A qualitative investigation into why patients change their GPs

BACKGROUND: In the past patients have rarely changed doctor. The UK Government has made such change easier and it appears to be becoming more common. Changing doctor without changing address may be indicative of dissatisfaction with the GP service. Previous research in this area has been largely quantitative. OBJECTIVE: To identify why patients change their GP although they have not moved house. METHOD: Qualitative investigation of patients' experiences. In depth interviews of 24 patients were conducted to determine why they had left their previous doctor. Letters describing the process of change were received from a further 17 patients. Analysis was performed using standard qualitative techniques. RESULTS: The decision to change was in most cases multi- factorial. Interviews yielded more detailed and richer accounts than letters. For interviewees, rudeness or the attitude of the doctor was the commonest reason. Overall, 19 different reasons, in four categories, were identified. The largest single category was accessibility, closely followed by attitudinal problems. Clinical issues and personal characteristics of the doctor were less common. The majority of those responding by letter gave only one reason, usually distance. CONCLUSION: Patients change doctor after careful consideration and commonly for interpersonal reasons. There is usually one critical factor in the decision to change. Factors may be modifiable or non-modifiable. Critical event audit may enable GPs to analyse the reasons why patients leave their lists.      

Meniscal tears: pathologic correlation with MR imaging

Menisci from 12 autopsies and above-knee amputations were imaged with magnetic resonance (MR) at 1.5 T and then sectioned for gross and histologic examination. A histologic staging system was developed and showed a one-to-one correlation with corresponding grades of MR signal intensities. Histologic stages 1 and 2 represented a continuum of degeneration culminating in stage 3 fibrocartilaginous tears, seen most frequently in posterior-horn segments of the medial meniscus. Correlation of histologic stages with MR signal intensity allows for an improved diagnostic reading of MR images.     

Temporomandibular joint: MR assessment of rotational and sideways disk displacements

The accuracy of coronal and sagittal magnetic resonance (MR) imaging was examined in the assessment of rotational and sideways displacements of the temporomandibular joint (TMJ) disk. Rotational disk displacement implies a combination of anterior and medial or lateral displacements, whereas sideways displacement implies pure medial or lateral displacement without an anterior component. Multiple 3-mm-thick coronal and sagittal MR images were obtained of 18 fresh TMJ autopsy specimens and compared with the observations in corresponding coronal cryosections. MR imaging correctly delineated the mediolateral position of the disk in 15 joints (83%) and incorrectly delineated it in three joints (17%). Osseous anatomy was correctly assessed in 17 joints (94%). On cryosections, six joints (33%) showed medial disk displacement and two joints (11%) showed lateral displacement. In five of these eight joints the medial or lateral displacement occurred in conjunction with an anterior displacement, that is, rotational displacement. Clinical MR imaging in 37 patients (61 joints with coronal images) showed medial or lateral disk displacement in 16 joints (26%). This study suggests that rotational and sideways displacements of the TMJ disk are an important aspect of internal derangement. The multiplanar capabilities of MR are suitable for an assessment of these abnormalities.     

Biosynthesis of prothrombin: intracellular localization of the vitamin K-dependent carboxylase and the sites of gamma-carboxylation

Prothrombin is a vitamin K-dependent blood coagulation protein that undergoes posttranslational gamma-carboxylation and propeptide cleavage during biosynthesis. The propeptide contains the gamma-carboxylation recognition site that directs gamma-carboxylation. To identify the intracellular sites of carboxylation and propeptide cleavage, we monitored the synthesis of prothrombin in Chinese hamster ovary cells stably transfected with the prothrombin cDNA by immunofluorescent staining. The vitamin K-dependent carboxylase was located in the endoplasmic reticulum and Golgi complex. Antibodies specific to prothrombin processing intermediates were used for immunocytolocalization. Anti-des-gamma-carboxyprothrombin antibodies stained only the endoplasmic reticulum whereas antiproprothrombin antibodies (specific for the propeptide) and antiprothrombin:Mg(II) antibodies (which bind the carboxylated forms of proprothrombin and prothrombin) stained both the endoplasmic reticulum and the Golgi complex. Antiprothrombin:Ca(II)-specific antibodies (which bind only to the carboxylated form of prothrombin lacking the propeptide) stained only the Golgi complex and secretory vesicles, and colocalized with antimannosidase II and anti-p200 in the juxtanuclear Golgi complex. These results indicate that uncarboxylated proprothrombin undergoes complete gamma-carboxylation in the endoplasmic reticulum and that gamma-carboxylation precedes propeptide cleavage during prothrombin biosynthesis.