What can patients do to facilitate shared decision making? A qualitative study of patients with depression or schizophrenia and psychiatrists.

PURPOSE: Patient involvement in decision making is endorsed by patients and professionals. While research has recently been conducted on how professionals can promote shared decision making (SDM), little is known about how patients can also facilitate SDM. METHODS: Seven focus groups were conducted: 3 with psychiatrists and 4 with patients with schizophrenia or depression. The focus groups were transcribed and independently coded line by line by 2 researchers. Data were analyzed using content analysis. RESULTS: Seven themes related to patient attitudes and behaviors were identified: honesty and openness with one's psychiatrist and oneself, trust in one's psychiatrist and patience with the treatment, respect and politeness, informing the psychiatrist and giving feedback, engagement/active participation during the consultation, gathering information/preparing for the consultation and implementing decisions. Barriers (e.g., avolition, lack of decisional capacity, powerlessness during involuntary treatment) and facilitators of active patient behavior were also identified. CONCLUSIONS: There are various ways in which patients can facilitate SDM/play a more active role in decision making, with patients emphasizing being open and honest and psychiatrists emphasizing being active in the consultation. Interventions to increase active patient behavior may enhance SDM in mental health care.

Mutations in a polycistronic nuclear gene associated with molybdenum cofactor deficiency.

All molybdoenzymes other than nitrogenase require molybdopterin as a metal-binding cofactor. Several genes necessary for the synthesis of the molybdenum cofactor (MoCo) have been characterized in bacteria and plants. The proteins encoded by the Escherichia coli genes moaA and moaC catalyse the first steps in MoCo synthesis. The human homologues of these genes are therefore candidate genes for molybdenum cofactor deficiency, a rare and fatal disease. Using oligonucleotides complementary to a conserved region in the moaA gene, we have isolated a human cDNA derived from liver mRNA. This transcript contains an open reading frame (ORF) encoding the human moaA homologue and a second ORF encoding a human moaC homologue. Mutations can be found in the majority of MoCo-deficient patients that confirm the functional role of both ORFs in the corresponding gene MOCS1 (for 'molybdenum cofactor synthesis-step 1'). Northern-blot analysis detected only full-length transcripts containing both consecutive ORFs in various human tissues. The mRNA structure suggests a translation reinitiation mechanism for the second ORF. These data indicate the existence of a eukaryotic mRNA, which as a single and uniform transcript guides the synthesis of two different enzymatic polypeptides with disease-causing potential.

[Understanding the term burnout in psychiatry and psychotherapy]. / Verständnis des Begriffs Burnout in Psychiatrie und Psychotherapie.

BACKGROUND: Currently there is much debate about the concept of burnout and its use as a diagnostic entity. The aim of the present survey was to present the view of mental health professionals towards the concept of burnout. METHODS: A total of 300 mental health professionals were surveyed using a structured questionnaire. RESULTS: The majority of participants see burnout as a state of exhaustion which constitutes a risk factor for later developing a mental disorder. Participants reported that from their point of view typical triggers for burnout exist while symptoms overlap to a great extent with depression. Psychotherapy as well as interventions at the workplace are regarded as promising interventions; however, in the clinical routine only a minority of participants actually contacted the patients' workplace. In the participants workplace settings most Burnout-Patients suffered from a diagnosis defined in ICD 10 but judged themselves to be suffering from burnout. DISCUSSION: Burnout-Patients in mental health settings differ from the picture currently drawn in the media, probably because Burnout-Patients reach the mental health sector only after already having developed a manifest psychiatric disorder.

Confirmation bias: why psychiatrists stick to wrong preliminary diagnoses.

