Action-Depicting Gestures and Morphosyntax: The Function of Gesture-Speech Alignment in the Conversational Turn.

The current study examines the role of action-depicting gestures in conversational turns by focusing on their semantic characteristics and temporal position in relation to their verbal affiliates (action verbs or more complex verb phrases). The data are video recordings of naturally occurring interactions in multilingual construction sites in Norway. The analysis distinguishes two modes of action depiction: generic depictions, which represent the action as a general type, and contextualized depictions, which in addition include deictic references to the spatio-material environment or iconic representations of the specific manner of action performance. These two modes typically occupy different positions in the turn. Generic depictions are mostly initiated before the verbalization of the action or are synchronized with it, while contextualized depictions mostly start simultaneously with the verbalization and extend beyond the verb phrase or the turn. The pre-positioned and synchronized generic gestures are shown to serve as a practice for facilitating recognition of the verbalized action and may be temporally manipulated in order to pre-empt understanding problems in the face of reduced common linguistic resources. The post-positioned contextualized depictions serve instead to add specifying information about aspects of the action referred to and thereby to complement or supplement the meaning of the verb phrase, securing understanding of action specifics. The study contributes to research on gesture-speech synchrony by demonstrating how variation in the alignment of action depiction and syntax is used to direct the recipient's attention toward different interactional goals.

Code-switching in multilinguals with dementia: patterns across speech contexts.

The study investigates code-switching by multilingual persons with dementia in two different speech contexts, picture naming tests and spontaneous conversation. It combines a psycholinguistic perspective on cognitive and linguistic skills with a qualitative conversation analytic approach to understanding the functions and appropriateness of code-switching in social interaction. The analysis shows that code-switching is used as a resource for compensating for word-retrieval problems in both the naming tests and in word search sequences in conversation. Furthermore, it serves to demarcate meta-communicative parentheses in which the participants comment on their process of word retrieval or express frustration about processing problems. Code-switching is generally treated as appropriate and relevant by the participants. In most instances, the speakers switch to a language known by the interlocutor. Only a few instances are treated as inappropriate by not being understandable to the interlocutor or by not adapting to the established language of the conversation. The patterns of code-switching are discussed considering typical symptoms of cognitive decline associated with dementia. Only very few instances may be interpreted as caused by a lack of awareness of the interlocutor's language background (associated with reduced episodic memory) or a lack of inhibition. Code-switching thereby presents itself primarily as a communicative resource for handling and overcoming another dementia-related symptom, namely anomia.

Lexical access in a bilingual speaker with dementia: Changes over time.

In this article, we explore the naming skills of a bilingual English-Norwegian speaker diagnosed with Primary Progressive Aphasia, in each of his languages across three different speech contexts: confrontation naming, semi-spontaneous narrative (picture description), and conversation, and at two points in time: 12 and 30 months post diagnosis, respectively. The results are discussed in light of two main theories of lexical retrieval in healthy, elderly speakers: the Transmission Deficit Hypothesis and the Inhibitory Deficit Theory. Our data show that, consistent with the participant's premorbid use of and proficiency in the two languages, his performance in his L2 is lower than in his L1, but this difference diminishes as the disease progresses. This is the case across the three speech contexts; however, the difference is smaller in the narrative task, where his performance is very low in both languages already at the first measurement point. Despite his word finding problems, he is able to take active part in conversation, particularly in his L1 and more so at the first measurement point. In addition to the task effect, we find effects of word class, frequency, and cognateness on his naming skills. His performance seems to support the Transmission Deficit Hypothesis. By combining different tools and methods of analysis, we get a more comprehensive picture of the impact of the dementia on the speaker's languages from an intra-individual as well as an inter-individual perspective, which may be useful in research as well as in clinical practice.

Eliciting patient preferences in shared decision-making (SDM): Comparing conversation analysis and SDM measurements.

