Vaginal Myomectomy Using the Dührssen (Longitudinal Median Cervical) Incision: A Case Series of 19 Patients.

STUDY OBJECTIVE: To examine demographics and outcome measures of women having undergone vaginal excision of myomas through the Dührssen (longitudinal median cervical) incision. DESIGN: Prospective case series (Canadian Task Force classification II-3). SETTING: A London teaching hospital. PATIENTS: Nineteen patients with either a submucous myoma (type 1) located near the cervix or a pedunculated intracavity myoma (type 0), excised via the Dührssen incision. INTERVENTIONS: Dührssen (median longitudinal) incision on the anterior or posterior cervical lip. MEASUREMENTS AND MAIN RESULTS: Duration of procedures, intraoperative complications, estimated blood loss, length of stay, percent of patients discharged in 24 hours, and readmission rates were studied. Between 2009 and 2016, 19 women had their myomas (submucous type 1, n = 17; pedunculated intracavity type 0, n = 2) removed vaginally with the Dührssen incision. The median age at time of procedure was 46 years (range, 43-55), and the most common indication was menorrhagia, which occurred in 90% of cases. The median myoma size was 7 cm (range, 6-9), whereas the median duration of surgery was 60 minutes (range, 40-120). Anterior cervical incisions were performed in 60% of cases, and 20% of the patients received gonadotropins for medical debulking of the myomas before surgery. One patient sustained a bladder injury that occurred when making the anterior cervical incision. The median length of stay was 8 hours (range, 6-36) and the median estimated blood loss was 90 mL (range, 50-150). The median duration of follow-up was 4 years (range, .5-6), and no patients had symptoms that were attributable to the procedure. CONCLUSION: This is a useful technique that complements a minimally invasive surgeon's repertoire and is a viable alternative when hysteroscopic myomectomy is deemed unsuitable because of location and size of the myomas.

Patients' Perspective on the Value of Medication Management Appointments.

OBJECTIVES: There is ongoing concern that psychiatric medication management appointments add little value to care. The present study attempted to address this concern by capturing depressed patients' views and opinions about the value of psychiatric medication management appointments. METHODS: Seventy-eight semi-structured interviews were performed with white and African American depressed patients post medication management appointments. These interviews tapped patients' views and opinions about the value of attending medication management appointments. ANALYSIS: An iterative thematic analysis was performed. FINDINGS: Patients reported greater appointment value when appointments included obtaining medications, discussing the need for medication changes or dose adjustments, and discussing the impact of medications on their illness. Additionally, greater appointment value was perceived by patients when there were non-medical conversations about life issues, immediate outcomes from the appointment such as motivation to continue in care, and specific qualities of providers that were appealing to patients. CONCLUSIONS: Patients' perceived value of psychiatric medication management appointments is complex. Though important patient outcomes are obtaining medicine and perceiving improvement in their mental health, there are other valued appointment and provider factors. Some of these other valued factors embedded within medication management appointments could have therapeutic properties. These findings have implications for future clinical research and service delivery.

Appointment length, psychiatrists' communication behaviors, and medication management appointment adherence.

OBJECTIVE: The authors explored the relationship between critical elements of medication management appointments (appointment length, patient-centered talk, and positive nonverbal affect among providers) and patient appointment adherence. METHODS: The authors used an exploratory, cross-sectional design employing quantitative analysis of 83 unique audio recordings of split treatment medication management appointments for 46 African-American and 37 white patients with 24 psychiatrists at four ambulatory mental health clinics. All patients had a diagnosis of depression. Data collected included demographic information; Patient Health Questionnaire-9 scores for depression severity; psychiatrist verbal and nonverbal communication behaviors during medication management appointments, identified by the Roter Interaction Analysis System during analysis of audio recordings; and appointment adherence. Bivariate analyses were employed to identify covariates that might influence appointment adherence. Generalized estimating equations (GEEs) were employed to assess the relationship between appointment length, psychiatrist patient-centered talk, and positive voice tone ratings and patient appointment adherence, while adjusting for covariates and the clustering of observations within psychiatrists. Wald chi square analyses were used to test whether all or some variables significantly influenced appointment adherence. RESULTS: GEE revealed a significant relationship between positive voice tone ratings and appointment adherence (p=.03). Chi square analyses confirmed the hypothesis of a positive and significant relationship between appointment adherence and positive voice tone ratings (p=.03) but not longer visit length and more patient-centered communication. CONCLUSIONS: The nonverbal conveyance of positive affect was associated with greater adherence to medication management appointments by depressed patients. These findings potentially have important implications for communication skills training and adherence research.

Psychiatrist-patient verbal and nonverbal communications during split-treatment appointments.

