Treatment of periprosthetic femoral fractures following total hip arthroplasty: results of an online survey of the European Hip Society.

BACKGROUND: Periprosthetic femoral fractures (PPF) are a devastating complication after total hip arthroplasty (THA). Both trauma and adult reconstruction surgeons or combined teams treat these fractures following management algorithms. The aim of this study is to investigate the current treatment of PPF by members of the European Hip Society (EHS). METHODS: An online survey of the members of the European Hip Society (EHS) was conducted. 20 cases of periprosthetic fracture were presented and surgeons were asked to answer questions regarding classification, treatment and postoperative treatment protocol. RESULTS: A total of 132 (130 male; 2 female) EHS members responded. Mean years in surgical practice was 18.8 (min. 1 year; max. 50 years). The preferred surgical method was combined open reduction and internal fixation (ORIF) (30.3%) for AG fractures, ORIF with cables (30.4%) for AL fractures, combined ORIF (cable and plate) for B1 fractures (49.2%), stem revision with cables for B2 fractures (73.1%), stem revision with cables for B3 (55.9%) fractures and combined ORIF (cable and plate: 55.5%) for C fractures. Surprisingly, 10.8% suggested various stem revision techniques for B1 and 17.4% for C fractures. Strong variations were observed regarding postoperative weight-bearing protocol. CONCLUSIONS: A strong consensus was found for the choice of conservative or surgical treatment of the different PPF types according to the Vancouver Classification. Various stem revision techniques were the preferred surgical techniques for Vancouver B2 (91.2%) and B3 (88.6%) fractures. However, for postoperative weight-bearing, when the ORIF technique was used, a significant variation of protocols was found.

Improving patient-centered communication: Results of a randomized controlled trial.

OBJECTIVE: Patient-centered communication is a key element for improving the quality of care in terms of therapeutic relationship, patient participation, and treatment process. Postgraduate trainings provide an essential way of promoting patient centeredness on the job where learning opportunities are often limited by time, patient volume, and economic pressure. In the present study, changes in patient centeredness during clinical routines of postgraduate physicians (internal medicine) after a three-day communication training were assessed. METHODS: A randomized controlled trial was conducted in a primary care clinic. The intervention consisted of a communication training that aimed to enhance patient centeredness in postgraduate physicians. The training was based on a need assessment and the principles of deliberate practice. Workplace-based assessment of physicians' communication behavior was obtained using the Roter Interaction Analysis System. RESULTS: Three months after the intervention, trained physicians showed significantly increased patient centeredness (F=5.36, p=.04; d=0.42). CONCLUSION: The communication training significantly improved patient centeredness during routine clinical practice. Thus, this training provides a structured and theory-based concept to foster patient centeredness. PRACTICE IMPLICATIONS: The results support the implementation of communication trainings as a part of faculty development and medical specialization training.

[Integrated Peer Teaching of Communication and Clinical Skills: How to Train Student Tutors?]. / Integriertes Peer Teaching klinischer und kommunikativer Kompetenzen: Wie bereiten wir studentische Tutoren darauf vor?

AIM: This paper describes the theory-based development of a standardized training model for peer tutors. The aim is to qualify tutors to teach communication skills integrated with practical clinical skills, to medical students in the pre-clinical curriculum. As a result, students are encouraged to form a basic understanding of the biopsychosocial model of diseases early in their studies. METHOD: The training model's design is based on the Kern model for curriculum development as adapted by McLean et al., who outlined the following steps: planning, implementation, and evaluation/feedback. Our focus is on development, review of feasibility, and evaluation as measured by the subjectively perceived effectiveness of the implemented training model. 2 target groups were considered: the peer tutors and the student tutees. RESULTS: In 2009, a 3-step training model consisting of 12 units was developed, based on the theory of patient-centered communication and the biopsychosocial model. The training was rated very positively on a 5-point Likert scale by all tutors at 2 points in time: t1 (directly after training) and t2 (after conducting 2 tutorials) (t1: M=1.67; SD=±0.86; t2: M=1.75; SD=±0.71). On a 6-point Likert scale, the tutees also evaluated their communication and clinical skills as being significantly better after completing the 10 tutorials (t2: scale for interaction and communication: M=4.81; SD: 1.09; scale for clinical examination: M=4.99; SD: 0.85) than before the tutorials (t0: scale for communication and interaction: M=3.18; SD=1.15; scale for clinical examination: M=2.88; SD: 1.09). CONCLUSIONS: By implementing a standardized tutor training model, one can qualify peer tutors to teach communication skills integrated with practical clinical skills during the pre-clinical phase. Practice teaching of the curricular material via role playing, tutorial simulation and an extensive feedback session, along with the definition of clinical standards for recording case histories and performing examinations, have proven themselves to be core elements of effective tutor training.

