Estudio Transdiagnóstico de la Impulsividad y de la Conducta Autolítica en los Trastornos Impulsivos e Inestables / Transdiagnostic study of impulsivity and self-injurious behavior in unstable and impulsive disorders

Introducción. La elevada comorbilidad entre el trastorno límite de la personalidad (TLP) y los trastornos de la conducta alimentaria (TCA) pone de manifiesto la necesidad de establecer modelos transdiagnósticos, donde la impulsividad podría tener un papel relevante en las manifestaciones dela conducta autolítica. Objetivos: 1) Comparar los niveles de impulsividad y conducta autolítica entre personas con TLP, personas con TCA y controles. 2) Predecir la presencia de conductas autolíticas a partir de la impulsividad y otras variables clínicas relevantes, como la vivencia de acontecimientos traumáticos y la sensibilidad al rechazo. Método. 108 mujeres (23 controles; 29 con diagnóstico de TCA restrictivo (TCAr); 21 con diagnóstico de TCA purgativo (TCAp); y 35 con diagnóstico de TLP) fueron evaluadas a través de la Escala de Impulsividad de Barratt, el Cuestionario para Experiencias Traumáticas y el Cuestionario de Sensibilidad al Rechazo. La información sobre conducta autolítica fue recogida a través de entrevista e historia clínica. Resultados. Se encontraron diferencias en las puntuaciones de impulsividad y conducta autolítica entre los grupos, encontrándose mayor impulsividad en los grupos TLP y TCAp, y mayores índices de conducta autolítica en el grupo TLP seguido de ambos grupos de TCA. Por otro lado, la impulsividad predecía los intentos de suicidio, y junto con la sensibilidad al rechazo interpersonal predecía las autolesiones no suicidas (ANS).Conclusión. La impulsividad es una variable dimensional en el TLP y en los TCA, que a su vez juega un papel relevante en la predicción de las conductas autolíticas. (AU)

Introduction. High comorbidity between borderline personality disorder (BPD) and eating disorders (ED) shows the necessity of developing transdiagnostic models, where impulsivity could play a relevant role in the manifestations ofself-injurious behaviour. Objectives: 1) To compare the levelsof impulsivity and self-injurious behaviour among peoplewith BPD, people with ED and controls. 2) To predict the presence of self-injurious behaviour based on impulsivity andother relevant clinical variables, such as the experience oftraumatic events and sensitivity to rejection. Methods. 108 women (23 controls; 29 with a diagnosis of restrictive ACT (rED); 21 with a diagnosis of purgative ACT(pED); and 35 with a diagnosis of BPD) were assessed usingthe Barratt Impulsivity Scale, the Traumatic Experiences Questionnaire and the Sensitivity to Rejection Questionnaire. Information about self-injurious behaviour was collectedthrough interview and clinical history. Results. Differences in impulsivity and self-injurious behaviour scores were found between the groups, with higherimpulsivity in the BPD and pED groups, and higher rates ofself-injurious behaviour in the BPD group followed by both ED groups. On the other hand, impulsivity predicted suicideattempts, and together with sensitivity to interpersonal rejection predicted nonsuicidal self-harm (NSSH). Conclusion. Impulsivity is a dimensional variable in BPD and ED, which in turn plays a relevant role in the prediction of self-injurious behaviour. (AU)

Effect of Family Navigation on Diagnostic Ascertainment Among Children at Risk for Autism: A Randomized Clinical Trial From DBPNet.

