Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility

OBJECTIVES: To develop a video assessment method for General Practitioners (GPs) by analysing issues of validity, reliability and feasibility of observation of videotaped regular consultations. DESIGN: In a cross-sectional study consultations of 93 GPs were video recorded in the practice during 1 week. The GPs registered consultation and patient data in a logbook; 16 consultations per GP were selected using preset criteria. The quality of communicative and medical performance of these consultations was assessed by GP observers with a validated instrument. The validity of the procedure was evaluated by checking the content of each GP's sample using specific sample criteria. Selection bias was estimated by multiple regression analysis, with sample characteristics as independent variables and scores on communication and medical performance as dependent variables. The influence of observation on GPs and patients was assessed by a questionnaire. Generalizability theory was used to estimate reliability. Feasibility was assessed by conducting a questionnaire, by keeping accounts, and by checking the technical quality of the videotaped consultations. SETTING: Universities of Nijmegen and Maastricht, The Netherlands. SUBJECTS: General Practitioners (GPs). RESULTS: The domain of general practice was well covered in the samples; content validity was satisfactory. With regard to the sample characteristics, only the total duration of consultations appeared to correlate significantly with both the score on communication and the score on medical performance. A majority (71%) of GPs reported not being influenced by the observation, except in the first cases, and recognizing their usual daily performance in the videotaped consultations. An acceptable level of reliability was reached after 2.5 hours of observation, i.e. 12 cases by a single observer. The method was well accepted by both GPs and patients. The costs were pound250 per GP. CONCLUSIONS: Video assessment of GPs in daily practice according to the procedures described is a valid and reliable method, one which is useful for education and quality improvement. There is a trade-off between feasibility on one hand and validity, reliability and credibility on the other hand. Compared to investments in observation methods in standardized settings, the costs of video observation of GPs' actual performance are acceptable.     

角膜异物分区分级和记录方法

目的探讨角膜异物分区、分级及记录方法。方法对５６０例角膜异物分区、分级研究,在此基础上提出一种较为适用的记录方法,并用此指导临床实践。结果角膜异物有其分布特点,区、级不同,治疗及愈后不同。用此记录方法指导临床实践准确方便,不会出现误治漏治。结论角膜异物分区、分级及记录方法在临床上科学实用,在法医学上亦有使用价值     

Single-channel and whole-cell analysis of ethanol inhibition of NMDA-activated currents in cultured mouse cortical and hippocampal neurons

The effects of 0.1 to 500 mM ethanol on NMDA-activated currents were studied in primary cultures of mouse cortical and hippocampal neurons. In whole-cell recordings the IC₅₀S for inhibition of NMDA-activated currents by ethanol were 129 mM ± 20 mM in hippocampal neurons and 126 ± 18 mM in cortical neurons. In single-channel recordings from excised outside-out patches of cortical neurons, ethanol inhibited total charge per minute with an IC₅₀ of 174 ± 23 mM, which was not significantly different from the IC₅₀S for inhibition of whole-cell current. The reduction in mean open channel lifetime by ethanol was fit by the logistic equation with an apparent IC₅₀ of 340 ± 28 mM. Analysis of single-channel data indicated that ethanol inhibition of NMDA currents did not involve substantial changes in fast closed state kinetics, changes in open channel conductance, or block of the open channel. At the whole-cell IC₅₀, of ethanol, mean open channel lifetime would decrease by 28% and frequency of opening would decline by 31% to account for the reduction in current. Single-channel data were consistent with ethanol being an allosteric modulator of gating which reduces agonist efficacy.     

Sensory Excitatory Postsynaptic Potentials Mediated by NMDA and non-NMDA Receptors in the Thalamus in vivo

Excitatory amino acid neurotransmitters, such as l-glutamate, act at several receptors in the brain, which are sometimes referred to as N-methyl-d-aspartate (NMDA) and non-NMDA receptors. Extensive in vitro work indicates that both NMDA receptors and non-NMDA receptors contribute to excitatory postsynaptic potentials (epsps). The contribution of NMDA receptors to epsps in vivo under physiological conditions is, however, almost unknown. The receptors that mediate the epsps evoked in thalamic relay cells by natural stimulation of sensory afferents have been investigated in anaesthetized rats, and we report the first pharmacological characterization of an excitatory amino acid receptor-mediated epsp in vivo involving both non-NMDA receptors and, in particular, NMDA receptors.     

Participation of low-threshold calcium spikes in excitatory synaptic transmission in guinea pig medial frontal cortex

We studied the activation of low-threshold calcium spikes (LTS) by excitatory postsynaptic potentials in pyramidal neurons from guinea pig medial frontal cortex with intracellular recording. We used extracellular bicuculline and phaclofen and intracellular QX-314 to block inhibitory synaptic potentials and sodium currents. Postsynaptic potentials were evoked by stimulation of layer I. We found that large (> 10-15 mV) excitatory synaptic potentials evoked from membrane potentials more negative than -75 mV were able to trigger LTS. The activation of LTS resulted in an increase of the rising slope or amplitude of the synaptic potentials depending on the size of the excitatory postsynaptic potential (EPSP). We used 100 microM NiCl2 to confirm the presence of LTS as part of the EPSPs. The N-methyl-D-aspartate (NMDA) and non-NMDA components of the excitatory synaptic potentials were isolated using (+/-)2-amino-5-phosphonovaleric acid (APV; 50 microM) or 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX; 20 microM); both components could, independently, trigger an LTS. With recordings made with K+ acetate-filled electrodes, we show that the activation of LTS was critical to allow excitatory synaptic potentials to reach the threshold of action potential firing; also, this amplification of synaptic responses produced the firing of more than a single action potential by the postsynaptic cell. These results demonstrate that in cortical pyramidal neurons the activation of low-threshold calcium spikes results in the amplification of synaptic responses.     

