Agency and the telephone: Patient contributions to the clinical and interactional agendas in telehealth consultations

ObjectivePatient-centredness is central to providing safe care and is achieved, in part, through involving patients in developing the agenda of the consultation. Medical consultations have changed significantly over the last two years as a result of COVID-19 and thus understanding how patients contribute to the clinical and interactional agendas within a telehealth consultation is important to supporting quality care.MethodsA collection (15) of consultations (in English) between specialists (3) and patients (14) were recorded in a metropolitan gastrointestinal clinic in Australia. These recordings were closely examined using conversation analysis, which focuses on the structural and sequential organisation of interaction.ResultsPatients used a variety of interactional approaches to contribute to the agenda throughout the consultations. This was achieved in collaboration with the doctors, whose responses generally allowed for these contributions. However, there were few doctor-driven, explicit opportunities provided to patients to contribute to the agenda.ConclusionMany patients and doctors are adept at managing the interactional challenges of telehealth consultations but there are clear opportunities to extend this advantage to those patients with less agency.Practice implicationsProviding an explicit space for patients to ask questions within the consultation would support those patients less inclined or able to assert themselves during a telehealth consultation.     

Active listening in medical consultations: development of the Active Listening Observation Scale (ALOS-global)

OBJECTIVE: Active listening is a prerequisite for a successful healthcare encounter, bearing potential therapeutic value especially in clinical situations that require no specific medical intervention. Although generally acknowledged as such, active listening has not been studied in depth. This paper describes the development of the Active Listening Observation Scale (ALOS-global), an observation instrument measuring active listening and its validation in a sample of general practice consultations for minor ailments. METHODS: Five hundred and twenty-four videotaped general practice consultations involving minor ailments were observed with the ALOS-global. Hypotheses were tested to determine validity, incorporating patients' perception of GPs' affective performance, GPs' verbal attention, patients' self-reported anxiety level and gender differences. RESULTS: The final 7-item ALOS-global had acceptable inter- and intra-observer agreement. Factor analysis revealed one homogeneous dimension. The scalescore was positively related to verbal attention measured by RIAS, to patients' perception of GPs' performance and to their pre-visit anxiety level. Female GPs received higher active listening scores. CONCLUSION: The results of this study are promising concerning the psychometric properties of the ALOS-global. More research is needed to confirm these preliminary findings. PRACTICE IMPLICATIONS: After establishing how active listening differentiates between health professionals, the ALOS-global may become a valuable tool in feedback and training aimed at increasing listening skills.     

Mimicking non-verbal emotional expressions and empathy development in simulated consultations: An experimental feasibility study

Objective

To explore the feasibility of applying an experimental design to study the relationship between non-verbal emotions and empathy development in simulated consultations.

'Talking of Sex': developing and piloting a sexual health communication tool for use in primary care

Objective

To develop and pilot a communication aid aimed at increasing the frequency with which sexual health issues are raised proactively with young people in primary care.

Methods

Group interviews among primary health care professionals to guide development of the tool, simulated consultations to pre-test it, and a pilot study to assess effectiveness.

Results

We developed an electronic consultation aid: Talking of Sex and piloted it in eight general practices across the UK. 188 patients and 58 practitioners completed questionnaires pre-intervention, and 92 patients and 45 practitioners post-intervention. There was a modest increase in the proportion of consultations in which sexual health was raised, from 28.1% pre-intervention to 32.6% post-intervention. In consultations with nurses the rise was more marked. More patients reported discussing preventive practices such as condom use post-intervention. Patients unanimously welcomed the opportunity to discuss sexual health matters with their practitioner.

Conclusion

The tool has capacity to increase the frequency with which sexual health is raised in primary care, particularly by nurses, to influence the topics discussed, and to improve patient satisfaction.

Practice implications

The tool has potential in increasing the proportion of young people whose sexual health needs are addressed in general practice.     

Application of the component paradigm for analysis and design of advanced health system architectures

Based on the component paradigm for software engineering as well as on a consideration of common middleware approaches for health information systems, a generic component model has been developed supporting analysis, design, implementation and harmonisation of such complex systems. Using methods like abstract automatons and the Unified Modelling Language (UML), it could be shown that such components enable the modelling of real-world systems at different levels of abstractions and granularity, so reflecting different views on the same system in a generic and consistent way. Therefore, not only programs and technologies could be modelled, but also business processes, organisational frameworks or security issues as done successfully within the framework of several European projects.     

