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BACKGROUND: Due to its high impact on quality of life and mental health, close monitoring and often psychotherapy is recommended for patients with a ventricular assist device (VAD). This study investigates the psychological comorbidity and the corresponding psychotherapeutic treatment situation of VAD patients. Special attention is also given to the professional perspective VAD team (assistant and senior cardiologists and specialized nurses). METHODS: We conducted a cross-sectional observational study. Data from 50 VAD patients (mean age = 53.52, standard deviation = 13.82 years, 84.0% male) and their VAD team were analyzed. The presence of a psychological disorder was evaluated by structured clinical interviews for DSM-IV (SCID-I-Interviews). Patients answered a questionnaire regarding their current psychotherapeutic treatment status and their attitude towards psychotherapy. The VAD team answered a questionnaire about the patients' needs for psychotherapy and indicated whether they addressed this topic with the patient. Data were analyzed descriptively, by analysis of variance and t-test. RESULTS: A total of 58% of VAD patients suffered from at least one significant psychological disorder, 79.3% of those were not in psychotherapy. The VAD team could not identify the patients who suffered from a psychological disorder (F = 1.90; p = 0.18). They perceived more need for psychotherapy than they addressed with their patients (T = 3.39; p < 0.001). CONCLUSIONS: While there is a high psychological morbidity among VAD patients, only few receive psychotherapy. Psychological comorbidity is not easily detected by the VAD team. Standardized psychosocial care could be implemented by regular psychological assessments and further information of patients and their VAD teams.
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BACKGROUND: Patients with heart failure (HF) are the most commonly readmitted group of adult patients in Germany. Most patients with HF are readmitted for noncardiovascular reasons. Understanding the relevance of HF management outside the hospital setting is critical to understanding HF and factors that lead to readmission. Application of machine learning (ML) on data from statutory health insurance (SHI) allows the evaluation of large longitudinal data sets representative of the general population to support clinical decision-making. OBJECTIVE: This study aims to evaluate the ability of ML methods to predict 1-year all-cause and HF-specific readmission after initial HF-related admission of patients with HF in outpatient SHI data and identify important predictors. METHODS: We identified individuals with HF using outpatient data from 2012 to 2018 from the AOK Baden-Württemberg SHI in Germany. We then trained and applied regression and ML algorithms to predict the first all-cause and HF-specific readmission in the year after the first admission for HF. We fitted a random forest, an elastic net, a stepwise regression, and a logistic regression to predict readmission by using diagnosis codes, drug exposures, demographics (age, sex, nationality, and type of coverage within SHI), degree of rurality for residence, and participation in disease management programs for common chronic conditions (diabetes mellitus type 1 and 2, breast cancer, chronic obstructive pulmonary disease, and coronary heart disease). We then evaluated the predictors of HF readmission according to their importance and direction to predict readmission. RESULTS: Our final data set consisted of 97,529 individuals with HF, and 78,044 (80%) were readmitted within the observation period. Of the tested modeling approaches, the random forest approach best predicted 1-year all-cause and HF-specific readmission with a C-statistic of 0.68 and 0.69, respectively. Important predictors for 1-year all-cause readmission included prescription of pantoprazole, chronic obstructive pulmonary disease, atherosclerosis, sex, rurality, and participation in disease management programs for type 2 diabetes mellitus and coronary heart disease. Relevant features for HF-specific readmission included a large number of canonical HF comorbidities. CONCLUSIONS: While many of the predictors we identified were known to be relevant comorbidities for HF, we also uncovered several novel associations. Disease management programs have widely been shown to be effective at managing chronic disease; however, our results indicate that in the short term they may be useful for targeting patients with HF with comorbidity at increased risk of readmission. Our results also show that living in a more rural location increases the risk of readmission. Overall, factors beyond comorbid disease were relevant for risk of HF readmission. This finding may impact how outpatient physicians identify and monitor patients at risk of HF readmission.
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Doctors' interactional competencies play a crucial role in patient satisfaction, well-being, and compliance. Accordingly, it is in medical schools' interest to select candidates with strong interactional abilities. While Multiple Mini Interviews (MMIs) provide a useful context to assess such abilities, the evaluation of candidate performance during MMIs is not always based on a solid theoretical framework. The newly developed selection procedure "Interactional Competencies - Medical Doctors (IC-MD)" uses an MMI circuit with five simulation patient scenarios and is rated based on the theoretically and empirically grounded construct of emotional availability. A first validation study with N = 70 first-semester medical students took place in 2021. In terms of convergent validity, IC-MD ratings showed strong correlations with simulation patients' satisfaction with the encounter (r =.57) but no association with emotional intelligence measures. IC-MD ratings were not related to high school performance or a cognitive student aptitude test, indicating divergent validity. Inter-rater reliability (ICC = 0.63) and generalizability (Eρ2 = 0.64) were satisfactory. The IC-MD proved to be fair regarding participants' age and gender. Participants with prior work experience in healthcare outperformed those without such experience. Participant acceptance of the procedure were good. The IC-MD is a promising selection procedure capable of assessing interactional competencies relevant to the medical setting. Measures of interactional competencies can complement the use of cognitive selection criteria in medical student admission. The predictive validity of the IC-MD needs to be addressed in future studies.
