Tapping the Potential of Resilience to Support an Integrated and Person-Centred Approach to Health and Wellbeing-Developing a Simple Assessment Tool for Practice.

(1) Background: The push towards population health management and the need for new approaches in health services delivery focusing on the prevention and management of chronic diseases has helped in advocating for more person-centred care, and thus for integration of physical and mental health. Resilience plays a key role in supporting sustainable lifestyle changes and promoting health and wellbeing, but most assessment tools available today are too long for widespread use. The purpose of this paper is to describe the development of a new diagnostic tool to capture a person's resilience and resources. (2) Methods: This paper outlines the interrelatedness of different theories of salutogenesis, social determinants of health and health promotion with resilience and establishes resilience as a key enabler to promote health and wellbeing. (3) Results: A new, short questionnaire is proposed based on the triade of evidence-based medicine, which should be easy to use and give a good assessment of a person's resilience. (4) Conclusions: There are many reasons why the call for a short and easy-to-use assessment tool for resilience is warranted. In view of the international transition towards integrated, person-centred health systems, such a tool would find many usages. It would also support the strategies to tackle multi-morbidity, complex conditions and the social determinants of health in its focus on strengthening an individual's ability to cope with adverse events, and actively engage in health promotion and community involvement programmes. The next step is to test the tool in practice and validate it.

Case Report: Dynamic Interdependencies Between Complementary and Alternative Medicine (CAM) Practice, Urinary Interleukin-6 Levels, and Fatigue in a Breast Cancer Survivor.

Background: This study investigated the influence of complementary and alternative medicine (CAM) techniques (i.e., Jin Shin Jyutsu, music, physiotherapy, Tai Chi, and energy healing) on urinary interleukin-6 (IL-6) levels and fatigue in a 49-year-old breast cancer survivor suffering from cancer-related fatigue and depression. Data were sampled under conditions of "life as it is lived." Methods: For 28 days, a female breast cancer survivor collected her full urine output in 12-h intervals from about 8 a.m. to 8 p.m. and from about 8 p.m. to 8 a.m. These urine samples were used to determine urinary IL-6 levels through ELISA and creatinine concentrations via HPLC. In 12-h intervals (every morning and evening), the patient completed the DIARI, which included fatigue measurement and notes on incidents and activities such as CAM practice. In addition, the patient was interviewed weekly to identify meaningful everyday incidents. In this context, CAM practice was also discussed. Time series analysis consisted of ARIMA modeling and cross-correlational analyses (p < 0.05). Results: When each CAM technique was considered separately in time series analysis, CAM was consistently associated with increases in urinary IL-6 release and decreases in fatigue. Furthermore, when all CAM techniques experienced as positive were included in one time series, a biphasic urinary IL-6 response pattern was found in which CAM practice was first preceded by decreases in IL-6 by 12-0 h and then followed by increases in IL-6 after 108-120 h. Finally, cross-correlations between IL-6 and fatigue showed that increases in IL-6 were followed by decreases in fatigue intensity after 48-60 h and, conversely, that decreases in fatigue intensity were followed by decreases in IL-6 after 24-36 h and 48-60 h. Conclusion: IL-6 increases and fatigue decreases highlight potential health-promoting effects of CAM practice. Moreover, a cyclic IL-6 pattern in response to all CAM activities experienced as positive underscores that CAM was meaningful to the patient. Additionally, a negative feedback circuit between IL-6 and fatigue intensity was detected. Taken together, this study confirms the necessity of integrating subjective meaning and dynamic complexity into biopsychosocial research in order to understand human functioning under real-life conditions.

NeoAct: A Randomized Prospective Pilot Study on Communication Skill Training of Neonatologists.

