Empathy in the dentist-patient relationship: review and application.

BACKGROUND AND OBJECTIVES: A review of psychology, dental, and medical literature aimed to identify key variables for an ideal dentist-patient relationship. When empathy surfaced as the key positive variable, a further aim, which became the aim of this paper, was to explore how empathy could be intentionally applied. METHODS: An online database search, limited to judgementally selected target-words, was conducted for peer-reviewed papers on the dentist-patient relationship. Review guidelines from the American Psychological Association were used to clarify concepts, identify where most work was focussed, and to explore the superiority of any approach to the topic, over another. RESULTS: The distinction between instrumental (information) and affective (emotional) communication was important with empathy being the key variable. Empathy was seen clearly to facilitate improved communication and the experience of dentistry for patient and practitioner alike. Empathy was positively associated with negotiated treatment plans, treatment adherence, increased patient satisfaction, and reduced dental anxiety. However, the concept of empathy was rarely operationally defined, or empirically measured. At best it was a scale score or a theme in qualitative data analysis. As such, applied empathy is discussed as a perceived concept. Dental school curricula and patient request forms were found to have the greatest potential to train dentists to convey empathy, and for patients to perceive empathy. CONCLUSION: Future directions are proposed, to apply empathy in the dentist-patient relationship through an integrated model of patient-centred communication.

The rationale and pilot study of a new paediatric dental patient request form to improve communication and outcomes of dental appointments.

BACKGROUND: Children's unhappy visits to the dentist can negatively impact lifelong oral health. A possible intervention is to enhance empathy in the child patient-dental practitioner relationship through communication. The present paper presents a new instrument, the Survey of Anxiety and Information for Dentists (SAID), which targets children's dental anxiety, coping preferences and dental neglect, and offers children a change to request information and engage in treatment planning. METHOD: Five children's focus groups pilot tested the content, wording and response format of a prototype patient request form, the SAID. Participants were 34 10- to 13-year-old children who individually completed the form then discussed it item by item in their small groups. RESULTS: Children had no difficulty completing most items. They identified ambiguities, and items that were meaningless to them, and proposed a new item asking the dentist about their job. Children were polarized over the response format, but they were emphatic about passing the form directly to the dentist, and not to a receptionist or assistant, stressing the importance of having a conversation with their dentist. CONCLUSIONS: Before the pilot, dentists had expressed concerns about the potential for words in the SAID-provoking negative feelings. Children, however, wanted and needed facts, so requested that dentists use plain language, not euphemisms, to describe problems and treatment options. We report their selected practical suggestions. SAID-informed negotiated care may promote more patient cooperation and satisfaction at appointments, and more attention to oral hygiene between appointments.

Post-dexamethasone cortisol correlates with severity of depression before and during carbamazepine treatment in women but not men.

OBJECTIVE: Previous studies show a state-dependent relationship between depression and post-dexamethasone suppression test (DST) cortisol level, as well as differences in DST response with age and gender. METHOD: In this study, 74 research in-patients with affective disorders were given the DST on placebo and in a subgroup following treatment with carbamazepine. Depression was evaluated twice daily with the Bunney-Hamburg (BH) rating scale. Data were examined for the total subject population, by gender and by menopausal status in women. RESULTS: A robust positive correlation was observed between depression severity and post-DST cortisol in pre- and postmenopausal females, but not in males. This relationship persisted in women when restudied on a stable dose of carbamazepine (n=42). CONCLUSION: The pathophysiological implications of this selective positive relationship between severity of depression and post-DST cortisol in women, but not men, should be explored further.

Cognitive effects of 1- and 20-hertz repetitive transcranial magnetic stimulation in depression: preliminary report.