OBJECTIVE: To explore how physicians bring up patient preferences, and how it aligns with assessments of shared decision-making. METHODS: Qualitative conversation analysis of physicians formulating hypotheses about the patient's treatment preference was compared with quantitative scores on SDM and 'patient preferences' using OPTION(5) and MAPPIN'SDM. RESULTS: Physicians occasionally formulate hypotheses about patients' preferences and then present a treatment option on the basis of that ("if you think X+we can do Y"). This practice may promote SDM in that the decisions are treated as contingent on patient preferences. However, the way these hypotheses are formulated, simultaneously constrains the patient's freedom of choice and exerts a pressure to accept the physician's recommendation. These opposing effects may in part explain cases where different assessment instruments yield large variations in SDM measures. CONCLUSION: Eliciting patient preferences is a complex phenomenon that can be difficult to reduce into an accurate number. Detailed analysis can shed light on how patient preferences are elicited, and its consequences for patient involvement. Comparing CA and SDM measurements can contribute to specifying communicative actions that SDM scores are based on. PRACTICE IMPLICATIONS: Our findings have implications for SDM communication skills training and further development of SDM measurements.

Patient involvement and language barriers: Problems of agreement or understanding?

OBJECTIVE: This study aims to explicate efforts for realizing patient-centeredness (PCC) and involvement (SDM) in a difficult decision-making situation. It investigates what communicative strategies a physician used and the immediate, observable consequences for patient participation. METHODS: From a corpus of videotaped hospital encounters, one case in which the physician and patient used Norwegian as lingua franca was selected for analysis using conversation analysis (CA). Secondary data were measures of PCC and SDM. RESULTS: Though the physician did extensive interactional work to secure the patient's understanding and acceptance of a treatment recommendation, his persistent attempts did not succeed in generating the patient's participation. In ratings of PCC and SDM, this case scored well above average. CONCLUSION: Despite the fact that this encounter displays some of the 'best actual practice' of PCC and SDM within the corpus, our analysis of the interaction shows why the strategies were insufficient in the context of a language barrier and possible disagreement. PRACTICE IMPLICATIONS: When facing problems of understanding, agreement and participation in treatment decision-making, relatively good patient centered skills may not suffice. Knowledge about the interactional realization of key activities is needed for developing training targeted at overcoming such challenges.

Negotiating treatment preferences: Physicians' formulations of patients' stance.

Eliciting patients' values and treatment preferences is an essential element in models of shared decision making, yet few studies have investigated the interactional realizations of how physicians do this in authentic encounters. Drawing on video-recorded encounters from Norwegian secondary care, the present study uses the fine-grained empirical methodology of conversation analysis (CA) to identify one conversational practice physicians use, namely, formulations of patients' stance, in which physicians summarize or paraphrase their understanding of the patient's stance towards treatment. The purpose of this study is twofold: (1) to explore what objectives formulations of patients' stance achieve while negotiating treatment and (2) to discuss these objectives in relation to core requirements in shared decision making. Our analysis demonstrates that formulating the patient's stance is a practice physicians use in order to elicit, check, and establish patients' attitudes towards treatment. This practice is in line with general recommendations for making shared decisions, such as exploring and checking patients' preferences and values. However, the formulations may function as a device for doing more than merely checking and establishing common ground and bringing up patients' preferences and views: Accompanied by subtle deprecating expressions, they work to delegitimize the patients' stances and indirectly convey the physicians' opposing stance. Once established, these positions can be used as a basis for challenging and potentially altering the patient's attitude towards the decision, thereby making it more congruent with the physician's view. Therefore, in addition to bringing up patients' views towards treatment, we argue that physicians may use formulations of patients' stance as a resource for directing the patient towards decisions that are congruent with the physician's stance in situations with potential disagreement, whilst (ostensibly) avoiding a more authoritarian or paternalistic approach.

Achievements in congenital heart defect surgery: a prospective, 40-year study of 7038 patients.