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OBJECTIVES: Against the backdrop of poor discharge communication in hospitals, this study explores the purpose of discharge interviews from the physicians' perspective and the challenges they are confronted with. Discharge interviews are legally required in Germany as part of the discharge management. Led by the ward physician, the discharge interview should summarize relevant information about the hospital stay, medication, lifestyle interventions and follow-up treatment. METHODS: Semi-structured interviews with n = 12 physicians were conducted at Heidelberg University Hospital between February and April 2020. Qualitative content analysis was carried out using MAXQDA. RESULTS: Physicians reported gaining information, providing information, and answering open-ended questions as the purpose of the discharge interview. Challenges in conducting discharge interviews were related to finding a common language, patient-related challenges, conditions of everyday ward life, and lack of training. Physicians reported receiving no explicit training on discharge interviews. While professional experience seems to mitigate the lack of training, some physicians expressed a prevailing sense of insecurity. CONCLUSION: The lack of preparation for discharge interviews in medical school makes it particularly challenging for physicians to translate their theoretical knowledge into patient-centered discharge communication. Medical training on discharge interviews should be expanded in terms of theoretical input on the ideal content, its purpose and potential (e.g. in reducing readmissions), as well as practical exercises.
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Entrevistas como Asunto , Alta del Paciente , Médicos , Investigación Cualitativa , Humanos , Masculino , Femenino , Alemania , Médicos/psicología , Adulto , Comunicación , Persona de Mediana Edad , Actitud del Personal de SaludRESUMEN
AIMS: Takotsubo syndrome (TTS) is an acute heart failure (AHF) syndrome mimicking the symptoms of acute myocardial infarction. Impaired outcome has been shown, making risk stratification and novel therapeutic concepts a necessity. We hypothesized insulin resistance with elevated plasma glucose and potentially myocardial glucose deprivation to contribute to the pathogenesis of TTS and investigated the therapeutic benefit of insulin in vivo. METHODS AND RESULTS: First, we retrospectively analysed patient data of n = 265 TTS cases (85.7% female, mean age 71.1 ± 14.1 years) with documented initial plasma glucose from the Department of Cardiology of the University Hospital Heidelberg in Germany (May 2011 to May 2021). Median split of the study population according to glucose levels (≤123 mg/dL vs. >123 mg/dL) yielded significantly elevated mean heart rate (80.75 ± 18.96 vs. 90.01 ± 22.19 b.p.m., P < 0.001), left ventricular end-diastolic pressure (LVEDP, 18.51 ± 8.35 vs. 23.09 ± 7.97 mmHg, P < 0.001), C-reactive protein (26.14 ± 43.30 vs. 46.4 ± 68.6 mg/L, P = 0.006), leukocyte count (10.12 ± 4.29 vs. 15.05 ± 9.83/nL, P < 0.001), peak high-sensitive Troponin T (hs-TnT, 515.44 ± 672.15 vs. 711.40 ± 736.37 pg/mL, P = 0.005), reduced left ventricular ejection fraction (EF, 34.92 ± 8.94 vs. 31.35 ± 8.06%, P < 0.001), and elevated intrahospital mortality (2.3% vs. 12.1%, P = 0.002) in the high-glucose group (Student's t-test, Mann-Whitney U test, or chi-squared test). Linear regression indicated a significant association of glucose with HR (P < 0.001), LVEDP (P = 0.014), hs-TnT kinetics from admission to the next day (P < 0.001), hs-TnT the day after admission (P < 0.001), as well as peak hsTnT (P < 0.001). Logistic regression revealed significant association of glucose with a composite intrahospital outcome including catecholamine use, respiratory support, and resuscitation [OR 1.010 (1.004-1.015), P = 0.001]. To further investigate the potential role of glucose in TTS pathophysiology experimentally, we utilized an in vivo murine model of epinephrine (EPI)-driven reversible AHF. For this, male mice underwent therapeutic injection of insulin (INS, 1 IU/kg) or/and glucose (GLU, 0.5 g/kg) after EPI (2.5 mg/kg), both of which markedly improved mean EF (EPI 34.3% vs. EPI + INS + GLU 43.7%, P = 0.025) and significantly blunted mean hs-TnT (EPI 14 393 pg/mL vs. EPI + INS 6864 pg/mL at 24 h, P = 0.039). Particularly, insulin additionally ameliorated myocardial pro-inflammatory gene expression, suggesting an anti-inflammatory effect of acute insulin therapy. CONCLUSIONS: Elevated initial plasma glucose was associated with adverse outcome-relevant parameters in TTS and may present a surrogate parameter of heightened catecholaminergic drive. In mice, insulin- and glucose injection both improved EPI-induced AHF and myocardial damage, indicating insulin resistance rather than detrimental effects of hyperglycaemia itself as the underlying cause. Future studies will investigate the role of HbA1c as a risk stratifier and of insulin-based therapy in TTS.