OBJECTIVE: To determine the cognitive effects of daily repetitive transcranial magnetic stimulation (rTMS) administered under the conditions of a treatment trial for major depression. BACKGROUND: Although daily left dorsal prefrontal rTMS has improved mood in some patients with treatment-refractory depression, potential cognitive side effects of extended daily treatment have not been systematically studied. METHOD: In a randomized double-blind treatment study, 10 subjects (mean age, 42 +/- 15 years) with an episode of major depression received either 2 weeks of low-frequency (1 Hz) or high-frequency (20 Hz) rTMS (800 pulses, 20 trains over 20 minutes, 80% of motor threshold, 5 days per week) to the left dorsolateral prefrontal cortex and then were crossed over to the other treatment condition. Patients received cognitive testing at baseline and after the first and second weeks of low- or high-frequency rTMS, which was examined by repeated-measures ANOVA. RESULTS: Of 16 cognitive measures tested after 1 or 2 weeks of rTMS compared with baseline status, none showed deterioration, and the only significant main treatment effect indicated improvement on a list-recall test from pre- to post-rTMS after 1 week (p <0.05). CONCLUSIONS: These preliminary data suggest no gross deleterious cognitive effects of 2 weeks of 1- or 20-Hz rTMS at 80% of motor threshold over the left prefrontal cortex. Further cognitive studies of the effects of rTMS at other parameters used in clinical trials for mood disorders remain to be undertaken.

The increasing use of polypharmacotherapy for refractory mood disorders: 22 years of study.

BACKGROUND: Few studies have approached the subject of polypharmacotherapy systematically. This retrospective review of 178 patients with refractory bipolar disorder or unipolar depression (Research Diagnostic Criteria or DSM-III-R criteria) discharged from the National Institute of Mental Health (NIMH) Biological Psychiatry Branch between 1974 and 1996 was conducted to assess the degree and efficacy of "add-on" pharmacotherapy. METHOD: Following completion of formal structured blinded research protocols, patients entered a treatment phase (often again on a blind basis) in which all agents available in the community could be utilized. Each patient's retrospective life chart and all prospective double-blind nurse- and self-rated NIMH data were reviewed. The overall degree of improvement at discharge was assessed by rating on the Clinical Global Impressions scale (CGI) as modified for bipolar illness (CGI-BP). RESULTS: A 78% improvement rate (moderate or marked on the CGI) was achieved at the time of discharge. There was a significant relationship between number of medications utilized at discharge as a function of discharge date (r = 0.45, p < .0001). The percentages of patients discharged on treatment with 3 or more medications were 3.3% (1974-1979), 9.3% (1980-1984), 34.9% (1985-1989), and 43.8% (1990-1995). No correlation was found between polypharmacy and age (r = -0.03, p = .66). Patients more recently discharged from the NIMH had an earlier age at illness onset, more lifetime weeks depressed, and a higher rate of rapid cycling than patients in the earlier cohorts. CONCLUSION: Increasing numbers of medications in more recent NIMH cohorts were required to achieve the same degree of improvement at hospital discharge. More systematic approaches to the complex regimens required for treatment of patients with refractory mood disorder are clearly needed.

CSF thyrotropin-releasing hormone gender difference: implications for neurobiology and treatment of depression.

In light of the postulated role of thyrotropin-releasing hormone (TRH) as an endogenous anti-depressant, 56 refractory mood-disordered patients and 34 healthy adult control subjects underwent lumbar puncture for cerebrospinal fluid (CSF) TRH analysis. By two-way analysis of variance, there was no difference between CSF TRH in patients (as a group or by diagnostic subtype) and control subjects (n = 90, F = 0.91, df = 2.84, P = 0.41). There was, however, a CSF TRH gender difference (females, 2.95 pg/ml; males, 3.98 pg/ml; n = 90, F = 4.11, df = 1.84, P < 0.05). A post hoc t-test revealed the greatest gender difference in the bipolar group (t = 2.52, P < 0.02). There was no significant difference in CSF TRH in "ill" vs. "well" state (n = 20, P = 0.41). The role of elevated levels of CSF TRH in affectively ill men--or the role of decreased levels of CSF TRH in affectively ill women--remains to be investigated but could be of pathophysiological relevance.

