Patient-present teaching in the clinic: Effect on agency and professional behaviour.

BACKGROUND/PURPOSE: Although much has been written about the medical learning environment, the patient, who is the focus of care, is rarely the focus in this literature. The purpose of this study was to explore the role of the patient as an active participant with agency in the medical learning environment from the standpoint of the learner, the attending physician, and most importantly, the patient. We hoped to gain insights into the mechanisms that can reinforce professional values such as patient-centred and respectful behaviours in a patient-present learning environment. METHODS: We conducted this study in an ambulatory internal medicine clinic using 'patient-present' clinic visits. All case presentations occurred in examination rooms with the patient. We invited participants (attending physicians, undergraduate and postgraduate learners, patients and family members) to participate in semistructured interviews after each clinic visit to explore the impact of the patient-present learning environment. We recruited 34 participants in the study; 10 attending physicians, 12 learners, 10 patients and 2 family members. We analysed the data deductively using a conceptual framework of agency. SUMMARY/RESULTS: We identified three major insights: (1) Patients felt engaged and valued opportunities to be heard; (2) Attending physicians and learners reported a more respectful learning environment and a positive though challenging teaching and learning experience; and (3) A hidden curriculum emerged in a performance-based view of professional behaviour. CONCLUSIONS: Patient-present teaching engaged patients and enhanced their agency by recasting the patient as the central focus within the healthcare encounter. We identified a tension between performing and learning. This study adds new insights to the concept of patient centredness and professionalism from the perspectives of all participants in the medical teaching and learning environment.

S-adenosyl methionine (SAMe) for depression in adults.

BACKGROUND: Depression is a recurrent illness with high rates of chronicity, treatment-resistance and significant economic impact. There is evidence in the literature that S-adenosyl methionine (SAMe), a naturally occurring compound in the human body, has antidepressant efficacy. This product may be an important addition to the armamentarium of antidepressant agents. OBJECTIVES: To assess the effects of SAMe in comparison with placebo or antidepressants for the treatment of depression in adults. SEARCH METHODS: We searched the Cochrane Common Mental Disorders Group's Specialised Register (CCMDCTR Studies and Reference Register), MEDLINE, EMBASE, PsycINFO, international trial registers ClinicalTrials.gov and the World Health Organization trials portal (ICTRP). We checked reference lists, performed handsearching and contacted experts in the field. The CCMDCTR literature search was last updated on 5 February 2016. SELECTION CRITERIA: Randomised controlled trials comparing SAMe with placebo or antidepressants in adults with a diagnosis of major depression. DATA COLLECTION AND ANALYSIS: Two authors independently performed extraction of data and assessment of risk of bias. We contacted trialists of included studies for additional information. MAIN RESULTS: This systematic review included eight trials comparing SAMe with either placebo, imipramine, desipramine or escitalopram. We accepted trials that used SAMe as monotherapy or as add-on therapy to selective serotonin reuptake inhibitors (SSRIs), and we accepted both oral and parenteral administration. The review involved 934 adults, of both sexes, from inpatient and outpatient settings.The trials were at low risk of reporting bias. We judged the risk of selection, performance, detection and attrition bias as unclear or low, and one study was at high risk of attrition bias.There was no strong evidence of a difference in terms of change in depressive symptoms from baseline to end of treatment between SAMe and placebo as monotherapy (standardised mean difference (SMD) -0.54, 95% confidence interval (CI) -1.54 to 0.46; P = 0.29; 142 participants; 2 studies; very low quality evidence). There was also no strong evidence of a difference in terms of drop-out rates due to any reason between SAMe and placebo, when used as monotherapy (risk ratio (RR) 0.88, 95% CI 0.61 to 1.29; P = 0.52; 142 participants; 2 studies; low quality evidence).Low quality evidence showed that the change in depressive symptoms from baseline to end of treatment was similar between SAMe and imipramine, both as monotherapy (SMD -0.04, 95% CI -0.34 to 0.27; P = 0.82; 619 participants; 4 studies). There was also no strong evidence of a difference between SAMe and a tricyclic antidepressant in terms of drop-outs due to any reason (RR 0.61, 95% CI 0.28 to 1.31; P = 0.2; 78 participants; 3 studies; very low quality evidence).There was little evidence of a difference in terms of change in depressive symptoms from baseline to end of treatment between SAMe and escitalopram, both as monotherapy (MD 0.12, 95% CI -2.75 to 2.99; P = 0.93; 129 participants; 1 study; low quality evidence). There was no strong evidence of a difference between SAMe and escitalopram in terms of drop-outs due to any reason (RR 0.81, 95% CI 0.57 to 1.16; P = 0.26; 129 participants; 1 study; low quality evidence).There was low quality evidence that SAMe is superior to placebo as add-on to SSRIs in terms of change in depressive symptoms from baseline to end of treatment (MD -3.90, 95% CI -6.93 to -0.87; P = 0.01; 73 participants; 1 study). There was no strong evidence of a difference between SAMe and placebo as adjunctive therapy to an SSRI in terms of drop-outs due to any reason (RR 0.70, 95% CI 0.31 to 1.56; P = 0.38; 73 participants; 1 study; very low quality evidence).For all comparisons, secondary outcome measures of response and remission rates were consistent with these primary outcome measures.With regard to all extractable measures of the acceptability of SAMe, the quality of the evidence was low to very low. SAMe was not different from placebo and established antidepressants. The exception was that compared to imipramine, fewer participants experienced troublesome adverse effects when treated with parenteral SAMe.The specific adverse effects were not detailed in most of the included studies. There were two reports of mania/hypomania recorded for 441 participants in the SAMe arm. AUTHORS' CONCLUSIONS: Given the absence of high quality evidence and the inability to draw firm conclusions based on that evidence, the use of SAMe for the treatment of depression in adults should be investigated further. Future trials should be in the form of large randomised controlled clinical trials of high methodological quality, with particular attention given to randomisation, allocation concealment, blinding and the handling of missing data. Comparator antidepressants from all classes should be used. Adverse events should be detailed for each participant, bearing in mind that induction of mania is of particular interest.

