Correcting biases in psychiatric diagnostic practice in Northwest Russia: Comparing the impact of a general educational program and a specific diagnostic training program

<p>Abstract</p> <p>Background</p> <p>A general education in psychiatry does not necessary lead to good diagnostic skills. Specific training programs in diagnostic coding are established to facilitate implementation of ICD-10 coding practices. However, studies comparing the impact of these two different educational approaches on diagnostic skills are lacking. The aim of the current study was to find out if a specific training program in diagnostic coding improves the diagnostic skills better than a general education program, and if a national bias in diagnostic patterns can be minimised by a specific training in diagnostic coding.</p> <p>Methods</p> <p>A pre post design study with two groups was carried in the county of Archangels, Russia. The control group (39 psychiatrists) took the required course (general educational program), while the intervention group (45 psychiatrists) were given a specific training in diagnostic coding. Their diagnostic skills before and after education were assessed using 12 written case-vignettes selected from the entire spectrum of psychiatric disorders.</p> <p>Results</p> <p>There was a significant improvement in diagnostic skills in both the intervention group and the control group. However, the intervention group improved significantly more than did the control group. The national bias was partly corrected in the intervention group but not to the same degree in the control group. When analyzing both groups together, among the background factors only the current working place impacted the outcome of the intervention.</p> <p>Conclusion</p> <p>Establishing an internationally accepted diagnosis seems to be a special skill that requires specific training and needs to be an explicit part of the professional educational activities of psychiatrists. It does not appear that that skill is honed without specific training. The issue of national diagnostic biases should be taken into account in comparative cross-cultural studies of almost any character. The mechanisms of such biases are complex and need further consideration in future research. Future research should also address the question as to whether the observed improvement in diagnostic skills after specific training actually leads to changes in routine diagnostic practice.</p

Impact on continuity of care of decentralized versus partly centralized mental health care in Northern Norway

<p><strong>Background: </strong>The issue of continuity of care is central in contemporary psychiatric services research. In Norway, inpatient admissions are mainly to take place locally, in a system of small bed-units that represent an alternative to traditional central psychiatric hospitals. This type of organization may be advantageous for accessibility and cooperation, but has been given little scientific attention.</p><p><strong>Aims: </strong>To study whether inpatients' utilization of outpatient services differ between an area with a decentralized care model in comparison to an adjacent area with a partly centralized model. <strong> </strong></p><p><strong>Method: </strong>The study was based on data from a one-year registered prevalence sample, drawing on routinely sampled data supplemented with data from medical records. Service-utilization for 247 inpatients was analyzed. The results were controlled for diagnosis, demographic variables, type of service system, localization of inpatient admissions, and length of hospitalization.<strong> </strong></p><p><strong>Results</strong>: Most inpatients in the area with the decentralized care model also utilized outpatient consultations, whereas a considerable number of inpatients in the area with a partly centralized model did not enter outpatient care at all. Type of service system, localization of inpatient admission, and length of hospitalization predicted inpatients' utilization of outpatient consultations. The results are discussed in the light of systems integration, particularly management-arrangements and clinical bridging over the transitional phase from inpatient to outpatient care. </p><p><strong>Conclusion</strong>: Inpatients' utilization of outpatient services differed between an area with a decentralized care model in comparison to an adjacent area with a partly centralized care model. In the areas studied, extensive decentralization of the psychiatric services positively affected coordination of inpatient and outpatient services for people with severe psychiatric disorders. Small, local-bed units may therefore represent a favourable alternative to traditional central psychiatric hospitals.</p

Time-trends in the utilization of decentralized mental health services in Norway - A natural experiment: The VELO-project

