Audit of an inpatient neurology consultation service in a tertiary referral centre: value of the consulting neurologist

The Mater Misericordiae Hospital is a 575-bed tertiary referral centre with busy medical and surgical subspecialty services (including the national cardiac, cardiothoracic, spinal cord injury and pulmonary hypertension units). An audit of in-patient referrals to a neurology service was carried out over the twelve-month period of January to December 2002 inclusively. Five hundred and seventy seven inpatients were evaluated and managed in conjunction with the referring services. Consultation by the neurological service led to a significant contribution in the management of clinical cases in one of three ways: establishing a de novo diagnosis in patients admitted with active neurological symptoms where no working diagnosis exists (40.7% of referrals), significant alteration in diagnosis where the referring service have already established a specific working diagnosis (11.1% of referrals), or offering advice in the ongoing management of active neurological symptoms when the diagnosis is historically established and secure (48.2% of referrals). In order of frequency the most common reason for referral was stroke (131 cases (22.7%)), seizures unrelated to alcohol (59 cases (10.2%)), alcohol-related neurological problems (55 cases (9.5%)), movement disorders (41 cases (7.1%)), neuromuscular (40 cases (6.9%)), coma (35 cases (6%)), disorders of cognition (31 cases (5.3%)), acute headache (28 case (4.8%)) and functional neurological syndromes (26 cases (4.5%)). This audit highlights the value of a consulting neurology service in a multidisciplinary tertiary referral setting.     

Repeat consultations after antibiotic prescribing for respiratory infection: a study in one general practice.

BACKGROUND. Several new antibacterial drugs have been introduced in the last 10 years with the aim of improved treatment of respiratory tract infection. AIM. The study set out to use repeat consultations as a measure of the outcome of antibiotic treatment for respiratory tract infection, and to develop a simple model for discussion of the cost effectiveness of alternative antibiotic treatments. METHOD. All consultations to one practice during a single winter were reviewed by one general practitioner. RESULTS. A total of 1140 patients had acute symptoms suggestive of respiratory infection. Of these, 899 patients (79%) were prescribed antibiotics at the first consultation and 160 of the 899 patients (18%) returned for one or more repeat consultations; only nine repeat consultations were due to adverse effects of the antibiotics prescribed. Only two patients were admitted to hospital for respiratory symptoms following initial antibiotic therapy and both patients had additional reasons for their admission. Using the highest estimates, the cost of a repeat consultation was found to be 28.54 pounds. These data were used to calculate how much more might be spent on more effective antibiotics at the first consultation. It would be difficult to justify increasing the cost of antibiotic treatment by more than 5 pounds per patient, even if the new treatment were 100% effective and all repeat consultations were due to treatment failure (5 pounds is equal to 28.54 pounds x 0.18, which is the maximum cost of a repeat consultation multiplied by the proportion of patients prescribed antibiotics who make repeat consultations). CONCLUSION. From these results and a review of the literature it can be concluded that new antibacterial drugs will have to be carefully targeted if they are to prove cost effective in practice. Other methods for reducing repeat consultation merit investigation.     

Molecular heterogeneity and fine specificity of BALB/c antibodies elicited by isologous myeloma protein.

BALB/c mice immunized with the isologous myeloma protein MOPC-315 (M315; α, λ₂) develop antibodies most of which are directed to idiotypic antigens (Id315) located in or near the CNP binding sites of M315, In order to more precisely establish the fine specificity of anti-Id315 antibodies, and to obtain an estimate of the size of the BALB/c anti-Id315 repertoire, we examined anti-Id315 antibodies from individual mice by analytical isoelectric focusing followed by autoradiography. ¹²⁵I-labeled probes were prepared from purified mildly reduced and alkylated M315 protein (RA315) (7 S monomer), Fab'315, Fv315, L315, H315, DNP affinity-labeled RA315, mildly reduced and alkylated MOPC-460 (RA460; 7 S; α, k, Fab'460, H460, and DNP affinity-labeled RA460. We observed that (a) the majority of BALB/c antibodies elicited by immunization with RA315 are specific for idiotypic antigens in the variable region which are rendered inaccessible in the presence of DNP-hapten; (b) distinctly separate antibodies are specific for idiotypic antigens also located in the variable regions but which are not influenced by DNP hapten; (c) about 30 % of BALB/c mice develop antibodies which appear to be specific for a determinant located in the second or third, homology regions of the constant region of the α chain which is not influenced by DNP hapten, and which is also present in the same region of H460; (d) none of the antibodies elicited by M315 recognize free L315; (e) the total antibody response is quite restricted; (f) shared spectrotypes are common between individual mice; and (g) unique or infrequently shared spectrotypes do occur. These studies demonstrate, by a direct technique, the fine specificity and the clonal and molecular heterogeneity of the B cell response induced by immunization with RA315.     