BACKGROUND: Diagnostic errors can have tremendous consequences because they can result in a fatal chain of wrong decisions. Experts assume that physicians' desire to confirm a preliminary diagnosis while failing to seek contradictory evidence is an important reason for wrong diagnoses. This tendency is called 'confirmation bias'. METHOD: To study whether psychiatrists and medical students are prone to confirmation bias and whether confirmation bias leads to poor diagnostic accuracy in psychiatry, we presented an experimental decision task to 75 psychiatrists and 75 medical students. RESULTS: A total of 13% of psychiatrists and 25% of students showed confirmation bias when searching for new information after having made a preliminary diagnosis. Participants conducting a confirmatory information search were significantly less likely to make the correct diagnosis compared to participants searching in a disconfirmatory or balanced way [multiple logistic regression: odds ratio (OR) 7.3, 95% confidence interval (CI) 2.53-21.22, p<0.001; OR 3.2, 95% CI 1.23-8.56, p=0.02]. Psychiatrists conducting a confirmatory search made a wrong diagnosis in 70% of the cases compared to 27% or 47% for a disconfirmatory or balanced information search (students: 63, 26 and 27%). Participants choosing the wrong diagnosis also prescribed different treatment options compared with participants choosing the correct diagnosis. CONCLUSIONS: Confirmatory information search harbors the risk of wrong diagnostic decisions. Psychiatrists should be aware of confirmation bias and instructed in techniques to reduce bias.

How psychiatrists inform themselves and their patients about risks and benefits of antipsychotic treatment.

OBJECTIVE: In order to choose the best treatment option, physicians have to inform themselves and their patients about both the benefits and risks of available treatment options equally. Our study aims to investigate whether psychiatrists actually do conduct such a balanced information search and presentation. METHOD: Psychiatrists' information search and information presentation to a patient with schizophrenia were studied using two separate experiments. In both, participants were presented with hypothetical case vignettes and descriptions of fictitious antipsychotics. RESULTS: When searching for information, psychiatrists looked more for risks than benefits of antipsychotic treatment options (t = -3.4, df = 74, P = 0.001). However, when informing a patient, they named more benefits than risks (t = 17.1, df = 224, P < 0.001). CONCLUSION: The risk-biased information search presumably follows the principle of 'primum non nocere'. The benefit-biased information presentation might be motivated by the wish to persuade patients to accept the proposed therapy.

Significance of plant sulfite oxidase.

Sulfite oxidizing activities are known since years in animals, microorganisms, and also plants. Among plants, the only enzyme well characterized on molecular and biochemical level is the molybdoenzyme sulfite oxidase (SO). It oxidizes sulfite using molecular oxygen as electron acceptor, leading to the production of sulfate and hydrogen peroxide. The latter reaction product seems to be the reason why plant SO is localized in peroxisomes, because peroxisomal catalase is able to decompose hydrogen peroxide. On the other hand, we have indications for an additional reaction taking place in peroxisomes: sulfite can be nonenzymatically oxidized by hydrogen peroxide. This will promote the detoxification of hydrogen peroxide especially in the case of high amounts of sulfite. Hence we assume that SO could possibly serve as "safety valve" for detoxifying excess amounts of sulfite and protecting the cell from sulfitolysis. Supportive evidence for this assumption comes from experiments where we fumigated transgenic poplar plants overexpressing ARABIDOPSIS SO with SO(2) gas. In this paper, we try to explain sulfite oxidation in its co-regulation with sulfate assimilation and summarize other sulfite oxidizing activities described in plants. Finally we discuss the importance of sulfite detoxification in plants.

Interaction of sulfur and nitrogen nutrition in tobacco (Nicotiana tabacum) plants: significance of nitrogen source and root nitrate reductase.

The significance of root nitrate reductase for sulfur assimilation was studied in tobacco (NICOTIANA TABACUM) plants. For this purpose, uptake, assimilation, and long-distance transport of sulfur were compared between wild-type tobacco and transformants lacking root nitrate reductase, cultivated either with nitrate or with ammonium nitrate. A recently developed empirical model of plant internal nitrogen cycling was adapted to sulfur and applied to characterise whole plant sulfur relations in wild-type tobacco and the transformant. Both transformation and nitrogen nutrition strongly affected sulfur pools and sulfur fluxes. Transformation decreased the rate of sulfate uptake in nitrate-grown plants and root sulfate and total sulfur contents in root biomass, irrespective of N nutrition. Nevertheless, glutathione levels were enhanced in the roots of transformed plants. This may be a consequence of enhanced APR activity in the leaves that also resulted in enhanced organic sulfur content in the leaves of the tranformants. The lack of nitrate reductase in the roots in the transformants caused regulatory changes in sulfur metabolism that resembled those observed under nitrogen deficiency. Nitrate nutrition reduced total sulfur content and all the major fractions analysed in the leaves, but not in the roots, compared to ammonium nitrate supply. The enhanced organic sulfur and glutathione levels in ammonium nitrate-fed plants corresponded well to elevated APR activity. But foliar sulfate contents also increased due to decreased re-allocation of sulfate into the phloem of ammonium nitrate-fed plants. Further studies will elucidate whether this decrease is achieved by downregulation of a specific sulfate transporter in vascular tissues.

