Janka Koschack

Effects of Frontal Transcranial Direct Current Stimulation on Emotional State and Processing in Healthy Humans

The prefrontal cortex is involved in mood and emotional processing. In patients suffering from depression, the left dorsolateral prefrontal cortex (DLPFC) is hypoactive, while activity of the right DLPFC is enhanced. Counterbalancing these pathological excitability alterations by repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) improves mood in these patients. In healthy subjects, however, rTMS of the same areas has no major effect, and the effects of tDCS are mixed. We aimed to evaluate the effects of prefrontal tDCS on emotion and emotion-related cognitive processing in healthy humans. In a first study, we administered excitability-enhancing anodal, excitability-diminishing cathodal, and placebo tDCS to the left DLPFC, combined with antagonistic stimulation of the right frontopolar cortex, and tested acute emotional changes by an adjective checklist. Subjective emotions were not influenced by tDCS. Emotional face identification, however, which was explored in a second experiment, was subtly improved by a tDCS-driven excitability modulation of the prefrontal cortex, markedly by anodal tDCS of the left DLPFC for positive emotional content. We conclude that tDCS of the prefrontal cortex improves emotion processing in healthy subjects, but does not influence subjective emotional state.

Small hippocampal size in cognitively normal subjects with coronary artery disease

OBJECTIVE Hippocampal size reduction detected by three-dimensional structural magnetic resonance imaging (3D-MRI) represents an important hallmark of Alzheimers disease (AD). Recently, epidemiological and neuropathological studies have associated coronary artery disease (CAD) and cardiovascular risk factors with AD. The present study aimed to assess whether small hippocampal size is also a feature of CAD. METHODS Hippocampal volumes were assessed in 20 men with CAD and 20 healthy matched control subjects by use of 3D-MRI. Subjects with a history of neurological or psychiatric disorder, or signs of cognitive impairment were rigorously excluded. RESULTS Compared with controls, subjects with CAD had significantly smaller (-14%) hippocampal volumes. Cardiovascular risk factors were not related to hippocampal volumes of CAD subjects. CONCLUSIONS Our results demonstrate small hippocampal size in CAD subjects without any cognitive impairment. Future studies should clarify whether the annual rate of hippocampal volume loss of persons with CAD is greater than that of healthy individuals and predicts later cognitive decline or dementia.

Differential impairments of facial affect priming in subjects with acute or partially remitted major depressive episodes.

Eleven subjects with acute major depressive episodes and 9 subjects with partially remitted major depressive episodes were compared with 24 healthy control subjects on an emotional priming task. Positive and negative emotional facial expressions were presented as subthreshold primes, followed by a neutral pattern mask, and an emotionally neutral face as suprathreshold target. Subjects had to judge if they had seen a pleasant or an unpleasant facial expression. Healthy subjects and subjects with partially remitted depression judged the neutral target as significantly more unpleasant when negative emotional facial expressions were presented as primes as compared with when positive facial expressions were presented as primes. In contrast, subjects with acute depression did not show a significant judgment shift. It is concluded that subjects with acute depression are not able to preactivate emotional concepts by subthreshold-presented emotional facial expressions.

Sources of Information and Behavioral Patterns in Online Health Forums: Observational Study

Background Increasing numbers of patients are raising their voice in online forums. This shift is welcome as an act of patient autonomy, reflected in the term “expert patient”. At the same time, there is considerable concern that patients can be easily misguided by pseudoscientific research and debate. Little is known about the sources of information used in health-related online forums, how users apply this information, and how they behave in such forums. Objective The intent of the study was to identify (1) the sources of information used in online health-related forums, and (2) the roles and behavior of active forum visitors in introducing and disseminating this information. Methods This observational study used the largest German multiple sclerosis (MS) online forum as a database, analyzing the user debate about the recently proposed and controversial Chronic Cerebrospinal Venous Insufficiency (CCSVI) hypothesis. After extracting all posts and then filtering relevant CCSVI posts between 01 January 2008 and 17 August 2012, we first identified hyperlinks to scientific publications and other information sources used or referenced in the posts. Employing k-means clustering, we then analyzed the users’ preference for sources of information and their general posting habits. Results Of 139,912 posts from 11,997 threads, 8628 posts discussed or at least mentioned CCSVI. We detected hyperlinks pointing to CCSVI-related scientific publications in 31 posts. In contrast, 2829 different URLs were posted to the forum, most frequently referring to social media, such as YouTube or Facebook. We identified a total of 6 different roles of hyperlink posters including Social Media Fans, Organization Followers, and Balanced Source Users. Apart from the large and nonspecific residual category of the “average user”, several specific behavior patterns were identified, such as the small but relevant groups of CCSVI-Focused Responders or CCSVI Activators. Conclusions The bulk of the observed contributions were not based on scientific results, but on various social media sources. These sources seem to contain mostly opinions and personal experience. A small group of people with distinct behavioral patterns played a core role in fuelling the discussion about CCSVI.

