Disentangling the change-alliance relationship: Observational assessment of the therapeutic alliance during change and stuck episodes.

The therapeutic alliance is considered the most robust process variable associated with positive therapeutic outcome in a variety of psychotherapeutic models [Alexander, L. B., & Luborsky, L. (1986). The Penn Helping Alliance Scales. In L. S. Greenberg & W. M. Pinsoff (Eds.), The psychotherapeutic process: A research handbook (pp. 325-356). New York: Guilford Press; Horvath, A. O., Gaston, L., & Luborsky, L. (1993). The alliance as predictor of benefits of counseling and therapy. In N. Miller, L. Luborsky, J. Barber, & J. P. Docherty (Eds.), Psychodynamic treatment research: A handbook for clinical practice (pp. 247-274). New York, NY: Basic Books; Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16; Orlinky, D., Grawe, K., & Parks, B. (1994). Process and outcome in psychotherapy: Noch einmal. In A. Bergin & J. S. Garfield (Eds.), Handbook of psychotherapy and behaviour change (4th ed., pp. 270-378). New York, NY: Wiley and Sons]. The relationship between alliance and outcome has traditionally been studied based on measures that assess these therapy factors at a global level. However, the specific variations of the alliance process and their association with therapy segments that are relevant for change have not yet been fully examined. The present study examines the variations in the therapeutic alliance in 73 significant in-session events: 35 change and 38 stuck episodes identified through the observation of 14 short-term therapies of different theoretical orientations. Variations in the alliance were assessed using the VTAS-SF [Shelef, K., & Diamond, G. (2008). Short form of the revised Vanderbilt Therapeutic Alliance Scale: Development, reliability, and validity. Psychotherapy Research, 18, 433-443]. Nested analyses (HLM) indicate a statistically significant better quality of the alliance during change episodes.

Generic change indicators in therapeutic processes with different outcomes.

OBJECTIVES: This paper analyzes the relationship between ongoing change and final outcome in therapies carried out in natural settings with 39 clients. METHOD: Ongoing change was assessed through generic change indicators (GCIs), an observational method designed to label the content of change moments by selecting one specific GCI from the sequence of 19 that covers from more rudimentary and low complexity to more elaborated and complex changes. These GCIs can also be grouped into three broad stages of change, according to their level of complexity. Productivity indicators were generated to account for the number of GCIs (total and grouped by stage) adjusted by the length of therapy and the respective individual production of GCIs. Outcome, in turn, is understood as the final result of therapy and was measured by Lambert's Outcome Questionnaire (OQ 45.2). RESULTS: Using the Reliable Change Index of this measure, which qualifies the difference between initial and final scores, therapies were grouped into "good outcome" and "poor outcome" cases. Findings indicate that therapies with good final outcome show a greater presence of Stage III GCIs during the process. Furthermore, in these therapies there is a significant association between Stage I GCI productivity and the productivity of Stages II and III GCIs. This is not the case for poor outcome cases, where results show a greater productivity of initial stage GCIs, mostly in the second half of therapy and no relation of this productivity with Stage II and Stage III GCIs. CONCLUSIONS: Results support the relation of ongoing change and final outcome. Possibilities for the clinical use of GCIs, specifically for monitoring ongoing therapies, are discussed.

[Pilot plan for a mobile health communication and monitoring system for people with diabetes]. / Plan piloto del sistema de comunicación y seguimiento móvil en salud para personas con diabetes.

mHealth is a practical, useful, and available tool for one-way or two-way communication between health professionals and patients. It is especially promising in countries such as Chile, with widespread and growing mobile telephone coverage that is very well accepted by the public. Our objective is to demonstrate the process for designing a mobile communication and monitoring model, aimed at providing communication between professionals in primary healthcare centers and their patients, to facilitate timely diagnosis and initiation of treatment for type 2 diabetes. This model's characteristics include use of mobile telephones as a communication tool, a one-way method (from health centers to patients), integration into in-person care delivered at health centers, use of different communication strategies (voice and written), and integrated functioning using open-source software. The system includes personalized communication, automated voice communication, and automated written communication using short message service (SMS). We describe the strategies and components of the system. The lessons learned include the contribution from successful implementation of COSMOS (consolidated online modulated operating systems), a technological innovation, to support the health care of people with suspected type 2 diabetes in primary healthcare centers. Working together with teams in the field is essential to this achievement.

