Diagnostic interview for genetic studies (DIGS): inter-rater and test-retest reliability of alcohol and drug diagnoses

The semi-structured diagnostic interview for genetic studies (DIGS) was developed to assess major mood and psychotic disorders and their spectrum manifestations in genetic studies. Our research group developed a French version of the DIGS and tested its inter-rater and test-retest reliability in psychiatric patients. In this article, we present estimates of the reliability of substance use and antisocial personality disorders. High kappa coefficients for inter-rater reliability were found for drug and alcohol as well as antisocial personality diagnoses and slightly lower kappas for test-retest reliability. Combined with evidence of the reliability of major mood and psychotic disorders, these findings support the suitability of the DIGS for studies of familial aggregation and comorbidity of psychiatric disorders including substance use and antisocial personality disorders.

Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients

BACKGROUND: No randomized study has yet compared efficacy and safety of aspirin and anticoagulants in patients with spontaneous dissection of the cervical carotid artery (sICAD). METHODS: Prospectively collected data from 298 consecutive patients with sICAD (56% men; mean age 46 +/- 10 years) treated with anticoagulants alone (n = 202) or aspirin alone (n = 96) were retrospectively analyzed. Admission diagnosis was ischemic stroke in 165, TIA in 37, retinal ischemia in 8, and local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy) in 80 patients, while 8 patients were asymptomatic. Clinical follow-up was obtained after 3 months by neurologic examination (97% of patients) or structured telephone interview. Outcome measures were 1) new cerebral ischemic events, defined as ischemic stroke, TIA, or retinal ischemia, 2) symptomatic intracranial hemorrhage, and 3) major extracranial bleeding. RESULTS: During follow-up, ischemic events were rare (ischemic stroke, 0.3%; TIA, 3.4%; retinal ischemia, 1%); their frequency did not significantly differ between patients treated with anticoagulants (5.9%) and those treated with aspirin (2.1%). The same was true for hemorrhagic adverse events (anticoagulants, 2%; aspirin, 1%). New ischemic events were significantly more frequent in patients with ischemic events at onset (6.2%) than in patients with local symptoms or asymptomatic patients (1.1%). CONCLUSIONS: Within the limitations of a nonrandomized study, our data suggest that frequency of new cerebral and retinal ischemic events in patients with spontaneous dissection of the cervical carotid artery is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants).

ClInt: A bilingual Spanish-Catalan spoken corpus of clinical interviews

In this paper we present ClInt (Clinical Interview), a bilingual Spanish-Catalan spoken corpus that contains 15 hours of clinical interviews. It consists of audio files aligned with multiple-level transcriptions comprising orthographic, phonetic and morphological information, as well as linguistic and extralinguistic encoding. This is a previously non-existent resource for these languages and it offers a wide-ranging exploitation potential in a broad variety of disciplines such as Linguistics, Natural Language Processing and related fields.