Importance: Early identification of autism spectrum disorder (ASD) is associated with improved cognitive and behavioral outcomes. Targeted strategies are needed to support equitable access to diagnostic services to ensure that children from low-income and racial/ethnic minority families receive the benefits of early ASD identification and treatment. Objective: To test the efficacy of family navigation (FN), an individually tailored, culturally informed care management strategy, to increase the likelihood of achieving diagnostic ascertainment among young children at risk for ASD. Design, Setting, and Participants: This randomized clinical trial of 249 families of children aged 15 to 27 months who had positive screening results for possible ASD was conducted in 11 urban primary care sites in 3 cities. Data collection occurred from February 24, 2015, through November 5, 2018. Statistical analysis was performed on an intent-to-treat basis from November 5, 2018, to July 27, 2020. Interventions: Families were randomized to FN or conventional care management (CCM). Families receiving FN were assigned a navigator who conducted community-based outreach to families to address structural barriers to care and support engagement in recommended services. Families receiving CCM were assigned to a care manager, who did limited telephone outreach. Families received FN or CCM after positive initial screening results and for 100 days after diagnostic ascertainment. Main Outcomes and Measures: The primary outcome, diagnostic ascertainment, was measured as the number of days from randomization to completion of the child's clinical developmental evaluation, when a diagnosis of ASD or other developmental disorder was determined. Results: Among 250 families randomized, 249 were included in the primary analysis (174 boys [69.9%]; mean [SD] age, 22.0 [3.5] months; 205 [82.3%] publicly insured; 233 [93.6%] non-White). Children who received FN had a greater likelihood of reaching diagnostic ascertainment over the course of 1 year (FN, 108 of 126 [85.7%]; CCM, 94 of 123 [76.4%]; unadjusted hazard ratio [HR], 1.39 [95% CI, 1.05-1.84]). Site (Boston, New Haven, and Philadelphia) and ethnicity (Hispanic vs non-Hispanic) moderated the effect of FN (treatment × site interaction; P = .03; Boston: HR, 2.07 [95% CI, 1.31-3.26]; New Haven: HR, 1.91 [95% CI, 0.94-3.89]; and Philadelphia: HR, 0.91 [95% CI, 0.60-1.37]) (treatment × ethnicity interaction; P < .001; Hispanic families: HR, 2.81 [95% CI, 2.23-3.54] vs non-Hispanic families: HR, 1.49 [95% CI, 1.45-1.53]). The magnitude of FN's effect was significantly greater among Hispanic families than among non-Hispanic families (diagnostic ascertainment among Hispanic families: FN, 90.9% [30 of 33], and CCM, 53.3% [16 of 30]; vs non-Hispanic families: FN, 89.7% [35 of 39], and CCM, 77.5% [31 of 40]). Conclusions and Relevance: Family navigation improved the likelihood of diagnostic ascertainment among children from racial/ethnic minority, low-income families who were detected as at risk for ASD in primary care. Results suggest differential effects of FN by site and ethnicity. Trial Registration: ClinicalTrials.gov Identifier: NCT02359084.

Understanding Taiwanese Women's Decisional Experiences Regarding Prenatal Screening Procedures And Diagnostics: A Phenomenological Study.

PURPOSE: This study sought to understand Taiwanese women's decisional experiences regarding prenatal screening procedures and diagnostics. METHODS: A hermeneutic phenomenological design guided semistructured interviews with 33 women who were 36 weeks pregnant. Data were collected between February and October 2016. Verbatim transcripts were analyzed following hermeneutic circle to cocreate an understanding of Taiwanese women's decision-making in prenatal screening and diagnostics. RESULTS: Women's existential experiences were derived from their decision-making process on prenatal screening procedures and diagnostics for chromosomal aneuploidy. These decisional experiences were captured by four theme clusters and eight themes, which were inductively derived from 16 meaning units: (1) accessing health information; (2) considering what was best for my baby; (3) considering family finance; and (4) feeling anxiety posttest. CONCLUSION: Participants made informed choices on several prenatal screening procedures, ostensibly, based on their personal values and considerations. During the decision-making process, often-cited benefits of genetic screenings were emphasized, but test limitations were often unheeded. A fundamental need for supportive information in decision making was further identified with recommended strategies. Hence, a revision of traditional genetic counseling approaches is recommended. As genomics technologies are increasingly available during antenatal services, women should be sufficiently educated about them to support decision making.

[Do artificial intelligence systems reason in the same way as clinicians when making diagnoses?] / Une intelligence artificielle raisonne-t-elle de la même façon que les cliniciens pour poser des diagnostics ?

