medical damage. As commonly captured by their current practice, medical teams may not favour systemic analysis of events occurring in their setting. They require an easy-to-use method, more or less intuitive and easy-to-learn. It is the reason why ORION(®) has been set up. METHODS: ORION(®) is based on experience acquired in aeronautics which is the main precursor in risk management since aircraft crashes are considered as unacceptable even though the mortality from aircraft crashes is extremely low compared to the mortality from medical errors in hospital settings. The systemic analysis is divided in six steps: (i) collecting data, (ii) rebuilding the chronology of facts, (iii) identifying the gaps, (iv) identifying contributing and influential factors, (v) proposing actions to put in place, (vi) writing the analysis report. When identifying contributing and influential factors, four kinds of factors favouring the event are considered: technical domain, working environment, organisation and procedures, human factors. Although they are essentials, human factors are not always considered correctly. The systemic analysis is done by a pilot, chosen among people trained to use the method, querying information from all categories of people acting in the setting. RESULTS: ORION(®) is now used in more than 400 French hospital settings for systemic analysis of either morbimortality cases or event precursors. It is used, in particular, in 145 radiotherapy centres for supporting CREX. CONCLUSION: As very simple to use and quasi-intuitive, ORION(®) is an asset to reach the objectives defined by HAS: to set up effective morbi-mortality reviews (RMM) and CREX for improving the quality of care in hospital settings. By helping the efforts of medical teams, ORION(®) is an essential tool contributing to the patients' security.

Increased plasticity of the bodily self in eating disorders.

BACKGROUND: The rubber hand illusion (RHI) has been widely used to investigate the bodily self in healthy individuals. The aim of the present study was to extend the use of the RHI to examine the bodily self in eating disorders (EDs). METHOD: The RHI and self-report measures of ED psychopathology [the Eating Disorder Inventory - 3 (EDI-3) subscales of Drive for Thinness, Bulimia, Body Dissatisfaction, Interoceptive Deficits, and Emotional Dysregulation; the 21-item Depression, Anxiety and Stress Scale (DASS-21); and the Self-Objectification Questionnaire (SOQ)] were administered to 78 individuals with an ED and 61 healthy controls. RESULTS: Individuals with an ED experienced the RHI significantly more strongly than healthy controls on both perceptual (i.e. proprioceptive drift) and subjective (i.e. self-report questionnaire) measures. Furthermore, both the subjective experience of the RHI and associated proprioceptive biases were correlated with ED psychopathology. Approximately 23% of the variance for embodiment of the fake hand was accounted for by ED psychopathology, with interoceptive deficits and self-objectification significant predictors of embodiment. CONCLUSIONS: These results indicate that the bodily self is more plastic in people with an ED. These findings may shed light on both aetiological and maintenance factors involved in EDs, particularly visual processing of the body, interoceptive deficits, and self-objectification.

The use of motivational enhancement strategies for the maintenance of weight loss among obese individuals: a preliminary investigation.

AIM: To investigate the efficacy of motivational enhancement strategies integrated within a standard lifestyle modification program for the maintenance of weight loss and improved psychosocial functioning of obese adults. METHODS: Twenty-two obese adults completed 20 sessions of a motivationally informed cognitive behavioural treatment for weight loss and maintenance. Treatment outcome measures included anthropometrics, obesity-specific quality of life, impulsive eating tendencies, body dissatisfaction, mood disturbance and maladaptive cognitions. RESULTS: At post-treatment, there was a significant decrease in body weight (123.04 +/- 22.06 vs. 116.84 +/- 23.53, p < 0.001) with no significant change by the 12-month follow-up. Patients also reported significant improvements in obesity-related quality of life, impulsive eating tendencies, body dissatisfaction and maladaptive cognitions at post-treatment that were maintained at the 1-year follow-up. CONCLUSIONS: The implementation of motivational enhancement strategies within a cognitive behavioural program results in sustained weight loss that compares favourably to previous lifestyle modification programs.

Cross-Cultural Research on Anorexia Nervosa: Assumptions Regarding the Role of Body Weight.

OBJECTIVE: To critically examine two assumptions guiding cross-cultural research on the weight concerns of anorexia nervosa: (1) that weight concerns are specific to contemporary, Western manifestations of the disorder and (2) that the dissemination of Western values regarding thinness is primarily responsible for the development of anorexia nervosa in non-Western contexts. METHOD: A review of theoretical and empirical literature on cross-cultural aspects of anorexia nervosa and the medical records of 14 Asian patients treated for eating disorders in Sydney, Australia. RESULTS AND DISCUSSION: Regarding the first assumption: It is argued that weight concerns when defined as weight loss that is positively valued (rather than a fat phobia) is a defining characteristic of anorexia nervosa and is not limited to contemporary, Western cases of the disorder. Regarding the second assumption: It is argued that the occurrence of anorexia nervosa in non-Western contexts cannot be solely attributed to the acceptance of Western thinness ideals because values and practices intrinsic to non-Western cultures are also likely to be etiologically relevant.