Home Blood Pressure Measurement – Epidemiology and Clinical Application

Verenpaineen kotimittaus − epidemiologia ja kliininen käyttö Kohonnutta verenpainetta, maailmanlaajuisesti merkittävintä ennenaikaiselle kuolemalle altistavaa riskitekijää, ei voida tunnistaa tai hoitaa ilman tarkkoja ja käytännöllisiä verenpaineen mittausmenetelmiä. Verenpaineen kotimittaus on saavuttanut suuren suosion potilaiden keskuudessa. Lääkärit eivät ole kuitenkaan vielä täysin hyväksyneet verenpaineen kotimittausta, sillä riittävä todistusaineisto sen toimivuudesta ja eduista on puuttunut. Tämän tutkimuksen tarkoituksena oli osoittaa, että kotona mitattu verenpaine (kotipaine) on perinteistä vastaanotolla mitattua verenpainetta (vastaanottopaine) tarkempi, ja että se on tehokas myös kliinisessä käytössä. Tutkimme kotipaineen käyttöä verenpainetaudin diagnosoinnissa ja hoidossa. Lisäksi tarkastelimme kotipaineen yhteyttä verenpainetaudin aiheuttamiin kohde-elinvaurioihin. Ensimmäinen aineisto, joka oli edustava otos Suomen aikuisväestöstä, koostui 2 120 45–74-vuotiaasta tutkimushenkilöstä. Tutkittavat mittasivat kotipainettaan viikon ajan ja osallistuivat terveystarkastukseen, johon sisältyi kliinisen tutkimuksen ja haastattelun lisäksi sydänfilmin otto ja vastaanottopaineen mittaus. 758 tutkittavalle suoritettiin lisäksi kaulavaltimon seinämän intima-mediakerroksen paksuuden (valtimonkovettumataudin mittari) mittaus ja 237:lle valtimon pulssiaallon nopeuden (valtimojäykkyyden mittari) mittaus. Toisessa aineistossa, joka koostui 98 verenpainetautia sairastavasta potilaasta, hoitoa ohjattiin satunnaistamisesta riippuen joko ambulatorisen eli vuorokausirekisteröinnillä mitatun verenpaineen tai kotipaineen perusteella. Vastaanottopaine oli kotipainetta merkittävästi korkeampi (systolisen/diastolisen paineen keskiarvoero oli 8/3 mmHg) ja yksimielisyys verenpainetaudin diagnoosissa kahden menetelmän välillä oli korkeintaan kohtalainen (75 %). 593 tutkittavasta, joilla oli kohonnut verenpaine vastaanotolla, 38 %:lla oli normaali verenpaine kotona eli ns. valkotakkiverenpaine. Verenpainetauti voidaan siis ylidiagnosoida joka kolmannella potilaalla seulontatilanteessa. Valkotakkiverenpaine oli yhteydessä lievästi kohonneeseen verenpaineeseen, matalaan painoindeksiin ja tupakoimattomuuteen, muttei psykiatriseen sairastavuuteen. Valkotakkiverenpaine ei kuitenkaan vaikuttaisi olevan täysin vaaraton ilmiö ja voi ennustaa tulevaa verenpainetautia, sillä siitä kärsivien sydän- ja verisuonitautien riskitekijäprofiili oli normaalipaineisten ja todellisten verenpainetautisten riskitekijäprofiilien välissä. Kotipaineella oli vastaanottopainetta vahvempi yhteys verenpainetaudin aiheuttamiin kohde-elinvaurioihin (intima-mediakerroksen paksuus, pulssiaallon nopeus ja sydänfilmistä todettu vasemman kammion suureneminen). Kotipaine oli tehokas verenpainetaudin hoidon ohjaaja, sillä kotipaineeseen ja ambulatoriseen paineeseen, jota on pidetty verenpainemittauksen ”kultaisena standardina”, perustuva lääkehoidon ohjaus johti yhtä hyvään verenpaineen hallintaan. Tämän ja aikaisempien tutkimusten tulosten pohjalta voidaan todeta, että verenpaineen kotimittaus on selkeä parannus perinteiseen vastaanotolla tapahtuvaan verenpainemittaukseen verrattuna. Verenpaineen kotimittaus on käytännöllinen, tarkka ja laajasti saatavilla oleva menetelmä, josta voi tulla jopa ensisijainen vaihtoehto verenpainetautia diagnosoitaessa ja hoitaessa. Verenpaineen mittauskäytäntöön tarvitaan muutos, sillä näyttöön perustuvan lääketieteen perusteella vaikuttaa, että vastaanotolla tapahtuvaa verenpainemittausta tulisi käyttää vain seulontatarkoitukseen.

The new final Clinical Skills examination in human medicine in Switzerland: Essential steps of exam development, implementation and evaluation, and central insights from the perspective of the national Working Group.