Wellbeing, social media addiction and coping strategies among Chilean adolescents during the pandemic.

Introduction: During the COVID-19 pandemic, adolescents had to deal with a range of mental health problems that has increased social media addiction levels with adverse effects on life satisfaction. Previous studies have explored coping mechanisms to deal with this addiction problem, but did not consider the need to simultaneously cope with different dimensions. Therefore, our study aimed to examine the moderating effect of various coping mechanisms on the relationship between social media addiction and adolescent life satisfaction. Methods: Self-report questionnaires were applied to 1290 secondary school students (age mean = 16.03, SD = 1.27, range: 14 to 19; and 57% female). An exploratory and a confirmatory factor analysis were performed to determine the factor structure of the Brief-Cope 28 scale. Then, a descriptive and correlational analysis of the variables and a multiple linear regression analysis was performed. Results: We found that the social media addiction risk was negatively associated with life satisfaction, adaptive strategies were positively correlated to life satisfaction, and maladaptive strategies were negatively correlated to it. Also, a moderation model was evaluated in which four stress management strategies, namely acceptance and perspective-taking, seeking socio-emotional support, active coping, and maladaptive strategies all conditioned the relationship between social media addiction risk and life satisfaction after controlling for demographic variables and the specific strategies of using comedy, religion and substance use. Results indicate additive and multiplicative effects of management strategies for stressful situations in the studied relationship. Seeking socio-emotional support and active coping were positively related to life satisfaction and maladaptive strategies were negatively associated with it. Multiplicative effects indicate that the relationship between the social media addiction risk and life satisfaction depends only on the acceptance and perspective taking that adolescents report. When adolescents reported having low or average levels of acceptance and perspective taking, there was a negative correlation with general life satisfaction, a connection that grew markedly stronger. In contrast, no connection between social media addiction and life satisfaction was detected for adolescents who report higher levels of acceptance and perspective-taking. Discussion: Abuse of social media and the use of maladaptive stress coping strategies were risk factors that decreased life satisfaction among adolescents during the COVID-19 pandemic period.

Trajectories of Parental Daily Stress: An Ecological Momentary Assessment Study during the COVID-19 Lockdown.

The COVID-19 pandemic was a source of significant stress due to health and safety concerns and measures to control the virus' spread, such as mobility restrictions. This measure was especially demanding for parents with school aged children, who had to find new work-family balance as their children participate in online education while attempting to work remotely. To evaluate parents' stress trajectories during the pandemic, we conducted Ecological Momentary Assessments (EMAs) during lockdown for 29 days in 68 families in Santiago, Chile. In addition, we evaluated the role of educational level and income, co-parenting, and number of children in parents' stress trajectories. Our results showed that during the first weeks of lockdown expected protective factors (i.e., income and co-parental support) were not able to influence parents' daily stress management. Moreover, parents with higher educational levels reported worse stress adaptation than less educated parents. On the other hand, co-parental conflict was significantly associated with parent's stress. Our study captured an acute response to COVID-19 related challenges. This study contributes to understanding how parents adjust to stress during adverse circumstances such as the COVID-19 pandemic.

Analysis of verbalized emotions in the psychotherapeutic dialogue during change episodes.

As described by many theorists, emotional expressions contribute to the activation and regulation of personal emotional experiences and communicate something about internal states and intentions. These emotional expressions can be observed in the words used in our speech and nonverbal behaviors, even when nonverbal behaviors are synchronized to one's own speech or to the speech of others. Using a quantitative and qualitative methodology, this article reports a classification of verbal emotional expressions of both psychotherapists and patients in change episodes. Assuming that the emotions loaded in linguistic contents are explicit emotions shown by emotion words, this methodology allows for a complete and differentiating assessment of affective qualities in both patients and psychotherapists during the psychotherapeutic dialogue.