BACKGROUND: This article presents an update of the results achieved by modern surgery in congenital heart defects (CHDs) over the past 40 years regarding survival and the need for reoperations, especially focusing on the results from the past 2 decades. METHODS AND RESULTS: From 1971 to 2011, all 7038 patients <16 years of age undergoing surgical treatment for CHD at Rikshospitalet (Oslo, Norway) were enrolled prospectively. CHD diagnosis, date, and type of all operations were recorded, as was all-cause mortality until December 31, 2012. CHDs were classified as simple (3751/7038=53.2%), complex (2918/7038=41.5%), or miscellaneous (369/7037=5.2%). Parallel to a marked, sequential increase in operations for complex defects, median age at first operation decreased from 1.6 years in 1971 to 1979 to 0.19 years in 2000 to 2011. In total, 1033 died before January 1, 2013. Cumulative survival until 16 years of age in complex CHD operated on in 1971 to 1989 versus 1990 to 2011 was 62.4% versus 86.9% (P<0.0001). In the comparison of patients operated on in 2000 to 2004 versus 2005 to 2011, 1-year survival was 90.7% versus 96.5% (P=0.003), and 5-year cumulative survival was 88.8% versus 95.0% (P=0.0003). In simple versus complex defects, 434 (11.6%) versus 985 (33.8%) patients needed at least 1 reoperation before 16 years of age. In complex defects, 5-year cumulative freedom of reoperation among patients operated on in 1990 to 1999 versus 2000 to 2011 was 66% versus 73% (P=0.0001). CONCLUSIONS: Highly significant, sequential improvements in survival and reductions in reoperations after CHD surgery were seen. A future challenge is to find methods to reduce the need for reoperations and further reduce long-term mortality.

Mediastinitis after coronary artery bypass grafting increases the incidence of left internal mammary artery obstruction.

Mediastinitis after coronary artery bypass grafting (CABG) gives a longstanding chronic inflammation and has a detrimental negative effect on long-term survival. For this reason, we aimed to study the effect of mediastinitis on graft patency after CABG. The epidemiologic design was of an exposed (mediastinitis, n = 41) versus non-exposed (non-mediastinitis, controls, n = 41) cohort with two endpoints: (i) obstruction of saphenous vein grafts (SVG) and (ii) obstruction of the internal mammary artery (IMA) grafts. The graft patency was evaluated with coronary CT-angiography examination at a median follow-up of 2·7 years. The number of occluded SVG in the mediastinitis group was 18·9% versus 15·5% in the control group. Using generalized estimating equations model with exchangeable matrix, and confounding effect of ischaemic time and patients age, we found no significant association between presence of mediastinitis and SVG obstruction [rate ratio (RR) = 0·96, 95% CI (0·52-2·67), P = 0·697]. The number of occluded IMA grafts was 10·5% in the mediastinitis group and 2·4% in the control group. Using the Poisson regression model, we estimated RR = 5·48, 95% CI (1·43-21·0) and P = 0·013. There was a significant association between mediastinitis and IMA graft obstruction, when controlling for the confounding effect of ischaemic time, body mass index, presence of diabetes mellitus and the number of diseased vessels. Presence of mediastinitis increases the risk of IMA graft obstruction. This may confirm the importance of inflammation as a major contributor to the pathogenesis of atherosclerosis and explain the negative effect of mediastinitis on a long-term survival.

Mediastinitis after coronary artery bypass grafting: the effect of vacuum-assisted closure versus traditional closed drainage on survival and re-infection rate.

