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PubMed2006

What does the use of a computerized checklist mean for patient-centered care? The example of a routine diabetes review.

The authors examine the interaction between nurses and patients with type 2 diabetes during routine consultations in primary care settings in the United Kingdom. Through preconsultation interviews, the authors identified the patients' expectations. The article draws on videotaped consultations with 25 patients with type 2 diabetes. Using conversation analysis, the authors examine the use of a rigid agenda, imposed via a computerized checklist, and consider how far this is able to suppress the patient's agenda. They consider the potential impact for the patient and the factors that might encourage the clinician, and the nurse specifically, to adopt a narrowly task-based approach to the consultation. They identify two potentially conflicting strands within contemporary diabetes care, patient-centered practice and an emphasis on biomedical audit, and suggest that achievement of the former might be compromised by the demands of the latter.

Adolescent↗

PubMed2002

Presenting the problem in pediatric encounters: "symptoms only" versus "candidate diagnosis" presentations.

This article examines 2 practices that are used to present children's problems to their pediatricians in acute care encounters. Using the methodology of conversation analysis, this article examines the alternative stances embodied by problem presentations, which offer "symptoms only" versus problem presentations, which also include a "candidate diagnosis." This article suggests that parents who offer only symptoms in their problem presentations are hearable as adopting a stance that they are primarily seeking medical evaluations of their children. By contrast, a parent who includes a candidate diagnosis of the problem is hearable as adopting a stance that he or she is seeking confirmation of the diagnosis and treatment for that illness condition. This communication practice may be treated by physicians as placing pressure on them to prescribe treatment-in particular antibiotic treatment. The implications of this are discussed.

Acute Disease↗

PubMed2003

An interactional structure of medical activities during acute visits and its implications for patients' participation.

Within the context of primary-care, physician-patient visits, researchers have documented both patients' low levels of communicative participation (e.g., question asking) and the advantages of such participation to healthcare (e.g., improved physical health and satisfaction). Prior research has offered a variety of partial, non-exclusive explanations for patients' low levels of participation. This article investigates one underdeveloped source of explanation: the organization of interaction itself. This article argues that the establishment of new medical problems in acute visits makes relevant an organized structure of social action that is composed of an ordered series of medical activities: establishing the reason for the visit, physicians gathering additional information (i.e., history taking and physical examination), physicians delivering diagnoses, and physicians providing treatment recommendations. This "project" of medical activity shapes physicians' and patients' understanding and production of communicative behavior. Using the method of conversation analysis, and analyzing transcribed audio- and videotape data of actual acute visits, this article describes and grounds this project and discusses its implications for research, theory, and improvement on patient participation.

California↗

PubMed2006

The structure of patients' presenting concerns: physicians' opening questions.

This article uses conversation analysis to develop a typology of questions that physicians use to solicit patients' problems and then tests question-format effects on patients' subsequent problem presentations. Data are videotapes of 302 primary-, acute-, and outpatient-care visits involving 77 physicians in 41 urban and rural clinics, as well as pre- and post-visit questionnaires. The most frequent question formats were general inquiries (62%; e.g., "What can I do for you today?") and requests for confirmation (27%; e.g., "I understand you're having some sinus problems today?"). Compared to confirmatory questions, general inquiries were associated with significantly longer problem presentations ( p<.0001) that included more discrete symptoms ( p<.0001). Physicians were more likely to use confirmatory questions in the urban setting ( p=.003).

California↗

PubMed2002

Variant amino acids in the extracellular loops of murine and human vasopressin V2 receptors account for differences in cell surface expression and ligand affinity.

