Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial.

BACKGROUND: Current clinical guidelines identify several psychological treatments for irritable bowel syndrome (IBS). IBS patients, however, have elevated trauma, life stress, relationship conflicts, and emotional avoidance, which few therapies directly target. We tested the effects of emotional awareness and expression training (EAET) compared to an evidence-based comparison condition-relaxation training-and a waitlist control condition. METHODS: Adults with IBS (N=106; 80% female, Mean age=36 years) were randomized to EAET, relaxation training, or waitlist control. Both EAET and relaxation training were administered in three, weekly, 50-minute, individual sessions. All patients completed the IBS Symptom Severity Scale (primary outcome), IBS Quality of Life, and Brief Symptom Inventory (anxiety, depressive, and hostility symptoms) at pretreatment and at 2 weeks posttreatment and 10 weeks follow-up (primary endpoint). KEY RESULTS: Compared to waitlist controls, EAET, but not relaxation training, significantly reduced IBS symptom severity at 10-week follow-up. Both EAET and relaxation training improved quality of life at follow-up. Finally, EAET did not reduce psychological symptoms, whereas relaxation training reduced depressive symptoms at follow-up (and anxiety symptoms at posttreatment). CONCLUSIONS & INFERENCES: Brief emotional awareness and expression training that targeted trauma and emotional conflicts reduced somatic symptoms and improved quality of life in patients with IBS. This emotion-focused approach may be considered an additional treatment option for IBS, although research should compare EAET to a full cognitive-behavioral protocol and determine which patients are best suited for each approach. Registered at clinicaltrials.gov (NCT01886027).

Screening adolescents for depression and parent-teenager conflict in an ambulatory medical setting: a preliminary investigation.

Because more than 60% of adolescent visits to physicians last less than 10 minutes, simple screening devices to identify persons at risk for social morbidity are needed. The result of a pilot screening instrument for depression and parent-teenager conflict is described. A seven-item questionnaire (three items for depression and four items for parent-teenager conflict), the Beck Depression Inventory (BDI), and the Conflict Behavior Questionnaire (CBQ), were administered to 226 adolescents at a high-risk adolescent heath center. After the visit, the provider rated each patient on a five-point Likert scale for level of depression and parent-teenager conflict. The screening questionnaire and the provider ratings were compared with the BDI and CBQ for sensitivity, specificity, and predictive value. A majority of the subjects (61% for depression and 63% for parent-teenager conflict) had no positive screening responses and, of these, less than 3% were classified as being depressed or having parent-teenager conflict by the BDI or CBQ. There were three or four positive screening responses (three responses for the depression questions and 20 responses for the parent-teenager conflict questions) among 23 adolescents and all of these scored in the abnormal range on the BDI or CBQ. Approximately one third of the subjects had intermediate responses. With one positive response, the predictive value for depression and parent-teenager conflict was 17% and 24%, respectively, whereas with two positive responses the predictive values were 56% and 26%. It was shown by receiver operating characteristic curves that the combined sensitivity and specificity of the screening questionnaire was superior to that of the physician ratings.(ABSTRACT TRUNCATED AT 250 WORDS)

The dual diagnosis of attention-deficit/hyperactivity disorder and substance abuse: case reports and literature review.

BACKGROUND: It is now recognized that attention-deficit/hyperactivity disorder (ADHD) may persist into adulthood. A number of studies have found an association between ADHD and substance abuse. This article describes three adult patients with both ADHD and substance abuse who were treated successfully with psychostimulants. A review of the relevant literature is included. METHOD: The patients were drawn from a university-based referral center for adults with ADHD. Evaluations for ADHD and substance abuse were completed. Medical therapy and follow-up were completed by the first author. RESULTS: All of the patients responded to psychostimulants and have remained abstinent from alcohol and other drugs for the past 2 to 3 years. CONCLUSION: This case series and review of the literature suggest that specific treatment for ADHD with psychostimulants is feasible in patients who also have substance abuse. Future studies should evaluate the prevalence of this "dual diagnosis" and the efficacy of differing management strategies.

Prevalence of attention-deficit/hyperactivity disorder and conduct disorder among substance abusers.

