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.     

The Prevalence of Mutations in KCNQ1, KCNH2, and SCN5A in an Unselected National Cohort of Young Sudden Unexplained Death Cases

Introduction: Sudden unexplained death account for one‐third of all sudden natural deaths in the young (1–35 years). Hitherto, the prevalence of genopositive cases has primarily been based on deceased persons referred for postmortem genetic testing. These deaths potentially may represent the worst of cases, thus possibly overestimating the prevalence of potentially disease causing mutations in the 3 major long‐QT syndrome (LQTS) genes in the general population. We therefore wanted to investigate the prevalence of mutations in an unselected population of sudden unexplained deaths in a nationwide setting. Methods: DNA for genetic testing was available for 44 cases of sudden unexplained death in Denmark in the period 2000–2006 (equaling 33% of all cases of sudden unexplained death in the age group). KCNQ1, KCNH2, and SCN5A were sequenced and in vitro electrophysiological studies were performed on novel mutations. Results: In total, 5 of 44 cases (11%) carried a mutation in 1 of the 3 genes corresponding to 11% of all investigated cases (R190W KCNQ1, F29L KCNH2 (2 cases), P297S KCNH2 and P1177L SCN5A). P1177L SCN5A has not been reported before. In vitro electrophysiological studies of P1177L SCN5A revealed an increased sustained current suggesting a LQTS phenotype. Conclusion: In a nationwide setting, the genetic investigation of an unselected population of sudden unexplained death cases aged 1–35 years finds a lower than expected number of mutations compared to referred populations previously reported. We therefore conclude that the prevalence of mutations in the 3 major LQTS associated genes may not be as abundant as previously estimated. (J Cardiovasc Electrophysiol, Vol. 23 pp. 1092‐1098, October 2012)     

AUTOFLUORESCENCE GUIDED BIOPSY FOR THE EARLY DIAGNOSIS OF BLADDER CARCINOMA

Purpose

We validate the usefulness of laser-induced autofluorescence for the detection of bladder carcinoma.

Materials and Methods

We obtained and analyzed fluorescence spectra from 75 patients in whom bladder cancer was suspected. Tissue fluorescence was excited by a nitrogen laser using a quartz optical fiber placed in gentle contact with the area of interest. The laser-induced autofluorescence spectrum was recorded using an intensified optical multichannel analyzer system. Spectra were corrected for the spectral response of the optical system, and the ratios of laser-induced autofluorescence intensities (I) at 385 and 455 nm. (I₃₈₅/I₄₅₅) were determined. We had previously established this ratio as a diagnostic algorithm. We included only suspicious bladder lesions (erythematous, edematous, raised and so forth) that were difficult to diagnose by cystoscopy as well as areas from which random biopsies were obtained. The fluorescence ratio algorithm was applied to 130 bladder areas.

Results

Of the 130 biopsies obtained during routine cystoscopy 107 (82%) were nonmalignant by histological classification. In contrast, because laser-induced autofluorescence effectively guides biopsies towards malignant lesions, only 30 biopsies (72% fewer) would have been obtained from nonmalignant tissue if the fluorescence ratio that identifies 95% of malignant lesions (95th percentile) had been selected as the decision criterion during standard cystoscopy.

Conclusions

By guiding the surgeon to suspicious lesions that are most likely to be malignant, laser-induced autofluorescence substantially decreases the number of biopsies obtained from nonmalignant tissue during cystoscopy to diagnose bladder carcinoma.     

THE USE OF IMMUNOHISTOCHEMISTRY TO IMPROVE SENSITIVITY AND SPECIFICITY IN THE DIAGNOSIS OF SYSTEMIC MYCOSES IN PATIENTS WITH HAEMATOLOGICAL MALIGNANCIES

The original histomorphological diagnoses in a series of 34 mycotic lesions from 23 patients with haematological malignancies were re-evaluated by immunohistochemistry. A panel of antibodies was used to identify the agents of aspergillosis, candidosis, fusariosis, scedosporiosis (pseudallescheriosis), and zygomycosis. Apart from improving the diagnosis of aspergillosis, candidosis, and zygomycosis, the application of immunohistochemistry also disclosed three lesions of aspergillosis which had been overlooked during the original screening. It is concluded that the use of immunohistochemistry for the diagnosis of common opportunistic mycoses will not only increase diagnostic specificity, but will also reveal more tissue infections than the conventional histomorphological examination of traditionally stained sections. © 1997 by John Wiley & Sons, Ltd.     