Abnormal facial emotion recognition in depression: serial testing in an ultra-rapid-cycling patient.

Normal subjects use the right insula and bilateral anterior temporal and prefrontal cortices to recognize the emotion expressed in a human face. Mood disorder subjects have a selective deficit in recognizing human facial emotion. Brain imaging studies show that they fail to activate the right insula to the same degree as controls, even when accurately assessing facial emotion. Many issues remain, however, including whether the facial emotion recognition errors in mood disorder subjects are state dependent or persist during normal mood states (and, thus, reflect a trait abnormality). To probe this issue, we repeatedly studied a male bipolar II patient's ability to recognize faces' emotional content. This patient made significantly more errors in facial emotion recognition during the depressed state. He also demonstrated a significant negative bias when he was depressed compared with nondepressed states. This case study demonstrates the state dependency of the defect in human facial emotion recognition.

Rapid cycling bipolar affective disorder: lack of relation to hypothyroidism.

Thyroid indices were measured after an extended period of medication-free evaluation averaging 6 weeks in 67 consecutively admitted patients with bipolar illness. Thyroid hormone levels -- thyroxine (T4), free T4 and triiodothyronine (T3) -- were not significantly different in the 31 rapid cyclers (> or = 4 affective episodes/year) than in 36 non-rapid cyclers. Analysis of covariance indicated a non-significant trend relation between higher T4 and a greater number of affective episodes in the year prior to admission and male gender when age was covaried. Several previous reports, primarily in medicated subjects, have suggested a link between rapid cycling patients and decreased peripheral thyroid indices (low hormone levels and elevated TSH), but now the majority of studies do not support such a relation. Among those in the literature, this study includes patients studied for the longest time off medications and further suggests that the commonly-cited relation between subclinical hypothyroidism and rapid cycling bipolar illness be reevaluated.

Eosinophilic gastroenteritis.

Eosinophilic gastroenteritis is a rare condition of unknown etiology characterized by peripheral eosinophilia, eosinophilic infiltration of the gastrointestinal tract, and gastrointestinal symptomatology. Eosinophilic gastroenteritis is generally classified according to the layer of gastrointestinal tract involved. Mucosal involvement may result in abdominal pain, nausea, vomiting, diarrhea, weight loss, anemia, protein-losing enteropathy, and intestinal perforation. Patients with muscular layer disease generally have obstructive symptoms. Subserosal eosinophilic infiltration may result in development of eosinophilic ascites. Patients with mild and sporadic symptoms can be managed with reassurance and expectant observation. Patients with disabling symptoms can be effectively treated with corticosteroids after other systemic disorders associated with peripheral eosinophilia have been excluded. Occasionally, sodium cromolyn, ketotifen, and/or elimination diets have been shown to be effective in the management of patients who have a significant history of allergic disorder. Surgical intervention may be required in patients with obstructive complications or refractory disease.

Cerebrospinal fluid total protein in patients with affective disorders.

Cerebrospinal fluid (CSF) total protein was evaluated in 240 patients with affective disorders and compared with findings in 55 normal comparison subjects. Subtype diagnoses were as follows: bipolar I (n = 108, 47 men, 61 women); bipolar type II (n = 67, 26 men, 41 women); and unipolar (n = 65, 22 men, 43 women). Men had significantly elevated values compared with women. In men with bipolar I disorder, mean CSF protein levels were found to be significantly elevated over those in normal subjects, with 31.9% above the traditional normal range cutoff of 45 mg/dl. Moreover, CSF protein levels in male bipolar I patients were found to be positively correlated with severity of depression at the time of the lumbar puncture and with duration of illness. It thus appears that increased protein levels may be associated with illness severity or progression in male patients with bipolar I disorder. Although elevated CSF protein is a nonspecific marker of cerebral pathology, further search for the potential underlying pathophysiological mechanisms related to this finding would now appear to be warranted.

