Virtual outreach: a randomised controlled trial and economic evaluation of joint teleconferenced medical consultations

OBJECTIVES

To test the hypotheses that virtual outreach would reduce offers of hospital follow-up appointments and reduce numbers of medical interventions and investigations, reduce numbers of contacts with the health care system, have a positive impact on patient satisfaction and enablement, and lead to improvements in patient health status. To perform an economic evaluation of virtual outreach.

DESIGN

A randomised controlled trial comparing joint teleconsultations between GPs, specialists and patients with standard outpatient referral. It was accompanied by an economic evaluation.

SETTING

The trial was centred on the Royal Free Hampstead NHS Trust, London, and the Royal Shrewsbury Hospital Trust in Shropshire. The project teams recruited and trained a total of 134 GPs from 29 practices and 20 consultant specialists.

PARTICIPANTS

In total, 3170 patients were referred, of whom 2094 consented to participate in the study and were eligible for inclusion. In all, 1051 patients were randomised to the virtual outreach group and 1043 to standard outpatient appointments. The patients were followed 6 months after their index consultation.

INTERVENTIONS

Patients randomised to virtual outreach underwent a joint teleconsultation, in which they attended the general practice surgery where they and their GP consulted with a hospital specialist via a videolink between the hospital and the practice.

MAIN OUTCOME MEASURES

Outcome measures included offers of follow-up outpatient appointments, numbers of tests, investigations, procedures, treatments and contacts with primary and secondary care, patient satisfaction (Ware Specific Visit Questionnaire), enablement (Patient Enablement Instrument) and quality of life (Short Form-12 and Child Health Questionnaire). An economic evaluation of the costs and consequences of the intervention was undertaken. Sensitivity analysis was used to test the robustness of the results.

RESULTS

Patients in the virtual outreach group were more likely to be offered a follow-up appointment. Significant differences in effects were observed between the two sites and across different specialities. Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ENT and orthopaedics than in the other specialities. Fewer tests and investigations were ordered in the virtual outreach group, by an average of 0.79 per patient. In the 6-month period following the index consultation, there were no significant differences overall in number of contacts with general practice, outpatient visits, accident and emergency contacts, inpatient stays, day surgery and inpatient procedures or prescriptions between the randomised groups. Tests of interaction indicated that virtual outreach decreased the number of tests and investigations, particularly in patients referred to gastroenterology, and increased the number of outpatient visits, particularly in those referred to orthopaedics. Patient satisfaction was greater after a virtual outreach consultation than after a standard outpatient consultation, with no heterogeneity between specialities or sites. However, patient enablement after the index consultation, and the physical and psychological scores of the Short Form-12 for adults and the scores on the Child Health Questionnaire for children under 16, did not differ between the randomised groups at 6 months' follow-up. NHS costs over 6 months were greater for the virtual outreach consultations than for conventional outpatients, pound 724 and pound 625 per patient, respectively. The index consultation accounted for this excess. Cost and time savings to patients were found. Estimated productivity losses were also less in the virtual outreach group.

CONCLUSIONS

Virtual outreach consultations result in significantly higher levels of patient satisfaction than standard outpatient appointments and lead to substantial reductions in numbers of tests and investigations, but they are variably associated with increased rates of offer of follow-up according to speciality and site. Changes in costs and technological advances may improve the relative position of virtual consultations in future. The extent to which virtual outreach is implemented will probably be dependent on factors such as patient demand, costs, and the attitudes of staff working in general practice and hospital settings. Further research could involve long-term follow-up of patients in the virtual outreach trial to determine downstream outcomes and costs; further study into the effectiveness and costs of virtual outreach used for follow-up appointments, rather than first-time referrals; and whether the costs of virtual outreach could be substantially reduced without adversely affecting the quality of the consultation if nurses or other members of the primary care team were to undertake the hosting of the joint teleconsultations in place of the GP. Qualitative work into the attitudes of the patients, GPs and hospital specialists would also be valuable.

