Communicating and Dealing with Uncertainty in General Practice: The Association with Neuroticism

Background

Diagnostic reasoning in primary care setting where presented problems and patients are mostly unselected appears as a complex process. The aim was to develop a questionnaire to describe how general practitioners (GPs) deal with uncertainty to gain more insight into the decisional process. The association of personality traits with medical decision making was investigated additionally.

Methods

Raw items were identified by literature research and focus group. Items were improved by interviewing ten GPs with thinking-aloud-method. A personal case vignette related to a complex and uncertainty situation was introduced. The final questionnaire was administered to 228 GPs in Germany. Factorial validity was calculated with explorative and confirmatory factor analysis. The results of the Communicating and Dealing with Uncertainty (CoDU) – questionnaire were compared with the scales of the ‘Physician Reaction to Uncertainty’ (PRU) questionnaire and with the personality traits which were determined with the Big Five Inventory (BFI-K).

Results

The items could be assigned to four scales with varying internal consistency, namely ‘communicating uncertainty’ (Cronbach alpha 0.79), ‘diagnostic action’ (0.60), ‘intuition’ (0.39) and ‘extended social anamnesis’ (0.69). Neuroticism was positively associated with all PRU scales ‘anxiety due to uncertainty’ (Pearson correlation 0.487), ‘concerns about bad outcomes’ (0.488), ‘reluctance to disclose uncertainty to patients’ (0.287), ‘reluctance to disclose mistakes to physicians’ (0.212) and negatively associated with the CoDU scale ‘communicating uncertainty’ (−0.242) (p<0.01 for all). ‘Extraversion’ (0.146; p<0.05), ‘agreeableness’ (0.145, p<0.05), ‘conscientiousness’ (0.168, p<0.05) and ‘openness to experience’ (0.186, p<0.01) were significantly positively associated with ‘communicating uncertainty’. ‘Extraversion’ (0.162), ‘consciousness’ (0.158) and ‘openness to experience’ (0.155) were associated with ‘extended social anamnesis’ (p<0.05).

Conclusion

The questionnaire allowed describing the diagnostic decision making process of general practitioners in complex situations. Personality traits are associated with diagnostic reasoning and communication with patients, which might be important for medical education and quality improvement purposes.     

PARTAKE Survey of Public Knowledge and Perceptions of Clinical Research in India

Background

A public that is an informed partner in clinical research is important for ethical, methodological, and operational reasons. There are indications that the public is unaware or misinformed, and not sufficiently engaged in clinical research but studies on the topic are lacking. PARTAKE – Public Awareness of Research for Therapeutic Advancements through Knowledge and Empowerment is a program aimed at increasing public awareness and partnership in clinical research. The PARTAKE Survey is a component of the program.

Objective

To study public knowledge and perceptions of clinical research.

Methods

A 40-item questionnaire combining multiple-choice and open-ended questions was administered to 175 English- or Hindi-speaking individuals in 8 public locations representing various socioeconomic strata in New Delhi, India.

Results

Interviewees were 18–84 old (mean: 39.6, SD±16.6), 23.6% female, 68.6% employed, 7.3% illiterate, 26.3% had heard of research, 2.9% had participated and 58.9% expressed willingness to participate in clinical research. The following perceptions were reported (% true/% false/% not aware): ‘research benefits society’ (94.1%/3.5%/2.3%), ‘the government protects against unethical clinical research’ (56.7%/26.3%/16.9%), ‘research hospitals provide better care’ (67.2%/8.7%/23.9%), ‘confidentiality is adequately protected’ (54.1%/12.3%/33.5%), ‘participation in research is voluntary’ (85.3%/5.8%/8.7%); ‘participants treated like ‘guinea pigs’’ (20.7%/53.2%/26.0%), and ‘compensation for participation is adequate’ (24.7%/12.9%/62.3%).

Conclusions

Results suggest the Indian public is aware of some key features of clinical research (e.g., purpose, value, voluntary nature of participation), and supports clinical research in general but is unaware of other key features (e.g., compensation, confidentiality, protection of human participants) and exhibits some distrust in the conduct and reporting of clinical trials. Larger, cross-cultural surveys are required to inform educational programs addressing these issues.     

