Implicit gender bias in the diagnosis and treatment of type 2 diabetes: A randomized online study.

AIMS: Implicit gender biases (IGBs) are unconscious evaluations about a person based on gender. IGBs of healthcare providers may affect medical decision making. This study investigated whether IGBs and genders of patients and general practitioners (GPs) influence diagnostics and treatment decisions in the context of diabetes type 2. METHODS: Ninety-nine GPs participated in this randomized online study. Implicit Associations Tasks were used to measure two IGBs, related to lifestyle (women have a healthier lifestyle than men) and communication (men are less communicative than women). Clinical decisions regarding type 2 diabetes were measured with vignettes that included a fictional male or female patient case. RESULTS: Female GPs exhibited a significant lifestyle IGB (p < 0.001). GPs of both genders exhibited a significant communication IGB (p < 0.001). Several associations between IGBs and clinical decisions were found. The gender of the vignette character affected several outcomes, for example GPs were less certain in the diabetes diagnosis when the character was a woman (p < 0.001). CONCLUSION: We demonstrated that GPs have IGBs and these biases as well as patient's gender affect decisions of GP's when they are solving a diabetes vignette case. Future research is needed to understand the most important consequences of IGBs in the context of type 2 diabetes.

The burden of common skin diseases assessed with the EQ5D™: a European multicentre study in 13 countries.

BACKGROUND: Generic instruments measuring health-related quality of life (HRQoL), like EQ5D™, enable comparison of skin diseases with healthy populations and nondermatological medical conditions, as well as calculation of utility data. OBJECTIVES: To measure HRQoL in patients with common skin diseases and healthy controls across Europe using the EQ5D. METHODS: This multicentre observational cross-sectional study was conducted in 13 European countries. Each dermatology clinic recruited at least 250 consecutive adult outpatients to complete questionnaires, including the EQ5D. RESULTS: There were 5369 participants (4010 patients and 1359 controls). Mean ± SD self-rated health state reported by patients was 69·9 ± 19·7; for controls it was 82·2 ± 15·5. When adjusted for confounding factors, including comorbidity, mean patient EQ visual analogue scores were 10·5 points lower than for controls (standardized ß = -0·23). Odds ratio with 95% confidence interval for impairment in all five dimensions of EQ5D adjusted for confounders was doubled for patients compared with controls. Patients with hidradenitis suppurativa (HS), blistering conditions, leg ulcers, psoriasis and eczemas had the highest risk for reduction in HRQoL in most dimensions (2-10-fold). Data on differences of impairment by dimensions offer new insights. CONCLUSIONS: This study confirms the large impact skin conditions have on patients' well-being, differentiating between aspects of HRQoL. Patients with HS, blistering diseases, leg ulcers, infections and most chronic skin diseases reported reduced HRQoL compared with patients with chronic obstructive lung disease, diabetes mellitus, cardiovascular disease and cancers. These findings are important in the prioritization of resource allocation between medical fields and within dermatological subspecialities.

Predictors of perceived stigmatization in patients with psoriasis.

BACKGROUND: The physical appearance of psoriasis can be cosmetically disfiguring, resulting in a substantial social burden for patients. An important aspect of this burden is the experience of stigmatization. While stigmatization is known to be disabling and stressful for patients, little is known about its correlates, and effective interventions are lacking. OBJECTIVES: To examine predictor variables for perceived stigmatization in psoriasis. METHODS: Questionnaires were administered to 514 patients with psoriasis in a cross-sectional study. Zero-order correlation and multiple-regression analyses were conducted including sociodemographic, disease-related, personality, illness cognitions and social support predictor variables. RESULTS: Stigmatization was experienced by 73% of patients to some degree, and correlated with all five categories of predictor variables. In multiple-regression analyses, stigmatization was associated with higher impact on daily life; lower education; higher disease visibility, severity and duration; higher levels of social inhibition; having a type D personality; and not having a partner. CONCLUSIONS: The results indicate that perceived stigmatization is common in psoriasis, and can be predicted by sociodemographic, disease-related and personality variables. These predictor variables provide indications of which patients are especially vulnerable regarding perceived stigmatization, which might be used in treatment.

The Course and Predictors of Health-Related Quality of Life in Living Kidney Donors: A Systematic Review and Meta-Analysis.

