A taxonomy of requests by patients (TORP): a new system for understanding clinical negotiation in office practice

BACKGROUND: The goal of our investigation was to facilitate research on clinical negotiation between patients and physicians by developing a reliable and valid classification system for patients' requests in office practice. METHODS: We developed the Taxonomy of Requests by Patients (TORP) using input from researchers, clinicians, and patient focus groups. To assess the system's reliability and validity, we applied TORP to audiotaped encounters between 139 patients and 6 northern California internists. Reliability was assessed with the kappa statistic as a measure of interrater agreement. Face validity was assessed through expert and patient judgment of the coding system. Content validity was examined by monitoring the incidence of unclassifiable requests. Construct validity was evaluated by examining the relationship between patient requests and patient health status; patient request fulfillment and patient satisfaction; and patient requests and physician perceptions of the visit. RESULTS: The 139 patients made 772 requests (619 requests for information and 153 requests for physician action). Average interrater agreement across a sample of 40 cases was 94% (kappa = 0.93; P <.001). Patients with better health status made fewer requests (r = -0.17; P = .048). Having more chronic diseases was associated with more requests for physician action (r = 0.32; P = .0002). Patients with more unfulfilled requests had lower visit satisfaction (r = -0.32; P <.001). More patient requests was also associated with physician reports of longer visit times (P = .016) and increased visit demands (P = .006). CONCLUSIONS: Our study provides evidence that TORP is a reliable and valid system for capturing and categorizing patients' requests in adult primary care. Further research is needed to confirm the system's validity, expand its applicability, and explore its usefulness as a tool for studying clinical negotiation.     

Point-of-Care-Testing – das Intensivlaboratorium

After successful centralization of laboratory analyses since more than 30 years, advances in biosensors, microprocessors, measurement of undiluted whole blood and miniaturization of laboratory analyzers are leading nowadays more and more to a re-decentralization in the laboratory medicine. Point-of-care-testing (POCT), which is defined as any laboratory test performed outside central or decentralized laboratories, is becoming more and more popular. The theoretical advantages of POCT are faster turn-around-times (TAT), more rapid medical decisions, avoidance of sample identification and sample transport problems and the need of only small specimen volumes. These advantages are frequently mentioned, but are not associated with a clear clinical benefit. The disadvantages of POCT such as incorrect handling and/or maintenance of the analyzers by nontrained clinical staff, inadequate or even absent calibrations and/or quality controls, lack of cost-effectiveness because of an increased number of analyzers and more expensive reagents, insufficient documentation and difficult comparability of the obtained POCT-results with routine laboratory results, are strongly evident. According to the authors' opinion the decision for the establishing of POCT has only to be made in a close co-operation between physicians and laboratorians in order to vouch for necessity and high quality of the analyses. Taking the local situation into consideration (24-h-central laboratory, etc.) the spectrum of parameters measured by means of POCT should be rigorously restricted to the vital functions. Such analytes should be: hemoglobin or hematocrit, activated whole blood clotting time, blood gases, sodium, potassium, ionized calcium, glucose, creatinine, ammonia and lactate.     

Gefühl ohne Sprache oder Sprache ohne Gefühl? Weitere Hinweise auf die Validität der Entkopplungshypothese der Alexithymie

The theoretical background of the present investigation was the decoupling hypothesis of alexithymia, which presumes for alexithymic individuals a dissociation of psychophysiological indicators of emotion from verbal cognitive awareness of one's emotional state. To study alterations in reactivity to emotionally distressing stimuli in alexithymic individuals, 12 high-alexithymic and 14 low-alexithymic subjects (separated by TAS) out of a general sample of 54 were investigated. All subjects were exposed to cognitive (CPT) and affect inductive (film sequences) distress. During stimulus exposition electrodermal activity (spontaneous fluctuations) was recorded. After stimulus exposition the subjects assessed their emotional reaction towards the film sequences (DAS). Concerning electrodermal activity no differences were found between high and low alexithymics under cognitive distress. In any case a significant autonomous arousal was registered. However, only the low alexithymic subjects but not the high alexithymics showed a significant increase of spontaneous fluctuations as expression of autonomous arousal during presentation of affect inductive stimuli. The altered psychophysiological reactivity found in high alexithymics in contrast to low alexithymic subjects was revealed specifically for the processing of emotional qualified stimuli. However, there was no difference between the groups in cognitive self assessment of emotional response towards the film sequences. The findings are discussed with reference to neurophysiological and psychodynamic models and the decoupling hypothesis of alexithymia.     

A decade of spontaneous long-term course of psychogenic impairment in a community population sample

Background: Our epidemiological study demonstrates the spontaneous long-term course of predominantly psychosocially influenced (“psychogenic”) disorders (neurotic spectrum disorders, personality disorders, stress reactions and somatoform disorders) in a representative community sample of the normal adult population of Mannheim, an industrial and university town in Germany. The natural spontaneous course of these disorders in a population sample over a long period remains largely unknown. Method: Beginning in 1979 (n _t1 = 600) a random population sample was investigated three times over a mean period of approximately 11 years. The last follow-up study ended in 1994 (n _t3 = 301). The follow-up sample was representative of the t1 sample. Psychodynamically trained and clinically experienced interviewers used a semi-structured interview and standardized clinical and psychometric instruments. Psychogenic impairment was assessed using a standardized expert rating (Impairment Score, IS). Results: The mean sum-score of psychogenic impairment after 11 years exceeded the value at t1. The case rate (point prevalence, ICD diagnosis + clinical cut-off/IS) increased from 21.6% at t1 to 26.2% at t3 in the investigated follow-up sample. Intra-individual correlation of psychogenic impairment between t1 and t3 was high (r = 0.55). We found strong evidence for an unfavorable long-term course of psychogenic impairment and only a weak tendency (23.1%) for spontaneous remission of clinically relevant psychogenic impairment. Within a regression model clinical variables, childhood development conditions and personality traits at t1 predicted psychogenic impairment at t3. Conclusion: All clinical variables conclusively indicate an unfavorable spontaneous long-term course of psychogenic impairment. Together with the well-known high prevalence of psychogenic disorders in the normal population, this underlines the need for early therapeutic and preventive intervention. Accepted: 20 August 1999     

Female gender is a risk factor for torsades de pointes in an in vitro animal model.