Appealing to Altruism is Not Enough: Motivators for Participating in Health Services Research

this pilot study sought to identify motivators and barriers to participating in a longitudinal survey; we interviewed patients and practitioners at a multidisciplinary primary care clinic where the proposed project would be based. While altruism motivates participation in medical research, we found that for many potential participants, the opportunity to benefit directly was the primary, and sometimes the only motive to participate or encourage participation in the research project. Patients often wanted direct feedback from their individual results, and they expected to provide consent before the results were forwarded to other parties such as their practitioners. Similarly, some practitioners were more likely to support the project if participation benefited patients directly. Other factors were also identified that influenced the acceptability and perceived risks and benefits of participating. More work is needed to understand these motivators and how patients might benefit directly from participating in health services research, especially when direct medical benefit is not possible.     

How Possibly Do Leisure and Social Activities Impact Mental Health of Middle-Aged Adults in Japan?: An Evidence from a National Longitudinal Survey

Objectives

This study aimed to investigate longitudinal relations between leisure and social activities and mental health status, considering the presence or absence of other persons in the activity as an additional variable, among middle-aged adults in Japan. This study used nationally representative data in Japan with a five-year follow-up period.

Methods

This study focused on 16,642 middle-aged adults, age 50–59 at baseline, from a population-based, six-year panel survey conducted by the Japanese Ministry of Health, Labour and Welfare. To investigate the relations between two leisure activities (‘hobbies or cultural activities’ and ‘exercise or sports’) and four social activities (‘community events’, ‘support for children’, ‘support for elderly individuals’ and ‘other social activities’) at baseline and mental health status at follow-up, multiple logistic regression analysis was used. We also used multiple logistic regression analysis to investigate the association between ways of participating in these activities (‘by oneself’, ‘with others’, or ‘both’ (both ‘by oneself’ and ‘with others’)) at baseline and mental health status at follow-up.

Results

Involvement in both leisure activity categories, but not in social activities, was significantly and positively related to mental health status in both men and women.Furthermore, in men, both ‘hobbies or cultural activities’ and ‘exercise or sports’ were significantly related to mental health status only when conducted ‘with others’. In women, the effects of ‘hobbies or cultural activities’ on mental health status were no differences regardless of the ways of participating, while the result of ‘exercise or sports’ was same as that in men.

Conclusions

Leisure activities appear to benefit mental health status among this age group, whereas specific social activities do not. Moreover, participation in leisure activities would be effective especially if others are present. These findings should be useful for preventing the deterioration of mental health status in middle-aged adults in Japan.     

Promoting Help-Seeking in Response to Symptoms amongst Primary Care Patients at High Risk of Lung Cancer: A Mixed Method Study

BackgroundLung cancer symptoms are vague and difficult to detect. Interventions are needed to promote early diagnosis, however health services are already pressurised. This study explored symptomology and help-seeking behaviours of primary care patients at ‘high-risk’ of lung cancer (≥50 years old, recent smoking history), to inform targeted interventions.MethodsMixed method study with patients at eight general practitioner (GP) practices across south England. Study incorporated: postal symptom questionnaire; clinical records review of participant consultation behaviour 12 months pre- and post-questionnaire; qualitative participant interviews (n = 38) with a purposive sample.ResultsA small, clinically relevant group (n = 61/908, 6.7%) of primary care patients was identified who, despite reporting potential symptoms of lung cancer in questionnaires, had not consulted a GP ≥12 months. Of nine symptoms associated with lung cancer, 53.4% (629/1172) of total respondents reported ≥1, and 35% (411/1172) reported ≥2. Most participants (77.3%, n = 686/908) had comorbid conditions; 47.8%, (n = 414/908) associated with chest and respiratory symptoms. Participant consulting behaviour significantly increased in the 3-month period following questionnaire completion compared with the previous 3-month period (p = .002), indicating questionnaires impacted upon consulting behaviour. Symptomatic non-consulters were predominantly younger, employed, with higher multiple deprivation scores than their GP practice mean. Of symptomatic non-consulters, 30% (18/61) consulted ≤1 month post-questionnaire, with comorbidities subsequently diagnosed for five participants. Interviews (n = 39) indicated three overarching differences between the views of consulting and non-consulting participants: concern over wasting their own as well as GP time; high tolerance threshold for symptoms; a greater tendency to self-manage symptoms.ConclusionsThis first study to examine symptoms and consulting behaviour amongst a primary care population at ‘high- risk’ of lung cancer, found symptomatic patients who rarely consult GPs, might respond to a targeted symptom elicitation intervention. Such GP-based interventions may promote early diagnosis of lung cancer or other comorbidities, without burdening already pressurised services.     

