A telephone call reminder to improve outpatient attendance in patients referred from the emergency department: a randomised controlled trial

BACKGROUND

Poor compliance with attendance at outpatient clinic appointments in patients referred from emergency departments (EDs) is a major problem in public hospitals.

AIMS

To determine whether the intervention of a telephone call within three days of ED attendance would improve: 1. the proportion of patients making recommended outpatient appointments; and 2. the proportion of patients attending scheduled appointments. To characterise reasons for non-attendance at appointments made by patients referred from the ED.

METHODS

A randomised controlled trial was undertaken of 400 patients recommended to make outpatient appointments during attendance at The Royal Melbourne Hospital ED in July-August 1999.

INTERVENTION

a telephone call one to three days after attendance to remind the patient about the appointment (and its importance for medical follow-up) if one had been made and to offer to make an appointment if one had not been made.

OUTCOME MEASURES

1. making the recommended appointment; 2. attendance at the scheduled appointment; and 3. reasons for non-attendance at scheduled appointments.

RESULTS

The telephone intervention improved attendance at scheduled appointments from 54.4% to 70.7% (p=0.002). The proportion of patients making appointments was not significantly affected. The commonest reasons given for non-attendance were: attended general practitioner (13%), attended private specialist (6.6%), inpatient in hospital at time of appointment (6.6%), too busy or inconvenient (5.3%), claimed to have attended (5.3%) and did not differ by intervention.

CONCLUSIONS

A significant improvement in the proportion of patients attending outpatients appointments can be made by a simple reminder telephone call one to three days after attendance at the ED.

Peptoid-containing collagen mimetics with cell binding activity

Collagen mimetic peptides containing the peptoid residue Nleu (Goodman Bhumralkar, Jefferson, Kwak, Locardi. Biopolymers 1998;47:127-142) were tested for interactions with epithelial cells and fibroblasts. Molecules containing the sequence Gly-Pro-Nleu with a minimum of nine repeats showed cell binding activity. The activity of these molecules appeared to be conformationally sensitive, with the triple-helical form being preferred. When immobilized on a surface, the (Gly-Pro-Nleu)(10)-Gly-Pro-NH(2) sequence stimulated the attachment and growth of corneal epithelial cells and fibroblasts and the migration of epithelial tissue. The peptide sequence KDGEA inhibited cell attachment to the (Gly-Pro-Nleu)(10)-Gly-Pro-NH(2) sequence, suggesting that cell binding to this collagen mimetic involves the alpha2beta1 heterodimer integrin receptor. Interestingly, peptides containing the sequence (GlyNleu-Pro-)(10)-NH(2) did not have cell binding activity. The discovery that triple-helical peptides containing the Gly-Pro-Nleu sequences interact with cells opens up new opportunities in the design of collagen mimetic biomaterials.

Retrograde nailing for subtrochanteric femur fractures

This study reviews the results of subtrochanteric femur fractures treated with a retrograde nail at a level 1 trauma center. Sixteen patients with 17 fractures were followed up until union. The average Injury Severity Score (ISS) was 19, and average knee range of motion was 127 degrees. Four patients required dynamization of their nail, and three healed over a prolonged period of time. Two patients required exchange nailing: one after failure of union after dynamization and one with a broken nail that was revised to an antegrade nailing. The average varus deformity was 5.06 degrees and only 35% of fractures healed in greater than 5 degrees of varus, with an average time to union of 22.4 weeks (range, 6-54 weeks). Antegrade nailing remains the treatment of choice for the vast majority of subtrochanteric femur fractures. However, retrograde femoral nailing may be an effective treatment option for some subtrochanteric fractures in a selected group of patients.

Reflex responses induced by tooth unloading

The reflex response of the masseter muscle to the rapid unloading of a single maxillary incisor tooth was studied. Unloading of a static force of 2 N in the horizontal direction resulted in a short-latency excitation, inhibition, and long-latency excitation of masseter muscle activity occurring at latencies of approximately 13, 20, and 40 ms, respectively, with a corresponding change in bite force occurring slightly later in each case. Following the blocking of periodontal input by the injection of local anesthetic around the stimulated tooth, inhibitory responses were abolished. Therefore, it is concluded that the observed masseteric inhibition was caused by the unloading of periodontal mechanoreceptors and thus that these receptors may contribute to the jaw unloading reflex.

