Risk stratification in cardiac surgery: is it worthwhile?

Outcome analysis of many surgical procedures has become increasingly important to surgeons, institutions, and the public. Because there may be wide differences in case mix, outcomes must be evaluated in light of the patient's preoperative status. All relevant preoperative conditions must be identified and weighted, so that when risk factor scores are combined in some fashion, they will provide a single preoperative risk estimate for the individual patient, representing the likelihood of dying as a consequence of the operation. Comparing the mean risk adjusted score of a group of patients undergoing the same procedure with the observed mortality rate for the same group yields an index of the quality of care, provided all preoperative risk scores are calculated with reference to the same benchmark. We question the logic and wisdom of surgical outcome analysis because of the infinitely complex nature of biological and pathological processes, as well as the practical problems of reliable data collection. The assumption of true scientific accuracy may be illusory. Even though risk adjusted outcome analysis has merit in studying trends in therapy, it should be regarded with caution when used as a tool for evaluating quality of care. If publicized at all, the results should not be represented as "hard" scientific fact.     

Hot or cold: Is communicating anger or threats more effective in negotiation?

Is communicating anger or threats more effective in eliciting concessions in negotiation? Recent research has emphasized the effectiveness of anger communication, an emotional strategy. In this article, we argue that anger communication conveys an implied threat, and we document that issuing threats is a more effective negotiation strategy than communicating anger. In 3 computer-mediated negotiation experiments, participants received either angry or threatening messages from a simulated counterpart. Experiment 1 showed that perceptions of threat mediated the effect of anger (vs. a control) on concessions. Experiment 2 showed that (a) threat communication elicited greater concessions than anger communication and (b) poise (being confident and in control of one's own feelings and decisions) ascribed to the counterpart mediated the positive effect of threat compared to anger on concessions. Experiment 3 replicated this positive effect of threat over anger when recipients had an attractive alternative to a negotiated agreement. These findings qualify previous research on anger communication in negotiation. Implications for the understanding of emotion and negotiation are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Is satisfaction with self a measure of adjustment?

Two hypotheses tested in this experiment are "(a) degree of self-satisfaction is curvilinearly related to the social dimension of adjustment and (b) degree of self-satisfaction is ordinarily related to the conceptual dimension of ego-control." Both hypotheses are supported when tested on a sample of 56 college students by comparing their MMPI scores with their ratings of self relevance on a list of 80 adjectives. Implications are drawn with regard to an index of effectiveness of psychotherapy proposed by Rogers. The concept of metastability of adjustment is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is androgen deprivation therapy effective in the treatment of sex offenders?

We review the effects of androgen deprivation on the sexual behavior of human males. Although eunuchs have existed in many cultures over the last 4,000 years, there is scant detailed and specific information in the historical record about castration status and sexual behavior. From the literature on modern-day eunuchs who are not sex offenders, we conclude that androgen deprivation reduces sexual desire and behavior, including sexual intercourse. Most men, especially those who did not volunteer for the treatment, experience the side effects as extremely bothersome. Androgen deprivation therapy (ADT) receives endorsements from some clinicians who treat sex offenders, and it probably reduces sexual recidivism among men who freely request the procedure, but good evidence is sorely lacking. Men who freely request and persist with ADT are probably an especially low-risk group. Little is known about the effects of sexual or violent recidivism among sex offenders who do not freely request it. Little is known about the long term effects of ADT on sexual behavior in general, and sexual recidivism in particular, or about long-term health effects. Clearly, much more research is needed before ADT has a sufficient scientific basis to be relied upon as a principal component of sex offender treatment. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

What works in coping with HIV? A meta-analysis with implications for coping with serious illness.

Knowledge of effective ways of coping with HIV is critical to help individuals with HIV maintain the best possible psychological and physical well-being. The purpose of the present article is to determine, through meta-analysis, the strength of the evidence regarding 2 questions: (a) Which types of coping are related to psychological and physical well-being among people with HIV? and (b) Do contextual (pre?post introduction of highly active antiretroviral therapies [HAART]; time since diagnosis), measurement (HIV-related event vs. generic prompts for coping measurement), or individual (gender) variables affect the extent to which coping is related to physical and psychological well-being? The authors' analysis demonstrates that Direct Action and Positive Reappraisal were consistently associated with better outcomes in people coping with HIV across affective, health behavior, and physical health categories. In contrast, disengagement forms of coping, such as Behavioral Disengagement and Use of Alcohol or Drugs to Cope, were consistently associated with poorer outcomes. The findings also indicate that in some cases, coping effectiveness was dependent on contextual factors, including time since diagnosis and the advent of HAART. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is EEG useful in assessing patients with acute encephalitis treated with acyclovir?