Cloning and sequencing of the murine chromosomal region XB harboring the murine vasopressin V(2) receptor (mV(2)R) gene and comparison with the orthologous human Xq28 region harboring the human vasopressin V(2) receptor (hV(2)R) revealed conservation of the genomic organization and a high degree of sequence identity in the V(2)R coding regions. Despite an identity of 87% of the amino acid sequences, both receptors show marked functional differences upon stable expression in Chinese hamster ovary cells: the mV(2)R displayed a 5-fold higher affinity for [(3)H]AVP than the human ortholog; similar differences were found for the AVP-mediated activation of adenylyl cyclase. Saturation binding experiments with transiently transfected intact COS.M6 cells showed that the mV(2)R was 3- to 5-fold less abundantly expressed at the cell surface than the hV(2)R. Laser scanning microscopy of fusion proteins consisting of the V(2)Rs and green fluorescent protein (GFP) (mV(2)R/GFP, hV(2)R/GFP) demonstrated that the hV(2)R/GFP was efficiently transported to the plasma membrane, whereas the mV(2)R/GFP was localized mainly within the endoplasmic reticulum. Chimeric hV(2)Rs, in which the first and/or second extracellular loop(s) were replaced by the corresponding loop(s) of the mV(2)R, revealed that the second extracellular loop accounts for the differences in ligand binding, but the first extracellular loop accounts for the reduced cell surface expression. The exchange of lysine 100 by aspartate in the first extracellular loop of hV(2)R was sufficient to reduce cell surface expression, which was accompanied by intracellular retention as observed in laser scanning microscopy analysis. Conversely, the exchange of aspartate 100 by lysine in the mV(2)R increased the cell surface expression and resulted in predominant plasma membrane localization. Thus, a single amino acid difference in the first extracellular loop between mV(2)R and hV(2)R determines the efficiency of cell surface expression.

Amino Acid Motifs↗

PubMed1998

Antisense oligonucleotides against 'cardiac' and 'skeletal' DHP-receptors reveal a dual role for the 'skeletal' isoform in EC coupling of skeletal muscle cells in primary culture.

Two dihydropyridine receptor mRNA isoforms (cardiac and skeletal) are expressed in rat skeletal muscle cells in primary culture. The progressive changes in excitation-contraction coupling mode from dual mode ('skeletal' and 'cardiac') to predominant 'skeletal' one during in vitro myogenesis are thought to be linked to the developmental changes in the relative expression of the two types of molecular entity previously observed in this preparation. In order to test this hypothesis, myotube cultures (5- to 7-day-old) were treated with antisense phosphorothioated oligodeoxynucleotides against cardiac or skeletal alpha1 subunit of L-type calcium channel. The oligodeoxynucleotide uptake by cells was checked by means of imaging of fluorescent oligodeoxynucleotide derivatives within the cells. Optimum concentration used (10 microM in the extracellular medium) and incubation time (70 hours) were empirically determined. Antisense directed against the cardiac type led to a 54% decrease in the averaged L-type calcium current peak density at -10 mV. The same type of experiment was performed with antisense against the skeletal isoform and led to a same order of inhibition (46%). This result clearly shows that the two isoforms can work as a calcium channel. Conversely, analysis of the shape of T-V (relative contractile amplitude versus membrane potential) curves shows that the treatment with 'skeletal' antisense depressed the contractile response in the medium membrane potential range whereas treatment with 'cardiac' antisense had no effect. This and other results taken together suggest that the skeletal isoform of dihydropyridine receptor is involved in both 'cardiac' and 'skeletal' types of EC coupling mechanisms at work in early stages of myotubes in vitro development. The type of coupling probably depends on the proximity of the skeletal dihydropyridine receptor and the ryanodine receptor.

Animals↗

PubMed2000

Williams syndrome and happiness.

Williams syndrome is a genetic disorder resulting in a variety of medical and developmental features, one of which is a frequent outward presentation of substantial happiness. In this paper we describe the unique expression of happiness in people with Williams syndrome, with several anecdotes and a frame by frame conversational analysis. We then discuss this happiness in the context of other dimensions of the impact of Williams syndrome, especially anxiety. We conclude with a discussion of the role of genetics in emotions.

Adult↗

PubMed2005

Communicating about medications during primary care outpatient visits: the role of electronic medical records.