The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review.

AIMS: This study provides a systematic review of existing research that has empirically evaluated interventions designed to reduce stigma related to substance use disorders. METHODS: A comprehensive review of electronic databases was conducted to identify evaluations of substance use disorder related stigma interventions. Studies that met inclusion criteria were synthesized and assessed using systematic review methods. RESULTS: Thirteen studies met the inclusion criteria. The methodological quality of the studies was moderately strong. Interventions of three studies (23%) focused on people with substance use disorders (self-stigma), three studies (23%) targeted the general public (social stigma) and seven studies (54%) focused on medical students and other professional groups (structural stigma). Nine interventions (69%) used approaches that included education and/or direct contact with people who have substance use disorders. All but one study indicated their interventions produced positive effects on at least one stigma outcome measure. None of the interventions have been evaluated across different settings or populations. CONCLUSIONS: A range of interventions demonstrate promise for achieving meaningful improvements in stigma related to substance use disorders. The limited evidence indicates that self-stigma can be reduced through therapeutic interventions such as group-based acceptance and commitment therapy. Effective strategies for addressing social stigma include motivational interviewing and communicating positive stories of people with substance use disorders. For changing stigma at a structural level, contact-based training and education programs targeting medical students and professionals (e.g. police, counsellors) are effective.

Nonmedical prescription opioid use and mental health and pain comorbidities: a narrative review.