OBJECTIVE: Since 2011, the new national final examination in human medicine has been implemented in Switzerland, with a structured clinical-practical part in the OSCE format. From the perspective of the national Working Group, the current article describes the essential steps in the development, implementation and evaluation of the Federal Licensing Examination Clinical Skills (FLE CS) as well as the applied quality assurance measures. Finally, central insights gained from the last years are presented. METHODS: Based on the principles of action research, the FLE CS is in a constant state of further development. On the foundation of systematically documented experiences from previous years, in the Working Group, unresolved questions are discussed and resulting solution approaches are substantiated (planning), implemented in the examination (implementation) and subsequently evaluated (reflection). The presented results are the product of this iterative procedure. RESULTS: The FLE CS is created by experts from all faculties and subject areas in a multistage process. The examination is administered in German and French on a decentralised basis and consists of twelve interdisciplinary stations per candidate. As important quality assurance measures, the national Review Board (content validation) and the meetings of the standardised patient trainers (standardisation) have proven worthwhile. The statistical analyses show good measurement reliability and support the construct validity of the examination. Among the central insights of the past years, it has been established that the consistent implementation of the principles of action research contributes to the successful further development of the examination. CONCLUSION: The centrally coordinated, collaborative-iterative process, incorporating experts from all faculties, makes a fundamental contribution to the quality of the FLE CS. The processes and insights presented here can be useful for others planning a similar undertaking.

Characterization of clinical and electrocardiographic findings in a youth population

Resting 12-lead electrocardiogram (ECG) has been employed in the evaluation of young asymptomatic subjects to detect pre-existing heart diseases. Although the incorporation of routine ECG remains controversial, there is increasing evidence that cardiomyopathies and ion channelopathies show ECG changes as the initial manifestation. The causes of sudden cardiac death in young people show a significant geographical variation. We aim to determine the prevalence and spectrum of ECG findings in a youth population. Methodology: From May 2010 to April 2013, a total of 976 young secondary school students (mean age, 14 years; range, 13-15) underwent voluntary medical screening that included a resting 12-lead ECG and structured clinical survey. Subjects with abnormal ECG findings were classified into two groups: major ECG findings group, which fulfilled a pre-specified checklist to screen for principal structural and electrical cardiopathies, and minor ECG findings group showing other ECG changes. The major ECG findings group was referred for secondary diagnostic tests at a tertiary institution. Results: Of the 976 subjects screened, 252 (25.82%; CI95%, 23.17-28.66) had ECG findings. Of note, 17 (1.74%) had major findings and 235 (24.08%) had minor findings on ECG. The prevalence of cardiovascular pathology within the major ECG findings group was 35.29%. The prevalence of ECG abnormalities was significantly higher in males than in females (29% vs 20.9%, P<0.01). Conclusions: The prevalence of ECG findings in a youth population was 25.82%. There were significant gender differences. The inclusion of universal ECG screening, in addition to medical history, may increase the sensitivity of a cardiovascular screening program. Knowledge of the spectrum and prevalence of ECG findings and disease conditions would be pivotal in designing customized screening programs

Is avoidant disorder part of the social phobia spectrum in a referred sample of Brazilian children and adolescents?

The diagnosis of avoidant disorder was deleted from the Diagnostic and Statistical Manual of Mental disorders - fourth edition (DSM-IV) based on a `committee decision' suggesting that avoidant disorder is part of the social phobia spectrum. The objective of the present study was to examine the nature of this clinical association in a referred sample of Brazilian children and adolescents. We assessed a referred sample of 375 youths using semi-structured diagnostic interview methodology. Demographic (age at admission to the study and sex) and clinical (level of impairment, age at onset of symptoms and pattern of comorbidity) data were assessed in subsamples of children with avoidant disorder (N = 7), social phobia (N = 26), and comorbidity between both disorders (N = 24). Although a significant difference in the male/female ratio was detected among groups (P = 0.03), none of the other clinical variables differed significantly among subjects that presented each condition separately or in combination. Most of the children with avoidant disorder fulfilled criteria for social phobia. Thus, our findings support the validity of the conceptualization of avoidant disorder as part of the social phobia spectrum in a clinical sample.