OBJECTIVE: This study characterized psychiatrist and patient communication behaviors and affective voice tones during pharmacotherapy appointments with depressed patients at four community-based mental health clinics where psychiatrists provided medication management and other mental health professionals provided therapy ("split treatment"). METHODS: Audiorecordings of 84 unique pairs of psychiatrists and patients with a depressive disorder were analyzed with the Roter Interaction Analysis System, which identifies 41 discrete speech categories that can be grouped into composites representing broad conceptual communication domains. Cluster analysis identified psychiatrist communication patterns. T test and chi square analyses compared the clusters for verbal dominance, affective voice tone, and characteristics of psychiatrist and patients. RESULTS: On average, 53% of psychiatrist talk was devoted to partnering and relationship building, and 67% of patient talk was about biomedical subjects, such as depression symptoms, and psychosocial information giving. Psychiatrist communication patterns were characterized by two clusters, a biomedical-centered cluster that emphasized biomedical questions (η²=.22, df=82, p<.001) and education or counseling (η²=.20, df=82, p<.001) and a patient-centered cluster focused on psychosocial and lifestyle questions (η²=.24, df=82, p<.001) and information giving (η²=.17, df=82, p<.001). The patient-centered cluster was associated with patients' expression of distress, anger, or other negative affects (t=3.22, df= 82, p=.002). CONCLUSIONS: Psychiatrists devoted much of their talk to partnering and relationship building while maintaining a focus on symptoms or psychosocial issues. However, patient behaviors did not reflect a similar level of partnering. Future studies should identify psychiatrist communication behaviors that activate collaborative patient communications or improve treatment outcomes.

Speech-independent production of communicative gestures: evidence from patients with complete callosal disconnection.

Recent neuropsychological, psycholinguistic, and evolutionary theories on language and gesture associate communicative gesture production exclusively with left hemisphere language production. An argument for this approach is the finding that right-handers with left hemisphere language dominance prefer the right hand for communicative gestures. However, several studies have reported distinct patterns of hand preferences for different gesture types, such as deictics, batons, or physiographs, and this calls for an alternative hypothesis. We investigated hand preference and gesture types in spontaneous gesticulation during three semi-standardized interviews of three right-handed patients and one left-handed patient with complete callosal disconnection, all with left hemisphere dominance for praxis. Three of them, with left hemisphere language dominance, exhibited a reliable left-hand preference for spontaneous communicative gestures despite their left hand agraphia and apraxia. The fourth patient, with presumed bihemispheric language representation, revealed a consistent right-hand preference for gestures. All four patients displayed batons, tosses, and shrugs more often with the left hand/shoulder, but exhibited a right hand preference for pantomime gestures. We conclude that the hand preference for certain gesture types cannot be predicted by hemispheric dominance for language or by handedness. We found distinct hand preferences for specific gesture types. This suggests a conceptual specificity of the left and right hand gestures. We propose that left hand gestures are related to specialized right hemisphere functions, such as prosody or emotion, and that they are generated independently of left hemisphere language production. Our findings challenge the traditional neuropsychological and psycholinguistic view on communicative gesture production.

Hemispheric specialisation for imitation of hand-head positions and finger configurations: a controlled study in patients with complete callosotomy.

Several studies of patients with unilateral brain damage and a patient with spontaneous callosal disconnection [Journal of Neurology, Neurosurgery, and Psychiatry 61 (1996) 176; Neuropsychologia 37 (1999) 559; Neuropsychologia 39 (2001) 1432] suggest that the imitation of positions of the hand relative to the head is a strongly lateralised left hemispheric function. In contrast, the imitation of finger configurations draws on resources of both hemispheres with a predominance of the right hemisphere. While these findings suggest a specific pattern of imitation impairment in split-brain patients, thus far, no imitation deficits have been reported in split-brain patients. Three patients with complete callosotomy and two control groups, four patients with partial callosotomy and 10 healthy subjects, imitated hand-head positions and finger configurations with non-lateralised and tachistoscopic stimulus presentation. In addition, the influence of visual control on the imitation performance was examined. One split-brain patient showed the predicted dissociation as she had severe right hemispheric deficit in imitating hand-head positions, while finger configuration imitation was preserved. The other two split-brain patients had no impairment in hand-head position imitation. Withdrawal of visual control significantly deteriorated imitation of finger configurations in the split-brain group, but not in the controls, demonstrating that the split-brain patients relied heavily on visual control as a compensatory strategy indicating an imitation deficit in the separate hemispheres. The findings question the previously held belief that in split-brain patients both hemispheres are perfectly capable of imitating gestures and that imitation is not dependent on hemispherically specialised functions.

Effect of camera resolution and bandwidth on facial affect recognition.

