Referral letters: are form letters better?

An essential mode of contact between general practitioners (GPs) and hospital staff is the referral letter. This must be clear and concise with sufficient information to aid the GP, the consultant and the patient. In order to ensure this, a proposal was made for the use of a structured or standardized referral letter: a form letter. This report shows that form letters were shorter than typed letters. Form letters were also proven to contain more information than nonform letters.     

Identification of Enterobacteriaceae by the automicrobic system: Enterobacteriaceae biochemical cards versus Enterobacteriaceae-plus biochemical cards.

Enterobacteriaceae Biochemical Cards (EBC) may be used in the AutoMicrobic system for identification of enteric bacilli. Recently, the card has been modified to permit identification of enteric and certain nonenteric bacilli. Also, minor modifications have been in the computer program used for interpretation of tests with the new cards (EBC+). The two types of cards (EBC and EBC+) were tested in parallel and found to be in agreement with 97% of 650 Enterobacteriaceae. Most of the discrepancies were resolved when selected strains were retested on 3 separate days. A lack of absolute reproducibility with either system was demonstrated and explained most of the initial discrepancies. Approximately 97% of the AutoMicrobic system identifications agreed with those obtained from standard reference methods, after equivocal AutoMicrobic system results (P less than 0.80) were excluded. Equivocal responses occurred with 4% of our EBC tests and 7% of our EBC+ tests; additional tests are needed before such strains can be identified with confidence.     

A Debate on Public Health Responses to COVID-19: Focused Protection versus Sustained Suppression

With the coronavirus disease 2019 (COVID-19) pandemic persisting for a long time, there have been debates about the public health response strategies. We conducted a survey of adult infectious disease specialists on public health responses to COVID-19. Most responded that regulations on multi-use facilities should be maintained or strengthened, but schools should not be closed, except in cases where an outbreak occurs within the school. A slightly higher percentage of experts supported focused protection rather than sustained suppression. While the focused protection strategy might suffice in low-level epidemic situations, social distancing should be reinforced by shifting to a strategy closer to sustained suppression in the eventuality of rapid spread of outbreaks.     

Copying referral letters to patients: prepare for change

The National Health Service (NHS) Plan for England has directed that from April 2004 clinicians will offer patients the opportunity to receive copies of letters that are written about them. Patients like to have more information and patients who have received copies of letters have found them useful. It is hoped that copying letters will improve relationships between doctors and patients, encourage patients to be better informed, and improve the quality of information provided to patients. Relatively little empirical research has been performed in this area but what exists is generally supportive. Attention will need to be paid to issues of confidentiality, the language and content of letters, and individuals who may have difficulty obtaining information from letters. This initiative is one of many that the NHS has introduced to enhance openness, honesty and the quality of information provided to patients.     

One man's answer to immunological information overload: microcomputer management of the personal reprint collection

The subject of information overload in immunology has been addressed recently by Waksman, who proposed some innovative solutions for the afferent pathways^1,2, (see also reactions by Sanderson³, Turk⁴ and Franklin⁵). Here Eric Martz describes his solution for efferent overload.     

Responses to multi-directional surface translations involve redistribution of proximal versus distal strategies to maintain upright posture

Evaluation of postural control in multiple planes is necessary to determine the movement strategies used to respond to unexpected perturbations. The present study quantified net joint torques of the lower limbs and trunk in the sagittal and frontal planes following multi-directional surface translations. Twenty-one healthy subjects stood with feet on separate force plates mounted on a moveable platform, translated unexpectedly in one of 12 directions. Peak net torque magnitudes and latencies following perturbation onset were determined as were the relative contributions of each joint to total torque production. Magnitude of net torque generated by each leg varied by perturbation direction, with the largest individual joint magnitude elicited in directions of limb loading. Relative contributions of individual joint torques to the total response were dependent upon perturbation direction. Results suggest that a redistribution of the relative contributions of hip/trunk versus ankle strategies occurs dependent on perturbation direction, with a significant contribution by the knee joint in response to forward perturbations. Direction-specific redistribution of proximal versus distal strategies appears to depend upon the biomechanical constraints imposed by a given perturbation direction. Thus, it appears that sagittal and frontal plane posture-righting responses may not be uniquely controlled, and may instead be governed similarly, with modulation of relative torque contributions among joints when necessary, given direction-specific anatomical constraints.     