Complex health care decisions with older patients in general practice: Patient-centeredness and prioritization in consultations following a geriatric assessment

Objective

To examine to what extent general practitioners in consultations after a geriatric assessment set shared health priorities with older patients experiencing multimorbidity and to what extent this was facilitated through patient-centered behavior.

Methods

Observation of consultations embedded in a cluster randomized controlled trial,¹ in which 317 patients from 41 general practices received the STEP assessment followed by a care planning consultation with their GPs. GPs in the intervention group used a structured procedure for setting health (care) priorities in contrast to control GPs. A sample of 43 consultations (24 intervention; 19 control) were recorded, transcribed and analyzed with regard to priority setting and patient-centeredness.

Results

Patient-centeredness was only moderately apparent in consultations dealing with complex care plans for older patients with multimorbidity. The shared determination of health priorities seemed unusual for both doctors and patients and was rarely practiced, albeit more frequently in intervention consultations.

Conclusion

Setting health care priorities with patients experiencing multimorbidity is ethically desirable and medically appropriate. Yet a short structured guide for doctors cannot easily achieve this.

Practice implications

More research is needed in regard to handling complex health needs of older patients. It requires a professional approach and training in patient-centered holistic care planning.     

Consequences of the presence and absence of empathy during consultations in primary care: A focus group study with patients

ObjectiveThere is general consensus that explicit expression of empathy in patient-GP communication is highly valued. Yet, little is known so far about patients’ personal experiences with and expectations of empathy. Insight into these experiences and expectations can help to achieve more person-centeredness in GP practice care.MethodsParticipants were recruited by a press report in local newspapers. Inclusion criteria: adults, a visit to the GP in the previous year. Exclusion criterion: a formal complaint procedure. Five focus groups were conducted. The discussions were analyzed using constant comparative analysis.ResultsIn total 28 participants took part in the focus group interviews. Three themes were identified: (1) Personalized care and enablement when empathy is present; (2) Frustrations when empathy is absent; (3) Potential pitfalls of empathy. Participants indicated that empathy helps build a more personal relationship and makes them feel welcome and at ease. Furthermore, empathy makes them feel supported and enabled. A lack of empathy can result in avoiding a visit to the GP.ConclusionEmpathy is perceived as an important attribute of patient-GP communication. Its presence results in feelings of satisfaction, relief and trust. Furthermore, it supports patients, resulting in new coping strategies. A lack of empathy causes feelings of frustration and disappointment and can lead to patients avoiding visiting their GP.Practice implicationsMore explicit attention should be given to empathy during medical education in general and during vocational GP-training.     

B-cell neoplasms of the lymphocytic, lymphoplasmacytoid, and plasma cell types: immunohistologic analysis and clinical correlation

The relation between chronic lymphocytic leukemia (CLL, lymphocytic lymphoma (SL), plasmacytoid lymphocytic lymphoma (LP), plasmacytoma (PL), and multiple myeloma (MM) was investigated with cryostat sections stained with antibodies to immunoglobulin heavy and light chains and the B-cell differentiation antigens B1, B2, Ia, T1, and CALLA. Neoplasms were subclassified according to plasmacytoid features, leukemia (CLL) site of involvement (nodal or extranodal), serum monoclonal immunoglobulin, or clinical evidence of MM. The results defined two groups of lymphocytic lymphomas without plasmacytoid features (16 cases). Ten of these lymphomas were associated with CLL. Nine involved lymph nodes, all expressed IgM, five expressed IgD, nine were B2-positive, eight were T1-positive, and all were B1- and Ia-positive. Six of the lymphomas were not associated with CLL. Five of these tumors were extranodal, all were T1- B1+ B2- Ia+, five expressed IgM without IgD, and one contained IgG. These differences in clinical and immunologic phenotypes suggest that CLL and SL without CLL may be related to different stages of B-cell differentiation. T1 appeared to be a marker for CLL, since all T1-positive neoplasms were leukemic. Lymphomas with plasmacytoid features (ten cases) were more often extranodal, and none was leukemic. The immunologic phenotypes were heterogeneous: all of these lymphomas were T1-negative, most were IgM+ IgD-, three were B2-positive, and all were Ia-positive. The plasma cells in five lymphomas with marked plasmacytoid features were B1-negative; they were Ia-positive in four and Ia-negative in one. These data suggest that LP is a heterogeneous group, reflecting B cells at diverse stages of differentiation. Ten plasmacytomas, nine of which were associated with MM, differed from LP in showing heavy chain class switching; all were T1- B1- B2-, and all but one were Ia-negative. These results are consistent with the existence of two pathways or stages of B-cell differentiation: one that generates IgM-producing plasma cells, as seen in the primary immune response or in response to pokeweed mitogen, and one that generates IgG- or IgA-positive plasma cells, as seen in the late primary or secondary immune response. Plasmacytoid lymphocytic lymphoma reflects the first, while PL/MM reflects the second pathway. B1 appears to be lost before Ia in terminal plasma cell differentiation.     