Mediastinitis is treated with either vacuum-assisted closure (VAC) or traditional closed drainage (TCD) with irrigation. The aim of the study was to determine the effect of the two treatments on mortality and re-infection rate in a source population, using 21 314 consecutive patients undergoing isolated coronary artery bypass grafting (CABG) from January 1997 to October 2010. Median observation time was 2·9 years in the VAC group and 8·0 years in the TCD group. The epidemiological design was of an exposed (VAC, n = 64) versus non-exposed (TCD, n = 66) cohort with two endpoints: (1) mortality and (2) failure of sternal wound healing or re-infection. The crude effect of treatment technique versus endpoint was estimated by univariate analysis. Stratification analysis by the Mantel-Haenszel method was performed to quantify confounders and to pinpoint effect modifiers. Adjustment for confounders was performed using Cox regression analysis. Mediastinitis was diagnosed 6-105 (median 14) days after primary operation in the VAC group and 13 (5-29) days in the TCD group. There was no difference between groups in long-term survival. Failure of sternal wound healing or re-infection occurred less frequently in the VAC group (6%) than in the TCD group (21%; relative risk = 0·29, 95% CI = 0·06-0·88, P = 0·01). There are concerns for increase in right ventricle rupture in VAC compared with TCD. There was no difference in survival after VAC therapy and TCD therapy of post-CABG mediastinitis. Failure of sternal wound healing or re-infection was more common after TCD therapy.

Psychiatric outcome after severe cardio-respiratory failure treated with extracorporeal membrane oxygenation: a case-series.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is increasingly used to save patients with severe cardiopulmonary failure at high risk of dying, but the long-term psychiatric outcome of the treatment has not been studied. METHODS: Twenty-eight adults who survived ECMO were subjected to psychiatric assessment 5 years after ECMO by means of interviews (MINI-Neuropsychiatric Interview and Montgomery-Åsberg Depression Rating Scale) and psychometrics [Neuroticism and social conformity (EPQ-N+L); General Health Questionnaire (GHQ), Hospital Anxiety Depression Scale; Aggression Questionnaire, Toronto Alexithymia Scale, and Giessener somatic symptom checklist (GBB)]. RESULTS: Fifteen patients (54%) suffered lifetime psychiatric disorders prior to ECMO. After ECMO, 11 subjects (39%) developed new psychiatric disorders, mostly organic mental (18%), obsessive-compulsive disorders (OCD) 15%, and/or post-traumatic stress disorders (PTSD) 11%. These 11 patients reported higher scores on Montgomery-Åsberg Depression Rating Scale (MADRS), GHQ, EPQ-N, and GBB. Disregarding the presence of psychiatric disorders at follow-up, ECMO patients reported high levels of distress, physical aggression, anger, and alexithymic traits. CONCLUSIONS: Severe life-threatening cardiovascular or pulmonary failure with subsequent ECMO is associated with an increased prevalence of long-term psychiatric disorders and distress. Studies addressing the etiology and prevalence of psychiatric consequences after ECMO are needed.

The Scandinavian multicenter hemodynamic evaluation of the SJM Regent aortic valve.

BACKGROUND: 112 patients who received small and medium sized St. Jude Regent heart valves (19-25 mm) at 7 Scandinavian centers were studied between January 2003 and February 2005 to obtain non-invasive data regarding the hemodynamic performance at rest and during Dobutamine stress echocardiography (DSE) testing one year after surgery. MATERIAL AND METHODS: 46 woman and 66 men, aged 61.8 ± 9.7 (18-75) years, were operated on for aortic regurgitation (17), stenosis (65), or mixed dysfunction (30). Valve sizes were 19 mm (6), 21 mm (33), 23 mm (41), 25 mm (30). Two patients receiving size 27 valves were excluded from the hemodynamic evaluation. Pledgets were used in 100 patients, everted mattress in 66 and simple interrupted sutures in 21. Valve orientation varied and was dependent on the surgeons' choice. 34 patients (30.4%) underwent concomitant coronary artery surgery. RESULTS: There were two early deaths (1.8%) and three late deaths, one because of pancreatic cancer. Late events during follow-up were: non structural dysfunction (1), bleeding (2), thromboembolism (2). At one year follow up 93% of the patients were in NYHA classes 1-2 versus 47.8% preoperatively. Dobutamine stress echocardiography (DSE) was performed in a total of 66 and maximal peak stress was reached in 61 patients. During DSE testing, the following statistically significant changes took place: Heart rate increased by 73.0%, cardiac output by 85.5%, left ventriclular ejection fraction by 19.6%, and maximal mean prosthetic transvalvular gradient by 133.8%, whereas the effective orifice area index did not change. Left ventricular mass fell during one year from 215 ± 63 to 197 ± 62 g (p < 0.05). CONCLUSION: The Dobutamine test induces a substantial stress, well suitable for echocardiographic assessment of prosthesis valve function and can be performed in the majority of the patients. The changes in pressure gradients add to the hemodynamic characteristics of the various valve sizes. In our patients the St. Jude Regent valve performed satisfactory at rest and under pharmacological stress situation.