Delayed hyperbaric intervention in life-threatening decompression illness.

Arterial gas embolism is a catastrophic event. Bubbles in the arterial circulation may lodge in the brain and cause infarction in the affected area and/or in a coronary vessel causing acute myocardial ischaemia. There is no well-defined window of time beyond which a response to hyperbaric oxygen is not expected. Major improvement may occur if the patient is treated as soon as possible, but is less likely in divers with severe decompression illness who have delayed intervention. We report on a 51-year-old, male rebreather diver who suffered loss of consciousness and cardiovascular collapse within minutes of a 30-metre deep dive at a remote Micronesian dive site. Recompression treatment did not start for six days for reasons to be presented, during which time he remained deeply comatose, cardiovascularly unstable and intubated on ventilator support. Despite this, following aggressive hyperbaric treatment over many days he made a functional recovery. At one year post injury, he is leading a functional life but has not returned to his previous occupation as a diver and suffers from moderately severe tinnitus and impaired right ear hearing and occasional mild speech problems. He is undertaking a number of on-line courses with a view to re-employment.

Oncology Nurse Navigation: Development and Implementation of a Program at a Comprehensive Cancer Center
.

BACKGROUND: Oncology nurse navigation programs enhance coordination of care and patient satisfaction. 
. OBJECTIVES: The objective was to evaluate the effect of oncology nurse navigation on access to care, patient and provider satisfaction, and clinical trial enrollment of patients with hematologic or gynecologic malignancies.
. METHODS: A descriptive cohort study with a historic control was undertaken. Data were collected from electronic health records and patient and provider surveys in two disease-specific groups.
. FINDINGS: A significant decrease in the mean days from first provider visit to first therapy was observed in the hematology population. In both groups, time from contact to first visit and from first visit to initiation of treatment decreased. Mean satisfaction survey scores for both groups were high regarding relationships with the navigator and care received. Providers were highly satisfied with the program, and the navigation program did not increase clinical trials enrollment.

CYP2D6 genotype and phenotype in Amerindians of Tepehuano origin and Mestizos of Durango, Mexico.

Although the drug-metabolizing enzyme CYP2D6 has been studied extensively in subjects of differing ethnicities, limited CYP2D6 pharmacogenetic data are available for the Amerindian population and Mestizos of Mexico. Dextromethorphan hydroxylation phenotype was studied in Tepehuano Amerindian (n = 58) and Mestizo (n = 88) subjects, and 195 individuals (85 Tepehuano Amerindians and 110 Mestizos) were genotyped by polymerase chain reaction-restriction fragment length polymorphism methods to identify the frequencies of the CYP2D6*3, *4, *6, and *10 alleles. Tepehuano Amerindian subjects lacked the poor metabolizer (PM) phenotype, whereas in Mestizos the PM phenotype frequency was 6.8%. The CYP2D6*3, *6, and *10 alleles were not found in Tepehuano Amerindians. The CYP2D6*4 allele had a low frequency (0.006) in this Amerindian group. In the Mestizo group, the CYP2D6*3, *4, and *10 alleles had frequencies of 0.009, 0.131, and 0.023, respectively. The CYP2D6*6 allele was not found in Mestizos. The genotype-phenotype association was strongly statistically significant (r(2) = .45; P = .005) in Mestizos. The Tepehuano population was found to have a low phenotypic and genotypic CYP2D6 diversity and differed from other Amerindian groups. On the other hand, the frequencies of the CYP2D6 variant alleles in Mestizos were similar to those reported for whites.

Advances in radiation treatment of patients with breast cancer.