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Resistencia a la Insulina , Cardiomiopatía de Takotsubo , Humanos , Cardiomiopatía de Takotsubo/fisiopatología , Cardiomiopatía de Takotsubo/diagnóstico , Femenino , Masculino , Estudios Retrospectivos , Resistencia a la Insulina/fisiología , Anciano , Glucemia/metabolismo , Insulina/uso terapéutico , Función Ventricular Izquierda/fisiología , Estudios de SeguimientoRESUMEN
BACKGROUND: Targeted mental health interventions are increasingly described as individualised, personalised or person-centred approaches. However, the definitions for these terms vary significantly. Their interchangeable use prevents operationalisations and measures. OBJECTIVE: This scoping review provides a synthesis of key concepts, definitions and the language used in the context of these terms in an effort to delineate their use for future research. STUDY SELECTION AND ANALYSIS: Our search on PubMed, EBSCO and Cochrane provided 2835 relevant titles. A total of 176 titles were found eligible for extracting data. A thematic analysis was conducted to synthesise the underlying aspects of individualisation, personalisation and person-centredness. Network visualisations of co-occurring words in 2625 abstracts were performed using VOSViewer. FINDINGS: Overall, 106 out of 176 (60.2%) articles provided concepts for individualisation, personalisation and person-centredness. Studies using person-centredness provided a conceptualisation more often than the others. A thematic analysis revealed medical, psychological, sociocultural, biological, behavioural, economic and environmental dimensions of the concepts. Practical frameworks were mostly found related to person-centredness, while theoretical frameworks emerged in studies on personalisation. Word co-occurrences showed common psychiatric words in all three network visualisations, but differences in further contexts. CONCLUSIONS AND CLINICAL IMPLICATIONS: The use of individualisation, personalisation and person-centredness in mental healthcare is multifaceted. While individualisation was the most generic term, personalisation was often used in biomedical or technological studies. Person-centredness emerged as the most well-defined concept, with many frameworks often related to dementia care. We recommend that the use of these terms follows a clear definition within the context of their respective disorders, treatments or medical settings. SCOPING REVIEW REGISTRATION: Open Science Framework: osf.io/uatsc.
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Atención a la Salud , Servicios de Salud Mental , Humanos , Instituciones de Salud , Salud Mental , LingüísticaRESUMEN
Heart failure (HF) is a major public health problem. Early identification of at-risk individuals could allow for interventions that reduce morbidity or mortality. The community-based FINRISK Microbiome DREAM challenge (synapse.org/finrisk) evaluated the use of machine learning approaches on shotgun metagenomics data obtained from fecal samples to predict incident HF risk over 15 years in a population cohort of 7231 Finnish adults (FINRISK 2002, n=559 incident HF cases). Challenge participants used synthetic data for model training and testing. Final models submitted by seven teams were evaluated in the real data. The two highest-scoring models were both based on Cox regression but used different feature selection approaches. We aggregated their predictions to create an ensemble model. Additionally, we refined the models after the DREAM challenge by eliminating phylum information. Models were also evaluated at intermediate timepoints and they predicted 10-year incident HF more accurately than models for 5- or 15-year incidence. We found that bacterial species, especially those linked to inflammation, are predictive of incident HF. This highlights the role of the gut microbiome as a potential driver of inflammation in HF pathophysiology. Our results provide insights into potential modeling strategies of microbiome data in prospective cohort studies. Overall, this study provides evidence that incorporating microbiome information into incident risk models can provide important biological insights into the pathogenesis of HF.
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BACKGROUND: The COVID-19 pandemic severely affected everyday life and working conditions for most Europeans, particularly health care professionals (HCPs). Over the past 3 years, various policies have been implemented in various European countries. Studies have reported on the worsening of mental health, work-related stress, and helpful coping strategies. However, having a closer look is still necessary to gain more information on the psychosocial stressors and unmet needs of HCPs as well as nonmedical staff. OBJECTIVE: This study aimed to obtain quantitative information on job-related stressors of physicians and nurses and the coping strategies of HCPs and nonmedical staff at 2 periods of the COVID-19 pandemic. By further analyzing qualitative comments, we wanted to gain more information on the psychosocial stressors and unmet needs of HCPs as well as nonmedical staff on different levels of experience. METHODS: A cross-sectional survey was conducted at 2 time points during the COVID-19 pandemic in several European countries. The first study period (T1) lasted between April 1 and June 20, 2020, and the second study period (T2) lasted between November 25, 2021, and February 28, 2022. On a quantitative level, we used a questionnaire on stressors for physicians and nurses and a questionnaire on coping strategies for HCPs and nonmedical staff. Quantitative data were descriptively analyzed for mean values and differences in stressors and coping strategies. Qualitative data of free-text boxes of HCPs and nonmedical staff were analyzed via thematic analysis to explore the experiences of the individuals. RESULTS: T1 comprised 609 participants, and T2 comprised 1398 participants. Overall, 296 participants made 438 qualitative comments. The uncertainty about when the pandemic would be controlled (T1: mean 2.28, SD 0.85; T2: mean 2.08, SD 0.90) and the fear of infecting the family (T1: mean 2.26, SD 0.98; T2: mean 2.02, SD 1.02) were the most severe stressors identified by physicians and nurses in both periods. Overall, the use of protective measures (T1: mean 2.66, SD 0.60; T2: mean 2.66, SD 0.60) and acquiring information about COVID-19 (T1: mean 2.29, SD 0.82; T2: mean 1.99, SD 0.89) were identified as the most common coping strategies for the entire study population. Using thematic analysis, we identified 8 themes of personal experiences on the micro, meso, and macro levels. Measures, working conditions, feelings and emotions, and social climate were frequently mentioned topics of the participants. In T1, feelings of isolation and uncertainty were prominent. In T2, feelings of exhaustion were expressed and vaccination was frequently discussed. Moreover, unmet psychosocial needs were identified. CONCLUSIONS: There is a need for improvement in pandemic preparedness. Targeted vocational education measures and setting up of web-based mental health support could be useful to bridge gaps in psychosocial support needs in future crises.