Crystal structures of human gephyrin and plant Cnx1 G domains: comparative analysis and functional implications.

The molybdenum cofactor (Moco) consists of a unique and conserved pterin derivative, usually referred to as molybdopterin (MPT), which coordinates the essential transition metal molybdenum (Mo). Moco is required for the enzymatic activities of all Mo-enzymes, with the exception of nitrogenase and is synthesized by an evolutionary old multi-step pathway that is dependent on the activities of at least six gene products. In eukaryotes, the final step of Moco biosynthesis, i.e. transfer and insertion of Mo into MPT, is catalyzed by the two-domain proteins Cnx1 in plants and gephyrin in mammals. Gephyrin is ubiquitously expressed, and was initially found in the central nervous system, where it is essential for clustering of inhibitory neuroreceptors in the postsynaptic membrane. Gephyrin and Cnx1 contain at least two functional domains (E and G) that are homologous to the Escherichia coli proteins MoeA and MogA, the atomic structures of which have been solved recently. Here, we present the crystal structures of the N-terminal human gephyrin G domain (Geph-G) and the C-terminal Arabidopsis thaliana Cnx1 G domain (Cnx1-G) at 1.7 and 2.6 A resolution, respectively. These structures are highly similar and compared to MogA reveal four major differences in their three-dimensional structures: (1) In Geph-G and Cnx1-G an additional alpha-helix is present between the first beta-strand and alpha-helix of MogA. (2) The loop between alpha 2 and beta 2 undergoes conformational changes in all three structures. (3) A beta-hairpin loop found in MogA is absent from Geph-G and Cnx1-G. (4) The C terminus of Geph-G follows a different path from that in MogA. Based on the structures of the eukaryotic proteins and their comparisons with E. coli MogA, the predicted binding site for MPT has been further refined. In addition, the characterized alternative splice variants of gephyrin are analyzed in the context of the three-dimensional structure of Geph-G.

Managers' reactions towards employees' disclosure of psychiatric or somatic diagnoses.

AIMS: To study whether employees who disclose a psychiatric diagnosis, such as depression risk stigmatisation and discrimination at the workplace. METHODS: Randomised experimental study with 748 managers from German companies incorporating four case vignettes displaying an employee with different 'diagnoses' (depression, burnout, private crisis and thyroid dysfunction), but identical unspecific complaints. Main outcome measures were the managers' attitudes and their impact on stigmatisation with respect to job performance. RESULTS: In nearly all aspects of job performance, the diagnosis depression (psychiatric disorder) was seen as more critical than the diagnosis of a thyroid dysfunction (somatic disease). The diagnosis 'burnout' did not prove to be less stigmatising than 'depression'. Likewise 'private crisis' was rated less favourably than thyroid dysfunction. CONCLUSIONS: Therefore, employees have to evaluate if they disclose their psychiatric disorder or if they conceal it as a somatic illness.

The Chlamydomonas reinhardtii MoCo carrier protein is multimeric and stabilizes molybdopterin cofactor in a molybdate charged form.