Multicentre quality control study for detection of Mycobacterium tuberculosis in clinical samples by nucleic amplification methods

The aim of this study was to evaluate the laboratory performance of nucleic acid amplification tests (NATs) for detection of the Mycobacterium tuberculosis complex. A proficiency panel consisting of eight sputum specimens and four specimens diluted in phosphate-buffered saline (PBS) was sent to 82 laboratories in 23 countries by the Quality Control for Molecular Diagnostics (QCMD) TB programme. The performance of different NATs was analysed in combination with a questionnaire on the applied methods. Seventy-eight participants (95.2%) contributed a total of 85 evaluable data sets. The percentage of correct results on the eight sputum samples was 86.3% (586/679). Of the sputum specimens considered as 'smear-negatives' (650 CFU/250 micro L), only 61.2% (104/170) were reported positive. The percentage of correct results for the three scored PBS samples was 75.7% (193/255). The total number of false-positive results was 11 (4.3%); these were reported for seven (8.2%) of the 85 data sets. In 32 (37.6%) data sets an 'in-house' NAT method was used, and in 53 (62.4%) sets a commercial assay was tested. The percentage of data sets achieving correct results on all sputum samples was 35.3% and 37.8%, respectively. For the PBS samples this was 45.8% and 41.5%. Overall, the results of this study demonstrated that the performance of NATs for the detection of M. tuberculosis has improved since previous studies. The percentage of false-positives has decreased considerably. However, a large number of procedures still lack sufficient sensitivity for application to smear-negative samples.

DOWN YOUR DRINK: A WEB-BASED INTERVENTION FOR PEOPLE WITH EXCESSIVE ALCOHOL CONSUMPTION

AIMS

To conduct a pilot study of the usefulness of Down Your Drink (DYD), a web-based intervention to encourage excessive drinkers to adopt a healthy pattern of drinking and reduce alcohol-associated harm. The DYD website was structured as a 6-week programme, derived from a manual which included elements of motivational approaches and cognitive behavioural therapy.

METHODS

Visitors whose responses to the Fast Alcohol Screening Test were positive, and those indicating excessive alcohol consumption, were encouraged to register. Users completed alcohol dependence and mental health questionnaires before the programme, and a drinking diary at each of the weekly sessions. Follow-up questionnaires were sent electronically to those who completed the programme, or who missed three or more sessions.

RESULTS

During the 6-month study there were 7581 visits to the site and 1319 registrations. Of the registrants, 61.8% completed week 1, and 6.0% stayed with the programme until the end. The 6% who stayed for 6 weeks provided encouraging feedback about the value of the site. Little information was obtained from those who dropped out, but some reported that the programme was too time-consuming.

CONCLUSIONS

Web site interventions for excessive drinkers are feasible and merit evaluation of their effectiveness.

Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion

OBJECTIVES

To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.

DESIGN

Cost consequences study alongside randomised controlled trial.

SETTING

Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.

PARTICIPANTS

3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.

MAIN OUTCOME MEASURES

NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.

RESULTS

Overall six months costs were greater for the virtual outreach consultations ( pound 724 per patient) than for conventional outpatient appointments ( pound 625): difference in means pound 99 ($162; 138) (95% confidence interval pound 10 to pound 187, P=0.03). If the analysis is restricted to resource items deemed "attributable" to the index consultation, six month costs were still greater for virtual outreach: difference in means pound 108 ( pound 73 to pound 142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost pound 8 ( pound 5 to pound 10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost pound 11 ( pound 10 to pound 12, P < 0.0001).

CONCLUSION

The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.

An exploratory study of language interpretation services provided by videoconferencing

We explored the feasibility and acceptability of the remote provision of a language interpretation service during general practice consultations. Three methods were used to provide an interpretation service: a physically present interpreter (PI), a remote interpreter accessed using an ISDN videoconferencing link at 128 kbit/s (VI) and a remote interpreter accessed by telephone (TI). Thirty-six non-English-speaking patients were invited to take part and 35 agreed to do so. Twenty-nine (83%) of the patients recruited were female. The age range of the participants was 24-51 years. Fourteen consultations took place with a physically present interpreter, 11 using videoconferencing and 10 using the telephone. Mean scores on the Patient Enablement Instrument were 5.2 for the PI group, 2.3 for the VI group and 5.1 for the TI group. Mean scores on the Medical Interview Satisfaction Scale were 5.3 for the PI group, 4.9 for the VI group and 5.3 for the TI group. The visual quality and sound quality of remote interpreting were satisfactory. Both videoconferencing and hands-free telephones can deliver an acceptable interpreting service in primary care.

Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

BACKGROUND

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

METHODS

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

FINDINGS

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1.52 [95% CI 1.27-1.82], p<0.0001). Significant differences in effects were observed between the two sites (p=0.009) and across different specialties (p<0.0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0.79 per patient (0.37-1.21, p=0.0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0.33 scale points [95% CI 0.23-0.43], p<0.0001), with no heterogeneity between specialties or sites.

INTERPRETATION

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Selective inhibition of thapsigargin-induced contraction and capacitative calcium entry in mouse anococcygeus by trifluoromethylphenylimidazole (TRIM)

This study examined the effects of trifluoromethylphenylimidazole (TRIM) on tone, and calcium entry, in mouse anococcygeus stimulated by either thapsigargin (Tg; 100 nM) which activates capacitative calcium entry (CCE), or high K (60 mM) which activates voltage-operated calcium channels. TRIM (1 - 333 microM) produced concentration-related relaxation of Tg-induced tone (EC(50), 42 microM) but was much less effective against high K. In single smooth muscle cells loaded with FURA-2, TRIM reduced the increase in fluorescence ratio produced by Tg but had no effect on that produced by high K. The relaxations of Tg-induced tone, and reduction in fluorescence ratio, were obtained in the presence of L-N(G)-nitroarginine and were thus independent of nitric oxide synthase inhibition; further, TRIM had no discernible effect on nitrergic responses. TRIM provides a novel drug for the selective inhibition of CCE and a template for the development of more potent inhibitors.

General practitioner participants in a telemedicine trial: comparisons with their peers

A study was conducted to determine whether general practitioners (GPs) participating in a telemedicine trial were self-selected enthusiasts for information technology compared with GPs in general. We compared two experimental groups of GPs in London and Wales (n = 126) who had volunteered to participate in a telemedicine trial and two randomly selected groups of GPs from the same areas (total n = 300) who acted as controls. A postal questionnaire was used and achieved a 79% response rate. There were no significant differences in the demographic characteristics of the experimental and control groups in London and Wales, except that the London telemedicine GPs (mean age 41.9 years) were significantly younger than the London controls (mean age 46.6 years). The control GPs were similar to the telemedicine GPs in terms of frequency of computer use and their responses to statements about their attitudes to computers. In the combined telemedicine and control groups, 85% and 77% respectively said that they enjoyed using computers. Telemedicine GPs used computers more frequently for administrative purposes but they shared the same attitudes towards information technology as GPs in general. In all situations where GPs could exercise personal choice, the control and experimental groups were similar.

Improving palliative care through effective communication

Effective communication in palliative care is instrumental in the development of the therapeutic relationship that should exist between patients and nurses, and the importance of it is well recognized by nurses working in this specialist practice area. This article examines the reason behind the need for effective communication, identifies systems of communication and explores the influence and value of contemporary communication theories and models in palliative care. It recommends that palliative care nurses develop a framework that will facilitate and give structure to the interview process with the aim of alleviating anxieties, encouraging situational control and promoting quality of life for patients.

CeMENT: evaluation of a regional development programme integrating hospital and general practice clinical teaching for medical undergraduates. The Community-Based Medical Education in North Thames

OBJECTIVES

To determine the feasibility and effectiveness of shared hospital and general practice clinical teaching for medical undergraduates.

DESIGN

A multifaceted approach employing quantitative and qualitative techniques.

SETTING

All medical schools in North Thames Region.

SUBJECTS

Students, GP tutors and hospital specialists.

RESULTS

The model was successfully adopted in a broad range of clinical specialties in all of the participating medical schools, resulting in a doubling of the involvement of general practice in clinical teaching. Participating students provided an overwhelmingly positive evaluation of the attachments and there was a clear perception of benefit amongst the participating GPs. However, the views of the participating hospital clinicians were less positive and the true nature and extent of the educational impact proved difficult to assess.

CONCLUSIONS

This model of collaborative clinical teaching between hospital and general practice can be implemented in accordance with the project's key aims, but the enthusiastic involvement of hospital clinicians may be difficult to secure.