BACKGROUND: This cross-sectional study sought to determine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and conduct disorder among adults admitted to 2 chemical dependency treatment centers. It was hypothesized that ADHD alone or in combination with conduct disorder would be overrepresented in a population of patients with psychoactive substance use disorders. METHOD: Two hundred one participants were selected randomly from 2 chemical dependency treatment centers. Standardized clinical interviews were conducted using the Structured Clinical Interview for DSM-IV, the Addiction Severity Index, and DSM-IV criteria for ADHD. Reliabilities for the diagnostic categories were established using the Cohen kappa, and the subgroups of individuals with and without ADHD and conduct disorder were compared. RESULTS: Forty-eight (24%) of the participants were found to meet DSM-IV criteria for ADHD. The prevalence of ADHD was 28% in men (30/106) and 19% in women (18/95; NS). Seventy-nine participants (39%) met criteria for conduct disorder, and 34 of these individuals also had ADHD. Overall, individuals with ADHD (compared with those without ADHD) were more likely to have had more motor vehicle accidents. Women with ADHD (in comparison with women without ADHD) had a higher number of treatments for alcohol abuse. Individuals with conduct disorder (in comparison with those without conduct disorder) were younger, had a greater number of jobs as adults, and were more likely to repeat a grade in school, have a learning disability, be suspended or expelled from school, have an earlier age at onset of alcohol dependence, and have had a greater number of treatments for drug abuse. They were more likely to have a lifetime history of abuse of and/or dependence on cocaine, stimulants, hallucinogens, and/or cannabis. CONCLUSION: A significant overrepresentation of ADHD exists among inpatients with psychoactive substance use disorders. Over two thirds of those with ADHD in this sample also met criteria for conduct disorder. Our sample had a very large overlap between ADHD and conduct disorder, and the major comorbidities identified here were attributable largely to the presence of conduct disorder. Individuals who manifest conduct disorder and/or ADHD represent a significant proportion of those seeking treatment for psychoactive substance use disorders. They appear to have greater comorbidity and may benefit from a treatment approach that addresses these comorbidities specifically through medical and behavioral therapies.

Current positions of graduates of internal medicine-pediatrics training programs.

OBJECTIVE: To determine what positions graduates of internal medicine-pediatrics programs currently hold. DESIGN: A survey of the program directors of residencies in internal medicine-pediatrics. PARTICIPANTS: Program directors of the 85 internal medicine-pediatrics training programs listed in the 1993-1994 Graduate Medical Education Directory. MAIN OUTCOME MEASURES: A 1-page survey that described the current positions of trainees graduating between 1987 and 1993. RESULTS: Seventy-four (87%) of the 85 program directors completed the survey. Of the 708 graduates reported on, 68% were practicing as generalists. The generalists of this cohort (n = 480) were primarily in private practice settings (n = 390, 81%) and most were practicing internal medicine-pediatrics (n = 416, 85%). Only 12% of the generalists had chosen to practice either pediatrics or internal medicine. Twenty-one percent of the total graduates had entered subspecialty training. CONCLUSIONS: To our knowledge, the sample of 708 graduates is the largest survey of graduates of internal medicine-pediatrics programs to date and shows that 68% of graduates are practicing in primary care fields. Graduates of internal medicine-pediatrics programs should be considered as an important source of primary care physicians.

Parent and adolescent perceived need for parental consent involving research with minors.

OBJECTIVE: To assess parents' and adolescents' perceived need for parental consent for minor adolescents to participate in minimal risk research studies based on procedural invasiveness (anonymous surveys, interviews, and blood or urine testing) and sensitivity of the topics (sexuality, drug and alcohol use, and sexually transmitted diseases and human immunodeficiency virus [HIV]). METHODS: An anonymous self-report questionnaire was administered to 100 adolescent-parent pairs at 2 clinical sites (urban and suburban) of Children's Hospital of Michigan in Detroit. RESULTS: By invasiveness of the research procedure, the proportions of parents and adolescents who perceived a need for parental consent were as follows: face-to-face interviews, 62% vs 48%; telephone interviews, 72% vs 46%; blood or urine testing, 77% vs 62%; and blood testing for HIV status, 78% vs 59%. These differences were only significant for telephone interviews and HIV blood testing. For anonymous surveys, a minority of parents (33%) and adolescents (26%) reported that parental consent was needed. Based on sensitivity of the research topics, the proportions of parents and adolescents who perceived a need for parental consent were as follows: sexuality, 60% vs 34%; drug and alcohol use, 56% vs 44%; contraception, 62% vs 46%; and sexually transmitted diseases and HIV testing, 56% vs 52%. These differences were only significant for sexuality. Parents with higher education believed that teens could give their own consent (P < .05). Fifty-seven percent of parents and their teens agreed that parental consent for anonymous surveys was not necessary. For more invasive procedures and more sensitive topics, the percentage of disagreement ranged from 28% to 55.5%. CONCLUSIONS: There is a greater perceived need for parental consent to adolescent participation in research studies among parents than among teens for more invasive procedures and more sensitive topics. These results suggest the need for sensitivity to differing adolescent and parental perceived need for parental consent for a minor adolescent to participate in such studies. Further studies with larger samples are needed to determine what factors influence diverse parent and adolescent opinions.