Reliability and validity of a Portuguese version of the Young Mania Rating Scale

The reliability and validity of a Portuguese version of the Young Mania Rating Scale were evaluated. The original scale was translated into and adapted to Portuguese by the authors. Definitions of clinical manifestations, a semi-structured anchored interview and more explicit rating criteria were added to the scale. Fifty-five adult subjects, aged 18 to 60 years, with a diagnosis of Current Manic Episode according to DSM-III-R criteria were assessed using the Young Mania Rating Scale as well as the Brief Psychiatric Rating Scale in two sessions held at intervals from 7 to 10 days. Good reliability ratings were obtained, with intra-class correlation coefficient of 0.97 for total scores, and levels of agreement above 0.80 (P < 0.001) for all individual items. Internal consistency analysis resulted in an alpha = 0.67 for the scale as a whole, and an alpha = 0.72 for each standardized item (P < 0.001). For the concurrent validity, a correlation of 0.78 was obtained by the Pearson coefficient between the total scores of the Young Mania Rating Scale and Brief Psychiatric Rating Scale. The results are similar to those reported for the English version, indicating that the Portuguese version of the scale constitutes a reliable and valid instrument for the assessment of manic patients.

A critical and descriptive approach to interictal behavior with the Neurobehavior Inventory (NBI)

Purpose: The purpose of this study was to test the psychometric properties of the Neurobehavior Inventory (NBI) in a group of temporal lobe epilepsy (TLE) patients from a tertiary care center, correlating its scores with the presence of psychiatric symptoms. Methods: Clinical and sociodemographic data from ninety-six TLE outpatients were collected, and a neuropsychiatric evaluation was performed with the following instruments: Mini-Mental State Examination (MMSE), structured psychiatric interview (MINI-PLUS), Neurobehavior Inventory (NBI), and Hamilton Depression Rating Scale (HAM-D). Results: Some traits evaluated by the NBI showed adequate internal consistency (mean inter-item correlation between 0.2 and 0.4) and were frequent, such as religiosity (74%) and repetitiveness (60.4%). Principal component analysis showed three factors, named here as emotions (Factor 1), hyposexuality (Factor 2), and unusual ideas (Factor 3). Depressive symptoms on HAM-D showed a strong association with emotions and hyposexuality factors. When patients with left TLE and right TLE were compared, the former exhibited more sadness (p=0.017), and the latter, a greater tendency toward sense of personal destiny (p=0.028). Conclusion: Depression influences NBI scoring, mainly emotionality and hyposexuality traits. Neurobehavior Inventory subscales can be better interpreted with an appropriate evaluation of comorbid mood and anxiety disorders. Compromise in left temporal mesial structures is associated with increased tendency toward sad affect, whereas right temporal pathology is associated with increased beliefs in personal destiny. (C) 2012 Elsevier Inc. All rights reserved.

Do Central Hypersensitivity and Altered Pain Modulation Predict the Course of Chronic Low Back and Neck Pain?

OBJECTIVES:: Widespread central hypersensitivity and altered conditioned pain modulation (CPM) have been documented in chronic pain conditions. Information on their prognostic values is limited. This study tested the hypothesis that widespread central hypersensitivity (WCH) and altered CPM, assessed during the chronic phase of low back and neck pain, predict poor outcome. METHODS:: A total of 169 consecutive patients with chronic low back or neck pain, referred to the pain clinic during 1 year, were analyzed. Pressure pain tolerance threshold at the second toe and tolerance time during cold pressor test at the hand assessed WCH. CPM was measured by the change in pressure pain tolerance threshold (test stimulus) after cold pressor test (conditioning stimulus). A structured telephone interview was performed 12 to 15 months after testing to record outcome parameters. Linear regression models were used, with average and maximum pain intensity of the last 24 hours at follow-up as endpoints. Multivariable analyses included sex, age, catastrophizing scale, Beck Depression Inventory, pain duration, intake of opioids, and type of pain syndrome. RESULTS:: Statistically significant reductions from baseline to follow-up were observed in pain intensity (P<0.001). No evidence for an association between the measures of WCH or CPM and intensity of chronic pain at follow-up was found. DISCUSSION:: A major predictive value of the measures that we used is unlikely. Future studies adopting other assessment modalities and possibly standardized treatments are needed to further elucidate the prognostic value of WCH and altered CPM in chronic pain.