Detection of left ventricular dysfunction by global longitudinal systolic strain in patients with chronic aortic regurgitation.

BACKGROUND: The purpose of this study was to investigate whether global longitudinal strain measured by two-dimensional speckle tracking echocardiography could detect incipient myocardial dysfunction in patients with chronic aortic regurgitation (AR). Disclosing left ventricular (LV) dysfunction is of decisive importance for optimal timing of surgery but challenging because of the altered loading conditions. METHODS: Forty-seven patients referred for aortic valve replacement because of chronic AR were studied, along with 31 healthy controls. Myocardial deformation as determined by longitudinal, circumferential, and radial strain was calculated using two-dimensional speckle-tracking echocardiography technique, in addition to LV volumes, dimensions, and ejection fraction. Strain values were normalized to end-diastolic volume to correct for the volume dependency of deformation. RESULTS: Global systolic longitudinal strain was significantly lower in patients with AR before surgery compared with the healthy controls (-17.5 ± 3.1% vs -22.1 ± 1.8%, P < .01), while global circumferential strain and LV ejection fraction did not differ (-21.7 ± 3.4% vs -22.6 ± 2.5%, P = .22 and 59 ± 5% vs 59 ± 6%, P = .59, respectively). However, differences between patients and controls were evident for both longitudinal and circumferential strain when normalized to end-diastolic volume (-0.09 ± 0.04 vs -0.23 ± 0.08, P < .01, and -0.11 ± 0.05 vs -0.24 ± 0.08, P < .01, respectively). In contrast to their absolute values, both normalized variables demonstrated improvement in myocardial shortening after valve replacement (P < .01). CONCLUSIONS: The study demonstrated reduced global longitudinal strain in patients with chronic AR with preserved LV ejection fractions. Global longitudinal strain might therefore disclose incipient myocardial dysfunction with a consequent potential for improved timing of aortic valve surgery.

Mediastinitis after coronary artery bypass grafting risk factors and long-term survival.

BACKGROUND: Mediastinitis is a severe complication of coronary artery bypass grafting. The aim of the present study was to determine incidence of mediastinitis, its risk factors, and its effect on early and long-term survival. METHODS: The study has a dual design, a case-control, and a retrospective cohort, using a source population of 18,532 consecutive patients who underwent coronary artery bypass grafting from January 1989 to December 2000. The closing date was February 1, 2008. Median follow-up was 10.3 (range 8.1 to 18.9) years. Patients with mediastinitis were compared with a random control group without mediastinitis issued from the same source population in a ratio 1:4. The crude effect of mediastinitis was estimated using rate ratio and 95% confidence limits. Adjustment for multiconfounders was done with the Cox model. A logistic model was used to pinpoint risk factors of mediastinitis. Calibration and discrimination of a prognostic model was done. RESULTS: One hundred seven patients (0.6%) developed mediastinitis. Diagnosis was made 12 (9 to 19) days postoperatively. Independent risk factors of mediastinitis using the logistic model were advanced age, male gender, left main stenosis, body mass index 30 kg/m(2) or greater, chronic obstructive pulmonary disease, diabetes, and increased amount of blood transfusion. There was no increased risk of early mortality (odds ratio = 0.58; 95% confidence interval 0.13 to 2.61) (p = 0.48) but there was increased risk of morbidity (intraaortic balloon pump, ventricular and supraventricular arrhythmia, stroke, inotrope, and myocardial infarction). Follow-up had a median observation time of 10.3 years. Survival for patients with mediastinitis was 49.5 +/- 5.0% versus 71.0 +/- 2.2% for controls (p < 0.01). Analysis of specific death causes documented that cardiac deaths were significantly more frequent in mediastinitis patients than in control patients. When controlling for the confounding effect of the other variables (age, cardiopulmonary bypass time, body mass index, chronic obstructive pulmonary disease), the hazard ratio associated with mediastinitis on long-term mortality was 1.59, 95% confidence limits (1.16 and 2.70) (p = 0.003). CONCLUSIONS: The incidence of mediastinitis in 18,532 patients undergoing coronary artery bypass grafting surgery was low. The major preventable risk factor of mediastinitis was amount of blood transfusion. Mediastinitis had an excess risk of early morbidity and was associated with a significant reduced long-term survival. Most deaths were considered to be cardiac.

