Brief Intervention as a Method to Reduce Z-Hypnotic Use by Older Adults: Feasibility Case Series.

BACKGROUND: Z-hypnotics or z-drugs are commonly prescribed for insomnia and sleep difficulties in older adults. These drugs are associated with adverse events and dependence and are not recommended for long-term use. Despite evidence of older adults being more sensitive to a wide array of adverse events and clinical guidelines advocating limiting use, inappropriate use in this population is still prevalent. Previous intervention studies have focused mainly on prescriber information. Simple, individually focused intervention designs are less studied. Brief intervention (BI) is a simple, easily transferable method mainly used to treat patients at risk of alcohol overuse. OBJECTIVE: Our objective was to design and test the feasibility and acceptability of a BI intervention adapted to address individual, inappropriate use of z-hypnotics among older adults. This preparatory study aimed to optimize the intervention in advance of a quantitative randomized controlled trial investigating the treatment effect in a larger population. METHODS: This feasibility case series was conducted at Akershus University Hospital, Norway, in autumn 2021. We included 5 adults aged ≥65 years with long-term (≥4 weeks) use of z-hypnotics and 2 intervening physicians. Additionally, 2 study investigators contributed with process evaluation notes. The BI consists of information on the risk of inappropriate use and individualized advice on how to reduce use. The focus of the intervention is behavioral and aims, in cooperation with the patient and based on shared decision-making, to change patient behavior regarding sleep medication rather than physician-based detoxification and termination of z-hypnotic prescriptions. Qualitative and descriptive quantitative data were collected from intervening physicians, study investigators, and participants at baseline, immediately after the intervention, and at the 6-week follow-up. RESULTS: Data were obtained from 2 physicians, 2 study investigators, and 5 participants (4 women) with a median age of 84 years. The average time spent on the BI consultation was 15 minutes. All 5 participants completed the intervention without problems. The participants and 2 intervening physicians reported the intervention as acceptable and were satisfied with the delivery of the intervention. After the intervention, 2 participants stopped their use of z-hypnotics completely and participated in the follow-up interview. Study investigators identified logistical challenges regarding location and time requirements. Identified aspects that may improve the intervention and reduce dropouts included revising the intervention content, focusing on rebound insomnia, adding an information leaflet, and supporting the patient in the period between the intervention and follow-up. The notion that the intervention should best be located and conducted by the patient's own general practitioner was supported by the participants. CONCLUSIONS: We identified important aspects to improve the designed intervention and found that the BI is feasible and acceptable for incorporation into a larger randomized trial investigating the treatment effect of BI for reducing z-hypnotic use by older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT03162081; http://tinyurl.com/rmzx6brn.

miR-Blood - a small RNA atlas of human blood components.

miR-Blood is a high-quality, small RNA expression atlas for the major components of human peripheral blood (plasma, erythrocytes, thrombocytes, monocytes, neutrophils, eosinophils, basophils, natural killer cells, CD4+ T cells, CD8+ T cells, and B cells). Based on the purified blood components from 52 individuals, the dataset provides a comprehensive repository for the expression of 4971 small RNAs from eight non-coding RNA classes.

What do we mean by "tailoring" of medical information during clinical interactions?

Although medical information is essential for all patients, information needs and information processing capacities vary between individual patients and over time and context, within patients. Therefore, it is often recommended to "tailor" medical information to individual patients during clinic visits. However, there is a lack of consensus on what "tailoring" in clinical interactions represents since the definitions provided in the literature thus far generally regard tailoring of written text, rather than in dialogue during face-to-face interactions. To provide clinicians with guidance on how to tailor information to individual patients and to allow researchers to assess the effectiveness thereof, clarity is urgently needed regarding what "tailoring" actually means and what it entails in practice. In this paper we outline the current challenges of applying the concept of "tailoring" to the clinical setting and present existing definitions. Importantly, we introduce a new working definition of the concept that encompasses essential informational and dialogic components. We believe this provisional definition promotes much-needed conceptual precision in how communication researchers and educators define and assess tailored information provision in clinical consultations.

How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis.

During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don't like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians' information-sharing praxis.

Communicative Practices Clinicians Use to Correct Patient Misconceptions in Primary Care Visits.