OBJECTIVES: To assess the role of electronic medical records (EMR) in facilitating the content and process of patient-provider exchanges about medications during outpatient primary care visits. METHODS: Fifty encounters with six physicians using the EMR were videotaped, transcribed and content-analysed by applying conversation analysis and ethnomethodology techniques. The analysis focused on three aspects of medication communication: (1) process of care: practices by patients and physicians to implement medication decisions; (2) themes: medication topics that consistently emerge; and (3) names: ways patients and physicians refer to medications. In-depth analysis of 20 encounters examined the extent to which either or both parties initiated, expanded and concluded medication discussions. RESULTS: On average 21.2 (range: 8-35; SD=7.4) distinct exchanges per encounter were observed. Of those, 33% were related to medication. Of the 350 medication-related exchanges throughout the encounters, 56% were categorised as routine medication discussion such as ordering and/or refilling medications. Mailing issues were the next most common medication-related exchanges (10.6%), followed by partial adherence (8.9%), self-regulation (7.4%), alternative therapy/over-the-counter medication (6.6%), side effects (6%) and formulary issues (4.6%). Patients and providers used three ways to name medications: generic/scientific name (42%); physical description (39.7%) and brand name (18.3%). Forty-one percent of exchanges included initiation by one or both parties but no further discussion of the issue; 42% included initiation and expansion by both parties but not conclusion; only 17% of exchanges contained complete medication exchanges (initiation, expansion and conclusion) by both parties. CONCLUSIONS: EMR facilitated content and process of communication regarding medications during outpatient encounters, especially among patients taking multiple medications and patients who used physical descriptions to identify their medications. EMR use stimulated medication exchanges, leading to further expansion about the topic. However, fewer than one-fifth of exchanges ended with clear conclusions by both parties regarding prescribed medication regimens.

Adult↗

PubMed2006

Constructing 'expertness': a novice pharmacist's development of interactional competence in patient consultations.

It has been argued that being able to utilize expertise in discourse is as important as having expertise (C. Candlin and S. Candlin 2002). From a constructivist perspective, knowledgeability does not exist outside of social interaction: being expert involves performing knowledge and skills effectively in social practices (cf. Butler 1990; Lave and Wenger 1991). It is, then, crucial that novice professionals develop the interactional competence to construct themselves as experts in interaction. This study brings together perspectives from research on expert-lay communication, social interaction, and situated learning to examine how a pharmacy intern performed his professional knowledge in the practice of patient consultation over time. Using conversation analysis complemented by the interactional competence framework (Hall 1995; Young 2002), I demonstrate that as the novice pharmacist gained more experience over the course of one internship, he was able to employ professional knowledge in ways that were sensitive to the sequential organization of talk, and to share the patients' lifeworld perspectives (Mishler 1984) more effectively, thus successfully managing the transactional and interpersonal functions of the consultations. This study contributes to research on expert-lay interaction, particularly in pharmacy, and to the under-studied area of interactional competence development in the professions.

Community Pharmacy Services↗

PubMed2005

'Things aren't the same, are they?': The management of bad news delivery in the discourse of stroke care.

Health professionals associated with stroke care tend to emphasize the optimistic possibilities for recovery from stroke and downplay its disabling nature. Therefore, unlike in cancer care, the 'bad news' interview is not a recognized part of stroke care. Nevertheless, at some stages in the trajectory of the illness the issue of disability may have to be discussed and this paper concerns one such occasion. The data are taken from a corpus of video-recorded naturally occurring interactions between stroke patients and health professionals. In the case studied here, an occupational therapist discusses with a patient the arrangements for her care after discharge from hospital. It emerges over the course of the interaction that the patient has to face some unpleasant realities about her future daily life. By conducting a microanalysis of this interaction, using appropriate concepts from conversation analysis and politeness theory, we show how the patient and therapist collaboratively manage the emergent 'bad news' situation and, over the course of the interaction, arrive at the realization that 'things are not the same'.

Communication↗

PubMed2006

The involvement of the apoptosis-modulating proteins ERK 1/2, Bcl-xL and Bax in the resolution of acute inflammation in vivo.

