Assessing the consultation: methods of observing trainees in general practice.

We compared two different methods of observing trainees at work in general practice: the traditional one of a senior or training general practitioner sitting in during selected surgeries and the more modern video recording, with the patients'' written consent. Patients who had experienced the presence of a second doctor during the consultation were less likely to show an increase in arousal after their consultations than those who had been recorded on video. Patients who refused consent to be recorded were more highly stressed than those who agreed and showed smaller decreases in stress after consultations. The presence of two doctors generated fewer reductions in stress after the consultation than video recording did, but this was a non-significant trend. The group that was recorded on video did not differ appreciably from a control group in changes in stress or arousal.     

Computer assisted screening: effect on the patient and his consultation.

The initial impact of computer assisted preventive screening in general practice consultations has been monitored. The technology has not been found stressful by patients, and the power of the consultation to alleviate low arousal has been increased by computer use. No appreciable increase in the durations of consultation was detected, despite an average computer initiated input of two minutes eight seconds. The computer has successfully prompted preventive screening and health education with a sixfold increase in the number of potentially relevant procedures being mentioned. The actual information presented by the computer has been shown to be crucial, with the terminal''s mere presence an ineffective reminder. The computer terminal was used in 65% of the consultations for which it was available, which, if sustained, represents an effective screening programme for attending patients.     

Comparison of medical care in prison and in general practice.

The medical care of prisoners "declaring sick" to the medical officer and hospital officers in Bedford Prison was surveyed and compared with the medical care given to the medical officer''s patients in general practice. The consultation rate of prisoners was higher than that of patients in the practice. Part of this increase was because household remedies were not available to prisoners except through the prison medical service and part may also have been due to the stresses of life in prison. Few psychoactive drugs were prescribed in prison. The problems that prisoners presented reflected the problems of violence and poor hygiene in prison. Some problems that more commonly present in prison than in general practice may be related to stress.     

Outcome of low back pain in general practice: a prospective study

Objectives: To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Design: Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Setting: Two general practices in south Manchester. Subjects: 490 subjects (203 men, 287 women) aged 18-75 years. Main outcome measures: Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Results: Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

Key messages

• It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
• In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
• While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
• Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
• Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: dealing with the opiate misuser.

Because there has been a substantial increase in the scale of drug misuse general practitioners have become increasingly concerned in responding to this problem. Little is known, however, about how general practitioners manage drug misusers. The findings from a national survey carried out in mid-1985 of a 5% random sample of general practitioners in England and Wales show the extent to which various actions were undertaken by general practitioners who reported on the consultation with the opiate misuser whom they last attended. In more than half of the cases the opiate misuser had been under the care of the general practitioners for this problem for at least six months. The findings indicate that most general practitioners refer these patients to specialist drug dependence clinics or to general psychiatric services but rarely to other agencies. Opiate drugs had been prescribed in nearly a third of cases. The rate of notification to the Home Office conforms with that in other studies and indicates a high degree of undernotification. More detailed study of general practitioners'' activities in managing drug misusers is needed.     

Experimental Coxsackie B-3 virus infection in Citellus lateralis

Coxsackie B-3 virus produces a mild infection which passes unnoticed in the non-hibernating Citellus lateralis. A severe infection occurs in the hibernating animal. The progress of infection in the hiberating animal is related to the number of arousal hours and quite independent of the number of infected days. Nevertheless, it has been shown that the low-temperature hibernation phase has a potentiating effect upon subsequent viral production. Infective virus has not been found in the inoculated brown fat pads during the hibernation phase but very high virus titers are recorded 48 hours after arousal. This results in an earlier viraemia and earlier and higher titers in other organs of the body. A similar effect is noted when virus is inoculated at the very beginning of the arousal phase. While most animals recover with subsequent antibody development, a few succumb. Antibody development is slow and related only to the number of arousal hours experienced. Particular note is made of the fact that an animal may successfully resume hibernation despite complete loss of the axillary brown fat pads.     

