Doctor-patient communication with people with intellectual disability - a qualitative study

Background

Patients' priorities and views on quality care are well-documented in Western countries but there is a dearth of research in this area in the East. The aim of the present study was to explore Chinese patients' views on quality of primary care consultations in Hong Kong and to compare these with the items in the CARE measure (a process measure of consultation quality widely used in the UK) in order to assess the potential utility of the CARE measure in a Chinese population.

Methods

Individual semi-structured interviews were conducted on 21 adult patients from 3 different primary care clinics (a public primary healthcare clinic, a University health centre, and a private family physician's clinic). Topics discussed included expectations, experiences, and views about quality of medical consultations. Interviews were typed verbatim, and a thematic approach was taken to identify key issues. These identified issues were then compared with the ten CARE measure items, using a CARE framework: Connecting (Care Measure items 1–3), Assessing (item 4), Responding (items 5,6), and Empowering (items 7–10).

Results

Patients judged doctors in terms of both the process of the consultation and the perceived outcomes. Themes identified that related to the interpersonal process of the consultation fitted well under the CARE framework; Connecting and communicating (18/21 patients), Assessing holistically (10/21 patients), Responding (18/21 patients) and Empowering (19/21 patients). Patients from the public clinic, who were generally of lower socio-economic status, were least likely to expect holistic care or empowerment. Two-thirds of patients also judged doctors on whether they performed an adequate physical examination, and three-quarters on the later outcomes of consultation (in terms of relief or cure and/or side-effects of prescribed drugs).

Conclusion

These findings suggest that Chinese patients in Hong Kong value engaged, empathic primary care doctors and judge the quality of consultations largely on these human skills and the attitudes and values that underpin them, as well as on the perceived outcomes of treatment. The match between themes relating to consultation process and the CARE Measure items suggests utility of this measure in this population, but further quantitative validation is required.     

The rs743572 common variant in the promoter of CYP17A1 is not associated with prostate cancer risk or circulating hormonal levels

OBJECTIVE

To use a large population‐based case‐control study to test the association between the common genetic variant rs743572 (?34 T to C), prostate cancer risk and circulating levels of several hormones.

SUBJECTS AND METHODS

A previous meta‐analysis concluded that reported associations between rs743572 in the promoter of CYP17A1 and prostate cancer risk might reflect publication bias, but a few recent studies reported associations with prostate cancer risk and data suggesting that rs743572 is functional. We genotyped 824 prostate cancer cases and 737 population‐based controls, and applied unconditional logistic regression to estimate the association between rs743572 and prostate cancer risk. We also used linear regression of transformed testosterone, androstanediol glucuronide, dehydroepiandrosterone sulphate, androstenedione, sex hormone‐binding globulin and oestradiol (circulating levels) measured for controls, to estimate the association between these levels and rs743572. The linear models were adjusted for age and laboratory batch.

RESULTS

Men with different genotypes had similar circulating levels of all the hormones measured (all P < 0.05). In the case‐control comparison using unconditional unadjusted logistic regression, the odds ratios (95% confidence interval) for prostate cancer were 1.07 (0.87–1.32) and 0.94 (0.71–1.25) for the dominant and recessive models, respectively, and for the co‐dominant model, 1.10 (0.88–1.36) and 0.99 (0.73–1.35) for carriers of one or two copies of the C allele, respectively. There was no evidence of heterogeneity in the odds ratios by tumour stage (all P > 0.3) and grade (all P > 0.3).

CONCLUSION

The results of the present study are consistent with the conclusions of the previous meta‐analysis, and suggest that rs743572 has no role in the risk of prostate cancer for men of Caucasian origin.     

Ultrasound evaluation of the abductor hallucis muscle: Reliability study

Background

The Abductor hallucis muscle (AbdH) plays an integral role during gait and is often affected in pathological foot conditions. The aim of this study was to evaluate the within and between-session intra-tester reliability using diagnostic ultrasound of the dorso-plantar thickness, medio-lateral width and cross-sectional area, of the AbdH in asymptomatic adults.

