The general practice perspective on cancer services in Lothian.

OBJECTIVES: The aim of the present study was to obtain views from general practices about current and potential improvements to services for patients with suspected lung, large bowel, non-melanoma skin and breast cancer. METHOD: A questionnaire study was carried out of 134 general practices within the Lothian Health Board boundary. Information was sought about referral choices, communication, quality of care, liaison between community and hospital, health promotion, treatment outcomes and palliative care. Main outcome measures were determinants of primary care referral behaviour and clinical investigation strategies, and perception of quality in secondary care and health promotion services. RESULTS: Seventy-nine general practices (59%) returned completed questionnaires. One-fifth of practices maintained a cancer register, and 85% provide patient information about cancer prevention. Initial management was disease dependent. Most cases of suspected lung cancer, about half of suspected colorectal cancer cases and very few cases of suspected breast cancer were investigated in primary care before referral to hospital. Hospital referral depended on knowledge of local services. A minority of practices wanted referral guidelines. It was estimated that 92% of lung and breast cancer cases, 68% of colorectal cancers and 35% of skin cancers are seen within 4 weeks. Breast cancer care was rated more highly than that for other cancers. One-third ranked community nursing support as 'excellent' and 10-15% described it as 'fair' or 'poor'; 77% describe palliative care as 'excellent' or 'good'. Fifty-one percent believe that communication with hospital is 'excellent' or 'good'. Practices were sometimes unaware of the hospital's post-diagnosis management plan; communication was often too slow and practices often received 'poor' advice about symptom control. Eighty percent thought that hospital follow-up for breast, colorectal and lung cancer should be routine; 20% thought that it was indicated for non-melanomatous skin cancer. CONCLUSIONS: Communication problems between primary and secondary sectors need to be tackled innovatively and the perceived quality variation in services addressed-perhaps by developing local guidelines. Practices would welcome further education about health promotion resources and cancer epidemiology.

The accuracy of medication histories in the hospital medical records of elderly persons.

Medication histories written in medical records are important sources of information for clinicians and researchers. Medication histories in outpatient records are frequently inaccurate; the accuracy of the histories in hospital records has not previously been studied. We evaluated the accuracy of medication histories recorded in hospital medical records of 122 persons over the age of 65 at three sites, comparing the written record to a structured history obtained from the patient by the research staff. We defined an error as either the failure to record the use of a medication the patient claimed to use or the recording of a medication that the patient denied using. We found that 83% of all patients had at least one such error, and 46% had three or more. We reanalyzed the data excluding over-the-counter, tropical, and cold medications, and found that 60% of all patients still had at least one error, and 18% had three or more. Failure to record use in the record was more common than recording medications the patient denied using. There were no qualitative differences between hospitals or between the histories obtained by interns and attending physicians. This analysis suggests that medication histories in the hospital medical record are not accurate sources of information in elderly persons. Errors in the history may adversely affect clinical care; researchers relying on hospital medical records to determine medication use at the time of admission should first validate their data.

Diabetes-related changes in chromatin structure of brain, liver, and intestinal epithelium.

To determine whether diabetes alters chromatin structure in vivo, fluorometric analysis of alkali-induced DNA unwinding was carried out in various tissues of streptozocin-induced diabetic rats and genetically obese diabetic (db/db) mice. When zero-order kinetics were used to analyze the data, the percentage of double-stranded DNA (%dsDNA) unwinding in brain, liver, and intestinal epithelium of diabetic rats maintained for 4 wk was significantly reduced compared with vehicle-injected control rats (%dsDNA 0.37 +/- 0.05 vs. 0.73 +/- 0.02 for brain, 0.59 +/- 0.1 vs. 0.84 +/- 0.02 for liver, and 0.58 +/- 0.07 vs. 0.90 +/- 0.13 for intestinal epithelium). Insulin treatment of diabetic rats normalized the rate of DNA unwinding in liver (0.82 +/- 0.09 %dsDNA/min) and intestinal epithelium (1.05 +/- 0.09 %dsDNA/min), but the increase in the unwinding rate of brain DNA (0.51 +/- 0.06 %dsDNA/min) did not achieve control values. Similarly, alkali-induced DNA unwinding was significantly slower in brain and liver of db/db mice compared with homozygote controls. When first-order kinetics were used to analyze the data, fractional rate constants of DNA unwinding in brain and liver of diabetic rats or mice were significantly smaller than observed in nondiabetic control animals. The fractional rate constant of DNA unwinding in intestinal epithelium was not altered with diabetes. We conclude that chronic uncontrolled hyperglycemia can alter chromatin structure in vivo.