In Chlamydomonas reinhardtii, molybdopterin cofactor (MoCo) able to reconstitute active nitrate reductase (NR) with apoenzyme from the Neurospora crassa mutant nit-1 was found mostly bound to a carrier protein (CP). This protein is scarce in the algal free extracts and has been purified 520-fold. MoCoCP is a protein of 64 kDa with subunits of 16.5 kDa and an isoelectric point of 4.5. In contrast to free MoCo, MoCo bound to CP was remarkably protected against inactivation under both aerobic conditions and basic pH. MocoCP transferred active MoCo to apoNR in vitro without addition of molybdate, though reconstituted activity was 20% higher in the presence of molybdate. Incubation with tungstate specifically inhibited MoCoCP activity but had no effect on the activity of free MoCo released from milk xanthine oxidase. MoCoCP did not charge molybdate unless in the presence of N. crassa extracts. Our data support that MoCoCP stabilizes MoCo in an active form charged with molybdate to provide MoCo to apomolybdoenzymes.

Influence of a 'brain protector' drug 21-amino steroid on the effects of experimental embolic stroke treated by thrombolysis.

This study was designed to evaluate the effects of tissue-type plasminogen activator (tPA) and 21- amino steroid (U74006F) in experimental embolic stroke in rabbits. The size of infarction from embolism was compared to controls with tPA alone, 21-amino steroid alone, and in combination. The middle cerebral artery of the rabbit was embolized by injecting an arterial ('white') thrombus in the right internal carotid artery. The rabbit treatment was 2 mg kg-1 of tissue-type plasminogen activator and/or 3 mg kg-1 of 21 amino steroid started at 2 h post-embolization. The animals were terminated 4 h post-treatment and brains were examined for evidence of ischemia and/or hemorrhage. Administration of tissue-type plasminogen activator and/or 21-amino steroid in the raw data show that there is a tendency for all treatments to reduce the ischemic volume when compared to the control group, also it is evident the standard deviation of these estimates is rather large when compared to the differences between treatments. The results of the analysis of variance shows that the differences expressed are not statistically significant. (No statistical differences were found between the treatment groups and the control group.) The results show that administration of tissue-type plasminogen activator and/or 21 amino steroid at 2 h post-embolization alone or in simultaneous administration does not significantly reduce the volume of infarction. Further studies need to be addressed in regards to the region of viable brain in the peri-infarct area, in reducing the time to treatment.

Fluorescent proteins in poplar: a useful tool to study promoter function and protein localization.

The jellyfish (Aequorea victoria) green fluorescent protein (GFP) and its variants (CFP [cyan] and YFP [yellow]) were successfully used as a vital marker system for the transformation of hybrid poplar (Populus tremula x P. alba). Our results show that, in this woody plant, fluorescent proteins can be expressed: (i) transiently in protoplasts after PEG-mediated transformation, as well as in leaf cells after particle bombardment, and (ii) stably in callus cells and plants after Agrobacterium-mediated transformation. For these studies, we constructed vectors permitting easy recloning of any promoter fragments of interest. Confocal laser scanning microscopy was used both for visualization and differentiation between the different colours of the GFP variants and autofluorescence of chlorophyll and lignified xylem vessels. Peroxisomes were chosen as target organelles for GFP translocation via the peroxisomal targeting sequence PTS1 because this allowed us to concentrate the fluorochrome in the small volume of a few peroxisomes, giving a bright fluorescence over background noise.

Vectors for RNAi technology in poplar.

The potential of double-stranded RNA interference (RNAi) technology was studied for down-regulation of gene expression in poplar. A set of vectors was constructed generating RNAs capable of duplex formation of sequences specific for the beta-glucuronidase (GUS) reporter gene system. These gene cassettes are driven by the CaMV-35S promoter. To address the question of gene silencing, we tested the functionality of these vectors, both in transient assays by transforming protoplasts with the RNAi constructs, and in stably transformed GUSexpressing poplar plants. Agrobacterium-mediated transformation of those GUS-expressing plants with a GUS-specific RNAi construct showed a strong down-regulation of the reporter gene. From these results we conclude that RNAi is also functional in poplar.

Pediatric eighth cranial nerve schwannoma without evidence of neurofibromatosis.