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COVID-19 , Pandemias , Humanos , Estudios Transversales , Personal de Salud , Europa (Continente)RESUMEN
BACKGROUND: Comorbidities are expected to impact the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). However, comorbidity profiles are usually reduced to a few comorbid disorders. Systems medicine approaches can model phenome-wide comorbidity profiles to improve our understanding of HFpEF and infer associated genetic profiles. METHODS: We retrospectively explored 569 comorbidities in 29,047 HF patients, including 8062 HFpEF and 6585 HF with reduced ejection fraction (HFrEF) patients from a German university hospital. We assessed differences in comorbidity profiles between HF subtypes via multiple correspondence analysis. Then, we used machine learning classifiers to identify distinctive comorbidity profiles of HFpEF and HFrEF patients. Moreover, we built a comorbidity network (HFnet) to identify the main disease clusters that summarized the phenome-wide comorbidity. Lastly, we predicted novel gene candidates for HFpEF by linking the HFnet to a multilayer gene network, integrating multiple databases. To corroborate HFpEF candidate genes, we collected transcriptomic data in a murine HFpEF model. We compared predicted genes with the murine disease signature as well as with the literature. RESULTS: We found a high degree of variance between the comorbidity profiles of HFpEF and HFrEF, while each was more similar to HFmrEF. The comorbidities present in HFpEF patients were more diverse than those in HFrEF and included neoplastic, osteologic and rheumatoid disorders. Disease communities in the HFnet captured important comorbidity concepts of HF patients which could be assigned to HF subtypes, age groups, and sex. Based on the HFpEF comorbidity profile, we predicted and recovered gene candidates, including genes involved in fibrosis (COL3A1, LOX, SMAD9, PTHL), hypertrophy (GATA5, MYH7), oxidative stress (NOS1, GSST1, XDH), and endoplasmic reticulum stress (ATF6). Finally, predicted genes were significantly overrepresented in the murine transcriptomic disease signature providing additional plausibility for their relevance. CONCLUSIONS: We applied systems medicine concepts to analyze comorbidity profiles in a HF patient cohort. We were able to identify disease clusters that helped to characterize HF patients. We derived a distinct comorbidity profile for HFpEF, which was leveraged to suggest novel candidate genes via network propagation. The identification of distinctive comorbidity profiles and candidate genes from routine clinical data provides insights that may be leveraged to improve diagnosis and identify treatment targets for HFpEF patients.
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Insuficiencia Cardíaca , Medicina , Humanos , Animales , Ratones , Estudios Retrospectivos , Volumen Sistólico , ComorbilidadRESUMEN
BACKGROUND: The EQ-5D and the SF-6D are examples of commonly used generic preference-based instruments for assessing health-related quality of life (HRQoL). However, their suitability for mental disorders has been repeatedly questioned. OBJECTIVE: To assess the responsiveness and convergent validity of the EQ-5D-3L and SF-6D in patients with depressive symptoms. METHODS: The data analyzed were from cardiac patients with depressive symptoms and were collected as part of the SPIRR-CAD (Stepwise Psychotherapy Intervention for Reducing Risk in Coronary Artery Disease) trial. The EQ-5D-3L and SF-6D were compared with the HADS (Hospital Anxiety and Depression Scale) and PHQ-9 (Patient Health Questionnaire) as disease-specific instruments. Convergent validity was assessed using Spearman's rank correlation. Effect sizes were calculated and ROC analysis was performed to determine responsiveness. RESULTS: Data from 566 patients were analysed. The SF-6D correlated considerably better with the disease-specific instruments (|rs|= 0.63-0.68) than the EQ-5D-3L (|rs|= 0.51-0.56). The internal responsiveness of the SF-6D was in the upper range of a small effect (ES: - 0.44 and - 0.47), while no effect could be determined for the EQ-5D-3L. Neither the SF-6D nor the EQ-5D-3L showed acceptable external responsiveness for classifying patients' depressive symptoms as improved or not improved. The ability to detect patients whose condition has deteriorated was only acceptable for the EQ-5D-3L. CONCLUSION: Overall, both the convergent validity and responsiveness of the SF-6D are better than those of the EQ-5D-3L in patients with depressive symptoms. The SF-6D appears, therefore, more recommendable for use in studies to evaluate interventions for this population.