Comparison of the Kallested Pathfinder EIA, cytocentrifuged direct fluorescent antibody, and cell culture for the detection of Chlamydia trachomatis.

A total of 203 duplicate endocervical samples collected from patients at an adolescent health care center were tested for the presence of Chlamydia trachomatis by cell culture, Pathfinder enzyme immunoassay (EIA) (Kallestad) and cytocentrifuged direct fluorescent antibody (DFA). Compared to cell culture, the Pathfinder assay demonstrated a sensitivity and specificity of 85.2% and 100%, whereas the DFA procedure demonstrated to be 92.6% sensitive and 99.4% specific.

A time-motion study of the activities of attending physicians in an internal medicine and internal medicine-pediatrics resident continuity clinic.

PURPOSE: To describe the activities of attending physicians in a residency-based continuity clinic and to examine factors that affect their teaching of, supervision of, and interaction with residents. METHOD: Six full-time board-certified faculty members (three internal medicine, three internal medicine-pediatrics) in an urban residency program participated in a descriptive observational time-motion study. The attending faculty were directly observed by "shadow" technique for 30 half-day sessions from April 1994 through September 1994. Each activity was measured by a trained research assistant using a digital stopwatch. The observed activities were assigned to one of 16 subcategories. RESULTS: 6,389 minutes of activities were observed. Activities were distributed among four general categories: direct contact with residents (43.1%), clinic operations (33.7%), personal and/or professional activities (18.0%), and miscellaneous time (5.2%). Attending physicians spent the most time in direct contact with residents when the patient-to-attending ratio was 10-14:1. DISCUSSION: The activities of the clinic's attending physicians were quite varied. Less than half of their time in the clinic was spent in contact with residents. This contact time may be significantly increased by changes to clinic policies, such as optimizing the patient-to-faculty ratio and increasing administrative support for the clinic. These findings can be used as a reference point for studies of attending physicians' activities since the federally mandated rules changes regarding their responsibilities for supervising residents.

Fifteen years of a videotape review program for internal medicine and medicine-pediatrics residents.

The medical interview remains the most valuable component in patient evaluation. In addition to its diagnostic usefulness, it is the foundation upon which the doctor-patient relationship is built. It is essential, therefore, that health care providers be well trained in interviewing. Evidence suggests that having residents conduct videotaped interviews with patients and review the videotapes with faculty is an excellent way to teach interviewing skills. Videotape review has been part of the residency programs in primary care internal medicine and medicine-pediatrics at Wayne State University School of Medicine for 15 years. Throughout the history of the videotape program, the authors have endeavored to make the review process less stressful for residents by ensuring that the reviews are nonthreatening, nonjudgmental, and learner-centered. In this paper, the authors discuss (1) the structure and process of the videotape review program; (2) recurrent themes of the review sessions; (3) residents' perspectives on the process; and (4) potential barriers to a successful videotape review program and suggestions for how to avoid or overcome them.

Strategies for health education for adolescent patients: a preliminary investigation.

OBJECTIVE: To determine the effect of unidirectional and bidirectional health education strategies on the amount of patient participation in the discourse between adolescent patients and physicians. METHODS: Videotapes of medical interviews between physician and adolescent patients that had been made in an earlier study of the efficacy of a self-report questionnaire were reviewed. An inductive method of content analysis from a small sample of videotapes was used to develop mutually exclusive categories of health education communication strategies from the variety of strategies employed by physicians. Seven different strategies were identified and grouped into two categories, unidirectional and bidirectional. Thirty videotapes were randomly selected (from the 79 available videotapes) and health education segments were identified, categorized, and coded for the amount of time the patient and physician spent talking. Paired student's t-tests were used to compare the time spent talking by patients and physicians in the two health education strategy categories. RESULTS: The patients consisted of 17 females and 13 males (mean age = 19.3). Two hundred thirty five individual health education strategies were identified, of which 183 (78%) were unidirectional and 52 (22%) were bidirectional. Physicians spent an average of 44.4 seconds talking in the unidirectional strategies, and 11.4 seconds in the bidirectional strategies (p = 0.0001). Patients spent 10.9 seconds and 26.1 seconds talking, respectively, in response to these strategies, (p = 0.07). The ratio of the time spent talking by patients to physicians was 0.14 for the unidirectional strategies and 1.06 for the bidirectional strategies (p = 0.004). CONCLUSIONS: Bidirectional health education communication strategies increase the amount of participation of adolescent patients in physician-patient discourse when compared to unidirectional strategies. The implications of these data for health education with adolescent patients are discussed.

