Clinical Interviewing: An Essential but Neglected Method of Medicine.

Clinical interviewing is the basic method to understand how a person feels and what are the presenting complaints, obtain medical history, evaluate personal attitudes and behavior related to health and disease, give the patient information about diagnosis, prognosis, and treatment, and establish a bond between patient and physician that is crucial for shared decision making and self-management. However, the value of this basic skill is threatened by time pressures and emphasis on technology. Current health care trends privilege expensive tests and procedures and tag the time devoted to interaction with the patient as lacking cost-effectiveness. Instead, the time spent to inquire about problems and life setting may actually help to avoid further testing, procedures, and referrals. Moreover, the dialogue between patient and physician is an essential instrument to increase patient's motivation to engage in healthy behavior. The aim of this paper was to provide an overview of clinical interviewing and its optimal use in relation to style, flow and hypothesis testing, clinical domains, modifications according to settings and goals, and teaching. This review points to the primacy of interviewing in the clinical process. The quality of interviewing determines the quality of data that are collected and, eventually, of assessment and treatment. Thus, interviewing deserves more attention in educational training and more space in clinical encounters than it is currently receiving.

Perioperative Factor Concentrate Use is Associated With More Beneficial Outcomes and Reduced Complication Rates Compared With a Pure Blood Product-Based Strategy in Patients Undergoing Elective Cardiac Surgery: A Propensity Score-Matched Cohort Study.

OBJECTIVE: The goal of this study was to compare factor concentrate (FC)-based and blood product-based hemostasis management of coagulopathy in cardiac surgical patients in terms of postoperative bleeding, required blood products, and outcome. DESIGN: Retrospective, propensity score-matched analysis. SETTING: Single, tertiary, academic medical center. PARTICIPANTS: One hundred eighteen matched pairs of 433 consecutive patients scheduled for cardiac surgery in two isolated periods with distinct strategies of hemostasis management. INTERVENTIONS: Patients received either blood product-based (period I) or FC-based (period II) hemostasis management to treat perioperative coagulopathy. MEASUREMENTS AND MAIN RESULTS: Patients treated with FC management experienced less postoperative blood loss (907 v 1,153 mL, p = 0.014) and required less red blood cell and fresh frozen plasma transfusion (2.3 v 3.7 units p < 0.0001, and 2.0 v 3.4 units p < 0.0001, respectively) compared with subjects in the blood product-based management group. The frequency of Stage 3 acute kidney injury and 30-day mortality rate were significantly higher in the blood product-based group than in the FC management group (6.8% v 0.8%, p = 0.016, and 7.2% v 0.8%, p = 0.022, respectively). FC management-related thromboembolic events were not registered. The FC strategy was associated with a 2.19-fold decrease in the odds of massive postoperative bleeding (p < 0.0001), a 2.56-fold decrease in the odds of polytransfusion (p < 0.0001), and a 13.16-fold decrease in the odds of early postoperative death (p = 0.003). CONCLUSIONS: FC-based versus blood product-based management is associated with reduced blood product needs and fewer complications, and was not linked to a higher frequency of thromboembolic events or a decrease in long-term survival in cardiac surgical patients developing perioperative coagulopathy and bleeding.

Physical Exercise as a Resilience Factor to Mitigate COVID-Related Allostatic Overload.

INTRODUCTION: The long-lasting threat of COVID-19 makes it necessary to explore strategies to improve coping skills which enable us to master a balanced life in the face of adversity. OBJECTIVE: To unravel the most challenging aspects of COVID-19 in a nonclinical adult population and identify predictors of lost balance and consequent allostatic overload (AO). We examined the role of regular, moderate-intensity formula aerobic exercise (312 meridian exercise) in preventing allostatic overload through increasing well-being. METHODS: An online survey was conducted to measure CO-VID-related allostatic overload according to clinimetric criteria. The Psychosocial Index (PSI), Kellner's Symptom Questionnaire (KSQ), short Depression Anxiety Stress Scales (DASS-21), Public Health Surveillance Well-Being Scale -(PHS-WB), and Whiteley-7 were used to explore mental health characteristics. Univariate statistics logistic regression analysis and a general linear model were used. RESULTS: According to 442 valid answers, 217 adults practiced physical exercise (PE) frequently (fPE, 3-5 times/every day) while 120 did it less regularly (1-2 times/week), and 105 did not exercise/practiced irregularly (controls). Restriction-related stressors were most challenging, resulting in AO in 29% (n = 128) of the sample. The main predictors were additional stressors (p = 0.005) and anxiety symptoms (p < 0.001). The prevalence of AO was lower (p = 0.018) in the fPE group when compared to controls. KSQ distress symptoms were also lower in fPE (p < 0.0001), while total well-being was increased (p < 0.001) after adjusting for sex, age, and number of chronic diseases. According to the PHS-WB, both physical and mental well-being were higher (p = 0.003 and p = 0.004, respectively) in fPE. CONCLUSIONS: Frequent moderate exercise is associated with better mental and physical well-being and a lower prevalence of AO.

