Medical patients aged 65 and over admitted to an accident and emergency department.

A study of 100 consecutive emergency medical admissions to Oldchurch Hospital was made to establish if the mode of referral--either by the general practitioner or self referral--influenced the presentation and severity of illness and the eventual outcome. Of the 94 cases analysed, 55 were self referred and 39 were sent in by their general practitioners. No significant differences were found between the two groups of patients, which suggests that the patient (or the patient''s family or companion) is as discriminating as the general practitioner in deciding when emergency referral to hospital is necessary.     

The (Un)managed Self: Paradoxical Forms of Agency in Self-Management of Bipolar Disorder

Self-management of mental illness is a therapeutic paradigm that draws on a distinctly biomedical conceptualization of the isolability of personhood from pathology. This discourse posits a stable and rational patient/consumer who can observe, anticipate, and preside over his disease through a set of learned practices. But in the case of bipolar disorder, where the rationality of the patient is called into question, the managing self is elusive, and the disease that is managed coincides with the self. While humanist critiques of the biomedical model as applied to mental illness have argued that its logic fatalistically denies patients intentionality and effectiveness (Luhrmann, Of Two Minds: The Growing Disorder in American Psychiatry, 2000), biomedical proponents claim that psychiatry’s way of envisioning the body as under the control of the intentional mind actually returns agency to the patient/consumer. Rose (The Psychiatric Gaze, 1999) remarks that biomedical models have the potential to “[open] that which was considered natural to a form of choice” (p. 37), and that techniques of medical self-control help constitute the free embodied liberal subject who is obliged to calculate and choose. Through an examination of clinical literature as well as the practices and narratives of members of a bipolar support group, this paper explores ethnographically the possibilities for subjectivity and agency that are conditioned or foreclosed by the self-management paradigm, which seems to simultaneously confer and deny rational selfhood to bipolar patients. To express their expertise as rational self-managers, patients/consumers must, paradoxically, articulate constant suspicion toward their present thoughts and emotions, and distrust of an imagined future self. I argue that through their self-management practices, bipolar support group members model provisional and distributed forms of agency based on an elusive, discontinuous, and only partially knowable or controllable self—revealing, perhaps, the limits of the contemporary reification and medicalization of both selfhood and disease.     

"Post-residency disease" and the medical self: identity, work, and health care among doctors who become patients

Doctors who become patients due to serious illnesses face many challenges related to issues of identity, work, and professionalism. In-depth interviews with such doctors reveal the complex ways in which illness threatens identity in these professionals. In comparison with "medical student's disease," these doctors now exhibit "post-residency disease"-minimizing physical symptoms that are in fact present, leading to decreases in care sought. Doctors often feel they are somehow invulnerable to disease and have to remain strong, not burdening others. Many describe themselves as "workaholics," which can prove to be a double-edged sword, posing problems as well as providing benefits. This professional commitment could interfere with preventive health behaviors and with "practicing what they preach." Some view their illness with their "medical self" - as if they were a physician observing another patient rather than themselves. These doctors often support their approach by choosing a colleague as a doctor who will not challenge them, thereby establishing a "denial system" as opposed to a support system. These doctor-patients confront difficult issues of how much their physicianhood is an identity or an activity, illustrating the intricate relationships and tensions between work, identity, professionalism, and health in contemporary medicine.     

The Cost-Effectiveness Analysis of Teleglaucoma Screening Device

Glaucoma is the leading cause of irreversible vision loss and costs the American economy $2.9 billion. Teleglaucoma remotely detects glaucoma improving access to ophthalmic care in rural areas. It helps manage glaucoma more efficiently to preserve vision and reduce healthcare costs. A cost-effectiveness analysis was conducted using healthcare provider or third-party payer perspective within rural Canada. The study population were patients at-risk of glaucoma which includes those with diabetes and/or hypertension, family history of glaucoma, adults older than 50 years, and concurrent ocular conditions in rural Alberta. Markov modelling was used to model glaucoma health states. Effectiveness was measured in Quality-Adjusted Life Years (QALYs) and costs were used in Canadian dollars. Using TreeAge Pro 2009, incremental cost-effectiveness ratios (ICER) were developed in dollars per QALYs. Deterministic and probabilistic sensitivity analyses were performed to assess the factors affecting cost-effectiveness. Teleglaucoma had a 20% increase in ophthalmologist-referral rate; it reduced patient travel times by 61 hours and physician wait times by 30% in comparison to in-person examination (standard of care). Teleglaucoma costs $872 per patient screened which was 80% less than in-person examination. Teleglaucoma had a greater incremental effectiveness providing an additional 0.12 QALY per patient examination. It was more sensitive (86.5%) and less specific (78.6%) than in-person examination. Teleglaucoma was more cost-effective than in-person examination with an ICER of-$27,460/QALY. This indicated that teleglaucoma will save $27, 460 for each additional QALY gained. Long term benefits showed teleglaucoma prevents 24% cases of glaucoma blindness after 30 years. Teleglaucoma demonstrated improved health outcomes, as well as, cost benefits. It increases access to ophthalmic care and improves healthcare service efficiency, specifically in rural areas. Teleglaucoma is more cost-effective than current in-person examination and can improve the quality of life in glaucoma patients.     

