Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation.

AIMS: The aim of this study was to evaluate an innovative approach to the provision of primary care-based diabetes services in Bradford, UK. The service model differs from others in comprising 19 clinics which offer a specialist service, intermediate between primary and secondary care, to all patients within the Bradford area. METHODS: The study included: analysis of referral, attendance and register data; questionnaires to general practitioners (GPs) and specialist clinic providers; qualitative interviews with clinic and other professional staff and patients; and an economic analysis. RESULTS: The 19 clinics adopt a range of organizational models. In the first 3 1/2 years, 2415 patients were referred. There was a significant reduction in out-patient attendances at hospital, but also a significant increase in overall patient attendances. Specialist clinic patients differed from hospital patients in being older and having had diabetes for longer since diagnosis. Ten of the 14 clinics run by practising GPs attracted more referrals from within their practices than from outside. GPs and patients across the city believed the clinics were valuable, the main benefits being geographical accessibility, availability of specialists in a community setting, short waiting times for first appointments at most clinics, and continuity of staff. Their reservations included a lack of strategic planning in the location of clinics, long waiting times at some clinics, and poor communication at some clinics with referring GPs. The cost of the primary care clinics is similar to hospital clinics. CONCLUSIONS: This model of specialist primary care services offers an opportunity to develop diabetes services that are convenient to patients, popular with practitioners, and increase capacity. However, the shortcomings as well as the advantages of the model need to be addressed if it is to be implemented elsewhere or for other patient groups.

The career aspirations of women doctors who qualified in 1974 and 1977 from a United Kingdom medical school.

The career aspirations of doctors who qualified from a UK medical school were examined in relation to firmness of career choice and marital and family circumstances 1 year and 7 years after qualification. Although there was greater certainty of career choice amongst all doctors, the women were consistently less likely to be certain than the men. The men were more likely than the women to be married (and more likely to have children). The main differences in patterns of career choice were the greater popularity of medicine and surgery among the men and of general practice and community medicine among the women. The most plausible explanation for these differences is the different marital and family pressures experienced by men and women.

Impact of home infusion therapy on the Colorado Medicaid program budget.

The impact of home infusion therapies on the pharmaceutical services drug budget of the Colorado Medicaid program was evaluated retrospectively. Pharmacy billing claims and prior authorization forms for home infusion therapies submitted to the Colorado Department of Social Services during a 26-month period were reviewed to determine the costs of the drug or hydration solutions and ancillary products necessary for the preparation and administration of the solutions. A dispensing fee of +3.40 per dose was figured into calculations of total costs of home infusion therapies, and an estimated cost of +100-+150 per day for follow-up care was added. Equivalent costs of hospitalization were calculated using an average per diem charge of +315. A total of 61 patients received 1361 days of home infusion therapy during the study period. The majority of patients received home antimicrobial therapy; 752 days of hospitalization theoretically were avoided because of home administration of antimicrobial agents, which translates into a cost savings of +76,716-+114,316. Patients also received home parenteral nutrition therapy, analgesic therapy, and rehydration therapy that yielded cost savings of +48,374-+78,824 but in some cases resulted in higher costs than hospitalization would have. Home infusion therapies increased pharmaceutical services costs by +99,475, representing an important shift of costs from the hospital services budget to the pharmaceutical services budget. Home infusion therapies generally incur lower costs than would be incurred during an equivalent hospital stay. The Colorado Medicaid budget should be adjusted to compensate for the shift of costs from hospital to pharmaceutical services.

Consumer preferences for verbal and written medication information.

The extent of medication use and drug information preferences was surveyed randomly from patients at six different pharmacy health care systems. Following verbal consultation, each patient was given one or more modified United States Pharmacopoeia drug information leaflets corresponding to the verbal information and a self-addressed, stamped questionnaire to complete. Chi-square analysis was performed on 317 responses with overwhelming acceptance (96 percent) of the medication information provided. Although a majority of respondents (62 percent) preferred a combination of both written and oral information, specific information preferences (oral, written, or both) were significantly related to educational level, pharmacy attended, and prescription status. Nearly 45 percent of the respondents indicated the information was responsible for changing their medication use. Subjects who were elderly, taking cardiovascular medications, or getting refill prescriptions were significantly less likely to change as a result of the information provided. Although 65 percent of the respondents were unwilling to pay an additional fee for the service, females and those who were 45-54 years and over 65 years old were significantly more willing to pay for the information. In addition, the willingness to pay tended to increase as the number of daily medications taken increased. Consideration of socioeconomic and prescription variables may help define subgroups with specific information preferences and counseling activities that may be directly reimbursable.

Monolayer culture of cells originating from a preimplantation bovine embryo.