‘What Do I Know? Should I Participate?’ Considerations on Participation in HIV Related Research among HIV Infected Adults in Bangalore,South India

Background

India has the highest number of HIV infected persons in the world after South Africa. Much HIV related behavioral, clinical and laboratory based research is ongoing in India. Yet little is known on Indian HIV patients'' knowledge of research, their processes of decision making and motives for participation. We aimed to explore these areas among HIV infected individuals to understand their reasons for participating in research.

Methodology/Principal Findings

This is a cross sectional survey among 173 HIV infected adults at a tertiary level hospital in Bangalore, India, done between October 2010 and January 2011. A pre-tested questionnaire was administered to the participants by trained research assistants to assess their knowledge regarding research, willingness to participate, decision making and determinants of participation. Participants were presented with five hypothetical HIV research studies. Each study had a different level of intervention and time commitment. Of respondents, 103(60%), said that research meant ‘to discover something new’ and 138(80%) were willing to participate in research. A third of the respondents were unaware of their right to refuse participation. Willingness to participate in research varied with level of intervention. It was the lowest for the hypothetical study involving sensitive questions followed by the hypothetical drug trial; and was the highest for the hypothetical cross sectional questionnaire based study (p<0.0015). Individual health benefits and altruism were the primary motives for participation in research and indicate the presence of therapeutic misconception. Women were less likely to make autonomous decisions for participation in interventional studies.

Conclusions/Significance

Despite a majority willing to participate, over a third of respondents did not have any knowledge of research or the voluntary nature of participation. This has ethical implications. Researchers need to focus on enabling potential research participants understand the concepts of research, promote autonomous decisions, especially by women and restrict therapeutic misconception.     

Species,Habitats, Society: An Evaluation of Research Supporting EU's Natura 2000 Network

The Natura 2000 network is regarded as one of the conservation success stories in the global effort to protect biodiversity. However, significant challenges remain in Natura 2000 implementation, owing to its rapid expansion, and lack of a coherent vision for its future. Scientific research is critical for identifying conservation priorities, setting management goals, and reconciling biodiversity protection and society in the complex political European landscape. Thus, there is an urgent need for a comprehensive evaluation of published Natura 2000 research to highlight prevalent research themes, disciplinary approaches, and spatial entities. We conducted a systematic review of 572 scientific articles and conference proceedings focused on Natura 2000 research, published between 1996 and 2014. We grouped these articles into ‘ecological’ and ‘social and policy’ categories. Using a novel application of network analysis of article keywords, we found that Natura 2000 research forms a cohesive small-world network, owing to the emphasis on ecological research (79% of studies, with a strong focus on spatial conservation planning), and the underrepresentation of studies addressing ‘social and policy’ issues (typically focused on environmental impact assessment, multi-level governance, agri-environment policy, and ecosystem services valuation). ‘Ecological’ and ‘social and policy’ research shared only general concepts (e.g., Natura 2000, Habitats Directive) suggesting a disconnection between these disciplines. The UK and the Mediterranean basin countries dominated Natura 2000 research, and there was a weak correlation between number of studies and proportion of national territory protected. Approximately 40% of ‘social and policy’ research and 26% of ‘ecological’ studies highlighted negative implications of Natura 2000, while 21% of studies found positive social and biodiversity effects. We emphasize the need for designing inter- and transdisciplinary research in order to promote a social-ecological understanding of Natura 2000, and advance EU conservation policies.     