OBJECTIVE: In North America, the prevalence of nonmedical prescription opioid use (NMPOU), and morbidity and mortality related to prescription opioid analgesics (POAs) has risen sharply. Epidemiologic studies have suggested a high prevalence of mental health and pain comorbidities in NMPOU samples. Given the potential importance for interventions, a narrative review was conducted on studies reporting data on the co-occurrence of NMPOU with mental health problems and pain symptoms in general, treatment, or special populations. METHOD: A search of MEDLINE, PubMed, PsycINFO, and Web of Science using defined search terms yielded 74 studies on NMPOU and mental health and (or) pain. Thirty-nine studies published between 1997 and 2009 were included in the review-based on the data they provided on NMPOU and mental health and pain comorbidities. RESULTS: Our review found strong associations between NMPOU and the comorbidities of interest. Associations between NMPOU and mental health were strongest for depression (OR range 1.2 to 4.3) followed by anxiety disorders (OR range 1.2 to 3.0) in general and treatment populations. The prevalence of pain ranged from 14.5% to 61.5% in general, treatment, and street drug user samples reporting NMPOU. CONCLUSIONS: The extensive associations observed between NMPOU and mental health and pain comorbidities suggest that effective preventive or treatment interventions for NMPOU must consider and attend to these comorbidities. As POAs are widely available and used in North America, POAs may increasingly be used in nonmedical ways for pain or mental health problems not effectively diagnosed or treated.

Self-management strategies used by 'high functioning' individuals with bipolar disorder: from research to clinical practice.

INTRODUCTION: Bipolar disorder (BD) is a complex mental illness that results in substantial costs, both at a personal and societal level. Research into BD has been driven by a strongly medical model conception, with a focus upon pathology and dysfunction. Little research to date has focused upon strategies used to maintain or regain wellness in BD. Here, we present results from a qualitative study of self-management strategies used by a Canadian sample of 'high-functioning' individuals with BD. The aims of the present paper are two-fold: (1) To provide a description of the self-management strategies identified as effective by this sample of high functioning individuals and 2) to explore these results from a clinical perspective. METHODS: High functioning (determined as a score of either 1 or 2 on the objectively-rated Multidimensional Scale of Independent Functioning) individuals with BD type I or II (N = 33) completed quantitative scales to assess depression, mania, psychosocial functioning and quality of life, and underwent either an individual interview or focus group about the self-management strategies they used to maintain or regain wellness. RESULTS: The specific self-management strategies that individuals enacted are contained within the following categories: (1) sleep, diet, rest and exercise; (2) ongoing monitoring; (3) reflective and meditative practices; (4) understanding BD and educating others; (5) connecting to others and (6) enacting a plan. These strategies are discussed in the context of current treatment interventions and research findings, offering clinicians a broad range of potential techniques or tools to assist with their efforts to support individuals with BD in maintaining or regaining wellness. CONCLUSIONS: The strategies adopted by a sample of people coping well with their BD show remarkable overlap with the targets of existing adjunctive psychosocial interventions for BD. The clinician can use this information to motivate clients to engage with such strategies. The present findings also serve to remind the clinician of significant individual differences in the personal meaning and concrete application of superficially similar strategies.

Telephone and web-based pediatric day surgery questionnaires.

PURPOSE: Patient questionnaires are popular tools for assessing and improving service quality, especially as administrators are increasingly expected to consider the patient's voice in their decision making. Despite web-based questionnaire advantages, they have not been previously compared to telephone questionnaires for assessing quality. The purpose of this paper is to compare telephone questionnaire administration with a web-based version. DESIGN/METHODOLOGY/APPROACH: Day surgery patients from a tertiary pediatric hospital completed a telephone interview and a web-based questionnaire with identical questions. The appropriateness of the web version as a telephone version substitute was ascertained by comparing the number of changes in responses, non-responses, differences in means, the number of non-substantive responses and reliability. FINDINGS: The web-based questionnaire tended towards more negative responses. The mean number of missing responses did not differ between versions, although the web-questionnaire had more "not sure" responses. Inter-rater reliability was acceptable. RESEARCH LIMITATIONS/IMPLICATIONS: Parents without internet access were unable to participate. PRACTICAL IMPLICATIONS: The web-based questionnaire is a good substitute for telephone-administered questionnaires. ORIGINALITY/VALUE: The paper shows that parents were able to rate items more candidly owing to the increase in privacy and lack of interviewer bias, which is crucial for improving health service quality.