Exposure to violence among inner-city youth.

Interpersonal violence is a major cause of morbidity and mortality among adolescents and young adults. In this study, 246 inner city, predominantly black youth (ages 14-23 years) were surveyed regarding their exposure to, and participation in, violent acts. An in-depth psychological interview was also completed. A total of 44% reported they could access a gun within one day, 42% have seen someone shot or knifed, and 22% have seen someone killed. In the preceding 3 months, 18% reported carrying a gun, and 32% had been in a physical fight; 34 subjects were rated by the psychologists as a high risk for involvement in violent acts. Those subjects were more likely to be of lower socioeconomic status (p < 0.01) and to have been physically abused (p < 0.001) but no more likely to be a witness to violent events. Inner-city youth are frequently exposed to violence. Those at risk for perpetration of violence were more likely to be at high risk for most other health-risk behaviors.

The clinical utility of the Safe Times Questionnaire.

PURPOSE: To evaluate a valid, reliable self-report health behavior screening instrument, the Safe Times Questionnaire (STQ), in a clinical setting. METHODS: One hundred and fifty-two patients at a primary care health center completed the STQ and were randomized into two groups; physicians in the "STQ group" (79 patients) used the STQ while physicians in the "interview group" (73 patients) were blinded to the STQ. Physicians rated each patient on their need for intervention in nine topic areas. Patients then had a psychological interview and were rated on the same topic areas. RESULTS: The total time of the patient visit was significantly longer in the interview group than in the STQ group. Physicians in the STQ group had significantly higher accuracy in identification of subjects at risk for depression and family conflict. CONCLUSIONS: The Safe Times Questionnaire is a potentially useful instrument to efficiently screen adolescents.

Issues in adolescent gynecologic care.

Adolescence is a period of transition from childhood to adulthood. During this period, the potential for high-risk behaviors that may negatively impact on gynecologic health care are great. To enhance the potential for optimal care of this group of individuals, the physician must understand that (1) adolescents must be active participants in the decision making concerning their gynecologic health, (2) adolescents need to be able to communicate their concerns about gynecologic health in a confidential forum, and (3) there are areas of early gynecologic development and maturation for which anticipatory guidance is required.

Readability of pediatric patient education materials. Current perspectives on an old problem.

Written patient education materials are an important part of ambulatory pediatric practices. We evaluated the readability of 33 representative pediatric education materials using three common formulas: Fog, Fry, and SMOG. The majority of pamphlets had readabilities of grade nine or above. The need to use multiple readability formulas was also demonstrated. Although the three readability formulas were highly correlated, they were significantly different from each other when using a repeated measures analysis of variance (ANOVA) design. In almost half, the readability estimates differed by at least two grade levels. In addition, a large intrapamphlet variability for some pamphlets suggests a need to focus more attention on the readability of multiple sections within a pamphlet, not only on the overall or average readability. We conclude that the readability levels of patient education materials continue to be too high.

Pyogenic osteomyelitis versus pseudo-osteomyelitis in Gaucher's disease. Report of a case and review of the literature.

Presented is a young girl with Gaucher's disease who developed acute bone pain accompanied by signs of inflammation and who was felt to have possible pyogenic osteomyelitis. The lack of significant pathogenic bacterial growth on culture and the findings at orthopedic surgery led the authors to conclude that this child probably represented a case of pseudo-osteomyelitis, but the isolation of an anaerobe from the operative culture of the involved bone leaves the exact diagnosis unclear. Since this child underwent an open surgical procedure, she was treated with antibiotics to prevent the possible development of chronic osteomyelitis. This anaerobic growth on culture, although strongly felt to be a contaminant, also played a role in this decision. She had an uneventful hospital course and subsequently has done well. It is suggested that great caution be taken before subjecting a patient with Gaucher's disease to orthopedic surgical procedures. If pyogenic osteomyelitis is strongly suspected, obtaining multiple blood cultures and culture by needle aspirate may be preferred over an open surgical procedure. The use of empiric antibiotic therapy without an attempt at further diagnosis is not recommended. If an orthopedic surgical procedure is necessary in a patient with Gaucher's disease, antibiotic coverage is indicated and long-term observation of the operative sight for drainage and/or other signs of chronic inflammatory changes in mandatory.

Preventive health screening in adolescent patients.

