Richard Klaghofer

Antonovsky's sense of coherence: trait or state?

Background: The aim of this study was first to analyze the stability of Antonovsky’s Sense of Coherence (SOC) as a measure of a person’s world view over time; secondly, to investigate its relationship with depression and anxiety. Methods: Data from two longitudinal studies were used: a study of severely injured accident victims (n = 96), and a study of patients suffering from rheumatoid arthritis (RA, n = 60). The 13 items short version of the SOC scale and measures of depression and anxiety (Symptom Checklist, Hospital Anxiety and Depression Scale) were administered repeatedly over 6–12 months in both studies. Results: In the sample of accident victims, a significant decrease in the SOC mean score was observed during the first half year after the accident. During the same time period, symptoms of anxiety and depression decreased significantly. In the second half year after the accident, SOC as well as measures of psychopathology remained stable. RA patients showed high stability of SOC and measures of anxiety and depression over time. In both samples, between-time correlations of SOC scores were high (r ≥ 0.70, p < 0.01), indicating a high test-retest stability of SOC. Furthermore, in both samples, significant negative correlations of a moderate to high degree (r = –0.28 to –0.73, p < 0.01) were found between SOC and measures of anxiety and depression. Conclusions: SOC can be seen as a relatively stable (trait) measure. However, traumatic events such as life-threatening accidents may change a person’s world view and thus their SOC, even if psychiatric symptoms abate. This suggests that SOC is not merely a proxy measure of psychopathology, but rather a partially independent, general measure of a person’s world view.

Anesthetic-induced improvement of the inflammatory response to one-lung ventilation.

Background:Although one-lung ventilation (OLV) has become an established procedure during thoracic surgery, sparse data exist about inflammatory alterations in the deflated, reventilated lung. The aim of this study was to prospectively investigate the effect of OLV on the pulmonary inflammatory response and to assess possible immunomodulatory effects of the anesthetics propofol and sevoflurane. Methods:Fifty-four adults undergoing thoracic surgery with OLV were randomly assigned to receive either anesthesia with intravenously applied propofol or the volatile anesthetic sevoflurane. A bronchoalveolar lavage was performed before and after OLV on the lung side undergoing surgery. Inflammatory mediators (tumor necrosis factor &agr;, interleukin 1&bgr;, interleukin 6, interleukin 8, monocyte chemoattractant protein 1) and cells were analyzed in lavage fluid as the primary endpoint. The clinical outcome determined by postoperative adverse events was assessed as the secondary endpoint. Results:The increase of inflammatory mediators on OLV was significantly less pronounced in the sevoflurane group. No difference in neutrophil recruitment was found between the groups. A positive correlation between neutrophils and mediators was demonstrated in the propofol group, whereas this correlation was missing in the sevoflurane group. The number of composite adverse events was significantly lower in the sevoflurane group. Conclusions:This prospective, randomized clinical study suggests an immunomodulatory role for the volatile anesthetic sevoflurane in patients undergoing OLV for thoracic surgery with significant reduction of inflammatory mediators and a significantly better clinical outcome (defined by postoperative adverse events) during sevoflurane anesthesia.

Work stress and reduced health in young physicians: prospective evidence from Swiss residents