Reactions of patients to video recording of consultations in general practice.

The potential value of video recording for examining medical consultations depends on the extent to which recordings are representative of unfilmed consultations. This paper examines the views of 295 patients in two general practices whose consultations were filmed and compares them with the views of a control group of 185 patients. Most of those who were filmed reported that the consultation was not directly affected, and no overall effect of filming was discovered when patients rated their stress after the consultations, their rapport with the doctor, or other aspects of the consultation. At one practice, however, filming was significantly associated with lower ratings of rapport between doctor and patient among those patients who reported some direct effect of filming. Patient refusal rates from other studies are also examined and shown to vary systematically--the more opportunity patients are given to decline the more likely they are to take it. Consideration of doctors'' responses to being filmed would usefully complement the emphasis on the views of patients.     

Enhanced Sympathetic Arousal in Response to fMRI Scanning Correlates with Task Induced Activations and Deactivations

It has been repeatedly shown that functional magnetic resonance imaging (fMRI) triggers distress and neuroendocrine response systems. Prior studies have revealed that sympathetic arousal increases, particularly at the beginning of the examination. Against this background it appears likely that those stress reactions during the scanning procedure may influence task performance and neural correlates. However, the question how sympathetic arousal elicited by the scanning procedure itself may act as a potential confounder of fMRI data remains unresolved today. Thirty-seven scanner naive healthy subjects performed a simple cued target detection task. Levels of salivary alpha amylase (sAA), as a biomarker for sympathetic activity, were assessed in samples obtained at several time points during the lab visit. SAA increased two times, immediately prior to scanning and at the end of the scanning procedure. Neural activation related to motor preparation and timing as well as task performance was positively correlated with the first increase. Furthermore, the first sAA increase was associated with task induced deactivation (TID) in frontal and parietal regions. However, these effects were restricted to the first part of the experiment. Consequently, this bias of scanner related sympathetic activation should be considered in future fMRI investigations. It is of particular importance for pharmacological investigations studying adrenergic agents and the comparison of groups with different stress vulnerabilities like patients and controls or adolescents and adults.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Neuroelectric responses of sportsmen and sedentaries under cognitive stress

Stress and anxiety are states which sportsmen are continuously exposed to. Our study aimed to evaluate neuroelectrical peripheral and central nervous system responses of sportsmen (SPR) and sedentary individuals (SED) during concentration grid test (CGT) employed under time pressure. Forty three SPR and 33 SED participated in the study. Neuroelectrical responses were simultaneously obtained during baseline and CGT. All responses were observed to increase under stress in both SED and SPR. The SPR’s stress related peripheral responses were lower than SED’s. When central values were evaluated a stress related increase according to baseline was observed in all frequency powers in all of the participants. Statistical comparison of increase rates revealed a significantly greater increase in beta in SED compared to SPR. Beta has been associated to alertness and cortical arousal. As SED exhibit greater beta increase under stress compared to SPR their state of cortical arousal and alertness may be interpreted to be higher than SPR. However the SPR’s weak increase in beta and their lower peripheral responses taken together may imply that they are better in stress management. In fact according to their performance scores the SPR’s higher level of performance under stress compared to SED shows that they are better at maintaining and focusing their attention under stress than SED.     

C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder: a pilot study

BACKGROUND: it has been reported that psychological stress in humans is associated with a derangement of biological homeostasis. This pilot study aimed to examine the inflammatory response to post-traumatic stress disorder (PTSD) through measurements of the serum levels of the receptor to interleukin 6 (sIL-6r) and C-reactive protein (CRP), in relation to measures of psychological disturbance. METHODS: 15 patients with established PTSD and eight control patients with musculoskeletal injuries were studied at least three months after their index trauma. All completed revised impact of events scale (RIES), Davidson's trauma scale (DTS) and the general health questionnaire (GHQ), and gave blood samples that were assayed for CRP and sIL-6r. Statistical analysis was by the Mann-Whitney U-Wilcoxon rank sum tests. RESULTS: positive relationships were found between sIL-6r and the RIES intrusion score (P=0.026), and between CRP and DTS intrusion scores (P=0.016), GHQ depression (P=0.028), and RIES intrusion (P=0.044) in the case group. DISCUSSION: we have demonstrated a relationship between post-traumatic psychological and biological disturbance, which provides the basis for further research on the effects of psychological disturbance on physical recovery after injury.     