Inflammatory cell recruitment, activation, and apoptosis are highly regulated processes involving several checkpoints controlling the resolution of inflammation. We investigated the role of the mitogen-activated protein kinase (MAPK) signaling pathway (ie, ERK1/2) and apoptosis-regulating Bcl-2 family members (ie, Bcl-x(L) and Bax) in the resolution of a rat carrageenan-induced pleurisy model. The specific ERK1/2 inhibitor PD98059 enhanced the resolution of inflammation, whereas the MEK1/2 inhibitor U0126 had no effect and the flavonoid apigenin, a nonspecific inhibitor of ERK1/2 and COX-2, augmented inflammation. Specifically, PD98059 significantly decreased the total number of macrophages and neutrophils in the pleural cavity, mainly by increasing the rate of neutrophil apoptosis, as measured by Annexin V labeling and morphological analysis. Conversely, a specific inhibitor of proapoptotic Bax (V5) increased inflammation, indicating that by preventing apoptosis in vivo, resolution of inflammation is delayed. This was associated with a decrease in neutrophil apoptosis and an increase in macrophage and neutrophil numbers perpetuating the inflammatory response. In conclusion, this study shows that ERK1/2, Bax, and Bcl-x(L) play important functional roles in the resolution phase of the acute inflammatory response in vivo by influencing apoptosis. Importantly, these data may provide novel therapeutic targets for the treatment of inflammatory diseases.

Animals↗

PubMed2001

Fountaindale Communication Project.

Voice output communication aids are expensive in terms of initial outlay and ongoing staff support. Further efficacy research and innovative methodologies are necessary to explore the role of this technology in facilitating communication and to develop more informed, effective therapeutic approaches to service delivery in this area. A research project is reported that evaluates the progress of four children using voice output communication aids. The children's progress has been video-recorded at six monthly intervals and analysed using conversation analysis and feedback questionnaires. Initial observations and implications for service delivery are discussed.

Cerebral Palsy↗

PubMed2005

An oscillator model of the timing of turn-taking.

When humans talk without conventionalized arrangements, they engage in conversation--that is, a continuous and largely nonsimultaneous exchange in which speakers take turns. Turn-taking is ubiquitous in conversation and is the normal case against which alternatives, such as interruptions, are treated as violations that warrant repair. Furthermore, turn-taking involves highly coordinated timing, including a cyclic rise and fall in the probability of initiating speech during brief silences, and involves the notable rarity, especially in two-party conversations, of two speakers' breaking a silence at once. These phenomena, reported by conversation analysts, have been neglected by cognitive psychologists, and to date there has been no adequate cognitive explanation. Here, we propose that, during conversation, endogenous oscillators in the brains of the speaker and the listeners become mutually entrained, on the basis of the speaker's rate of syllable production. This entrained cyclic pattern governs the potential for initiating speech at any given instant for the speaker and also for the listeners (as potential next speakers). Furthermore, the readiness functions of the listeners are counterphased with that of the speaker, minimizing the likelihood of simultaneous starts by a listener and the previous speaker. This mutual entrainment continues for a brief period when the speech stream ceases, accounting for the cyclic property of silences. This model not only captures the timing phenomena observed inthe literature on conversation analysis, but also converges with findings from the literatures on phoneme timing, syllable organization, and interpersonal coordination.

Communication↗

PubMed1994

The successful fieldwork student: supervisor perceptions.

Qualitative research methodology was used to explore supervisor perceptions of learning style characteristics required for student success in fieldwork. A focus discussion group was used to elicit success themes identified by clinicians. These themes were compared to learning style themes previously identified in quantitative studies. Techniques of conversation analysis were used to assess congruence of verbalized themes with participant interactions during the discussion group. Themes that emerged were the importance of teamwork, active experimentation, flexibility, adaptability, and doing. Discussion participants actively modeled teamwork.

Adult↗

PubMed2000

Regulation of TCL1 expression in B- and T-cell lymphomas and reactive lymphoid tissues.