PURPOSE: Three patients with acute hepatitis B virus infection were identified who had been hospitalized on the same medical ward during a 19-day period several months earlier. An investigation was undertaken to determine if nosocomial transmission had occurred. SUBJECTS AND METHODS: A cohort study of patients admitted to the medical ward during the 19-day period in 1995 was conducted. In addition, we reviewed medical charts and laboratory records of all patients with acute hepatitis B virus infection who had been admitted to the hospital from 1992 through October 1996 to identify other cases with possible nosocomial acquisition. RESULTS: The 3 patients who had developed acute hepatitis B infection 2 to 5 months after hospitalization on the same medical ward had diabetes mellitus but no identified risk factors for hepatitis B infection. A source patient with diabetes mellitus and hepatitis B "e" antigenemia also was present on the same medical ward at the same time; all 4 patients were infected with the same viral subtype (adw2). Diabetes mellitus and fingerstick monitoring were associated with illness (P <0.001). Through the review of medical charts and laboratory records, 11 additional cases of suspected nosocomial acquisition via fingersticks were identified in 1996, including two clusters involving an unusual subtype of hepatitis B virus (adw4). The fingerstick device employed had a reusable base onto which disposable lancet caps were inserted. There was ample opportunity for cross-contamination among patients because deficiencies in infection control practices, particularly failure to change gloves between patients, were reported by nurses and patients with diabetes mellitus. CONCLUSION: Transmission during fingerstick procedures was the most likely cause of these cases of nosocomial hepatitis B infection. Contamination probably occurred when healthcare workers failed to change gloves between patients undergoing fingerstick monitoring, although other means of contamination cannot be ruled out.     

Adverse impact: Is it a viable concept?

It appears that those federal agencies responsible for enforcement persist in the belief that a given test score can mean one thing in one subgroup and something else in another and/or that inferences from a set of test scores can be valid for one subgroup but not for another. First surfacing in early agency regulations in connection with the now discontinued "differential validity" requirement, the belief still manifests itself in the concepts of "unfairness" and "adverse impact." Furthermore, the determination of the presence or absence of adverse impact on the basis of the impact ratio involves numerous statistical and measurement issues. Use of the impact ratio to establish the prosecutorial posture of an enforcement agency is clearly flawed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is the common 677C-->T mutation in the methylenetetrahydrofolate reductase gene a risk factor for neural tube defects? A meta-analysis

In both jurisdiction and medical science, given conditions require appropriate intervention, which may in turn result in norms being created. Norms, however, counteract individuality. An essential prerequisite for free decision--making is an absolute awareness of all possibilities available. Therefore the physician/surgeon too, is obliged to impart all relevant information to the patient prior to an operation to enable the patient to reach a decision, either to agree to or refuse the operation. This process of information transfer may sometimes fail on one or both sides. Treatment errors are usually classified according to scientific medical practice. In the case of "breach to duty in information patient" the final decision is the judges. As judicial decisions are not foreseeable, the communication between patient and surgeon thus becomes standardized and doctors tend to become defensive, resulting in the information becoming even more extensive covering all possible situations. There is no guarantee of success in surgery. Selective perception on the part of the patient is unavoidable and confidence in the relationship between patient and surgeon is beneficial to the patient's rehabilitation. Therefore, we should strive to decriminalize the preoperative talk held between surgeon and patient.     

Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?

BACKGROUND AND OBJECTIVE: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals. METHODS: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology. RESULTS: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat." CONCLUSIONS: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.     

Is there a pervasive implicit bias against theism in psychology?

To address the title question, the authors first conceptualize the worldview of theism in relation to its historical counterpart in Western culture, naturalism. Many scholars view the worldview of naturalism as not only important to traditional science but also neutral to theism. This neutrality has long provided the justification for psychological science to inform and even correct theistic understandings. Still, this view of neutrality, as the authors show, stems from the presumption that these two worldviews are philosophically compatible. The authors’ review of the traditional candidates for compatibility suggests not only that these candidates fail to reconcile naturalism and theism but also that these worldviews are fundamentally incompatible. Therefore, attempts to use the insights gleaned from a naturalistic worldview to inform or correct the understandings of a theistic worldview could constitute a significant prejudice against theism and theists. The authors then provide practical examples of this prejudice in the following: (1) mainstream psychology and its history, (2) research design and explanation in the psychology of religion, and (3) interpretations of important philosophers and scholars relevant to psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Self-efficacy as a health-protective resource in teachers? A biopsychological approach.