To investigate how clinicians correct patient misconceptions, we analyzed 23 video recordings of primary care visits. Analysis focused on operationalizing, identifying, and characterizing clinician corrections, integrating two inductive approaches: microanalysis of clinical interaction and conversation analysis. According to our definition, patient misconception-clinician correction episodes met three essential criteria: (1) the clinician refuted something the patient had said, (2) which the patient had presented without uncertainty, and (3) which contained a proposition that was factually incorrect. We identified 59 such episodes; the patient misconceptions most commonly related to medication issues; fewer than half had foreseeable implications for patients' future actions. We identified seven clinician correction practices: Three direct practices (displaying surprise, marking disagreement, contradicting the patient) and four indirect practices (presenting the correct proposition, providing explanations, invoking an outside authority, demonstrating with evidence). We found an almost equal distribution of these direct and indirect practices.

WITHDRAWN: If I say teach-back.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Early Detection of Lung Cancer Using Small RNAs.

INTRODUCTION: Lung cancer remains the deadliest cancer in the world, and lung cancer survival is heavily dependent on tumor stage at the time of detection. Low-dose computed tomography screening can reduce mortality; however, annual screening is limited by low adherence in the United States of America and still not broadly implemented in Europe. As a result, less than 10% of lung cancers are detected through existing programs. Thus, there is a great need for additional screening tests, such as a blood test, that could be deployed in the primary care setting. METHODS: We prospectively recruited 1384 individuals meeting the National Lung Screening Trial demographic eligibility criteria for lung cancer and collected stabilized whole blood to enable the pipetting-free collection of material, thus minimizing preanalytical noise. Ultra-deep small RNA sequencing (20 million reads per sample) was performed with the addition of a method to remove highly abundant erythroid RNAs, and thus open bandwidth for the detection of less abundant species originating from the plasma or the immune cellular compartment. We used 100 random data splits to train and evaluate an ensemble of logistic regression classifiers using small RNA expression of 943 individuals, discovered an 18-small RNA feature consensus signature (miLung), and validated this signature in an independent cohort (441 individuals). Blood cell sorting and tumor tissue sequencing were performed to deconvolve small RNAs into their source of origin. RESULTS: We generated diagnostic models and report a median receiver-operating characteristic area under the curve of 0.86 (95% confidence interval [CI]: 0.84-0.86) in the discovery cohort and generalized performance of 0.83 in the validation cohort. Diagnostic performance increased in a stage-dependent manner ranging from 0.73 (95% CI: 0.71-0.76) for stage I to 0.90 (95% CI: 0.89-0.90) for stage IV in the discovery cohort and from 0.76 to 0.86 in the validation cohort. We identified a tumor-shed, plasma-bound ribosomal RNA fragment of the L1 stalk as a dominant predictor of lung cancer. The fragment is decreased after surgery with curative intent. In additional experiments, results of dried blood spot collection and sequencing revealed that small RNA analysis could potentially be conducted through home sampling. CONCLUSIONS: These data suggest the potential of a small RNA-based blood test as a viable alternative to low-dose computed tomography screening for early detection of smoking-associated lung cancer.

HAPLN1 potentiates peritoneal metastasis in pancreatic cancer.

Pancreatic ductal adenocarcinoma (PDAC) frequently metastasizes into the peritoneum, which contributes to poor prognosis. Metastatic spreading is promoted by cancer cell plasticity, yet its regulation by the microenvironment is incompletely understood. Here, we show that the presence of hyaluronan and proteoglycan link protein-1 (HAPLN1) in the extracellular matrix enhances tumor cell plasticity and PDAC metastasis. Bioinformatic analysis showed that HAPLN1 expression is enriched in the basal PDAC subtype and associated with worse overall patient survival. In a mouse model for peritoneal carcinomatosis, HAPLN1-induced immunomodulation favors a more permissive microenvironment, which accelerates the peritoneal spread of tumor cells. Mechanistically, HAPLN1, via upregulation of tumor necrosis factor receptor 2 (TNFR2), promotes TNF-mediated upregulation of Hyaluronan (HA) production, facilitating EMT, stemness, invasion and immunomodulation. Extracellular HAPLN1 modifies cancer cells and fibroblasts, rendering them more immunomodulatory. As such, we identify HAPLN1 as a prognostic marker and as a driver for peritoneal metastasis in PDAC.

Proficiency in the Norwegian language and self-reported health among 12 immigrant groups in Norway: A cross-sectional study.