The effect of stress imagery on arousal and its implications for biofeedback of the frontalis muscles

The purpose of this study was to determine whether the frontal muscles of the forehead during the imagination of an individualized stress situation reflect general arousal. Physiological arousal and subjective feelings of tension were measured during a stress and a relaxing imaginative situation, utilizing a counterbalanced design. Frontalis EMG during stress imagination was raised and was paralleled by more reported tension, elevated skin conductance, and trends toward increments in heart rate and respiration rate. The raised frontalis EMG can be seen as a consequence of the greater effort spent in the stress imaginative situation than in the relaxing one. This experiment supports an important assumption of the clinical application of frontalis EMG biofeedback to stress-related disorders. Other assumptions still remain to be examined.     

Heart Rate Variability During a Working Memory Task: Does Touching a Dog or Person Affect the Response?

The presence of a dog has been associated with reduced responses to stressors in several, but not all, previous studies. The presence of a dog has also been related to improved performance on some cognitive tasks. The current study was designed to evaluate the effect of touching a dog on stress responses to a working memory task (WMT). Heart rate variability (HRV) responses to a WMT while touching a dog were compared with responses while touching a stuffed dog and a person. HRV was recorded while 53 university students aged 18 to 41 years sat on the floor next to a randomly assigned co-participant (real dog, stuffed dog, or human) and listened to a reading before and after completing a WMT. This procedure was repeated with the two other co-participants, in a randomized block order. All participants wore an HRV monitor and placed their non-dominant hand on the co-participant throughout the appropriate phase. The WMT involved pointing to increasingly complicated sequences of geometric shapes until the participant failed three times at one level. Linear mixed models analysis for nested data revealed that the memory task was stressful, with parasympathetic nervous system arousal significantly lower during the memory task than the preor post-memory listening tasks (rMSSD: ps < 0.001, = 0.023; high frequency: ps < 0.001, = 0.001). Neither of the measures differed significantly among the three conditions. There also were no significant interactions, indicating that the stress response to the memory task did not differ when the participants were touching the three different co-participants. Touching a dog did not reduce arousal in response to a stressful memory task. This research suggests that a dog may not be effective at reducing stress responses to this type of stressor. Another possibility is that the presence of a dog is more effective than touching a dog at reducing stress responses. Further investigation will be required to evaluate these possibilities.     

Multiplication and distribution of iris severe mosaic virus in secondarily-infected iris bulbs after stress induced by heat and wounding

In freshly-lifted iris bulbs infected with iris severe mosaic virus (ISMV), virus was not always detected in the basal plate and rarely in bulb scale tissue. After exposing the bulbs to stress (wounding or high-temperature treatment) the sensitivity of virus detection was enhanced. The improved detection of viral antigen after local stress (wounding) coincided with an increase of viral RNA synthesis. When general stress (high-temperature treatment) was applied, the virus could be reliably detected in the basal plate, and usually in vascular bundles and surrounding tissue. Virus was detected in the upper part of the bulb scale when such tissues were detached from the basal plate. Thus, virus must have been present in the scales in localised spots, albeit at a very low concentration, and multiplication is likely to be the main factor involved in the improved sensitivity of viral detection. The distribution of ISMV in the bulb after local or general stress treatment is discussed.     