Chromosomal rearrangements observed in T-cell prolymphocytic leukemia involve the translocation of one T-cell receptor gene to either chromosome 14q32 or Xq28, deregulating the expression of cellular protooncogenes of unknown function, such as TCL1 or its homologue, MTCP1. In the human hematopoietic system, TCL1 expression is predominantly observed in developing B lymphocytes, whereas its overexpression in T cells causes mature T-cell proliferation in transgenic mice. In this study, using a newly generated monoclonal antibody against recombinant TCL1 protein, we extended our analysis mainly by immunohistochemistry and also by fluorescence-activated cell sorting and Western blot to a large tumor lymphoma data bank including 194 cases of lymphoproliferative disorders of B- and T-cell origin as well as reactive lymphoid tissues. The results obtained show that in reactive lymphoid tissues, TCL1 is strongly expressed by a subset of mantle zone B lymphocytes and is expressed to a lesser extent by follicle center cells and by scattered interfollicular small lymphocytes. In B-cell neoplasia, TCL1 was expressed in the majority of the cases, including lymphoblastic lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma, follicular lymphoma, Burkitt lymphoma, diffuse large B-cell lymphoma (60%), and primary cutaneous B cell lymphoma (55%). TCL1 expression was observed in both the cytoplasmic and nuclear compartments, as confirmed by Western blot analysis. Conversely, TCL1 was not expressed in Hodgkin/Reed-Sternberg cells, multiple myelomas, marginal zone B-cell lymphomas, CD30+ anaplastic large cell lymphoma, lymphoblastic T-cell lymphoma, peripheral T-cell lymphoma, and mycosis fungoides. These data indicate that TCL1 is expressed in more differentiated B cells, under both reactive and neoplastic conditions, from antigen committed B cells and in germinal center B cells and is down-regulated in the latest stage of B-cell differentiation.

Aged↗

PubMed1975

Circadian rhythms of the endocrine pancreas. A quantitative biochemical and immumocytochemical study.

Cellular hormone levels of insulin and glucagon in the endocrine pancreas of the rat have been observed and quantified over the 24-hours period, at 3-hourly intervals, by T.V. image conversion analysis on immunocytochemical preparations. Parallel estimations of blood sugar were carried out. Glucagon levels were at their lowest when the blood sugar levels were at their highest. Quantitative cytochemistry is regarded as a valuable tool for the investigation of changes in intracellular hormone levels under physiological and pathological conditions.

Animals↗

PubMed1979

Early effects of dimethylnitrosamine on protein chain initiation and postmicrosomal polyadenylic acid-containing RNA content in mouse liver.

A mouse liver S-30 system was used to study the early effects of dimethylnitrosamine (DMNA) on polypeptide chain initiation and messenger RNA content. The inhibition of protein synthesis after DMNA administration was associated with a reduced capacity of the S-30 system to form 80S ribosomal initiation complexes. The binding of formylatable methionyl transfer RNA to polysomes was also depressed. The initiation defect was detectable in the assay system slightly later than the decrease in protein synthesis. Addition of mRNA stimulated both translation and 80S initiation complex formation but could not fully restore the activity of the S-30 system from DMNA-treated mice. A loss of poly(A)+ RNA from the postmicrosomal subfraction of the S-30 fraction was observed as early as 15 min after DMNA administration. Later, polyriboadenylic acid also decreased in the microsomal fraction. Monosomes accumulating in response to DMNA treatment were deficient in mRNA as measured by polyriboadenylic acid analysis. Conversely, the proportion of polyriboadenylic acid in the remaining polysomes increased, indicating that the mRNA had become less densely occupied with ribosomes.

Animals↗

PubMed1995

[Qualitative research in social psychiatry--methods and applications].

History and perspectives of qualitative research are presented together with an overview of the major methods in their application in the field of social psychiatry. Methods for analyzing subjective points of view (various forms of interviews), for describing everyday life and routines of actions in and outside of institutions (participant observation, conversation analysis), and for interpreting in-depth-structures (objective hermeneutics, theoretical coding) are discussed. Triangulation of different methods, strategies for assessing interpretations, and findings and processual evaluation of qualitative research are outlined as perspectives.

Activities of Daily Living↗