Phase I pilot trial of the bispecific antibody MDXH210 (anti-Fc gamma RI X anti-HER-2/neu) in patients whose prostate cancer overexpresses HER-2/neu

The goal of this study was to evaluate, in patients with prostate cancer, the toxicity profile and biologic activity of the bispecific antibody MDXH210, which has specificity for the non-ligand-binding site of the high-affinity immunoglobulin G receptor (Fc gamma RI) and the extracellular domain of the HER-2/neu proto-oncogene product. Patients with prostate cancer that expressed HER-2/neu were entered into a phase I dose-escalation trial of MDXH210. Patients received an intravenous infusion MDXH210 during a period of 2 h three times per week for 2 weeks and were monitored for toxicity. Pharmacokinetic and pharmacodynamic parameters were measured and included the biologic end points of monocyte-bound MDXH210, cytokine production, and clinical response. Seven patients were treated with MDXH210 doses ranging from 1 to 8 mg/m2. In general, MDXH210 was well tolerated, with only mild infusion-related malaise, fever, chills, and myalgias. No dose-limiting toxic effects were observed. Biologic effects included induction of low plasma concentrations of tumor necrosis factor-alpha and interleukin-6 observed immediately after MDXH210 infusion and 70% saturation of circulating monocyte-associated Fc gamma RI with MDXH210 at a dose level of 4 to 8 mg/m2. Five of six patients had stable prostate-specific antigen levels during the course of 40 days or more. Circulating plasma HER-2/neu levels decreased by 80% at days 12 and 29 (p = 0.03 and 0.06, respectively, by the Wilcoxon signed rank test). MDXH210 can be given safely to patients with HER-2/neu-positive prostate cancer in doses of at least 8 mg/m2. At the doses studied, biologic activity was demonstrated and characterized by binding of MDXH210 to circulating monocytes, release of monocyte-derived cytokines, a decrease in circulating HER-2/neu, and short-term stabilization of prostate-specific antigen levels.

Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial

BACKGROUND

Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care.

AIM

To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care.

DESIGN OF STUDY

Randomised trial with parallel group design.

SETTING

Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas.

METHOD

Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients' satisfaction with care.

RESULTS

One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al's standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months' follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups.

CONCLUSION

Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.

Chronic fatigue in general practice: economic evaluation of counselling versus cognitive behaviour therapy

BACKGROUND

There is a paucity of evidence relating to the cost-effectiveness of alternative treatment responses to chronic fatigue.

AIM

To compare the relative costs and outcomes of counselling versus cognitive behaviour therapy (CBT) provided in primary care settings for the treatment of fatigue.

DESIGN OF STUDY

A randomised controlled trial incorporating a cost-consequences analysis.

SETTING

One hundred and twenty-nine patients from 10 general practices across London and the South Thames region who had experienced symptoms of fatigue for at least three months.

METHOD

An economic analysis was performed to measure costs of therapy, other use of health services, informal care-giving, and lost employment. The principal outcome measure was the Fatigue Questionnaire; secondary measures were the Hospital Anxiety and Depression Scale and a social adjustment scale.

RESULTS

Although the mean cost of treatment was higher for the CBT group (164 Pounds, standard deviation = 67) than the counselling group (109 Pounds, SD = 49; 95% confidence interval = 35 to 76, P < 0.001), a comparison of change scores between baseline and six-month assessment revealed no statistically significant differences between the two groups in terms of aggregate health care costs, patient and family costs or incremental cost-effectiveness (cost per unit of improvement on the fatigue score).

CONCLUSIONS

Counselling and CBT both led to improvements in fatigue and related symptoms, while slightly reducing informal care and lost productivity costs. Counselling represents a less costly (and more widely available) intervention but no overall cost-effectiveness advantage was found for either form of therapy.

Is participation in research as an investigator an effective form of continuing medical education?

Continuing medical education and research are a daily necessity for general practitioners (GPs). This study investigated the possibility that participation in research is an effective form of continuing medical education. Although there was an indication that some modification of GPs' knowledge and skills had occurred, it was not possible to conclude that this was entirely due to participation in research.