A comparison of GP,pharmacist and nurse prescriber responses to patients’ emotional cues and concerns in primary care consultations

Objective

Recognising patients’ cues and concerns is an important part of patient centred care. With nurses and pharmacists now able to prescribe in the UK, this study compared the frequency, nature, and professionals’ responses to patient cues and concerns in consultations with GPs, nurse prescribers and pharmacist prescribers.

Methods

Audio-recording and analysis of primary care consultations in England between patients and nurse prescribers, pharmacist prescribers and GPs. Recordings were coded for the number of cues and concerns raised, cue or concern type and whether responded to positively or missed.

Results

A total of 528 consultations were audio-recorded with 51 professionals: 20 GPs, 19 nurse prescribers and 12 pharmacist prescribers. Overall there were 3.5 cues or concerns per consultation, with no difference between prescriber groups. Pharmacist prescribers responded positively to 81% of patient's cues and concerns with nurse prescribers responding positively to 72% and GPs 53% (PhP v NP: U = 7453, z = −2.1, p = 0.04; PhP v GP: U = 5463, z = −5.9, p < 0.0001; NP v GP: U = 12,070, z = −4.9, p < 0.0001).

Conclusion

This evidence suggests that pharmacists and nurses are responding supportively to patients’ cues and concerns.

Practice implications

The findings support the importance of patient-centredness in training new prescribers and their potential in providing public health roles.     

Ocular microtremor measurement system: Design and performance

The frequency of ocular microtremor (OMT) is related to the functional status of the brain stem, and thus OMT may be useful in the diagnosis and management of brain stem disorders. The paper discusses the design of an OMT measurement system and reports quantitative specifications for three portable systems. All systems use a piezo-electric element as the transducer, which measures the displacement of the sclera during eye rotations. The systems differ in the manner in which the signal is recorded. All systems can detect eye movements corresponding to displacements of the sclera ranging from 12 to over 3000 nm. The frequency responses of all systems are flat (<2 dB deviation from peak response) between 20 and 150 Hz. The phase response shows deviations (<π) at the extremes of this range, but qualitative comparison of input and measured signals demonstrates that phase distortion is not excessive. Thus all systems are acceptable for clinical studies involving OMT.     

Polytetrafluoroethylene-covered stents in the venous and arterial system: angiographic and pathologic findings in a swine model

BACKGROUND: Although polytetrafluoroethylene (PTFE) is now used as a covering in a wide variety of vascular stents, little is known about the resultant pathologic and angiographic changes in the arterial and venous system after stent deployment. METHODS: Atrium PTFE-covered stents were deployed in the abdominal aorta and the inferior vena cava (IVC) of two Yorkshire pigs. Angiograms were performed after deployment and at recatheterization. A complete histopathological exam was performed after sacrifice, and angiographic and histology findings were then compared between the two types of blood vessels. RESULTS: The arterial stents demonstrated no stenosis on angiography and minimal in-stent intimal proliferation by histopathology. A uniform layer of neointima coated the inside of the stent by 1 month with no obvious thrombus formation. In contrast, the venous stents demonstrated angiographic evidence of significant in-stent stenosis of variable degrees and the histology showed increased intimal hyperplasia with fibrin deposition. PTFE from both the arterial and venous stents had variable amounts of tissue ingrowth with cells observed to be growing into and through the PTFE fibers. CONCLUSIONS: Atrium PTFE-covered stents have excellent short-term angiography and histopathology in the arterial system, while stents in the venous system developed rapid in-stent intimal hyperplasia. PTFE fibers from both types of vasculature permitted cells to grow through and within them.     