Clinical reasoning is at the heart of physicians' competence, as it allows them to make diagnoses. However, diagnostic errors are common, due to the existence of reasoning biases. Artificial intelligence is undergoing unprecedented development in this context. It is increasingly seen as a solution to improve the diagnostic performance of physicians, or even to perform this task for them, in a totally autonomous and more efficient way. In order to understand the challenges associated with the development of artificial intelligence, it is important to understand how the machine works to make diagnoses, what are the similarities and differences with the physician's diagnostic reasoning, and what are the consequences for medical training and practice.

Interventions to Improve Patient Comprehension in Informed Consent for Medical and Surgical Procedures: An Updated Systematic Review.

Background. Patient comprehension is fundamental to valid informed consent. Current practices often result in inadequate patient comprehension. Purpose. An updated review to evaluate the characteristics and outcomes of interventions to improve patient comprehension in clinical informed consent. Data Sources. Systematic searches of MEDLINE and EMBASE (2008-2018). Study Selection. We included randomized and nonrandomized controlled trials evaluating interventions to improve patient comprehension in clinical informed consent. Data Extraction. Reviewers independently abstracted data using a standardized form, comparing all results and resolving disagreements by consensus. Data Synthesis. Fifty-two studies of 60 interventions met inclusion criteria. Compared with standard informed consent, a statistically significant improvement in patient comprehension was seen with 43% (6/14) of written interventions, 56% (15/27) of audiovisual interventions, 67% (2/3) of multicomponent interventions, 85% (11/13) of interactive digital interventions, and 100% (3/3) of verbal discussion with test/feedback or teach-back interventions. Eighty-five percent of studies (44/52) evaluated patients' understanding of risks, 69% (41/52) general knowledge about the procedure, 35% (18/52) understanding of benefits, and 31% (16/52) understanding of alternatives. Participants' education level was reported heterogeneously, and only 8% (4/52) of studies examined effects according to health literacy. Most studies (79%, 41/52) did not specify participants' race/ethnicity. Limitations. Variation in interventions and outcome measures precluded conduct of a meta-analysis or calculation of mean effect size. Control group processes were variable and inconsistently characterized. Nearly half of studies (44%, 23/52) had a high risk of bias for the patient comprehension outcome. Conclusions. Interventions to improve patient comprehension in informed consent are heterogeneous. Interactive interventions, particularly with test/feedback or teach-back components, appear superior. Future research should emphasize all key elements of informed consent and explore effects among vulnerable populations.

Honesty and comfort levels in mothers when screened for perinatal depression and anxiety.

PURPOSE: To evaluate the degree of honesty and level of comfort reported by women when questioned about their emotional wellbeing during the perinatal period; to investigate if honesty and comfort are associated with perinatal depression or perinatal anxiety; and to examine the reasons why women may not always respond honestly. METHODS: Qualitative and quantitative data from 1597 women from the cross-sectional perinatal mental health substudy (part of the Australian Longitudinal Study on Women's Health) were analysed using a mixed methods approach. RESULTS: When questioned by their health practitioner about their emotional wellbeing in the perinatal period, 20.7% of women indicated they had not always responded honestly. Reasons for not being honest reflected four main themes: normalizing of symptoms/coping; negative perceptions (self-and others); fear of adverse repercussions; and fear of involvement of health services (trust and confidentiality). The 38.9% of women who did not feel comfortable when questioned by their health practitioner about their emotional wellbeing were four times more likely to report perinatal depression (odds ratio = 4.09; 95% confidence interval = 2.55, 6.57) and nearly twice as likely to report perinatal anxiety (odds ratio = 1.90; 95% confidence interval = 1.24, 2.94) than other women. CONCLUSIONS: Women who are most likely to need mental health care during the perinatal period are also those least likely to be honest about their mental health. A non-judgemental, open and reassuring approach by clinicians may help to reduce the stigma and fears contributing to lack of honest responses, and improve early diagnosis and treatment of mental health problems.