Clinimetric Criteria for Patient-Reported Outcome Measures.

Patient-reported outcome measures (PROMs) are self-rated scales and indices developed to improve the detection of the patients' subjective experience. Given that a considerable number of PROMs are available, it is important to evaluate their validity and usefulness in a specific research or clinical setting. Published guidelines, based on psychometric criteria, do not fit in with the complexity of clinical challenges, because of their quest for homogeneity of components and inadequate attention to sensitivity. Psychometric theory has stifled the field and led to the routine use of scales widely accepted yet with a history of poor performance. Clinimetrics, the science of clinical measurements, may provide a more suitable conceptual and methodological framework. The aims of this paper are to outline the major limitations of the psychometric model and to provide criteria for clinimetric patient-reported outcome measures (CLIPROMs). The characteristics related to reliability, sensitivity, validity, and clinical utility of instruments are critically reviewed, with particular reference to the differences between clinimetric and psychometric approaches. Of note is the fact that PROMs, rating scales, and indices developed according to psychometric criteria may display relevant clinimetric properties. The present paper underpins the importance of the clini-metric methodology in choosing the appropriate PROMs. CLIPROM criteria may also guide the development of new indices and the validation of existing PROMs to be employed in clinical settings.

Mental Pain as a Transdiagnostic Patient-Reported Outcome Measure.

Patient-reported outcomes (PROs) refer to any report coming directly from patients about how they function or feel in relation to a health condition or its therapy. PROs have been applied in medicine for the assessment of the impact of clinical phenomena. Self-report scales and procedures for assessing physical pain in adults have been developed and used in clinical trials. However, insufficient attention has been dedicated to the assessment of mental pain. The aim of this paper is to outline the implications that assessment of mental pain may entail in psychiatry and medicine, with particular reference to a clinimetric index. A simple 10-item self-rating questionnaire, the Mental Pain Questionnaire (MPQ), encompasses the specific clinical features of mental pain and shows good clinimetric properties (i.e., sensitivity, discriminant and incremental validity). The preliminary data suggest that the MPQ may qualify as a PRO measure to be included in clinical trials. Assessment of mental pain may have important clinical implications in intervention research, both in psychopharmacology and psychotherapy. The transdiagnostic features of mental pain are supported by its association with a number of psychiatric disorders, such as depression, anxiety, eating disorders, as well as borderline personality disorder. Further, addressing mental pain may be an important pathway to prevent and diminish the opioid epidemic. The data summarized here indicate that mental pain can be incorporated into current psychiatric assessment and included as a PRO measure in treatment outcome studies.

Influence of the postoperative inflammatory response on cognitive decline in elderly patients undergoing on-pump cardiac surgery: a controlled, prospective observational study.

