Differences in Referral Rates from General Practice

There are many unexplained differences in the rates at whichgeneral practitioners make referrals to other medical specialists.This study investigated 17 586 referrals from 141 general practitionersto specialists in seven specialties in Ringkjøbing countyin Denmark. As an expression of the referral rate, a referralindex was estimated for every general practitioner. The referralindex was the number of referrals to the specialist per 1000patients per year, including children, standardized for ageand sex to the average population in Ringkjøbing county.The following six variables were evaluated in relation to thereferral index: specialists in the local area, doctors per practice,consultations per general practitioner per year, patients registered,consultations per 1000 patients per year standardized for ageand sex, and supplementary procedures per consultation. Stepwisemultiple regression analysis was used. The study showed thatthe referral index rose both with a better access to specialistand with an increasing number of consultations per practitionerper year. The referral index fell with increased numbers ofpatients registered. No correlation was found between the referralindex and number of supplementary procedures per consultation,number of doctors per practice and number of consultations per1000 patients per year.     

Excessive Hypercalcaemia and Mixed Connective Tissue Disease

ABSTRACT A 23-year-old female with extreme hypercalcaemia was treated with calcitonin, mitramycin and parathyroidectomy and normocalcaemia was achieved after 4 weeks. Nevertheless, the patient later died of cutaneous necrosis, impaired circulation and multiple organ failure. Serum immunoreactive parathyroid hormone was in the normal range and parathyroid tissue normal. Mixed connective tissue disease was diagnosed on the basis of high titers of antibody to extractable nuclear antigen, moderately elevated levels of antibody to nuclear antigen and only marginal elevation of anti-double standed DNA. The role of Cl. difficile toxin in the blood and an acinic cell tumour is unclear.     

SPINAL ANAESTHESIA IN YOUNG PATIENTS USING A 29-GAUGE NEEDLE: TECHNICAL CONSIDERATIONS AND AN EVALUATION OF POSTOPERATIVE COMPLAINTS COMPARED WITH GENERAL ANAESTHESIA

One hundred patients aged 18–49 yr, undergoing electivearthroscopy of the knee joint, were allocated randomly to eitherspinal anaesthesia using a 29-gauge spinal needle or generalanaesthesia. Dural puncture was considered difficult in 18%of the patients receiving spinal anaesthesia. In three patients(6%) it was necessary to supplement the spinal anaesthetic withgeneral anaesthesia. Spinal and general anaesthesia were otherwiseuneventful in all patients. The incidence of postoperative headachewas similar in the two groups. One patient developed post duralpuncture headache following spinal anaesthesia. This headachewas of short duration and disappeared without treatment. Spinalanaesthesia caused more backache than general anaesthesia, otherwisethe frequency of postoperative complaints was the same or lower.Ninety-six percent of the patients receiving spinal anaesthesiawould prefer the same anaesthetic for a similar procedure inthe future ^*Department of Anaesthesiology, Hvidovre University Hospital,DK-2650 Hvidovre, Copenhagen, Denmark     

Histopathology and ultrastructure of primary adrenocortical nodular dysplasia with Cushing''s syndrome

The characteristic adrenal lesions of five patients with bilateral primary adrenocortical nodular dysplasia and Cushing's syndrome developing in adolescence are presented histopathologically, and in two cases ultrastructurally. Two of the patients were siblings with additional extra-adrenal lesions such as pigmented spots on the face, myxoid cutaneous tumours and in one case familial cardiac myxoma. The adrenals were small with an uneven surface due to numerous small brown to black pigmented nodules in the inner cortex. The nodules were composed of eosinophilic giant cells filled with lipofuscin granules. The familial cases in addition revealed a pronounced disorganization of the adrenocortical architecture with capsular disruption and infiltration of periadrenal fatty tissue. The early onset of Cushing's syndrome in the second decade, the bilateral involvement of adrenal glands despite ACTH independence and the familial occurrence in combination with other peculiar rare lesions are strongly suggestive of a malformative process of the zona reticularis of the adrenal glands.     

CONTINUOUS SUBCUTANEOUS PUMP INFUSION OF SOMATOSTATIN ANALOGUE SMS 201-995 VERSUS SUBCUTANEOUS INJECTION SCHEDULE IN ACROMEGALIC PATIENTS

Diurnal serum GH patterns were determined in 10 acromegalic patients before treatment, after 3 d continuous s.c. pump infusion and then after 3 d with three equal daily s.c. injections in both instances totalling 100 μg/24 h. Subcutaneous injections (33 μg) induced impressive suppression of serum GH lasting 3-6 h in eight patients followed by escape to pretreatment values before the next injection. In contrast, continuous infusion resulted in greater and more stable 24 h suppression to the levels reached at the nadir between injections. Suppression of mean 24 h serum GH below 5 ng/ml was achieved by pump treatment in four patients, while two patients had mean values between 5 rig/ml and 10 ng/ml. In four patients occasional or all levels were above 10 ng/ml (24 h average 12.4-102 ng/ml) implying either that adequate suppression by the SMS 201-995, was impossible during the 3 d pump infusion period, or that the dose administered was inadequate. Carbohydrate tolerance was unaffected in either regimen, indicating that reduction in insulin antagonistic hormones balanced inhibition of insulin release. Interestingly, and in contrast to somatostatin, SMS 201-995 did not inhibit TSH release. No untoward effects were observed at the moderate dosage and blood clinical chemistry was unchanged. Fairly constant diurnal serum SMS 201-995 values were obtained during pump infusion, while levels undulated inversely with serum GH during injection treatment. Average diurnal serum somatostatin-C immunoreactivity (all patients) decreased from 496 ± 129 (mean ± SD) to 385 ± 100 ng/ml ( P < 0 003) during pump treatment and did not decrease further during the following 3 d injection treatment (363 ± 76 ng/ml).     

THIOPENTONE SENSITIVITY IN YOUNG AND ELDERLY WOMEN

Induction and maintenance doses of thiopentone were smallerin eight elderly women than in eight younger women. Mean venousanaesthetic concentrations were 34% less (P = 0.02) in the elderly.For each patient an "expected maintenance dose" was calculatedfrom serum clearance and the area under the curve during theanaesthesia. In the elderly the average expected dose was equalto the dose given, but in the younger patients the dose givenwas greater than the expected (P<0.02). In younger women,but not in the elderly, a high cardiac output was accompaniedby the need for a relatively high maintenance dose if a certainserum concentration was to be maintained. Cardiac output wasequally reduced in both patient groups (30–40%). Afterinduction the heart rate was reduced in the elderly during theentire period of anaesthesia and always more than in the younger.No correlation was found between serum concentration of thiopentoneand haemodynamic effects.     

INFLUENCE OF AGE AND SEX ON THE PHARMACOKINETICS OF THIOPENTONE

Thiopentone was given to eight women and eight men (60–79yr). The disappearance of thiopentone from the venous bloodwas described by a three-compartment open model. The only significantdifference between the sexes was a higher initial venous concentrationin males. The dose (mg kg ^–1) for induction was 70% ofthe value (P<0.05) previously reported for a comparable groupof younger men and women (20–40 yr). The volumes of distributionV₂ and V₃ were larger in the elderly (P<0.05). The terminalhalf-lives were increased with advancing age (from 75% to 100%on average) (P0.01). The clearance value was 50% greater inthe older women than in a group of young women. For all groupsa significant correlation between initial drug concentrationand k₁₂ supported the hypothesis that the redistribution rateconstant k₁₂ is the predominant factor in the pharmacokineticprofile of a dose of thiopentone sufficient to obtund the eyelashreflex.