Aspirin vs anticoagulation in carotid artery dissection: a study of 298 patients

BACKGROUND: No randomized study has yet compared efficacy and safety of aspirin and anticoagulants in patients with spontaneous dissection of the cervical carotid artery (sICAD). METHODS: Prospectively collected data from 298 consecutive patients with sICAD (56% men; mean age 46 +/- 10 years) treated with anticoagulants alone (n = 202) or aspirin alone (n = 96) were retrospectively analyzed. Admission diagnosis was ischemic stroke in 165, TIA in 37, retinal ischemia in 8, and local symptoms and signs (headache, neck pain, Horner syndrome, cranial nerve palsy) in 80 patients, while 8 patients were asymptomatic. Clinical follow-up was obtained after 3 months by neurologic examination (97% of patients) or structured telephone interview. Outcome measures were 1) new cerebral ischemic events, defined as ischemic stroke, TIA, or retinal ischemia, 2) symptomatic intracranial hemorrhage, and 3) major extracranial bleeding. RESULTS: During follow-up, ischemic events were rare (ischemic stroke, 0.3%; TIA, 3.4%; retinal ischemia, 1%); their frequency did not significantly differ between patients treated with anticoagulants (5.9%) and those treated with aspirin (2.1%). The same was true for hemorrhagic adverse events (anticoagulants, 2%; aspirin, 1%). New ischemic events were significantly more frequent in patients with ischemic events at onset (6.2%) than in patients with local symptoms or asymptomatic patients (1.1%). CONCLUSIONS: Within the limitations of a nonrandomized study, our data suggest that frequency of new cerebral and retinal ischemic events in patients with spontaneous dissection of the cervical carotid artery is low and probably independent of the type of antithrombotic treatment (aspirin or anticoagulants).

Does a Pre-Treatment Diagnostic Interview Affect the Outcome of Internet-Based Self-Help for Social Anxiety Disorder? A Randomized Controlled Trial

BACKGROUND: Numerous studies suggest that Internet-based self-help treatments are effective in treating anxiety disorders. Trials evaluating such interventions differ in their screening procedures and in the amount of clinician contact in the diagnostic assessment phase. The present study evaluates the impact of a pre-treatment diagnostic interview on the outcome of an Internet-based treatment for Social Anxiety Disorder (SAD). METHOD: One hundred and nine participants seeking treatment for SAD were randomized to either an interview-group (IG, N = 53) or to a non-interview group (NIG, N = 56). All participants took part in the same 10-week cognitive-behavioural unguided self-help programme. Before receiving access to the programme, participants of the IG underwent a structured diagnostic interview. Participants of the NIG started directly with the programme. RESULTS: Participants in both groups showed significant and substantial improvement on social anxiety measures from pre- to post-assessment (d IG = 1.30-1.63; d NIG = 1.00-1.28) and from pre- to 4-month follow-up assessment (d IG = 1.38-1.87; d NIG = 1.10-1.21). Significant between-groups effects in favour of the IG were found on secondary outcome measures of depression and general distress (d = 0.18-0.42). CONCLUSIONS: These findings suggest that Internet-based self-help is effective in treating SAD, whether or not a diagnostic interview is involved. However, the pre-treatment interview seems to facilitate change on secondary outcomes such as depression and general distress.

The new final Clinical Skills examination in human medicine in Switzerland: Essential steps of exam development, implementation and evaluation, and central insights from the perspective of the national Working Group

Objective: Since 2011, the new national final examination in human medicine has been implemented in Switzerland, with a structured clinical-practical part in the OSCE format. From the perspective of the national Working Group, the current article describes the essential steps in the development, implementation and evaluation of the Federal Licensing Examination Clinical Skills (FLE CS) as well as the applied quality assurance measures. Finally, central insights gained from the last years are presented. Methods: Based on the principles of action research, the FLE CS is in a constant state of further development. On the foundation of systematically documented experiences from previous years, in the Working Group, unresolved questions are discussed and resulting solution approaches are substantiated (planning), implemented in the examination (implementation) and subsequently evaluated (reflection). The presented results are the product of this iterative procedure. Results: The FLE CS is created by experts from all faculties and subject areas in a multistage process. The examination is administered in German and French on a decentralised basis and consists of twelve interdisciplinary stations per candidate. As important quality assurance measures, the national Review Board (content validation) and the meetings of the standardised patient trainers (standardisation) have proven worthwhile. The statistical analyses show good measurement reliability and support the construct validity of the examination. Among the central insights of the past years, it has been established that the consistent implementation of the principles of action research contributes to the successful further development of the examination. Conclusion: The centrally coordinated, collaborative-iterative process, incorporating experts from all faculties, makes a fundamental contribution to the quality of the FLE CS. The processes and insights presented here can be useful for others planning a similar undertaking. Keywords: national final examination, licensing examination, summative assessment, OSCE, action research

Sustained impact of a short small group course with systematic feedback in addition to regular clinical clerkship activities on musculoskeletal examination skills-a controlled study.