ObjectivesJob stress, investigated by the effort–reward model in various working environments in different countries, has been widely reported, yet studies addressing physicians are lacking. The present study investigated the perceived job stress, its association with the amount of working hours, and its impact on young physicians’ self-reported health and their satisfaction with life during residency.MethodsIn a prospective study design, a cohort of Swiss medical school graduates was followed up, beginning in 2001. In their second and fourth years of residency, 433 physicians assessed their effort–reward imbalance, overcommitment, physical and mental well-being and satisfaction in life. Taking the longitudinal design into account, four categories of stressed residents were defined: (1) subjects not reporting high work stress at either measurement, (2) subjects reporting high work stress in the second but not in the fourth year of residency, (3) subjects with onset of high work stress in fourth year and (4) residents reporting high work stress at both measurements.ResultsAll components of the perceived stress at work were significantly correlated with the amount of working hours, effort showing the highest correlation. While two-thirds of the participants do not report high work stress, assessed by the extrinsic part of the effort–reward imbalance model (the ratio between effort and reward) and 12% show a decrease of stress over time, there are 15% with an increase of stress over time, and 10% with persistently high stress experience. In terms of the intrinsic stress component (overcommitment), 71% show low values, 12% show a decrease, 9% an increase and 8% constantly high values. The groups with constant and increasing extrinsic and intrinsic stress experience exhibit significantly worse health and life satisfaction compared to the remaining groups, after controlling for gender and baseline health.ConclusionsStress at work in young physicians, especially when being experienced over a longer period in postgraduate training, has to be a matter of concern because of its negative impact on health and life satisfaction and the risk of developing symptoms of burnout in the long run.

Impact of gastric banding on eating behavior and weight.

Background: Laparoscopic adjustable gastric banding (LAGB) is now the most frequently performed gastric restriction procedure. While short- and longterm outcome have been described extensively, the relationship between eating behavior and weight reduction is still unclear. Methods: The present study examined the eating behavior of 66 selected morbidly obese subjects before and after LAGB by means of the Eating Inventory (EI), the Binge Scale Questionnaire (BSQ) and additional items. Assessments were conducted 6 months before surgery and at 3, 9, and 12 months after surgery. Results: Significant reductions of weight and BMI were observed until 9 months after surgery, with a loss of 34.5% of excess weight. Later, a slight weight regain was noted. At baseline, Cognitive Restraint (CR), Hunger (H) and Flexible Control (FC) were within the norm, whereas Disinhibition (D) and Rigid Control (RC) were significantly elevated. None of the scales were related to BMI. At follow-up, significant changes were observed between presurgery and 3 months follow-up (T2), with increased CR, FC, and RC, and decreased D, H, and Binge Eating. These changes mostly remained stable. The largest changes were observed 3 months postsurgery in Flexible Control (FC), followed by D, CR, H, and RC. At follow-up, again no correlation was found between eating behavior and the total difference of BMI. Conclusion: LAGB results in significant reductions of weight, disinhibition and hunger during the first 9 months postoperatively. The change in eating behavior after surgery is independent of BMI and characterized mostly by elevated flexible control. Results indicate also changes of other behaviors that contribute to weight loss but are difficult to control.

Swiss residents' speciality choices--impact of gender, personality traits, career motivation and life goals.

BackgroundThe medical specialities chosen by doctors for their careers play an important part in the development of health-care services. This study aimed to investigate the influence of gender, personality traits, career motivation and life goal aspirations on the choice of medical speciality.MethodsAs part of a prospective cohort study of Swiss medical school graduates on career development, 522 fourth-year residents were asked in what speciality they wanted to qualify. They also assessed their career motivation and life goal aspirations. Data concerning personality traits such as sense of coherence, self-esteem, and gender role orientation were collected at the first assessment, four years earlier, in their final year of medical school. Data analyses were conducted by univariate and multivariate analyses of variance and covariance.ResultsIn their fourth year of residency 439 (84.1%) participants had made their speciality choice. Of these, 45 (8.6%) subjects aspired to primary care, 126 (24.1%) to internal medicine, 68 (13.0%) to surgical specialities, 31 (5.9%) to gynaecology & obstetrics (G&O), 40 (7.7%) to anaesthesiology/intensive care, 44 (8.4%) to paediatrics, 25 (4.8%) to psychiatry and 60 (11.5%) to other specialities. Female residents tended to choose G&O, paediatrics, and anaesthesiology, males more often surgical specialities; the other specialities did not show gender-relevant differences of frequency distribution. Gender had the strongest significant influence on speciality choice, followed by career motivation, personality traits, and life goals. Multivariate analyses of covariance indicated that career motivation and life goals mediated the influence of personality on career choice. Personality traits were no longer significant after controlling for career motivation and life goals as covariates. The effect of gender remained significant after controlling for personality traits, career motivation and life goals.ConclusionGender had the greatest impact on speciality and career choice, but there were also two other relevant influencing factors, namely career motivation and life goals. Senior physicians mentoring junior physicians should pay special attention to these aspects. Motivational guidance throughout medical training should not only focus on the professional career but also consider the personal life goals of those being mentored.