一种简便通用的超声工作站的设计和开发

目的 为基层医院超声科提供一种廉价实用的超声工作平台,设计开发一种简便通用的超声工作站.方法 采用DirectShow技术和应用CxImage图像处理库完成图像的采集处理,在此基础之上构建超声工作站的基本功能.结果 将此工作站连接超声诊断仪GE-LOGIQ7、Phihip Sono 5500彩色超声诊断仪和ALOKA SSD-1000 B型超声诊断仪后运行稳定.结论 此超声工作站应用方便快捷,配置费用低廉,对提高工作效率、改善服务质量有着重要的作用,同时有利于超声资料的保存,值得在基层超声科推广.     

Scenario-based design: a method for connecting information system design with public health operations and emergency management

Responding to public health emergencies requires rapid and accurate assessment of workforce availability under adverse and changing circumstances. However, public health information systems to support resource management during both routine and emergency operations are currently lacking. We applied scenario-based design as an approach to engage public health practitioners in the creation and validation of an information design to support routine and emergency public health activities. Methods: Using semi-structured interviews we identified the information needs and activities of senior public health managers of a large municipal health department during routine and emergency operations. Results: Interview analysis identified 25 information needs for public health operations management. The identified information needs were used in conjunction with scenario-based design to create 25 scenarios of use and a public health manager persona. Scenarios of use and persona were validated and modified based on follow-up surveys with study participants. Scenarios were used to test and gain feedback on a pilot information system. Conclusion: The method of scenario-based design was applied to represent the resource management needs of senior-level public health managers under routine and disaster settings. Scenario-based design can be a useful tool for engaging public health practitioners in the design process and to validate an information system design.     

Teledermatology in a capitated delivery system using distributed information architecture: design and development.

OBJECTIVE: This report describes the design, development, and technical evaluation of a teledermatology system utilizing digital images and electronic forms captured through, stored on, and viewed through a common web server in an urban capitated delivery system. MATERIALS AND METHODS: The authors designed a system whereby a primary care physician was able to seek a dermatologic consultation electronically, provide the specialist with digital images acquired according to a standardized protocol, and review the specialist response within 2 business days of the request. The settings were two primary care practices in eastern Massachusetts that were affiliated with a large integrated delivery system. Technical evaluation of the effectiveness of the system involved 18 patients. Main outcome measures included physician and patient satisfaction and comfort and efficiency of care delivery. RESULTS: In 15 cases, the consultant dermatologist was comfortable in providing definitive diagnosis and treatment recommendations. In 3 cases, additional information (laboratory studies or more history) was requested. There were no instances where the dermatologist felt that a face-to-face visit was necessary. CONCLUSIONS: This novel approach shows promise for the delivery of specialist expertise via the internet. Cost-effectiveness studies may be necessary for more widespread implementation.     

计算机模拟药物筛选在新药设计与开发中的应用

过去十几年中 ,研制新药的环境和条件发生了巨大变化 ,使得传统的药物开发途径步履艰难。传统的药物开发模式 (见图 1)往往需花费数亿美元、十数年的时间 ,从上万个化合物中才能发掘出一个有应用价值的新药[1] 。由于这种方法周期长、耗费巨大 ,有很大的随机性和盲目性 ,人们在寻找新的药物发现的新方法。文献来源内部资料→药物化学药理模型筛选先导化合优化天然产物筛选候选药物图 1　传统的药物开发模式Ｆｉｇ 1　Ｔｈｅｍｏｄｅｌｏｆｃｌａｓｓｉｃａｌｄｒｕｇｄｅｖｅｌｏｐｍｅｎｔ生命科学和信息科学的发展推动了二十一世纪的创新…     

Modular design,application architecture,and usage of a self-service model for enterprise data delivery: The Duke Enterprise Data Unified Content Explorer (DEDUCE)