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Trastornos Mentales , Calidad de Vida , Humanos , Depresión , Encuestas y Cuestionarios , Psicometría , Reproducibilidad de los ResultadosRESUMEN
OBJECTIVE: Psychosocial parameters play a pivotal role in organ recipient evaluation before wait-listing for transplantation because of their impact on organ and patient outcome. Patients in need of heart (HTx), liver (LTx), or kidney transplantation (KTx) face distinct physical and psychological challenges. This study compares the psychosocial characteristics and preferences for additional therapy for patients undergoing assessment for these three types of organ transplantation to optimize patient-tailored psychological, social, and other supportive interventions. METHODS: We conducted a cross-sectional, observational study with 1110 potential transplantation candidates (LTx, n = 544; KTx, n = 330; HTx, n = 236), psychosocial status was determined for depressive symptoms (Patient Health Questionnaire Depression Scale), anxiety symptoms (seven-item Generalized Anxiety Disorder Screener), health-related quality of life (36-Item Short Form Health Survey), perceived social support (Perceived Social Support Questionnaire), sense of coherence (SoC; short form of the Sense of Coherence Scale), self-efficacy (General Self-Efficacy Short Scale), and body image (German Body Image Questionnaire-20). Preferences for additional supportive therapy were assessed dichotomously. Data were analyzed using multivariate analysis of covariance and χ2 tests. RESULTS: Patient groups differed significantly regarding depression ( F (2,1107) = 35.283, p < .001, partial η2 = 0.01), anxiety ( F (2,1107) = 15.027, p < .001, partial η2 = 0.03), health-related quality of life (physical: F (2,1107) = 96.772, p < .001, partial η2 = 0.15; mental: F (2,1107) = 11.442, p < .001, partial η2 = 0.02), perceived social support ( F (2,1107) = 20.813, p < .001, partial η2 = 0.04), SoC ( F (2,1107) = 12.920, p < .001, partial η2 = 0.02), self-efficacy ( F (2,1107) = 17.308, p < .001, partial η2 = 0.03), and body image (rejecting body evaluation: F (2,1107) = 5.006, p = .007, partial η2 = 0.01; vital body dynamics: F (2,1107) = 40.216, p < .001, partial η2 = 0.07). Patients evaluated for HTx showed the highest psychosocial impairment and the highest inclination regarding additional supportive therapy. CONCLUSIONS: Patients evaluated for HTx, LTx, and KTx have distinct psychosocial characteristics and treatment preferences. HTx patients display the highest psychosocial impairment. We suggest psychocardiological treatment structures for optimal outcome.
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Trasplante de Corazón , Trasplante de Riñón , Trasplante de Hígado , Humanos , Estudios Transversales , Trasplante de Corazón/psicología , Riñón , Hígado , Calidad de Vida/psicología , Trasplante de Riñón/psicología , Trasplante de Hígado/psicología , Depresión , Ansiedad , Apoyo Social , Imagen Corporal , AutoeficaciaRESUMEN
BACKGROUND: The effectiveness of virtual reality exposure (VRE) in the treatment of anxiety disorders is well established. Several psychological mechanisms of VRE have been identified, whereby both emotional processing and the sense of presence play a key role. However, there are only few studies that contribute to our knowledge of examples of implementation in the case of VRE for claustrophobia based on patients' experiences and the perspective of therapists. OBJECTIVE: This study asks for key elements of a VRE app that are necessary for effective exposure for people with claustrophobic symptoms. METHODS: A mixed methods design was applied in which patients (n=15) and therapeutic experts (n=15) tested a VRE intervention of an elevator ride at 5 intensity levels. Intensity was varied by elevator size, duration of the elevator ride, and presence of virtual humans. Quantitative measures examined self-reported presence with the Igroup Presence Questionnaire (IPQ) ranging from 0 to 6 and 15 Likert-scaled evaluation items that had been developed for the purpose of this study, ranging from 1 to 5. In both measures, higher scores indicate higher levels of presence or agreement. Think-aloud protocols of the patients and semistructured interviews posttreatment of all participants were conducted to gain in-depth perspectives on emotional processes. RESULTS: The intervention induced a feeling of presence in patients and experts, posttreatment scores showed a high IPQ presence score (mean 3.84, SD 0.88), with its subscores IPQ spatial presence (mean 4.53, SD 1.06), IPQ involvement (mean 3.83, SD 1.22), and IPQ experienced realism (mean 2.75, SD 1.02). Patients preferred a setting in the presence of a therapist (mean 4.13, SD 0.83) more than the experts did (mean 3.33, SD 1.54). Think-aloud protocols of the patients revealed that presence and anxiety both were achieved. Qualitative interviews of patients and experts uncovered 8 topics: feelings and emotions, personal story, telepresence, potential therapeutic effects, barriers, conditions and requirements, future prospects, and realization. The intensity levels were felt to appropriately increase in challenge, with ambivalent results regarding the final level. Virtual humans contributed to feelings of fear. CONCLUSIONS: Key elements of a VRE app for claustrophobic symptoms should include variation of intensity by adding challenging cues in order to evoke presence and anxiety. Virtual humans are a suitable possibility to make the intervention realistic and to provide a sense of closeness; however, some of the fears might then be related to symptoms of social phobia or agoraphobia. Patients may need the physical presence of a therapist, though not all of them share this view. A higher degree of sophistication in the intensity levels is needed to deliver targeted help for specific symptoms of anxiety.
