Situational trust and co-operative partnerships between physicians and their patients: a theoretical explanation transferable from business practice

A model to explain interpersonal trust development, and its consequences for co-operative behaviour in doctor/patient partnerships derived from the context of business relationships is applied to patient/physician relationships. Threshold barriers exist against all human behaviours or actions and trust is the process by which barriers to co-operation and compliance are overcome. Dispositional trust (a psychological trait to be trusting) is dominant in the early stages of a relationship and contributes to the weight of subsequent trust development. Co-operative behaviour or compliance ultimately requires a secure situational trust emerging from consultations, which is carried forward as learnt trust and modified in each subsequent consultation. The model comprises three types of situational trust (calculus-based, knowledge-based, and identification trust) and five co-operation criteria from which to determine an individual's tendency for co- operative behaviour. These model components can be identified and mapped from a range of qualitative data, with the aim of enhancing co-operative behaviour and efficiently achieving optimal patient compliance.     

Localization of arginine biosynthetic enzymes in renal proximal tubules and abundance of mRNA during development

Argininosuccinate synthetase and argininosuccinate lyase catalyze the conversion of citrulline to arginine in kidney. Immunohistochemical staining of mouse kidney sections with antibodies to these two enzymes, compared with the staining patterns of known markers for proximal tubules, demonstrated that these enzymes are localized within the proximal tubules. The relative abundance of mRNA encoding argininosuccinate synthetase and argininosuccinate lyase during fetal and postnatal development of mouse kidney was also determined. Changes in relative abundance of these mRNA in kidney are coordinate during development, paralleling the developmental profile of phosphoenolpyruvate carboxykinase mRNA, which is also expressed in proximal tubules. Although relative abundances of the mRNA are comparable in liver and kidney of adult mice, the profiles of mRNA abundance during development of these two organs are distinct. The results indicate that these enzymes and their corresponding mRNA can serve as useful markers for examining the differentiation and development of renal proximal tubules in vivo and in cultured explants.     

Absence from school related to cancer and other chronic conditions.

Absence from school during the first year after starting major treatment for cancer or chronic or orthopaedic conditions was examined. Retrospective data were collected on 72 children and obtained from hospital records, school registers, and interviews with parents and teachers. Median initial absences caused by treatment were 91, 29-5, and 15 days for cancer, chronic, and orthopaedic patients respectively. The mean proportions of the remaining school time in the year occupied by absences caused by treatment and those not caused by treatment were respectively 17% and 17% for oncology patients, 8% and 12% for chronic patients, and 2% and 11% for orthopaedic patients. The only significant factor associated with the amount of absence caused by treatment was the type of illness. Increased absence not caused by treatment was associated with the amount of treatment time and the patient being a girl. The proportion of absence not caused by treatment decreased if the mother was educated beyond the age of 18. The possible reasons for and effects of excess absence are discussed.     

Serum inhibin levels in polycystic ovary syndrome: effect of insulin resistance and insulin secretion

Insulin resistance is common in women with the polycystic ovary syndrome. We investigated the relationship between insulin resistance and the serum inhibin concentration in a group of 19 women with polycystic ovary syndrome and eight control subjects at different phases of the menstrual cycle. Insulin resistance was measured by the frequently sampled intravenous glucose tolerance test, and inhibin was measured by a specific radioimmunoassay. Insulin sensitivity (mean +/- SE) was significantly reduced in the polycystic ovary syndrome group compared with controls: reduced insulin sensitivity 46.7 +/- 5.0 min-1/(nmol/mL), normally insulin-sensitive 106.6 +/- 11.7 min-1/(nmol/mL) (P less than .01). The women with polycystic ovary syndrome had inhibin levels (126 +/- 15.2 microLEq/mL) comparable to those found during the early follicular phase of the control group (117 +/- 22.1 microLEq/mL), but significantly lower than late follicular phase (259 +/- 25.6 microLEq/mL) or luteal phase (448 +/- 91.8 microLEq/mL) levels in the control group. No association was found between the degree of insulin resistance and the inhibin concentration, which remained unaltered over a 3-hour period despite maximal stimulation of endogenous insulin secretion. The inhibin concentrations in polycystic ovary syndrome may reflect impaired follicular maturation. Inhibin secretion is not acutely affected by insulin secretion in normal or in hyperandrogenic women.     