A better understanding of the course and risk factors for impaired long-term health-related quality of life (HRQoL; ie, physical, psychological, and social-relational functioning) after kidney donation might help clinicians improve the care of live kidney donors. This systematic review and meta-analysis summarizes prospective studies about the course and predictors of HRQoL in living kidney donors. Studies indicate that shortly after donation, donors have lower HRQoL, with minor to moderate changes in psychological and social-relational functioning and major changes in physical functioning. At 3-12 months after donation, HRQoL returned to baseline or was slightly reduced, particularly for fatigue, but scores were still comparable to general population norms. Results were mainly robust across surgery techniques. A limited number of studies examined risk factors for impaired HRQoL, with low psychological functioning before donation as the most consistent predictor. Based on these results, clinicians can inform potential donors that, on average, kidney donors have high long-term HRQoL; however, donors with low psychological functioning at baseline are those most at risk of impaired long-term HRQoL. Future studies should focus on other potentially relevant predictors of postdonation HRQoL, including donor eligibility criteria and donor-recipient relationships, to optimize screening and interventions for donors at risk.

The psychophysiological stress response in psoriasis and rheumatoid arthritis.

BACKGROUND: Psychosocial stress can be a risk factor for the maintenance and exacerbation of chronic inflammatory diseases, such as psoriasis and rheumatoid arthritis (RA). OBJECTIVES: To gain insight into the specificity of the psychophysiological stress response during chronic inflammation, we assessed autonomic and neuroendocrine responses to stress in different chronic inflammatory diseases. METHODS: Thirty patients with psoriasis (nine women, mean age 58·5 years ± 12·4), 34 patients with RA (16 women, mean age 60·8 years ± 9·2) and 25 healthy controls (16 women, mean age 55·6 years ± 8·7) underwent a standardized psychosocial stress task (Trier Social Stress Test). Salivary levels of α-amylase and cortisol and self-reported tension levels were measured before and after the stress test. RESULTS: The cortisol response to stress was heightened in patients with psoriasis compared with patients with RA and healthy controls, whereas there were no differences in the autonomic and self-reported measures. CONCLUSIONS: The altered neuroendocrine stress response in patients with psoriasis suggests that stressful events might have different physiological consequences for specific patient groups with chronic inflammatory conditions, possibly adversely affecting disease status.

The STRESS-NL database: A resource for human acute stress studies across the Netherlands.

Stress initiates a cascade of (neuro)biological, physiological, and behavioral changes, allowing us to respond to a challenging environment. The human response to acute stress can be studied in detail in controlled settings, usually in a laboratory environment. To this end, many studies employ acute stress paradigms to probe stress-related outcomes in healthy and patient populations. Though valuable, these studies in themselves often have relatively limited sample sizes. We established a data-sharing and collaborative interdisciplinary initiative, the STRESS-NL database, which combines (neuro)biological, physiological, and behavioral data across many acute stress studies in order to accelerate our understanding of the human acute stress response in health and disease (www.stressdatabase.eu). Researchers in the stress field from 12 Dutch research groups of 6 Dutch universities created a database to achieve an accurate inventory of (neuro)biological, physiological, and behavioral data from laboratory-based human studies that used acute stress tests. Currently, the STRESS-NL database consists of information on 5529 individual participants (2281 females and 3348 males, age range 6-99 years, mean age 27.7 ±â€¯16 years) stemming from 57 experiments described in 42 independent studies. Studies often did not use the same stress paradigm; outcomes were different and measured at different time points. All studies currently included in the database assessed cortisol levels before, during and after experimental stress, but cortisol measurement will not be a strict requirement for future study inclusion. Here, we report on the creation of the STRESS-NL database and infrastructure to illustrate the potential of accumulating and combining existing data to allow meta-analytical, proof-of-principle analyses. The STRESS-NL database creates a framework that enables human stress research to take new avenues in explorative and hypothesis-driven data analyses with high statistical power. Future steps could be to incorporate new studies beyond the borders of the Netherlands; or build similar databases for experimental stress studies in rodents. In our view, there are major scientific benefits in initiating and maintaining such international efforts.

Patient and spouse appraisals of health status in rheumatoid arthritis and fibromyalgia: discrepancies and associations with invalidation.

