Effect of patient completed agenda forms and doctors' education about the agenda on the outcome of consultations: randomised controlled trial.

OBJECTIVE: To assess the effect of patient completed agenda forms for the consultation and doctors' education on identifying patients' agendas on the outcome of consultations. DESIGN: Randomised controlled trial. SETTING: General practices in Leicestershire and Nottinghamshire, United Kingdom. PARTICIPANTS: 46 general practitioners and 976 patients. INTERVENTIONS: Education for general practitioners, with an embedded clustered randomised controlled trial of a patient agenda form. MAIN OUTCOME MEASURES: Number of problems identified, time required to manage each problem, duration of consultations, number of problems raised after the doctor considered the consultation finished ("by the way" questions), and patient satisfaction. RESULTS: Data were available from 45 doctors (98%) and 857 patients (88%). The number of problems identified in each consultation increased by 0.2 (95% confidence interval 0.1 to 0.4) with the agenda form, by 0.3 (0.1 to 0.6) with education, and by 0.5 (0.3 to 0.7) with both interventions. The time required to manage each problem was not affected. The duration of consultations with the agenda form was increased by 0.9 minutes (0.3 to 1.5 minutes) and with the combined intervention by 1.9 minutes (1.0 to 2.8 minutes). Patient satisfaction with the depth of the doctor-patient relationship was increased with the agenda form. The occurrence of "by the way" presentations did not change. CONCLUSION: A patient completed agenda form before the consultation or general practitioner education about the agenda form, or both, enabled the identification of more problems in consultations even though consultations were longer.

What do patients want from doctors? Content analysis of written patient agendas for the consultation.

BACKGROUND: Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect. AIM: To describe the expectations of a large group of patients who consulted with their GPs. METHOD: A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed. RESULTS: A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation. CONCLUSION: These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.

Characterization of a secretory type Theileria parva glutaredoxin homologue identified by novel screening procedure.

The schizont stage of the protozoan parasite Theileria parva induces features characteristic of tumor cells in infected bovine T-cell lines. Most strikingly T. parva-infected cell lines acquire unlimited growth potential in vitro. Their proliferative state is entirely dependent on the presence of a viable parasite within the host cell cytoplasm. It has been postulated that parasite proteins either secreted into the host cell or expressed on the parasite surface membrane are involved in the parasite-host cell interaction. We used an in vitro transcription-translation-membrane translocation system to identify T. parva-derived cDNA clones encoding secretory or membrane proteins. Within 600 clones we found one encoding a 17-kDa protein which is processed by microsomal membranes to a 14-kDa protein (11E), presumably by signal peptidase. The processed form is expressed in the T-cell line TpM803 harboring viable parasites. By immunolocalization we show that the 11E protein mostly resides within the parasite, often in close vicinity to membranous structures, but in addition it appears at the surface membrane. Amino acid sequence comparison suggests that 11E belongs to the glutaredoxin family, but is unique so far in containing a signal sequence for endoplasmic reticulum membrane translocation.

Upregulation of insulin-like growth factor I gene expression in the lesions of osteoarthritic human articular cartilage.

Expression of insulin-like growth factor I (IGF-I)mRNA and IGF-I protein was studied in human osteoarthritic and young articular cartilage by in situ hybridisation and immunohistochemistry. In situ hybridisation showed that relatively low amounts of IGF-I mRNA signal were present in anatomically normal regions of osteoarthritic and young cartilage. In fibrillated osteoarthritic cartilage, however, the signal intensity was significantly higher than in non-fibrillated cartilage. Particularly high levels of IGF-I mRNA were present in the surface cell clones of more advanced lesions, the amount of signal being about four to five times greater than in anatomically normal cartilage. The amount of message varied with cartilage depth. In young cartilage there was less IGF-I mRNA in the superficial zone than in the middle and deep zones. In fibrillated regions of osteoarthritic joints the amount of message in surface cells was greater than in deeper regions. A specific human IGF-I antibody was used to show the presence intracellularly of IGF-I protein in osteoarthritic and young cartilage. Raised levels of IGF-I message in osteoarthritic chondrocytes may represent an attempt at increased matrix repair, operating by an autocrine/paracrine mechanism.

The exceptional potential of the consultation revisited.

A new framework is proposed for analysing the consultation in primary care, and for integrating other models relevant to the consultation. Use of communication skills helps to reconcile the respective agendas of doctor and patient into a negotiated plan, which includes both management of problems and health promotion. Achieving the potential of consultations depends on cooperation between patient and doctor, and on sufficient time for appointments.

Modifying the behaviour of doctors and their receptionists in recurrent stressful situations.