Genetic diversity at the FMR1 locus in the Indonesian population

We report an analysis of allelic diversity at short tandem repeat polymorphisms within the fragile XA locus in 1069 male volunteers from twelve Indonesian sub-populations. An odd numbered allele of DXS548 was found at high frequency in all Indonesian populations. Greater allelic diversity was identified at the loci under study than has been previously reported for an Asian population. These differences distinguish the Indonesian population from all previously reported Asian, European and African populations. A high frequency of small premutation alleles, 4/120 (3.3%, 95% CI 0.9-8.3%), was identified in the Moluccan population of Hiri Island.

General practitioners: their contact with maternal and child health nurses in postnatal care

OBJECTIVE

To assess the level of contact of general practitioners (GP) with maternal and child health nurses (MCHN) in postnatal care.

METHODOLOGY

A postal survey of 1104 Victorian GP was used, with a response rate of 70%. To account for the clustered sampling frame, hierarchical data analysis techniques were used.

RESULTS

Half of the GP (351/710) had no contact with their local MCHN in the previous month; and one in 10 had four or more contacts. Eighty-eight per cent of GP described the contact as helpful. In 56% of cases the MCHN was reported as the usual initiator of the contact. The most common reason for contact concerned the baby's physical problems (42%). After adjusting for the number of women seen for the routine 6-week postnatal review and other GP characteristics, male GP were as likely as female GP to report MCHN contact (odds ratio (OR) = 1.00; 95% confidence interval (CI) = 0.67-1.62). General practitioners aged 31-40 years were more likely to report contact with MCHN than GP aged 51-60 (OR = 0.45; 95% CI = 0.22-0.86) as were GP with the FRACGP qualification (OR = 1.64; 95% CI = 1.21-2.45).

CONCLUSIONS

This study provides baseline information on the level of GP contact with MCHN as they provide postnatal care. Although there were GP in Victoria who maintained a level of contact with MCHN, almost half reported no contact in the previous month. Most GP who reported contact with MCHN found it useful. This finding should encourage GP and MCHN coordination to improve continuity and postnatal care outcomes.

A membrane-bound Fas decoy receptor expressed by human thymocytes

Human thymocytes at several stages of maturation express Fas, yet resist apoptosis induction through its ligation. A proximal step in apoptotic signaling through Fas is implicated in this resistance, as these cells undergo normal levels of apoptosis induction after exposure to tumor necrosis factor-alpha. We studied the Fas receptors expressed in human thymocytes to search for mechanisms of receptor-mediated inhibition of Fas signaling in these cells. We describe here a unique, membrane-bound form of Fas receptor that contained a complete extracellular domain of Fas but that lacked a death domain due to alternative splicing of exon 7. This Fas decoy receptor (FDR) was shown to have nearly wild-type ability to bind native human Fas ligand and was expressed predominantly at the plasma membrane. Unlike soluble forms of Fas receptor, FDR dominantly inhibited apoptosis induction by Fas ligand in transfected human embryonic kidney cells. Titration of FDR in Fas-expressing cells suggests that FDR may operate through the formation of mixed receptor complexes. FDR also dominantly inhibited Fas-induced apoptosis in Jurkat T cells. In mixing experiments with wild-type Fas, FDR was capable of inhibiting death signaling at molar ratios less than 0.5, and this relative level of FDR:wild type message was observed in at least some thymocytes tested. The data suggest that Fas signal pathways in primary human cells may be regulated by expression of a membrane-bound decoy receptor, analogous to the regulation of tumor necrosis factor-related apoptosis inducing ligand (TRAIL)-induced apoptosis by decoy receptors.