Development of an instrument to assess readiness to recover in anorexia nervosa.

OBJECTIVE: The degree to which patients with anorexia nervosa demonstrate readiness to recover from their illness has received scant theoretical or empirical attention. Investigating the prevalence and degree of amotivation for recovery in anorexia nervosa, its role in outcome, and the effectiveness of interventions designed to enhance readiness to recover necessitates the existence of a reliable and valid measure of motivational issues relevant to the disorder. The present study aimed to develop and evaluate an instrument for assessing readiness to recover in anorexia nervosa, namely, the Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ), a 23-item self-report questionnaire based on Prochaska and DiClemente's stages of change model. METHOD: Seventy-one inpatients with anorexia nervosa participated in the study. On several occasions during their admission, participants completed the ANSOCQ as well as questionnaires assessing readiness to recover, anorexic symptomatology, general distress, and social desirability. RESULTS: The ANSOCQ demonstrated good internal consistency (.90) and 1-week test-retest reliability (.89). Various aspects of validity were also supported, such as significant relationships with other instruments assessing readiness to recover and the prediction of weight gain during different periods of treatment. DISCUSSION: The results suggest that the ANSOCQ is a psychometrically sound instrument that may prove useful in investigating the role of readiness to recover in anorexia nervosa.

Hymenoptera venom allergy: time course of specific IgE concentrations during the first weeks after a sting.

Detection of IgE antibodies specific to honeybee or Vespula venoms is an important criterium firstly for the diagnosis of sensitization and secondly for the indication for a specific immunotherapy. Some authors recommend to postpone blood analysis after an insect sting for a certain time because circulating IgE antibodies might be consumed by the allergic reaction, which would result in a false-negative test outcome. We investigated IgE concentrations during the first weeks after an insect sting in 31 patients with an unequivocal history of an anaphylactic reaction after a honeybee (n = 13) or Vespula (n = 18) sting. Blood samples for analysis of specific IgE concentrations (CAP system, Pharmacia Diagnostics, Sweden) were collected within 2 weeks and 5+/-2 weeks after the insect sting. 12/13 patients with honeybee venom and 14/18 patients with Vespula venom sensitization had CAP classes 1 or higher within the first 2 weeks. Those 5 patients with CAP class 0 within the first 2 weeks had detectable IgE concentrations a few weeks later. We conclude that testing for specific IgE to hymenoptera venoms is in most cases useful even during the first 2 weeks after the hymenoptera sting. This allows early decisions on further diagnostic procedures and the therapeutic way to choose. Patients with no detectable IgE should, however, be retested after a few weeks.

Effects of the presentation of false heart-rate feedback on the performance of two common heartbeat-detection tasks.

Research has indicated that performance on heartbeat counting tasks may be influenced by beliefs about heart rate. Sixty male subjects were administered the Schandry heartbeat counting task after viewing fast, slow, or no heart rate feedback. Subjects were also administered the Whitehead signal-detection type task. Results indicated that subjects who received fast or no heartbeat feedback performed better on the Schandry task than subjects who received slow feedback. Feedback presentation did not affect performance on the Whitehead task. These results suggest that the Schandry task is influenced by external variables (expectations, beliefs) beyond pure awareness of "discrete" visceral sensations and, thus, may not be as powerful a method for determining awareness of individual heartbeats as some other paradigms.

Reactive angioendotheliomatosis or intravascular histiocytosis? An immunohistochemical and ultrastructural study in two cases of intravascular histiocytic cell proliferation.

Two elderly women with complex medical histories presented with erythematous patches, in one case involving the face and forearms, and in the other both elbows. Punch biopsies from both patients revealed intravascular proliferations of medium-sized and large cells with luminal occlusion typical of angioendotheliomatosis. Immunostaining did not show either lymphocytic or endothelial cell antigens but was consistent with a histiocytic differentiation of the intravascular cells in both cases, and was further substantiated by ultrastructural examination in one case. One patient received a course of cyclophosphamide therapy over 15 days. Skin lesions faded but did not disappear. The patient died 10 months later from cardiac and renal failure, which was most probably unrelated to the skin lesions. In the other case, lesions diminished but did not entirely resolve with treatment with low doses of oral prednisone. Angioendotheliomatosis can be divided into a malignant variant, which is an angiotropic lymphoma mostly of B-cell phenotype, and a benign, reactive variant, which is characterized by a proliferation of cells expressing endothelial cell markers. Only one case of angioendotheliomatosis with cells of histiocytic differentiation has been published previously under the name of intravascular histiocytosis. Our cases are very similar to the latter. The question arises as to whether intravascular histiocytic cell proliferation is a neoplastic proliferation of histiocytes or an early stage of classic reactive angioendotheliomatosis representing the residual cells associated with organization of microthrombi, which will be later followed by endothelial cell proliferation.