O brincar como experiência intersubjetiva de comunicação no psicodiagnóstico interventivo infantil / El jugar como experiencia intersubjetiva de comunicación en el psicodiagnóstico que interviene en la niñez / Playing as intersubjective experience of communication in the interventional psychodiagnosis with children

O psicodiagnóstico infantil é uma prática avaliativa que busca promover a compreensão das experiências intrapsíquicas, intersubjetivas e socioculturais da criança. Neste cenário, o brincar se institui como modo de comunicação da criança com o examinador e como recurso para a observação de elementos constitutivos de seu mundo relacional. O brincar, apesar de comum aos diferentes modelos de avaliação infantil, se mostra atrelado a concepções teóricas e técnicas bastante diferenciadas. Neste artigo são apresentadas e discutidas as diferenças entre os paradigmas do psicodiagnóstico tradicional e o interventivo em suas relações com o brincar e com a comunicação durante o processo avaliativo.

El psicodiagnóstico infantil es una práctica evaluativa que busca fomentar la comprensión de las experiencias instrapsíquicas, intersubjetivas y socioculturales del niño. En esta escena el jugar se instituye como modo de comunicación del niño con el examinador y como recurso para la observación de elementos constitutivos de su mundo relacional. El jugar, a pesar de común a los diferentes modelos de evaluación infantil, se muestra vinculado a concepciones teóricas y técnicas demasiado distintas. En este artículo se presentan y se discuten las diferencias entre los paradigmas del psicodiagnóstico tradicional y el que interviene en sus relaciones con el jugar y con la comunicación mientras el proceso evaluativo.

Child psychodiagnosis is an evaluation practice that seeks to promote understanding of intrapsychic, intersubjective and sociocultural experiences of the child. In this scenario play is established as a way of communicating the child with the examiner and as a resource for observing constitutive elements of their relational world. The play, although common to the different models of child evaluation, shows itself linked to very different theoretical and technical conceptions. In this article, the differences between the paradigms of traditional and interventive psychodiagnosis in their relationship with play and communication during the evaluation process are presented and discussed.

Impact of a Lung Cancer Screening Information Film on Informed Decision-making: A Randomized Trial.

Rationale: Lung cancer screening has the potential to save lives, but it also carries a risk of potential harms. Explaining the benefits and harms of screening in a way that is balanced and comprehensible to individuals with various levels of education is essential. Although a shared decision-making approach is mandated by the Centers for Medicare & Medicaid Services, there have been no randomized studies to evaluate the impact of different forms of lung screening information. Objectives: To evaluate the impact of a novel information film on informed decision-making in individuals considering participating in lung cancer screening. Methods: A subset of participants from LSUT (Lung Screen Uptake Trial) were randomly allocated either to view the information film and receive a written information booklet or to receive the booklet alone. The primary outcome was the objective knowledge score after intervention. Secondary outcomes included subjective knowledge, decisional conflict, final screening participation, and acceptability of the materials. Univariate and multivariate analyses were performed to determine differences in pre- and postintervention knowledge scores in both groups and between groups for the primary and secondary outcomes. Results: In the final analysis of 229 participants, both groups showed significantly improved subjective and objective knowledge scores after intervention. This improvement was greatest in the film + booklet group, where mean objective knowledge improved by 2.16 points (standard deviation [SD] 1.8) compared with 1.84 points (SD 1.9) in the booklet-alone group (ß coefficient 0.62; confidence interval, 0.17-1.08; P = 0.007 in the multivariable analysis). Mean subjective knowledge increased by 0.92 points (SD 1.0) in the film + booklet group and 0.55 points (SD 1.1) in the booklet-alone group (ß coefficient 0.32; CI, 0.05-0.58; P = 0.02 in the multivariable analysis). Decisional certainty was higher in the film + booklet (mean 8.5/9 points [SD 1.3], group than in the booklet-alone group (mean 8.2/9 points [SD 1.5]). Both information materials were well accepted, and there were no differences in final screening participation rates between groups. Conclusions: The information film improved knowledge and reduced decisional conflict without affecting lung-screening uptake. Clinical trial registered with clinicaltrials.gov (NCT02558101).