BACKGROUND: The role of non-infective inflammatory response (IR) in the aetiology of postoperative cognitive dysfunction (POCD) is still controversial. The aim of this controlled, prospective observational study was to assess the possible relationship between the grade of IR, defined by procalcitonin (PCT) changes, and development of POCD related to cardiac surgery. METHODS: Forty-two patients, who were ≥ 60 years of age and scheduled for elective cardiac surgery, were separated into the low inflammatory (LIR) and high inflammatory (HIR) response groups based on their PCT levels measured on the first postoperative day. A matched normative control group of 32 subjects was recruited from primary care practice. The PCT and C-reactive protein (CRP) levels were monitored daily during the first five postoperative days. The cognitive function and mood state were preoperatively tested with a set of five neurocognitive tests and two mood inventories and at the seventh postoperative day. The Reliable Change Index modified for practice (RCIp) using data from normative controls was applied to determine the significant decline in test performance. RESULTS: The LIR (n = 20) and HIR (n = 22) groups differed significantly in the PCT (p < 0.001) but not in the CRP time courses. The incidence of POCD at the first postoperative week was 35.7% in the cohort. The LIR and HIR groups did not vary in the RCIp Z scores of neurocognitive tests and frequencies of POCD (7 vs 8 cases, respectively, p > 0.05). Additionally, there was no difference in the mood states, anxiety levels and perioperative parameters known to influence the development of POCD. CONCLUSIONS: In this study, the magnitude of the non-infective inflammatory response generated by on-pump cardiac surgery did not influence the development of POCD in the early postoperative period in elderly patients.

[Opinions of Hungarian family physicians and residents on vocation and informal payment]. / Hivatással és hálapénzzel kapcsolatos vélekedések a magyarországi családorvosok és családorvos rezidensek körében.

INTRODUCTION: The changing of the family medicine can be observed in the New Millennium. Migration, the aging of the healers and informal payment are crucial to the human resource crisis of the health sector. AIM: The aim of this study was to investigate the family physicians' and residents' opinions about the vocation and informal payment. METHOD: Exploratory, quantitative study was carried out among family physicians (n = 363) and family physician residents (n = 180). The central questions of the study were the vocation, the income and the informal payment. RESULTS: The most decisive factors of the carrier choice were altruism, service and responsibility. Residents were significantly rejective (19.7% vs. 38.3%, p<0.001) about informal payment. They would accept smaller amounts of informal payment (14.3% vs. 8.9%, p<0.034), and would spend it on praxis development (1.4% vs.9.4% p<0.023). CONCLUSIONS: The attitudes of family physicians and residents are the same in case of the vocation, but on the issue of informal payment, the two generations have different opinions. Orv. Hetil., 2016, 157(36), 1438-1444.

Identification of hypertensive patients with dominant affective temperaments might improve the psychopathological and cardiovascular risk stratification: a pilot, case-control study.

BACKGROUND: Although mood disorders and cardiovascular diseases have widely studied psychosomatic connections, data concerning the influence of the psychopathologically important affective temperaments in hypertension are scarce. To define a possibly higher cardiovascular risk subpopulation we investigated in well-treated hypertensive patients with dominant affective temperaments (DOM) and in well-treated hypertensive patients without dominant temperaments the level of depression and anxiety, arterial stiffness and serum Brain-derived Neurotrophic Factor (seBDNF). METHODS: 175 hypertensive patients, free of the history of psychiatric diseases, completed the TEMPS-A, Beck Depression Inventory and Hamilton Anxiety Scale questionnaires in two primary care practices. Of those 175 patients, 24 DOM patients and 24 hypertensive controls (matched in age, sex and the presence of diabetes) were selected for measurements of arterial stiffness and seBDNF level. RESULTS: Beck and Hamilton scores in DOM patients were higher compared with controls. Pulse wave velocity and augmentation index did not differ between the groups while in the DOM patients decreased brachial systolic and diastolic and central diastolic blood pressures were found compared with controls. SeBDNF was lower in the DOM group than in the controls (22.4 ± 7.2 vs. 27.3 ± 7.8 ng/mL, p < 0.05). CONCLUSIONS: Although similar arterial stiffness parameters were found in DOM patients, their increased depression and anxiety scores, the decreased brachial and central diastolic blood pressures as well as the decreased seBDNF might refer to their higher vulnerability regarding the development not only of major mood disorders, but also of cardiovascular complications. These data suggest that the evaluation of affective temperaments should get more attention both with regard to psychopathology and cardiovascular health management.

[Alternative and complementary medicine from the primary care physician's viewpoint]. / Nem-konvencionális gyógymódok a háziorvos szemszögébol.