A new anthropometric phantom for calibrating in vivo measurements of stable lead in the human leg using x-ray fluorescence

A new anthropometric phantom has been developed for calibrating in vivo measurements of stable lead deposited in bone using x-ray fluorescence. The phantom reproduces the shape of the mid shaft of the adult human leg and is fabricated using polyurethanes and calcium carbonate to produce materials that exhibit the same density, energy transmission, and calcium content as cortical bone, bone marrow, and muscle. The phantom includes a removable tibia fabricated using simulants for cortical bone and bone marrow to which a precise amount of stable lead has been added to cortical bone. The formulations used in fabricating the new anthropometric phantom are much more uniform in density and composition than the conventional phantom made from Plexiglas cylinders filled with plaster-of-Paris. The energy spectrum from an x-ray fluorescence measurement of the phantom using a 109Cd source is indistinguishable from an in vivo x-ray fluorescence measurement of the human leg, demonstrating that the materials used in the phantom exhibit the same radiological properties as human tissue. Likewise, results from x-ray fluorescence measurements of the phantom exhibit the same positional dependency as the human leg and vary by approximately 36% when, for example, the phantom containing 54 ppm of stable lead in the tibia was rotated by only 15 degrees. The detection limit for a 30 min 109Cd K shell x-ray fluorescence in vivo measurement is approximately 20 ppm determined from a background measurement using the new phantom containing no added lead in the muscle, bone, or bone marrow. The new anthropometric phantom significantly improves in vivo x-ray fluorescence calibration measurements by (1) faithfully reproducing the anatomy of the human leg, (2) having components that exhibit radiological properties similar to that of human tissue, and (3) providing a realistic calibration standard that can be used for in vivo x-ray fluorescence intercomparison measurements.

American Burn Association/Shriners Hospitals for Children burn outcomes questionnaire: construction and psychometric properties

To develop a standardized, practical, self-administered questionnaire to monitor pediatric patients with burns and to evaluate the effectiveness of comprehensive pediatric burn management treatments, a group of experts generated a set of items to measure relevant burn outcomes. Children between the ages of 5 and 18 years were assessed in a cross-sectional study. Both parent and adolescent responses were obtained from children 11 to 18 years old. The internal reliability of final scales ranged from 0.82 to 0.93 among parents and from 0.75 to 0.92 among adolescents. Mean differences between parent and adolescent were small; the greatest difference occurred in the appearance subscale. Parental scales showed evidence of validity and potential for sensitivity to change. In an effort to support the construct validity of the new scales, they were compared with the Child Health Questionnaire and related to each other in clinically sensible ways. These burn outcomes scales reliably and validly assess function in patients with burns, and the scales have been developed in such a way that they are likely to be sensitive to change over time.

A comparison of the plasma disappearance of iohexol and 99mTc-DTPA for the measurement of glomerular filtration rate (GFR) in diabetes

BACKGROUND

Changes in glomerular filtration rate (GFR) provide a valuable indicator of the progression of diabetic nephropathy. GFR is most commonly measured by the plasma clearance of radioisotopes, however, use of iohexol, a non-ionic radiocontrast medium, is a recently described alternative and has shown good agreement with inulin clearance. A one-compartment model is used for calculating GFR in most Australian centres but a two-compartment model is more accurate.

AIMS

To set up a non-radioisotopic method for assessment of GFR using iohexol, and to compare this with the currently used 99mTc-diethylene-triamine-penta-acetic acid (DTPA) method. Secondly, to compare GFR results using an unmodified one-compartment model with a one-compartment model subjected to the Brochner-Mortensen modification.

METHODS

Twenty-one patients with diabetes had assessment of GFR with simultaneous measurements of 99mTc-DTPA and iohexol plasma clearance. Plasma clearance was determined by the slope intercept method and then modified according to the Brochner-Mortensen equation. Plasma iohexol concentrations were determined by capillary electrophoresis.

RESULTS

There was no significant difference between iohexol and 99mTc-DTPA derived GFR values, difference 4.3+/-7.7 mL/minute (mean+/-SD). This was despite 99mTc-DTPA protein binding demonstrated in the range of 5-10%. Comparison of GFR results using an unmodified one-compartment model with a Brochner-Mortensen corrected one-compartment model showed higher GFR values with the former, in the range of 20-30% for GFR values > 100 mL/minute.

CONCLUSION

Iohexol provides an efficient alternative to radioisotopic methods for serial measurement of GFR in diabetic patients with hyperfiltration, incipient and overt nephropathy. A one-compartment model with its inherent overestimation of GFR should be replaced by the Brochner-Mortensen modified one-compartment model.