<p>Abstract</p> <p>Background</p> <p>There are few reports on the effects of extensive decentralization of mental health services. We investigated the total patterns of utilization in a local-bed model and a central-bed model.</p> <p>Methods</p> <p>In a time-trend case-registry design, 7635 single treatment episodes, from the specialist and municipality services in 2003-2006, were linked to 2975 individual patients over all administrative levels. Patterns of utilization were analyzed by univariate comparisons and multivariate regressions.</p> <p>Results</p> <p>Total treated prevalence was consistently higher for the central-bed system. Outpatient utilization increased markedly, in the central-bed system. Utilization of psychiatric beds decreased, only in the central-bed system. Utilization of highly supported municipality units increased in both systems. Total utilization of all types of services, showed an additive pattern in the local-bed system and a substitutional pattern in the central-bed system. Only severe diagnoses predicted inpatient admission in the central-bed system, whereas also anxiety-disorders and outpatient consultations predicted inpatient admission in the local-bed system. Characteristics of the inpatient populations changed markedly over time, in the local-bed system.</p> <p>Conclusions</p> <p>Geographical availability is not important as a filter in patients' pathway to inpatient care, and the association between distance to hospital and utilization of psychiatric beds may be an historical artefact. Under a public health-insurance system, local psychiatric personnel as gatekeepers for inpatient care may be of greater importance than the availability of local psychiatric beds. Specialist psychiatric beds and highly supported municipality units for people with mental health problems do not work together in terms of utilization. Outpatient and day-hospital services may be filters in the pathway to inpatient care, however this depends on the structure of the whole service-system. Local integration of psychiatric services may bring about additive, rather than substitutional patterns of total utilization. A large proportion of decentralized psychiatric beds may hinder the development of various local psychiatric services, with negative consequences for overall treated prevalence.</p

Decentralization matters – Differently organized mental health services relationship to staff competence and treatment practice: the VELO study

<p>Abstract</p> <p>Background</p> <p>The VELO study is a comparative study of two Community Mental Health Centres (CMHC) in Northern Norway. The CMHCs are organized differently: one has no local inpatient unit, the other has three. Both CMHCs use the Central Mental Hospital situated rather far away for compulsory and other admissions, but one uses mainly local beds while the other uses only central hospital beds. In this part of the study the ward staffs level of competence and treatment philosophy in the CMHCs bed units are compared to Central Mental Hospital units. Differences may influence health service given, resulting in different treatment for similar patients from the two CMHCs.</p> <p>Methods</p> <p>167 ward staff at Vesterålen CMHCs bed units and the Nordland Central Mental Hospital bed units answered two questionnaires on clinical practice: one with questions about education, work experience and clinical orientation; the other with questions about the philosophy and practice at the unit. An extended version of Community Program Philosophy Scale (CPPS) was used. Data were analyzed with descriptive statistics, non-parametric test and logistic regression.</p> <p>Results</p> <p>We found significant differences in several aspects of competence and treatment philosophy between local bed units and central bed units. CMHC staff are younger, have shorter work experience and a more generalised postgraduate education. CMHC emphasises family therapy and cooperation with GP, while Hospital staff emphasise diagnostic assessment, medication, long term treatment and handling aggression.</p> <p>Conclusion</p> <p>The implications of the differences found, and the possibility that these differences influence the treatment mode for patients with similar psychiatric problems from the two catchment areas, are discussed.</p

Decentralization matters - Differently organized mental health services relationship to staff competence and treatment practice : the VELO study

Background: The VELO study is a comparative study of two Community Mental Health Centres (CMHC) in Northern Norway. The CMHCs are organized differently: one has no local inpatient unit, the other has three. Both CMHCs use the Central Mental Hospital situated rather far away for compulsory and other admissions, but one uses mainly local beds while the other uses only central hospital beds. In this part of the study the ward staffs level of competence and treatment philosophy in the CMHCs bed units are compared to Central Mental Hospital units. Differences may influence health service given, resulting in different treatment for similar patients from the two CMHCs. Methods: 167 ward staff at Vesterålen CMHCs bed units and the Nordland Central Mental Hospital bed units answered two questionnaires on clinical practice: one with questions about education, work experience and clinical orientation; the other with questions about the philosophy and practice at the unit. An extended version of Community Program Philosophy Scale (CPPS) was used. Data were analyzed with descriptive statistics, non-parametric test and logistic regression. Results: We found significant differences in several aspects of competence and treatment philosophy between local bed units and central bed units. CMHC staff are younger, have shorter work experience and a more generalised postgraduate education. CMHC emphasises family therapy and cooperation with GP, while Hospital staff emphasise diagnostic assessment, medication, long term treatment and handling aggression. Conclusion: The implications of the differences found, and the possibility that these differences influence the treatment mode for patients with similar psychiatric problems from the two catchment areas, are discussed