Methods

The AbdH muscles of thirty asymptomatic subjects were imaged and then measured using a Philips HD11 Ultrasound machine. Interclass correlation coefficients (ICC) with 95% confidence intervals (CI) were used to calculate both within and between session intra-tester reliability.

Results

The within-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.99–0.99); medio-lateral width an ICC: of 0.97 (95% CI: 0.92–0.97) and cross-sectional area an ICC of 0.98 (95% CI: 0.98–0.99). Between-session reliability results demonstrated for dorso-plantar thickness an ICC of 0.97 (95% CI: 0.95 to 0.98); medio-lateral width an ICC of 0.94 (95% CI 0.90 to 0.96) and for cross-sectional area an ICC of 0.79 (95% CI 0.65 to 0.88).

Conclusion

Diagnostic ultrasound has the potential to be a reliable tool for evaluating the AbdH muscle in asymptomatic subjects. Subsequent studies may be conducted to provide a better understanding of the AbdH function in foot and ankle pathologies.     

Functional interactions between presynaptic NMDA receptors and metabotropic glutamate receptors co-expressed on rat and human noradrenergic terminals

BACKGROUND AND PURPOSE: Electrophysiological studies described potentiation of NMDA receptor function by metabotropic glutamate receptors (mGluRs) of group I occurring postsynaptically. Since release-enhancing NMDA receptors exist on noradrenergic terminals and group I mGluRs have recently been identified on these nerve endings, we have investigated if NMDA receptor-mGluR interactions also can occur at the presynaptic level. EXPERIMENTAL APPROACH: Rat hippocampus and human neocortex synaptosomes were labelled with [(3)H]noradrenaline and superfused with mGluR agonists and antagonists. NMDA-evoked [(3)H]noradrenaline release was produced by removal of external Mg(2+) or by simultaneous application of NMDA and AMPA in Mg(2+)-containing solutions. KEY RESULTS: The mGluR1/5 agonist 3,5-DHPG, inactive on its own, potentiated both the release of [(3)H]noradrenaline elicited by AMPA/NMDA/glycine and that evoked by NMDA/glycine following Mg(2+) removal. The effect of 3,5-DHPG on the AMPA/NMDA/glycine-induced release was insensitive to the mGluR1 antagonist CPCCOEt, but it was abolished by the mGluR5 antagonist MPEP; moreover, it was potentiated by the mGluR5 positive allosteric modulator DFB. When NMDA receptors were activated by Mg(2+) removal, both mGluR5 and mGluR1 contributed to the evoked release, the mGluR-mediated release being blocked only by CPCCOEt and MPEP in combination. Experiments with human neocortex synaptosomes show NMDA receptor-mGluR interactions qualitatively similar to those observed in rodents. CONCLUSIONS AND IMPLICATIONS: Group I mGluRs, both of the mGluR1 and mGluR5 subtypes, co-localize with NMDA receptors on noradrenergic terminals of rat hippocampus and human neocortex. Depending on the mode of activation, NMDA receptors exert differential permissive roles on the activation of presynaptic mGluR1 and mGluR5.     

Heart rate response to hemodialysis-induced changes in potassium and calcium levels.

BACKGROUND: It is well known that hemodialysis affects cardiovascular functions, mainly because of excess body water removal. Conversely, the role of hemodialysis-induced modifications in body fluid characteristics is not yet well-grounded. In particular, the impact of modifications in plasma electrolytes on the pacemaking rhythm of the sinus node has not yet been evaluated. METHODS: Eight patients on regular hemodialysis treatment were studied along a two-hour diffusive dialysis study session without fluid removal. Biochemical (metabolic and hormonal) as well as hemodynamic parameters were measured during the treatment. A computer model of the sinus node cell electrical activity was used to analyse the experimental data. The measured changes in electrolyte concentrations and pH were imposed as model inputs and the model-computed heart rate changes were validated against the measured ones. After validation, numerical simulation was used to obtain a quantitative evaluation of the comparative weight of calcium and potassium on heart rate changes, by simulating treatments leading to different changes in plasma concentrations of such electrolytes. RESULTS: A significant heart rate increase (11%) was obtained following potassium, calcium and pH changes, with no significant variations in indices of autonomic activity. Simulation results revealed that calcium load and potassium removal both accelerate sinoatrial pacemaker beating. Concurrent changes in these electrolyte concentrations may cause heart rate to increase up to 30% at the end of hemodialysis. Heart rate sensitivity to extracellular potassium changes appears to be strictly dependent upon calcium concentration. CONCLUSIONS: Hemodialysis-induced changes in calcium and potassium concentrations may greatly affect the rhythm of the sinus node pacemaker.     