This preliminary study explored the effect of camera resolution and bandwidth on facial affect recognition, an important process and clinical variable in mental health service delivery. Sixty medical students and mental health-care professionals were recruited and randomized to four different combinations of commonly used teleconferencing camera resolutions and bandwidths: (1) one chip charged coupling device (CCD) camera, commonly used for VHSgrade taping and in teleconferencing systems costing less than $4,000 with a resolution of 280 lines, and 128 kilobytes per second bandwidth (kbps); (2) VHS and 768 kbps; (3) three-chip CCD camera, commonly used for Betacam (Beta) grade taping and in teleconferencing systems costing more than $4,000 with a resolution of 480 lines, and 128 kbps; and (4) Betacam and 768 kbps. The subjects were asked to identify four facial affects dynamically presented on videotape by an actor and actress presented via a video monitor at 30 frames per second. Two-way analysis of variance (ANOVA) revealed a significant interaction effect for camera resolution and bandwidth (p = 0.02) and a significant main effect for camera resolution (p = 0.006), but no main effect for bandwidth was detected. Post hoc testing of interaction means, using the Tukey Honestly Significant Difference (HSD) test and the critical difference (CD) at the 0.05 alpha level = 1.71, revealed subjects in the VHS/768 kbps (M = 7.133) and VHS/128 kbps (M = 6.533) were significantly better at recognizing the displayed facial affects than those in the Betacam/768 kbps (M = 4.733) or Betacam/128 kbps (M = 6.333) conditions. Camera resolution and bandwidth combinations differ in their capacity to influence facial affect recognition. For service providers, this study's results support the use of VHS cameras with either 768 kbps or 128 kbps bandwidths for facial affect recognition compared to Betacam cameras. The authors argue that the results of this study are a consequence of the VHS camera resolution/bandwidth combinations' ability to improve signal detection (i.e., facial affect recognition) by subjects in comparison to Betacam camera resolution/bandwidth combinations.

A longitudinal study of neuropsychological change in individuals with Parkinson's disease.

OBJECTIVES: Neuropsychological changes in individuals with Parkinson's disease (PD) were studied longitudinally. METHODS: Sixty-nine idiopathic PD patients, with Mini-Mental State Examination (MMSE) scores falling within normal range, and 37 elderly control participants were given neuropsychological tests twice approximately two years apart. RESULTS: The PD group performed poorer than the control group on Semantic Fluency, Letter Fluency, Modified Wisconsin Card Sorting Task, and Block Design at test time 1. Two years later, the PD group showed significant decline in Semantic and Letter Fluency. A subset of 12 PD patients declined in mental status by second testing (>4 MMSE points). Cox proportional-hazards models were used to see if any baseline measures were associated with relative risk of decline in mental status. In the final model, Repetition performance and Age were significantly associated with cognitive decline. CONCLUSIONS: Consistent with previous studies, executive function tasks were those most susceptible to disease progression.

A longitudinal study of neuropsychological change in individuals with Parkinson's disease.

Neuropsychological changes in individuals with Parkinson's disease (PD) were studied longitudinally. Sixty-nine idiopathic PD patients, with Mini-Mental State Examination (MMSE) scores falling within normal range, and 37 elderly control participants were given neuropsychological tests twice approximately two years apart. The PD group performed poorer than the control group on Semantic Fluency, Letter Fluency, Modified Wisconsin Card Sorting Task, and Block Design at test time 1. Two years later, the PD group showed significant decline in Semantic and Letter Fluency. A subset of 12 PD patients declined in mental status by second testing (> or =4 MMSE points). Cox proportional-hazards models were used to see if any baseline measures were associated with relative risk of decline in mental status. In the final model, Repetition performance and Age were significantly associated with cognitive decline. Consistent with previous studies, executive function tasks were those most susceptible to disease progression.

Pantomime to visual presentation of objects: left hand dyspraxia in patients with complete callosotomy.

Investigations of left hand praxis in imitation and object use in patients with callosal disconnection have yielded divergent results, inducing a debate between two theoretical positions. Whereas Liepmann suggested that the left hemisphere is motor dominant, others maintain that both hemispheres have equal motor competences and propose that left hand apraxia in patients with callosal disconnection is secondary to left hemispheric specialization for language or other task modalities. The present study aims to gain further insight into the motor competence of the right hemisphere by investigating pantomime of object use in split-brain patients. Three patients with complete callosotomy and, as control groups, five patients with partial callosotomy and nine healthy subjects were examined for their ability to pantomime object use to visual object presentation and demonstrate object manipulation. In each condition, 11 objects were presented to the subjects who pantomimed or demonstrated the object use with either hand. In addition, six object pairs were presented to test bimanual coordination. Two independent raters evaluated the videotaped movement demonstrations. While object use demonstrations were perfect in all three groups, the split-brain patients displayed apraxic errors only with their left hands in the pantomime condition. The movement analysis of concept and execution errors included the examination of ipsilateral versus contralateral motor control. As the right hand/left hemisphere performances demonstrated retrieval of the correct movement concepts, concept errors by the left hand were taken as evidence for right hemisphere control. Several types of execution errors reflected a lack of distal motor control indicating the use of ipsilateral pathways. While one split-brain patient controlled his left hand predominantly by ipsilateral pathways in the pantomime condition, the error profile in the other two split-brain patients suggested that the right hemisphere controlled their left hands. In the object use condition, in all three split-brain patients fine-graded distal movements in the left hand indicated right hemispheric control. Our data show left hand apraxia in split-brain patients is not limited to verbal commands, but also occurs in pantomime to visual presentation of objects. As the demonstration with object in hand was unimpaired in either hand, both hemispheres must contain movement concepts for object use. However, the disconnected right hemisphere is impaired in retrieving the movement concept in response to visual object presentation, presumably because of a deficit in associating perceptual object representation with the movement concepts.