OBJECTIVES: The health problems of patients with rheumatoid arthritis and fibromyalgia are mostly invisible to others, which can lead to a discrepancy between patients' and spouses' appraisals of the severity of the health problems. As a consequence, some patients may feel 'invalidation' from their spouse, such as not being understood and believed. Aim of this study was to compare patients' and spouses' appraisals of the health status of patients with rheumatoid arthritis and patients with fibromyalgia, and to examine whether discrepancies in these appraisals are associated with invalidation experiences of the patient. METHODS: Eighty-four patients with rheumatoid arthritis and 95 patients with fibromyalgia filled out a health status questionnaire (MOS short-form general health survey, SF-20) and a questionnaire on invalidation by the spouse (Illness Invalidation Inventory, 3*I). The spouses appraised the patients' health status independently from the patients using a spouse version of the SF-20. RESULTS: Patients with fibromyalgia and their spouses appraised the patients' health status significantly worse than patients with rheumatoid arthritis and their spouses. The agreement between patients and spouses was generally fair with somewhat more agreement in rheumatoid arthritis than in fibromyalgia. Patient-spouse discrepancies in health status appraisals were not associated with invalidation experiences. CONCLUSIONS: The invisibility of health problems in fibromyalgia and rheumatoid arthritis is not accompanied by large patient-spouse discrepancies of health status appraisals, which suggests that invalidation by spouses is not dependent on observable evidence such as clinical signs of damage or pathology.

Case-control study of patient characteristics, knowledge of the COVID-19 disease, risk behaviour and mental state in patients visiting an emergency room with COVID-19 symptoms in the Netherlands.

BACKGROUND: Coronavirus disease 2019 is a serious respiratory virus pandemic. Patient characteristics, knowledge of the COVID-19 disease, risk behaviour and mental state will differ between individuals. The primary aim of this study was to investigate these variables in patients visiting an emergency department in the Netherlands during the COVID-19 pandemic and to compare the "COVID-19 suspected" (positive and negative tested group) with the "COVID-19 not suspected" (control group) and to compare in the "COVID-19 suspected" group, the positive and negative tested patients. METHODS: Consecutive adult patients, visiting the emergency room at the Franciscus Gasthuis & Vlietland, Rotterdam, the Netherlands, were asked to fill out questionnaires on the abovementioned items on an iPad. The patients were either "COVID-19 suspected" (positive and negative tested group) or "COVID-19 not suspected" (control group). RESULTS: This study included a total of 159 patients, 33 (21%) tested positive, 85 (53%) negative and 41 (26%) were COVID-19 not suspected (control group). All patients in this study were generally aware of transmission risks and virulence and adhered to the non-pharmaceutical interventions. Working as a health care professional was correlated to a higher risk of SARS-Cov-2 infection (p- value 0.04). COVID-19 suspected patients had a significantly higher level of anxiety compared to COVID-19 not suspected patients (p-value < 0.001). The higher the anxiety, the more seriously hygiene measures were followed. The anxiety scores of the patients with (pulmonary) comorbidities were significantly higher than without comorbidities. CONCLUSION: This is one of the first (large) study that investigates and compares patient characteristics, knowledge, behaviour, illness perception, and mental state with respect to COVID-19 of patients visiting the emergency room, subdivided as being suspected of having COVID-19 (positive or negative tested) and a control group not suspected of having COVID-19. All patients in this study were generally aware of transmission risks and virulence and adhered to the non-pharmaceutical interventions. COVID-19 suspected patients and patients with (pulmonary) comorbidities were significantly more anxious. However, there is no mass hysteria regarding COVID-19. The higher the degree of fear, the more carefully hygiene measures were observed. Knowledge about the coping of the population during the COVID-19 pandemic is very important, certainly also in the perspective of a possible second outbreak of COVID-19.

Lack of understanding in fibromyalgia and rheumatoid arthritis: the Illness Invalidation Inventory (3*I).