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BACKGROUND: The Chinese healthcare system is affected by frequent disputes between physicians and patients. Although recent reforms have contributed towards improving the patient-physician relationship, distrust in physicians is still high. Communication skills (CS) training of physicians holds the key to improving patient confidence and diffusing stressful situations. This survey reports on the status of CS training in medical education in China, and the experiences and attitudes of physicians towards CS training. METHODS: A cross-sectional survey was conducted at medical institutions across China. A questionnaire developed for this study included the status of CS training, current aspects of patient-physician relationships, perceived own CS and patient-centeredness with Likert-scaled items from 1 (most negative) to 6 (most positive). Physicians' attitude towards CS training was measured with the Communication Skills Attitude Scale (CSAS) and its subscales PAS (Positive Attitude Scale) and NAS (Negative Attitude Scale). Data were analyzed descriptively and for group differences between the hospital level and operating vs. non-operating physicians. Binary logistic regression analysis was done to find associations explaining the occurrence of verbal and physical attacks and the role of CS attitudes. RESULTS: Out of 1080 questionnaires, 772 physicians met inclusion criteria. A total of 466/772 participants (60.4%) had received at least one CS training during their career. The participants rated the current situation related to patient-physician relationship in China as highly stressful (mean = 4.52, SD = 1.26, 95% CI: 4.43-4.60), experiencing verbal attacks in the past three years once a year in 372/772 cases (48.2%) and physical attacks 111/772 times (14.4%). The mean PAS was 62.96 (SD = 7.63, 95% CI: 62.41-63.47). Being female was associated with increased risk of verbal attacks (OR = 1.51, 95% CI: 1.01-2.25) while working in a tertiary hospital and showing high levels of PAS decreased this risk (OR = 0.62, 95% CI: 0.43-0.89, and OR = 0.95, 95% CI: 0.93-0.98). Having received a previous CS training decreased the odds of physical attacks (OR = 0.54, 95% CI: 0.35-0.83). CONCLUSIONS: A majority of Chinese physicians showed a high positive attitude towards CS training, were trained in CS and would value further training. Our results highlight that CS training is likely to promote patient-centered communication and reduce attacks against physicians. Both of these effects are to improve the patient-physician-relationship in the long run. More CS training should be offered to Chinese physicians, especially at secondary- and primary-care hospitals, where such practices remain infrequent.
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Actitud del Personal de Salud , Médicos , Humanos , Femenino , Masculino , Estudios Transversales , Relaciones Médico-Paciente , Comunicación , Encuestas y Cuestionarios , ChinaRESUMEN
Myocardial infarction (MI) with subsequent depression is associated with increased cardiac mortality. Impaired central mineralocorticoid (MR) and glucocorticoid receptor (GR) equilibrium has been suggested as a key mechanism in the pathogenesis of human depression. Here, we investigate if deficient central MR/GR signaling is causative for a poor outcome after MI in mice. Mice with an inducible forebrain-specific MR/GR knockout (MR/GR-KO) underwent baseline and follow-up echocardiography every 2 weeks after MI or sham operation. Behavioral testing at 4 weeks confirmed significant depressive-like behavior and, strikingly, a higher mortality after MI, while cardiac function and myocardial damage remained unaffected. Telemetry revealed cardiac autonomic imbalance with marked bradycardia and ventricular tachycardia (VT) upon MI in MR/GR-KO. Mechanistically, we found a higher responsiveness to atropine, pointing to impaired parasympathetic tone of 'depressive' mice after MI. Serum corticosterone levels were increased but-in line with the higher vagal tone-plasma and cardiac catecholamines were decreased. MR/GR deficiency in the forebrain led to significant depressive-like behavior and a higher mortality after MI. This was accompanied by increased vagal tone, depleted catecholaminergic compensatory capacity and VTs. Thus, limbic MR/GR disequilibrium may contribute to the impaired outcome of depressive patients after MI and possibly explain the lack of anti-depressive treatment benefit.
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Depresión , Infarto del Miocardio , Animales , Humanos , Ratones , Infarto del Miocardio/patología , Miocardio/patología , Prosencéfalo/metabolismo , Receptores de Glucocorticoides/metabolismoRESUMEN
Objective: Previous studies have shown positive treatment outcomes of e-mental health applications targeting depression. However, few applications provide personalized features. The aim of the present study is to ask for the user experience and acceptance of patients with depression and healthy adults, who tested the self-management app Self-administered Psycho Therapy SystemS over a period of 5 days. The results serve as a source for evidence-based recommendations for developers and clinicians. Methods: A total of 110 participants (41 patients and 69 healthy controls) tested the app Self-administered Psycho Therapy SystemS over a period of 5 days and completed evaluation sheets developed for the purpose of this study. Quantitative measures were asked with 5-point Likert-scaled items (range: -2 to + 2) for the perceived quality of the programme and its components, its practicality (both referred to as user experience) and its acceptance. Student's t-tests and Pearson correlations were calculated for group comparisons and associations, respectively. Open text fields were analysed by applying a qualitative structuring content analysis. Results: The perceived quality of the total programme was rated with M = 0.96 (SD = 0.82), the practicality was M = 0.84 (SD = 0.08) and the acceptance was M = 0.25 (SD = 1.04). Patients rated perceived quality of the total programme and acceptance higher than healthy adults, while there was no difference in practicality. Acceptance was associated with increased depression scores (r = 0.33, p = .01), higher scores of perceived quality of the total programme (r = 0.48, p< .001) and of practicality (r = 0.45, p < .001). Feedback of both groups regarding usability, therapeutic content and personalization revealed a strong wish for guidance and insights into mood progress, opportunities for choice of interventions and features of customization for individualized treatment. Conclusions: Patients with depression accepted the app Self-administered Psycho Therapy SystemS more than healthy adults and gave higher ratings in quality. User experience of all users shows a need for features of guidance, choice and personalization that clinicians and developers of future apps should pay attention to.