Psicodiagnóstico na internação psiquiátrica da infância e adolescência: panorama do triênio 2015-2016-2017 / Psychological assessment in a child and adolescent inpatient psychiatric unit: 2015-2016-2017 triennial overview

Introdução: A internação psiquiátrica é um recurso terapêutico utilizado para a estabilização dos sintomas, contenção de riscos, elucidação diagnóstica e planejamento terapêutico. O psicodiagnóstico permite acesso a questões emocionais e cognitivas do indivíduo. Objetiva-se apresentar um panorama referente à realização de psicodiagnósticos em leitos da especialidade da Psiquiatria Infância e Adolescência de um hospital geral nos anos 2015, 2016 e 2017. Métodos: Trata-se de um estudo transversal, em que foram obtidas informações a partir do prontuário eletrônico de pacientes internados em leitos da especialidade. Os dados analisados foram sexo, idade, naturalidade, realização de psicodiagnóstico, motivo e tempo de internação. Resultados: Durante o triênio estudado, houve realização de psicodiagnóstico em 65,1% das internações. Entretanto, constatou-se diminuição estatisticamente significativamente (p = 0,006) no número de psicodiagnósticos em relação ao número de internações: 82% em 2015; 63% em 2016; e 53% em 2017. Conclusão: Esta diminuição no número de psicodiagnósticos realizados durante a internação indica que houve uma mudança nesse processo, onde se passou de um período em que a grande maioria das crianças e adolescentes (82%) realizava a avaliação, para um panorama onde metade dos pacientes (53%) realiza o psicodiagnóstico. Esse resultado sugere que estratégias de psicoeducação, voltadas para equipes assistentes, tendo por objetivo otimizar custo-efetividade e qualidade da assistência, levaram esses profissionais a refletirem sobre relevância, riscos e benefícios da realização do psicodiagnóstico durante a internação psiquiátrica de crianças e adolescentes. (AU)

Introduction: Inpatient psychiatry is a therapeutic resource for symptom stabilization, risk management, diagnostic clarification and/or treatment planning. Psychological assessment provides information on emotional and cognitive functioning. This study aims to provide an overview of psychological assessment in a child and adolescent inpatient psychiatric unit at a general hospital in southern Brazil in 2015, 2016 and 2017. Methods: This cross-sectional retrospective study obtained information from electronic medical records of patients admitted to the hospital psychiatric unit. Data for analysis were sex, age, place of birth, psychological assessment, reason and length of stay. Results: In those three years, psychological assessments were requested in 65.1% of all unit admissions. However, there was a statistically significant decrease (p = 0.006) in the number of psychological assessments in relation to the number of admissions: 82% in 2015; 63% in 2016; and 53% in 2017. Conclusion: The decrease in the number of psychological assessments performed in the inpatient unit indicates that there was some changes in the process, as first most children and adolescents (82%) underwent the assessment and then the rate reduced to half of all patients (53%). This can be explained by the implementation of strategies to educate the health care team about psychological assessment, with the purpose of improving costeffectiveness and quality of care. This led to greater reflection on relevance, risks and benefits of psychological assessment in a child and adolescent inpatient psychiatric unit. (AU)

Getting personal on overdiagnosis: On defining overdiagnosis from the perspective of the individual person.

How can overdiagnosis be defined, explained, and estimated on an individual level? The answers to this question are essential for persons to be able to make informed choices and give valid consents for tests. Traditional conceptions of overdiagnosis tend to depend on counterfactual thinking and prophetic abilities as you would have to know what would happen in the future if you did not test now. To avoid this, overdiagnosis can be defined in terms of the chance of diagnosing a person with a disease when this does not avoid or reduce manifest disease. To be able to relate this to 1's own life and deliberation, I argue that we need answers to specific questions such as the following: If I am tested, and the test and subsequent test results are positive, but I am not treated, what is the chance that I would not experience and suffer from manifest disease? A definition of overdiagnosis that aims at providing answers to this question is as follows: Prospectively overdiagnosis (of an individual person) is given by the estimated chance that a person having a positive test result would not experience and suffer from manifest disease if not treated or followed up in any way. Getting personal on overdiagnosis directs the attention of overdiagnosis estimates towards what matters in medicine: the experience of individual persons.

