How nice is good for patients and for therapy outcome? The role of confrontation in the process of psychotherapy

It is well established that the therapeutic relationship contributes about as much to therapy outcome as ‘technical’ intervention. Furthermore, it follows clear prescriptive concepts in the same manner as technical interventions do. ‘Motive Oriented Therapeutic Relationship’ is such a concept for establishing a solid basis for whatever therapeutic work the patients’ problems require (Grawe, 1980, 1992; Caspar, 1996). Yet, the therapeutic relationship doesn’t explain everything because other factors play a significant role too. Previous studies showed that outcome is clearly better when therapists achieved a generally high quality of a therapeutic relationship when they did not shy away from possibly threatening interventions such as confrontations. This ratio of a fruitful alliance and marginally present confrontations in the same session also showed significant correlations with patient’s assessment of alliance and progress in therapy (Figlioli et al., 2009). These findings are also very much in line with Sachse’s metaphor of accumulating, but then also using ‘relationship credits’ and Farrelly’s ‘Provocative Therapy’ (1986), as well as the ‘Intensive Short-Term Dynamic Psychotherapy’ by Davanloo (1980).Aim: The current state of research in the field does not give any answers to questions like how good and bad confrontations can be characterized or what role does the intensity, respectively frequency of confrontations play in the process of psychotherapy.Methods: A sample of 80 therapies of 3 sessions each representing either good or bad outcome was judged moment by moment by independent raters if and how therapists used confrontative interventions. Results / Discussion: The results will be discussed in terms of their implications for the clinical daily work. Preliminary analyses show that successful confrontations are explicitly uttered, short but intense, related to important patients goals in therapy and embedded in prior complementarity.

Multi-modal glioblastoma segmentation: man versus machine

BACKGROUND AND PURPOSE Reproducible segmentation of brain tumors on magnetic resonance images is an important clinical need. This study was designed to evaluate the reliability of a novel fully automated segmentation tool for brain tumor image analysis in comparison to manually defined tumor segmentations. METHODS We prospectively evaluated preoperative MR Images from 25 glioblastoma patients. Two independent expert raters performed manual segmentations. Automatic segmentations were performed using the Brain Tumor Image Analysis software (BraTumIA). In order to study the different tumor compartments, the complete tumor volume TV (enhancing part plus non-enhancing part plus necrotic core of the tumor), the TV+ (TV plus edema) and the contrast enhancing tumor volume CETV were identified. We quantified the overlap between manual and automated segmentation by calculation of diameter measurements as well as the Dice coefficients, the positive predictive values, sensitivity, relative volume error and absolute volume error. RESULTS Comparison of automated versus manual extraction of 2-dimensional diameter measurements showed no significant difference (p = 0.29). Comparison of automated versus manual segmentation of volumetric segmentations showed significant differences for TV+ and TV (p<0.05) but no significant differences for CETV (p>0.05) with regard to the Dice overlap coefficients. Spearman's rank correlation coefficients (ρ) of TV+, TV and CETV showed highly significant correlations between automatic and manual segmentations. Tumor localization did not influence the accuracy of segmentation. CONCLUSIONS In summary, we demonstrated that BraTumIA supports radiologists and clinicians by providing accurate measures of cross-sectional diameter-based tumor extensions. The automated volume measurements were comparable to manual tumor delineation for CETV tumor volumes, and outperformed inter-rater variability for overlap and sensitivity.

Patterns and Correlates of Expressed Emotion, Perceived Criticism, and Rearing Style in First Admitted Early-Onset Schizophrenia Spectrum Disorders

The aim of this study was to assess patterns and correlates of family variables in 31 adolescents treated for their first episode of a schizophrenia spectrum disorder (early-onset schizophrenia [EOS]). Expressed emotion, perceived criticism, and rearing style were assessed. Potential correlates were patient psychopathology, premorbid adjustment, illness duration, quality of life (QoL), sociodemographic variables, patient and caregiver "illness concept," and caregiver personality traits and support. Families were rated as critical more frequently by patients than raters (55% vs. 13%). Perceived criticism was associated with worse QoL in relationship with parents and peers. An adverse rearing style was associated with a negative illness concept in patients, particularly with less trust in their physician. Future research should examine perceived criticism as a predictor of relapse and indicator of adolescents with EOS who need extended support and treatment. Rearing style should be carefully observed because of its link with patients' illness concept and, potentially, to service engagement and medication adherence

Effect of standardized training on the reliability of the Cochrane risk of bias assessment tool: a study protocol