Responses of the human auditory cortex to changes in one versus two stimulus features

Neuromagnetic responses were recorded with a 24 SQUID magnetometer in two oddball experiments to determine whether mismatch responses to changes in single stimulus features are additive. In experiment 1, the one feature deviants differed from standards in interstimulus interval (ISI) or frequency, and the two feature deviants in both ISI and frequence. In experiment 2, deviants differed in duration, frequency, or both. All deviants evoked a mismatch field (MMF) with sources close to each other in the supratemporal auditory cortex. Except for the ISI deviants, the MMF sources were about 1 cm anterior to the source of the 100ms response, N100m, to the standards. In the two experiments, MMFs obtained in response to the two feature deviants resembled closely the sum of MMFs in response to one feature deviants. The results suggest that the standards leave a multiple neuronal representation in the human auditory cortex. The particular neuronal traces of the representation react independently to changes in different features of sound stimuli.     

Referral letters to colorectal surgeons: the impact of peer-mediated feedback.

BACKGROUND: General practitioners (GPs) select few patients for specialist investigation. Having selected a patient, the GP writes a referral letter which serves primarily to convey concerns about the patient and offer background information. Referral letters to specialists sometimes provide an inadequate amount of information. The content of referral letters to colorectal surgeons can now be scored based on the views of GPs about the ideal content of referral letters. AIM: To determine if written feedback about the contents of GP referral letters mediated by local peers was acceptable to GPs and how this feedback influenced the content and variety of their referrals. DESIGN: A non-randomised control trial. SETTING: GPs in North Nottinghamshire. METHOD: In a controlled trial, 26 GPs were offered written feedback about the documented contents of their colorectal referral letters over 1 year. The feedback was designed and mediated by two nominated local GPs. The contents of referral letters were measured in the year before and 6 months after feedback. GPs were asked about the style of the feedback. The contents of referral letters and the proportion of patients with organic pathology were compared for the feedback GPs and other local GPs who could be identified as having used the same hospital for their referrals in the period before and after feedback. RESULTS: All GPs declared the method of feedback to be acceptable but raised concerns about their own performance, and some were upset by the experience. None withdrew from the project. There was a difference of 7.1 points (95% confidence interval = 1.9 to 12.2) in the content scores between the feedback group and the controls after adjusting for baseline differences between the groups. Of the GPs who referred to the same hospital before and after feedback, the feedback GPs referred more patients with organic pathology than other local colleagues. CONCLUSIONS: GPs welcome feedback about the details appearing on their referral letters, although peer comparisons may not always lead to changes in practice. However, in some cases feedback improves the content of GP referral letters and may also impact on the type of patients referred for investigation by specialists.     

Responses to basic taste qualities in rats selectively bred for high versus low saccharin intake

Rats selectively bred for relatively high (HiS) and relatively low (LoS) saccharin intake were offered sweet (sucrose), bitter (quinine, sucrose octaacetate), salty (sodium chloride), starchy (Polycose((R))), and sour (citric acid) solutions at several concentrations; sucrose/quinine, and sucrose/citric acid mixtures were also tested. Compared to HiS rats, LoS rats displayed weaker preferences for and lower consumption of sweet, salty, and starchy solutions. HiS and LoS rats did not differ in responses to simple bitter or sour solutions or to adulteration of sucrose with citric acid. However, quinine adulteration reduced sucrose preference more among LoS rats. Thus, selection on a saccharin intake phenotype has yielded line differences on all hedonically positive tastants and, probably as a consequence of that difference, greater finickiness specifically towards bittersweet solutions in the low saccharin-consuming line. Additional work can clarify the psychobiological mechanisms for the phenotypic difference and, potentially, the reasons for its relationship to measures of emotionality.     

Responses to the Trier Social Stress Test (TSST) in single versus grouped participants

Psychological stress plays an important role in psychopathologies. Laboratory methods have been designed to study stress responses in health and disease. The Trier Social Stress Test is a procedure designed to induce psychosocial stress, but the method is costly in terms of time and personnel requirements. We investigated whether conducting the task with multiple participants influenced cortisol, heart rate, and subjective responses and improved efficiency. Healthy male and female volunteers (N = 32) performed the task individually or in groups. Salivary cortisol, anxiety, and jitteriness increased and calmness decreased similarly in both conditions. Grouped participants exhibited greater peak increases in heart rate than those who performed individually. The findings suggest that the TSST may be conducted with multiple participants without significantly affecting subjective and cortisol responses to the task.     

