Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues

The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.     

Frontal-striatal disconnection disrupts cognitive performance of the frontal-type in the rat

The prefrontal cortex is considered to provide executive control of response selection and planning in diverse cognitive tasks, translated into action via descending subcortical projections (or 'loops') through the basal ganglia. We have used a disconnection strategy to demonstrate first that bilateral fronto-striatal disconnection disrupts rats' abilities to perform delayed alternation, the classic test of prefrontal function in rats and monkeys, and second that crossed unilateral cortical and striatal lesions on opposite sides similarly disrupt rats' abilities to perform the same cognitive task. We found that effective disconnection requires interruption of interhemispheric transfer, achieved by transection of the anterior corpus callosum. This produces a moderate deficit in its own right, which is not exacerbated by additional prefrontal and striatal lesions in one hemisphere. Conversely, the animals are significantly more impaired after crossed prefrontal and striatal lesions of similar total magnitude. The results demonstrate than an intact cortico-striatal pathway is necessary to sustain performance on a classical prefrontal task, and provide a model within which to assess circuit reconstruction with novel cell therapies for brain repair.     

Comparison of the antiviral effects of 5-methoxy-methyldeoxyuridine-5′-monophosphate with adenine arabinoside-5′-monophosphate

Methoxymethyldeoxyuridine-5′-monophosphate (MMUdR-MP) and arabinofuranosylade-nine-5′-monophosphate (Ara-AMP) had significant antiviral activity against herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) in RK-13 and Vero cells. MMUdR-MP and Ara-AMP were more potent than methoxymethyldeoxyuridine (MMUdR) and arabinofuranosyladenine (Ara-A) against the MS strain of HSV-2. MMUdR-MP inhibited replication of HSV-1^r (mutant resistant to MMUdR). MMUdR in combination with Ara-AMP showed additive activity; whereas the MMUdR-MP and Ara-AMP combination was antagonistic against herpes viruses. MMUdR in combination with Ara-A was synergistic in reducing the log virus yield. Cytotoxicity (microscopic lesions) was observed on exposure to MMUdR-MP and Ara-AMP at 450 and 90 μM, respectively. Rapidly proliferating RK-13 cells exposed to Ara-AMP (64 μM) were killed. In the same system, the cells surviving after incubation with MMUdR-MP (650 μM), multiplied at an almost normal rate.     

Acute dystonia as an idiosyncratic response to neuroleptics in baboons.

Among 25 baboons, Papio papio, 2 consistently showed acute dystonic reactions, with mouthing, compulsive gnawing and limb and trunk dystonia, following the intravenous administration of neuroleptics and related drugs (haloperidol, 0-6-1-2 mg/kg; pimozide 0-5-2-5 mg/kg; chlorpromazine 5-25 mg/kg; metoclopramide 1-5-1-7 mg/kg; oxyperomide 0-25-1-0 mg/kg). The syndrome was not seen after thioridazine (3-7 mg/kg). The dystonic responses occurred within 1-2 h of drug injection and lasted for 2-24 h. They were abolished for 1-3 h within 1-2 min of the intravenous injection of acetylcholine antagonists (benztropine 0-2 mg/kg; hyoscine 0-02 mg/kg). Pre-treatment with a combination of reserpine (2 mg/kg) and alpha-methylparatyrosine (2 X 200 mg/kg) substantially reduced the dystonic response to haloperidol. A second larger dose of haloperidol (5 mg/kg), given 60-90 min after 0-5 mg/kg) initially reduced the intensity of the dystonic response, but after 29 min induced vomiting and generalized seizures in the idiosyncratic baboons. The hypothesis is advanced that the dystonic responses result from release of dopamine on to a sub-population of receptors in the striatum that are relatively insensitive to blockade by neuroleptics.     

Posttraumatic stress disorder: An exploratory study examining rates of trauma and PTSD and its effect on client outcomes in community mental health

Background

Rates of trauma and Posttraumatic Stress Disorder (PTSD) were examined in order to compare the profile in clients of an Australian Public Mental Health Service with that reported in the international literature for clients with major mental illness and to explore the effect of this on client health outcomes. Potential factors contributing to increased levels of trauma/PTSD in this group of clients and the issue of causality between PTSD and subsequent mental illness was also explored.

Methods

A convenience sample of 29 clients was screened for trauma and PTSD using the Posttraumatic Stress Diagnostic Scale? (PDS) and selected outcome measures. Paired and independent samples t-test and ANOVA were applied to the data.

Results

High levels of undocumented trauma and PTSD were found. Twenty clients, (74%) reported exposure to multiple traumatic events; 33.3% (9) met DSM IV diagnostic criteria for PTSD. Significant difference was found for PTSD symptomatology, severity and impairment and for client and clinician-rated scores of Quality of Life (QOL) outcomes in the PTSD group. No effect for PTSD symptomatology on the Working Alliance (WA) was found. Factors that may influence higher rates of PTSD in this group were identified and included issues associated with the population studied, the predominance of assaultive violence found, and vulnerability and risks factors associated with re-traumatisation within the social and treating environments.

Conclusion

A similar trauma and PTSD profile to that reported in the international literature, including greater levels of trauma and PTSD and a poorer QOL, was found in this small sample of clients. It is postulated that the increased levels of trauma/PTSD as reported for persons with major mental illness, including those found in the current study, are primarily related to the characteristics of the population that access public mainstream psychiatric services and that these factors have specific implications for service delivery, and raise issues of efficiency and effectiveness of resource use in achieving successful outcomes in public mental health services for clients with co-morbid PTSD. Further research with a more rigorous design is needed to test these preliminary findings within Australian Community Mental Health Services.