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.     

Moderate maternal and paternal alcohol consumption and the risk of spontaneous abortion.

Maternal alcoholism can lead to the fetal alcohol syndrome in offspring, but the effect of more moderate alcohol consumption during pregnancy remains an issue of concern. Therefore, we analyzed data from a large case-control study of spontaneous abortion (626 cases, 1,300 controls) that ascertained maternal alcohol consumption before and during pregnancy, as well as paternal consumption. Asking when in pregnancy alcohol consumption changed allowed us to calculate a weighted average of the amount consumed weekly during the first trimester. The odds ratio for consumption of seven or more drinks per week was 1.9 [95% confidence interval (CI) = 1.1-3.4] when adjusted for maternal smoking, passive smoking, and maternal age. Data were too sparse to examine higher consumption levels. There was some evidence that cases may have had less opportunity than controls to decrease consumption during their shorter pregnancies, potentially biasing the odds ratio upward. The adjusted odds ratio for any paternal alcohol consumption was 1.2 (CI = 0.93-1.5), with no dose-response effect seen. Among pregnancies in which the mother did not drink, there was no association with paternal drinking.     

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…     

Prenatal active or passive tobacco smoke exposure and the risk of preterm delivery or low birth weight

We examined the association of exposure to environmental tobacco smoke with birth weight and gestational age in a large, prospective study. We also compared these endpoints between infants of active maternal smokers and those of non-smoking, non-ETS exposed women. Pregnant women were interviewed by telephone during the first trimester, and pregnancy outcome was determined for 99%. Among the 4,454 singleton live births that could be linked to their birth certificate, we confirmed increased risks of low birth weight and small for gestational age with heavier maternal smoking (> 10 cigarettes/day), as well as noting an increased risk for "very preterm" birth (< 35 weeks). These associations were generally stronger among infants of older (> or = 30 years) than those of younger mothers, as well as among non-whites. High environmental tobacco smoke exposure (> or = 7 hours/day in non-smokers) was moderately associated with low birth weight (adjusted odds ratio (AOR) 1.8, 95% confidence limits (95% CL) = 0.82, 4.1), preterm birth (AOR 1.6, 95% CL = 0.87, 2.9), and most strongly with very preterm birth (AOR 2.4, 95% CL = 1.0, 5.3). These associations were generally greater among non-whites than whites. The data support earlier studies suggesting that prenatal environmental tobacco smoke exposure, in addition to maternal smoking, affects infant health.     

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.