Objective: To examine the psychobiological correlates of self-efficacy in teachers. Design: Study 1 examined associations between teacher self-efficacy and cardiac activation on a working day and Study 2 assessed the cortisol morning response in teachers with varying levels of teacher self-efficacy. Main outcome measures: Teacher self-efficacy was assessed by questionnaire. In Study 1 heart rate, heart rate variability, and locomotor activity were recorded by 22 hours ambulatory monitoring and subjective measures of stress and strain were obtained. Study 2 assessed the cortisol response to awakening to obtain a measure of HPA-axis activation and teachers filled in a questionnaire on physical complaints. Results and Conclusion: Study 1 found that self-efficacy proved protective for psychological well-being. Moreover, after controlling for locomotor activity, demographic, and lifestyle variables, self-efficacy was associated with elevated heart rate and attenuated heart rate variability during school and leisure time, respectively, but not during the night, thus questioning the health-implications of self-efficacy. Study 2 found that teachers high in self-efficacy exhibited an attenuated cortisol response to awakening and fewer cardiac complaints. The results of both studies are compatible with the view that teacher self-efficacy might act as a physiological toughening agent with possibly favorable health outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is ambulatory electrocardiography useful in the evaluation of patients with recent stroke?

This study was designed to determine whether ambulatory electrocardiography in patients with recent stroke would lead to a change in clinical management or outcome and to express these findings in terms of cost benefit. A prospective, consecutive sample of patients (n = 100) with recent stroke referred from the neurology or medical services for ambulatory electrocardiography was identified. Ambulatory electrocardiograms were reviewed to identify patients with potentially important bradyarrhythmias, tachyarrhythmias, or atrial fibrillation. Patients were then followed up without interference with ongoing care to determine whether these findings led to changes in clinical management that might influence patient outcome. Of the 100 patients, 16 had an index "important" arrhythmia. No significant bradyarrhythmias were noted. Nonsustained ventricular tachycardia (> or = 6 complexes) in two patients and supraventricular tachycardia (> or = 10 complexes) in seven patients did not lead to management changes. Four patients had a history of atrial fibrillation who were in sinus rhythm; anticoagulation had been addressed in three; the fourth patient died before the issue could be addressed. Of three patients in atrial fibrillation, there was a history of atrial fibrillation and a decision regarding anticoagulation in each before monitoring. The cost of these 100 ambulatory electrocardiograms was about $55,000. In conclusion, these findings do not support the routine use of ambulatory electrocardiography in the evaluation of patients with stroke.     

Is the orthographic/phonological onset a single unit in reading aloud?

Two main theories of visual word recognition have been developed regarding the way orthographic units in printed words map onto phonological units in spoken words. One theory suggests that a string of single letters or letter clusters corresponds to a string of phonemes (Coltheart, 1978; Venezky, 1970), while the other suggests that a string of single letters or letter clusters corresponds to coarser phonological units, for example, onsets and rimes (Treiman & Chafetz, 1987). These theoretical assumptions were critical for the development of coding schemes in prominent computational models of word recognition and reading aloud. In a reading-aloud study, we tested whether the human reading system represents the orthographic/phonological onset of printed words and nonwords as single units or as separate letters/phonemes. Our results, which favored a letter and not an onset-coding scheme, were successfully simulated by the dual-route cascaded (DRC) model (Coltheart, Rastle, Perry, Langdon, & Ziegler, 2001). A separate experiment was carried out to further adjudicate between 2 versions of the DRC model. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Exile as a dissociative state: When a self is “lost in transit”.

