Acknowledgement of referees

Interaction of tamoxifen, trioxifene and LY117018 with cytosol-estrogen receptors from immature rat uteri was compared. Determination of relative binding affinity (RBA) by competition with [³H] estradiol under various assay conditions revealed that the RBA of LY117018 increased with temperature while that of tamoxifen and trioxifene declined. Furthermore, the RBA values of tamoxifen and trioxifene observed after 24 h of incubation at 4°C were significantly lower than those obtained with 1-h incubations. However RBA values obtained with 1- or 24-h incubations of LY117018 at 4°C were similar. The complex formed by estradiol or LY117018 at 4°C was relatively stable for 24 h, while significant dissociation of tamoxifen and trioxifene was detected under these conditions. At 30°C estradiol displayed a biphasic pattern of dissociation, but tamoxifen and trioxifene dissociated rapidly and little evidence of a stable phase was apparent. By contrast, the complex formed by LY117018 exhibited greater stability than that of estradiol at 30°C. These results establish a relationship between shifts in competition curves (RBA) and rates of dissociation relative to estradiol; and clearly reveal that LY117018 has different binding characteristics than tamoxifen and trioxifene.     

Telephone triage, expert systems and clinical expertise

This paper reports on a qualitative study of the use of an expert system developed for the British telephone triage service NHS Direct. This system, known as CAS, is designed to standardise and control the interaction between NHS Direct nurses and callers. The paper shows, however, that in practice the nurses use CAS in a range of ways and, in so doing, privilege their own expertise and deliver an individualised service. The paper concludes by arguing that NHS Direct management's policy of using CAS as a means of standardising service delivery will achieve only limited success due not only to the professional ideology of nursing but also to the fact that rule-based expert systems capture only part of what 'experts' do.     

An electron microscopic study of rubrospinal projections to the lumbar spinal cord of the opossum

The rubrospinal system is a major suprasegmental input to the important interneuronal pool at the base of the lumbar dorsal horn in the North American opossum. After appropriate lesions, rubral axons and their synaptic terminals were found in electron micrographs of lamina IV, V and VI as well as within the dorsal extreme of lamina VII. Degenerating terminals contact small diameter dendrites in the lateral terminal zone and large dendritic profiles in the medial terminal zone. Correlating these data with the dendritic arborizations of interneurons in Golgi preparations and with existing physiologic studies, it appears that interneurons in the intermediate and medial aspects of lamina V, VI and VII receive rubral input on both their proximal and distal dendrites.     

Assessing competence in communication and interpersonal skills: the Kalamazoo II report.

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.     

Male callers to NHS Direct: the assertive carer, the new dad and the reluctant patient

It has been suggested in the light of mortality and morbidity rates, and men's reluctance to seek medical help and advice, that there is a crisis in men's health. Little is known about men's experiences of using health care services, despite an emergent UK men's health movement. NHS Direct, the new telephone advice line, was designed to be more accessible, convenient and responsive to the public's needs for health care. In-depth interviews with male callers to the service, aged between 29 and 59, reveal that they sought help in their roles as fathers, partners and on their own behalf. Having used it once, they anticipated doing so again. Their learning about health matters, from both the formal structure and the informal agenda of the telephone consultation, suggests the potential of men's use of this service for 'normalizing' help seeking by men, and thereby for longer-term improvements in men's health.     

When is "good enough"? The role and responsibility of physicians to improve patient safety.

In September 2001, the Agency for Healthcare Research and Quality (AHRQ) and the ABIM Foundation jointly sponsored an invitational conference entitled "The Role and Responsibility of Physicians to Improve Patient Safety." The goal of the conference was to begin a national conversation focusing on the individual clinician's role and strategies physicians might employ to advance patient safety. The authors summarize the main themes and issues that emerged at the conference. The authors draw from work by the Institute of Medicine (IOM) to support the need for greater emphasis on quality improvement. To date, most of the work in this area has involved a systems-level approach, and physicians are often viewed as obstacles to improvement programs. By contrast, physicians may view population- or systems-based approaches to health care as interfering with the delivery of care to specific patients. The authors argue that physicians, individually and collectively, have a key role in quality improvement efforts, albeit a role that is yet fully defined. After reviewing successful examples involving physicians, the authors explore the major levers to achieve change-removing barriers, creating incentives, emphasizing collaboration, increasing education, and promulgating regulation-and summarize ten recurring themes, including both current and near-term opportunities, for physicians to exercise leadership in quality improvement and patient safety. Finally, they assert that even modest change can lead to substantial improvements, particularly if medical societies and the profession's standard-setting bodies work together.     

Mandibular sarcoidosis: case presentation

Oral and maxillofacial sarcoidosis is rare. Although the systemic effects and course of the disease are well described, the etiology of sarcoidosis remains unknown. Diagnosis involves histologic, radiographic, and clinical correlation, and laboratory tests can be used to monitor disease activity. Treatment is directed at suppression of the immune system, and communication among members of the healthcare team is important for successful therapy.