The role of the clinical psychologist in gynecological cancer.

Gynecological cancers, which account for a substantial proportion of cancer cases in women, can precipitate a wide range of psychological difficulties including affective disturbances, sexual problems, certain somatic symptoms, and family issues. The clinical psychologist has a unique contribution to make in the assessment and treatment of the psychological needs of gynecological cancer patients, while also conducting research and providing training for health professionals regarding the psychological issues associated with gynecological cancer. Although the gynecological cancer setting affords the clinical psychologist multiple personal benefits, strategies must usually be implemented to minimize any negative impact arising from working in an area of considerable psychological stress.

Ultraviolet radiation of melanocytic nevi: a dermoscopic study.

BACKGROUND: UV radiation can lead to clinical, histological, and ultrastructural changes in melanocytic nevi. In this study, we investigated whether exposure to 2 minimal erythema doses of UV radiation induces changes in the dermoscopic image of acquired melanocytic nevi. OBSERVATIONS: Fifteen melanocytic nevi were exposed to 2 minimal erythema doses of UV radiation. Differences in dermoscopic parameters (asymmetry, border, erythema, and telangiectasias in the nevus; pigmentation; hypopigmented areas; presence, regularity, and sharpness of pigment network; and brown-black globules) in digital dermoscopic images taken before and 3, 7, 14, and 28 days after UV irradiation were scored. Three days after UV irradiation, the borders of nevi were more faded (P<.02), the nevi were darker brown (P<.02), the hypopigmented areas were smaller (P<.02), and the pigment network structures were more faded (P<.007) and less prominent (P<.02) than before UV irradiation. Seven days after UV irradiation, pigmented globules have also grown (P<.05). After 28 days, all parameters, except hypopigmented areas, were essentially the same as before UV irradiation. CONCLUSION: UV irradiation of melanocytic nevi with 2 minimal erythema doses induces transient changes in their dermoscopic appearance that are sometimes suggestive of malignant melanoma.

Attentional biases in eating disorders: a visual probe detection procedure.

OBJECTIVE: To investigate attentional biases for body shape and weight-related stimulus words among subjects with anorexia nervosa, bulimia nervosa, and control subjects classified using a measure of dietary restraint. METHODS: A visual probe detection task was used to assess attention toward stimulus words reflecting either a thin or a large physique and positively or negatively valenced emotion words. RESULTS: In comparison to controls, subjects with eating disorders detected target probes more slowly when they appeared in the same location as had stimulus words connoting a thin physique. In addition, there was a trend toward faster detection or target probes that appeared in the same location as had stimulus words connoting a large physique. Neither of these effects were observed among restrained eaters. DISCUSSION: Our results extend prior work suggesting information-processing biases for body shape and weight-related stimuli among persons with eating disorders.

Does surgical removal of primary melanoma trigger growth of occult metastases? An analytical epidemiological approach.

BACKGROUND: In several human tumor systems a potential role of surgical removal of the primary tumor upon metastatic tumor growth has been evaluated, as it has been in experimental models. The present study addresses the question of whether the removal of primary melanomas disinhibits growth of metastatic disease and results in more rapid progression. METHODS: In a data set of 1224 primary cutaneous melanomas the risk of "thin" melanomas to develop metastases within 1 year was compared with the risk of matched pairs of "thick" melanomas to present metastases at the time of diagnosis. For this purpose, a pairwise matching procedure based on certain assumptions as to tumor volume and tumor doubling time has been applied. RESULTS: When a long tumor doubling time is assumed (200, 400, or 800 days), the tumors removed seem to have a significantly higher risk of metastases to become clinically apparent within 1 year than the matched pairs of tumors to present metastatic disease at the time of diagnosis (chi-square < 0.01). When short tumor doubling time is assumed (50 or 100 days), the difference is not significant, but there also seems to be no benefit for the operated patients. CONCLUSION: In the present data set there is evidence that surgery of primary melanoma may enhance tumor growth at metastatic sites.

