New referrals to a diabetic clinic

New referrals to a diabetic clinic were studied over 6 months. One hundred and twelve patients were referred from their General Practitioner (GP) and 49 from other hospital departments. Thirty percent of GP referrals and 10% of hospital referrals were made on the basis of glycosuria alone. From all the patients referred six were found to be non-diabetic and a further 19 had been prescribed drugs inappropriately (either the wrong drug or the right drug in excessive dose), some with potentially dangerous consequences. Almost half of the patients were given no dietary advice at all. There is, still much ignorance concerning diagnosis and initial management of diabetes in both general and hospital medical practice.     

Undiagnosed myasthenia gravis in emergency psychiatric referrals

The diagnosis of myasthenia gravis is difficult to make in the emergency department. Reported are two cases in which myasthenia was not suspected and the patients were referred to the emergency psychiatrist. In both cases, when appropriate medical treatment was instituted, the psychological symptoms disappeared.     

Extra AV nodal Wenckebach periodicity

Extra AV nodal Wenckebach periodicity was diagnosed in seven patients. The most frequent form of this conduction abnormality was an exit block. The underlying block was localized in the sinoatrial junction and in the atria in two patients; the AV junction and the ventricle were the site of the Wenckebach periodicity in one case each. In extra AV nodal exit block, the actual conduction delay is not seen on the ECG and the diagnosis is based on the progressive shortening of the P-P or R-R intervals followed by a pause which is less than twice the shortest P-P (R-R) interval depending on the level of the block. A Wenckebach periodicity in the bundle branches or within the reentry pathway each occurred in one patient. In these forms of Wenckebach periodicity, the diagnosis is established more readily because the conduction delay can be demonstrated on the surface ECG. The clinical significance of extra AV nodal Wenckebach periodicity is discussed.     

A guide to sending e-mail telemedicine referrals

This article describes simple e-mail protocols that have proven their effectiveness in the telemedicine links established by the Swinfen Charitable Trust.They are presented here as a guide for the benefit of those doctors who may be considering setting up their own telemedicine links.     

Reasons for outpatient referrals from generalists to specialists

OBJECTIVE: To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals. DESIGN: Prospective survey of all referrals from generalists to subspecialists over a 5-month period. SETTING: University hospital outpatient clinics. PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology. MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals. CONCLUSIONS: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.     

Extra sounds occurring in cardiac systole

During the last five years we have seen a number of patients who have displayed on auscultation a distinct sound occurring in cardiac systole. The character of this sound varied somewhat, but in most instances it was of such short duration that it could best be described as a click. The extra sound frequently gave rise to a gallop rhythm, which, in a few cases, had been confused with the more common type of gallop where the third sound occurs in diastole. Although few reports regarding systolic gallop rhythm are to be found in the literature, Macleod, Wilson, and Barker,¹, Wolferth and Margolies^{2, 3} and White⁴ have briefly discussed the condition and have agreed that its presence has no unfavorable prognostic significance. Gallavardin,⁵ Lian and Deparis⁶ and a few other workers in Europe have reported a number of cases with clicking sounds in systole. On the basis of three autopsied cases where pleuropericardial adhesions were found these observers^{5, 6} believe that the clicks may arise from the presence of delicate strands joining pericardium and pleura. Thompson and Levine⁷ have recently published a clinical study of 35 patients displaying systolic gallop rhythm. They pointed out that the condition is not rare since it occurred in 16 per cent of all patients with gallop rhythm encountered over a period of eleven years. They emphasized further that organic heart disease is usually absent in these patients and that systolic gallop rhythm does not indicate a bad prognosis. It is the purpose of this paper to present a study of 21 cases of systolic gallop rhythm studied by means of sound tracings.