Background: This randomized interventional study evaluated the impact of a 1-day experiential communication skills training on neonatologists' performance in doctor-parents-communication. Methods: 17 neonatologists with different levels of professional experience from the Medical University of Vienna were randomized into one of two study groups: The intervention group (IG) as opposed to the control group (CG) participated in a 1-day experiential communication training. Eight weeks after the training, participants' communication skills were assessed during an objective structured clinical examination (OSCE). Neonatologists were assessed in a simulated conversation by how effectively they performed when conveying complex health-related information to parents of ill infants. Participants in the control group (CG) were assessed first during the OSCE and received their communication training later on. Self-assessment questionnaires before and after the workshop and OSCE were completed. Results: The study determined that neonatologists in the IG subjectively perceived that their competence level regarding their communication skills had increased after the workshop, while this was not reflected by their performance during the OSCE assessment. Discussion: A 1-day experiential communication skills training significantly increased physicians' self-evaluation concerning their communicative competence. This perceived competence did not manifest itself in increased communication skills during the OSCE. Conclusion: Repeated training is needed.

Patients and staff perceptions of cancer patients' quality of life.

BACKGROUND: Discrepancies exist in estimation of quality of life (QL) by patients and caregivers but underlying factors are incompletely characterised. METHODS: QL of 153 patients was estimated by themselves, by 70 nurses and by 53 physicians in a cross-sectional study. Variables which could influence inter-rater agreement were evaluated. RESULTS: Inter-rater agreement of QL was fair (r = .292) between patients and nurses and between patients and physicians (r = .154). Inter-rater agreement with nurses was significantly lower concerning fatigue and pain for patients with a Karnofsky Index <50 when compared to patients with a KI > 50. Their inter-rater agreement with physicians was significantly lower for fatigue, pain and physical functioning. Agreement on the degree of anxiety was significantly (p = .009) better for female patients. Agreement on the need for social assistance (p = .01) and physical functioning (p = .03) was significantly better for male patients. Agreement with patients on their physical functioning was significantly (p = .03) better for male nurses and male physicians (r = .944) than for female nurses and female physicians (r = .674). CONCLUSIONS: Our study showed that estimation of overall QL of patients by professional caregivers is inaccurate. Inter-rater agreement was influenced by KI of patients, by gender of patients and caregivers and by professional experience of nurses.

Psychological stress assessment of patients suffering from prostate cancer.

OBJECTIVE: The aim of this study was to assess the psychological distress of men with prostate cancer (PC) throughout the whole process from initial diagnosis to therapy and to evaluate patients' tolerance regarding treatment delay. MATERIAL AND METHODS: This prospective study, performed between July 2007 and March 2010, evaluated the psychological distress of 28 men who underwent prostate biopsy (PB), who were confronted with a cancer diagnosis and were about to undergo radical prostatectomy (RP). Three evaluation points were defined: E1, immediately before PB; E2, after definitive diagnosis and when RP was scheduled; and E3, on the day of admission for RP. RESULTS: Emotional distress was highest before PB, declining significantly until RP (p = 0.02). Symptoms of depression and anxiety were low at all evaluation points, with anxiety rising significantly after cancer diagnosis (p = 0.008). Concerns about postoperative erectile dysfunction and incontinence were registered at all evaluation points. Concerns about the effect on their partnership due to PC were low. The patient's tolerable waiting time for RP differed significantly from daily practice. CONCLUSIONS: Anxiety and depression as well as concerns about a negative effect on their partnership were shown to play a minor role in patients during the interval between PB and RP, while distress and concerns about erectile dysfunction and urinary incontinence were more prevalent. Support from the patient's medical and social environment and a sound partnership may have a protective effect on emotional status. Waiting time for surgery exceeded the patients' tolerated time-frames and may further contribute to the psychological distress of PC.

Attitudes towards palliative care in primary metastatic cancer: a survey among oncologists.

Oncologists differ widely in their attitudes towards palliative care and services. These attitudes depend on a number of individual and society-based variables. It is recommended that palliative care be started early in the disease trajectory of patients with a life-threatening disease but in Austria we lack data on oncologists' adherence to this recommendation. We surveyed 785 oncologists in Austria by presenting the clinical course of a hypothetical patient with primary metastatic breast cancer from diagnosis until death. The majority of oncologists would involve palliative care services when the patient's Karnofsky index (KI) was < 50, and hospice services when the KI was < 40. Special training in palliative care was significantly associated with early use of hospice services. Reasons for not involving palliative care and hospice services earlier than indicated were systematically evaluated and included, among others, "fear of destroying the patient's hopes" (36% of respondents with regard to palliative services, 57% with regard to hospices). Overall, 67% of the oncologists would inform the patient about the malignant nature of her disease and the anticipated limitation of her life expectancy at the time of diagnosis. Issuing an advance directive would be discussed by only 25% at that time. Our data show that oncologists involve palliative care services at an advanced stage of disease in patients with primary metastatic cancer and that information about malignancy and the incurable nature of the disease is not uniformly provided at the time of diagnosis.