Virtual outreach: a telemedicine pilot study using a cluster-randomized controlled design

A pilot study was carried out in preparation for a full-scale randomized controlled trial of teleconsultations versus routine outpatient consultation. The method of study recruited sufficient numbers of patients and avoided selection bias. Over five months, 439 referrals were received, but 297 patients were not eligible to enter the trial because they did not fall within the specialties/consultants included in it. Of the 132 referrals entering the trial, 62 were randomized to the intervention group and 70 to the control group. Consent to participate in the experimental arm of the trial was obtained for all but 13 patients. The results also suggested that patient satisfaction with teleconsultation may exceed that with conventional outpatient consultation, with a strong indication of overall time savings for patients.

Up-regulation of novel intermediate filament proteins in primary fiber cells: an indicator of all vertebrate lens fiber differentiation?

The early embryonic development and expression patterns of the eye lens specific cytoskeletal proteins, CP49 and CP95, were determined for the chick and were found to be similar in both human and mouse. These proteins, as well as their homologs in other species, are obligate polymerization partners which form unique filamentous structures termed "beaded filaments." CP49 and CP95 appeared as protein products after 3 days of embryonic development in the chick during the elongation of primary fiber cells. Although limited data were obtained for human embryos at these early developmental timepoints, they were consistent with the interpretation that the up-regulation of these lens specific proteins began only after the initiation of lens vesicle closure. In situ hybridization with the mouse lens confirmed that message levels for beaded filament proteins were greatly elevated in differentiating primary fiber cells. Nuclease protection assays established that mRNA levels for CP49 remained relatively constant while CP95 mRNA levels increased once the process of secondary fiber formation was under way. Although present in relatively low abundance, the mRNA for a unique splice variant of CP49, CP49(INS), was also detected early in embryonic development and into adulthood. Peptide-specific antibodies directed against unique predicted sequences were able to confirm the protein expression of CP49(INS) in both embryonic and adult chick lens cells. These data present the first detailed study of the expression of CP49 and CP95 during early lens development. They suggest that the up-regulated expression of CP49 and CP95 could serve as pan-specific markers for all vertebrate lens fiber development.

Anesthesia in the oral and maxillofacial surgery office: past, present and future

In this day and age, the fear of not "waking up" from a general anesthetic has little basis in fact. Serious complications almost never occur in the absence of a preexisting medical problem. By virtue of extensive training, proper patient selection, vigilant monitoring, and judicious use anesthetic agents, the oral and maxillofacial surgeon continues to provide a very high level of anesthetic care. Besides being safe, it is also very cost effective. The surgical removal of four impacted third molars in the office costs four to five times less than a similar procedure in the typical ambulatory surgery unit. Thus, it would appear that the oral surgeon's expertise in delivering office anesthesia not only predates the current popularity of ambulatory surgery, but may well have been the pioneering model from which it arose.

Thapsigargin-induced tone and capacitative calcium influx in mouse anococcygeus smooth muscle cells

The sarcoplasmic reticulum Ca-ATPase inhibitor thapsigargin (Tg; 0.4-100 nM) produced concentration-related, strong and sustained contractions of the mouse-isolated anococcygeus muscle; these contractions were dependent on extracellular calcium but were only partially reduced (by about 50%) in the presence of verapamil (10 and 100 microM). The verapamil-resistant component of the Tg-induced contraction was relaxed by the general calcium entry blockers SKF96365 (0.4-40 microM) and cadmium (50-300 microM), and by the tyrosine kinase inhibitor genistein (10-180 microM). In single smooth muscle cells loaded with Fura-2, addition of Tg (100 nM) to calcium-free medium produced a small, transient increase in fluorescence; subsequent addition of calcium (2.5 mM) produced a larger and sustained increase which was abolished on return to calcium-free conditions, but was only partially reduced by verapamil (10 microM; by about 30%). Manganese quenching of Fura-2 was enhanced in cells treated with Tg. The verapamil-resistant calcium influx was reduced by SKF96365 (20 microM) and to a lesser extent by genistein (40 microM); cadmium (200 microM) produced an initial decrease in fluorescence followed by a marked increase. These results demonstrate that, in the mouse anococcygeus, Tg can cause sustained contractions and elevations of calcium influx in the presence of verapamil; the time-course, calcium dependence and, although to a lesser extent, pharmacology of these effects generally support the proposal that excitation-contraction coupling in this tonic smooth muscle involves sustained capacitative calcium influx.