This article describes an approach to health screening and promotion in adolescents. Key concepts in interviewing adolescents are presented along with practical suggestions for health education. Emphasis is given to psychosocial topics that contribute to morbidity in adolescents that is potentially preventable.

Medical student interest in combined internal medicine-pediatrics.

OBJECTIVE: To determine the level of interest in and perceptions of the field of internal medicine-pediatrics among third-year medical students. DESIGN: A questionnaire was sent to medical students assessing their career choices, how they envision their future practices, the importance of selected professional goals in relation to their career choices, and their impressions of the likelihood of achieving these goals in given medical fields. SETTING: Two large Midwestern medical schools. PARTICIPANTS: Medical students at the end of their third year. INTERVENTIONS: None. RESULTS: Three hundred of 425 students (70%) participated. One hundred thirty-three students (44%) chose a primary care field as their first choice. Seventy-one (54% of the 133) chose internal medicine-pediatrics as their first, second, or third choice. Students rated the likelihood of achieving certain professional goals by specialty. Internal medicine-pediatrics was ranked almost identically with internal medicine and pediatrics. However, internal medicine-pediatrics differed from family medicine in that it was ranked higher in intellectual stimulation, association with interesting colleagues, attaining a position of leadership, entering a respected profession, and involvement in science and research (p less than 0.0001). CONCLUSIONS: The field of internal medicine-pediatrics attracts significant interest among medical students and is viewed as similar to internal medicine and less similar to family medicine.

Tobacco cessation and youth: the feasibility of brief office interventions for adolescents.

BACKGROUND: The prevalence of tobacco use among adolescents remains high and the great majority of adult smokers begin smoking prior to the age of 18. While there have been a number of primary prevention projects in communities and schools, less attention has been given to smoking cessation for adolescents. This paper reviews the literature on the theory and practice of cessation as applicable to adolescents. METHODS: The relevant literature was culled from a MEDLINE search and supplemented with secondary searches from those articles. RESULTS: There have been few studies on brief interventions for adolescent smoking cessation in health care settings. However, there are several models for smoking cessation that are either applicable to or designed for adolescents. Pharmacologic treatments are also beginning to be used. CONCLUSIONS: There is a great need for the development and evaluation of models for adolescent smoking cessation in health care settings. Recent developments, however, give cause for optimism in helping adolescent smokers in tobacco cessation.

Discrimination of intranasal cocaine.

In the development of medications for the treatment of cocaine abuse, the drug discrimination paradigm can be used to identify medications that can attenuate the discriminative stimulus effects of cocaine. To ascertain that participants are basing the discrimination on the drug's central effects, this paradigm requires that the drug and placebo administrations do not produce any peripheral effects on which the discrimination can be based. This study examined whether intranasal cocaine (50 mg) can be discriminated from placebo (46 mg lactose + 4 mg cocaine), how quickly this discrimination can be made, and whether pretreatment with intranasal benzocaine can affect this discrimination. Results showed that subjects were generally able to discriminate the drug conditions correctly 15 s after administration, and this was unaffected by benzocaine. These results suggest that subjects base the discrimination on peripheral drug effects (e.g. taste) that are not affected by anaesthesia of the nasal passage, and that the intranasal route of cocaine administration is unlikely to be feasible with a drug discrimination paradigm.

The perspectives of current trainees in combined internal medicine-pediatrics. Results of a national survey.

OBJECTIVE: To gather information from combined internal medicine-pediatric residents about their application process for residency, their perceptions of the stressors during residency, and their future plans. DESIGN: Survey of all combined internal medicine-pediatric residents-in-training in the 1989-1990 academic year. PARTICIPANTS: Fifty-four percent of residents-in-training responded to the survey, representing 70% of the programs. RESULTS: Combined residents often investigate and rank other generalist residences. However, internal medicine is significantly (P < .005) considered more often than pediatrics or family medicine. Sixty percent of combined residents do not anticipate further training beyond the 4 years and expect to practice both specialties. The majority of those interested in a subspecialty expect to continue to combine internal medicine and pediatrics in their subspecialty practice. Switching services during the residency engenders stress. Factors that decrease stress include more frequent switches and increasing seniority. Switching from pediatrics to internal medicine is more stressful (P < .0001) than switching to pediatrics from internal medicine. The residents considered ambulatory training sites and a specific coordinator for the program to be the most important features of the residency. CONCLUSIONS: Combined internal medicine-pediatric programs continue to attract a small cohort of well-qualified US medical school graduates, the majority of whom intend to practice as generalists in both pediatrics and internal medicine.