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OBJECTIVE: The relevance of communication in medical education is continuously increasing. At the Medical Faculty of Hamburg, the communication curriculum was further developed and optimized during this project. This article aims to describe the stakeholders' perceived challenges and supporting factors in the implementation and optimization processes. METHODS: The initial communication curriculum and its development after a one-year optimization process were assessed with a curricular mapping. A SWOT analysis and group discussions were carried out to provide information on the need for optimization and on challenges the different stakeholders faced. RESULTS: The curricular mapping showed that the communication curriculum is comprehensive, coherent, integrated and longitudinal. In both the implementation and the project-related optimization processes, support from the dean, cooperation among all stakeholders and structural prerequisites were deemed the most critical factors for successfully integrating communication content into the curriculum. CONCLUSION: The initiative and support of all stakeholders, including the dean, teachers and students, were crucial for the project's success. PRACTICE IMPLICATIONS: Although the implementation of a communication curriculum is recommended for all medical faculties, their actual implementation processes may differ. In a "top-down" and "bottom-up" approach, all stakeholders should be continuously involved in the process to ensure successful integration.
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Comunicación , Curriculum , Educación Médica , Docentes Médicos/psicología , Participación de los Interesados , Curriculum/normas , Curriculum/tendencias , Educación Médica/métodos , Educación Médica/organización & administración , Educación Médica/normas , Educación Médica/tendencias , Docentes Médicos/normas , Alemania , Historia del Siglo XXI , Humanos , Ciencia de la Implementación , Relaciones Interprofesionales , Percepción , Relaciones Médico-Paciente , Habilidades Sociales , Participación de los Interesados/psicología , Enseñanza/psicología , Enseñanza/normasRESUMEN
Cadaver-specific postmortem computed tomography (PMCT) has become an integral part in anatomy teaching at several universities. Recently, the feasibility of contrast-enhanced (CE)-PMCT has been demonstrated. The purpose of this study was to identify particular strengths and weaknesses of both non-enhanced and contrast-enhanced PMCT compared to conventional cadaver dissection. First, the students' perception of the learning effectiveness of the three different modalities have been assessed using a 34-item survey (five-point Likert scale) covering all anatomy course modules. Results were compared using the nonparametric Friedman Test. Second, the most frequent artifacts in cadaver CT scans, were systematically analyzed in 122 PMCT and 31 CE-PMCT data sets to quantify method-related limitations and characteristics. Perfusion quality was assessed in 57 vascular segments (38 arterial and 19 venous). The survey was answered by n = 257/320 (80.3%) students. Increased learning benefits of PMCT/ CE-PMCT compared to cadaver dissection were found in osteology (2/3 categories, P < 0.001), head and neck (2/5 categories, P < 0.01), and brain anatomy (3/3 categories, P < 0.01). Contrast-enhanced-PMCT was perceived particularly useful in learning vascular anatomy (10/10 categories, P < 0.01). Cadaver dissection received significantly higher scores compared to PMCT and CE-PMCT in all categories of the abdomen and thorax (7/7 categories, P < 0.001), as well as the majority of muscular anatomy (5/6 categories, P < 0.001). Frequent postmortem artifacts (total n = 28, native-phase n = 21, contrast injection-related n = 7) were identified and assessed. The results of this work contribute to the understanding of the value of integrating cadaver-specific PMCT in anatomy teaching.