BACKGROUND: Patients with rheumatic diseases may face 'discounting' (denying and patronising) or 'lack of understanding' because of having symptoms without external clinical signs, but instruments to assess such invalidation experiences are lacking. OBJECTIVES: To develop and evaluate the Illness Invalidation Inventory (3*I), to compare invalidation experiences of two groups of patients who differ in visual signs and laboratory findings-rheumatoid arthritis (RA) and fibromyalgia-and to examine the association of invalidation with health status. METHODS: A questionnaire (eight items with respect to five sources: spouse, family, medical professionals, work environment and social services) was constructed. It was completed by 142 patients with RA and 167 patients with fibromyalgia. RESULTS: Principal axis factoring with oblimin rotation yielded two factors with high internal consistency (α>0.70): 'discounting' (five items) and 'lack of understanding' (three items). Patients with fibromyalgia experienced significantly more discounting and lack of understanding from their family, medical professionals, colleagues and social services than did patients with RA. Both patient groups experienced more invalidation from social services, colleagues and family than from medical professionals and spouses. More discounting and lack of understanding correlated with poorer mental well-being and social functioning in both patient groups. Discounting correlated with more physical disability and pain in patients with RA. CONCLUSIONS: The 3*I is a brief, reliable instrument for assessing patients' perceptions of invalidation from different sources, which differ between patient groups and are associated with health status. Future validation research should clarify the clinical impact of invalidation on treatment adherence and outcome.

How to best measure quality of life in coeliac disease? A validation and comparison of disease-specific and generic quality of life measures.

OBJECTIVE: Health-related quality of life (HRQoL) is an important outcome in chronic disease. Generic HRQoL questionnaires may not adequately reflect disease-specific challenges in coeliac disease. We investigated whether disease-specific HRQoL questionnaires add relevant information to generic measures that will better help to identify patients experiencing problems. PATIENTS AND METHODS: We performed a cross-cultural validation of the Celiac Disease Quality Of Life-survey (CD-QOL), next we developed and validated a new disease-specific HRQoL questionnaire, and finally compared their predictive validity with the disease-generic RAND SF-36/SF-12 in 825 patients (mean age: 56.1±15.8 years) with (reported) biopsy-proven coeliac disease. Internal consistency and convergent, discriminative and predictive validity of the questionnaires was determined. RESULTS: Two Dutch versions of the CD-QOL were validated, consisting of 14 and six items, respectively (CD-QOL-14-NL, CD-QOL-6-NL). We developed and validated the CeliacQ-27, which has 27-items across three subscales (Limitations, Worries and Impact on daily life), and a short seven-item version, the CeliacQ-7. All questionnaires had excellent psychometric properties and differentiated well between active disease and clinical remission and strict versus poor dietary adherence. The added value of the disease-specific questionnaires to the generic HRQoL measure to the explained variance of symptom burden and dietary adherence was limited. CONCLUSION: HRQoL in patients with coeliac disease can easily be assessed by brief generic as well as disease-specific measures. Disease-specific questionnaires, however, provide more explicit information on disease-relevant areas of functioning.

Conditioning cortisol in humans: design and pilot study of a randomized controlled trial.

BACKGROUND: Conditioning of physiological responses can be achieved by repeatedly pairing a previously neutral conditioned stimulus with the administration of a pharmacologically salient unconditioned stimulus. This type of conditioning has been effective for specific immune and endocrine responses, but results with regard to conditioning of cortisol, a key stress-regulatory parameter, are currently unclear. This paper describes a pharmacological conditioning design, optimized for the examination of effects of cortisol conditioning under both basal conditions and in response to stress. METHODS: A double-blind randomized controlled conditioning paradigm aimed at conditioning of cortisol is conducted in 48 healthy female volunteers. During the acquisition phase, a gustatory stimulus (conditioned stimulus) is paired with hydrocortisone (100 mg, capsulated, unconditioned stimulus) three times before being administered together with placebo during three evocation sessions. To investigate possible effects of cortisol conditioning in response to stress, participants are exposed to the Trier Social Stress Test during the third evocation session. Primary outcome measure of this study is the mean area under the curve of salivary cortisol during the first two evocation sessions. As secondary outcomes, self-reported affect and stress as well as alpha-amylase are investigated. A pilot study was conducted to ensure that this design is feasible to be used in a larger study. DISCUSSION: This study design provides an innovative opportunity to examine the conditioning of cortisol under basal conditions and in response to stress. Also, the possible effect of cortisol conditioning on secondary outcomes of self-reported affect and alpha-amylase can be investigated. If cortisol could successfully be conditioned, this would be of conceptual relevance, showing that hypothalamic pituitary adrenal (HPA) axis regulation can be influenced by associative learning processes. Eventually, this could also have important clinical implications for understanding and treating stress-related disorders in which HPA axis dysregulation might play a role. TRIAL REGISTRATION: Nederlands Trial Register, NTR4651. Registered on 29 July 2014.