BACKGROUND The Cochrane risk of bias (RoB) tool has been widely embraced by the systematic review community, but several studies have reported that its reliability is low. We aim to investigate whether training of raters, including objective and standardized instructions on how to assess risk of bias, can improve the reliability of this tool. We describe the methods that will be used in this investigation and present an intensive standardized training package for risk of bias assessment that could be used by contributors to the Cochrane Collaboration and other reviewers. METHODS/DESIGN This is a pilot study. We will first perform a systematic literature review to identify randomized clinical trials (RCTs) that will be used for risk of bias assessment. Using the identified RCTs, we will then do a randomized experiment, where raters will be allocated to two different training schemes: minimal training and intensive standardized training. We will calculate the chance-corrected weighted Kappa with 95% confidence intervals to quantify within- and between-group Kappa agreement for each of the domains of the risk of bias tool. To calculate between-group Kappa agreement, we will use risk of bias assessments from pairs of raters after resolution of disagreements. Between-group Kappa agreement will quantify the agreement between the risk of bias assessment of raters in the training groups and the risk of bias assessment of experienced raters. To compare agreement of raters under different training conditions, we will calculate differences between Kappa values with 95% confidence intervals. DISCUSSION This study will investigate whether the reliability of the risk of bias tool can be improved by training raters using standardized instructions for risk of bias assessment. One group of inexperienced raters will receive intensive training on risk of bias assessment and the other will receive minimal training. By including a control group with minimal training, we will attempt to mimic what many review authors commonly have to do, that is-conduct risk of bias assessment in RCTs without much formal training or standardized instructions. If our results indicate that an intense standardized training does improve the reliability of the RoB tool, our study is likely to help improve the quality of risk of bias assessments, which is a central component of evidence synthesis.

The Multimodal Brain TumorImage Segmentation Benchmark (BRATS)

In this paper we report the set-up and results of the Multimodal Brain Tumor Image Segmentation Benchmark (BRATS) organized in conjunction with the MICCAI 2012 and 2013 conferences. Twenty state-of-the-art tumor segmentation algorithms were applied to a set of 65 multi-contrast MR scans of low- and high-grade glioma patients - manually annotated by up to four raters - and to 65 comparable scans generated using tumor image simulation software. Quantitative evaluations revealed considerable disagreement between the human raters in segmenting various tumor sub-regions (Dice scores in the range 74-85%), illustrating the difficulty of this task. We found that different algorithms worked best for different sub-regions (reaching performance comparable to human inter-rater variability), but that no single algorithm ranked in the top for all subregions simultaneously. Fusing several good algorithms using a hierarchical majority vote yielded segmentations that consistently ranked above all individual algorithms, indicating remaining opportunities for further methodological improvements. The BRATS image data and manual annotations continue to be publicly available through an online evaluation system as an ongoing benchmarking resource.

Moments of tension and strain in psychotherapy and how they promote a good alliance and outcome

It is well established that the therapeutic relationship contributes about as much to therapy outcome as ‘technical’ intervention. Furthermore, it follows clear prescriptive concepts in the same manner as technical interventions do. ‘Motive Oriented Therapeutic Relationship’ is such a concept for establishing a solid basis for whatever therapeutic work the patients’ problems require (Grawe, 1980, 1992; Caspar, 1996). Yet, the therapeutic relationship doesn’t explain everything because other factors play a significant role too. Previous studies showed that outcome is clearly better when therapists achieved a generally high quality of a therapeutic relationship when they did not shy away from possibly threatening interventions such as confrontations. This ratio of a fruitful alliance and marginally present confrontations in the same session also showed significant correlations with patient’s assessment of alliance and progress in therapy (Figlioli et al., 2009). The current state of research in the field, however, does not give any answers to questions like how good and bad confrontations can be characterized or what role does the intensity, respectively frequency of confrontations play in the process of psychotherapy. Therefore, we analyzed a sample of 80 therapies of 3 sessions each representing either good or bad outcome. Independent raters judged moment by moment how therapists used confrontative interventions. 20 cases, which showed an excellent or a very poor outcome, as well as an unexpected pattern were analyzed in further quantitative details. We found that confrontations are correlated to good outcome when they are uttered implicitly, related to an important topic of the patient (e.g. one of the defined therapy goals), long but weak, embedded in prior complementarity and not in the first three sessions of a therapy, as well as not an interactional discrepancy between the patient and the therapist.

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.