Immature human monocyte-derived dendritic cells migrate rapidly to draining lymph nodes after intradermal injection for melanoma immunotherapy

Injected antigen-loaded immature monocyte-derived dendritic cells (DCs) may be incapable of migrating from skin to draining lymph nodes for antigen presentation. The in vivo migratory capacity of intradermally administered immature monocyte-derived DCs was therefore investigated during a phase I/II clinical trial for metastatic melanoma. DCs cultured from adherent monocytes in the presence of autologous serum, granulocyte-macrophage colony stimulating factor and interleukin-4 were pulsed with antigen and labelled with technetium-99m hexamethylpropylene-amineoxime (99mTc-HMPAO) ex vivo, then injected intradermally. A 99mTc-HMPAO control containing an equivalent amount of radioactivity was injected into the opposite thigh. The pelvis was then imaged with a gamma camera. The DCs were characterized as immature by functional and phenotypic analysis. Labelled DCs travelled to the draining inguinal lymph nodes within 10 min, and the draining lymph nodes were clearly outlined up to 4 h after injection. Free NmTc outlined draining lymph nodes after 10 min but was cleared from the nodes within 1 h. Thus, immature human monocyte-derived DCs migrate rapidly to and remain in draining lymph nodes after intradermal injection for immunotherapy.

Fas is expressed early in human thymocyte development but does not transmit an apoptotic signal

We investigated the expression and function of Fas on human thymocytes prepared from fetal and pediatric tissue specimens and from SCID-hu Thy/Liv grafts. Unlike mouse thymocytes, human thymocytes exhibited a pattern of Fas expression skewed to immature cells, in that the highest expression was seen on double negative thymocytes and on intrathymic T progenitor cells. Fas expression was intermediate on double positive human thymocytes, and low or negative on mature single positive CD4 and CD8 medullary thymocytes. In spite of this relatively abundant surface expression, cross-linking of Fas with agonist mAb was incapable of triggering an apoptotic signal in human thymocytes. Apoptotic signaling was not enhanced by treatment with cycloheximide, nor by restoring a cosignaling milieu by addition of thymic stromal cells. Mouse thymocytes were induced to apoptosis by cross-linked recombinant soluble human Fas ligand both in vitro and in vivo, though human thymocytes were also resistant to this mode of receptor ligation. Membrane-bound Fas ligand also induced apoptotic death in murine thymocytes but not in human thymocytes. Human thymocytes were as sensitive as Jurkat cells, however, to apoptosis induced by TNF-alpha, suggesting that these cells have a signaling defect before activation of the earliest caspases. These data demonstrate a durable and specific resistance of human thymocytes to apoptosis induced through Fas receptor engagement, and reveal significant species-specific differences in the biology of thymocyte-programmed cell death.

Pediatric patients experiencing postoperative nausea and vomiting after burn reconstruction surgery: an analysis

Nausea and vomiting after a surgical procedure has a significant impact on a patient's hospital course. A perceived increased incidence of postoperative nausea and vomiting (PONV) in pediatric patients undergoing reconstructive scalp surgery had been clinically observed. A chart review to determine if a relationship existed between the surgical procedure and the incidence of PONV was conducted by selecting patients who were 5 to 12 years old and whose surgery fell between April 1995 and August 1995. Thirty-eight patients were evaluated for 46 procedures; 8 patients were evaluated for both insertion and removal of scalp expanders. No differences were identified between groups for previous history of PONV, length of anesthesia, or position during surgery. Data from the retrospective review suggested that pediatric patients with reconstructive surgeries of the scalp experienced PONV at 100% (24 procedures), whereas only 45% (10 procedures) of patients whose surgeries did not involve the scalp experienced PONV. In addition, despite significant earlier return of bowel sounds, episodes of PONV and time to oral intake were also increased in the group of patients whose operations involved the scalp. On the basis of these findings, a prospective study has been initiated to determine if changes in the perioperative protocol will improve patient outcomes and reduce the incidence of PONV.

Histopathologic evaluation of an expanded polytetrafluoroethylene-nitinol stent endoprosthesis in canine iliofemoral arteries

PURPOSE

The authors assess a new ePTFE-nitinol stent for its long-term patency, healing, and properties of endothelialization.