Expectations about the effectiveness of pain- and itch-relieving medication administered via different routes.

BACKGROUND: Placebo effects on pain have been found to vary in size for different routes of medication administration (e.g. oral vs. injection). This has important implications for both clinical research and practice. To enhance our understanding of these differential placebo effects, research on the underlying expectations about multiple routes and symptoms other than pain is vital. METHODS: A cross-sectional, Internet-based survey was conducted in a representative sample of the Dutch population (n = 508). Respondents rated the expected effectiveness of pain- and itch-relieving medication in six forms, representing oral, injection and topical routes of administration. RESULTS: Injected medication was expected to be most effective for relieving pain, and topical medication for relieving itch. Furthermore, exploratory analyses showed that injections were expected to have the most rapid onset and long-lasting effects, and to be most frightening and expensive, while topical medication was expected to be the safest and the easiest to use, and oral medication was expected to have the most side effects. Higher expected effectiveness was moderately associated with expectations of more rapid onset and long-lasting effects, and better safety and ease of use. Associations of expected effectiveness with respondent characteristics (e.g. medication use and personality characteristics) were statistically small or nonsignificant. CONCLUSIONS: Expected effectiveness of medication differed depending on route of administration and targeted symptom. These findings have important implications for the design and interpretation of clinical trials and suggest that medication effects might be enhanced by prescribing medicine via the route that patients expect to be most effective for their complaint. SIGNIFICANCE: Differences in the expected effectiveness of medication depend on the route of administration (oral, injection, topical) and targeted symptom (pain, itch). These findings have important implications for clinical practice and the design and interpretation of clinical trials.

An improved metabolic calibrator for stress test equipment: protocol for its clinical utilization.

In previous articles, the technical specifications, validation and clinical applicability of a new metabolic calibrator for stress test apparatuses were described. However no indication was given of a basic protocol for the current clinical practice. Here we present an organised check system to satisfy this aim. A method for the exhaustive evaluation of the technical reliability of the metabolic instruments is presented together with the proposal of a uniform simulation approach to organise checks on-line of the apparatuses' ability to follow correctly the various test phases (protocol). Examples of recordings of checks using the standardised approach are shown. The method seems to be very effective. Every operation is computer directed.

Emotion regulation predicts change of perceived health in patients with rheumatoid arthritis.

OBJECTIVES: To examine whether emotion regulation predicts change of perceived health in patients with rheumatoid arthritis (RA). METHODS: Sixty six patients (44 female, 22 male; mean (SD) age 57.7 (11.6) years) participated in a prospective study. Hierarchical regression analysis was used to predict change of perceived health between study entry and follow up (1(1/2) years later) from the emotion regulation styles ambiguity, control, orientation, and expression at study entry. RESULTS: Valuing and intensely experiencing emotions (emotional orientation) predicted a decrease of positive affect. Difficulty recognising and expressing emotions (ambiguity) predicted an increase of perceived disease activity. Emotion regulation showed no associations with change of negative affect and social and physical functioning. CONCLUSIONS: Two styles of emotion regulation were shown to have a significant though modest role in the prediction of perceived health change in patients with RA. This suggests that the monitoring of emotion regulation may help to identify patients who are at risk for a reduction of perceived health. If our findings were confirmed by experimental research, improving emotion regulation skills might favourably affect perceived health.

Neuroendocrine-immune relationships between emotion regulation and health in patients with rheumatoid arthritis.