Correlation between store-operated cation current and capacitative Ca2+ influx in smooth muscle cells from mouse anococcygeus

In mouse anococcygeus cells, simultaneous measurements of membrane currents and changes in intracellular Ca2+ were obtained using "perforated-patch" whole-cell recordings and Fura-2 microfluorimetry. Carbachol (50 microM) and cyclopiazonic acid (10 microM) produced a biphasic inward current; a transient Ca2+-dependent chloride current (I(ClCa)), followed by a smaller, sustained current (I(DOC)) This response was mirrored by a biphasic increase in the intracellular Ca2+ concentration. SKF96365 (1-{beta-[3-(4-methoxyphenyl) propoxyl]-4-methoxyphenethyl}-1H-imidazole; 10 microM) and Cd2+ (100 microM) inhibited both I(DOC) and the sustained increase in intracellular Ca2+; La3+ (400 microM) inhibited neither response. The results confirm that the non-selective cation current I(DOC) underlies capacitative Ca2+ influx supporting sustained contractions in this tonic smooth muscle.

The eye lens cytoskeleton

During lens cell differentiation there are a number of very characteristic morphological changes that occur. These include a 50- to 100-fold increase in cell length as the equatorial lens epithelial cells differentiate into fibre cells and the loss of the cellular organelles such as mitochondria, nuclei, Golgi apparatus and endoplasmic reticulum. Coincident with these changes are dramatic alterations in the organisation of the lens fibre cell cytoskeleton and in particular the lens-specific intermediate filament network comprising CP49 and filensin. Cell shape and cell polarisation as well as tissue integrity are all processes that depend upon the cytoskeleton and are therefore important to the lens. The unique aspects of the lenticular cytoskeleton are the subject of this review.

A study of 9-nitrocamptothecin (RFS-2000) in patients with advanced pancreatic cancer

This ongoing study evaluates the efficacy of oral 9-nitrocamptothecin (9NC), or RFS-2000, in the treatment of advanced pancreatic cancer. Patients received 9NC orally for 5 days/week; 8 weeks of therapy is required to achieve minimum effective dose. Starting dose was 1.5 mg/m2/day, with adjustments made as necessary. Patients were analyzed for changes in tumor size by CT scan, changes in serum CA 19-9 tumor marker levels, quality of life, and survival. 107 consecutive patients with advanced adenocarcinoma of the pancreas were enrolled before November 3, 1997. Of this group, 47 patients did not receive the minimum 2 courses of treatment necessary to induce response, leaving 60 evaluable patients. Primary dose-limiting toxicities were myelosuppression and interstitial cystitis. No deaths were attributed to 9NC. Median survival was 6.5 months for the 107 total patients and 8.7 months for the 60 evaluable patients, with one patient surviving at 44+ months. Of the 60 evaluable patients, 31.7% were responders (median survival 18.6 months; range 6.5-44.7+ months), 31.7% were stable (median survival 9.7 months), and 36.6% were non-responders (median survival 6.8 months). Fifty-seven previously untreated patients had a median survival of 7.3 months compared to 4.7 months for the 50 previously treated patients. Thirty-three patients who failed gemcitabine therapy prior to 9NC treatment had a median survival of 4.7 months. 9NC is safe and efficacious as first-line therapy for the treatment of advanced pancreatic cancer. It also shows some modest success as second-line therapy in treating gemcitabine failures.

Embedding guidelines into direct physician order entry: simple methods, powerful results

Kaiser Permanente in the Northwest Region has implemented a comprehensive outpatient computer-based patient record (CPR). Using this system, clinicians electronically order laboratory tests, radiology tests, and prescriptions. Clinicians also use this comprehensive CPR to document encounters, code diagnoses and procedures, maintain problem lists, and to send patient-specific messages and referrals to other medical providers. Healthcare for our entire membership of 440,000 covered lives is now provided through this system [1]. Implementation of a comprehensive CPR with direct physician order-entry provides the opportunity to embed guidelines into the ordering process. This article describes the underlying theme and various simple but effective methods we use to embed guidelines into the ordering process. Our experience demonstrates the powerful effect of these simple methods to reduce unnecessary variation and to reduce cost while maintaining or improving the quality of care delivery.