Treatment of glaucoma secondary to ICE syndrome

Iridocorneal Endothelial (ICE) Syndrome refers to a group of three similar entities consisting of a combination of abnormalities to the corneal endothelium and iris. Approximately 50% of all patients who present with an ICE syndrome will later develop secondary angle closure glaucoma which is often refractory to conventional therapy. The following case report presents a patient with essential iris atrophy and secondary angle closure glaucoma. The clinical features of the disease, mechanisms of secondary glaucoma, and management strategies will be discussed.     

Corneal thickness in pseudoexfoliative glaucoma

Measurements of central cornea thickness (CCT) have a very important value in glaucoma patients; if the central cornea is thinner than it suggests, then the intraocular pressure is falsely low. This study compares the central cornea thickness between patients with pseudoexfoliative glaucoma, open angle glaucoma, angle closure glaucoma and control group. This study included 34 patients with pseudoexfoliative glaucoma, 31 patient with open angle laucoma, 28 patients with angle closure laucoma and 36 normal subjects in a control group. Patients in all groups and also normal subjects in control group had no other corneal disorders, no history of trauma, corneal surgery and were not patients with contacts lens use. Patients with pseudoexfoliative glaucoma and also patients with open angle glaucoma had significantly lower values of central cornea thickness compared with normal subjects in control group. Tomey EM 3000 is a non contact specular microscope which was used to measure central corneal thickness in this study. Pachymetry is an important method for diagnoses of glaucoma and for examination of the intraocular pressure in glaucoma patients, because values of the central corneal thickness affect the exact intraocular pressure readings.     

Special considerations in the treatment of patients with bipolar disorder and medical co-morbidities

BACKGROUND: The pharmacological treatment of bipolar disorder has dramatically improved with multiple classes of agents being used as mood-stabilizers, including lithium, anticonvulsants, and atypical antipsychotics. However, the use of these medications is not without risk, particularly when a patient with bipolar disorder also has comorbid medical illness. As the physician who likely has the most contact with patients with bipolar disorder, psychiatrists must have a high index of suspicion for medical illness, as well as a basic knowledge of the risks associated with the use of medications in this patient population. METHODS: A review of the literature was conducted and papers addressing this topic were selected by the authors. RESULTS AND DISCUSSION: Common medical comorbidities and treatment-emergent illnesses, including obesity, diabetes mellitus, dyslipidemia, cardiac disease, hepatic disease, renal disease, pulmonary disease and cancer are reviewed with respect to concomitant use of mood stabilizers. Guidance to clinicians regarding effective monitoring and treatment is offered. CONCLUSIONS: Mood-stabilizing medications are necessary in treating patients with bipolar disorder and often must be used in the face of medical illness. Their safe use is possible, but requires increased vigilance in monitoring for treatment-emergent illnesses and effects on comorbid medical illness.     

Conditional and Unconditional Simulation of Healthy Patients' Visual Fields

This paper describes a simulation problem, motivated by the study of glaucoma, a very serious and widespread ocular illness. To ascertain whether a patient suffers from glaucoma, a perimetric test is done, but the evolution of the disease is very slow, and large longitudinal sets of tests taken on the same patient are needed to study its evolution, to analyze the efficiency of existing methods to detect the progression of glaucoma and to develop new ones. Simulation can be a very useful procedure to get appropriate data sets to work with. Our aim in this work is to simulate several VFs in a healthy patient to reflect his evolution in time. We use a spatio‐temporal model to simulate from, taking into account the correlation existing between the observed (or simulated) values in space and time. Two different simulation procedures (unconditional and conditional) are studied, and applied to obtain the simulations we are interested in. (© 2004 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Unrecognized ocular problems associated with port-wine stain of the face in children

The port-wine stain, a relatively rare subgroup of capillary hemangiomas, usually involves the face and in children it may be associated with glaucoma. A series of 50 patients with facial port-wine stains had ocular examination at The Hospital for Sick Children, Toronto. When the facial areas supplied by both the ophthalmic and maxillary divisions of the sensory branch of the trigeminal nerve were involved (26 patients) there was about a 45% chance of diagnosing glaucoma, either as “true” glaucoma (with visual loss and raised intraocular pressure) or as “glaucoma suspect” (without visual loss). Involvement of the area supplied by either division alone was not associated with glaucoma.     