Isolated focal lesion in the splenium of the corpus callosum in a patient with acute viral hepatitis A

Mitochondrial dysfunction - Nm vs ctr - FDR5. (XLS 46 kb

Distinct microRNA and protein profiles of extracellular vesicles secreted from myotubes from morbidly obese donors with type 2 diabetes in response to electrical pulse stimulation

Lifestyle disorders like obesity, type 2 diabetes (T2D), and cardiovascular diseases can be prevented and treated by regular physical activity. During exercise, skeletal muscles release signaling factors that communicate with other organs and mediate beneficial effects of exercise. These factors include myokines, metabolites, and extracellular vesicles (EVs). In the present study, we have examined how electrical pulse stimulation (EPS) of myotubes, a model of exercise, affects the cargo of released EVs. Chronic low frequency EPS was applied for 24 h to human myotubes isolated and differentiated from biopsy samples from six morbidly obese females with T2D, and EVs, both exosomes and microvesicles (MV), were isolated from cell media 24 h thereafter. Size and concentration of EV subtypes were characterized by nanoparticle tracking analysis, surface markers were examined by flow cytometry and Western blotting, and morphology was confirmed by transmission electron microscopy. Protein content was assessed by high-resolution proteomic analysis (LC-MS/MS), non-coding RNA was quantified by Affymetrix microarray, and selected microRNAs (miRs) validated by real time RT-qPCR. The size and concentration of exosomes and MV were unaffected by EPS. Of the 400 miRs identified in the EVs, EPS significantly changed the level of 15 exosome miRs, of which miR-1233-5p showed the highest fold change. The miR pattern of MV was unaffected by EPS. Totally, about 1000 proteins were identified in exosomes and 2000 in MV. EPS changed the content of 73 proteins in exosomes, 97 in MVs, and of these four were changed in both exosomes and MV (GANAB, HSPA9, CNDP2, and ATP5B). By matching the EPS-changed miRs and proteins in exosomes, 31 targets were identified, and among these several promising signaling factors. Of particular interest were CNDP2, an enzyme that generates the appetite regulatory metabolite Lac-Phe, and miR-4433b-3p, which targets CNDP2. Several of the regulated miRs, such as miR-92b-5p, miR-320b, and miR-1233-5p might also mediate interesting signaling functions. In conclusion, we have used a combined transcriptome-proteome approach to describe how EPS affected the cargo of EVs derived from myotubes from morbidly obese patients with T2D, and revealed several new factors, both miRs and proteins, that might act as exercise factors

Acute psychiatric admissions from an out-of-hours Casualty Clinic; how do referring doctors and admitting specialists agree?