BACKGROUND The discrepancy between the extensive impact of musculoskeletal complaints and the common deficiencies in musculoskeletal examination skills lead to increased emphasis on structured teaching and assessment. However, studies of single interventions are scarce and little is known about the time-dependent effect of assisted learning in addition to a standard curriculum. We therefore evaluated the immediate and long-term impact of a small group course on musculoskeletal examination skills. METHODS All 48 Year 4 medical students of a 6 year curriculum, attending their 8 week clerkship of internal medicine at one University department in Berne, participated in this controlled study. Twenty-seven students were assigned to the intervention of a 6×1 h practical course (4-7 students, interactive hands-on examination of real patients; systematic, detailed feedback to each student by teacher, peers and patients). Twenty-one students took part in the regular clerkship activities only and served as controls. In all students clinical skills (CS, 9 items) were assessed in an Objective Structured Clinical Examination (OSCE) station, including specific musculoskeletal examination skills (MSES, 7 items) and interpersonal skills (IPS, 2 items). Two raters assessed the skills on a 4-point Likert scale at the beginning (T0), the end (T1) and 4-12 months after (T2) the clerkship. Statistical analyses included Friedman test, Wilcoxon rank sum test and Mann-Whitney U test. RESULTS At T0 there were no significant differences between the intervention and control group. At T1 and T2 the control group showed no significant changes of CS, MSES and IPS compared to T0. In contrast, the intervention group significantly improved CS, MSES and IPS at T1 (p < 0.001). This enhancement was sustained for CS and MSES (p < 0.05), but not for IPS at T2. CONCLUSIONS Year 4 medical students were incapable of improving their musculoskeletal examination skills during regular clinical clerkship activities. However, an additional small group, interactive clinical skills course with feedback from various sources, improved these essential examination skills immediately after the teaching and several months later. We conclude that supplementary specific teaching activities are needed. Even a single, short-lasting targeted module can have a long lasting effect and is worth the additional effort.

The influence of students' prior clinical skills and context characteristics on mini-CEX scores in clerkships - a multilevel analysis.

BACKGROUND In contrast to objective structured clinical examinations (OSCEs), mini-clinical evaluation exercises (mini-CEXs) take place at the clinical workplace. As both mini-CEXs and OSCEs assess clinical skills, but within different contexts, this study aims at analyzing to which degree students' mini-CEX scores can be predicted by their recent OSCE scores and/or context characteristics. METHODS Medical students participated in an end of Year 3 OSCE and in 11 mini-CEXs during 5 different clerkships of Year 4. The students' mean scores of 9 clinical skills OSCE stations and mean 'overall' and 'domain' mini-CEX scores, averaged over all mini-CEXs of each student were computed. Linear regression analyses including random effects were used to predict mini-CEX scores by OSCE performance and characteristics of clinics, trainers, students and assessments. RESULTS A total of 512 trainers in 45 clinics provided 1783 mini-CEX ratings for 165 students; OSCE results were available for 144 students (87 %). Most influential for the prediction of 'overall' mini-CEX scores was the trainers' clinical position with a regression coefficient of 0.55 (95 %-CI: 0.26-0.84; p < .001) for residents compared to heads of department. Highly complex tasks and assessments taking place in large clinics significantly enhanced 'overall' mini-CEX scores, too. In contrast, high OSCE performance did not significantly increase 'overall' mini-CEX scores. CONCLUSION In our study, Mini-CEX scores depended rather on context characteristics than on students' clinical skills as demonstrated in an OSCE. Ways are discussed which focus on either to enhance the scores' validity or to use narrative comments only.