Serological diagnosis of infection with human herpesvirus type 6.

OBJECTIVE--To identify clinical consequences of acute human herpesvirus type 6 infection by hypothesising that the virus will induce similar clinical syndromes to cytomegalovirus. DESIGN--Examination of consecutive serum samples from patients with illnesses compatible with acute cytomegalovirus infection or exanthem subitum by indirect immunofluorescence for the presence of antibodies to human herpesvirus type 6. An IgG absorption step was included to avoid false positive and negative results for IgM. The criterion standard for diagnosis of human herpesvirus type 6 infection was the presence of IgM human herpesvirus type 6 antibody (titre greater than 20) and a rising titre of IgG human herpesvirus type 6 antibody without serological evidence of alternative infection. SETTING--Routine viral diagnostic and reference laboratory in the largest teaching hospital in Sydney. PATIENTS--341 Consecutive serum samples were analysed from patients with hepatitis (147 samples); infectious mononucleosis-like illness (106); screens for toxoplasma, other viruses, rubella, cytomegalovirus, and herpesvirus (38); fever in an immunocompromised patient (eight); unusual neurological (nine) or haematological syndromes (14); splenomegaly (six); and rash in a child (13). RESULTS--Three cases of acute human herpesvirus type 6 infection were identified: in one patient aged 65 with a previous diagnosis of acute non-A non-B hepatitis, one aged 25 with a glandular fever-like illness, and one aged 6 with a glandular fever-like illness. All three illnesses resolved completely. 15 Further serum samples were positive for human herpesvirus type 6 antibody but were also diagnostic for acute infection with other viruses (cytomegalovirus (nine), Epstein-Barr virus (three), and HIV (one] or had a titre of IgM human herpesvirus type 6 antibody less than 20 (two). CONCLUSIONS--Acute human herpesvirus type 6 infection in immunocompetent patients may result in a mononucleosis-like illness or an acute but self limiting hepatitis.     

Factors associated with dental anxiety among older people in Britain

Objective: This paper reports on a study of denial anxiety among adults aged 60 years living independently in Britain. Design: A national cross‐sectional study carried out with the assistance of the Office for National Statistics' Omnibus Surveys in 1999. Setting: Data was collected by face to face interviews with older people in their homes Measurements : Data on dental anxiety were collected from 973 subjects by means of face to face interviews and was measured by the Dental Anxiety Scale (DAS) (Corah, 1969). In addition, data on dental service use and oral health status (self‐reported) was collected. Results: The mean DAS score was 8.4 (sd 3.5), and 13% (129) of subjects were classified as dentally anxious (DAS ≥ 13). DAS scores were associated with numerous socio‐demographic factors (P<0.01), self‐reported oral health status (P<0.01) and dental service (P<0.01) factors. A series of regression analyses revealed that dental anxiety was a significant predictor of a number of behavioural and oral health outcomes. Conclusion: One in eight older people in Britain are dentally anxious and this is associated with their use of services and oral health status (self‐reported).     

Obstacle Avoidance,Visual Detection Performance,and Eye-Scanning Behavior of Glaucoma Patients in a Driving Simulator: A Preliminary Study

The objective of this study was to evaluate differences in driving performance, visual detection performance, and eye-scanning behavior between glaucoma patients and control participants without glaucoma. Glaucoma patients (n = 23) and control participants (n = 12) completed four 5-min driving sessions in a simulator. The participants were instructed to maintain the car in the right lane of a two-lane highway while their speed was automatically maintained at 100 km/h. Additional tasks per session were: Session 1: none, Session 2: verbalization of projected letters, Session 3: avoidance of static obstacles, and Session 4: combined letter verbalization and avoidance of static obstacles. Eye-scanning behavior was recorded with an eye-tracker. Results showed no statistically significant differences between patients and control participants for lane keeping, obstacle avoidance, and eye-scanning behavior. Steering activity, number of missed letters, and letter reaction time were significantly higher for glaucoma patients than for control participants. In conclusion, glaucoma patients were able to avoid objects and maintain a nominal lane keeping performance, but applied more steering input than control participants, and were more likely than control participants to miss peripherally projected stimuli. The eye-tracking results suggest that glaucoma patients did not use extra visual search to compensate for their visual field loss. Limitations of the study, such as small sample size, are discussed.     