BACKGROUND: Migration presents numerous significant changes in a person's life, physically, emotionally and socially. How health develops in the host country depends on a range of factors, including language proficiency. We aimed to investigate associations between language proficiency and health. METHODS: Statistics Norway carried out the Living Conditions Survey for Immigrants (2016), conducting telephone (82%) or face-to-face (18%) interviews with immigrants (two or more years of residence) from 12 countries. The survey collected data on self-reported proficiency in the Norwegian language, health and socio-economic variables, and included 4077 people aged 16-66 years. RESULTS: In logistic regression models adjusted for age, sex and duration of residence, poor or medium self-reported Norwegian proficiency, as compared to good, was associated with poorer health outcomes, including lower odds of self-rated health (odds ratio (OR)=0.46; 95% confidence interval (CI) 0.39-0.54) and higher odds of hypertension (OR=1.74; 95% CI 1.34-2.26), back or neck pain (OR=1.52; 95% CI 1.28-1.80), mental health problems (OR=1.34; 95% CI 1.09-1.65), sleep disturbances (OR=1.51; 95% CI 1.23-1.86) and being overweight (OR=1.20; 95% CI 1.03-1.40). Adjustment for socio-economic status attenuated the associations, but further adjustments for perceived discrimination and lifestyle (smoking and physical activity) did not further alter the estimates. CONCLUSIONS: Host language proficiency has implications for health among immigrants. Equitable access to health services and quality of care requires adjustment to the language level needs of patients. Facilitating language learning for immigrants may be vital in providing access to health services and supporting newcomers in being more active participants in managing their health.

Health risks among long-term immigrants in Norway with poor Norwegian language proficiency.

BACKGROUND: Poor health among immigrants has been associated with longer duration of residence in the host country, poor host language proficiency and low education. However, the interplay among these factors is under-studied. OBJECTIVE: To assess health among immigrants in Norway by combinations of duration of residence, Norwegian language proficiency and education. METHODS: In 2015/2016 Statistics Norway carried out two cross-sectional Living Conditions Surveys in the general adult population (N=5703, response rate 59%) and among immigrants from 12 countries, with ⩾2 years of residence (N=3993, response rate 54%). Health outcomes (poor self-reported health, diabetes, cardiovascular disease, hypertension, obesity, mental health problems, back/neck pain) were assessed with logistic regressions according to combinations of duration of residence, Norwegian language proficiency and education. RESULTS: Negative health conditions were more common among immigrants than in the general population, and varied by duration of residence, proficiency in the Norwegian language and education. In age- and sex-adjusted regressions, immigrants had higher odds of all negative health conditions, except hypertension, regardless of their duration of residence, proficiency of the Norwegian language and educational level. Immigrants with a long duration of residence and poor proficiency in the Norwegian language had the highest odds of negative health conditions. CONCLUSIONS: Special attention is warranted towards health among immigrants who have lived in Norway the longest without acquiring good Norwegian language proficiency.

Physicians' responses to advanced cancer patients' existential concerns: A video-based analysis.

OBJECTIVE: In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns. METHODS: We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. RESULTS: We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients' existential concerns. CONCLUSIONS: Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients' existential concerns. PRACTICE IMPLICATIONS: Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients' existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training.

"Eh - What type of cells are these - flourishing in the liver?" Cancer patients' disclosure of existential concerns in routine hospital consultations.

OBJECTIVE: Advanced cancer poses a threat to all aspects of being, potentially causing existential suffering. We explore what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation, and how they communicate such concerns. METHODS: We analyzed thirteen video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue. RESULTS: Nearly all patients disclosed how the illness experience included losses and threats of loss that are strongly associated with existential suffering, displaying uncertainty about future and insecurity about self and coping. Patients usually disclosed existential concerns uninvited, but they did so indirectly and subtly, typically hiding concerns in biomedical terms or conveying them with hesitation and very little emotion. CONCLUSIONS: Patients may have existential concerns they want to address, but they may be uncertain whether these are issues they can discuss with the physician. PRACTICE IMPLICATIONS: Health professionals should be attentive to underlying existential messages embedded in the patient's questions and concerns. Acknowledging these existential concerns provides an opportunity to briefly explore the patient's needs and may direct how the physician tailors information and support to promote coping, autonomy, and existential health.

Evaluating a training intervention for improving alignment between emergency medical telephone operators and callers: a pilot study of communication behaviours.