Doing good or bad: How interactions between action and emotion expectations shape the sense of agency.

The emotional consequences of our own and others' actions can influence our agentive self-awareness in social contexts. Positive outcomes are usually linked to the self and used for self-enhancement, whereas negative outcomes are more often attributed to others. In most situations, these causal attribution tendencies seem to be immediately present instead of involving reflective interpretations of the action experience. To address the question at which level of the cognitive hierarchy emotions and action perception interact, we adopted a social reward anticipation paradigm. Here, participants or their interaction partner received positive or negative action outcomes and performed speeded attribution choices regarding causation of the action outcome. Event-Related Potential (ERP) results showed that the emotional value of an outcome already influenced the classical N1 self-attenuation effect, with reduced embodied agentive self-awareness for negative outcomes at initial sensorimotor stages. At the level of the N300, the degree of updating and affective evaluation associated with the respective attributive decision was reflected and particularly associated to attribution tendencies for positive events. Our results show an early interaction between emotion and agency processes, and suggest that self-serving cognition can be grounded in embodied knowledge from low-level sensorimotor mechanisms.

Agency in the sensorimotor system and its relation to explicit action awareness.

People generally have a strong and immediate intuition whether they are the author of an action or not. Nevertheless, recent psychological studies focused on situations of ambiguous agency. These studies concluded that agency is an inference rather than a direct perception, and is, at least sometimes, illusory. Moreover, shared representations of executed and merely observed actions within the sensorimotor system pose a challenge to the idea that a sense of agency can be grounded within that system. Here, we sought to investigate whether the human motor system is indeed sensitive to whether observed actions are linked to agency or not. In addition, we investigated whether the mere observation of an action has comparable effects on low-level, sensorimotor measures of agency, and on high-level, explicit representations of agency. To this end, we instructed participants to make simple manual movements, and manipulated the temporal correspondence between the movement that they made and the movement that they observed. Motor-evoked potentials to single-pulse TMS were taken as a low-level, sensorimotor measure of agency. To assess explicit representations of agency, participants verbally judged whether or not the observed movement temporally corresponded to the movement they executed. The results showed that corticospinal excitability varied with the degree of temporal correspondence of the executed and observed movements. Moreover, explicit agency judgments could be predicted from corticospinal excitability. This suggests that explicit judgments of agency could be directly based on information within the sensorimotor system.

A preliminary study of motivational interviewing as a prelude to intensive treatment for an eating disorder.

BACKGROUND: Engaging patients with an eating disorder in change is difficult and intensive treatment programs have high drop-out rates. The purpose of the study was to determine whether Motivational Interviewing (MI) in the form of a brief, pre-treatment intervention would be associated with higher completion rates in subsequent intensive treatment for an eating disorder. Thirty-two participants diagnosed with an eating disorder participated in the study. All participants were on the waitlist for admission to an intensive, hospital-based treatment program. Sixteen participants were randomly assigned to four individual sessions of MI that began prior to entrance into the treatment program (MI condition) and 16 participants were assigned to treatment as usual (control condition). The main outcome was completion of the intensive treatment program. Participants also completed self-report measures of motivation to change. RESULTS: Participants in the MI condition were significantly more likely to complete intensive treatment (69% completion rate) than were those in the control condition (31%). CONCLUSIONS: MI can be a useful intervention to engage individuals with severe eating disorders prior to participation in intensive treatment. MI as a brief prelude to hospital-based treatment for an eating disorder may help to improve completion rates in such programs. Further research is required to determine the precise therapeutic mechanisms of change in MI.

Vicarious action preparation does not result in sensory attenuation of auditory action effects.