Breast cancer is the most commonly diagnosed cancer among women in the United States. Approximately half of all patients diagnosed with early-stage breast cancer receive conservative breast surgery followed by consolidative radiation treatment. A number of technologic advances have been made in radiation therapy planning and treatment that minimize early and late toxicities and may improve treatment outcomes. Among these are (a) the treatment of patients with large or pendulous breasts or cardiopulmonary disease in the prone position, (b) intensity-modulated radiation treatment, which delivers precise, highly conformal radiation dose distributions within the breast by using computerized inverse treatment planning and intensity-modulated radiation beams to produce the required dose distribution, and (c) brachytherapy, which is the placement of a radioactive source within the lumpectomy bed. These advances are gaining national recognition and are available at many institutions. Nurses play a vital role in educating patients; therefore, nurses must have the information they need to inform their patients about these advances. The information in this article will allow nurses to help patients understand the anticipated treatment and related side effects and make informed decisions.

Getting patients active: using national data to drive practice.

Data from a National Cancer Institute-designated comprehensive cancer center taking part in the ONS Foundation-supported Breast Cancer Care Quality Measures Set pilot study revealed a lack of interventions recommended for patient-reported symptoms of fatigue. A team was formed to address the issue using the steps of the evidence-based practice process and to implement practice changes. This article describes the barriers and challenges faced, in addition to the integration of exercise resources into patients' plans of care. The authors describe the curriculum for staff education regarding the practice change, implementation of an evidence-based fatigue assessment and interventions, and methods to integrate these resources into patient care.

Cardiopulmonary arrest in the outpatient setting: enhancing patient safety through rapid response algorithms and simulation teaching.

Ambulatory and outpatient centers constantly are challenged with administrating cancer treatments in an efficient and safe way. With the advent of numerous novel cancer medications known to cause hypersensitivity reactions, nurses have become experts in managing these emergencies. However, patients rarely exhibit severe infusion reactions or cardiopulmonary arrest. Outpatient nurse knowledge and comfort with grade 4, life-threatening emergencies requiring cardiopulmonary resuscitative measures often is low because of infrequent occurrence. That is largely a result of nurses' ability to immediately identify the need for emergency intervention, thus preventing the sequelae of patient deterioration that could lead to cardiopulmonary arrest. This article describes how the authors' institution developed methods to improve emergency care by bridging the gap between knowledge and experience of handling life-threatening emergencies.

Plan piloto del sistema de comunicación y seguimiento móvil en salud para personas con diabetes / Pilot plan for a mobile health communication and monitoring system for people with diabetes

La mSalud es una herramienta práctica, útil y disponible para la comunicación unidireccional o bidireccional entre profesionales de la salud y el paciente, cuyo uso es especialmente promisorio en países como Chile, con una amplia y creciente cobertura de telefonía móvil muy bien aceptada por la población. Nuestro objetivo es mostrar el proceso de diseño de un modelo de comunicación y seguimiento móvil, destinado a facilitar la comunicación entre profesionales de los centros atención primaria en salud y sus usuarios, para lograr el diagnóstico oportuno e inicio del tratamiento de la diabetes mellitus de tipo 2 (DM2). Este modelo se caracteriza por utilizar el teléfono móvil como herramienta de comunicación, ser un método unidireccional (desde los centros de salud hacia los usuarios), estar integrado con la atención presencial que se entrega en los centros de salud, utilizar diferentes estrategias de comunicación (vía voz y escrita), y funcionar integrado en un software diseñado en código abierto. El sistema incluyó la implementación de comunicación personalizada, comunicación automatizada de voz y comunicación automatizada escrita a través de servicio de mensaje corto de voz. Se describen estas estrategias y los componentes del sistema. Entre las lecciones aprendidas, se destaca el aporte de lograr implementar la innovación tecnológica COSMOS (sistemas operadores modulados consolidados en línea, por su sigla en inglés), para apoyar el proceso de cuidado de la salud de las personas con sospecha de DM2 en centros de atención primaria de salud. Para este logro, resulta imprescindible el trabajo conjunto con los equipos en terreno.