The impact of gender and parenthood on physicians' careers - professional and personal situation seven years after graduation

BackgroundThe profile of the medical profession is changing in regard to feminization, attitudes towards the profession, and the lifestyle aspirations of young physicians. The issues addressed in this study are the careers of female and male physicians seven years after graduation and the impact of parenthood on career development.MethodsData reported originates from the fifth assessment (T5) of the prospective SwissMedCareer Study, beginning in 2001 (T1). At T5 in 2009, 579 residents (81.4% of the initial sample at T1) participated in the questionnaire survey. They were asked about occupational factors, career-related factors including specialty choice and workplace, work-life balance and life satisfaction. The impact of gender and parenthood on the continuous variables was investigated by means of multivariate and univariate analyses of variance; categorical variables were analyzed using Chi-square tests.ResultsFemale physicians, especially those with children, have lower rates of employment and show lower values in terms of career success and career support experiences than male physicians. In addition, parenthood has a negative impact on these career factors. In terms of work-life balance aspired to, female doctors are less career-oriented and are more inclined to consider part-time work or to continue their professional career following a break to bring up a family. Parenthood means less career-orientation and more part-time orientation. As regards life satisfaction, females show higher levels of satisfaction overall, especially where friends, leisure activities, and income are concerned. Compared to their male colleagues, female physicians are less advanced in their specialty qualification, are less prone to choosing prestigious surgical fields, have a mentor less often, more often work at small hospitals or in private practice, aspire less often to senior hospital or academic positions and consider part-time work more often. Any negative impact on career path and advancement is exacerbated by parenthood, especially as far as women are concerned.ConclusionThe results of the present study reflect socially-rooted gender role stereotypes. Taking into account the feminization of medicine, special attention needs to be paid to female physicians, especially those with children. At an early stage of their career, they should be advised to be more proactive in seeking mentoring and career-planning opportunities. If gender equity in terms of career chances is to be achieved, special career-support measures will have to be provided, such as mentoring programs, role models, flexitime and flexible career structures.

Preliminary validation of PRISM (Pictorial Representation of Illness and Self Measure) - a brief method to assess suffering.

Background: Alleviation of suffering is widely acknowledged as one of the main goals of medicine. However, no measure to assess this crucial aspect of illness has been developed to date. Aims: To validate PRISM (Pictorial Representation of Illness and Self-Measure) as a simple quantitative method of assessing the perceived burden of suffering due to illness. Methods: Validity and reliability studies to date have involved over 700 patients with a variety of chronic physical illnesses. Results: Reliability of PRISM is good (test-retest reliability r = 0.95; p ≤ 0.001, interrater reliability r = 0.79; p ≤ 0.001). Qualitative data indicate that the interpretation of the PRISM task is not only consistent among patients, but also consistent with that expected from existing literature on suffering. As expected, PRISM shows strong correlations with psychological variables (notably depression and coping resilience) and also correlates with SF-36 subscale scores. Prospective longitudinal data demonstrate that PRISM is sensitive to therapeutic change. It is very acceptable to patients and takes less than 5 min to administer. Conclusion: In the absence of a ‘gold standard’ measure of suffering, our validation data must be interpreted with caution. However, the performance of PRISM is entirely consistent with what would be expected of a measure of suffering, based on current published work.

Associations between body weight, psychiatric disorders and body image in female adolescents.