Schwannomas of the eighth cranial nerve are rare in children. We report a 4 10/12 - year-old girl with no evidence of neurofibromatosis who presented with facial droop. Radiographic studies revealed a large cerebellopontine angle tumor. At surgery, the tumor was attached to the eighth cranial nerve and histologically was a schwannoma. This is the youngest reported case of unilateral eighth cranial nerve schwannoma in a patient without the stigmata of neurofibromatosis.

Management of opalescent dentin: report of case with long-term followup.

Several methods of treating dentinogenesis imperfecta have been reported as successful, but long-term followup is necessary to determine the ultimate prognosis for each approach.

Characteristics of predoctoral endodontic education in the United States and Canada.

A survey was conducted to assess the current state of predoctoral endodontic education programs in United States and Canadian dental schools. The investigation focused on faculty characteristics, the learning climate for endodontics, and problems of administration. Comparison was made between current learning conditions in the schools and desirability of these conditions. Comparisons also were made between large and small schools. Endodontic program directors identified numerous conditions associated with the enhancement of learning. Problems reported were inadequate time to pursue research and scarcity of full-time faculty in some programs.

Tenure in U.S. and Canadian dental schools.

This paper presents information about how tenure decisions are made in dental schools and examines dental deans' opinions regarding the value of the tenure system. Deans view teaching ability and scholarly accomplishments as the most important factors in tenure decisions. The tenure process usually involves a series of reviews by different groups of individuals. Deans perceive tenured faculty as having the greatest degree of influence in the decision to award or deny tenure. In addition, deans regard tenure as motivating younger faculty members to achieve excellence in teaching and scholarship. Deans also feel that the award of tenure is not detrimental to the continued productivity of faculty members.

The effect of teaching method on endodontic problem solving.

A study was conducted to determine the effects of seminars and computer-assisted self-evaluation (CASE) modules on third-year dental students' endodontic problem-solving abilities. Students studying by a combination of seminars and CASE modules did not differ in their ability to solve endodontic problems compared with students receiving CASE modules, but they demonstrated greater ability than did students in a control group or those participating only in seminars. Analysis of gain scores from pretest to post-test among the treatment groups showed significant improvement in learning after instruction, but failed to identify any method as more effective in facilitating this improvement. Previous grade point average was not a factor in problem-solving ability or in improvement instruction.

Update on scholarship among dental faculty.

A study was conducted to gather data from dental deans regarding the publication rates of faculty in dental schools. An analysis of the findings suggests that when compared with a previous study the rate of publication has increased. For tenure awardees, the number of publications has increased when the findings of the current study are compared with the original study. At all academic ranks, the publication rate has increased. The increase is more pronounced at the ranks of associate and full professor. The effect on the publication rate is the same for those schools with small numbers of advanced education programs when compared with schools that have larger numbers of advanced programs. The changing nature of dental education has resulted in an increased emphasis on scholarly activity involving a shift away from teaching and toward scholarship. This shift is evident in faculty publication rates when the findings of the two studies conducted by the authors are compared. In the future, it may be expected that dental faculty may be required to contribute to the professional literature at a rate equivalent to or greater than is required at the present time.

Psychiatrists' attitude to antipsychotic depot treatment in patients with first-episode schizophrenia.

OBJECTIVE: Despite good clinical evidence, depot antipsychotics are only seldom prescribed to patients with first episode schizophrenia. The present study aims at investigating psychiatrists' reasons for this reservation. METHOD: We surveyed 198 psychiatrists on their attitude toward offering depot treatment to first episode patients (FEP). Participants scored the extent of influence of individual factors on their decision on a seven-point-scale, additional data on their prescription practice and estimation of the relapse risk of FEP were collected. RESULTS: Psychiatrists reported that only three out of 12 factors were of influence. These were the limited availability of different second generation antipsychotic depot drugs, the frequent rejection of the depot offer by the patients and the patients' skepticism based on the lack in experience of a relapse. CONCLUSIONS: There is actually little specific reason for not prescribing depot to FEP according to the current survey. For those factors being reported to be of influence, psychoeducation, including profound information on depot treatment, the development of additional SGA depot drugs and the standard offer of depot treatment to all FEP in a shared-decision-making may be considered.