Using the International Classification of Functioning,Disability and Health (ICF) to Describe Children Referred to Special Care or Paediatric Dental Services

Children in dentistry are traditionally described in terms of medical diagnosis and prevalence of oral disease. This approach gives little information regarding a child’s capacity to maintain oral health or regarding the social determinants of oral health. The biopsychosocial approach, embodied in the International Classification of Functioning, Disability and Health - Child and Youth version (ICF-CY) (WHO), provides a wider picture of a child’s real-life experience, but practical tools for the application of this model are lacking. This article describes the preliminary empirical study necessary for development of such a tool - an ICF-CY Core Set for Oral Health. An ICF-CY questionnaire was used to identify the medical, functional, social and environmental context of 218 children and adolescents referred to special care or paediatric dental services in France, Sweden, Argentina and Ireland (mean age 8 years ±3.6yrs). International Classification of Disease (ICD-10) diagnoses included disorders of the nervous system (26.1%), Down syndrome (22.0%), mental retardation (17.0%), autistic disorders (16.1%), and dental anxiety alone (11.0%). The most frequently impaired items in the ICF Body functions domain were ‘Intellectual functions’, ‘High-level cognitive functions’, and ‘Attention functions’. In the Activities and Participation domain, participation restriction was frequently reported for 25 items including ‘Handling stress’, ‘Caring for body parts’, ‘Looking after one’s health’ and ‘Speaking’. In the Environment domain, facilitating items included ‘Support of friends’, ‘Attitude of friends’ and ‘Support of immediate family’. One item was reported as an environmental barrier – ‘Societal attitudes’. The ICF-CY can be used to highlight common profiles of functioning, activities, participation and environment shared by children in relation to oral health, despite widely differing medical, social and geographical contexts. The results of this empirical study might be used to develop an ICF-CY Core Set for Oral Health - a holistic but practical tool for clinical and epidemiological use.     

Self-Report of Healthcare Utilization among Community-Dwelling Older Persons: A Prospective Cohort Study

Background

Self-reported data are often used for estimates on healthcare utilization in cost-effectiveness studies.

Objective

To analyze older adults’ self-report of healthcare utilization compared to data obtained from the general practitioners’ (GP) electronic medical record (EMR) and to study the differences in healthcare utilization between those who completed the study, those who did not respond, and those lost to follow-up.

Methods

A prospective cohort study was conducted among community-dwelling persons aged 70 years and above, without dementia and not living in a nursing home. Self-reporting questionnaires were compared to healthcare utilization data extracted from the EMR at the GP-office.

Results

Overall, 790 persons completed questionnaires at baseline, median age 75 years (IQR 72–80), 55.8% had no disabilities in (instrumental) activities of daily living. Correlations between self-report data and EMR data on healthcare utilization were substantial for ‘hospitalizations’ and ‘GP home visits’ at 12 months intraclass correlation coefficient 0.63 (95% CI; 0.58–0.68). Compared to the EMR, self-reported healthcare utilization was generally slightly over-reported. Non-respondents received more GP home visits (p<0.05). Of the participants who died or were institutionalized 62.2% received 2 or more home visits (p<0.001) and 18.9% had 2 or more hospital admissions (p<0.001) versus respectively 18.6% and 3.9% of the participants who completed the study. Of the participants lost to follow-up for other reasons 33.0% received 2 or more home visits (p<0.01) versus 18.6 of the participants who completed the study.

Conclusions

Self-report of hospitalizations and GP home visits in a broadly ‘healthy’ community-dwelling older population seems adequate and efficient. However, as people become older and more functionally impaired, collecting healthcare utilization data from the EMR should be considered to avoid measurement bias, particularly if the data will be used to support economic evaluation.     

Delay in Diagnosis of Testicular Cancer; A Need for Awareness Programs

Background Aim

To gain insight into patient and doctor delay in testicular cancer (TC) and factors associated with delay.

Materials and Methods

Sixty of the 66 eligible men; median age 26 (range 17–45) years, diagnosed with TC at the University Medical Center Groningen completed a questionnaire on patients’ delay: interval from symptom onset to first consultation with a general practitioner (GP) and doctors’ delay: interval between GP and specialist visit.