Nasolabial symmetry and esthetics in cleft lip and palate: analysis of 3D facial images

OBJECTIVES To determine the relationship between nasolabial symmetry and esthetics in subjects with orofacial clefts. MATERIAL AND METHODS Eighty-four subjects (mean age 10 years, standard deviation 1.5) with various types of nonsyndromic clefts were included: 11 had unilateral cleft lip (UCL); 30 had unilateral cleft lip and alveolus (UCLA); and 43 had unilateral cleft lip, alveolus, and palate (UCLAP). A 3D stereophotogrammetric image of the face was taken for each subject. Symmetry and esthetics were evaluated on cropped 3D facial images. The degree of asymmetry of the nasolabial area was calculated based on all 3D data points using a surface registration algorithm. Esthetic ratings of various elements of nasal morphology were performed by eight lay raters on a 100 mm visual analog scale. Statistical analysis included ANOVA tests and regression models. RESULTS Nasolabial asymmetry increased with growing severity of the cleft (p = 0.029). Overall, nasolabial appearance was affected by nasolabial asymmetry; subjects with more nasolabial asymmetry were judged as having a less esthetically pleasing nasolabial area (p < 0.001). However, the relationship between nasolabial symmetry and esthetics was relatively weak in subjects with UCLAP, in whom only vermilion border esthetics was associated with asymmetry. CONCLUSIONS Nasolabial symmetry assessed with 3D facial imaging can be used as an objective measure of treatment outcome in subjects with less severe cleft deformity. In subjects with more severe cleft types, other factors may play a decisive role. CLINICAL SIGNIFICANCE Assessment of nasolabial symmetry is a useful measure of treatment success in less severe cleft types.

Description and repeatability of a newly developed spinal cord injury scale for dogs.

The objectives of this study were to describe a new spinal cord injury scale for dogs, evaluate repeatability through determining inter-rater variability of scores, compare these scores to another established system (a modified Frankel scale), and determine if the modified Frankel scale and the newly developed scale were useful as prognostic indicators for return to ambulation. A group of client-owned dogs with spinal cord injury were examined by 2 independent observers who applied the new Texas Spinal Cord Injury Score (TSCIS) and a modified Frankel scale that has been used previously. The newly developed scale was designed to describe gait, postural reactions and nociception in each limb. Weighted kappa statistics were utilized to determine inter-rater variability for the modified Frankel scale and individual components of the TSCIS. Comparisons were made between raters for the overall TSCIS score and between scales using Spearman's rho. An additional group of dogs with surgically treated thoracolumbar disk herniation was enrolled to look at correlation of both scores with spinal cord signal characteristics on magnetic resonance imaging (MRI) and ambulatory outcome at discharge. The actual agreement between raters for the modified Frankel scale was 88%, with a weighted kappa value of 0.93. The TSCIS had weighted kappa scores for gait, proprioceptive positioning and nociception components that ranged from 0.72 to 0.94. Correlation between raters for the overall TSCIS score was Spearman's rho=0.99 (P<0.001). Comparison of the overall TSCIS score to the modified Frankel score resulted in a Spearman's rho value of 0.90 (P<0.001). The modified Frankel score was weakly correlated with the length of hyperintensity of the spinal cord: L2 vertebral body length ratio on mid-sagittal T2-weighted MRI (Spearman's rho=-0.45, P=0.042) as was the overall TSCIS score (Spearman's rho=-0.47, P=0.037). There was also a significant difference in admitting modified Frankel scores (P=0.029) and admitting overall TSCIS scores (P=0.02) between dogs that were ambulatory at discharge and those that were not. Results from this study suggest that the TSCIS is an easy to administer scale for evaluating canine spinal cord injury based on the standard neurological exam and correlates well with a previously described modified Frankel scale.

Clinical Evaluation of a Fully-automatic Segmentation Method for Longitudinal Brain Tumor Volumetry.

Information about the size of a tumor and its temporal evolution is needed for diagnosis as well as treatment of brain tumor patients. The aim of the study was to investigate the potential of a fully-automatic segmentation method, called BraTumIA, for longitudinal brain tumor volumetry by comparing the automatically estimated volumes with ground truth data acquired via manual segmentation. Longitudinal Magnetic Resonance (MR) Imaging data of 14 patients with newly diagnosed glioblastoma encompassing 64 MR acquisitions, ranging from preoperative up to 12 month follow-up images, was analysed. Manual segmentation was performed by two human raters. Strong correlations (R = 0.83-0.96, p < 0.001) were observed between volumetric estimates of BraTumIA and of each of the human raters for the contrast-enhancing (CET) and non-enhancing T2-hyperintense tumor compartments (NCE-T2). A quantitative analysis of the inter-rater disagreement showed that the disagreement between BraTumIA and each of the human raters was comparable to the disagreement between the human raters. In summary, BraTumIA generated volumetric trend curves of contrast-enhancing and non-enhancing T2-hyperintense tumor compartments comparable to estimates of human raters. These findings suggest the potential of automated longitudinal tumor segmentation to substitute manual volumetric follow-up of contrast-enhancing and non-enhancing T2-hyperintense tumor compartments.