Cognitive bias: Its influence on clinical diagnosis.

In a busy practice, it's helpful to be aware of specific psychological tendencies that influence diagnostic reasoning and can lead to error.

Looking for trouble? Diagnostics expanding disease and producing patients.

Novel tests give great opportunities for earlier and more precise diagnostics. At the same time, new tests expand disease, produce patients, and cause unnecessary harm in overdiagnosis and overtreatment. How can we evaluate diagnostics to obtain the benefits and avoid harm? One way is to pay close attention to the diagnostic process and its core concepts. Doing so reveals 3 errors that expand disease and increase overdiagnosis. The first error is to decouple diagnostics from harm, eg, by diagnosing insignificant conditions. The second error is to bypass proper validation of the relationship between test indicator and disease, eg, by introducing biomarkers for Alzheimer's disease before the tests are properly validated. The third error is to couple the name of disease to insignificant or indecisive indicators, eg, by lending the cancer name to preconditions, such as ductal carcinoma in situ. We need to avoid these errors to promote beneficial testing, bar harmful diagnostics, and evade unwarranted expansion of disease. Accordingly, we must stop identifying and testing for conditions that are only remotely associated with harm. We need more stringent verification of tests, and we must avoid naming indicators and indicative conditions after diseases. If not, we will end like ancient tragic heroes, succumbing because of our very best abilities.

Précising definitions as a way to combat overdiagnosis.

Roughly, overdiagnosis (ODx) occurs when people are harmed by receiving diagnoses (often accompanied by interventions) that do not benefit them, usually because the diagnosed conditions do not pose a threat to their health. ODx is a theoretical as well as a practical problem as it relates to definitions of disease. Elsewhere, it has been argued that disease is a vague concept and that this vagueness may contribute to ODx. In response, we develop a stipulative or précising definition of disease, for the specific purpose of decreasing or preventing ODx. We call this diseaseODx , aimed at distinguishing cases where it would be beneficial to identify (and treat the condition) from those where diagnosis is more likely to harm than benefit. A preliminary definition of diseaseODx is that X is a diseaseODx iff there is dysfunction that has a significant risk of causing severe harm. This paper examines the 3 concepts in this definition, using a naturalistic account of function, a Feinbergian account of comparative harm, and a probabilistic understanding of risk. We then test the utility of this approach using examples of clinical conditions that are currently overdiagnosed.

The child's perspective on discomfort during medical research procedures: a descriptive study.

OBJECTIVE: The evaluation of discomfort in paediatric research is scarcely evidence-based. In this study, we make a start in describing children's self-reported discomfort during common medical research procedures and compare this with discomfort during dental check-ups which can be considered as a reference level of a 'minimal discomfort' medical procedure. We exploratory study whether there are associations between age, anxiety-proneness, gender, medical condition, previous experiences and discomfort. We also describe children's suggestions for reducing discomfort. DESIGN: Cross-sectional descriptive study. SETTING: Paediatric research at three academic hospitals. PATIENTS: 357 children with and without illnesses (8-18 years, mean=10.6 years) were enrolled: 307 from paediatric research studies and 50 from dental care. MAIN OUTCOME MEASURES: We measured various generic forms of discomfort (nervousness, annoyance, pain, fright, boredom, tiredness) due to six common research procedures: buccal swabs, MRI scans, pulmonary function tests, skin prick tests, ultrasound imaging and venepunctures. RESULTS: Most children reported limited discomfort during the research procedures (means: 1-2.6 on a scale from 1 to 5). Compared with dental check-ups, buccal swab tests, skin prick tests and ultrasound imaging were less discomforting, while MRI scans, venepunctures and pulmonary function tests caused a similar degree of discomfort. 60.3% of the children suggested providing distraction by showing movies to reduce discomfort. The exploratory analyses suggested a positive association between anxiety-proneness and discomfort. CONCLUSIONS: The findings of this study support the acceptability of participation of children in the studied research procedures, which stimulates evidence-based research practice. Furthermore, the present study can be considered as a first step in providing benchmarks for discomfort of procedures in paediatric research.