The perception of sensory effects generated by one's own actions is typically attenuated compared to the same effects generated externally. However, it is unclear whether this specifically relates to self-generation. Recent studies showed that sensory attenuation mainly relies on action preparation, not actual action execution. Hence, an attenuation of sensory effects generated by another person might occur if these actions can be anticipated and thus be prepared for. Here, we compared the perceived loudness of sounds generated by one's own actions and actions of another person that either could or could not be anticipated. We found an attenuation of the perceived loudness for self- as compared to other-generated sounds. This difference was independent of whether the sound-eliciting actions of the other person could be anticipated or not. Thus, sensory attenuation seems to be specifically tied to self-generation instead of being a secondary effect of agent-independent preparation for an upcoming action.

Believing and perceiving: authorship belief modulates sensory attenuation.

Sensory attenuation refers to the observation that self-generated stimuli are attenuated, both in terms of their phenomenology and their cortical response compared to the same stimuli when generated externally. Accordingly, it has been assumed that sensory attenuation might help individuals to determine whether a sensory event was caused by themselves or not. In the present study, we investigated whether this dependency is reciprocal, namely whether sensory attenuation is modulated by prior beliefs of authorship. Participants had to judge the loudness of auditory effects that they believed were either self-generated or triggered by another person. However, in reality, the sounds were always triggered by the participants' actions. Participants perceived the tones' loudness attenuated when they believed that the sounds were self-generated compared to when they believed that they were generated by another person. Sensory attenuation is considered to contribute to the emergence of people's belief of authorship. Our results suggest that sensory attenuation is also a consequence of prior belief about the causal link between an action and a sensory change in the environment.

A prospective study of predictors of relapse in anorexia nervosa: implications for relapse prevention.

Anorexia nervosa (AN) is a serious psychiatric disorder with a high rate of relapse. The goal of this study was to identify predictors of relapse in adult AN using a prospective, longitudinal design. Participants were 100 AN patients who had successfully completed specialized inpatient/day treatment, were weight-restored to a body mass index (BMI) of at least 20 for a minimum of 2 weeks, and reported less than one binge-purge (BP) episode over the previous 28 days at the end of treatment. Predictor variables included baseline demographic and clinical features, behavioral and psychological changes during treatment, residual psychopathology at post-treatment, and motivation to recover. Results indicated that 41% of participants relapsed during the 1-year follow-up period. The highest risk period for relapse was between 4 and 9 months post-treatment. Predictors of relapse included: the BP subtype of AN, severity of checking behaviors at pre-treatment, decrease in motivation to recover during treatment, and lower motivation to recover at post-treatment. These findings suggest that individuals with the BP subtype of AN are particularly susceptible to relapse. Increasing and maintaining motivation to recover during acute treatment may have an important impact on long-term outcome.

When sounds become actions: higher-order representation of newly learned action sounds in the human motor system.

In the absence of visual information, our brain is able to recognize the actions of others by representing their sounds as a motor event. Previous studies have provided evidence for a somatotopic activation of the listener's motor cortex during perception of the sound of highly familiar motor acts. The present experiments studied (a) how the motor system is activated by action-related sounds that are newly acquired and (b) whether these sounds are represented with reference to extrinsic features related to action goals rather than with respect to lower-level intrinsic parameters related to the specific movements. TMS was used to measure the correspondence between auditory and motor codes in the listener's motor system. We compared the corticomotor excitability in response to the presentation of auditory stimuli void of previous motor meaning before and after a short training period in which these stimuli were associated with voluntary actions. Novel cross-modal representations became manifest very rapidly. By disentangling the representation of the muscle from that of the action's goal, we further showed that passive listening to newly learnt action-related sounds activated a precise motor representation that depended on the variable contexts to which the individual was exposed during testing. Our results suggest that the human brain embodies a higher-order audio-visuo-motor representation of perceived actions, which is muscle-independent and corresponds to the goals of the action.

The self in social interactions: sensory attenuation of auditory action effects is stronger in interactions with others.