Attitudes of patients with malignancies towards completion of advance directives.

AIM: The purpose of advance directives (AD) is to preserve the patient's autonomy at the end of his/her life. In a cohort study, we investigated attitudes towards AD in hospitalized patients with malignant disease. MATERIALS AND METHODS: All patients were informed about the basic features of AD in a standardized manner by a single independent physician. One hundred and eight (39 women, 69 men; mean age 56.6 +/- 14.9 years) of 140 invited patients completed the study. MAIN RESULTS: Five percent of patients (5/108) already had an AD; 85% (92/108) did not wish to issue an AD. "Full confidence in physicians" (22%) and "not important for me at the moment" (15%) were the most frequently stated reasons for not issuing an AD. Only 10% (11/108) of patients decided to complete an AD. Their decision was not related to a specific diagnosis or a number of socio-demographic variables that were studied. Patients who decided in favor of an AD had significantly higher Hospital Anxiety and Depression Scale (HADS-D) score than those who decided against it (HADS-D, 8.3 +/- 5.0 vs.5.8 +/- 4.1, p = 0.035). The patients' HADS depression score was negatively associated with their Karnofsky index (r = -0.232, p = 0.017). CONCLUSIONS: Our data reveal a scarce demand for AD in our population of hospitalized cancer patients. Patients who wanted to issue an AD had a high HADS-D, which is associated with a low performance status.

[Doctor-patient-communication in an oncological outpatient department. A linguistic study of communication problems]. / "Seitdem mir der Arzt gesagt hat 'Tumor' - Das war's." : Arzt-Patient-Kommunikation an der onkologischen Ambulanz. Eine sprachwissenschaftliche Pilotstudie zu Problemen der Verständigung.

Recognising and attending to patients' most relevant issues and main concerns are the basis for patient-oriented work. This qualitative study investigates the ways in which doctors communicate with their patients. The method of study is conversation and discourse analysis. The source of data are audio recordings of 20 introductory medical consultations in an oncological outpatient department in Austria. In a macro-analytical approach the duration of verbal contribution as well as the topics mentioned are analyzed. Results show that 34% of the consultation time is used for activities other than the actual doctor-patient-communication. Furthermore, the share of patients' verbal contribution was found to be half that of the doctor. Much room is given to information about chemotherapy, less is dedicated to topics like the stages of the illness and the hope for recovery. The micro-analytical approach shows that patients keep trying to allude to topics which are especially relevant to them. This happens very subtly and implicitly by means of interactional markings of relevance. These are communicative and interactive methods such as a change in volume or in speech patterns, the use of strong metaphors or hesitation phenomena. Doctors, however, often give insufficient attention to such initiatives from patients and follow their own, often institutionally-related, pre-requisites. Drawing on two examples, this article shows how insufficient attention to patient-relevant issues results in a lower quality of doctor-patient-communication, and lower satisfaction of patients and doctors. Two positive examples show that adequate attention to patient-relevant issues is possible and increases quality of doctor-patient-communication, as well as participants' satisfaction. It is argued that insufficient attention to patient-relevant issues also reduces time efficiency.

[Shedding tears in hospitals - a survey of medical staff and students]. / Tränen im Krankenhaus - eine Bestandsaufnahme unter Arzten, Pflegepersonal und Medizinstudenten.

A questionnaire was used to investigate the crying behavior of medical personnel and medical students in Austrian hospitals. The results from 275 respondents show that shedding tears occurs relatively frequently. Main reasons were dying patients and having to give bad news. Explicitly negative reactions are rare. Attitudes towards crying are generally tolerant, although physicians tend to be more restrictive/(reserved?).