Doctors and receptionists in a group practice completed a questionnaire about the image of the practice and reactions to recurrent stressful situations. The results were shared among the participants in a way that preserved anonymity. A year later a further questionnaire was completed which showed that respondents perceived that beneficial changes had taken place. The changes were seen as being mainly due to an increase in mutual understanding between the doctors and their receptionists.

Electron probe X-ray microanalysis of the composition of hyaline articular and non-articular cartilage in young and aged rats.

Blocks of articular cartilage were taken from tibiae of young adult (8 week) and aged adult (50-60 week) rats; xiphisternal cartilage was obtained from young adult rats. Specimens were quench-frozen in nitrogen slush, freeze-fractured and examined by low-temperature scanning electron microscopy. The results of X-ray microanalysis of frozen-hydrated bulk cartilage are semi-quantitative. The composition of chondrocyte nuclei and cytoplasm are only marginally different. Xiphisternal chondrocytes contain lipid inclusions which show an absence of element peaks and are designated as being neutral lipid. Intra- and extracellular Na, P, S, Cl, K and Ca count rates are significantly different. Cartilage from older rats contains more S and Ca, and less K and Cl in the intercellular matrix than that from young rats. Intracellular K levels are lower in aged than in young rats. The intercellular matrix of xiphisternal cartilage contains larger amounts of S, Na and K, and a smaller amount of Cl compared to that of tibial articular cartilage.

Cation movement in rat articular and non-articular cartilage and in isolated chondrocytes: calcium influx and efflux.

1. Calcium ion influx varies between different types of young adult rat cartilage. Sternal cartilage accumulates significantly less Ca2+ than other cartilage types. 2. Influxes of Ca2+ into young adult and ageing tibial cartilage display no significant differences. 3. Efflux of Ca2+ from sternal and tibial cartilage resolves into exponential phases indicative of three compartments. Tracheal cartilage displays two compartment behaviour only. 4. Efflux of Ca2+ from isolated chondrocytes has different characteristics to cartilage efflux with the third slow compartment reduced. 5. Modification of Ca2+ efflux by lanthanum and barium is suggestive of an exchange of strongly bound extracellular calcium during the slow phase of the efflux from young adult tibial cartilage. 6. The metabolic inhibitor 2,4-dinitrophenol is without effect on the efflux of Ca2+ from tibial articular cartilage. 7. The degree of calcium binding exhibited during efflux depends upon cartilage type. Non-articular sternal cartilage binds calcium more strongly than articular tibial, both binding more strongly than non-articular tracheal cartilage. 8. In articular cartilage calcium binding shows an age-related increase.

Low temperature and conventional scanning electron microscopic observations of dog femoral condylar cartilage surface after anterior cruciate ligament division.

The left stifle joints of 16 beagle dogs were subjected to surgical division of the anterior cruciate ligament (ACL). The femoral condyles showed surface alterations and damage after 14 days when examined by low temperature (LTSEM) and conventional scanning electron microscopy (SEM). The first change was an increase in the fibrous texture of the articular cartilage surface. Folds and surface roughening were later recognised. After 112 days deformation and disruption gave way to cracking or fracture of the surface layers. Superficial damage was focal in distribution and accompanied by a decrease in the frequency of tertiary elevations. The affected areas of cartilage increased in frequency and size with time and surgery. The observations obtained from LTSEM, in which the tissue remains fully hydrated during examination, may be caused by alterations in water content and a loss of proteoglycan at the surface, together with changes in cell shape and size. Surface cracks may be the en face appearance of histological fibrillation.

Low temperature and conventional scanning electron microscopy of human urothelium.

The appearance of fixed dehydrated non-neoplastic human urothelium viewed by conventional scanning electron microscopy (CSEM) is different from that of frozen hydrated human urothelium viewed by low temperature scanning electron microscopy (LTSEM). In the fixed dehydrated material the surface is formed by well defined, polygonal, domed superficial urothelial cells which have prominent surface microridges. In places intermediate urothelial cells are visible and they have surface microvilli. In the frozen hydrated material viewed by LTSEM most of the surface is smooth. This is formed in part by a glutaraldehyde soluble extracellular secretion which may be a mucin barrier to bacteria. We believe that the rest of the smooth surface is formed by superficial urothelial cells which are not well defined and which lack microridges. There are islands of rounded cells lacking microvilli which are probably intermediate urothelial cells as they correspond in appearance with the intermediate urothelial cells seen in freeze fractured material. It seems likely that fixation and dehydration will cause some change in surface configuration and in theory the frozen hydrated material should more closely resemble the natural state. We believe that LTSEM will be of value in investigating normal and diseased urothelium.

Demonstration by X-ray microprobe analysis of relationship between chondrocytes and tertiary surface structure of hyaline articular cartilage.