OBJECTIVES: Emotion regulation is hypothesized to be related to health through neuroendocrine-immune changes. This study examined the role of the neuroendocrine variables 24-h urinary cortisol and noradrenaline, and the immune variable serum interleukin 6 as mediators between emotion regulation styles and health (perceived health and disease activity: erythrocyte sedimentation rate (ESR) and Thompson joint score). METHODS: Sixty patients with rheumatoid arthritis (mean age 59.0+/-11.2 yr; 38 female) participated. RESULTS: Emotion regulation was not associated with immune functioning or disease activity, but it was somewhat related to neuroendocrine functioning: one of the emotion regulation styles, ambiguity, was related to noradrenaline in women (r = 0.39) but not in men. The indicators of neuroendocrine functioning (cortisol and noradrenaline) were correlated (r = 0.40), as were indicators of immune functioning (interleukin 6) and inflammatory activity (ESR; r = 0.53), but analyses did not indicate a role of these physiological variables in mediating between emotion regulation and health: neuroendocrine variables were not related to interleukin 6 or ESR, and none of the physiological parameters was correlated with joint score or perceived health. CONCLUSIONS: To examine whether the proposed mediational processes apply to individual patients, a longitudinal within-subjects design is needed. In our cross-sectional study, emotion regulation was somewhat related to neuroendocrine functioning, but our study did not uncover a potential mediational role of cortisol, noradrenaline or interleukin 6 in the relationship between emotion regulation and health in rheumatoid arthritis.

The relative influence of physical fitness, acclimatization state, anthropometric measures and gender on individual reactions to heat stress.

An experiment was set up to quantify the relative influence of fitness, acclimatization, gender and anthropometric measures on physiological responses to heat stress. For this purpose, 12 male and 12 female subjects were exposed to a neutral [ambient temperature (Ta) 21 degrees C, relative humidity (r.h. 50%)], a warm, humid (Ta 34 degrees C, r.h. 80%) and a hot, dry (Ta 45 degrees C, r.h. 20%) climate at rest and at two exercise intensities [25%, and 45% maximal O2 intake (VO2max)], seated seminude in a net chair behind a cycle ergometer. Their physiological responses were recorded and the data submitted to a multiple regression analysis. It was shown that for the variance in heat storage, the percentage of body fat and the surface to mass ratio had relatively the largest influence of all the individual parameters, followed by VO2max and the sweat rate versus increase in core temperature (total r2 = 92%). For the skin temperature variation, the relative influence of individual parameters (sweat gain, VO2max) was small. For body core temperatures, individual parameters had a large influence. The largest effect was due to the percentage of fat and the surface to mass ratio, followed by the sweating setpoint and, finally, VO2max (total r2 = 54%-70%). For the variance in heart rate the VO2max was the most relevant parameter, followed by the setpoint of the sweat rate:rectal temperature relationship (total r2 = 88%). Blood pressure and skin blood flow predictions were also shown to improve by the addition of individual characteristics to the model.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychological adjustment of adolescent girls with chronic fatigue syndrome.

OBJECTIVE: To examine psychosocial problems and adaptation of adolescent girls with chronic fatigue syndrome (CFS). METHODOLOGY: Thirty-six adolescent girls with CFS (mean age: 15.2 years; mean syndrome duration: 19.7 months) who fulfilled the criteria of the Centers for Disease Control and Prevention were examined by interviews regarding premorbid problems and by questionnaires regarding psychosocial functioning and distress, psychological attitudes, and coping resources. Data were compared with normative data. RESULTS: Of the adolescents, 86.1% reported 1 or more premorbid problems (58.3% physical, 38.9% psychological, and 52.8% familial). Normal adjustment was reported for psychosocial self-esteem, social abilities, and attentional abilities. High adjustment to adult social standards of behavior was found, but low perceived competence in specific adolescent domains, such as athletic ability, romance, and participation in recreational activities. The girls reported predominantly internalizing problems. Normal achievement motivation, no debilitating fear of failure, and high internal locus of control were observed. Palliative reaction patterns and optimism were predominantly used as coping strategies. CONCLUSIONS: The large number of premorbid problems suggests a possible contributing factor to the onset of the syndrome, although there were no reference data of healthy adolescents. In distinct domains of psychosocial adjustment, the adolescent girls with CFS showed strengths such as adequate self-esteem and scholastic and social abilities, and weaknesses such as low competence in adolescent-specific tasks and internalizing distress, which may partly be explained by syndrome-specific somatic complaints. The use of optimistic and palliative reaction patterns as coping strategies in this patient group indicates that the patients with CFS seem to retain an active and positive outlook on life, which may result in a rather adequate psychological adaptation to the syndrome, but also in maintenance of the syndrome by exceeding the physical limits brought about by the CFS. Our results on adjustment and coping strategies may be helpful to implement (individual) rehabilitation programs.