BACKGROUND: Over the last decades there has been an increasing pressure on the acute psychiatric wards in Norway. The major contributor to psychiatric acute admissions at the University Hospital of North Norway in the city of Tromsø in 2001 was the GP-based Tromsø Casualty Clinic, only open out-of-hours. We explored all acute psychiatric referrals from Tromsø Casualty Clinic in 2001. The purpose of the study was to characterize the admissions and assess the agreement between the referring doctors and the hospital specialists according to the need for hospitalization, agreement on application of the law and the diagnostic evaluation to assess whether the admissions were appropriate. METHODS: Retrospective, record based, descriptive study comprising 101 psychiatric acute referrals from the Tromsø Casualty Clinic to the psychiatric acute wards at the University Hospital of North Norway. RESULTS: The specialists accepted all referrals except one, they mostly agreed upon the diagnoses suggested by the referring doctors and they mostly confirmed the application of the law. Seventy-five percent of the admissions took place during weekends, public holidays or nighttimes. Diagnoses of psychoses or suicidal attempts accounted for 76 % of the total referrals. Substance abuse was noted for 43 %, and in 22 % of all admissions the patients had stopped taking their psychopharmacological medication. The police assisted the referring doctors in one third of all admissions, and was the legal representative in 52 out of 59 involuntary admissions. Thirty percent of the admissions were first- time admissions. Thirty-two percent of the hospital stays lasted for three days or less. Median length of stay was 6.5 days. CONCLUSION: The casualty clinic physicians and the hospital specialists mostly agreed in their evaluation of patients indicating that most of the admissions were appropriate. The police was more often involved in the involuntary admissions than intended in the law. The proportion of patients with substance abuse was significant. Alternative treatment strategies should be developed for non-psychotic patients in need of short-term stays

A qualitative study of the learning processes in young physicians treating suicidal patients: from insecurity to personal pattern knowledge and self-confidence

<p>Abstract</p> <p>Background</p> <p>Little empirical work has been done in studying learning processes among newly educated physicians in the mental health field.</p> <p>The aim of the study was to shed light on the meaning of newly educated physicians' lived experiences of learning processes related to treating suicidal patients.</p> <p>Methods</p> <p>Thirteen newly educated physicians narrated their learning experiences while treating suicidal patients in their own practice. The interview texts were transcribed and interpreted using a phenomenological-hermeneutical method inspired by Ricoeur's philosophy.</p> <p>Results</p> <p>There was one main theme, four themes and eleven sub themes. The main theme was: Being in a transitional learning process. The themes and sub themes were: Preparing for practice (Getting tools and training skills, Becoming aware of one's own attitudes); Gaining experience from treating patients (Treating and following up patients over time, Storing memories and recognizing similarities and differences in patients); Participating in the professional community (Being an apprentice, Relating clinical stories and receiving feedback, Sharing emotions from clinical experiences, Receiving support from peers); and Developing personal competence (Having unarticulated awareness, Having emotional knowledge, Achieving self-confidence). The informants gave a detailed account of the learning process; from recognising similarities and differences in patients they have treated, to accumulating pattern knowledge, which then contributed to their personal feelings of competence and confidence. They described their personal competence with cognitive and emotional elements consisting of both articulated and less articulated knowledge. The findings are interpreted in relation to different learning theories that focus on both individual factors and the interaction with the learning environment.</p> <p>Conclusion</p> <p>This study provides additional information about learning experiences of young physicians during the critical transition phase from medical school to early professional life. Peers are used for both learning and support and might represent a more powerful resource in the learning process than previously recognized. Emotional experiences do not seem to be adequately focused upon in supervision, which obviously has relevance both for learning and for the well-being of young professionals. The study indicates some areas of the educational system that could profitably be expanded including stimulating more systematically to critical reflection on and in practice, attention to feelings in the reflective process and provision of more performance feedback to young physicians.</p

The prestige of somatic and mental disporders : A suvey among health professionals and a representative general population sample

Objective: The purpose of the paper is to study the ranking of disorders according to their perceived importance. Previous studies suggest that rankings according to the perceived or attributed “value” or importance create informal hierarchies of disorders on normative attitudes about symptoms, treatment and outcome. In this work we studied disorder ranking in the general population and among health professionals, and some possible explaining factors. Data source: 1,127 adults representative of the Norwegian National Population Register participated, of whom 220 representatives were of the broad range of health professionals. Study design: Respondents completed a survey questionnaire within a cross-sectional design. Principal findings: Somatic disorders were given the highest rank, but mental disorders were ranked higher than in previous studies. Modest effects were found for explaining variables. Conclusion: The general population rankings of disorders do not differ greatly from rankings made by health professionals. The impact of personalized variables was modest, indicating the need for future studies to explore the impact of more social and culture variables