Why Do Patients not Keep their Appointments? Prospective Study in a Gastroenterology Outpatient Clinic

Unkept outpatient appointments are a drain on resources. In a prospective study we asked non-attenders at a gastroenterology clinic why they had missed their appointment.

103 patients missed their appointment (14% of the total invited); 3 had died. The remaining 100 were asked to complete questionnaires, 68 by mail (43 returned) and 32 by telephone (30 successful); the response rate was thus 73%. 49 of the respondents were new patients, 6 of them with urgent referrals. The explanations for non-attendance by the 73 patients were: forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments. The non-attendance rates for different clinics ranged from 10% to 25% (average 14%).

A substantial number of non-attenders claimed to have forgotten their appointment or to cancel it. If, as we surmise, this reflects apathy, no strategy to improve attendance is likely to have great impact. Since the non-attendance rate is reasonably constant, it can be taken into account when patients are booked.

Mixed Micellar Systems of n-Alkyl-β-D Glucopyranosides with Hexadecyl Cationic Surfactants

Critical micelle concentrations (cmc) were obtained from tensiometric method on binary mixtures of decyl and dodecyl glucopyranoside nonionic surfactants with hexadecyl-triphenyl and tributyl phosphonium bromide and trimethylammonium bromide surfactants in aqueous media. The cmc data have been analysed in the context of pseudophase separation model. The interaction parameter (b) determined by using the regular solution theory (RST) was found to be negative and composition dependent. The values of interaction parameters were found to be more negative for C10 glucopyranoside mixtures. Employing Maeda's Theory, the chain/chain contribution parameter B1 was obtained and related to the Gibbs free energy of mixed micelle formation. Thermodynamics of adsorption, surface excess and minimum area occupied by surfactant molecules were also evaluated.

Metabolism of [14C]-5-chloro-1,3-benzodioxol-4-amine in male Wistar-derived rats following intraperitoneal administration

[14C]-5-chloro-1,3-benzodioxol-4-amine was administered intraperitoneally (i.p.) to bile duct-cannulated rats (Alpk:ApfSD, Wistar derived) at 25 mg kg-1 to determine the rates and routes of excretion of the compound and to investigate its metabolic fate. A total of 89.1% of the dose was excreted in the 48 h following administration, the majority being recovered in the urine during the first 12 h. The main metabolite in both urine and bile, detected by high-performance liquid chromatography (HPLC) with radioprofiling and mass spectrometry, was identified as a demethylenated monosulfate conjugate. Unchanged parent compound formed a major component of the radiolabel excreted in urine and, in addition to unchanged parent and demethylenated sulphate conjugate, a large number of minor metabolites were detected in urine and bile. The overall metabolic fate of 5-chloro-1,3-benzodioxol-4-amine in the rat was complex, with some similarities to previously studied methylenedioxyphenyl compounds.

An audit to evaluate the accessibility, cost, impact on work place absence and convenience of attending genitourinary medicine clinics in London and Plymouth

We conducted a survey to assess the accessibility, cost, impact on work place absence and convenience of attending two genitourinary medicine (GUM) clinics, one in London and one in Plymouth. Nine hundred and fifty-eight questionnaires were collected for analysis (448 from London [L] and 510 from Plymouth [P]). The majority in London used public transport whereas the majority in Plymouth used private transport. Journey costs were less than 5 for the majority (75% L and 59% P). Of those in employment 229/678 (44%) had to take time off from work to attend. Women were significantly less likely (13/308, 4%, 95% confidence interval (CI) 2-6.5%) than men (51/370, 14% 95% [CI] 10.317.3%) to give up annual leave to attend. Both clinics were judged accessible, affordable and convenient by the majority of clinic users.

Application of (1)H- and (19)F-NMR spectroscopy in the investigation of the urinary and biliary excretion of 3,5-, 2,4-ditrifluoromethylbenzoic and pentafluorobenzoic acids in rat

1. The metabolism and excretion of 2,4-, 3,5-ditrifluoromethyl- and pentafluorobenzoic acids were studied in the bile-cannulated rat using (1)H- and (19)F-NMR spectroscopy following intraperitoneal administration at 50 mg kg(-1). 2. Pentafluorobenzoic acid was excreted in the urine entirely unchanged. No detectable compound or metabolites were eliminated in the bile. A total of 63.5 +/- 6.7% of the dose was recovered in the 24-h collection period. 3. In the case of 2,4-ditrifluromethyl benzoic acid, 83.9 +/- 5.2% of the dose was recovered in the 24h after administration, with about 52% being excreted in the urine and 32% in the bile. The majority of the material present in the urine was unchanged parent compound. In bile, some 60% of the compound-related material excreted was present as transacylated ester glucuronide conjugates. 4. For 3,5-ditrifluoromethylbenzoic acid, 49.6 +/- 5.3% of the dose was recovered in the 24-h collection period, with about 22% being excreted in the urine and 28% in the bile. The material excreted in both the urine and bile was a mixture of the parent acid and transacylated ester glucuronides. 5. Urinary excretion in bile-cannulated animals was similar to that found in studies using non-cannulated animals dosed at 100mg kg(-1).