Total intravenous anesthesia and spontaneous respiration for airway endoscopy in children--a prospective evaluation.

INTRODUCTION: Inhalational anesthesia with spontaneous respiration is traditionally used to facilitate airway endoscopy in children. The potential difficulties in maintaining adequate depth of anesthesia using inhalational anesthesia and the anesthetic pollution of the surgical environment are significant disadvantages of this technique. We report our institutional experience using total intravenous anesthesia (TIVA) and spontaneous respiration. METHODS: We prospectively studied 41 pediatric patients undergoing 52 airway endoscopies and airway surgeries. Following induction of anesthesia, a propofol infusion was titrated to a clinically adequate level of anesthesia, guided by the Bispectral Index (BIS), and a remifentanil infusion was titrated to respiratory rate. ECG, BP, pulse oximetry, BIS level, transcutaneous CO(2) (TcCO(2)), respiratory rate, and drug infusion rates were recorded. Adverse events and the response to these events were also recorded. RESULTS: Forty-one children underwent 52 airway procedures; 17 rigid bronchoscopies and 35 micro-laryngobronchoscopies, including 18 LASER treatments, were performed. The mean (sd) age was 6.9 (5.8) years and weight 26.9 (21.2) kg. The mean induction time was 13 (6) min, and anesthesia duration was 49 (30) min. The mean highest TcCO(2) recorded during the procedures was 62.8 +/- 15.3 mmHg. Coughing occurred in 14 (27%) patients, requiring additional topical anesthesia (3), a bolus of propofol (4) or remifentanil (1), or removal of the bronchoscope (1). Desaturation below 90% occurred in 10 (19%) cases; only three required intervention in the form of temporary assisted ventilation (2) or inhaled bronchodilators (1). No laryngospasm, stridor, or arrhythmias were observed. CONCLUSION: TIVA and spontaneous respiration is an effective technique to manage anesthesia for airway endoscopy and surgery in children.

What works for people with bipolar disorder? Tips from the experts.

OBJECTIVES: Little is known about how patients successfully manage their bipolar disorder (BD). This is a remarkable gap in the BD literature, given that current treatments are inadequate and information about beneficial self-management strategies could have clinical and theoretical implications. Here, we present results from a study of self-management strategies used by a sample of high-functioning individuals with BD. METHODS: The objectively rated Multidimensional Scale of Independent Functioning (MSIF) was used to confirm high functioning status (score <3) amongst a sample of individuals self-described as functioning well with BD type I or II (N=32). Participants completed quantitative scales to assess psychiatric history, current symptoms, functioning and quality of life, and underwent either an individual interview or focus group to answer open questions about the self-management strategies they used to maintain or regain wellness. RESULTS: Wellness strategies fell into the following themes: 1) Sleep, rest, exercise and diet; 2) Ongoing monitoring; 3) Enacting a plan; 4) Reflective and meditative practices; 5) Understanding BD and educating others; 6) Connecting with others. CONCLUSIONS: The wellness strategies described by the current sample have substantial overlap with those identified in the sole comparable qualitative study. They are also broadly consistent with, and serve to elaborate on proposed mechanisms of therapeutic action in adjunctive psychosocial interventions for BD. The findings constitute hopeful stories for people affected by the disorder and suggest further research to confirm and refine mechanisms of beneficial effect in BD.

Defining rules for the identification of critical ventilatory events.