Recent clinical observations indicate that female gender is associated with a higher risk of developing torsades de pointes (TdP) cardiac arrhythmia. In this study, we used the Langendorff technique in isolated perfused rabbit hearts and the whole-cell patch-clamp technique in ventricular myocytes to examine the gender difference in TdP incidence and gain insight into the underlying mechanisms. Isolated rabbit hearts were perfused by using the Langendorff technique. TdP was induced by abrupt changes of cycle length (deltaCL) in the presence of Tyrode's solution containing 1 mM 4-aminopyridine (4AP) and 50% reduced Mg2+ and K+ (low K/Mg). The effects of 1 mM 4AP on cardiac potassium currents were characterized by using the patch-clamp technique. Results demonstrated that (a) no significant gender difference was observed in the absolute QT interval before or after 4AP perfusion in the presence of low K/Mg; (b) 4AP caused marked QT prolongation in the ECG; (c) a significantly higher TdP incidence (nine of 12) was found in female hearts compared with male hearts (three of 12; p < 0.05); (d) 1 mM 4AP primarily inhibited Ito, although a slight inhibition of IKr also occurred in low-K/Mg Tyrode's solution. (e) No inhibition of IK1 was observed. (f) No gender difference was found in the potassium current block produced by 4AP. Female gender is associated with a higher incidence of TdP in an experimental isolated heart model and mechanisms subsequent to QT prolongation may contribute to such a gender difference.     

A molecular scheme for the reaction between γ-aminobutyric acid and the most abundant chloride channel on crayfish deep extensor abdominal muscle

Single-channel measurements were performed with the aim of constructing a detailed molecular scheme for the reaction between -aminobutyric acid (GABA) and a chloride channel of crayfish deep extensor abdominal muscle (DEAM). GABA was applied in pulses to outside-out patches of muscle membrane, and, based on the dose-response of the peak currents and of their rise times, a linear model with five binding steps has been proposed. Evaluation of the single-channel kinetics indicated at least three open states. Two of them originate most probably from the fully liganded receptor state and are grouped in mixed bursts due to their different life times. The third one appears independently, outside the bursts, and originates from a lower liganded receptor state. Simulations of the dose-responses and the open time distributions with this model led to a set of rate constants which generated relatively optimal fits.     

An evaluation of seven postural reactions ("lagereflexe" selected by Vojta) in twenty-five healthy infants

Twenty-five healthy infants were followed from the newborn period to the age of eighteen months, by evaluation of their neuromotor performance. Evaluation of the specific postural reaction patterns (as described by Vojta) did not seem to be any use as a "short-cut" for the early diagnosis of neuromotor abnormalities, a considerable number of deviations from the normal/optimal pattern being noted even in completely normal infants.     

Analysis of linden flower mucilage.

Linden flowers are known to contain considerable amounts of mucilage. Quantitative determinations of these water soluble polysaccharides were carried out by viscosimetric measurements. It was shown that the mucilage after total hydrolysis in trifluoracetic acid was composed of D-galactose, L-arabinose and L-rhamnose and minor amounts of D-glucose, D-mannose and D-xylose. The high percentage of uronic acid (52%) was due to the presence of both, D-galacturonic acid and D-glucuronic acid. Fractionation of the mucilage polysaccharides on DEAE-cellulose resulted in a separation of five distinct polysaccharide fractions, which showed different sugar compositions and uronic acid content. The homogeneity of the polysaccharide fractions 1-5 was further examined by high voltage electrophoresis and analytical ultracentrifugation.     

Induction of vascular haemostasis by Nd:YAG laser light in melanin-rich and melanin-free tissue

Haemostasis was effected in vessels of melanin-rich (MR: choroid) and melanin-free (MF: mesentery) rabbit tissue irradiated with a cw-Nd: YAG laser. The following parameters were employed: - pulse duration: 200 ms (MR) and 100ms (MF); focal spot diameter: 200 m (MR) and 80 m (MF); pulse energies: 100–250 mJ (MR) and 0.5-1J (MF); irradiances: 1.6–4.0kWcm^–2 (MR) and 1–2 × 10²kWcm² (MF). In melanin-rich tissue, laser energy is absorbed principally by melanin granules contained within the stromal melanocytes. The heat generated in these structures radiates into the surrounding tissue where it is dissipated. The damage thus incurred by the endothelium of blood vessels encompassed within this field triggers the haemostatic mechanism whereby blood flow is arrested. This effect is realized by the formation of an occluding plug of platelets, which is stabilized by the deposition of fibrin, particularly in capillaries, and to a lesser degree in larger vessels of the vascular lamina. In melanin-free tissue, haemoglobin serves as the primary site of energy absorption, which is thus shifted from the stroma to the vessel lumen. Irradiation of vessels in such tissue leads to thermocoagulation of plasma proteins and consequent stasis of blood flow.