Why do patients not keep their appointments? Prospective study in a gastroenterology outpatient clinic

Unkept outpatient appointments are a drain on resources. In a prospective study we asked non-attenders at a gastroenterology clinic why they had missed their appointment. 103 patients missed their appointment (14% of the total invited); 3 had died. The remaining 100 were asked to complete questionnaires, 68 by mail (43 returned) and 32 by telephone (30 successful); the response rate was thus 73%. 49 of the respondents were new patients, 6 of them with urgent referrals. The explanations for non-attendance by the 73 patients were: forgot to attend or to cancel (30%); no reason (26%); clerical errors (10%); felt better (8%), fearful of being seen by junior doctor (3%); inpatient in another hospital (3%); miscellaneous other (20%). 13 (27%) of the review patients had not kept one or more previous appointments. The non-attendance rates for different clinics ranged from 10% to 25% (average 14%). A substantial number of non-attenders claimed to have forgotten their appointment or to cancel it. If, as we surmise, this reflects apathy, no strategy to improve attendance is likely to have great impact. Since the non-attendance rate is reasonably constant, it can be taken into account when patients are booked.

Increased responses of glucagon and glucose production to hypoglycemia with intraperitoneal versus subcutaneous insulin treatment

The study aim was to investigate the effect of the route of insulin treatment on the glucagon and glucose production (GP) responses to hypoglycemia in the diabetic rat. Experiments were performed in 4 groups of rats: (1) streptozotocin (STZ)-induced diabetic, untreated (D, n = 7), (2) diabetic treated with subcutaneous insulin (DSC, n = 8), (3) diabetic treated with intraperitoneal insulin (DIP, n = 6), and (4) normal control (N, n = 10). Slow-release insulin implants were used in DSC and DIP rats for 10 to 14 days (3 U/d). A hyperinsulinemic (120 pmol x kg(-1) x min(-1) insulin)-hypoglycemic (glycemia = 2.5 +/- 0.1 mmol/L) clamp following an isoglycemic basal period was performed in 5-hour fasted rats. Basal plasma glucose was normalized in both DSC and DIP rats; however, in DSC but not DIP rats, glucose normalization required peripheral hyperinsulinemia. Tracer-determined GP, which was elevated in D rats, was completely normalized in DIP but only partially corrected in DSC rats. Basal glucagon levels were similar in all groups. During hypoglycemia, GP was suppressed in D rats (delta, -28.9 +/- 5.0 micromol x kg(-1) x min(-1), moderately increased in DSC rats (delta, 6.1 +/- 5.6, P < .01 v D), but markedly increased in DIP and N rats (delta, 34.5 +/- 4.5 for DIP and 16.8 +/- 2.8 for N; P < .01 vD, P < .05 for DIP v DSC or N). Plasma glucagon increased 6-fold in N (945 +/- 129 pg/mL), only doubled in D (424 +/- 54), and tripled in DSC (588 +/- 83), but increased 5-fold in DIP rats (1,031 +/- 75, P < .05 v D and DSC). We conclude that in STZ-diabetic rats, (1) intraperitoneal but not subcutaneous insulin treatment normalizes basal GP, and (2) intraperitoneal insulin treatment as compared with subcutaneous treatment alleviates peripheral hyperinsulinemia and results in increased glucagon and GP responses to hypoglycemia.