INTRODUCTION: The patients initiate the use of complementary and alternative medicine and this often remains hidden from their primary care physician. AIM: To explore general practitioners' knowledge and attitude towards complementary and alternative medicine, and study the need and appropriate forms of education, as well as ask their opinion on integration of alternative medicine into mainstream medicine. METHOD: A voluntary anonymous questionnaire was used on two conferences for general practitioners organized by the Family Medicine Department of Semmelweis University. Complementary and alternative medicine was defined by the definition of the Hungarian Academy of Sciences and certified modalities were all listed. RESULTS: 194 general practitioners answered the questionnaire (39.8% response rate). 14% of the responders had licence in at least one of the complementary and alternative therapies, 45% used complementary and alternative therapy in their family in case of illness. It was the opinion of the majority (91.8%) that it was necessary to be familiar with every method used by their patients, however, 82.5% claimed not to have enough knowledge in complementary medicine. Graduate and postgraduate education in the field was thought to be necessary by 86% of the responders; increased odds for commitment in personal education was found among female general practitioners, less than 20 years professional experience and personal experience of alternative medicine. CONCLUSIONS: These data suggest that general practitioners would like to know more about complementary and alternative medicine modalities used by their patients. They consider education of medical professionals necessary and a special group is willing to undergo further education in the field.

[The association between diabetes complications and symptoms of depression and anxiety]. / A cukorbetegség szövodményeinek összefüggése a depressziós és szorongásos tünetekkel.

INTRODUCTION: The bidirectional relationship between diabetes and depression results in severe disease burden. Co-occurring depression is associated with a higher rate of diabetes complications. These complications impair quality of life, however, their impact on depressive symptoms is controversial. OBJECTIVE: In our cross-sectional study, we aimed to investigate whether the presence of diabetes complications is associated with depressive and anxiety symptoms among patients with type 2 diabetes in general practice. METHOD: We obtained patient history, anthropometric, socioeconomic, laboratory parameters. For symptom assessment, the Beck Depression Inventory (BDI) and the Hamilton Anxiety Scale (HAM-A) were used. We collected data between September 2018 and February 2020. RESULTS: We included 338 consecutive patients with type 2 diabetes. The mean age of the sample was 63.98 ± 11.51 (years ± SD), 61.2% of participants were female. We found significant univariate association between diabetes complications and older age, less physical activity, higher body mass index, insulin therapy, higher HbA1c, higher creatinine and carbamide concentrations, worse depressive and anxiety symptoms. In multivariate analysis, diabetes complications and certain socio-demographic factors (female gender, lower education, rural-dwelling) were the determinants of higher BDI and HAM-A scores. CONCLUSION: Among primary care patients with type 2 diabetes, the prevalence of depressive and anxiety symptoms was higher and more severe in patients with diabetes complications. The recommended screening for affective disorders among patients with diabetes is especially justified if complications are present. Orv Hetil. 2023; 164(3): 79-87.

Evaluating real-patient learning in medical education - Hungarian validation of the Manchester Clinical Placement Index.

Introduction: The Manchester Clinical Placement Index (MCPI) is an instrument to measure medical undergraduates' real-patient learning in communities of practice both in hospital and in GP placements. Its suitability to evaluate the quality of placement learning environments has been validated in an English-language context; however, there is a lack of evidence for its applicability in other languages. Our aim was to thoroughly explore the factor structure and the key psychometric properties of the Hungarian language version. Methods: MCPI is an 8-item, mixed-method instrument which evaluates the quality of clinical placements as represented by the leadership, reception, supportiveness, facilities and organization of the placement (learning environment) as well as instruction, observation and feedback (training) on 7-point Likert scales with options for free-text comments on the strengths and weaknesses of the given placement on any of the items. We collected data online from medical students in their preclinical (1st, 2nd) as well as clinical years (4th, 5th) in a cross-sectional design in the academic years 2019-2020 and 2021-2022, by the end of their clinical placements. Our sample comprises data from 748 medical students. Exploratory and confirmatory factor analyses were performed, and higher-order factors were tested. Results: Although a bifactor model gave the best model fit (RMSEA = 0.024, CFI = 0.999, and TLI = 0.998), a high explained common variance (ECV = 0.82) and reliability coefficients (ωH = 0.87) for the general factor suggested that the Hungarian version of the MCPI could be considered unidimensional. Individual application of either of the subscales was not supported statistically due to their low reliabilities. Discussion: The Hungarian language version of MCPI proved to be a valid unidimensional instrument to measure the quality of undergraduate medical placements. The previously reported subscales were not robust enough, in the Hungarian context, to distinguish, statistically, the quality of learning environments from the training provided within those environments. This does not, however, preclude formative use of the subscales for quality improvement purposes.