Anatomical differences in the psoas muscles in young black and white men

The anatomy of the psoas major muscle (PMA) in young black and white men was studied during routine autopsies. The forensic autopsies included 44 fresh male cadavers (21 black, 23 white) with an age span of 14 to 25 y. The range for weight was 66–76 kg and for height 169–182 cm. The PMA was initially measured in its entire length before measuring the diameter and circumference at each segmental level (L1–S1). At each segmental level, the calculated anatomical cross-sectional area (ACSA) was more than 3 times greater in the black group compared with the white ( P <0.001). The psoas minor muscle (PMI) was absent in 91% of the black subjects, but only in 13% of the white subjects. These data show that the PMA is markedly larger in black than white subjects. The marked race specific difference in the size of the PMA may have implications for hip flexor strength, spine function and race specific incidence in low back pathology, and warrants further investigation.     

Clinically Suspected Severe Ischaemia-induced Mitral Regurgitation

Abstract Eighteen patients with clinical signs suggesting severe mitral regurgitation secondary to ischaemic heart disease were assessed by echocardiography. Non-ischaemic diseases needing specific therapy were revealed in six patients. In the other 12 patients echocardiography demonstrated myocardial lesions explaining the mitral regurgitation. Apart from the distinction between non-ischaemic conditions and lesions induced by ischaemia, echocardiography seems to be helpful in the demonstration of severe yet operable mitral valve regurgitation due to a small ischaemic lesion. Such cases are opposed to functional mitral regurgitation caused by extensive myocardial injury as demonstrated by two-dimensional echocardiography and reflected by a minimum mitral valve/septum separation of more than 2 1/2 cm on the M-mode echocardiogram. These conditions make symptomatic improvement by mitral valve surgery unlikely and carry an extremely high operative mortality. A more precise definition by heart catheterization is required when serious clinical heart failure is not explained by the echocardiographic finding of severe global myocardial impairment.     

ANAL TONOMETRY A Diagnostic Help in Hirschsprung's Disease1

Manometrical measurements of reflex responses in the internal anal sphincter were made in 93 patients. In normal controls, a relaxation was obtained within the internal sphincter after distension of the rectum. Patients suffering from Hirschsprung's disease showed either a contraction in the muscle or an absence of sphincteric response. In 17 cases, where the diagnosis of Hirschsprung's disease was established by conventional means, the diagnosis was confirmed by anal tonometry in 13 cases and disproved by this method in 4 cases. The subsequent clinical course and histological findings have verified the diagnosis obtained by tonometry. In one patient it was not possible to make the diagnosis by means of the usual methods, anal tonometry showed Hirschsprung's disease and this was subsequently confirmed by biopsy.     

Early postoperative mortality following hysterectomy. A Danish population based study, 1977–1981

Summary. The main objective of this cohort study was to analyse the early postoperative mortality after 'simple' hysterectomy for benign indications and to compare it with that of a randomly selected reference group of women matched for age. Registry data covering the entire Danish female population were used. Included in the study were all patients operated in the period 1977–1981. Patients were only included if no cancer was diagnosed and if no major co-surgery was performed (29 192 patients). Cancer patients were also excluded in the reference group (16182 women). Mortality was studied according to characteristics of patients, their residential area, the surgical approach and operating hospital. Overall 47 patients died within 30 days of admission for hysterectomy (overall mortality 16.1 per 10000). Only seven deaths were expected on the basis of the population sample, and adjusted for age, the relative risk (RR) for hysterectomy patients was 6.38 (95% CI 4.33–9.39). Early postoperative mortality increased with age, and the risk was elevated among emergency patients (  RR = 3.22  ; 1.72–6.04). Patients with more than one diagnosis at discharge (  RR = 4.53  ; 2.12–9.70) were at high risk, but early postoperative mortality was independent of surgical approach. Causes of death are discussed. Compared to the general population, patients who undergo 'simple' hysterectomy are faced with a sixfold risk of dying within 30 days, but a complete assessment of the risks and benefits of hysterectomy requires prospective studies of survival and morbidity, including quality of life for longer periods of time following operations.