Changes in rat muscle with compensatory overload occur in a sequential manner

The present study was initiated to determine the time course of changes in the profile of selected skeletal muscle myofibril proteins during compensatory overload. Whole muscle isometric contractile properties were measured to assess the physiological consequences of the overload stimulus. Compensatory overload of plantaris muscle of rats was induced by surgical ablation of the synergistic soleus and gastrocnemius muscles. Myosin light chain (LC) and tropomyosin (TM) compositions of control (CP) and overloaded plantaris (OP) muscles were determined by electrophoresis and myofibrillar ATPase assays were performed to assess changes in contractile protein interactions. Within one week of overload decreases in the alpha:beta TM ratio and myofibrillar ATPase activity were observed. Following 30 days of overload, a transition in type II to type I fibres was associated with an increase in slow myosin LC1. Interestingly, after 77 days of overload, the TM subunit ratio returned to one resembling a fast twitch muscle. It is proposed that the early and transitory changes in the TM subunits of OP, as well as the rapid initial depression in maximum tetanic isometric force and myofibrillar ATPase activity may be explained as a result of muscle fibre degeneration-regeneration. We propose that alterations in protein expression induced by compensatory overload reflect both degenerative-regenerative change and increased neuromuscular activity.

Pancreatic abnormalities and AIDS related sclerosing cholangitis

OBJECTIVES

Biliary tract abnormalities are well recognised in AIDS, most frequently related to opportunistic infection with Cryptosporidium, Microsporidium, and cytomegalovirus. We noted a high frequency of pancreatic abnormalities associated with biliary tract disease. To define these further we reviewed the clinical and radiological features in these patients.

METHODS

Notes and radiographs were available from two centres for 83 HIV positive patients who had undergone endoscopic retrograde cholangiopancreatography for the investigation of cholestatic liver function tests or abdominal pain.

RESULTS

56 patients had AIDS related sclerosing cholangitis (ARSC); 86% of these patients had epigastric or right upper quadrant pain and 52% had hepatomegaly. Of the patients with ARSC, 10 had papillary stenosis alone, 11 had intra- and extrahepatic sclerosing cholangitis alone, and 35 had a combination of the two. Ampullary biopsies performed in 24 patients confirmed an opportunistic infection in 16. In 15 patients, intraluminal polyps were noted on the cholangiogram. Pancreatograms were available in 34 of the 45 patients with papillary stenosis, in which 29 (81%) had associated pancreatic duct dilatation, often with associated features of chronic pancreatitis. In the remaining 27 patients, final diagnoses included drug induced liver disease, acalculous cholecystitis, gall bladder empyema, chronic B virus hepatitis, and alcoholic liver disease.

CONCLUSION

Pancreatic abnormalities are commonly seen with ARSC and may be responsible for some of the pain not relieved by biliary sphincterotomy. The most frequent radiographic biliary abnormality is papillary stenosis combined with ductal sclerosis.

Use of high dose benzodiazepines in alcohol and sedative withdrawal delirium

The authors describe two patients who required massive doses of benzodiazepines to treat complicated alcohol and sedative withdrawal delirium. Some of the factors that contribute to difficulties in management are discussed. Finally, we describe the advantages and disadvantages of high dose pharmacologic management and controversies regarding psychopharmacologic management of such complex patients.

Consultations for 'maladaptive denial of illness' in patients with cancer: psychiatric disorders that result in noncompliance

Patients who present with late stages of cancer often have complicated medical and psychiatric problems which are labeled as 'maladaptive delay or denial.' In some of these patients, psychiatric problems have either contributed to the delay in medical presentation for care or have interfered with treatment of the late stage cancer. The authors review some of the factors that contributed to delay and noncompliance in a series of patients with cancer who were evaluated by the psychiatric consultation service of a university hospital. Specifically, psychoses and cognitive impairment played a major role in delay and noncompliance. The authors discuss recommendations for management of such patients, and suggest that clinicians often benefit from the assistance of the psychiatric consultant as part of the treatment team. Multiple resources and multiple types of intervention are needed in order to help such patients negotiate the clinical environment.

Pain and disability in families of chronic noncancer pain patients

The authors conducted a cross-sectional study to determine the prevalence of chronic noncancer pain or disability in first-degree relatives of patients who had sustained a physically traumatic injury with resultant chronic pain. A control group of general internal medicine patients was also interviewed about existence in their family of chronic pain or of disability, either pain-related or related to nonpainful chronic illness. None of the control patients were themselves experiencing acute or chronic pain. There was no statistically significant difference between the two groups in the prevalence of chronic pain or disability in family members. The study's findings suggest that chronic noncancer pain patients should not be viewed as a uniform group with regard to learned behaviors and/or familial aggregation.