The experience of oneself as an agent not only results from interactions with the inanimate environment, but often takes place in a social context. Interactions with other people have been suggested to play a key role in the construal of self-agency. Here, we investigated the influence of social interactions on sensory attenuation of action effects as a marker of pre-reflective self-agency. To this end, we compared the attenuation of the perceived loudness intensity of auditory action effects generated either by oneself or another person in either an individual, non-interactive or interactive action context. In line with previous research, the perceived loudness of self-generated sounds was attenuated compared to sounds generated by another person. Most importantly, this effect was strongly modulated by social interactions between self and other. Sensory attenuation of self- and other-generated sounds was increased in interactive as compared to the respective individual action contexts. This is the first experimental evidence suggesting that pre-reflective self-agency can extend to and is shaped by interactions between individuals.

The self in action effects: selective attenuation of self-generated sounds.

The immediate experience of self-agency, that is, the experience of generating and controlling our actions, is thought to be a key aspect of selfhood. It has been suggested that this experience is intimately linked to internal motor signals associated with the ongoing actions. These signals should lead to an attenuation of the sensory consequences of one's own actions and thereby allow classifying them as self-generated. The discovery of shared representations of actions between self and other, however, challenges this idea and suggests similar attenuation of one's own and other's sensory action effects. Here, we tested these assumptions by comparing sensory attenuation of self-generated and observed sensory effects. More specifically, we compared the loudness perception of sounds that were either self-generated, generated by another person or a computer. In two experiments, we found a reduced perception of loudness intensity specifically related to self-generation. Furthermore, the perception of sounds generated by another person and a computer did not differ from each other. These findings indicate that one's own agentive influence upon the outside world has a special perceptual quality which distinguishes it from any sort of external influence, including human and non-human sources. This suggests that a real sense of self-agency is not a socially shared but rather a unique and private experience.

Nonfat phobic anorexia nervosa: clinical characteristics and response to inpatient treatment.

OBJECTIVE: The aim of this study was to compare patients admitted to a specialized inpatient program for anorexia nervosa (AN) with and without a fear of weight gain in terms of specific eating disorder symptoms, general psychopathology, and treatment outcome. METHOD: Measures of specific and general psychopathology were administered at admission to and discharge from the inpatient program. Of the 138 participants, 81% (n = 112) were categorized as having clinical levels of "fear of weight gain" and 19% (n = 26) were categorized as having subclinical levels of this feature. RESULTS: The subclinical-level group had lower scores on measures of eating disorder psychopathology, depression, general psychiatric disturbance, and obsessive-compulsive symptomatology, but higher self-esteem scores. There were no differences found in terms of age of onset of AN, duration of illness, AN subtype, body mass index, or treatment outcome. DISCUSSION: The current findings provide evidence that underweight patients who deny a fear of weight gain are less disturbed in terms of both eating disorder pathology and general psychopathology.

Predictors of excessive exercise in anorexia nervosa.

OBJECTIVE: The aim of the present study was to replicate and amalgamate findings from previous research into a comprehensive regression model predicting excessive exercise in individuals with anorexia nervosa (AN). METHOD: Participants were 153 patients admitted to an inpatient treatment program for AN. Excessive exercise status was defined as a minimum of 1 hour of obligatory exercise aimed at controlling shape and weight, 6 days per week in the month before admission. RESULTS: Thirty-four percent (n = 52) of participants met criteria for excessive exercise. A logistic regression was conducted with excessive exercise status as the dependent variable and a number of variables previously found to be predictors of excessive exercise entered as independent variables on the same step. The overall regression model was statistically significant (P < .0005) and explained 31% of the variance in exercise status. Higher levels of dietary restraint (P = .03), depression (P = .04), and self-esteem (P = .02); lower levels of obsessive-compulsive symptomatology (P = .04); and the restricting subtype of AN (P = .03) were significantly associated with excessive exercise. CONCLUSIONS: Excessive exercise is associated with a number of independent psychologic and behavioral variables, some that suggest a negative impact and others that suggest positive effects.

Roughness perception during the rubber hand illusion.