Improving residency training with the help of multisource feedback: Generation of a model of influencing factors

Background: Feedback is considered to be one of the most important drivers of learning. One form of structured feedback used in medical settings is multisource feedback (MSF). This feedback technique provides the opportunity to gain a differentiated view on a doctor’s performance from several perspectives using a questionnaire and a facilitating conversation, in which learning goals are formulated. While many studies have been conducted on the validity, reliability and feasibility of the instrument, little is known about the impact of factors that might influence the effects of MSF on clinical performance. Summary of Work: To study under which circumstances MSF is most effective, we performed a literature review on Google Scholar with focus on MSF and feedback in general. Main key-words were: MSF, multi-source-feedback, multi source feedback, and feedback each combined with influencing/ hindering/ facilitating factors, effective, effectiveness, doctors-intraining, and surgery. Summary of Results: Based on the literature, we developed a preliminary model of facilitating factors. This model includes five main factors influencing MSF: questionnaire, doctor-in-training, group of raters, facilitating supervisor, and facilitating conversation. Discussion and Conclusions: Especially the following points that might influence MSF have not yet been sufficiently studied: facilitating conversation with the supervisor, individual aspects of doctors-in-training, and the causal relations between influencing factors. Overall there are only very few studies focusing on the impact of MSF on actual and long-term performance. We developed a preliminary model of hindering and facilitating factors on MSF. Further studies are needed to better understand under which circumstances MSF is most effective. Take-home messages: The preliminary model might help to guide further studies on how to implement MSF to use it at its full potential.

Assessing childhood difficulties: Comparing the SDQ and the BASC-2

This study of the Behavior Assessment System for Children, Second Edition (BASC-2), had two objectives. First, was to compare the Strengths and Difficulties Questionnaire (SDQ) and the BASC-2. Participants were students from SBISD, identified as having difficulties, assessed with the BASC-2 and completed the SDQ. Based on the small sample (N=8), scores from the SDQ and the BASC-2 were found to correlate highly with one another on most conceptually similar scales. With both Parent and Teacher raters, diagnostic concordance was high for nearly all behavior and emotional problem scales. While the diagnostic concordance of the SDQ and BASC-2 looks promising, results need to be replicated with a larger sample. ^ The second objective was to assess the BASC-2 inter-informant concordance (parent, teacher and child). Participants were 145 students, 3-17 years, 78.6% male, 28% Hispanic, 37% White, 34% Black, and 64% were economically disadvantaged. Of the four dyads, teacher-teacher pairs had the highest correlations and agreement levels, especially on externalizing scale items, regardless of the subjects' age group, gender or ethnicity. ^ Overall, parent-teacher pairs had low to moderate concordance for most scale items, with slightly higher agreement for externalizing problems, with better concordance for preschool children, very low correlations with girls' ratings, but moderate correlations with boy ratings. Correlational results were generally moderate for teachers and parents of White children and low for teachers and parents of Hispanic and Black children. ^ Parent-child self-reports had low concordance for nearly all scale items evaluated, particularly with girl self-raters, but moderate with the boys. Conversely, Teacher-Girl pairs had larger correlations than with Boy. Parents reported substantially higher frequency of disorder endorsement than reported by the children, regardless of the child's ethnicity or gender. While generally low, Teachers and Black students had higher concordance on internalizing measures than Hispanic or White students. Parents of Black students had higher frequency of disorder endorsements than other ethnicities. ^ The difference in format and lack of externalizing measures on the self-report version (SRP) hinders inter-rater comparisons. Future studies using the revised, BASC-2 with children in a school-based setting are needed to assess further its rater reliability. ^

The role of environmental tobacco smoke in the development and exacerbation of asthma among children in developing countries: A systematic review