Heroin users in general practice: ascertainment and features

A case-control study of heroin users in general practice showed a prevalence of roughly two per 1000 of the urban population or four per “average” general practice list of patients. A method of studying heroin users who attend general practice was used that has advantages over existing techniques. Thirty six heroin users had a statistically significantly higher yearly doctor-patient consultation rate than a group of matched controls. More heroin users also failed to attend appointments than controls. When consultations directly related to heroin and its effects were excluded, however, the consultation rates in the two groups were similar. The heroin users did not have an excess of psychiatric disorder or disturbed family background compared with controls but had a noticeable history of dishonest and violent behaviour towards medical staff.A high proportion of heroin users in the study were antibody positive for the human immunodeficiency virus. General practitioners should take advantage of their frequent contacts with heroin users and their families to give them support and counselling about the acquired immune deficiency syndrome.     

Neuro-evolutionary patterning of sociality

Evolutionary shifts in species-typical group size ('sociality') probably reflect natural selection on motivational processes such as social arousal, approach-avoidance, reward, stress/anxiety and dominance. Using four songbird species that differ selectively in sociality (one territorial, one modestly gregarious, and two highly gregarious species), we here examined immediate early gene (IEG) responses of relevant brain regions following exposure to a same-sex conspecific. The paradigm limited behavioural performance, thus species differences should reflect divergence in motivational and/or perceptual processes. Within the extended medial amygdala (which is involved in appetitive approach, social arousal and avoidance), we observed species differences in IEG response that are negatively graded in relation to sociality. In addition, brain areas that are involved in social stress and dominance-related behaviour (ventrolateral septum, anterior hypothalamus and lateral subdivision of the ventromedial hypothalamus) exhibited IEG responses that dichotomously distinguish the territorial species from the three gregarious species. The IEG responses of areas involved in reward (nucleus accumbens and ventral pallidum) and general stress processes (e.g. paraventricular hypothalamus, lateral bed nucleus of the stria terminalis and most areas of the lateral septum) do not correlate with sociality, indicating that social evolution has been accompanied by selection on a relatively discrete suite of motivational systems.     

Determinants of non-compliance with short term antibiotic regimens.

The contribution of doctor, patient, and consultation interaction patterns to compliance with antibiotic treatment was examined in 233 adult patients seen in general practice. Twelve variables were shown to discriminate between compliers and non-compliers. Discriminating variables relating to patients included health state, employment state, knowledge of tablet, and perception of anxiety level, difficulty in complying, and their observed anger, distance, and assertiveness in the consultation. Discriminating variables relating to doctors included provision of advice on duration of treatment, complexity of dosage schedule, age of doctor, and number of years in practice. For the most part these results confirmed previous research. It is concluded that the doctor should consider both the dosage schedule and the patient''s daily routine when prescribing antibiotic tablets. Advice on how to take the tablets should be given in specific rather than in general terms. The significant effect of the age of the doctor and the years spent in practice has not been found in previous work. This finding may reflect differences in behavior between younger doctors and their patients. This difference was not detected in the observation of consultation events.     

Beyond physiological hypoarousal: The role of life stress and callous-unemotional traits in incarcerated adolescent males

The development of antisocial behavior in youth has been examined with neurobiological theories that suggest that adolescents who are less responsive to their environments are less likely to develop empathy in the absence of extant physiological arousal. However, little attention is paid to these individuals' social context. Individuals with adverse early experiences can also exhibit attenuated physiological arousal. The current investigation examines whether psychopathic symptoms or life stress exposure is associated with cortisol and its diurnal rhythm within 50 incarcerated adolescent boys (14–18 years old). Ten saliva cortisol samples were collected 1–2 weeks after admission to a maximum-security juvenile facility. Hierarchical Linear Modeling distinguished waking cortisol levels, the awakening response (CAR) and the diurnal rhythm. Multiple interviews and self-report measures of CU traits and stressor exposure were collected. Boys with higher levels of CU traits or greater life stress exposure had flat diurnal rhythms and a steeper awakening response in analyses with lifetime stress exposure specifically. Nonetheless, boys who were elevated on both CU traits and prior stress exposure had steeper diurnal rhythms. These results extend neurobiological theories of cortisol and illustrate that boys with the combination of severe stress with CU traits have a unique physiological profile.