BACKGROUND: Calls to emergency medical lines are an essential component in the chain of survival. Operators make critical decisions based on information they elicit from callers. Although smooth cooperation is necessary, the field lacks evidence-based guidelines for how to achieve it while adhering to strict parameters of index-driven questioning. We aimed to evaluate the effect of a training intervention for emergency medical operators at a call centre in Tønsberg, Norway. The course was designed to enhance operators' communication skills for smoothing cooperation with callers. METHODS: Calls were analyzed using inductively developed coding based on the course rationale and content. To evaluate whether the course generated consolidated behavioral change in everyday practice, the independent analyst evaluated 32 calls, selected randomly from eight operators, two calls before and two after course completion. To measure whether skill attainment delayed decision making, we compared the time to the first decision logged by intervention operators to eight control operators. Analysis included 3034 calls: 1375 to intervention operators (T1 = 815; T2 = 560) and 1659 to control operators (T1 = 683; T2 = 976). RESULTS: Operators demonstrated improved behaviours on how they greeted the caller (p < .001), acknowledged the caller (p < .001), and displayed empathy (p = 0.015). No change was found in the use of open-ended questions and agreeing with the caller. Contrary to expectations, operators who took the course logged first decisions more quickly than the control group (p < .001). CONCLUSIONS: This pilot study demonstrated that the training intervention generated behavioural change in these operators, providing justification for scaling up the intervention.

"What should I do when I get home?" treatment plan discussion at discharge between specialist physicians and older in-patients: mixed method study.

BACKGROUND: During discharge from hospital, older patients and physicians discuss the plan for managing patients' health at home. If not followed at home, it can result in poor medication management, readmissions, or other adverse events. Comorbidities, polypharmacy and cognitive impairment may create challenges for older patients. We assessed discharge conversations between older in-patients and physicians for treatment plan activities and medication information, with emphasis on the role of cognitive function in the ongoing conversation. METHODS: We collected 11 videos of discharge consultations, medication lists, and self-reported demographic information from hospitalised patients ≥65 years at the Geriatric department in a general hospital. Mini Mental State Examination score < 25 was classified as low cognitive function. We used microanalysis of face-to-face dialogue to identify and characterise sequences of interaction focused on and distinguishing the treatment plan activities discussed. In addition to descriptive statistics, we used a paired-sample t-test and Mann-Whitney U test for non-parametric data. RESULTS: Patients' median age was 85 (range: 71-90);7 were females and 4 males. Median of 17 (range: 7 to 23) treatment plan activities were discussed. The proportions of the activities, grouped from a patient perspective, were: 0.40 my medications, 0.21 something the hospital will do for me, 0.18 someone I visit away from home, 0.12 daily routine and 0.09 someone coming to my home. Patients spoke less (mean 190.9 words, SD 133.9) during treatment plan activities compared to other topics (mean 759 words, SD 480.4), (p = .001). Patients used on average 9.2 (SD 3.1) medications; during the conversations, an average of 4.5 (SD 3.3) were discussed, and side effects discussed on average 1.2 (SD 2.1) times. During treatment plan discussions, patients with lower cognitive function were less responsive and spoke less (mean 116.5 words, SD 40.9), compared to patients with normal cognition (mean 233.4 words, SD 152.4), (p = .089). CONCLUSION: Physicians and geriatric patients discuss many activities during discharge conversations, mostly focusing on medication use without stating side effects. Cognitive function might play a role in how older patients respond. These results may be useful for an intervention to improve communication between physicians and older hospitalised patients.

Making the most of video recorded clinical encounters: Optimizing impact and productivity through interdisciplinary teamwork.

Patient-clinician interactions are central to technical and interpersonal processes of medical care. Video recordings of these interactions provide a rich source of data and a stable record that allows for repeated viewing and analysis. Collecting video recordings requires navigating ethical and feasibility constraints; further, realizing the potential of video requires specialized research skills. Interdisciplinary collaborations involving practitioners, medical educators, and social scientists are needed to provide the clinical perspectives, methodological expertise, and capacity needed to make collecting video worthwhile. Such collaboration ensures that research questions will be based on scholarship from the social sciences, resonate with practice, and produce results that fit educational needs. However, the literature lacks suggested practices for building and sustaining interdisciplinary research collaborations involving video data. In this paper, we provide concrete advice based on our experience collecting and analyzing a single set of video-recorded clinical encounters and non-video data, which have so far yielded nine distinct studies. We present the research process, timeline, and advice based on our experience with interdisciplinary collaboration. We found that integrating disciplines and traditions required patience, compromise, and mutual respect; learning from each other enhanced our enjoyment of the process, our productivity, and the clinical relevance of our research.

Saying "I Don't Know": A Video-Based Study on Physicians' Claims of No-Knowledge in Assisted Reproductive Technology Consultations.