Results

Median patient reported delay was 30 (range 1–365) days. Patient delay and TC tumor stage were associated (p = .01). Lower educated men and men embarrassed about their scrotal change reported longer patient delay (r = -.25, r = .79 respectively). Age, marital status, TC awareness, warning signals, nor perceived limitations were associated with patient delay. Median patient reported time from GP to specialist (doctors’ delay) was 7 (range 0–240) days. Referral time and disease stage were associated (p = .04). Six patients never reported a scrotal change. Of the 54 patients reporting a testicular change, 29 (54%) patients were initially ‘misdiagnosed’, leading to a median doctors’ delay of 14 (1–240) days, which was longer (p< .001) than in the 25 (46%) patients whose GP suspected TC (median doctors’ delay 1(0–7 days).

Conclusions

High variation in patients’ and doctors’ delay was found. Most important risk variables for longer patient delay were embarrassment and lower education. Most important risk variable in GP’s was ‘misdiagnosis’. TC awareness programs for men and physicians are required to decrease delay in the diagnosis of TC and improve disease free survival.     

Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec

Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs’ perceptions of best practices in the management of mental disorders. A collaboration model is also developed.Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation.Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients.Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.     

Beyond a Dichotomous View of the Concepts of ‘Sex’ and ‘Gender’ Focus Group Discussions among Gender Researchers at a Medical Faculty

Introduction

The concepts of ‘sex’ and ‘gender’ are both of vital importance in medicine and health sciences. However, the meaning of these concepts has seldom been discussed in the medical literature. The aim of this study was to explore what the concepts of ‘sex’ and ‘gender’ meant for gender researchers based in a medical faculty.

Methods

Sixteen researchers took part in focus group discussions. The analysis was performed in several steps. The participating researchers read the text and discussed ideas for analysis in national and international workshops. The data were analysed using qualitative content analysis. The authors performed independent preliminary analyses, which were further developed and intensively discussed between the authors.

Results

The analysis of meanings of the concepts of ‘sex’ and ‘gender’ for gender researchers based in a medical faculty resulted in three categories; “Sex as more than biology”, with the subcategories ‘sex’ is not simply biological, ‘sex’ as classification, and ‘sex’ as fluid and changeable; ”Gender as a multiplicity of power-related constructions”, with the subcategories: ‘gender’ as constructions, ‘gender’ power dimensions, and ‘gender’ as doing femininities and masculinities; “Sex and gender as interwoven”, with the subcategories: ‘sex’ and ‘gender’ as inseparable and embodying ‘sex’ and ‘gender’.

Conclusions

Gender researchers within medicine pointed out the importance of looking beyond a dichotomous view of the concepts of ‘sex’ and ‘gender’. The perception of the concepts was that ‘sex’ and ‘gender’ were intertwined. Further research is needed to explore how ‘sex’ and ‘gender’ interact.     

The Effects of Extra-Somatic Weapons on the Evolution of Human Cooperation towards Non-Kin

Human cooperation and altruism towards non-kin is a major evolutionary puzzle, as is ‘strong reciprocity’ where no present or future rewards accrue to the co-operator/altruist. Here, we test the hypothesis that the development of extra-somatic weapons could have influenced the evolution of human cooperative behaviour, thus providing a new explanation for these two puzzles. Widespread weapons use could have made disputes within hominin groups far more lethal and also equalized power between individuals. In such a cultural niche non-cooperators might well have become involved in such lethal disputes at a higher frequency than cooperators, thereby increasing the relative fitness of genes associated with cooperative behaviour. We employ two versions of the evolutionary Iterated Prisoner''s Dilemma (IPD) model – one where weapons use is simulated and one where it is not. We then measured the performance of 25 IPD strategies to evaluate the effects of weapons use on them. We found that cooperative strategies performed significantly better, and non-cooperative strategies significantly worse, under simulated weapons use. Importantly, the performance of an ‘Always Cooperate’ IPD strategy, equivalent to that of ‘strong reciprocity’, improved significantly more than that of all other cooperative strategies. We conclude that the development of extra-somatic weapons throws new light on the evolution of human altruistic and cooperative behaviour, and particularly ‘strong reciprocity’. The notion that distinctively human altruism and cooperation could have been an adaptive trait in a past environment that is no longer evident in the modern world provides a novel addition to theory that seeks to account for this major evolutionary puzzle.     