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Anatomía , Anatomía/educación , Cadáver , Curriculum , Disección , Humanos , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: e-Mental health apps targeting depression have gained increased attention in mental health care. Daily self-assessment is an essential part of e-mental health apps. The Self-administered Psycho-TherApy-SystemS (SELFPASS) app is a self-management app to manage depressive and comorbid anxiety symptoms of patients with a depression diagnosis. A self-developed item pool with 40 depression items and 12 anxiety items is included to provide symptom-specific suggestions for interventions. However, the psychometric properties of the item pool have not yet been evaluated. OBJECTIVE: The aim of this study is to investigate the validity and reliability of the SELFPASS item pool. METHODS: A weblink with the SELFPASS item pool and validated mood assessment scales was distributed to healthy subjects and patients who had received a diagnosis of a depressive disorder within the last year. Two scores were derived from the SELFPASS item pool: SELFPASS depression (SP-D) and SELFPASS anxiety (SP-A). Reliability was examined using Cronbach α. Construct validity was assessed through Pearson correlations with the Patient Health Questionnaire-9 (PHQ-9), the General Anxiety Disorder Scale-7 (GAD-7), and the WHO-5-Wellbeing-Scale (WHO-5). Logistic regression analysis was performed as an indicator for concurrent criterion validity of SP-D and SP-A. Factor analysis was performed to provide information about the underlying factor structure of the item pool. Item-scale correlations were calculated in order to determine item quality. RESULTS: A total of 284 participants were included, with 192 (67.6%) healthy subjects and 92 (32.4%) patients. Cronbach α was set to .94 for SP-D and α=.88 for SP-A. We found significant positive correlations between SP-D and PHQ-9 scores (r=0.87; P<.001) and between SP-A and GAD-7 scores (r=0.80; P<.001), and negative correlations between SP-D and WHO-5 scores (r=-0.80; P<.001) and between SP-A and WHO-5 scores (r=-0.69; P<.001). Increasing scores of SP-D and SP-A led to increased odds of belonging to the patient group (SP-D: odds ratio 1.03, 95% CI 1.01-1.05; P<.001; SP-A: 1.05, 1.05-1.01; P=.01). The item pool yielded 2 factors: one that consisted of mood-related items and another with somatic-related items. CONCLUSIONS: The SELFPASS item pool showed good psychometric properties in terms of reliability, construct, and criterion validity. The item pool is an appropriate source for daily mood tracking in future e-mental health apps among patients with depression. Our study provides general recommendations for future developments as well as recommendations within the item pool.
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BACKGROUND: International medical students are frequently confronted with intercultural, psychosocial, and language barriers and often receive lower marks in written, oral, and clinical-practical examinations than fellow local students. Training communication competence in procedural skills, such as blood sampling, is further challenge in this particular group of medical students. This pre-post comparative intervention study aimed to investigate the effects of training communication skills during the performance of procedural skills (taking blood samples from a silicone model) in international and local students as part of their clinical practical medical training. METHODS: Study participants performed blood sampling on an arm prosthesis model (part-task trainer) before and after the communication skills training, focusing on accompanying communication with a simulation patient sitting next to the arm model. The pre- and post-evaluation video was assessed by two independent evaluators using a binary checklist, the Integrated Procedural Performance Instrument (IPPI) and global assessments of clinical professionalism in terms of procedural and communication performance. Linear models with mixed effects were used. Group differences regarding global competence levels were analysed with χ2-tests. RESULTS: International medical students did not perform as well as their local counterparts in the pre- and post-examinations. Both groups improved their performance significantly, whereby the international students improved more than their local counterparts in terms of their communication performance, assessed via binary checklist. Clinical professionalism evaluated via global assessments of procedural and communication performance highlights the intervention's impact insofar as no international student was assessed as clinically not competent after the training. CONCLUSIONS: Our results suggest that already a low-dose intervention can lead to improved communication skills in medical students performing procedural tasks and significantly increase their confidence in patient interaction.
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Educación de Pregrado en Medicina , Estudiantes de Medicina , Competencia Clínica , Comunicación , Humanos , Examen FísicoRESUMEN
On the one hand, sustained ß-adrenergic stress is a hallmark of heart failure (HF) and exerts maladaptive cardiac remodelling. On the other hand, acute ß-adrenergic stimulation maintains cardiac function under physiological stress. However, it is still incompletely understood to what extent the adaptive component of ß-adrenergic signaling contributes to the maintenance of cardiac function during chronic ß-adrenergic stress. We developed an experimental catecholamine-based protocol to distinguish adaptive from maladaptive effects. Mice were for 28 days infused with 30 mg/kg body weight/day isoproterenol (ISO) by subcutaneously implanted osmotic minipumps ('ISO on'). In a second and third group, ISO infusion was stopped after 26 days and the mice were observed for additional two or seven days without further ISO infusion ('ISO off short', 'ISO off long'). In this setup, 'ISO on' led to cardiac hypertrophy and slightly improved cardiac contractility. In stark contrast, 'ISO off' mice displayed progressive worsening of left ventricular ejection fraction that dropped down below 40%. While fetal and pathological gene expression (increase in Nppa, decrease in Myh6/Myh7 ratios, increase in Xirp2) was not induced in 'ISO on', it was activated in 'ISO off' mice. After ISO withdrawal, phosphorylation of phospholamban (PLN) at the protein kinase A (PKA) phosphorylation site Ser-16 dropped down to 20% as compared to only 50% at the Ca2+/Calmodulin-dependent kinase II (CaMKII) phosphorylation site Thr-17 in 'ISO off' mice. PKA-dependent cardioprotective production of the N-terminal proteolytic product of histone deacetylase 4 (HDAC4-NT) was reduced in 'ISO off' as compared to 'ISO on'. Taken together, these data indicate that chronic ISO infusion induces besides maladaptive remodelling also adaptive PKA signalling to maintain cardiac function. The use of the 'ISO on/off' model will further enable the separation of the underlying adaptive from maladaptive components of ß-adrenergic signalling and may help to better define and test therapeutic targets downstream of ß-adrenergic receptors.