MATERIALS AND METHODS

Adult greyhounds (n = 18) underwent bilateral iliofemoral placement of an endoprosthesis (Hemobahn) consisting of a nitinol stent lined with an ultrathin expanded polytetrafluoroethylene (ePTFE) material. Histologic and quantitative morphometric analyses were performed on devices explanted at 2 weeks and 1, 3, 6, and 12 months. The source of endothelialization was examined in four additional devices modified by sealing either the proximal and distal ends or the entire graft with poly(tetrafluoroethylene-co-hexafluoropropylene) (FEP), a nonporous laminate to prevent potential transgraft endothelial cell migration.

RESULTS

Device patency assessed with both intravascular ultrasound and histologic study showed minimal arterial stenosis, irrespective of implant duration. The neointima at less than 3 months consisted of fibrin and inflammatory infiltrate; at later time points, it was composed of mostly smooth muscle cells. Flow surfaces were more than 75% endothelialized by 3 months, which was nearly complete by 6 months. Modified endoprostheses entirely enveloped with FEP resulted in endothelialization of only the proximal and distal ends; the middle regions showed nonocclusive thrombi. Conversely, devices wrapped proximally and distally showed nearly complete endothelialization.

CONCLUSIONS

This ePTFE-nitinol endoprosthesis demonstrated long-term patency at up to 1 year after implantation and showed early and nearly complete endothelialization by 6 months. The design promoted rapid endothelialization of flow surfaces, particularly in the midregion of the device possibly by transgraft migration.

The naming deficit in early Alzheimer's and vascular dementia

Patients with early Alzheimer's disease (AD) were compared to normal controls and patients with early vascular dementia (VaD) on their naming errors using the Boston Naming Test (H. Goodglass & E. Kaplan, 1983). All naming errors were classified into three general error categories: visuoperceptual, semantic, and phonemic. Semantic errors were further classified into coordinate errors (responses that belong to the same semantic category as the target words), superordinate errors (responses that belong to a broader semantic category than the target word), and functional-circumlocutory errors (circumlocutions and responses that functionally describe the target word). The findings indicated that AD participants display more overall naming errors than VaD participants, although the pattern of general errors was similar between the patient groups. However, the qualitative difference between the patient groups was observed within the semantic errors because the AD group made more superordinate errors.

Albumin-binding surfaces: synthesis and characterization

The nature of the proteinaceous film deposited on a biomaterial surface following implantation is a key determinant of the subsequent biological response. To achieve selectivity in the formation of this film, monoclonal antibodies have been coupled to a range of solid substrates using avidin-biotin technology. Antibody clones varied in their antigen-binding activity following insertion of biotin groups into lysine residues. Biotinylated antibodies coupled to solid substrates via an immobilized avidin bridge retained their biological activity. During immobilization of avidin a significant proportion of the protein molecules were passively adsorbed rather than covalently attached to the surface. This loosely bound material could be removed by stringent elution procedures which resulted in a surface density of 5.4 pmol avidin cm(-2). Although these conditions would be harsh enough to denature monoclonal antibodies, they did not destroy the biotin-binding activity of the residual surface-coupled avidin, enabling the subsequent immobilization of biotinylated antibodies. The two-step immobilization technique allowed the use of gentle protein modification procedures, reduced the risk of surface-induced denaturation and removed loosely bound material from the surface. The versatility of the technique encourages its application to a wide range of immobilization systems where retention of biological activity is a key requirement.

Albumin-binding surfaces: in vitro activity

Immobilized monoclonal antibodies (Mabs) have been used to attract specific molecules to a solid surface from complex mixtures such as blood, plasma or serum, thereby directing the response to the modified substrate, a key goal in rational biomaterial design. The nature of the Mab dictated the nature of the response: anti-albumin antibodies were used to prevent cell and platelet adhesion in vitro, whilst anti-fibronectin Mabs promoted attachment. Patterned surfaces could be formed, bearing Mabs that generated adhesive and non-adhesive regions. Fibrinogen adsorption from plasma showed a Vroman peak on unmodified control polymer, which was reduced by 64% in the presence of surface-bound anti-albumin Mab. Immobilization of a control Mab reduced fibrinogen adsorption only slightly, implying an albumin-mediated effect. In static tests, platelet adhesion from human platelet rich plasma was significantly reduced by the immobilization of anti-HSA Mab when compared to the untreated FEP surface (p < 0.0001). This effect was also seen with citrated blood flowing through Mab-treated polyurethane tubing at a shear rate of 132 s(-1) (p=0.034). Since platelets and proteins (as blood, plasma or serum) were introduced to the surface simultaneously, the generation of a defined protein film must have been sufficiently rapid as to shape the platelet or cell response.