The objective of this study was to establish a method by which trophectodermal cells originating from individual preimplantation bovine embryos could be perpetuated in monolayer culture. A single, Day-11 bovine embryo collected nonsurgically from a mixed-breed beef cow was cultured in Ham's F10 medium supplemented with fetal bovine serum, sodium pyruvate, insulin, and epidermal growth factor. After 13 d in culture the embryo had adhered to the surface of the plastic culture vessel and a monolayer covering 0.3 cm2 had developed in the manner of a tissue explant. The monolayer was successfully dispersed using trypsin-EDTA and the cells were passaged. Expansion to a 25-cm2 flask was achieved by the 4th passage. By passaging cultures at a dilution ratio of 1:2, cells were maintained for 38 passages before growth slowed. Transfers beyond the 44th passage were unsuccessful. The cell line, designated BE-13, was successfully frozen and thawed at the 9th, 12th, 15th, and 20th passages. The cell line contains both mono- and binucleate cells with a prominent rough endoplasmic reticulum characteristic of ruminant trophoblast cells. Susceptibility to eight bovine viruses was demonstrated. Such cell lines may provide inexpensive systems for the study of trophoblast metabolism and for investigation of the role of the trophoblast in the pathogenesis of selected bovine abortifacient diseases. Because of their range of viral susceptibility, these cells might also be useful for diagnostic purposes.

Evaluation of eight methods for estimating creatinine clearance in men.

Eight methods for estimating creatinine clearance (CLcr) were compared in 65 men with serum creatinine concentrations (SCr) less than or equal to 1.5 mg/dL (group 1) and 65 men with SCr greater than 1.5 mg/dL (group 2). All patients had SCr values that did not fluctuate by more than +/- 10% for two weeks before and two weeks after measurement of CLcr. For each patient, predictions of CLcr by each of eight currently used formulas were compared with measured CLcr values; both regression analysis and predictive error analysis were used. Group 1 patients ranged in age from 32 to 64 years (mean, 53), weighed from 48 to 105 kg (mean, 73), and were from 63 to 79 inches in height (mean, 69). Group 2 patients ranged from 26 to 63 years of age (mean, 53), weighed from 34 to 141 kg (mean, 80), and were from 63 to 76 inches in height (mean, 70). Measured CLcr values ranged from 29.8 to 197 mL/min in group 1 and from 2.8 to 118 mL/min in group 2. Ranges of SCr values were 0.7-1.5 mg/dL (mean, 1.1) in group 1 and 1.6-7.1 mg/dL (mean, 2.8) in group 2; the formula of Cockcroft and Gault, which uses age, body weight, and SCr, had the highest correlation and the greatest accuracy in group 1, whereas the formula of Jelliffe, which uses body surface area and SCr, had the highest correlation and the greatest accuracy in group 2. Estimation of creatinine clearance can be improved by identification and use of the formula that is best suited to a specific patient population.

A warfarin-piroxicam drug interaction.

A piroxicam-warfarin interaction is presented with a discussion of the possible mechanism of action. A 60-year-old white male on warfarin therapy for recurrent pulmonary embolism and deep venous thrombophlebitis showed a decrease in his previously therapeutic and stable prothrombin time when piroxicam was discontinued from his drug regimen. On two rechallenges over a ten-month period, his prothrombin times showed consistent and clinically significant fluctuations as piroxicam was added and deleted from his drug regimen.

A readily obtainable analog of propranolol suitable for use as internal standard in chromatographic assays for propranolol.

There appears to be a need for a readily and conveniently available close chemical analog of propranolol suitable for use as internal standard in a variety of chromatographic assays of the drug. With this purpose in mind, we developed a simple procedure for the preparation of N-cyclopentyldesisopropylpropranolol. The commercially available and inexpensive starting materials are mixed in a flask and after 48 hr at room temperature the precipitated product is filtered off. Mass spectrometry, melting point determinations, and elemental analysis were used to characterize the product. N-cyclopentyldesisopropylpropranolol was used as internal standard in a liquid-chromatographic assay of ten replicate 50 ng/ml propranolol plasma samples, and gave a coefficient of variation of 3.4%.

Stability of meperidine hydrochloride, promethazine hydrochloride, and atropine sulfate in plastic syringes.

The stability of a combination of meperidine hydrochloride 50 mg, promethazine hydrochloride 25 mg, and atropine sulfate 0.4 mg in plastic syringes at room temperature was studied. The samples were tested for each drug after 0.5, 1, 3, 6, and 24 hours in the syringes. Freshly prepared mixtures of the drugs in glass containers were used as controls, and three trials using separate test mixtures were performed. A gas chromatography procedure was used; atropine was separated from the mixture and assayed alone for greater accuracy. Drug concentrations in the plastic syringes were not significantly different from controls at any of the test times. A mixture of meperidine hydrochloride, promethazine hydrochloride, and atropine sulfate in dosages commonly administered as a preoperative medication was stable for 24 hours in plastic syringes.

Elimination kinetics and symptomatology of diazepam withdrawal in abusers.

This study was performed in order to correlate changes in blood levels of diazepam and desmethyldiazepam with the symptomatology of withdrawal and to examine their elimination kinetics in abusers. The determined half-life of desmethyldiazepam in five diazepam abusers had a wide range of 46.2 to 94.5 hours. Two episodic very high dose abusers exhibited shorter desmethyldiazepam half-lives than was considered normal, possibly due to auto-induction. The half-life of diazepam in a documented very high dose user exceeded that reported in the literature, probably due to accumulation. Withdrawal symptoms reported by the subjects were moderate and included some mental confusion. The most distressing symptom reported was dramatic mood swings which occurred over a matter of minutes. The disappearance of diazepam from blood appears to be the initial cause of withdrawal. Desmethyldiazepam may moderate the severity of the abstinence syndrome but probably lengthens the withdrawal process.