HOXC4, HOXC5, and HOXC6 expression in primary cutaneous lymphoid lesions. High expression of HOXC5 in anaplastic large-cell lymphomas.

Homeobox (HOX) genes are involved in the lineage-specific differentiation of bone marrow stem cells. Recently, we reported a largely similar expression pattern of HOXC4 and HOXC6 in normal and neoplastic cells of the lymphoid lineage. In contrast, HOXC5 was specifically expressed in a subset of B-cell non-Hodgkin's lymphomas (B-NHL) but not in normal lymphocytes or lymphoid leukemias. This might suggest a role for HOXC5 in the pathogenesis of these lymphomas. In the present study the expression of HOXC4, HOXC5, and HOXC6 in primary cutaneous lymphomas was investigated. Using RNA in situ hybridization (RISH) and semiquantitative reverse transcriptase polymerase chain reaction (RT-PCR), we found strong expression of HOXC4 and HOXC6 in all, except one, primary cutaneous lymphomas and all reactive cutaneous lymphoid infiltrates. Interestingly, a strong expression of HOXC5 in primary anaplastic CD30+ large T-cell lymphomas was found. RISH was consistently negative for HOXC5 in all other types of primary cutaneous B- and T-cell lymphomas. However, by semiquantitative RT-PCR these lymphomas showed a weak expression of HOXC5 mRNA. Therefore, we concluded that these lymphomas express low constitutive levels of HOXC5 mRNA. Furthermore, HOXC5 expression was consistently absent in reactive cutaneous lymphoid infiltrates, hyperplastic tonsils and lymph nodes, and peripheral blood lymphocytes either unstimulated or stimulated by a cocktail of CD3 and CD28 antibodies. As a strong expression of HOXC5 in primary cutaneous lymphomas was observed only in anaplastic large T-cell lymphomas and reactive control tissues lacked HOXC5 expression, these data strongly support a role for HOXC5 in the genesis of anaplastic large-T-cell lymphomas.

Normative data for the personal report of confidence as a speaker.

Normative data for the Personal Report of Confidence as a Speaker (PRCS; Paul, 1966), a measure of public-speaking anxiety, were collected by administering the PRCS to 1109 college students. PRCS scores were examined in relation to gender, race, age, and grade-point average. No significant between-group differences were found. The findings indicate that levels of public-speaking anxiety are generally constant across gender, race, and age. Normative data for all scores across Caucasian and African-American subjects are presented.

[Reticular lentigo]. / Retikuläre Lentigo.

We studied the clinical and histopathologic features in five patients with reticulated lentigo. This peculiar pigmented skin lesions has previously been described under the designations "acquired reticulated lentigo", ink spot lentigo, "reticulated melanotic macule" or "reticulated lentigo". Each of the 4 males and 1 females in our study (age range: 16 to 57 years; mean age: 34 years) had a single, 4-6 mm large, black macule with irregular, fingerlike extensions at the periphery. All lesions were situated on the upper back and surrounded by numerous sun-induced freckles. Dermatoscopic examination revealed irregularly formed "meshes" and confirmed the reticulated pattern seen clinically. Reticulated lentigo presented mostly in individuals with skin type 1, red to blond hair, and blue eyes. The clinical diagnosis in 4 out of 5 cases was melanoma in situ. Histopathologically, reticulated lentigo was mainly characterized by a sharply circumscribed hyperpigmentation of the lower epidermis with accentuation at the tips of elongated and clubbed rete ridges. In addition, a normal or slightly increased melanocyte number in the basal layer and an infiltrate of melanophages in the upper dermis was noted. Reticulated lentigo shows histopathologic features similar to those of melanotic macules on volar skin and mucous membranes. Because of its characteristic clinical, dermatoscopic and histopathologic features reticulated lentigo can be regarded as a distinctive clinicopathologic entity.

The diet-heart disease hypothesis: a response to Atrens.

In a recent examination of the main tenets of the widely accepted diet-heart disease hypothesis, Atrens concluded that the evidence to date is not sufficient to support the hypothesis. Reviewing Atrens' critique highlights both strengths and limitations in his case against the role of dietary lipids and cholesterol in coronary heart disease mortality. Research on the following hypothesized relationships is discussed in light of the objections raised by Atrens: the relationships between fat intake and heart disease mortality; dietary fat and serum cholesterol; serum cholesterol and atherosclerosis; atherosclerosis and heart disease death; and serum cholesterol and heart disease death. The inconsistency of the findings suggests that definitive answers regarding the diet-heart disease hypothesis are premature and that the polarized positions of acceptance vs rejection of the hypothesis fail to account for the full range of results.