Potential adverse drug interactions in the emergency room. An issue in the quality of care.

STUDY OBJECTIVE: To determine how often emergency department physicians prescribe medications that can adversely interact with other medications that their patients are already taking, which patients are at highest risk for potential adverse reactions, and which medications most frequently lead to adverse interactions. DESIGN: Survey of elderly persons and other adults seeking care at an emergency department. PATIENTS: Four-hundred twenty-four randomly selected adults seeking care at a university-affiliated hospital emergency department. MEASUREMENTS AND MAIN RESULTS: We evaluated 424 randomly selected visits to a hospital emergency department made by 186 persons over age 65 and 238 younger adults; all of the subjects were discharged without hospital admission. Forty-seven percent of visits led to added medication, and in 10% of the visits in which at least one medication was added, a new medication added a potential adverse interaction. The interactions were determined by a computer program, were reviewed using explicit criteria, and were excluded if of uncertain or trivial clinical significance, rare, or not established for that specific drug. The number of medications used at presentation was the best predictor of whether a potential interaction would be introduced. CONCLUSIONS: In the emergency departments studied, a medication history was recorded on every patient and was available to physicians, but physicians did not routinely screen for potential drug interactions. Further safeguards are needed to protect patients from receiving medications that could produce adverse interactions.

The tissue specificity of the age-related changes in alkali-induced DNA-unwinding.

To determine if the age-related changes in chromatin digestibility are tissue-specific, fluorometric analysis of the alkali-induced DNA unwinding technique was adapted for soft-tissue chromatin studies. The rate of DNA unwinding in the brain and liver of young Fischer 344 male rats (3 months of age) was significantly greater than the rates measured in middle-aged (15 months) or aged rats (26 months). In contrast, the rate of DNA unwinding in the intestinal epithelium, a continuously replicating tissue, did not significantly vary with age. Although this assay is capable of detecting DNA strand breaks in vivo following N-nitrosodimethylamine administration, the age-related changes could not be attributed to reduced DNA strand lesions in the aged animals. The % double-stranded DNA at time 0 of incubation in alkali was lower in the brain and liver of aged rats indicating that DNA strand breaks may actually increase with aging. These results indicate that proliferative activity of the tissue is an important determinant of age-related changes in chromatin structure.

Skin conductance: a potentially sensitive test for depression.

The mean resting skin conductance level (SCL) in 31 inpatients with major unipolar depression was 2.63 mumho/cm2 +/- SD 1.41 compared to 7.81 mumho/cm2 +/- SD 3.0 in the control group. The best criterion below which an SCL could be considered abnormal was 4.3 mumho/cm2 with a resulting sensitivity of 87% and specificity of 89%. There was a significant difference in SCL between males and females but none between drug-free and medicated patients. SCL was abnormal in all depression subtypes. The SCL may represent a biological final common pathway in depression and may prove to be a very effective diagnostic test for depression.

Skin conductance characteristics of depressed subjects before and after therapeutic intervention.

Three hypotheses were tested in a population of depressed patients: a) electrical skin conductance levels and responses are lower in depressed individuals; b) skin conductance levels and responses are lower in the right hand than the left hand of right-handed depressed individuals; and c) skin conductance levels and responses will increase in magnitude after successful therapeutic intervention. The data supported only the first hypothesis. Results may have implications for a trait vs. state differentiation of the depressive process.

Thrombocytopenia in the absence of leukopenia associated with the use of neuroleptics.

Thrombocytopenia, a fairly uncommon side effect of phenothiazine treatment, usually appears in the presence of a concommitant leukopenia. The authors report 1 patient in whom the illness appeared in the presence of a long known Beta thalassemia but without evidence of alteration in myeloid or lymphoid series. Platelet changes were seen in the presence of a butyrophenone and an aliphatic phenothiazine. A piperazine derivative was used without difficulty.