INTRODUCTION: The assisted reproductive technology (ART) field deals with consistent and predictable gaps in knowledge. Expressing lack of knowledge with a sentence like "I don't know" can be challenging for doctors. This study examined physicians' negative epistemic disclaimer "non lo so" in Italian ART doctor-couple interactions. In particular, it aimed to reveal specific features of "non lo so": function, topic, temporality, responsibility, and interactional aspects. METHODS: This was a video-based observational study. We used microanalysis of face-to-face dialogue to analyze 20 purposively selected triadic consultations from a corpus of 85. This inductive analysis focused on the function, the content (topic and temporality) and some selected interactional aspects of the "non lo so", quantifying and capturing the interaction between these qualitative features. RESULTS: We found 82 doctors' "non lo so" in the corpus (mean = 4.4; range = 0-15). We discovered three main functions of this expression: propositional (n = 73/82), relational (n = 6/82), discursive (n = 3/82). The most frequent topics raising doctors' "non lo so" were costs (n = 11/82), treatment-related aspects (n = 10/82), and timing issues (n = 9/82). In more than half of the cases (n = 44/82), present issues emerged. The majority (n = 70/82) of "non lo so" was framed using the "I," with doctors' taking personal responsibility. Patients played a role in these expressions from doctors: Patients initiated more than one third of them, and in one fourth of the cases, patients followed up immediately. CONCLUSION: Our findings may be related to characteristics of the specific field of ART. Doctors in this setting must frequently express a direct lack of knowledge to their patients, and when they do, they mean it literally. Patients contribute to such disclosures, and their responses suggest that they find them acceptable, showing that they may expect limitations in their potential to conceive.

Body-oriented gestures as a practitioner's window into interpreted communication.

With increasing global migration, health care providers and patients may lack a shared language. Interpreters help to secure understanding. Doctors and patients cannot evaluate how the interpreter translates their utterances; however, they can see hand movements, which can provide a window into the interpretation process. While research on natural language use has acknowledged the semiotic contribution of co-speech gestures (i.e., spontaneous hand and arm movements that are tightly synchronized with speech), their role in interpreted interactions is unstudied. We aimed to reveal whether gestures could shed light on the interpreting process and to develop a systematic methodology for investigating gesture-use in interpreted encounters. Using data from authentic, interpreted clinical interactions, we identified and analyzed gestures referring to the body (i.e., body-oriented gestures). Data were 76 min of video-recorded doctor-patient consultations at two UK inner-city general practices in 2009. Using microanalysis of face-to-face dialogue, we revealed how participants used body-oriented gestures and how interpreters transmitted them. Participants used 264 body-oriented gestures (doctors = 113, patients = 54, interpreters = 97). Gestures served an important semiotic function: On average, 70% of the doctors' and patients' gestures provided information not conveyed in speech. When interpreters repeated the primary participants' body-oriented gestures, they were highly likely to accompany the gesture with speech that retained the overall utterance meaning. Conversely, when interpreters did not repeat the gesture, their speech tended to lack that information as well. A qualitative investigation into the local effect of gesture transmission suggested a means for quality control: visible discrepancies in interpretation generated opportunities to check understanding. The findings suggest that clinical communication training could benefit from including skills to understand and attend to gestures. The analysis developed here provides a promising schema and method for future research informing clinical guidelines and training.

Invisible rights: Barriers and facilitators to access and use of interpreter services in health care settings by Polish migrants in Norway.

Aims: Polish migration to Norway is a relatively new phenomenon. Many Polish migrants do not speak Norwegian or have insufficient knowledge of the language, which makes it difficult or impossible to communicate with health personnel. The main aim of the study was to identify barriers and facilitators to Polish migrants' access and use of interpreter services in health care settings in Norway. Methods: Nineteen semi-structured interviews with Polish migrants were carried out in 2013 and 2014. Thematic analysis was performed to identify barriers and facilitators related to the use of interpreter services. Results: Participants often received information regarding their health condition and treatment in a language they did not fully understand. They reported that their access to interpretation services was limited or denied for a variety of reasons, such as reluctance of health personnel to book an interpreter and overestimation of patient's language skills. In many cases, using friends, relatives or bilingual staff instead of professional interpreters compromised the quality of interpretation. Conclusions: Even though migrants are entitled to free interpreter services, Polish migrants experience several barriers accessing interpreters in health care settings. A variety of practices such as selective use and use of unqualified and ad hoc interpreters reveals a failure to meet recommended standards of interpretation services. Not involving professional interpreters in language-discordant consultations constitutes a serious threat to practitioners' ability to work as competent professionals, potentially risking the quality and safety of health care for these patients.