Follow-up compliance after emergency department evaluation

STUDY OBJECTIVE

To identify factors associated with outpatient follow-up of emergency department visits.

DESIGN

A retrospective review of 587 ED charts meeting strict criteria was performed. The following variables were identified: method used to arrange follow-up, age, sex, consultant contacts, distance from patient's residence to hospital, previous physician, recommended time to clinic return, and funding source. Compliance was assessed using the outpatient registration computer data base.

SETTING

ED and outpatient clinics of an urban university teaching hospital.

PARTICIPANTS

Inclusion criteria were age between 18 and 75 years, patient released to outpatient care, and instructions specifying a university hospital clinic or ED follow-up and a time period within which this appointment was to occur. Follow-up options included patients being asked to return to the ED on a specific day (group 1), being given a specific clinic appointment (group 2), or being given the clinic telephone number and instructed to call for an appointment (group 3).

RESULTS

Compliance rates, defined as follow-up within seven days of the recommended date, were group 1, 51%; group 2, 65%; and group 3, 46%. Significant confounding factors adversely affecting follow-up as determined by multiple logistic regression analysis were decreasing age (P < .05), absence of insurance (P < .01), and no ED consultation with follow-up clinic physician (P < .01). Controlling for these factors and the reason for follow-up showed that having the patient schedule their own follow-up was associated with poor follow-up compliance (P < .001).

CONCLUSION

Compliance with follow-up is multifactorial. Consultant contact at the time of initial patient evaluation and provision of a return visit appointment at the time of ED release should improve compliance in a university hospital setting.

Role of 25-hydroxyvitamin D3 dose in determining rat 1,25-dihydroxyvitamin D3 production

To understand the relationships among 1) the dose of 25-hydroxyvitamin D [25(OH)D] in vivo, 2) the activity of 1-hydroxylase in renal mitochondria, and 3) the production of 1,25-dihydroxyvitamin D [1,25(OH)2D] in vivo, we gave rats different chronic or acute doses of 25-hydroxyvitamin D3 [25(OH)D3]. We followed the metabolism of intracardially administered [25-hydroxy-26,27-methyl-3H]cholecalciferol [25(OH)[3H]D3] for 24 h before killing by measuring extracts of serum by chromatography. Specific activity of 1-hydroxylase in kidney was measured at death. In rats given 0-2,000 pmol 25(OH)D3 chronically by mouth, there was a dose-dependent decline in the percent of serum radioactivity made up of 1,25-dihydroxy-[26,27-methyl-3H]cholecalciferol [1,25(OH)2[3H]D3] as well as a decline in mitochondrial 1-hydroxylase, and these correlated significantly (r = 0.83, P less than 0.001). Serum %1,25(OH)2[3H]D3 in this experiment ranged from 0.8 to 42%. A small part of this range could be accounted for by a faster metabolic clearance rate (MCR) of 1,25(OH)2D3 from rats supplemented with 25(OH)D3 (MCR, 2.12 +/- 0.10 ml/min) compared with rats restricted in vitamin D (MCR, 0.94 +/- 0.06 ml/min, P less than 0.001). The activity of 1-hydroxylase was by far the major factor determining serum %1,25(OH)2[3H]D3. When different acute doses of 25(OH)D3 were given to rats with identical specific activities of 1-hydroxylase, the resulting 1,25(OH)2D3 concentrations in serum correlated with the 25(OH)D3 dose (r = 0.99, P less than 0.001). We conclude that the behavior of 1-hydroxylase in vivo is analogous to the classic behavior in vitro of an enzyme functioning below its Michaelis constant (Km). The amount of 1-hydroxylase present in renal mitochondria determines the fraction (not simply the quantity) of 25(OH)D metabolized to 1,25(OH)2D3 in vivo.

Transaxial tomography: an alternative to computerized tomography in pediatric orthopedic problems

Because of the information it provides, computerized tomography has gained wide acceptance. However, the radiation delivered is considerable, and the gonads cannot be shielded effectively. Transaxial tomography also produces a cross-sectional image. While the image has less resolution, it is obtained at a fraction of the exposure. The use of transaxial tomography in several clinical situations is outlined here.

Intussusception and total body opacification

Because of atypical clinical presentations, two children with intussusception had intravenous urography as their initial examination of following plan films. In both patients the intussusception was outlined by an opaque rim due to the total body opacification effect on the bowel wall. One patient had a target-like blush on following films which strongly suggested the correct diagnosis. The authors do not advocate intravenous urography to diagnosis intussusception, but if this study is performed because of atypical clinical findings, the radiographic sign should be recognized and lead to a barium enema.

Massive pulmonary emboli diagnosed and followed in progress by lung imaging and radionuclide pulmonary angiography

A dramatic case of occlusion of the right pulmonary artery is presented. The diagnosis was clearly established by means of a lung scan and a radionuclide pulmonary angiogram. The entire course of the disease process was followed by radionuclide studies with a gradual but persistent return to normal. Due to the preciseness of the evidence presented, contrast angiography was not. thought necessary.