Responses of contralateral SI and SII in cat to same-site cutaneous flutter versus vibration.

The methods of (14)C-2-deoxyglucose ((14)C-2DG) metabolic mapping and optical intrinsic signal (OIS) imaging were used to evaluate the response evoked in the contralateral primary somatosensory receiving areas (SI and SII) of anesthetized cats by either 25 Hz ("flutter") or 200 Hz ("vibration") sinusoidal vertical skin displacement stimulation of the central pad on the distal forepaw. Unilateral 25-Hz stimulation consistently evoked a localized region of elevated (14)C-2DG uptake in both SI and SII in the contralateral hemisphere. In contrast, 200-Hz stimulation did not evoke elevated (14)C-2DG uptake in the contralateral SI but evoked a prominent, localized region of increased (14)C-2DG uptake in the contralateral SII. Experiments in which the OIS was recorded yielded results that complemented and extended the findings obtained with the 2DG method. First, 25-Hz central-pad stimulation evoked an increase in absorbance in a region in the contralateral SI and SII that corresponded closely to the region in which a similar stimulus evoked increased (14)C-2DG uptake. Second, 200-Hz stimulation of the central pad consistently evoked a substantial increase in absorbance in the contralateral SII but very little or no increase in absorbance in the contralateral SI. And third, 200-Hz central-pad stimulation usually evoked a decrease in absorbance in the same contralateral SI region that underwent an increase in absorbance during same-site 25-Hz stimulation. Experiments in which the OIS responses of both SI and SII were recorded simultaneously demonstrated that continuous (>1 s) 25-Hz central-pad stimulation evokes a prominent increase in absorbance in both SI and SII in the contralateral hemisphere, whereas only SII undergoes a sustained prominent increase in absorbance in response to 200-Hz stimulation to the same central-pad site. SI exhibits an initial, transient increase in absorbance in response to 200-Hz stimulation and at durations of stimulation >1 s, undergoes a decrease in absorbance. It was found that the stimulus-evoked absorbance changes in the contralateral SI and SII are correlated significantly during vibrotactile stimulation of the central pad-positively with 25-Hz stimulation and negatively with 200-Hz stimulation. The findings are interpreted to indicate that 25-Hz central-pad stimulation of the central pad evokes spatially localized and vigorous neuronal activation within both SI and SII in the contralateral hemisphere and that although 200-Hz stimulation evokes vigorous and well maintained neuronal activation within the contralateral SII, the principal effect on the contralateral SI of a 200-Hz stimulus lasting >1 s is inhibitory.     

Cellular Responses to Fmlp Challenging: A Mini-Review

FMLP (N-formyl-methionyl-leucyl-phenylalanine) and other N-formylpeptides are powerful “activators” of polymorphonuclear and mononuclear phagocytes, but they are also active on other cell types. Present knowledge about formylpeptide receptors and the relevant tools for their imaging and the study of their dynamics are briefly discussed. The main responses elicited by FMLP in granulocytes are cell polarisation, the generation of reactive oxygen species, the production of arachidonic acid metabolites, and the release of lysosomal enzymes. The transduction cascades involved and the agents able to modulate these responses are reviewed. Homologous desensitization and heterologous desensitization of the FMLP-receptor following ligation of other chemokine receptors are also outlined. Finally, the receptor expression and the pharmacological and toxic actions of FMLP upon other tissues and organs, and its actions on the developing embryo, are illustrated.     

Part 1: Children's Psychological Responses to Disasters

Reviews children's psychological responses to disasters and puts relevant work in historical perspective. Common responses include specific fears, separation difficulties, sleep problems, and symptoms associated with posttraumatic stress disorder (PTSD). After severe exposure, diagnosable PTSD, anxiety, and depression may occur. Factors influencing responses include disaster characteristics (exposure severity, extent of bereavement and other losses, separation from significant others), children's age and sex, and characteristics of family and community. Symptoms typically decrease rapidly, and recovery generally is complete by 18 months to 3 years except after severe life-threat or long-term family and community disruption.     

Copying general practitioner referral letters to patients: a study of patients' views.

Over the past decade there has been a significant shift towards greater involvement of patients in their health care and this has highlighted many areas relating to doctor-patient communication. One area of communication that has not been extensively researched is the referral letter between general practitioners (GPs) and their patients. This small study of patients' views suggests that patients value receiving a copy of their GP outpatient letter, appreciating greater understanding of, and involvement in, the referral process.