Carbamazepine increases cerebrospinal fluid thyrotropin-releasing hormone levels in affectively ill patients.

BACKGROUND: Thyrotropin-releasing hormone is an endogenous tripeptide with endocrine-independent neurophysiologic properties that may be relevant to affective or seizure disorders. We studied the effect of carbamazepine, which has both mood-stabilizing and anticonvulsant properties, on cerebrospinal fluid thyrotropin-releasing hormone levels in affectively ill patients. METHOD: Paired cerebrospinal fluid samples were collected from nine inpatients with mood disorders, both while medication free and while taking carbamazepine for an average of longer than 1 month at 950 mg/d, achieving blood levels of 8.8 mg/L. RESULTS: Carbamazepine treatment was consistently and significantly associated with increased cerebrospinal fluid thyrotropin-releasing hormone levels (P < .0001). CONCLUSION: As carbamazepine-induced increases in thyrotropin-releasing hormone levels could be relevant to either its psychotropic or anticonvulsant properties, further clinical and preclinical investigation of this finding appears indicated.

Formation of o-tyrosine and dityrosine in proteins during radiolytic and metal-catalyzed oxidation.

To evaluate their usefulness as chemical indicators of cumulative oxidative damage to proteins, we studied the kinetics and extent of formation of ortho-tyrosine (o-Tyr), dityrosine (DT), and dityrosine-like fluorescence (Ex = 317 nm, Em = 407 nm) in the model proteins RNase and lysozyme exposed to radiolytic and metal-catalyzed (H2O2/Cu2+) oxidation (MCO). Although there were protein-dependent differences, o-Tyr, DT, and fluorescence increased coordinately during oxidation of the proteins in both oxidation systems. The contribution of DT to total dityrosine-like fluorescence in oxidized proteins varied from 2-100%, depending on the protein, type of oxidation, and extent of oxidative damage. In proteins exposed to MCO, DT typically accounted for > 50% of the fluorescence at DT wavelengths. These studies indicate that o-Tyr and DT should be useful chemical markers of cumulative exposure of proteins to MCO in vitro and in vivo.

Oxidized amino acids in lens protein with age. Measurement of o-tyrosine and dityrosine in the aging human lens.

The concentrations of ortho-tyrosine (o-Tyr) and dityrosine (DT) were measured in noncataractous human lenses in order to assess the role of protein oxidation reactions in the aging of lens proteins. The measurements were conducted by selected ion monitoring-gas chromatography/mass spectrometry using deuterium-labeled internal standards, which provided both high sensitivity and specificity for the quantitation of o-Tyr and DT. Between ages 1 and 78 years, the o-Tyr concentration in lens proteins varied from 0.3 to 0.9 mmol of o-Tyr/mol of Phe (n = 19), while DT ranged from 1 to 3 mumol of DT/mol of Tyr (n = 30). There were no significant changes in levels of o-Tyr with lens age. There was a statistically significant, but only slight, increase in DT in lens proteins with age (approximately 33% increases between ages 1 and 78, r = 0.5, p < 0.01). At the same time, total protein fluorescence, measured at DT wavelengths (Ex = 317 nm, Em = 407 nm), increased 11-fold between ages 1 and 78 and correlated strongly with age (r = 0.82, p < 0.0001). Although the fluorescence maxima of lens proteins were similar to those of DT, DT accounted for less than 1% of the DT-like fluorescence in lens protein at all ages. These observations indicate that oxidation of Phe and Tyr plays a limited role in the normal aging of lens proteins in vivo.

Capillary electrophoresis/mass spectrometry determination of inorganic ions using an ion spray-sheath flow interface.