三七总皂苷抗大鼠心肌肥大的作用及其神经机制

目的　探讨三七总皂苷 (PNS)抗腹主动脉缩窄大鼠压力超负荷性心肌肥大的神经机制。方法　①用腹主动脉缩窄法建立心肌肥大模型 ,将大鼠分为假手术对照组、腹主动脉缩窄组及低、中、高剂量组 ,3个剂量组分别每日腹腔注射5 0、10 0和 15 0mgPNS·kg-1。 3wk后处死大鼠检测全心重量/体重 (HW/BW )、左室重量指数 (LVI) ,左心室组织切片HE染色后测心肌纤维直径 (MD)。②细胞内生物电记录技术观察PNS对大鼠星状神经节 (SG)的快兴奋性突触后电位 (f EPSP)、膜电位、膜电阻及对外源性乙酰胆碱引起的膜除极化反应的影响。结果　①高剂量组的HW /BW、LVI及MD显著低于缩窄组 ,P <0 0 1;中剂量组与缩窄组比较MD显著降低 ,P <0 0 5 ;低剂量组与缩窄组比较 ,HW/BW ,LVI和MD三项指标均无显著的变化。②PNS在 0 10～ 0 16g·L-1浓度范围内可使大鼠星状神经节f EPSP可逆性减小 ,PNS还可拮抗高钙对f EPSP的易化作用 ,但对膜电位、膜电阻及外源性ACh引起的膜除极反应无显著的影响。结论　PNS对f EPSP的抑制可能是其抗压力超负荷性心肌肥大的神经机制 ,而抑制作用则是通过突触前机制产生 ,且与拮抗Ca2 + 内流有关。     

Population coding in spike trains of simultaneously recorded retinal ganglion cells

To achieve a better understanding of the parallel information processing that takes place in the nervous system, many researchers have recently begun to use multielectrode techniques to obtain high spatial- and temporal-resolution recordings of the firing patterns of neural ensembles. Apart from the complexities of acquiring and storing single unit responses from large numbers of neurons, the multielectrode technique has provided new challenges in the analysis of the responses from many simultaneously recorded neurons. This paper provides insights into the problem of coding/decoding of retinal images by ensembles of retinal ganglion cells. We have simultaneously recorded the responses of 15 ganglion cells to visual stimuli of various intensities and wavelengths and analyzed the data using discriminant analysis. Models of stimulus encoding were generated and discriminant analysis used to estimate the wavelength and intensity of the stimuli. We find that the ganglion cells we have recorded from are non-redundant encoders of these stimulus features. While single ganglion cells are poor classifiers of the stimulus parameters, examination of the responses of only a few ganglion cells greatly enhances our ability to specify the stimulus wavelength and intensity. Of the parameters studied, we find that the rate of firing of the ganglion cells provides the most information about these stimulus parameters, while the timing of the first action potential provides almost as much information. While we are not suggesting that the brain is using these variables, our results show how a population of sensory neurons can encode stimulus features and suggest that the brain could potentially deduce reliable information about stimulus features from response patterns of retinal ganglion cell populations.     

提升护理记录书写质量的管理措施

目的 提升护理记录书写质量。方法为提升护理记录书写质量采取的管理措施：护理部成立护理记录书写督导网络组织并规定其职责；制订护理记录书写的质量标准；规定护理记录书写的内容；建立规范的培训方案；建全护理记录书写质量监控和考评体系。结果全院护士护理记录书写技能和内涵质量显著提高。结论对护理记录书写必须实施有效的管理措施，才能提高护理记录的合格率。     

碘化N-正丁基氟哌啶醇对豚鼠心房肌细胞乙酰胆碱敏感性钾通道的影响

目的研究碘化N正丁基氟哌啶醇(F2)对豚鼠心房肌细胞乙酰胆碱敏感性钾通道(KACh)的影响,探讨其对KACh的作用机制。方法采用膜片钳全细胞记录方法,测定F2对原代培养的豚鼠心房肌细胞乙酰胆碱敏感性钾电流IK(ACh)的影响。结果细胞外给予F2对豚鼠心房肌细胞IK(ACh)呈可逆性、浓度依赖性的阻断作用。细胞内添入抗水解的GTP类似物GTPγS后,结果同前。细胞内给予50μmol·L-1F2对IK(ACh)无作用。结论F2是豚鼠心房肌细胞KACh的一种快速通道阻断剂,发挥作用部位在细胞膜外侧,作用位点在钾通道本身,与乙酰胆碱受体无关。     

Beta-receptor activation increases sodium current in guinea pig heart

Aim： To study the influence of β-receptor activation on sodium channel current and the physiological significance of increased sodium current with regard to the increased cardiac output caused by sympathetic excitation. Methods： Multiple experimental approaches, including ECG, action potential recording with conventional microelectrodes, whole-cell current measurements, single-channel recordings, and pumping-force measurements, were applied to guinea pig hearts and isolated ventricular myocytes. Results： lsoprenaline was found to dose-dependently shorten QRS waves, increase the amplitude and the Vmax of action potentials, augment the fast sodium current, and increase the occurrence frequencies and open time constants of the long-open and burst modes of the sodium channel. Increased levels of membrane-permeable cAMP have similar effects. In the presence of a calcium channel blocker, TTX reversed the increased pumping force produced by isoprenaline. Conclusion： Beta-adrenergic modulation increases the inward sodium current and accelerates the conduction velocity within the ventricles by changing the sodium channel modes, which might both be conducive to the synchronous contraction of the heart and enhance its pumping function.