Reproduction and thermoregulation in Peromyscus: Effects of chronic short days

Seven groups of laboratory reared Connecticut P. leucopus were exposed to a 9L:15D photoperiod for either 6, 9, 12, 20, 25, 32, or 36 weeks. An eighth group was maintained on 16L:8D. During the final 6 weeks all mice were cold exposed (13°C). Substantial reproductive regression occurred in females following 6 weeks exposure to 9L:15D relative to 16L:8D animals. In males, a slight decrease in testicular weight occurred following 6 weeks on 9L:15D; this effect was pronounced by 9 weeks, along with a decrease in seminal vesicle weight. Reproductive recrudescence occurred in females by week 32 and in males by week 36. Between 10 and 12 weeks on 9L:15D mice exhibited increases in nesting, incidence of daily torpor, and presence of the winter molt. These increases persisted through 36 weeks on 9L:15D. An increase in the interscapular brown fat pad occurred between 12 and 25 weeks. Reproductive and thermoregulatory characters respond differently to prolonged exposure to a short day photoperiod in this species.     

Triplications of chromosome 1p36.3, including the genes GABRD and SKI,are associated with a developmental disorder and a facial gestalt

Triplication of chromosomal region 1p36.3 is a rare genomic rearrangement. In this report, we delineate the phenotypic spectrum associated with 1p36.3 triplications. We describe four patients with microtriplications of variable size, but with a strong phenotypic overlap, and compare them to previously described patients with an isolated triplication or duplication of this region. The 1p36.3 triplication syndrome is associated with a distinct phenotype, characterized by global developmental delay, moderate intellectual disability, seizures, behavioral problems, and specific facial dysmorphic features, including ptosis, hypertelorism, and arched eyebrows. The de novo occurrence of these microtriplications demonstrates the reduced reproductive fitness associated with this genotype, in contrast to 1p36.3 duplications which are mostly inherited and can be associated with similar facial features but with a less severe developmental phenotype. The shared triplicated region encompasses four disease-related genes of which GABRD and SKI are most likely to contribute to the phenotype.     

The Low-Grade Lymphomas

The lymphomas comprise a spectrum of diseases with vast variation in histologic appearance, presentation and natural history, and response to therapy. At one end of the spectrum are the low-grade lymphomas (LGLs), indolent malignancies characterized by paradox. Despite an exceedingly low growth fraction, the LGLs are usually extensive at presentation, and yet they rarely involve privileged sites, such as cortical bone or central nervous system, and rarely destroy adjacent tissue. They are exquisitely responsive to many different therapeutic interventions, but responses to most agents are transient and similar. Finally, although survival of most LGL patients is measured in years, the course of the disease is punctuated by both transient and long-term responses to treatment, and also by spontaneous regression and transformation to more aggressive lymphomas in the absence of therapy, rendering the evaluation of the true impact of treatment quite difficult. The focus of this review is on the management of the LGLs, in particular the role of radiotherapy.     

Comparison of ambulatory and inpatient experiences in five specialties

This study compared medical student evaluations of ambulatory and inpatient components of third-year clerkships in internal medicine, obstetrics/gynaecology, paediatrics, psychiatry, and surgery. Seventy-two students completed evaluation questionnaires at the conclusion of each of five clerkships over 12 months. Although ambulatory and inpatient evaluations were comparable across all five specialties in several areas, ambulatory education was rated more favorably in scheduling, clear definition of student roles and responsibilities, appropriate supervision, timely and constructive feedback, being welcomed, and working in a non-threatening environment.Student feedback thus implied that ambulatory experiences were comparable to, or better than, inpatient experiences and suggests areas for improving clinical education in inpatient settings.     

Drinking water source and chlorination byproducts in Iowa. III. Risk of brain cancer.

The authors conducted a population-based case-control study in Iowa of 375 brain cancer patients and 2,434 controls. A postal questionnaire was used to gather information on lifetime residential history, sources of drinking water, beverage intake, and other potential risk factors. Exposure to chlorination byproducts in drinking water was estimated by combining questionnaire data with historical information from water utilities and trihalomethane levels in recent samples. The analysis included 291 cases (77.6%) and 1,983 controls (81.5%), for whom water quality information was available for at least 70% of lifetime years. Proxies represented 74.4% of cases. The mean number and mean duration of places of residence were comparable between direct and proxy respondents, suggesting little contribution to bias. After multivariate adjustment, odds ratios for brain cancer were 1.0, 1.1, 1.6, and 1.3 for exposure to chlorinated surface water of 0, 1-19, 20-39, and > or =40 years (p trend = 0.1). Among men, odds ratios were 1.0, 1.3, 1.7, and 2.5 (p trend = 0.04), and among women, 1.0, 1.0, 1.6, and 0.7 (p trend = 0.7)). Similar findings were found with estimates of average lifetime level of trihalomethanes. The association was stronger among men with above-median tap water consumption. These observations deserve further attention, especially in view of increasing glioma rates.