Blocks of hyaline cartilage from the femoral condyles of five young adult beagles dogs were quench-frozen in nitrogen slush at 63 K. The free cartilage surfaces of blocks from three animals were examined in the secondary electron mode; the remaining specimens were cut by cryoultramicrotone (approximately 188 K) tangential to the surface to expose midzone cartilage which was examined in the backscattered electron mode. A random array of gently convex prominences was apparent at the free cartilage surfaces. When X-ray emissions were recorded from tissue immediately below these elevations, the spectra proved to be similar to those derived from midzone chondrocytes. These spectra revealed high count rates for the X-rays characteristic of P and K. By contrast, in areas of free surface remote from these prominences, and in midzone intercellular matrix, larger count rates for the X-rays characteristic of Na, S. Cl and Ca were detected. The evidence supports the hypothesis that the elevations seen on the non-loaded articular cartilage of disarticulated mammalian synovial joints are the surface representations of superficial chondrocytes.

An investigation by transmission electron microscopy of freeze replicas of dog articular cartilage surfaces: the fibre-rich surface structure.

Femoral condylar cartilage blocks from the disarticulated stifle joints of five inbred beagle dogs were rapidly frozen. Single stage platinum and carbon replicas were prepared at 78 K from the unfixed, hydrated frozen material. Transmission electron microscopic investigations of the replicas were then made. Two different forms of fine cartilage surface structure were suggested by the low temperature replicas. The first, amorphous and with few fibres, was thought to represent the normal, superficial lamina obscurans. The second displayed many delicate parallel arrays of collagen fibrils with a periodic structure of 68-71 nm. Between these arrays were gently convex smooth-surfaced elevations, 150-500 nm in diameter, and therefore two orders of magnitude smaller than the tertiary surface undulations previously identified by light microscopy and by scanning electron microscopy. It is suggested that the 150-500 nm elevations seen at the replicated surface may be expanded proteoglycans, restrained laterally and deeply, less restrained superficially because of the loss, during preparation, of the lamina obscurans. Other hemispherical, replicated surface deposits 400-1700 nm in diameter are believed to be lipid.

Cortical laterality and asymmetry of the Hoffmann reflex in psychiatric patients.

Thirty-six hospitalized patients with schizophrenia or schizo-affective disorder who were judged unresponsive to conventional treatment were tested 5 days after last receiving medication and retested 4 weeks after treatment with thiothixene, loxapine, or molindone. Cortical laterality for linguistic and motor functions was measured by visual half-field (VHF) recognition of words, dichotic listening (DL), the Crawford Small Parts (CSP) performance test, and finger-tapping (FT) dexterity. The recovery curve of the Hoffmann reflex was measured in both legs and lateral asymmetries of the recovery curve were calculated as lateralization coefficients. Cortical laterality measurements were also performed in 36 control subjects. Cortical laterality measures of patients were not significantly different from those of control subjects and were not related to measures of clinical symptomatology. The height of the H-reflex recovery curve (mean of both legs) was not related to clinical symptomatology. Recovery curve height of the right leg only was significantly correlated with the withdrawal-retardation (R) subscale of the Brief Psychiatric Rating Scale (BPRS). Recovery curve height was significantly correlated with number of schizophrenic symptoms recorded for diagnosis based on the Research Diagnostic Criteria (RDC). Recovery curve height (mean of both legs) in medicated patients was significantly correlated with right sided preference as measured by both VHF and DL. In unmedicated patients, lateralization of the recovery curve was correlated with clinical symptomatology, such that relative elevations of the right leg were associated with higher scores of the R subscale of the BPRS, while relative elevations of the left leg were associated with higher scores of the anxious-depression (D) subscale of the BPRS. Left hemispheric or subcortical dysfunction, manifested by recovery curve elevation of the right leg, was related to schizophrenic symptomatology (R subscale). Right hemispheric or subcortical dysfunction, manifested by relative recovery curve elevation in the left leg, was related to depression symptomatology (D subscale). These findings are compatible with asymmetries of subcortical amine function in schizophrenia and schizo-affective disorder.

Lateral asymmetry of the Hoffmann reflex: relation to cortical laterality.

Lateral asymmetry of the Hoffmann reflex (H-reflex) recovery curve was found in seven subjects with no personal or family history of neurological or psychiatric disorder. Differences between recovery curves from the right and left leg were larger than differences in the same leg on two successive test days. In a group of 27 psychiatric inpatients, lateral asymmetry of the later portion of the recovery curve was correlated with cortical laterality, as measured by selective identification of differing verbal stimuli presented simultaneously to both ears (DL) and to total laterality scores, a sum of visual half-field, DL, and motor laterality scores. Asymmetry of the recovery curve is related in part to cortical laterality, possibly through selective activation of cortical motor centres on the preferred side.