Necropsy findings in lysinuric protein intolerance

Lysinuric protein intolerance (LPI) is a rare autosomal recessive inborn error of metabolism, characterised by defective transport of the cationic amino acids lysine, arginine and ornithine. To date there are few reported necropsy cases. This report describes the necropsy findings in a 21 year old female patient originally diagnosed as having LPI in 1973. Liver function tests deteriorated and immediately before death jaundice, hyperammonaemia, coma, metabolic acidosis, and a severe bleeding diathesis developed. At necropsy, there was micronodular cirrhosis of the liver with extensive fatty change in hepatocytes. The lungs showed pulmonary alveolar proteinosis. Immunofluorescence and electron microscopy revealed the presence of a glomerulonephritis with predominant IgA deposition. These necropsy findings reflect the spectrum of lesions reported in LPI, providing further evidence of an association between this condition and pulmonary alveolar proteinosis, cirrhosis and glomerulonephritis.

Treating the patient who is disfigured by head and neck cancer

A 46-year-old man with laryngeal carcinoma was admitted to the medical service for lethargy. The medical team requested a psychiatric consultation to assist with the patient's depression, substance abuse, and noncompliance. The case is presented and discussed with reference to the issues of depression, disfigurement, dysfunction, and substance abuse in the patient with head and neck cancer.

Right-angle partially compressible hemostatic clip applier

A modification of a hemostatic clip applier is described that can apply clips at right angles to the plane of the handles. This device may be particularly useful in certain neurosurgical settings where use of the conventional clip applier is difficult. This device also prevents overcompression of clips.

Dietary vitamin B12 deficiency in a patient with multiple sclerosis

The authors present a case of dietary vitamin B12 deficiency in a patient with multiple sclerosis. A simple schemata for evaluating patients for vitamin B12 deficiency is included as a clinical aid for physicians.

Impact of pregnancy during training on a psychiatric resident cohort

The issues surrounding pregnancy during residency training include length of maternity leave, coverage during that leave, and relationships among resident colleagues. With more women entering medicine, the likelihood of a majority of residents in any postgraduate year being pregnant at one time has increased. This study presents an in-depth view of one such resident cohort. Conflicts occurred over the perception that pregnant residents received special treatment. The defenses mobilized by residents included projection and denial.

Computed tomography in crepitant myonecrosis

We report an unusual case of non-traumatic myonecrosis presenting as hip pain. Computed tomography helped to define the extent of the infection and its origin in the presacral space. The use of CT in diagnosis and management of gas-forming soft tissue infection is reviewed.

Extrapyramidal side effects of antiemetics presenting as psychiatric illness

Although extrapyramidal side effects of two commonly used antiemetics, metoclopramide and prochlorperazine, are well known, it may be difficult for even the experienced practitioner to distinguish some of these extrapyramidal reactions from such psychiatric symptoms as anxiety, depression, or catatonia. Certain patient groups have increased susceptibility to these extrapyramidal reactions, including patients under 30, those with AIDS, those with renal disease, oncology patients, and possibly women. Physicians should maintain a high index of suspicion for depression, anxiety, or catatonia if their patients are taking antiemetics. These symptoms may be extrapyramidal side effects of the antiemetic rather than indications of a primary mental disorder.

Physical and functional characterization of the gene cluster encoding the polyketide phytotoxin coronatine in Pseudomonas syringae pv. glycinea

Pseudomonas syringae pv. glycinea PG4180 produces the polyketide phytotoxin coronatine. The coronatine synthesis genes in PG4180 were previously shown to reside on a 90-kb plasmid designated p4180A. In the present study, clones containing a 34-kb region of p4180A were saturated with Tn5, and 71 unique mutations were recombined into p4180A by marker exchange. The effect of each mutation on coronatine synthesis was determined by analyzing the organic acids produced by the mutants by reverse-phase high-performance liquid chromatography. The organic acids of selected mutants were derivatized to their methyl esters and analyzed by gas chromatography and gas chromatography-mass spectrometry. Mutations in a 20.5-kb region of p4180A completely blocked the synthesis of coronafacic acid and coronatine. Mutations within a 4.4-kb region of p4180A prevented the formation of coronatine but allowed for production of coronafacic acid, coronafacoylvaline, coronafacoylisoleucine, and coronafacoylalloisoleucine. The phenotypes of selected mutants were further confirmed in feeding experiments in which coronafacic acid or coronamic acid was added to the culture media. The results of this study allow us to speculate on the likely sequence of steps in the later stages of coronatine biosynthesis.

c-myc antisense transcripts accelerate differentiation and inhibit G1 progression in murine erythroleukemia cells

