An ‘early warning system’ for health needs: surveillance of the quality of clinical services by audit of extra-contractual referrals (ECRs)

Extra-contractual referrals (ECRs) can be a cause of considerable anxiety to purchasing authorities, mainly because of their potential to generate unexpected expenditure. But ECRs can also be used as a tool for monitoring the demand for, and quality of, clinical services. ECRs were studied in the Darlington Health Authority district using a variety of methods including inter-disciplinary meetings, a series of interviews with local GPs, and a questionnaire to general practitioners on 230 consecutive ECRs. The methods and results of the questionnaire study are presented. The commonest reasons for making ECRs included the mistaken belief that a contract existed with the ECR provider, patient dissatisfaction with the local provider, and referral to benefit from shorter waiting lists. ECRs for bone-mass densitometry, orthopaedics, and ear nose and throat services were over-represented. Questionnaire results were validated by comparison with an interview study of all GPs in the district. We conclude that trends in ECRs can be monitored as a convenient ‘early warning system’ to alert purchasing authorities to changes in demand or perceived problems with local provider units. ECR data must be interpreted in the context of further local background information from sources such as GPs and public health physicians. In the case of Darlington, scrutiny of ECRs has led to changes in services and contracts.     

Cardiac herniation and volvulus: radiographic findings

Cardiac herniation with volvulus is a catastrophic complication of right intrapericardial pneumonectomy. This case illustrates diagnostic radiographic findings that may be essential for early diagnosis and survival, since the clinical signs are nonspecific.     

Comparison of Renal Hemodynamic Effect of Ramiprilat to Captopril: Possible Role of Kinins

Sincetheintroductionofthefirstlineofangiotensinconvertingenzyme(ACE)inhibitors,ofwhichcaptoprilistheprototype,morepotentlonger-lastingagentshavebecomeavailable[l].AmongtheseisramipriIat,anonsL1lfhydrylACEinhibitorsimilarchemicallytoenalaprilatbutcontaininginadditionapentanering.Benderetal[2Jdemonstratedinvitrothatramiprilatisatleast23timesmorelipophilicthanenalaprilatwithanaffinityforACE47timesgreatc'rthanthatofcaptopril.ItwaspostulatedthatthemorelipophiIicanACEinhibitor,thebetteraccessi…     

The beta-globin gene on the Chinese delta beta-thalassemia chromosome carries a promoter mutation

A new type of delta beta-thalassemia characterized by decreased expression of the beta-globin gene and increased expression of both G gamma and A gamma globin gene in the absence of a detectable deletion has recently been described in the Chinese population. In this study we characterize the mutant beta-globin gene from this delta beta- thalassemia chromosome. An A to G transversion is identified in the "ATA" sequence of the promoter region that leads to decreased expression of the beta-globin gene in vivo and in vitro. We also demonstrate the presence of this mutation in every individual with a high fetal hemoglobin phenotype in this family and its absence in every individual with a normal hemoglobin phenotype. This same promoter mutation has recently been detected in Chinese beta-thalassemia genes where it is present on chromosomes of the same haplotype as that of the delta beta-thalassemia chromosome we are studying. These data support the hypothesis that an as yet unidentified mutation occurred on the ancestral chromosome carrying the promoter mutation and subsequently gave rise to the delta beta-thalassemia phenotype.     

Comparison of Outcomes Between BRCA Pathogenic Variant Carriers Undergoing Breast-Conserving Surgery Versus Mastectomy

Annals of Surgical Oncology - Although outcomes are similar following breast-conserving surgery (BCS) or mastectomy among sporadic breast cancer patients, data are mixed for women with a germline...     

Platelet refractoriness and alloimmunization in pediatric oncology and bone marrow transplant patients

BACKGROUND: The purposes of this study were to determine the overall incidence of platelet refractoriness and alloimmunization among multiply transfused children on a medical oncology and bone marrow transplant service and to evaluate the effect of routine white cell reduction in blood components on that incidence. STUDY DESIGN AND METHODS : The platelet transfusion records of 128 consecutive children admitted to the hospital and requiring blood component support for the treatment of disease were evaluated retrospectively. Mean corrected count increments (CCIs) for each patient were calculated for all random- donor platelet transfusions given within 7 days of the routine weekly testings of the patient's serum for lymphocytotoxic antibodies (LCTAbs). Mean CCIs for HLA-matched platelet transfusions were calculated separately for the patients receiving them. RESULTS : Thirty- one patients (24%) had or developed persistently positive LCTAbs (patient's serum reacted with > or = 3/10 panel lymphocytes); 22 (71%) of these patients had a mean CCI < 7.5 to random-donor platelet transfusions. In contrast, of the 97 patients with negative or transiently positive LCTAbs, only 25 (26%) had a mean CCI < 7.5. The overall incidence of platelet refractoriness (CCI < 7.5) was 37 percent. Patients with acute myelogenous leukemia had a significantly (p < 0.01) reduced incidence (17%) of low CCIs, with or without positive LCTAbs, as compared to patients with other malignant or nonmalignant disorders (41%). No difference in the incidence of LCTAbs or low CCIs was seen in patients undergoing allogeneic or autologous bone marrow transplant or receiving drug therapy only. Among the 24 patients who received HLA-matched platelets, only those with positive LCTAbs showed a significant improvement in CCIs over that achieved with random-donor platelet transfusions. Routine white cell reduction in red cell and platelet components with third-generation white cell filters was performed prior to transfusion in 73 of the patients. There was no significant difference between the incidence of LCTAbs and/or low CCIs in this group and that in the 55 children receiving unfiltered transfusions. CONCLUSION : Alloimmunization and platelet refractoriness occur in pediatric oncology and bone marrow transplant patients, but the incidence-particularly in children with acute myelogenous leukemia- -appears to be low. The detection of LCTAbs predicts a poor response to random-donor platelet transfusion, but most such patients show improved CCIs with HLA-matched platelets. Routine use of white cell-reduction filters has thus far failed to eliminate alloimmunization in children requiring prolonged blood component support.     

Natural kinds, natural history and the clinician-researcher

Recent medical research has been based on a flawed rationale of clinical innovation (here termed the 'basic-to-mega model') which neglects the human organism as a vital focus of clinical scientific study. The consequent over-concentration upon cellular and population levels of analysis has probably damaged the rate of therapeutic progress. The key role in medical research should be acknowledged to lie with clinician-researchers whose 'experimental animal' is the patient and whose 'end-points' are health and disease. The distinctive strength of the clinician-researcher derives from an ability to combine understanding of the 'natural kinds' (i.e. true biological categories) relevant to human disease, with experience of the 'natural history' of disease (i.e. its longitudinal pattern, including the response to interventions). Such knowledge is explicitly formalized by the activities of clinical science and clinical epidemiology. A sufficient supply of active clinician-researchers is the catalyst of innovation, and an insufficient supply is currently a rate-limiting factor in therapeutic progress.