Objectives: The study explored associations between body weight, psychiatric disorders and body image in a nonclinical sample of female adolescents. It was also investigated whether complaints of negative body image could be an indicator of psychiatric morbidity. Methods: A sample of 136 Swiss female high school students, 15–20 years of age, initially had weight, height and body image (FBeK questionnaire) assessed and were screened for psychiatric morbidity (SSQ). Subsequently, they were assessed using the DIA-X psychiatric interview which generates DSM-IV diagnoses. Univariate, multivariate, regressive and canonical correlation analyses were performed. Results: Being overweight was significantly correlated with a more negative body image (attractiveness/self-confidence). There were also significant correlations between psychiatric diagnoses and unfavorable body image (3 of the 4 FBeK scales). Besides having a more disturbed body image, overweight subjects also evidenced more psychiatric morbidity. The multiple regression analysis revealed that psychiatric disorders had the greatest association with negative body image, followed by age and weight. The canonical correlation indicated that body image, psychiatric disorder, age and weight clearly correlated with one another (Rxy = 0.43). Conclusion: Psychosomatic research should be more concerned about issues of obesity and concurrent psychiatric morbidity and aim to develop preventative as well as therapeutic treatment methods. Physicians should be aware of the associations between obesity, negative body image and psychiatric morbidity.

Sense of Coherence – A Mediator between Disability and Handicap?

Background: The aim of this study was first to analyze the associations between disability and handicap and Antonovsky’s concept of sense of coherence (SOC); secondly, to find out how the SOC concept could be integrated in the WHO model of impairments, disabilities, and handicaps (ICIDH). Methods: Data from two studies were used: one on patients with rheumatoid arthritis, one on severely injured accident victims. Objective measures of the illness or the injury were conceptualized as indicator variables for disability, whereas variables related to the patients’ subjective judgement were conceptualized as indicator variables for handicap. Correlations were calculated between both sets of variables and the SOC scale total score. Results: SOC showed no significant correlation with ‘disability variables’ (rheumatoid arthritis: HAQ, SF36 physical functioning; accidental injuries: ISS, GCS). However, significant correlations were found between SOC and all ‘handicap variables’ (rheumatoid arthritis: HAD, SF36 social functioning; accidental injuries: CAPS-2, IES, SCL-90-R depression subscale). Conclusions: SOC is related to the psychosocial effects of health problems. It may be understood as a mediator between disability and handicap. Prospective studies are needed to clarify whether the SOC scale can be used as an outcome predictor with regard to psychosocial adaptation, in acute as well as in chronic health problems.

Psychosocial Profiles After Transplantation : A 24-Month Follow-Up of Heart, Lung, Liver, Kidney and Allogeneic Bone-Marrow Patients

Objectives. Quality of life and psychosocial well-being usually improve after an organ transplant and remain stable for a minimum of several years. These findings, however, mainly apply to the “average” trend for transplant patients. This study aims to investigate whether transplant patients fall into different groups in good or poor psychosocial outcome after organ transplantation. Methods. One hundred thirty-one patients were assessed before and 6, 12, and 24 months after a heart, lung, liver, kidney, or bone-marrow transplant. Cluster analysis was applied to identify typical outcome profiles of the patients’ mental health (SF-36); differences between the clusters were investigated with regard to further psychosocial parameters (sense of coherence, optimism, psychosocial functioning, anxiety, depression, life/health satisfaction, medication experience). Results. The analysis revealed two clusters of transplant patients. Cluster A (n=78, 59.5%) showed a fairly good psychosocial outcome, improving over the posttransplant period of 2 years. Cluster B (n=53, 40.5%) included patients who reported a limited or poor outcome, deteriorating after the transplant. Furthermore, there are significant differences between clusters A and B in psychosocial parameters and physical functioning. Conclusions. These findings indicate that the experience of the transplant process may vary greatly from patient to patient, and that a considerable number of transplant recipients require psychosocial support, despite the majority of patients showing an unquestionable posttransplant improvement in psychosocial well-being.