Serum 24S-hydroxycholesterol and hippocampal size in middle-aged normal individuals

The present study assessed the association between serum 24S-hydroxycholesterol (24S-OH-Chol) and 27-hydroxycholesterol (27-OH-Chol) and hippocampal volumes in 69 middle-aged cognitively normal individuals. Results showed that subjects with high levels of oxysterols had significantly larger hippocampal volumes than subjects with low levels of oxysterols. Multiple regression analysis revealed that 24S-OH-Chol, but not 27-OH-Chol or cholesterol, was able to significantly predict hippocampal size. Future studies should elucidate whether high brain cholesterol metabolism in the middle age is protective against hippocampal atrophy and cognitive decline.

[Psychosocial co-symptoms in primary care patients with heart failure].

ZusammenfassungHintergrund und Ziel:Angst und Depressivität von Herzpatienten sind häufige, aber unzureichend beachtete Phänomene. Die vorliegende Studie sollte die psychische Kosymptomatik von hausärztlichen Patienten mit Herzinsuffizienz unter Berücksichtigung klinischer und soziodemographischer Parameter untersuchen.Methodik:363 allgemeinärztliche Patienten mit Herzinsuffizienz wurden psychometrisch (HADS, FKV, FSozU, DS-14) untersucht. Gleichzeitig wurden der Schweregrad der Herzinsuffizienz (Selbstauskunft nach NYHA und Goldman) und soziodemographische Charakteristika erhoben.Ergebnisse:29,2% der untersuchten Herzinsuffizienzpatienten wiesen auffällig erhöhte Werte für Ängstlichkeit und/oder Depressivität auf. Diese Werte lagen signifikant über denjenigen der deutschen Allgemeinbevölkerung (p < 0,005). Die Werte stiegen mit zunehmendem Schweregrad der Herzinsuffizienz an (Ängstlichkeit: p = 0,001; Depressivität: p = 0,001). Ein Drittel der untersuchten Stichprobe ließ sich der prognostisch ungünstigen Typ-D-Persönlichkeit zuordnen. Klinische Krankheitsschwere ging mit stärkerer psychischer Belastung, soziale Unterstützung (bzw. Leben mit Partner oder mehreren Personen) mit geringerer Belastung einher. Durch multiple lineare Regression konnte die wahrgenommene Krankheitsschwere nach Goldman zu 20,3% (signifikant für Geschlecht, Alter, Depressivität und Krankheitsverarbeitung) und nach NYHA zu 18,6% durch demographische und psychologische Variablen vorhergesagt werden (signifikant für Ängstlichkeit).Diskussion:Schwere der Herzinsuffizienzsymptomatik und psychosoziales Befinden beeinflussen sich gegenseitig. Der nach Patientenangaben eingeschätzte Schweregrad der Herzinsuffizienz wird in relevantem Ausmaß durch demographische und psychologische Variablen mitbestimmt, gleichgültig ob er durch eine nichtvalidierte Selbsteinschätzung nach NYHA oder ein validiertes Instrument (Goldman) erhoben wird.Schlussfolgerung:In der hausärztlichen Versorgung von Patienten mit Herzinsuffizienz sind psychische Kosymptome ein häufiges Problem, das mit der wahrgenommenen Krankheitsschwere interferiert. Sie sollten insbesondere bei Alleinstehenden diagnostisch und therapeutisch adäquat berücksichtigt werden.AbstractBackground and Purpose:Psychosocial distress is a common phenomenon in patients with heart failure (HF). The aim of this study was to analyze psychosocial co-symptoms and their relationship with clinical and sociodemographic factors.Methods:In 363 primary care patients with HF, anxiety, depression and negative affectivity (HADS, DS-14), disease coping (FKV) and social support (F-SozU) were measured by validated questionnaires. Severity of HF (according to NYHA classification and Goldman’s Specific Activity Scale) and sociodemographic characteristics were documented by self-report instruments.Results:Increased anxiety and/or depression was found in 29.2% of patients. Anxiety and depression scores were significantly higher than in the German general population (p < 0.005). They were furthermore associated with NYHA and Goldman class (anxiety: p = 0.001; depression: p = 0.001). One third of the sample showed the type D personality pattern, which has been associated with increased mortality in cardiac patients. While HF severity correlated positively with psychological distress, patients living together with other persons had lower HF class than those living alone. Using regression analysis, sociodemographic and psychological variables predicted perceived severity of HF in 20.3% if measured by Goldman’s scale (significant for sex, age, depressive symptoms and disease coping), and in 18.6% if measured by NYHA (significant for anxiety).Discussion:Severity of HF symptoms and psychosocial factors are interrelated. Self-reported severity of HF is substantially influenced by demographic and psychological variables. In this, it is not relevant if severity is measured by a nonvalidated (NYHA) or a validated instrument (Goldman).Conclusion:In primary care patients with HF, psychosocial co-symptoms are frequent and interfere with perceived severity of disease. Psychological distress should be considered important in diagnostics and treatment, especially in patients living alone.