[Screening of depression in primary care in Hungary and its importance in suicide prevention]. / A depresszió szurése az alapellátásban Magyarországon és ennek jelentosége az öngyilkosság megelozésében.

The current prevalence of DSM-IV depressive disorders were surveyed among 984 primary care attendees in 6 PCPs in Hungary, using the Beck Depression Inventory (BDI) and the PRIME-MD screening instrument. The current prevalence rate of any DSM-IV depressive disorders, including symptomatic major depressive episode (MDE) were 18.5% and 7.3% respectively. BDI identified any current depressive disorders with 95% sensitivity and 56% specificity and the same figures for MDE were 83% and 23%, respectively. Current MDE was found 50% of patients with positive family history of suicide, comparing to the 14.3% of those without. The BDI and the PRIME-MD are useful screening tools for detecting depressive disorders in PCPs. Family history of completed suicide as a clinical marker could improve suicide prevention through the more effective management of MDE in primary care.

Severity of depressive but not anxiety symptoms impacts glucose metabolism among patients with type 2 diabetes in primary care.

Background: Data from primary care regarding the prevalence of symptoms of depression and anxiety, and their effect on glycemic control among people with diabetes is lacking in Hungary. The recently introduced Patient Health Record (PHR) requires family doctors to screen for depressive symptoms. Objectives: We aimed to investigate the prevalence of depressive and anxiety symptoms among patients with type 2 diabetes in the general practice, and the relationship between these affective disorders and glycated hemoglobin (HbA1c) level. Methods: We included 338 consecutive patients with type 2 diabetes from six primary care practices in this cross-sectional study. A self-administered questionnaire (patient history, anthropometric, socioeconomic, laboratory parameters), the Beck Depression Inventory (BDI) and the Hamilton Anxiety Scale (HAM-A) were used. Results: The mean age of the sample was 64.0 ± 11.5 (years ± SD), 61% of participants were female. The prevalence of depressive symptoms was 21%, mainly moderate/severe symptoms (13%). Anxiety symptoms were more common (35%). We found significant univariate association between the depressive symptoms and HbA1c (p = 0.001), suicide attempt (p < 0.001), anxiety (p < 0.001), micro- and macrovascular complication (p = 0.028 and p < 0.001), education (p = 0.001) and place of residence (p = 0.002). In multivariate analysis, however, only BDI score had significant (p = 0.03191) association with glycemic control. Conclusion: Among primary care patients with type 2 diabetes, the prevalence of depressive symptoms was less frequent than anxiety symptoms. More severe depressive symptoms were associated with worse glycemic control.

[Affective temperaments: from neurobiological roots to clinical application]. / Affektív temperamentumok: a neurobiológiai alapoktól a klinikai alkalmazásig.

The Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) has grown to be a clinically important outcome measure in the diagnosis and the clinical course of mood disorders. However, temperaments, which represent the biologically stable core of personality, are not just antecedents of major affective disorders, but also serve as a reservoir of genetically advantageous traits for the survival of different cultures. The rapidly growing body of research in psychiatric and non-psychiatric fields even raises the question of temperament as a common root in psychiatric and somatic disorders, providing a new meaning for the construct of psychosomatic disorders. In this review we aim to summarize current knowledge on both the neurobiological background and clinical importance of affective temperaments including implications for future research.

[The clinical importance of affective temperaments]. / Az affektív temperamentumok klinikai jelentosége.

Intensive research on affective temperaments began no more than a decade ago as a result of Akiskal's work in the field. Based on ancient Greek and later the Kraepelinian concept of temperament Akiskal created five distinct temperament types (hyperthym, cyclothym, depressive, irritable and anxious) which are now considered to be the preclinical background of affective disorders. In collaboration with an international workgroup, a semi-structured (TEMPS-I) and a self-rated (TEMPS-A) questionnaire was developed and translated into more than 25 languages intensifying research activity in the field. Based upon search of different databases (Scopus, Web of Knowledge, OVID Medline, PubMed, Psychinfo) and hand search of relevant Hungarian language literature, our review article aims to summarize current knowledge on affective temperaments. We cover their role in psychiatric and non-psychiatric disorders, investigate the scientific knowledge on their possible genetic background, highlight their importance on intercultural differences and outline the possibilities for future research discovering the common background between depression and other - non-psychiatric - disorders.