Friend murine erythroleukemia (F-MEL) cells were transfected with a plasmid bearing tandemly arranged mouse c-myc antisense and dihydrofolate reductase transcription units. Sixteen clones were isolated, each containing unrearranged c-myc sequences and expressing high levels of antisense transcripts. All antisense clones examined contained reduced amounts of cytoplasmic endogenous c-myc transcripts. The kinetics of reaccumulation of endogenous c-myc mRNA during a 24-h exposure to dimethyl sulfoxide (DMSO) were also retarded and the ultimate transcript levels attained were less than in control cells. Antisense clones grew as well as control F-MEL cells in medium containing 10% fetal calf serum but at only a half and a quarter of the control rates in media containing 5 and 2% serum, respectively. Antisense clones differentiated faster and to a greater degree than control cells following DMSO exposure. myc antisense transcript expression was increased by growing cells in methotrexate, which resulted in an enhanced response to DMSO. Fluorescence-activated cell sorter (FACS) analysis of cellular DNA content indicated that a greater fraction of antisense nuclei contained a G0/G1 2n DNA content following a 24-h exposure to DMSO. When density-arrested antisense clones were diluted into fresh medium to allow reentry into the cell cycle, they incorporated less [3H]thymidine than control cells. FACS analysis showed that this was because only a portion of the cell population was entering S phase. Whereas control cells did not increase in size following release from density arrested antisense cells contained a subpopulation which were initially smaller and which eventually attained the same size as control cells. Quiescent antisense cells thus comprise two populations, each arrested at a different point in G1. Dilutional replating allowed both populations to reenter the cell cycle. We propose a model which postulates that certain minimal myc levels are necessary for cells to traverse G1. Those with insufficient levels, due, for example, to antisense inhibition, are unable to completely traverse G1 during density arrest and synchronize at an earlier point than do control cells. This earlier point may be along the differentiation pathway and may account for the greater responsiveness of antisense cells to DMSO induction. This model postulates that F-MEL cells overexpressing myc fail to differentiate because myc levels are never sufficiently low enough to allow cells to enter the differentiation pathway.

Repeal of the Massachusetts seat belt law

In November 1986, the Massachusetts mandatory seat belt use law repealed in a referendum by a 53 per cent to 47 per cent vote. In an anonymous random digit telephone survey of 1,046 adults in Massachusetts in summer 1986, while the law was in effect, 61 per cent of respondents had said they would vote in favor of the law. A post-repeal follow-up of 80 per cent of these persons revealed initial supporters and opponents of the law were equally likely to vote, but 15 per cent of the summer supporters switched their opinions and voted for repeal, compared to only 4 per cent of summer opponents who switched. In addition, a separate survey of 167 households that had refused to answer the summer survey indicated that survey nonrespondents were more likely to vote against the law than for it. Those opposing the law saw it as an infringement on personal liberty and believed it was not effective in reducing injury and death.

Further modifications for the Frazier suction device. Technical note

Two modifications of the Frazier suction device are described: a removable distal retractor that is clipped to a modified suction tip and a coupling device that decreases counter-rotational torque.

Proposed pathogenic mechanism for the diarrhea associated with human intestinal spirochetes

Spirochetes resembling Brachyspira aalborgi were found in the feces and rectal biopsies of a patient with persistent diarrhea. Although the organism failed to grow on bacteriologic media, it was found attached to the surfaces of the epithelial cells on the rectal lumen. Blunting and destruction of the cellular microvilli was evident. These induced pathologic cell surface changes, together with the presence of intracellular bacteria in the cells of the rectal colon, suggest a pathogenic mechanism for the persistent diarrhea often associated with this condition. Both the spirochetosis and clinical symptoms disappeared on treatment with metronidazole.

Compression-expansion forceps for intracranial dissection and retraction. Technical note

A hand-held double-bladed retractor has been designed in the form of a cross-action bayonette. It acts to retract both lips of an incision simultaneously. The device can be adapted for other uses.

Assessment of some shock absorbing insoles

Due to the increase in prescription of insoles to relieve symptoms due to skeletal shocks at heel strike a pilot study was initiated to look at some materials used for this purpose. Five materials were examined (Plastazote, Spenco, Sorbothane, Poron (PPT) and Viscolas) by two methods. The first method used an accelerometer mounted between the teeth of one of the authors (PR) to record skeletal shock. The second method used a force plate to record the shock produced by dropping a ball-bearing onto the insoles from a standard height. The results showed that Plastazote is poor at absorbing shock with Spenco and Sorbothane being quite good. The best insole materials tested were Poron (PPT) and Viscolas with the latter being marginally superior. No account was taken of degradation of the materials in use except that Plastazote worn for 72 hours was also used in the study, this producing the worst results.