mHealth is a practical, useful, and available tool for one-way or two-way communication between health professionals and patients. It is especially promising in countries such as Chile, with widespread and growing mobile telephone coverage that is very well accepted by the public. Our objective is to demonstrate the process for designing a mobile communication and monitoring model, aimed at providing communication between professionals in primary healthcare centers and their patients, to facilitate timely diagnosis and initiation of treatment for type 2 diabetes. This model's characteristics include use of mobile telephones as a communication tool, a one-way method (from health centers to patients), integration into in-person care delivered at health centers, use of different communication strategies (voice and written), and integrated functioning using open-source software. The system includes personalized communication, automated voice communication, and automated written communication using short message service (SMS). We describe the strategies and components of the system. The lessons learned include the contribution from successful implementation of COSMOS (consolidated online modulated operating systems), a technological innovation, to support the health care of people with suspected type 2 diabetes in primary healthcare centers. Working together with teams in the field is essential to this achievement.

Episodios de cambio y estancamiento en psicoterapia: características de la comunicación verbal entre pacientes y terapeutas / Change and stuck episodes in psychotherapy: characterization of verbal communication between patients and therapists

Se presentan los resultados de un microanálisis de la conversación psicoterapéutica en episodios de cambio y de estancamiento. Se realizó un análisis comparativo de la comunicación verbal en una muestra de 33 episodios de cambio y 34 de estancamiento, correspondientes a 15 procesos terapéuticos, aplicando el sistema de codificación de la actividad terapéutica. Este sistema distingue cinco niveles de análisis: formas básicas, intenciones comunicacionales, técnicas, dominio y referencia. Los resultados muestran que los episodios de cambio y estancamiento se distinguen en cuanto a que, en los primeros, predomina un lenguaje más asertivo por parte del terapeuta y más receptivo en el paciente, estando ambos involucrados en la activa construcción de nuevos significados y el paciente centrado en sí mismo. En los segundos se rigidiza el lenguaje, se exacerban algunas técnicas por parte del terapeuta y se tiende a focalizar menos en el paciente como referente del diálogo terapéutico.

Results of a microanalysis of the psychotherapeutic conversation in change and stuck episodes are presented. For the comparison of the verbal communication, the therapeutic activity coding system was applied to a sample of 33 change episodes and 34 stuck episodes, corresponding to 15 therapeutic processes. This system includes five levels of analysis: basic forms, communicative intentions, techniques, domain and reference. Results show differences in change and stuck episodes. The former are characterized by an assertive speech on the therapists' side, and a more receptive language from the patients, with both actors involved in an active construction of new meanings, and the patients referring to him or herself. In contrast, the language in stuck episodes is less flexible, the use of some therapist techniques is exacerbated and the therapeutic dialogue tends to be less focused on the patient as a reference point.

Presentación de caso radiológico: Esclerosis tuberosa / Radiologic case presentation. Tuberous sclerosis

Se presenta un caso de una mujer de 27 años, quien acude al Cuerpo de Guardia con dolor abdominal moderado de reciente comienzo. Al examen físico, se constata una masa abdominal que ocupaba ambos flancos. Luego de los estudios clínicos e imagenológicos, se comprobó la presencia de angiomiolipomas renales bilaterales, nódulos subependimarios y lesiones en piel por lo que se diagnosticó esclerosis tuberosa. La esclerosis tuberosa es una enfermedad neurocutánea caracterizada por cambios hamartomatosos en los pulmones, cerebro, riñones, piel, corazón y otros órganos. Para el diagnóstico se aplican criterios basados en el hallazgo de manifestaciones mayores y menores. En esto, la Imagenología tiene un importante papel(AU)

A 27 year old woman was given to the emergency department with mild, acute onset of right side abdominal pain. Clinical examination revealed firm masses bilaterally occupying almost the entire abdomen. Because the presence of bilateral angiomyolipomas, subependymal tuberous and adenoma sebaceum of the skin the patient was diagnosed as having a case of tuberous sclerosis . TS is a neurocutaneous disease characterized by hamartomatous changes in the lungs, brain, kidneys, skin, heart and others organs. The diagnostic criteria consisted of a set of major and minor diagnostic features. The imagenology plays a very important role(AU)