Environmental tobacco smoke (ETS) is an important indoor air pollutant associated with adverse effects on the respiratory health of the general population, especially people with asthma. ETS consists mainly of sidestream smoke from burning cigarettes and a smaller quantity of mainstream smoke which is exhaled by the smoker. At least one out of every three children is frequently exposed to ETS. ^ This paper reviewed the literature for studies on the role of ETS in the development and exacerbation of asthma among children in developing countries, specifically the low and middle income countries from the year 1980 to the present. The databases searched in this systematic review were: Ovid Medline; PubMed (National Library of Medicine); and Cumulative Index to Nursing and Allied Health (CINAHL) (EBSCOhost). Out of a total of 197 articles initially identified, only four studies (two from China, one from Macedonia and one from Brazil) were rated by two independent raters as being of high quality, and were selected for final abstraction, synthesis and evidence weighting. Results from these four studies suggests that, in developing countries, ETS exposure is associated with childhood asthma, and that asthma prevalence increases with an increase in the amount and duration of exposure to ETS. Similarly, exposure to ETS is associated with persistent cough, current night dry cough, and exacerbation of asthma symptoms. ^ Therefore, as is the case in developed nations, there is suggestive evidence in the literature that ETS exposure plays substantial role in the development and/or exacerbation of asthma among children in developing countries. To decrease the likelihood of new asthma development, enhance asthma control, and reduce the rate of medical service utilization in children exposed to ETS, smoking should be eliminated at home and in public places.^

A study of nutrition promotion in and consumer nutrition environments of hospitals

Dietary intake is a complex, health-related behavior, and although individual-level theoretical models explain some variation in dietary intake, comprehensive theoretical models such as the ecological framework describe the multiple levels which influence diet-related behaviors. Thus, the ecological framework is a preferred model for designing comprehensive nutrition interventions. While ecological-based nutrition interventions have been described, little work has focused on interventions in the hospital setting. Because hospitals are considered the hallmarks of health, it might seem that hospitals would regularly engage in worksite nutrition promotion; however, recent publications and other anecdotal evidence have indicated otherwise. The first paper of this dissertation systematically reviewed the scientific literature between 1996 and 2012 and identified 13 outcome evaluation trials for hospital-based worksite nutrition interventions. Of these 13 interventions, only one intervention targeted three of the four levels of the ecological framework and no intervention targeted all four levels. Only half of the interventions targeted the physical environment of hospitals, thus warranting more investigation into this specific level of the ecological framework in this setting. ^ A critical type of nutrition-related physical environments is the consumer nutrition environment. Although other tools measure the consumer nutrition environments of stores and restaurants, no tool specifically measured the consumer nutrition environments of hospitals until the CDC developed the Healthy Hospital Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HHES-CVG). The HHES-CVG, a tool which measures the consumer nutrition environments of hospital cafeterias, vending machines, and gifts shops, was released in November 2011, and in the second paper of this dissertation, the reliability of this tool was investigated. Two trained raters visited 39 hospitals across Southern California between February and May 2012, and based on analyses of the raters' findings, the HHES-CVG exhibited strong reliability metrics (inter-observer agreement between 74 and 100%, and an intraclass correlation coefficient of 0.961 for the overall nutrition composite score). Because the HHES-CVG was found to be a reliable tool, the third paper of this dissertation presented HHES-CVG results from the 39 hospitals. Overall, hospitals only scored about one-fourth of the total possible points for the nutrition composite score, indicating that most facilities do not have acceptable consumer nutrition environments. Some of the best practices observed in cafeterias were significantly associated with having a large facility and with having a contracted foodservice operation, but overall nutrition composite score was not associated with any specific facility or operation type. ^ The dissertation concluded that much work is needed in order to improve the consumer nutrition environments of hospitals. Practitioners and healthcare administrators should consider starting with ecological-based interventions addressing all levels including the physical environment.^

Desarrollo y validación de una escala para evaluación de daño por orugas defoliadoras en soja (Glycine max L.), para el sur de la provincia de Córdoba

Para desarrollar y validar una escala logarítmica diagramática de evaluación de daño por orugas defoliadoras al cultivo de soja, para el centro-sur de Córdoba, se colectaron folíolos dañados a fin de obtener la máxima defoliación presente. Se calculó el porcentaje de defoliación escaneando cada folíolo, utilizando el software WinFolia. Se planteó una escala de siete clases obteniendo el valor medio de cada una con el programa DOSLOG. Posteriormente 140 folíolos, cuya defoliación real se determinó con WinFolia, fueron evaluados por seis evaluadores con y sin experiencia previa en estimaciones de defoliación, con y sin escala. La validación por precisión y exactitud se realizó por regresión lineal simple entre la defoliación real y la estimada, y la reproducibilidad por regresión entre las 140 estimaciones de los evaluadores combinados de a pares. Sin la escala la mayoría de los evaluadores sobreestimaron la defoliación, indicando desvíos positivos constantes para todos los niveles, y en 9 de 12 evaluadores ocurrieron desvíos sistemáticos. Con la escala mejoró la exactitud (-1,74 a 1,39), precisión (0,77 a 0,90) y reproducibilidad, por lo que se la considera adecuada para evaluaciones de daños causados por orugas defoliadoras al cultivo de soja, en la región centro-sur de Córdoba.