The determination of inorganic cations and anions by capillary electrophoresis/mass spectrometry (CE/MS) is reported using an ion spray-sheath flow interface coupling. A twelve-component synthetic mixture of cations which included the positive ions of K, Ba, Ca, Mn, Cd, Co, Pb, Cr, Ni, Zn, Ag, and Cu was loaded into the capillary column at levels ranging from 30 to 300 pg, separated by CE, and detected by indirect UV and in the full-scan (m/z 35-450) positive ion CE/MS mode using an aqueous buffer containing 30 mM creatinine and 8 mM alpha-hydroxyisobutyric acid, pH 4.8. Creatinine forms adducts with the cations which are observed in the gas phase and requires rather high (120 electron volts) declustering energy to dissociate. This produces a reduction in charge state to form the free, singly charged, inorganic cations which are observed in the mass spectra. CE/MS analysis of an aqueous acidic extract of used aircraft engine oil revealed high levels of lead as well as lower levels of chromium and nickel. CE-indirect UV analysis of a synthetic mixture containing 300 pg each of 11 inorganic ions, which included the anions of Br, Cl, NO2, NO3, S2O3, N3, SCN, SO4, SeO4, oxalate, and MoO4, is shown. The running buffer which affected this separation contained 5 mM ammonium dichromate, 10 mM ammonium acetate, and 20 mM diethylenetriamine at pH 9.3. Although indirect UV detection revealed good separation of these anions, CE/MS analysis of this mixture was complicated by interfering ion current signals from the cluster ions formed by the interaction between the additives and the analytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential time course of antidepressant effects after sleep deprivation, ECT, and carbamazepine: clinical and theoretical implications.

The pattern and time course of antidepressant response to different treatment modalities provide important clinical information and hints about underlying neurobiological mechanisms. Depressed patients who responded to 1 night's sleep deprivation (11 of 33 patients) showed maximal improvement on day 1 and deterioration in mood thereafter. In contrast, slower onset and more sustained effects were observed following carbamazepine (12 of 37) or electroconvulsive therapy (ECT) (8 of 8). Nearly maximal improvement required about 2 weeks for ECT and 3 weeks for carbamazepine. Possible differential or common biological mechanisms with differential times of action are implied by these data, which are of importance to the neuroscientist attempting to uncover neural substrates of antidepressant response and the clinician attempting to find rapid onset, yet sustained antidepressant treatments.

Routine hand doses vs monitoring regulations at a nuclear power plant.

Hand radiation doses to workers at a nuclear power plant were monitored in this study to evaluate compliance with dose limits and to determine whether hand monitoring on a routine basis is necessary. Two hundred in-plant workers at Carolina Power and Light Co.'s H.B. Robinson Steam Electric Generating Plant were monitored with a ring TLD dosimeter on each hand for four months during routine plant operations. Study participants included plant operators, electricians, mechanics, health physics technicians and decontamination personnel. Ring dosimeters were worn, in addition to whole-body TLD dosimeters, at all times workers were in radiation control areas. Hand dosimeters were read on the same monthly schedule as the whole-body dosimeters to ensure correlation of exposure periods. The results of the analysis of hand-dose data obtained for these workers are summarized as follows: (1) No worker's hand dose exceeded 25% of the allowable quarterly dose. (2) Ninety-nine percent of hand doses were less than 600 mrem/month. (3) The highest hand dose observed in any month was 1074 mrem which if received for three months, is below regulatory dose limits and below the dose value where monitoring is required. The highest actual hand dose observed in the last quarter of 1981 was 1335 mrem. (4) Examination of hand dose to whole-body dose ratios revealed that if the whole-body dose limit is approached, hand doses are still below the dose level where monitoring is required. (5) A linear-regression analysis of hand and whole-body dose data provides the ability to predict hand doses from the whole-body doses. From these results, it is concluded that routine monitoring of hand doses is not required at the H.B. Robinson plant. This conclusion should also be applicable to routine operations at other similar nuclear plants.

Cystitis glandularis: an unusual cause of ureteral obstruction.

Cystitis glandularis is an uncommon proliferative disease of the bladder epithelium. Involvement of the trigone, with infiltration of the submucosal ureter, may result in ureteral obstruction. We present 2 patients with biopsy-proven cystitis glandularis who presented with ureteral obstruction.