Die Beurteilung von Arztgesprächen beim Überbringen schlechter Nachrichten

Kommunikationsfähigkeit ist für die Qualität der medizinischen Versorgung wichtig. Daher gibt es eine Reihe von Methoden, die ärztliche Gesprächsleistung zu erfassen. In der vorliegenden Arbeit wurde diese Leistung mittels einer Adaptation des „Breaking Bad News Assessment Schedule“, kurz BAS, der sogenannten „Aufklärungsgesprächbewertungsskala“, kurz AGBS, in Form einer Replikationsstudie untersucht. Zusätzlich zum primären Ziel, die Gütekriterien Interrater-Reliabilität und Validität zu überprüfen, wurde das Studiendesign um eine Re-Test-Reliabilität erweitert. Neben der Bedeutung für die Testgüte sollte so auch die Frage nach der Stabilität der Raterleistung und dem Umfang der Raterschulung beantwortet werden. Es wurden insgesamt 50 Videoaufzeichnungen von Medizinstudenten und Ärzten mit Rollenspielen von Gesprächssituationen eines Arztes mit einem Elternpaar untersucht. Alle bisher erfolgten Anwendungen, von der Entwicklung des BAS über die Adaptation als AGBS bis hin zur vorliegenden Replikationsstudie, konnten zeigen, dass es sich um ein sehr gutes Instrument handelt. So ergab sich über alle Überprüfungsstufen eine durchweg sehr gute Validität mittels Cronbach’s α von deutlich über 0,8 und eine stabile Reliabilität mittels ICC von über 0,8. Es konnte gezeigt werden, dass Interraterreliabilität Schulung erfordert und die Re-Rate- oder Intraraterreliabilität mit dem durchgeführten Training über 6 Monate konstant war. Die Ergebnisse deuten daraufhin, dass mithilfe des Instrumentes bislang nicht alle der für die Arzt-Patienten-Kommunikation notwendigen Kompetenzen erfasst werden, so dass Weiterentwicklungen des Instrumentes sinnvoll erscheinen

DNA methylation analysis of the angiotensin converting enzyme (ACE) gene in major depression.

The angiotensin converting enzyme (ACE) has been repeatedly discussed as susceptibility factor for major depression (MD) and the bi-directional relation between MD and cardiovascular disorders (CVD). In this context, functional polymorphisms of the ACE gene have been linked to depression, to antidepressant treatment response, to ACE serum concentrations, as well as to hypertension, myocardial infarction and CVD risk markers. The mostly investigated ACE Ins/Del polymorphism accounts for ~40%-50% of the ACE serum concentration variance, the remaining half is probably determined by other genetic, environmental or epigenetic factors, but these are poorly understood. The main aim of the present study was the analysis of the DNA methylation pattern in the regulatory region of the ACE gene in peripheral leukocytes of 81 MD patients and 81 healthy controls. We detected intensive DNA methylation within a recently described, functional important region of the ACE gene promoter including hypermethylation in depressed patients (p = 0.008) and a significant inverse correlation between the ACE serum concentration and ACE promoter methylation frequency in the total sample (p = 0.02). Furthermore, a significant inverse correlation between the concentrations of the inflammatory CVD risk markers ICAM-1, E-selectin and P-selectin and the degree of ACE promoter methylation in MD patients could be demonstrated (p = 0.01 - 0.04). The results of the present study suggest that aberrations in ACE promoter DNA methylation may be an underlying cause of MD and probably a common pathogenic factor for the bi-directional relationship between MD and cardiovascular disorders

First results of a refeeding program in a psychiatric intensive care unit for patients with extreme anorexia nervosa

Background Anorexia nervosa (AN) is associated with a high mortality rate. This study describes a compulsory re-feeding program established in Munich for extremely underweight patients. Methods The contract between the patient and the therapeutic team included mandatory inpatient status, establishment of guardianship and compulsory re-feeding with a percutaneous gastric feeding tube, as indicated. The predefined target was a body mass index (BMI) of 17 kg/m2. Data on the first 68 patients with AN are presented. Results 65 (95.6%) patients were female and mean age at admission was 26.5 ± 8.5 years. BMI increased from 12.3 ± 1.4 kg/m2 at admission to 16.7 ± 1.7 kg/m2 at discharge. Thirty-two (47.1%) patients had the restrictive subtype (ANR) and 36 (52.9%) had the binging and purging subtype (ANBP). Duration of illness before admission (p = .004), days of treatment until discharge (p = .001) and weight increase (p = .02) were significantly different between subgroups in favor of patients with ANR. Also, seasonal differences could be found. Comparison of feeding methods showed that percutaneous tube feeding was superior. Almost half of the patients were treated with psychotropic medication. To date, however, the number of patients included in this program is too small to assess rare complications of this acute treatment program and long term outcomes of AN. Conclusions An intensive care program for severely ill AN patients has been successfully established. Besides averting physical harm in the short term, this program was designed to enable these patients to participate in more sophisticated psychotherapeutic programs afterwards. To our knowledge, this is the first such program that regularly uses percutaneous feeding tubes

Demographic characteristics of the depressed patients (MD) and healthy controls (CON).

<p>Demographic characteristics of the depressed patients (MD) and healthy controls (CON).</p

Frequency of DNA methylation at 24 CpG sites, located in the (−456/−255) region of the ACE gene in human post mortem samples of hippocampus and cortex from 13 control individuals.

<p>Frequency of DNA methylation at 24 CpG sites, located in the (−456/−255) region of the ACE gene in human post mortem samples of hippocampus and cortex from 13 control individuals.</p

Frequency of DNA methylation in the investigated ACE promoter region.

<p>(a) Frequency of DNA methylation at 24 CpG sites, located in the (−456/−255) region of the ACE gene in depressive patients (MD) and healthy controls (CON); *: p<0.05 (χ2-test). (b) Sequence of the (−456/−255) region (italic, underlined) including the 24 investigated CpG sites (bold). (c) Frequency of methylation and non-methylation at the 24 CpG sites, located in the (−456/−255) region of the ACE gene in depressive patients (MD) and healthy controls (CON). Patients have a significantly higher methylation status than the healthy controls (p = 0.008, χ2 = 7.1, df = 1). *: p<0.05 (χ2-test).</p

Correlation analysis between the inflammatory marker serum concentrations (baseline) and the ACE methylation frequency over all 24 CpG sites of each probe.

<p>We found a significant inverse correlation between the methylation frequency and the serum baseline concentrations of ICAM-1 (r = −0.289, p = 0.02), E-selectin (r = −0.249, p = 0.04) and P-selectin (r = −0.333, p = 0.01); (Pearson’s correlation).</p

ACE serum concentrations (baseline) among the total sample, medication-free depressive patients (MD) and controls (CON) in relation to their methylation status in the (−456/−255) region of the ACE gene.

<p>Methylated probes showed lower ACE concentrations (p = 0.005, F = 8.1). This effect was also obvious in depressive patient (p = 0.03, F = 5.1). In the control group there was a similar pattern, but without statistical significance. *: p<0.05 (ANCOVA). Data are mean values ± s.e.m.</p

Serum concentrations of inflammatory markers (baseline) among medication-free depressive patients in relation to their methylation status in the (−456/−255) region of the ACE gene.

<p>Patients with methylated CpG sites in the (−456/−255) region showed decreased concentrations of all inflammatory markers compared to unmethylated patient samples (not statistically significant).</p