The impact of economic information on medical decision making in primary care

BACKGROUND: Many general practitioners (GPs) are concerned about the increasing dominance of economic issues in major decisions about clinical care, and feel their opinions on economic matters have not been heard. It is unclear whether this information has any impact on everyday clinical practice in a primary care setting. AIM: To investigate GPs' perspectives on the use of economic information in medical decision making. DESIGN OF STUDY: Cross-sectional survey. SETTING: GP members of the West of Scotland Primary Care Research and Development Network (WestNet). METHODS: Questionnaire survey sent to GPs by post and by email. RESULTS: The overall response rate was 44%, favouring postal over email responses. All respondents indicated that economic information has previously influenced them and should be incorporated into their medical decision making. The most common source of this information was generated by local authorities such as health boards, primary care groups and local prescribing advisors--used by 80% of the respondents. However, publications, such as the British Journal of General Practice, locally produced newsletters and prescribing formularies, and feedback from the General Practice Administration System for Scotland, were used as sources of economic information by 20%, 27% and 33%, respectively. Published materials--in particular, locally specific information and summarized information in leaflet format--were favoured (54%) in comparison to verbally presented material. CONCLUSIONS: GPs believe that economic information should be incorporated in medical decision making. The need for precise and summarized information, produced locally, has been highlighted. Better understanding towards the type of economic evidence GPs find useful and comprehensible is required.     

Development of a training module on therapeutic boundaries for mental health clinicians and case managers

This article describes the development of a training model to teach mental health clinicians and case managers about therapeutic boundaries. Awareness of boundary transgressions is vital for establishing and maintaining the moral and ethical integrity of mental health treatment. Our structured teaching model was presented to staff from many different treatment settings throughout our mental health organization. A major portion of each session was utilized for exploration of common boundary dilemmas in the clinical setting as they relate to current policies and ethics codes. Efforts were made to mention the variety of boundary transgressions that may occur in various settings. Participants reported a broadened perspective in their work with clients, having learned about types of boundary issues that they had not previously recognized. Maintaining an understanding of boundary issues among staff requires ongoing educational efforts in training. The health organization's policies on boundaries must be clear and specific to guide the staff. Although training was given in a mental health setting, these lessons can be extended beyond the mental health arena. Safe therapeutic boundaries must be practiced in all settings.     

Primary lung tumor mimicking acute type A aortic dissection

A 64-year-old man presented with clinical features and echocardiographic diagnosis of an acute type A dissection. He underwent median sternotomy for definitive surgical treatment. On external examination of the aorta, other intrapericardial structures, and the right lung, it was evident that the patient had an advanced lung tumor. This was confirmed by frozen-section and histopathologic examinations. Epiaortic scanning showed beyond doubt the presence of a mobile intraaortic mass that had misled us in making the preoperative diagnosis of an acute type A dissection.     

Long-term results of thoracoscopic sympathectomy for hyperhidrosis

Background

Thoracoscopic sympathectomy is now the reference treatment for severe palmar hyperhidrosis, but this is offset by the occurrence of compensatory sweating. It has been studied in this series to improve the indications and information given to patients.

Methods

A retrospective review of 124 patients who were previously afflicted with bilateral thoracoscopic sympathectomy 6 years earlier was conducted. Patients were interviewed by postal questionnaire regarding the results and side effects.

Results

The series consisted of 89 females (72%) and 35 males and the mean age was 28 years. The main indication was palmo-plantar hyperhidrosis (34%). The mean operating time was 36 minutes and there were no intraoperative complications. Postoperative pneumothorax occurred in 9 patients and 3 patients required a chest drain. The hospital stay was 36 hours for 87.6% of the patients. Postoperative pain occurred in 78% of the patients. Neurologic complications (Horner syndrome, radial paralysis, and dysesthesia of the arm) occurred in 3 patients and disappeared after 2-6 months. Two patients required single-side reoperation because of failure with the first intervention. Eighty-nine replies to questionnaires were received (72%). The results for hands were favorable in 98% and in 63% for axillae. Compensatory sweating occurred in 87% of the patients (serious in 36% and incapacitating in 6%). Despite this 90% of the patients were satisfied or very satisfied.

Conclusions

This study confirms that thoracoscopic sympathectomy is a suitable method of treatment for severe palmar hyperhidrosis but emphasizes the need to offer the patient more informative information, especially regarding compensatory sweating which seems inescapable.     

D1 dopamine receptor signaling involves caveolin-2 in HEK-293 cells

BACKGROUND: Dopamine receptors in the kidney, especially those belonging to the D1-like receptor family, are important in the regulation of renal function and blood pressure. Because of increasing evidence that G protein-coupled receptors (GPCRs) are associated with caveolae and lipid rafts, we tested the hypothesis that the D1 dopamine receptor (D1R) and signaling molecules are regulated by caveolin in caveolae or lipid rafts. METHODS: Six experimental approaches were used: (1) construction of tagged human D1Rs (hD1Rs) and transfectants; (2) cell culture [human embryonic kidney (HEK)-293 and immortalized rat renal proximal tubule cells] and biotinylation; (3) cell fractionation by sucrose gradient centrifugation; (4) immunoprecipitation and immunoblotting; (5) immunofluorescence and confocal microscopy; and (6) adenylyl cyclase assays. RESULTS: hD1Rs, heterologously expressed in HEK-293 cells, formed protein species with molecular mass ranging from 50 to 250 kD, and were localized in lipid rafts and nonraft plasma membranes. The hD1Rs cofractionated with caveolin-2, G protein subunits, and several signaling molecules. Both exogenously expressed hD1Rs and endogenously expressed rat D1Rs colocalized and coimmunoprecipitated with caveolin-2. A D1R agonist (fenoldopam) increased the amount of caveolin-2beta associated with hD1Rs and activated adenylyl cyclase to a greater extent in lipid rafts than in nonraft plasma membranes. Reduction in the expression of caveolin-2 with antisense oligonucleotides attenuated the stimulatory effect of fenoldopam on cyclic adenosine monophosphate (cAMP) accumulation. CONCLUSION: The majority of hD1Rs are distributed in lipid rafts. Heterologously and endogenously expressed D1Rs in renal cells are associated with and regulated by caveolin-2.