General Practitioners’ Experiences of,and Responses to,Uncertainty in Prostate Cancer Screening: Insights from a Qualitative Study

BackgroundProstate-specific antigen (PSA) testing for prostate cancer is controversial. There are unresolved tensions and disagreements amongst experts, and clinical guidelines conflict. This both reflects and generates significant uncertainty about the appropriateness of screening. Little is known about general practitioners’ (GPs’) perspectives and experiences in relation to PSA testing of asymptomatic men. In this paper we asked the following questions: (1) What are the primary sources of uncertainty as described by GPs in the context of PSA testing? (2) How do GPs experience and respond to different sources of uncertainty?MethodsThis was a qualitative study that explored general practitioners’ current approaches to, and reasoning about, PSA testing of asymptomatic men. We draw on accounts generated from interviews with 69 general practitioners located in Australia (n = 40) and the United Kingdom (n = 29). The interviews were conducted in 2013–2014. Data were analysed using grounded theory methods. Uncertainty in PSA testing was identified as a core issue.FindingsAustralian GPs reported experiencing substantially more uncertainty than UK GPs. This seemed partly explainable by notable differences in conditions of practice between the two countries. Using Han et al’s taxonomy of uncertainty as an initial framework, we first outline the different sources of uncertainty GPs (mostly Australian) described encountering in relation to prostate cancer screening and what the uncertainty was about. We then suggest an extension to Han et al’s taxonomy based on our analysis of data relating to the varied ways that GPs manage uncertainties in the context of PSA testing. We outline three broad strategies: (1) taking charge of uncertainty; (2) engaging others in managing uncertainty; and (3) transferring the responsibility for reducing or managing some uncertainties to other parties.ConclusionOur analysis suggests some GPs experienced uncertainties associated with ambiguous guidance and the complexities of their situation as professionals with responsibilities to patients as considerably burdensome. This raises important questions about responsibility for uncertainty. In Australia in particular they feel insufficiently supported by the health care system to practice in ways that are recognisably consistent with ‘evidence based’ professional standards and appropriate for patients. More work is needed to clarify under what circumstances and how uncertainty should be communicated. Closer attention to different types and aspects of the uncertainty construct could be useful.     

Social Cognition in Individuals at Ultra-High Risk for Psychosis: A Meta-Analysis

Objective

Treatment in the ultra-high risk stage for a psychotic episode is critical to the course of symptoms. Markers for the development of psychosis have been studied, to optimize the detection of people at risk of psychosis. One possible marker for the transition to psychosis is social cognition. To estimate effect sizes for social cognition based on a quantitative integration of the published evidence, we conducted a meta-analysis of social cognitive performance in people at ultra high risk (UHR).

Methods

A literature search (1970-July 2015) was performed in PubMed, PsychINFO, Medline, Embase, and ISI Web of Science, using the search terms ‘social cognition’, ‘theory of mind’, ‘emotion recognition’, ‘attributional style’, ‘social knowledge’, ‘social perception’, ‘empathy’, ‘at risk mental state’, ‘clinical high risk’, ‘psychosis prodrome’, and ‘ultra high risk’. The pooled effect size (Cohen’s D) and the effect sizes for each domain of social cognition were calculated. A random effects model with 95% confidence intervals was used.

Results

Seventeen studies were included in the analysis. The overall significant effect was of medium magnitude (d = 0.52, 95% Cl = 0.38–0.65). No moderator effects were found for age, gender and sample size. Sub-analyses demonstrated that individuals in the UHR phase show significant moderate deficits in affect recognition and affect discrimination in faces as well as in voices and in verbal Theory of Mind (TOM). Due to an insufficient amount of studies, we did not calculate an effect size for attributional bias and social perception/ knowledge. A majority of studies did not find a correlation between social cognition deficits and transition to psychosis, which may suggest that social cognition in general is not a useful marker for the development of psychosis. However some studies suggest the possible predictive value of verbal TOM and the recognition of specific emotions in faces for the transition into psychosis. More research is needed on these subjects.