Video-assisted patient education to modify behavior: A systematic review

OBJECTIVE To evaluate the efficacy of video-assisted patient education to modify behavior. METHODS Fourteen databases were searched for articles published between January 1980 and October 2013, written in English or German. Behavioral change as main outcome had to be assessed by direct measurement, objective rating, or laboratory data. RESULTS Ten of the 20 reviewed studies reported successful behavioral modification in the treatment group. We discerned three different formats to present the information: didactic presentation (objective information given as verbal instruction with or without figures), practice presentation (real people filmed while engaged in a specific practice), narrative presentation (real people filmed while enacting scenes). Seven of the ten studies reporting a behavioral change applied a practice presentation or narrative presentation format. CONCLUSION The effectiveness of video-assisted patient education is a matter of presentation format. Videos that only provide spoken or graphically presented health information are inappropriate tools to modify patient behavior. Videos showing real people doing something are more effective. PRACTICE IMPLICATIONS If researchers wish to improve a skill, a model patient enacting the behavior seems to be the best-suited presentation format. If researchers aim to modify a more complex behavior a narrative presentation format seems to be most promising.

Changes in heart failure medications in patients hospitalised and discharged

BackgroundTo date, evidence-based recommendations help doctors to manage patients with heart failure (HF). However, the implementation of these recommendations in primary care is still problematic as beneficial drugs are infrequently prescribed. The aim of the study was to determine whether admission to hospital increases usage of beneficial HF medication and if this usage is maintained directly after discharge.MethodsThe study was conducted from November 2002 until January 2004. In 77 patients hospitalised with heart failure (HF), the medication prescribed by the referring general practitioner (GP) and drug treatment directed by the hospital physicians was documented. Information regarding the post-discharge (14 d) therapy by the GP was evaluated via a telephone interview. Ejection fraction values, comorbidity and specifics regarding diagnostic or therapeutic intervention were collected by chart review.ResultsWhen compared to the referring GPs, hospital physicians prescribed more ACE-inhibitors (58.4% vs. 76.6%; p = 0.001) and beta-blockers of proven efficacy in HF (metoprolol, bisoprolol, carvedilol; 58.4% vs. 81.8%). Aldosterone antagonists were also administered more frequently in the hospital setting compared to general practice (14.3% vs. 37.7%). The New York Heart Association classification for heart failure did not influence whether aldosterone antagonists were administered either in primary or secondary care. Fourteen days after discharge, there was no significant discontinuity in discharge medication.ConclusionPatients suffering from HF were more likely to receive beneficial medication in hospital than prior to admission. The treatment regime then remained stable two weeks after discharge. We suggest that findings on drug continuation in different cardiovascular patients might be considered validated for patients with HF.

Scientific Versus Experiential Evidence: Discourse Analysis of the Chronic Cerebrospinal Venous Insufficiency Debate in a Multiple Sclerosis Forum.

Background The vascular hypothesis of multiple sclerosis (MS), called chronic cerebrospinal venous insufficiency (CCSVI), and its treatment (known as liberation therapy) was immediately rejected by experts but enthusiastically gripped by patients who shared their experiences with other patients worldwide by use of social media, such as patient online forums. Contradictions between scientific information and lay experiences may be a source of distress for MS patients, but we do not know how patients perceive and deal with these contradictions. Objective We aimed to understand whether scientific and experiential knowledge were experienced as contradictory in MS patient online forums and, if so, how these contradictions were resolved and how patients tried to reconcile the CCSVI debate with their own illness history and experience. Methods By using critical discourse analysis, we studied CCSVI-related posts in the patient online forum of the German MS Society in a chronological order from the first post mentioning CCSVI to the time point when saturation was reached. For that time period, a total of 117 CCSVI-related threads containing 1907 posts were identified. We analyzed the interaction and communication practices of and between individuals, looked for the relation between concrete subtopics to identify more abstract discourse strands, and tried to reveal discourse positions explaining how users took part in the CCSVI discussion. Results There was an emotionally charged debate about CCSVI which could be generalized to 2 discourse strands: (1) the “downfall of the professional knowledge providers” and (2) the “rise of the nonprofessional treasure trove of experience.” The discourse strands indicated that the discussion moved away from the question whether scientific or experiential knowledge had more evidentiary value. Rather, the question whom to trust (ie, scientists, fellow sufferers, or no one at all) was of fundamental significance. Four discourse positions could be identified by arranging them into the dimensions “trust in evidence-based knowledge,” “trust in experience-based knowledge,” and “subjectivity” (ie, the emotional character of contributions manifested by the use of popular rhetoric that seemed to mask a deep personal involvement). Conclusions By critical discourse analysis of the CCSVI discussion in a patient online forum, we reconstruct a lay discourse about the evidentiary value of knowledge. We detected evidence criteria in this lay discourse that are different from those in the expert discourse. But we should be cautious to interpret this dissociation as a sign of an intellectual incapability to understand scientific evidence or a naïve trust in experiential knowledge. Instead, it might be an indication of cognitive dissonance reduction to protect oneself against contradictory information.

Prescriptions of recommended heart failure medications can be correlated with patient and physician characteristics.

Background:  Translating the findings from heart failure drug trials into clinical practice has been shown to take time. For the generation of a primary care guideline that takes preferences of general practitioners (GPs) and characteristics of their patients into account, it is necessary to identify the associations between patient and physician characteristics with the prescription of the recommended drugs.