Home treatment for acute psychiatric illness.

OBJECTIVE--To determine the factors influencing the successful outcome of community treatment for severe acute psychiatric illnesses that are traditionally treated in hospital. DESIGN--All patients from a single electoral ward who were either admitted to hospital or treated at home over a two year period (1 October 1987 to 30 September 1989) were included in the study and their case notes audited. The second year of the study is reported. SETTING--Electoral ward of Sparkbrook, Birmingham. SUBJECTS--99 Patients aged 16-65 with severe acute psychiatric illness. RESULTS--65 Patients were managed by home treatment alone; 34 required admission to hospital. The location of treatment was significantly (all p less than 0.05) influenced by social characteristics of the patients (marital state, age (in men), ethnicity, and living alone) and by characteristics of the referral (occurring out of hours; assessment taking place at hospital or police station). DSM-III-R diagnosis was more weakly associated with outcome. Violence during the episode was significantly related to admission, although deliberate self harm was not. CONCLUSIONS--Home treatment is feasible for most patients with acute psychiatric illness. A 24 hour on call assessment service increases the likelihood of success because admission is determined more strongly by social characteristics of the patient and the referral than by illness factors. Admission will still be required for some patients. A locally based mental health resource centre, a 24 hour on call service, an open referral system, and an active follow up policy increase the effectiveness of a home treatment service.     

Predicting potential placebo effect in drug treated subjects

Non-specific responses to treatment (commonly known as placebo response) are pervasive when treating mental illness. Subjects treated with an active drug may respond in part due to non-specific aspects of the treatment, i.e, those not related to the chemical effect of the drug. To determine the extent a subject responds due to the chemical effect of a drug, one must disentangle the specific drug effect from the non-specific placebo effect. This paper presents a unique statistical model that allows for the separate prediction of a specific effect and non-specific effects in drug treated subjects. Data from a clinical trial comparing fluoxetine to a placebo for treating depression is used to illustrate this methodology.     

The Effects of Face Masks on the Doctor-Patient Relationship in Orthopaedics

BackgroundSince the onset of the COVID-19 pandemic, the widespread use of face masks has grown exponentially. There is limited data highlighting the patient perception of face mask use during this pandemic, specifically in orthopaedic clinics. The purpose of this study was to determine the patient’s perception of the implementation of face masks in the orthopaedic clinic during a period of mask mandates and if this change impacted the success of their interactions with physicians. The secondary aim includes measures of patient satisfaction such as the ability to understand conversation and communicate effectively with the physician.MethodsParticipants were recruited on the day of their appointment at our institution’s orthopaedic clinic and provided with instructions via email. The online, anonymous survey included the CARE questionnaire - a tool to examine patient satisfaction by assessing perception of empathy and was conducted using Qualtrics.ResultsDoes patient preference to have their physician wear a face mask impact the success of their interactions with physicians? Overall, the use of face masks by physicians did not negatively impact patient encounters. CARE scores for patients who preferred masks (37.2) were similar to those who preferred their physician did not wear a mask (37.5). Is patient satisfaction affected by the use of face masks in the orthopaedic clinic? Patients who preferred that their doctor wear a face mask stated that it had no negative impact on the effect of communication or conversation with the physician. Other factors such as how well the patients knew the physician and patient gender had a greater impact on the CARE score than masks did.ConclusionOur study determined that the preference of face masks by patients does not impact the success of their interactions with physicians using the CARE score. The findings of this study are valuable in informing orthopaedic physicians about patient attitudes towards mask use and could influence decision making for not only the COVID-19 pandemic, but also future infectious outbreaks that may arise. Level of Evidence: III     

Neural Correlates of Own Name and Own Face Detection in Autism Spectrum Disorder

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental condition clinically characterized by social interaction and communication difficulties. To date, the majority of research efforts have focused on brain mechanisms underlying the deficits in interpersonal social cognition associated with ASD. Recent empirical and theoretical work has begun to reveal evidence for a reduced or even absent self-preference effect in patients with ASD. One may hypothesize that this is related to the impaired attentional processing of self-referential stimuli. The aim of our study was to test this hypothesis. We investigated the neural correlates of face and name detection in ASD. Four categories of face/name stimuli were used: own, close-other, famous, and unknown. Event-related potentials were recorded from 62 electrodes in 23 subjects with ASD and 23 matched control subjects. P100, N170, and P300 components were analyzed. The control group clearly showed a significant self-preference effect: higher P300 amplitude to the presentation of own face and own name than to the close-other, famous, and unknown categories, indicating preferential attentional engagement in processing of self-related information. In contrast, detection of both own and close-other''s face and name in the ASD group was associated with enhanced P300, suggesting similar attention allocation for self and close-other related information. These findings suggest that attention allocation in the ASD group is modulated by the personal significance factor, and that the self-preference effect is absent if self is compared to close-other. These effects are similar for physical and non-physical aspects of the autistic self. In addition, lateralization of face and name processing is attenuated in ASD, suggesting atypical brain organization.     