Testicular masses in association with adrenogenital syndrome: US findings.

Adrenogenital syndrome (AGS) is the result of inborn enzymatic defects in the synthesis of steroid hormones. The production of cortisol is deficient and that of adrenocorticotropic hormone is increased. Sometimes male patients have clinically detectable testicular lesions, known as testicular tumors of AGS (TTAGS). From 1985 to 1991, scrotal ultrasonography (US) was performed in 30 consecutive pubertal and postpubertal patients with AGS to investigate the prevalence and US characteristics of TTAGS. Eight of 30 patients had a testicular lesion (27%); six of the eight lesions were clinically undetected. The mean diameter of the lesions was 16.44 mm (range, 2-28 mm). The lesions were hypoechoic in all cases, with well-defined margins in six cases. The nodules were multifocal in all patients and bilateral in six (75%). If testicular lesions are present in a patient with AGS, TTAGS are likely, and frequent US monitoring is adequate for diagnostic evaluation.     

Optimisation of isolation of richly pure and homogeneous primary human colonic smooth muscle cells

BACKGROUND: Inherent properties of gastrointestinal smooth muscle can be assessed using isolated cell suspensions. Currently available isolation techniques, based on short 2-h enzymatic digestion, however, present the disadvantage of low cellular yield with brief viability. These features are an important limiting factor especially in studies in humans in which tissue may not be available daily and mixing of samples is not recommended. AIMS: To optimise the isolation procedure of cells from human colon to obtain a richly pure primary smooth muscle cell preparation. METHODS: Slices of circular muscle layer, obtained from surgical specimens of human colon, were incubated overnight in Dulbecco's modified eagle's medium supplemented with antibiotics, foetal bovine serum, an ATP-regenerating system and collagenase. On the following day, digested muscle strips were suspended in HEPES buffer, and spontaneously dissociated smooth muscle cells were harvested and used either immediately or maintained in suspension for up to 72 h. Cell yield, purity, viability, contractile responses, associated intracellular calcium signals and RNA and protein extraction were evaluated and compared to cell suspensions obtained with the current short digestion protocol. RESULTS AND CONCLUSION: The overnight isolation protocol offers the advantage of obtaining a pure, homogeneous, long-life viable cell suspension that maintains a fully differentiated smooth muscle phenotype unchanged for at least 72 h and that allows multiple functional/biochemical studies and efficient RNA extraction from a single human specimen.     

Dental amalgam, mercury toxicity, and renal autoimmunity.

Chronic exposure to elemental metallic mercury may induce an immunological glomerular disease. Since humans are exposed to mercury vapor (Hg0) from dental amalgam restorations and kidney is an important target organ of mercury vapor and mercury deposition in kidney increases proportionally with the dose, our aim was to test the occurrence of specific antibodies to antiglomerular basement membrane (anti-GBM-IgG) among individuals with adverse effects to mercury from dental amalgam fillings. We selected a group of patients (n=24) with a history of long-term exposure to mercury vapor from mercury-containing amalgam fillings and showing adverse effects that were laboratory confirmed. Enzyme-linked immunosorbent assays (ELISAs) were used to evaluate serum levels of antibodies to anti-GBM-IgG. None of the patients showed evidence of anti-GBM autoimmunity, either in subgroups with strong allergy to mercury or its compounds (i.e., organic mercury) or in those patients who had past thimerosal-containing vaccines coverage (7 of 24). There was no evidence of the presence of circulating anti-GBM antibodies in subjects suffering from adverse events due to long-term exposure to mercury from dental amalgams, even in individuals who presented allergy to mercury.