Neoadjuvant chemotherapy and interval debulking for advanced epithelial ovarian cancer

A retrospective matched-control study was conducted to review our experience with FIGO stage III and IV epithelial ovarian cancer in patients referred after initial laparotomy and biopsy only. The study group comprised 22 patients; planned treatment was two to four cycles of chemotherapy, interval debulking surgery, six more chemotherapy cycles, and second-look laparotomy. Two control groups were matched with the study group according to FIGO stage, histologic type, and grade (2 or 3) and patient age +/- 5 years. The first control group (22 patients) had greater than 2 cm residual disease after initial surgery; their planned treatment was a minimum of six cycles of chemotherapy plus second-look laparotomy. The second control group (18 patients) was referred after initial laparotomy and biopsy only; their disease was immediately reexplored and debulked. Subsequent planned treatment was a minimum of six cycles of chemotherapy plus second-look laparotomy. All patients received cisplatin-based chemotherapy. Optimal cytoreduction to less than or equal to 2 cm was achieved for 77% of the study group vs 39% of the immediate-reexploration group (P = 0.02). Median survival times for the three groups were not different (16 vs 19.3 vs 18 months, respectively) (P = 0.58). Within the study group, patients who were optimally debulked survived significantly longer than those who were not (18.1 vs 7.5 months) (P = 0.02). Morbidity of the interval debulking procedure was acceptable. Study findings suggest that patients with bulky residual disease have a uniformly poor prognosis regardless of the timing of further surgery.     

Prospective treatment of advanced or recurrent endometrial carcinoma with cisplatin, doxorubicin, and cyclophosphamide

Both single-agent cisplatin and the combination of doxorubicin and cyclophosphamide demonstrated moderate activity against endometrial carcinoma in earlier salvage trials. Since January 1979, 102 patients with advanced primary (n = 42) or recurrent (n = 60) endometrial carcinoma were prospectively treated with cisplatin (50 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (500 mg/m2) (PAC). PAC was administered monthly until disease progression or toxicity precluded additional therapy. Patients received a median of five treatment cycles (range 1-13). Of the 87 patients with measurable disease, 12 had a complete clinical response, while 27 had a partial clinical response, for an overall objective response rate of 45%. No differences in response rates between primary and recurrent disease patients were noted. Median time to response was 2.5 months with a median response duration of 4.8 months. Nonresponders included 33 patients with stable disease and 15 with progression. Median progression-free survival for all patients was 6 months. Dose escalation was possible in 25% of patients; however, 52% of patients required dose reductions during treatment. Clinically significant toxicities included neutropenia (65%), anemia (47%), emesis (21%), nephrotoxicity (17%), and neurotoxicity (4%). Our study indicates that endometrial cancer is significantly responsive to PAC. Enthusiasm for this regimen should be tempered by the limited duration of response and substantial treatment toxicity.     

Olfactory and trigeminal thresholds and nasal resistance to airflow

Nasal congestion associated with the common cold or allergy is associated with a decreased sensitivity of the sense of smell. This study was designed to detect any relationship between nasal resistance to airflow and the ability to detect odors presented to the nose. In particular we were interested to determine if the asymmetrical nasal resistance to airflow associated with the nasal cycle influenced nasal thresholds to menthol which is detected by trigeminal nerves and vanillin which is detected by olfactory nerves. Nasal resistance to airflow and the thresholds for L-menthol and vanillin were measured for each nasal passage in 17 normal volunteer subjects. Nasal resistance to airflow was asymmetrical due to the nasal cycle with a resistance on the high side of 0.94 +/- 0.15 Pa/cm3 s (mean +/- S.E. n = 17). and 0.48 +/- 0.04 Pa/cm3 s on the low side. The range of unilateral nasal resistances varied from 0.31-2.55 Pa/cm3 s. Despite these variations in nasal resistance to airflow no relationship was found between nasal resistance to airflow and thresholds for menthol or vanillin. Since threshold and nasal resistance are not related in normal subjects this may indicate that it is not the level of nasal congestion that affects the sense of smell in nasal infection and allergy, but some other factor related to the inflammatory response of the nasal mucosa.     

Effect of decreased mobility on body composition in patients with Alzheimer's disease

Randomly selected 50 patients with the diagnosis of probable Alzheimer's disease, hospitalized for long-term care in a Special Care Dementia unit, were examined. None of the patients were clinically malnourished although several had low cholesterol levels. The mean lean body mass, measured by bioelectrical impedance plethysmography, was 62.5% of total body mass. The average calorie intake was 2125+398 Kcal/day, ranging from 1300 to 2900 Kcal/day, and the body weight of most subjects was stable, with the average gain of 1 lbs in the previous three months. Eighteen patients ambulated independently, 14 required assistance, and 18 were non-ambulatory. The lean body mass index was associated with the patient's age and mobility status. These results indicate that patients with advanced dementia and compromised mobility have decreased muscle mass that may result in weight loss even in the absence of malnutrition.     

Promoting interactions with basic scientists and clinicians: the NIA Alzheimer's Disease Data Coordinating Center

To benefit Alzheimer's disease research, a central data co-ordinating centre (CDCC) is planned that will systematically collect data from 27 Alzheimer's disease centres (ADCs) located nationwide. This CDCC will combine, analyse and disseminate epidemiologic, demographic, clinical and neuropathological data to researchers from the ADCs and the broader scientific community. New and larger scale collaborative studies on Alzheimer's disease will be possible through this centre. Since 1 July 1997, an interim data co-ordinating centre (IDCC) has been serving as the agent of the ADCs to begin the data sharing process until a permanent CDCC is established. The data collected by the IDCC are limited to administrative information and to indexing of specimens and clinical material, with future plans for the transfer of the data collected to the CDCC once it is established.