The author explores “exile” as both a migratory and psychological phenomenon, with particular emphasis on it as a state of mind—one that, by virtue of the dissociative processes by which it is characterized, forecloses the (psychic) possibility of immigration. From this point of view, an exile is not simply one who cannot (physically) return; she is someone who cannot “remember” other versions of herself, who cannot bridge the gaps between versions of self rooted in disparate times, physical spaces and relationships, who cannot “stand in the spaces” between self-states. With a view of clinical process that forefronts dissociative phenomena in both patient and analyst/therapist, and their enactment in the therapeutic relationship, the author describes various forms of exile that emerged in working with his patient, Maria. He focuses on how, over time, the enactment of negation or “not-ness” (specifically, “not-Germanness” and “not-Jewishness”) in the therapeutic relationship catalyzed recognition and negotiation of exiled self-states in both patient and therapist—self-states that could themselves be understood as refractions of transgenerational exile, rooted in the respective (and respectively denied) European heritages of both patient and therapist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is resection of pulmonary and hepatic metastases warranted in patients with colorectal cancer?

BACKGROUND: Conventional management of stage IV colorectal carcinoma is palliative. The value of resecting both liver and lung colorectal metastases that occur in isolation of other sites of metastasis is undetermined. OBJECTIVES: Our objectives were to (1) assess the efficacy of resecting both hepatic and pulmonary metastases, (2) investigate the influence of the sequence and timing of metastases, and (3) identify the profile of patients likely to benefit from both hepatic and pulmonary metastasectomy. Patients and methods: Of 48 patients identified with resection of colorectal cancer and, at some point in time, both liver and lung metastases, 25 patients underwent metastasectomy (resection group). The remaining 23 patients comprised the nonresection group. Risk factors for death were identified by multivariable analyses. RESULTS: Median survival was longer after the last metastatic appearance in the resection group (16 months) than in the nonresection group (6 months; P <.001). The pattern of risk also differed; it peaked at 2 years and then declined in the resection group but was constant in the nonresection group. In the resection group, patients with metachronous resections survived longer after colorectal resection (median, 70 months) than patients with synchronous (median, 22 months) or mixed resections (median, 31 months; P <.001). Risk factors for death included older age, multiple liver metastases, and a short disease-free interval. CONCLUSIONS: Younger patients with solitary metachronous metastases to the liver, then the lung, and long disease-free intervals are more likely to benefit from resection of both liver and lung metastases. Patients with risk factors also had better survival with resection than without resection.     

Doctor in the lab: what is it like for a doctor to work with scientists?

As clinical academic medical departments strive to improve the quality of their research, clinicians and scientists are forced into closer liaison. In many cases, clinical departments now have research laboratories directed by "basic scientists" but often staffed, in part at least, by doctors. To someone who has not worked in one, these laboratories may seem uncompromising and forbidding work environments. This article presents a "case report" written from the viewpoints of the doctor, the scientist, and the professor.     

Ethical dilemmas in psychologists accessing Internet data: Is it justified?

Many psychologists search the Internet for both personal and professional information. Although various guidelines have been proposed for psychologists regarding therapeutic services provided over the Internet, few address the ethics and efficacy of gathering information about clients, students, or employees on the web. As quickly as guidelines are written, new technologies create new challenges. With the advent of social networking sites and numerous free and paid data search engines, unique dilemmas have arisen. The ready access of voluminous personal information raises perplexing questions for clinician psychologists, instructors, supervisors, and employers. An overarching consideration addressed in this article is whether in the course of one's professional activities it is ethically appropriate to conduct intentional Internet searches for information about patients, students, or employees. We discuss ethical dilemmas such as right to privacy, trust, confidentiality, informed consent, boundary violations, and best interest of the client, student, or employee. Next we provide a list of some extant electronic sources of information and offer case examples. The article concludes with recommendations that we hope will generate further dialogue and research on these perplexing issues and provide guidance on balancing situationally appropriate flexibility with the need for adopting wise parameters of professional behavior in regard to social networking activities and Internet “investigations.” (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Negative treatment effects: Is it time for a black box warning?

Comments on Negative effects from psychological treatments: A perspective by David Barlow (see record 2009-24989-002). The author addresses negative treatment effects in the psychotherapy field by stating that Barlow provided a historical perspective of clinical psychology’s long-standing interest in studying the positive effects of psychotherapy, and he indicated that although negative treatment effects have long been identified, little attention has been paid to them. Barlow also recommended a greater emphasis on more idiographic approaches to studying negative effects. He further added that “this would be best carried out in the context of a strong collaboration among frontline clinicians and clinical scientists”. I would argue that this may best be carried out between frontline clinicians and their clients. So the science that we use may not be clinical mandates prohibiting, for example, certain treatments but may simply be the sharing of our scientific knowledge about clinical possibilities so as to better inform clients about the treatment they are considering. (PsycINFO Database Record (c) 2010 APA, all rights reserved)