Watching a rubber hand being stroked by a paintbrush while feeling identical stroking of one's own occluded hand can create a compelling illusion that the seen hand becomes part of one's own body. It has been suggested that this so-called rubber hand illusion (RHI) does not simply reflect a bottom-up multisensory integration process but that the illusion is also modulated by top-down, cognitive factors. Here we investigated for the first time whether the conceptual interpretation of the sensory quality of the visuotactile stimulation in terms of roughness can influence the occurrence of the illusion and vice versa, whether the presence of the RHI can modulate the perceived sensory quality of a given tactile stimulus (i.e., in terms of roughness). We used a classical RHI paradigm in which participants watched a rubber hand being stroked by either a piece of soft or rough fabric while they received synchronous or asynchronous tactile stimulation that was either congruent or incongruent with respect to the sensory quality of the material touching the rubber hand. (In)congruencies between the visual and tactile stimulation did neither affect the RHI on an implicit level nor on an explicit level, and the experience of the RHI in turn did not cause any modulations of the felt sensory quality of touch on participant's own hand. These findings first suggest that the RHI seems to be resistant to top-down knowledge in terms of a conceptual interpretation of tactile sensations. Second, they argue against the hypothesis that participants own hand tends to disappear during the illusion and that the rubber hand actively replaces it.

The selective mGlu5 receptor antagonist MTEP, similar to NMDA receptor antagonists, induces social isolation in rats.

It has repeatedly been shown that uncompetitive N-methyl-D-aspartate (NMDA) receptor antagonists can mimic certain aspects of positive and negative symptoms of schizophrenia in human volunteers and laboratory animals. The purpose of the present study was to expand these findings and to determine whether the selective metabotropic glutamate receptor subtype 5 (mGluR5) antagonist, MTEP (3-[(2-methyl-1,3-thiazol-4-yl)ethynyl]pyridine), could induce similar effects in Wistar rats. First, MTEP (1.0-10.0 mg/kg; intraperitoneally) after acute and subchronic (daily for 5 days) administration as well as the uncompetitive antagonists of the NMDA receptor of either high affinity, phencyclidine (0.5-4.0 mg/kg; subcutaneously (s.c.)) and (+)-MK-801 (0.03-0.25 mg/kg; s.c.), or low-moderate affinity, ketamine (2.0-16.0 mg/kg; s.c.) and memantine (0.15-20.0 mg/kg; s.c.), following daily administration for 3 days were tested in the social interaction test to determine their ability to reproduce the negative and positive symptoms measured by social isolation and stereotyped behavior, respectively. Second, the compounds were tested in the motility test following acute administration to determine their ability to induce locomotor hyperactivity reflecting the positive symptoms. In line with previous findings, all examined NMDA receptor antagonists produced social interaction deficits, locomotor hyperactivity, and stereotypy except memantine. Notably, this study found that MTEP following both acute and subchronic administration dose-dependently induced social isolation, but did not cause either locomotor hyperactivity or stereotypy. These data demonstrate that social behavior deficits in rats can be caused by both the blockade of the NMDA receptor and the inhibition of mGluR5, whereas mGluR5 antagonists may not independently be able to mimic the positive symptoms.

Partial serotonergic denervation decreases progenitor cell proliferation in the adult rat hippocampus, but has no effect on rat behavior in the forced swimming test.

It has been hypothesized that impaired serotonin (5-HT) neurotransmission contributes to the pathophysiology of depression. Recently, it was shown in adult animals that antidepressants which influence 5-HT levels increase hippocampal progenitor cell proliferation, suggesting an important role of the 5-HT system in the regulation of adult neurogenesis. In this study, we investigated the effects of partial 5-HT denervation of the adult rat forebrain caused by a single para-chloroamphetamine (PCA) administration (10 mg/kg, s.c.) on hippocampal progenitor cell proliferation measured by Ki-67 immunohistochemistry over a 3-week time period. Moreover, behavior of rats was analyzed by using the forced swimming test which serves as a so-called animal model of depression. One week after PCA administration, a significant decrease of Ki-67 immunopositive cells and cell clusters (-25% and -53%, respectively) was found which was recovered over the 3-week period. The decrease in progenitor cell proliferation in the dentate gyrus per animal was positively correlated with the 5-HT denervation. Behavioral analysis of rats revealed no significant differences between vehicle and PCA-treated animals at any of the examined time points. These findings indicate a regulative role of 5-HT for hippocampal progenitor cell proliferation and neurogenesis, but its relation to animal models of depression remains to be elucidated.