Conclusion

The published literature indicates consistent general impairments in social cognition in people in the UHR phase, but only very specific impairments seem to predict transition to psychosis.     

Sex Differences in Itch Perception and Modulation by Distraction – an fMRI Pilot Study in Healthy Volunteers

Background

Even though itch is a common syndrome of many diseases there is only little knowledge about sex and gender differences in pruritus, especially in central itch perception and modulation. To our knowledge, this is the first fMRI study examining sex differences in perception and its modulation by distraction.

Methods

Experimental itch was induced by application of histamine (0.1 mM) via microdialysis fibers twice at the left forearm and twice at the left lower leg in 33 healthy volunteers (17 females, 16 males). The brain activation patterns were assessed by fMRI during itch without and with distraction (Stroop task). Between the various conditions, subjects were asked to rate itch intensity, desire to scratch and pain intensity. In a second experiment in 10 of the 33 volunteers histamine was replaced by saline solution to serve as control for the ‘Stroop’ condition.

Results

Women generally presented higher itch intensities compared to men during itch over the course of the experiment. A more specific analysis revealed higher itch intensities and desire to scratch in women during experimental induced itch that can be reduced by distraction at the lower legs when itch is followed by ‘Stroop’. In contrast, men depicted significant reduction of ‘itch’ by ‘Stroop’ at the forearms. Women depicted higher brain activation of structures responsible for integration of sensory, affective information and motor integration/planning during ‘itch’ and ‘Stroop’ condition when compared to men. No sex differences were seen in the saline control condition.

Conclusion

Women and men exhibited localisation dependent differences in their itch perception with women presenting higher itch intensities and desire to scratch. Our findings parallel clinical observations of women reporting higher itch intensities depending on itch localisation and suffering more from itch as compared to men.     

Variability in Vulnerability Assessment of Older People by Individual General Practitioners: A Cross-Sectional Study

Background

In clinical practice, GPs appeared to have an internalized concept of “vulnerability.” This study investigates the variability between general practitioners (GPs) in their vulnerability-assessment of older persons.

Methods

Seventy-seven GPs categorized their 75-plus patients (n = 11392) into non-vulnerable, possibly vulnerable, and vulnerable patients. GPs personal and practice characteristics were collected. From a sample of 2828 patients the following domains were recorded: sociodemographic, functional [instrumental activities in daily living (IADL), basic activities in daily living (BADL)], somatic (number of diseases, polypharmacy), psychological (Mini-Mental State Examination, 15-item Geriatric Depression Scale; GDS-15) and social (De Jong-Gierveld Loneliness Scale; DJG). Variability in GPs'' assessment of vulnerability was tested with mixed effects logistic regression. P-values for variability (p_var) were calculated by the log-likelihood ratio test.

Results

Participating GPs assessed the vulnerability of 10,361 patients. The median percentage of vulnerable patients was 32.0% (IQR 19.5 to 40.1%). From the somatic and psychological domains, GPs uniformly took into account the patient characteristics ‘total number of diseases’ (OR 1.7, 90% range  = 0, p_var = 1), ‘polypharmacy’ (OR 2.3, 90% range  = 0, p_var = 1) and ‘GDS-15’ (OR 1.6, 90% range  = 0, p_var = 1). GPs vary in the way they assessed their patients'' vulnerability in the functional domain (IADL: median OR 2.8, 90% range 1.6, p_var<0.001, BADL: median OR 2.4, 90% range 2.9, p_var<0.001) and the social domain (DJG: median OR 1.2, 90% range  = 1.2, p_var<0.001).

Conclusions

GPs seem to share a medical concept of vulnerability, since they take somatic and psychological characteristics uniformly into account in the vulnerability-assessment of older persons. In the functional and social domains, however, variability was found. Vulnerability assessment by GPs might be a promising instrument to select older people for geriatric care if more uniformity could be achieved.

Trial Registration

Netherlands Trial Register NTR1946