Effectiveness of programs for reducing the stigma associated with mental disorders. A meta‐analysis of randomized controlled trials

The stigma associated with mental disorders is a global public health problem. Programs to combat it must be informed by the best available evidence. To this end, a meta‐analysis was undertaken to investigate the effectiveness of existing programs. A systematic search of PubMed, PsycINFO and Cochrane databases yielded 34 relevant papers, comprising 33 randomized controlled trials. Twenty‐seven papers (26 trials) contained data that could be incorporated into a quantitative analysis. Of these trials, 19 targeted personal stigma or social distance (6,318 participants), six addressed perceived stigma (3,042 participants) and three self‐stigma (238 participants). Interventions targeting personal stigma or social distance yielded small but significant reductions in stigma across all mental disorders combined (d=0.28, 95% CI: 0.17‐0.39, p<0.001) as well as for depression (d=0.36, 95% CI: 0.10‐0.60, p<0.01), psychosis (d=0.20, 95% CI: 0.06‐0.34, p<0.01) and generic mental illness (d=0.30, 95% CI: 0.10‐0.50, p<0.01). Educational interventions were effective in reducing personal stigma (d=0.33, 95% CI: 0.19‐0.42, p<0.001) as were interventions incorporating consumer contact (d=0.47, 95% CI: 0.17‐0.78, p<0.001), although there were insufficient studies to demonstrate an effect for consumer contact alone. Internet programs were at least as effective in reducing personal stigma as face‐to‐face delivery. There was no evidence that stigma interventions were effective in reducing perceived or self‐stigma. In conclusion, there is an evidence base to inform the roll out of programs for improving personal stigma among members of the community. However, there is a need to investigate methods for improving the effectiveness of these programs and to develop interventions that are effective in reducing perceived and internalized stigma.     

Weight‐Related Terms Differentially Affect Self‐Efficacy and Perception of Obesity

Objective

Little work has explored the effect of weight‐related terms on treatment initiation; only one study has investigated weight‐related terms and the psychological constructs associated with treatment uptake. The present study examines the effects of four common weight‐related terms on treatment initiation and the moderating effect of weight bias internalization.

Methods

Adult participants with overweight and obesity (n = 436) were recruited online and asked to read three vignettes describing clinical encounters; the weight‐related term (i.e., “weight,” “BMI,” “obesity,” or “fat”) was varied randomly. Participants then reported self‐efficacy, cognitive and emotional illness beliefs about obesity (i.e., illness perception), and interest in a weight loss program.

Results

The term “obesity” resulted in the greatest self‐efficacy and perceived control over obesity. “Fat” resulted in the least illness coherence (i.e., understanding of obesity). Weight bias internalization did not moderate the effect of term on self‐efficacy, nor did it moderate illness perception. No differences in weight loss program enrollment were observed.

Conclusions

Use of the term “obesity” may promote patients’ perceived control and self‐efficacy. Use of “fat” should be avoided. Results suggest that, despite patient and clinician preference for euphemistic weight terms, use of clinical language such as “obesity” may perform better in provider intervention.

     

“Traveling Pains”: Embodied Metaphors of Suffering Among Southern Sudanese Refugees in Cairo

This paper presents the results of a larger study conducted among Southern Sudanese refugees in Cairo, Egypt. "Illness talk" and body metaphors are the focus of the present work, which is based mainly on an analysis of the illness narratives of people attending a church-run medical clinic. The findings suggest that refugees use certain narrative styles in discussing their illnesses that highlight the interconnection of bodily ills and refugee-related trauma. The refugees narrated the histories of their illnesses in terms consistent and coterminous with their refugee histories, and articulated illness causes in terms of threatening assaults on their sense of self as human beings and as part of a distinct community and culture. The use of embodied metaphors to understand and cope with their current and past traumatic experiences was echoed in narratives that were nonillness related. Metaphors such as "the heart," "blood," and "body constriction" were consistently used to discuss social and cultural losses. Understanding the role that the body plays in experience and communication within a given cultural context is crucial for physicians and others assisting refugees.