PurposeData generated in the care of patients are widely used to support clinical research and quality improvement, which has hastened the development of self-service query tools. User interface design for such tools, execution of query activity, and underlying application architecture have not been widely reported, and existing tools reflect a wide heterogeneity of methods and technical frameworks. We describe the design, application architecture, and use of a self-service model for enterprise data delivery within Duke Medicine.MethodsOur query platform, the Duke Enterprise Data Unified Content Explorer (DEDUCE), supports enhanced data exploration, cohort identification, and data extraction from our enterprise data warehouse (EDW) using a series of modular environments that interact with a central keystone module, Cohort Manager (CM). A data-driven application architecture is implemented through three components: an application data dictionary, the concept of “smart dimensions”, and dynamically-generated user interfaces.ResultsDEDUCE CM allows flexible hierarchies of EDW queries within a grid-like workspace. A cohort “join” functionality allows switching between filters based on criteria occurring within or across patient encounters. To date, 674 users have been trained and activated in DEDUCE, and logon activity shows a steady increase, with variability between months. A comparison of filter conditions and export criteria shows that these activities have different patterns of usage across subject areas.ConclusionsOrganizations with sophisticated EDWs may find that users benefit from development of advanced query functionality, complimentary to the user interfaces and infrastructure used in other well-published models. Driven by its EDW context, the DEDUCE application architecture was also designed to be responsive to source data and to allow modification through alterations in metadata rather than programming, allowing an agile response to source system changes.     

Severity score system for progressive myelopathy: development and validation of a new clinical scale

Progressive myelopathies can be secondary to inborn errors of metabolism (IEM) such as mucopolysaccharidosis, mucolipidosis, and adrenomyeloneuropathy. The available scale, Japanese Orthopaedic Association (JOA) score, was validated only for degenerative vertebral diseases. Our objective is to propose and validate a new scale addressing progressive myelopathies and to present validating data for JOA in these diseases. A new scale, Severity Score System for Progressive Myelopathy (SSPROM), was constructed covering motor disability, sphincter dysfunction, spasticity, and sensory losses. Inter-and intra-rater reliabilities were measured. External validation was tested by applying JOA, the Expanded Disability Status Scale (EDSS), the Barthel index, and the Osame Motor Disability Score. Thirty-eight patients, 17 with adrenomyeloneuropathy, 3 with mucopolysaccharidosis I, 3 with mucopolysaccharidosis IV, 2 with mucopolysaccharidosis VI, 2 with mucolipidosis, and 11 with human T-cell lymphotropic virus type-1 (HTLV-1)-associated myelopathy participated in the study. The mean ± SD SSPROM and JOA scores were 74.6 ± 11.4 and 12.4 ± 2.3, respectively. Construct validity for SSPROM (JOA: r = 0.84, P < 0.0001; EDSS: r = −0.83, P < 0.0001; Barthel: r = 0.56, P < 0.002; Osame: r = −0.94, P < 0.0001) and reliability (intra-rater: r = 0.83, P < 0.0001; inter-rater: r = 0.94, P < 0.0001) were demonstrated. The metric properties of JOA were similar to those found in SSPROM. Several clinimetric requirements were met for both SSPROM and JOA scales. Since SSPROM has a wider range, it should be useful for follow-up studies on IEM myelopathies.     

Obesity-related knowledge and beliefs in obese adults attending a specialist weight-management service: implications for weight loss over 1 year

OBJECTIVE: Cognitive approaches to obesity management assume that weight loss is more likely to occur if individuals perceive many benefits and few costs. Research to-date has been limited by the lack of prospective studies. METHODS: A longitudinal study design. At baseline, obese patients attending weight-management clinics (n=104) completed a questionnaire that assessed knowledge and beliefs regarding obesity's health and social/aesthetic consequences (Obesity Risk Knowledge (ORK-10) scale and the Obesity Beliefs scale), self-reported weight/height, goal weight, health-related quality of life, and sociodemographic characteristics. Medical records were also reviewed. At the 12-month follow-up, a second questionnaire assessed self-reported weight/height. RESULTS: At baseline, average ORK-10 scale scores were 4/10. At follow-up, 32 out of the 66 participants retained on the study did not gain weight (48.5%). For these participants, weight loss was associated with endorsement of the health (r(s)=0.40) and the social/aesthetic (r(s)=0.31) costs of obesity (p<0.05). CONCLUSION: Despite their high-risk status, participants demonstrated low levels of knowledge regarding obesity's health risks. Weight loss was associated with greater awareness of the health and social/aesthetic costs of obesity. PRACTICE IMPLICATIONS: This study suggests that health education is required to facilitate informed choices and supports the use of cognitive approaches which promote both the health and social/aesthetic consequences of obesity.     