Cost of extracorporeal membrane oxygenation: evidence from the Rikshospitalet University Hospital, Oslo, Norway.

OBJECTIVE: The main objective is to describe and analyse hospital costs of the extracorporeal membrane oxygenation (ECMO) procedure. STUDY SAMPLE AND METHODOLOGY: Between January and December 2007, 14 ECMO patients were consecutively included in the study. Costs at the patient level were registered prospectively, while overhead costs were registered retrospectively. Patient costs were obtained from patient records and time-motion studies and included personnel resources, diagnostic and laboratory tests, radiology and operating room procedures, medication and blood products. Overhead costs were allocated to clinical departments and further to the individual patients by predefined keys. To achieve estimates of total costs, patient-specific costs and patient-specified overhead costs were summarised. RESULTS: The mean estimated cost for the ECMO procedure was 73,122 USD (SD 34,786) and median 62,545 USD (range: 34,121-154,817). The mean estimated total hospital costs, including pre- and post-ECMO procedures, was 213,246 USD (SD 12,265), median 191,436 USD (range: 59,871-405,497). On average, 82% of costs for the total hospital stay were related to personnel use, and blood products constituted 7%, lab and radiology 2.5%, disposable items 3% and medication 1.5%. The mean duration of an ECMO procedure was 9.5 days (range: 4-23 days) and the average total length of stay in hospital was 51.5 days (range: 6-123 days). The cost data were converted from Norwegian kroner (NOK) to US dollars (USD), with an exchange rate of 1 USD=5.5 NOK. CONCLUSION: ECMO procedure is a resource-demanding procedure.

In vitro evaluation of PHISIO-coated sets for pediatric cardiac surgery.

OBJECTIVES: Phosphorylcholine coated cardiopulmonary bypass (CPB) circuits for children have been available for some years, but conflicting results regarding the inflammatory response have been reported. Accordingly, we aimed to investigate the effect of phosphorylcholine coating on the inflammatory response. DESIGN: Ten coated and nine uncoated pediatric CPB sets were tested in an in vitro CPB circuit model. The inflammatory response was assessed by serial assays of hemoglobin, hematocrit, leukocyte counts, platelet counts, activation of the complement system, activation of platelets measured as beta-thromboglobulin, activation of neutrophils measured as myeloperoxidase, activation of coagulation measured as prothrombin fragments 1+2, assessment of hemolysis measured as lactate dehydrogenase, and a panel of seven cytokines. Samples were obtained at baseline and after 15, 30, 60 and 120 minutes. RESULTS: There were no significant differences between the phosphorylcholine coated circuits and the uncoated circuits for any of the parameters during the observation period, although a potentially beneficial effect on platelets could not be ruled out. CONCLUSIONS: Phosphorylcholine coating of CPB equipment did not exert any beneficial effect on the inflammatory markers monitored.