PURPOSE: The automated recognition of critical clinical events by physiological monitors is a challenging task exacerbated by a lack of standardized and clinically relevant threshold criteria. The objective of this investigation was to develop consensus for such criteria regarding the identification of three ventilatory events: disconnection or significant leak in the anesthesia circuit, decreased lung compliance or increased resistance, and anesthetic overdose from inhaled anesthetics. METHODS: We individually administered a structured interview to five expert anesthesiologists to gain insight into the cognitive processes used by clinicians to diagnose ventilatory events and to determine the common heuristics (rules of thumb) used in clinical practice. We then used common themes, identified from analysis of the structured interviews, to generate questions for a series of web-based questionnaires. Using a modified Delphi technique, iterative questionnaire administration facilitated rapid consensus development on the thresholds for the specific rules used to identify ventilatory events. RESULTS: A threshold for 75% agreement was described for each scenario in a healthy ventilated adult. A disconnection or significant leak in the anesthesia circuit is diagnosed with peak airway pressure (< 5 cm H2O or change of 15 cm H2O), ETCO2 (0 mmHg, 40% drop, or value below 10 mmHg for a duration of 20 sec), and inspired-expired volume difference (300 mL). Increased resistance or decreased lung compliance is diagnosed with high peak airway pressure (40 cm H2O or a 20 cm H2O change), asymmetry of capnogram, and changes in measured compliance or resistance. Anesthetic overdose from inhaled anesthetics is diagnosed with high end-tidal anesthetic agent concentration (2 MAC in a patient less than 60 yr of age or 1.75 MAC in a patient over 60 yr of age), low systolic blood pressure (below 60 mmHg), and low modified electroencephalogram (bispectral index or entropy). CONCLUSION: This investigation has provided a set of consensus-based criteria for developing rules for the identification of three critical ventilatory events and has presented insight into the decision heuristics used by clinicians.

Relationship between age and spontaneous ventilation during intravenous anesthesia in children.

BACKGROUND: Maintaining spontaneous ventilation in children, using total intravenous anesthesia (TIVA), is often desirable, particularly for airway endoscopy. The aim of this study was to evaluate the effect of age on the dose of remifentanil tolerated during spontaneous ventilation under anesthesia maintained with infusions of propofol and remifentanil and to provide guidelines for the administration of remifentanil and propofol to maintain spontaneous ventilation in children. METHODS: Forty-five children scheduled for strabismus surgery were divided by age into three groups (group I: 6 months-3 years, group II: 3 years-6 years, and group III: 6 years-9 years). The propofol infusion was titrated using State Entropy as a pharmacodynamic endpoint and remifentanil infused, using a modified up-and-down method, with respiratory rate depression as a pharmacodynamic endpoint. A respiratory rate of just greater than 10, stable for 10 min, determined the final remifentanil infusion rate. The group mean was estimated from the final remifentanil infusion rate tolerated (RD(50)). RESULTS: The RD(50) of groups I, II, and III were 0.192 (0.08), 0.095 (0.04), and 0.075 (0.03) microg x kg(-1) x min(-1) respectively. Pair-wise comparisons between the groups for the rate of remifentanil tolerated revealed a statistically significant increase in the RD(50) in children less than 3 years of age compared with older children in groups II and III (P < 0.001). The relationship between remifentanil dose and age, weight or height was not linear. CONCLUSIONS: Younger children, especially those aged less than 3 years, tolerate a higher dose of remifentanil while still maintaining spontaneous respiration. TIVA with spontaneous ventilation is readily achieved in younger children and infants.

Measuring the quality of pediatric day surgery care.

This brief report describes the process of developing a valid and reliable questionnaire for quality measurement of pediatric day surgery care from the families' perspective. Questionnaire items were generated through a literature search and interviews with clinicians and parents. A computer-assisted telephone interview was used to administer the questionnaire to 448 parents within 72 hours of patient discharge. Tests of reliability and validity were administered, and questionnaire items were improved or omitted based on the results. The investigators plan to readminister the improved questionnaire to confirm its validity and reliability.