Early Identification of Reading Difficulties: A Screening Strategy that Adjusts the Sensitivity to the Level of Prediction Accuracy.

Early screening for reading difficulties before the onset of instruction is desirable because it allows intervention that is targeted at prevention rather than remediation of reading difficulties. However, early screening may be too inaccurate to effectively allocate resources to those who need them. The present study compared the accuracy of early screening before the onset of formal reading instruction with late screening six months into the first year of instruction. The study followed 164 Danish students from the end of Grade 0 to the end of Grade 2. Early screening included measures of phonemic awareness, rapid naming, letter knowledge, paired associate learning, and reading. Late screening included only reading. Results indicated that reading measures improved substantially as predictors over the first six months of Grade 1, to the point where late reading measures alone provided as much information as the early measures combined. In the light of these results and a less than perfect early screening accuracy, a new strategy for screening is introduced and discussed. The strategy proposes multi-point screening with gradually increasing sensitivity to strike a balance between manageable screening procedures and outcomes and early identification of students who are most likely in need of extra resources. Copyright © 2017 John Wiley & Sons, Ltd.

How doctors diagnose diseases and prescribe treatments: an fMRI study of diagnostic salience.

Understanding the brain mechanisms involved in diagnostic reasoning may contribute to the development of methods that reduce errors in medical practice. In this study we identified similar brain systems for diagnosing diseases, prescribing treatments, and naming animals and objects using written information as stimuli. Employing time resolved modeling of blood oxygen level dependent (BOLD) responses enabled time resolved (400 milliseconds epochs) analyses. With this approach it was possible to study neural processes during successive stages of decision making. Our results showed that highly diagnostic information, reducing uncertainty about the diagnosis, decreased monitoring activity in the frontoparietal attentional network and may contribute to premature diagnostic closure, an important cause of diagnostic errors. We observed an unexpected and remarkable switch of BOLD activity within a right lateralized set of brain regions related to awareness and auditory monitoring at the point of responding. We propose that this neurophysiological response is the neural substrate of awareness of one's own (verbal) response. Our results highlight the intimate relation between attentional mechanisms, uncertainty, and decision making and may assist the advance of approaches to prevent premature diagnostic closure.

Teen Preferences for Clinic-Based Behavior Screens: Who, Where, When, and How?

PURPOSE: Previous research examining computer-based adolescent risk behavior screening was done before widespread adoption of smartphones and merits updating. METHODS: This is a cross-sectional survey among 115 adolescents seeking primary care age 12-18 years. It is a diverse sample with 59% female, 51% white, 18% African-American, and 27% Latino. Respondents were asked level of comfort and honesty (1 = strongly disagree, 5 = strongly agree) when answering health behavior questions by paper, interview, or electronic device. Differences in the level of agreement were tested using a Wilcoxon signed rank test. RESULTS: Adolescents reported a higher level of comfort and honesty for screening conducted via electronic device versus paper (90% vs. 57%, p < .001; 89% vs. 61%, p < .001). Sixty-two percent adolescents prefer waiting room electronic screening versus at home (4.7%) or by provider in the examination room (11.2%). CONCLUSIONS: Electronic same-day risk behavior screening is the preferred method for adolescents and should be incorporated into preventive services.

Propuestas de acercamiento al diagnóstico de la afectación y el padecer en la carrera de Medicina / Approach proposals to the diagnosis of affectation and suffering in the medicine career

Introducción: A pesar del tiempo transcurrido, el paradigma biologicista de atención médica no ha sido sustituido por el paradigma biopsicosocial. En el programa de la carrera no hay definición clara de los términos para que los estudiantes de Medicina en su tercer año, durante la estancia en salas de Medicina Interna se acerquen al diagnóstico de la afectación y el padecer. Objetivo: Elaborar una propuesta argumentada de acercamiento al diagnóstico de la afectación y el padecer por estudiantes de Medicina durante su estancia en salas de Medicina Interna. Material y Métodos: Se realizó una revisión narrativa de la literatura seleccionada, obtenida mediante el motor de búsqueda Google Académico y la base de datos Scielo de la Biblioteca Virtual de Salud. Resultados: El Índice de Barthel permite suficiente acercamiento al diagnóstico de la discapacidad como concepto asociado a la afectación. La respuesta emocional del paciente puede definirse como adaptativa adecuada conveniente o como inadaptativa inadecuada inconveniente para la solución de su problema de salud. Conclusiones: Se proponen términos concretos para el acercamiento al diagnóstico de la afectación y el padecer para el estudiante de Medicina(AU)