Prevention of peripheral tolerance by a dendritic cell growth factor: flt3 ligand as an adjuvant

Injections of soluble proteins are poorly immunogenic, and often elicit antigen-specific tolerance. The mechanism of this phenomenon has been an enduring puzzle, but it has been speculated that tolerance induction may be due to antigen presentation by poorly stimulatory, resting B cells, which lack specific immunoglobulin receptors for the protein. In contrast, adjuvants, or infectious agents, which cause the release of proinflammatory cytokines such as tumor necrosis factor alpha and interleukin 1beta in vivo are believed to recruit and activate professional antigen-presenting cells to the site(s) of infection, thereby eliciting immunity. Here we show that administration of Flt3 ligand (FL), a cytokine capable of inducing large numbers of dendritic cells (DCs) in vivo, (a) dramatically enhances the sensitivity of antigen-specific B and T cell responses to systemic injection of a soluble protein, through a CD40-CD40 ligand-dependent mechanism; (b) influences the class of antibody produced; and (c) enables productive immune responses to otherwise tolerogenic protocols. These data support the hypothesis that the delicate balance between immunity and tolerance in vivo is pivotally controlled by DCs, and underscore the potential of FL as a vaccine adjuvant for immunotherapy in infectious disease and other clinical settings.

Thumb joint flexion. What is normal?

The purpose of this study was to measure the amount of active flexion from a neutral position in normal thumb metacarpophalangeal and interphalangeal joints and compare the results with previously published reports. One hundred and nineteen subjects (238 thumbs) volunteered to have active flexion of the metacarpophalangeal (MP) and interphalangeal (IP) joints of the thumb measured with a computerized Greenleaf goniometer by a certified hand therapist. The mean MP flexion was 59 degrees and IP flexion was 67 degrees. The results of this study suggest that the accepted normal values of thumb flexion should be reconsidered, particularly as a guide for determining impairment.

Unreliability of IgE/IgG4 antibody testing as a diagnostic tool in food intolerance

BACKGROUND

Some clinicians link chronic disease in certain patients to 'food intolerance'. This is currently diagnosed by exclusion dieting, a time-consuming and tedious technique. It has been claimed that IgE/IgG4 antibody testing is a rapid and valid method of determining food intolerance.

OBJECTIVE

To determine the test/retest reliability of IgE/IgG4 antibody testing as a diagnostic tool.

METHODS

Blinded testing of duplicate blood samples from nine patients with suspected food intolerance was undertaken by tertiary referral centre using the services of a commercial laboratory. The proportions of consistent and inconsistent results for tests of 95 different foods were analysed.

RESULTS

Test/retest reliability was low. Even though the study method systematically overestimated kappa, this value never exceeded 0.51, regardless of the statistical model used. All but one patient had a greater number of inconsistent results than had been prespecified as an unacceptable level of disagreement. In one case, 50 out of 95 test results were inconsistent on retest.

CONCLUSIONS

We found no evidence that IgE/IgG4 antibody testing as performed by this laboratory is a reliable diagnostic tool.

The naming deficit in early Alzheimer's and vascular dementia

Patients with early Alzheimer's disease (AD) were compared to normal controls and patients with early vascular dementia (VaD) on their naming errors using the Boston Naming Test (H. Goodglass & E. Kaplan, 1983). All naming errors were classified into three general error categories: visuoperceptual, semantic, and phonemic. Semantic errors were further classified into coordinate errors (responses that belong to the same semantic category as the target words), superordinate errors (responses that belong to a broader semantic category than the target word), and functional-circumlocutory errors (circumlocutions and responses that functionally describe the target word). The findings indicated that AD participants display more overall naming errors than VaD participants, although the pattern of general errors was similar between the patient groups. However, the qualitative difference between the patient groups was observed within the semantic errors because the AD group made more superordinate errors.