The patient, the doctor and the emergency department: a cross-sectional study of patient-centredness in 1990 and 2005

OBJECTIVE: To compare and contrast the duration and content of physician-patient interaction for patients presenting to an emergency department with problems of low acuity in 1990 and 2005 treated by different grades of physician. METHODS: Observational study with data collection in May-July 1990 and May-July 2005. Patients identified at nurse triage as presenting with 'primary care' problems were allocated by time of arrival to senior house officers (1990, n=7; 2005, n=10), specialist registrars/staff grades (1990, n=4; 2005, n=7) or sessionally employed general practitioners (1990, n=8; 2005, n=12) randomly rostered to work in a consulting room that had a wall-mounted video camera. A stratified sample of 430 video-taped consultations (180 (42%) from 1990 and 250 (58%) from 2005) was analysed using the Roter Interaction Analysis System. Main outcome measures -- length of consultation; numbers of utterances of physician and patient talk related to building a relationship, data gathering, activating/partnering (i.e. actively encouraging the patient's involvement in decision-making), and patient education/counselling. RESULTS: On average consultation length was 251s (95% CI for difference: 185-316) longer in 2005 than in 1990. The difference was especially marked for senior house officers (mean duration 385s in 1990 and 778s in 2005; 95% CI of difference: 286-518). All groups of physician showed increased communication related to activating and partnering and building a therapeutic relationship with the patient. While senior house officers demonstrated a greatly increased focus on data gathering, only general practitioners substantially increased the amount of talk centred on patient education and counselling; compared to senior house officers, the odds ratio for the number of such utterances included in consultations was 2.8 (95% CI: 1.4, 5.3). CONCLUSION: Although patient-centredness together with consultation length increased for all three physician groups over the duration of this study, senior house officers and specialist registrars/staff grades continued to place less emphasis on advice-giving and counselling than did general practitioners. The extent to which these observed changes in practice were determined by policy, management and training initiatives, and their impact on patient outcome, needs further study. PRACTICE IMPLICATIONS: Video-recording consultations is feasible in an acute hospital setting, and could be used to support training and workforce development. General practitioners can make a distinctive contribution to the workforce of emergency departments. Their consulting style differs from that of hospital physicians and may benefit patient care through a greater focus on patient education and counselling.     

Histochemical and morphologic studies of mucosa bordering rectosigmoid carcinomas: comparisons with normal, diseased, and malignant colonic epithelium

Surgically obtained rectosigmoid mucosa ("transitional" mucosa, TM) adjacent to eight primary carcinomas was compared with diseased mucosa (DM) from eight patients without primary carcinoma and mucosa from two normal control subjects by mucin histochemical and morphologic techniques. No differences were found between TM and DM that might have suggested premalignant changes unique to TM. An excess of sialidase-susceptible sialomucins was found in both TM and DM, as was loss of the sulfomucin-sialomucin gradient usually found between normal crypts and surface cells. Increased sialic acid in TM and DM may represent a nonspecific response to injury or inflammation and has been found in other epithelia under similar circumstances. Sialidase also induced substantial reduction of periodic acid-Schiff (PAS) staining, probably due to loss of sialic acid since no other sugars were released during sialidase digestion, as determined by thin-layer chromatography analysis of post-digestion supernatants. Carcinomas generally showed more staining with PAS than with basic dyes; PAS staining was minimally reduced by diastase and sialidase but markedly reduced by phenylhydrazine interposition, suggesting that some type of neutral glycoprotein was responsible. Finally, it was found that overreliance on the high-iron diamine-Alcian blue technique as a single procedure is unwise; this procedure should be accompanied by the use of singly applied dyes, especially high-iron diamine, together with other enzymatic and staining procedures.