Introduction: In spite of the elapsed time the biologistic paradigm of medical attention has not been substituted by the bio psychosocial. In the careers program, there is no obvious definition of terms in order that the third year medicine students, during their stay in the Internal Medicine wards, approach to the diagnosis of affectation and suffering.Objective: Elaborate an argued proposal of approach to the diagnosis of affectation and suffering for students of medicine during his stay in Internal Medicine wards. Material and Methods: Was performed a narrative revision of the selected literature obtained by means of the computer search engine google academic and SciELO data base of the Healths Virtual Library. Results: Barthel's index enables an enough approach to the diagnosis of the disability as a correlated concept with affectation. The patient's emotional reaction can be defined as adequate adaptive -convenient or inadequate inconvenient and maladaptive for the solution of his problem of health.Conclusions: The authors propose specific terms for the approach to the diagnosis of affectation and suffering for the student of medicine(AU)

Comparative analysis of syndromic and PCR-based diagnostic assay reveals misdiagnosis/ overtreatment for trichomoniasis based on subjective judgment in symptomatic patients.

BACKGROUND: Trichomoniasis, a sexually transmitted disease (STD), is caused by Trichomonas vaginalis in both men and women. Screening of trichomoniasis is problematic in resource challenged settings as currently available, inexpensive diagnostic methods are of low sensitivity and/or specificity. In India, National AIDS Control organization (NACO) recommended syndromic case management (SCM) for treatment. The objective of the present study was to compare the utility of the NACO-NACP III Algorithms for STI/RTI treatment used by clinicians with PCR based diagnosis. METHODS: Patients visiting Department of Obstetrics & Gynecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi from January 2011 to June 2014 were enrolled in the study to compare the diagnostic efficiency of PCR-based assays against SCM. Based on SCM, patients (n = 820) were treated with antibiotics using pre-packed STI/RTI kits (sexually transmitted infection/reproductive tract infection; procured by National AIDS Control/State AIDS Control Society (NACO/SACS), Ministry of Health and Family Welfare, Govt of India.) under National AIDS Control Programme (NACP III) for syndromic case management (SCM). Ectocervical dry swab samples were also obtained from these patients and out of that 634 samples were tested by PCR. Total genomic DNA was extracted from these samples and used as template for PCR amplification using pfoB, gyrA and orf1 gene specific primers for diagnosis of T. vaginalis (TV), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) respectively. RESULTS: Out of 6000 patients who visited OPD, 820 (14 %) female patients reported vaginal discharge and were recommended antibiotic treatment for one or more pathogens namely, TV, CT, NG and Candida or for co-infection. On the basis of signs & symptoms and NACO guidelines, the following distribution of various infections was observed: TV (46 %), CT (20 %), coinfection with TV and CT (12 %), coinfection with CT and NG (11 %), coinfection with TV, CT and Candida (7 %) and coinfection with TV and NG (2 %). Others were infected with NG alone (1 %), coinfected with TV and Candida (0.4 %) and 0.3 % were coinfected with CT, NG and Candida. Based on PCR method, 110 (17 %) women tested positive for one or more of these three pathogens while 524 (83 %) women were negative for any of these three pathogens but could be positive for other STIs not tested in this study. Since all the patients (634) were given antibiotics, we estimate that the over-treatment was 85 % while 524 (83 %) patients were also misdiagnosed by SCM. CONCLUSIONS: The over-treatment and inaccurate diagnosis of pathogens due to subjective judgment based on syndromic approach in symptomatic women is a large economic wastage and may also contribute towards increased resistance. The misdiagnosed patients will also serve as a reservoir for transmission of pathogens to their sexual partner.