To prevent being stressed-out: Allostatic overload and resilience of general practitioners in the era of COVID-19. A cross-sectional observational study.

BACKGROUND: Responsibility of general practitioners (GPs) in delivering safe and effective care is always high but during the COVID-19 pandemic they face even growing pressure that might result in unbearable stress load (allostatic overload, AO) leading to disease. OBJECTIVES: We aimed to measure AO of Hungarian GPs during the COVID-19 pandemic and explore their recreational resources to identify potential protective factors against stress load. METHODS: In a mixed-method design, Fava's clinimetric approach to AO was applied alongside the Psychosocial Index (PSI); Kellner's symptom questionnaire (SQ) to measure depression, anxiety, hostility and somatisation and the Public Health Surveillance Well-being Scale (PHS-WB) to determine mental, social, and physical well-being. Recreational resources were mapped. Besides Chi-square and Kruskal-Wallis tests, regression analysis was applied to identify explanatory variables of AO. RESULTS: Data of 228 GPs (68% females) were analysed. Work-related changes caused the biggest challenges leading to AO in 60% of the sample. While female sex (OR: 1.99; CI: 1.06; 3.74, p = 0.032) and other life stresses (OR: 1.4; CI: 1.2; 1.6, p < 0.001) associated with increased odds of AO, each additional day with 30 min for recreation purposes associated with 20% decreased odds (OR: 0.838; CI: 0.72; 0.97, p = 0.020). 3-4 days a week when time was ensured for recreation associated with elevated mental and physical well-being, while 5-7 days associated with lower depressive and anxiety symptoms, somatisation, and hostility. CONCLUSION: Under changing circumstances, resilience improvement through increasing time spent on recreation should be emphasised to prevent GPs from the adverse health consequences of stress load.

Comparative analysis of diagnostic probability estimates of some common diagnoses among family doctors, medical residents, and medical students reveals negative correlation between age and estimate of chronic obstructive pulmonary disease (COPD).

BACKGROUND: Patients with their given complaints and symptoms expect certain diagnoses to be estimated with the same probability when seen by different family doctors. These estimations showed extreme variation among family doctors in Switzerland. The present study investigated whether there is any difference in the probabilities of the same diagnoses given by Hungarian doctors and, if so, what the responsible factors are. Estimates given by specialists, residents of family medicine, and medical students were also compared. MATERIAL/METHODS: In this cross-sectional study, 484 family physicians, 124 medical residents, and 148 medical students completed a questionnaire that assessed the diagnostic probability of six clinical scenarios. RESULTS: Medians and ranges of probability were almost the same in both countries. Significant negative correlation was observed between age and the estimation of COPD among the family physicians (Spearman's r=-0.231, p<0.001). This correlation was even more expressed in men and was independent of gender, previous specialization in internal medicine or pulmonology, and the location of practice. Family physicians rated the probability of myocardial infarction higher than the residents (p<0.01). They also rated the probability of congestive heart disease higher than the medical students (p<0.001). Women residents and students gave higher estimates in almost all clinical settings than did men. CONCLUSIONS: Diagnostic estimates of the same clinical scenarios vary widely among Hungarian family doctors, residents, and medical students. The independent inverse relationship between the doctor's age and his/her estimate of the probability of COPD underscores the need to intensify education on this disease.

Training concept of integrative medicine in Hungary based on international models / Az integratív medicina képzésének hazai koncepciója nemzetközi minták alapján.

Integrative medicine is a new approach in the 21st century healthcare system, which integrates conventional medicine and evidence-based, safe and efficient complementary therapies into a unified biomedicine. Medical doctors and complementary therapists work together in partnership with patients to help them recover and live a whole life. Equally important is the maintenance and enhancement of health and well-being in which therapists become role-models. In this article, the authors introduce a proposal for the concept and major elements of a two-year integrative medicine postgraduate training for specialist doctors in Hungary and summarize international progress in the field. Orv Hetil. 2020; 161(27): 1122-1130.