Referral letters and replies from orthopaedic departments: opportunities missed.

OBJECTIVE--To study delays between sending referral letters and the outpatient appointment and to assess the content of referral and reply letters, their educational value, and the extent to which questions asked are answered by reply letters. DESIGN--Retrospective review of referrals to 16 consultant orthopaedic surgeons at five hospitals, comprising 288 referral letters with corresponding replies, by scoring contents of letters. SETTING--Orthopaedic teaching hospitals in Nottingham, Derby, and Mansfield. MAIN OUTCOME MEASURES--Weighted scores of contents of referral and reply letters, assessment of their educational value, and responses to questions in referral letters. RESULTS--Median outpatient delay was 23.4 weeks. There was no significant decrease in waiting time if the referral letter was marked "urgent" but a significantly greater delay (p less than 0.01) if referrals were directed to an unnamed consultant. The content score was generally unsatisfactory for both referrals and replies, and there was no correlation for the content scores of the referral letter and its reply (r = 0.13). Items of education were rare in the referral letters (8/288; 3%) and significantly more common in replies (75/288; 26%) (p much less than 0.001). Senior registrars were significantly more likely to attempt education than other writers (p less than 0.02). Education in replies was significantly related to increased length of the letter (p less than 0.05) and was more likely to occur if the referral was addressed to a named consultant (p less than 0.03). 48 (17%) Referral letters asked questions, of which 21 (44%) received a reply. No factor was found to influence the asking of or replying to questions. CONCLUSIONS--The potential for useful communication in the referral letter and in the reply from orthopaedic surgeons is being missed at a number of levels. The content is often poor, the level of mutual education is low, and the use of the referral letter to determine urgency is deficient. Most questions asked by general practitioners are not answered.     

The Arabidopsis phytochrome B gene influences growth of the apple rootstock M26

 The apple rootstock M26 (Malus domestica) was infected with a binary vector system of Agrobacterium tumefaciens carrying the neomycin phosphotransferase II and Arabidopsis phyB genes. Thirteen transformed clones were obtained from 329 infected leaves. Five of the clones had a single copy integration, six clones had two copies, one clone had five copies and one of the clones had eight copies of the phyB gene integrated. No differences in rooting were found between transformed and untransformed plants. The stem length was reduced in nine of the 13 transgenic clones, and shoot, root and plant dry weights were reduced in all transformed clones compared with untransformed control plants. Northern analysis showed that the Arabidopsis phyB gene was expressed in the transformed clones. Received: 28 April 1999 / Revision received: 28 February 2000 / Accepted:29 February 2000     

Evaluating Letter Recognition,Flicker Fusion,and the Talbot-Plateau Law using Microsecond-Duration Flashes

Four experiments examined the ability of respondents to identify letters that were displayed on an LED array with flashes lasting little more than a microsecond. The first experiment displayed each letter with a single, simultaneous flash of all the dots forming the letter and established the relation of flash intensity to the probability of letter identification. The second experiment displayed the letters with multiple flashes at different frequencies to determine the probability that the sequence of flashes would be perceived as fused. The third experiment displayed the letters at a frequency that was above the flicker-fusion frequency, varying flash intensity to establish the amount needed to elicit a given probability of letter identification. The fourth experiment displayed each letter twice, once at a frequency where no flicker was perceived and also with steady light emission. The intensity of each flash was fixed and the steady intensity was varied; respondents were asked to judge whether the fused-flicker display and the steady display appeared to be the same brightness. Steady intensity was about double the average flash intensity where the two conditions were perceived as being equal in brightness. This is at odds with Talbot-Plateau law, which predicts that these two values should be equal. The law was formulated relative to a flash lasting half of each period, so it is surprising that it comes this close to being correct where the flash occupies only a millionth of the total period.     

Two models of the recognition and detection of texture-defined letters compared

We quantified texture segregation by measuring psychophysically the percentage correct detection scores for each of a set of 10 texture-defined (TD) letters using the temporal two-alternative forced choice method, and at the same time quantified spatial discrimination of the TD form of measuring psychophysically the percentage correct letter recognition scores for the 10 letters. Ten levels of task difficulty were created by adding noise dots to the texture patterns. The resulting psychophysical data were used to test and compare models of the detection and recognition of texture-defined letters. Each model comprised a sequence of physiologically plausible stages in early visual processing. Each had the same first, second and third stages, namely linear orientation-tuned spatial filters followed by rectification and smoothing. Model 1 had only one non-linear stage. Model 2 had two non-linear stages. In model 2 the second non-linear stage was cross-orientation inhibition. This second non-linear stage enhanced the texture borders by, in effect, comparing textures at different locations in the texture pattern. In both models, the last stage modelled either letter detection or letter recognition. Letter recognition was modelled as follows. We passed a given letter stimulus through the first several stages of a model and, in 10 separate calculations, cross-correlated the output with a template of each of the 10 letters. From these 10 correlations we obtained a predicted percentage correct letter recognition score for the given letter stimulus. The predicted recognition scores closely agreed with the experimental data at all 10 levels of task difficulty for model 2, but not for model 1. We conclude that a borderenhancing algorithm is necessary to model letter recognition. The letter-detection algorithm modelled detection of part of a letter (a single letter stroke) in terms of the signal-to-noise ratio of a letter-segment detector. The predicted letter detection scores fitted the data closely for both models.     

A validation study of appropriate phonological verbal fluency stimulus letters for use with croatian speaking individuals

The aim of this study is to determine the word frequency for all thirty letters of the Croatian alphabet and to collect normative data for the letter fluency task in Croatian speakers. Ninety two healthy participants were given each of the Croatian letters, and asked to generate as many words as possible in 60 seconds for each letter Results suggested that participants generated most frequently words starting with the letters as follows: "K", "P", "S" and "M".     

Cellular versus acellular matrix devices in treatment of diabetic foot ulcers: study protocol for a comparative efficacy randomized controlled trial

Background

The referral letter plays a key role both in the communication between primary and secondary care, and in the quality of the health care process. Many studies have attempted to evaluate and improve the quality of these referral letters, but few have assessed the impact of their quality on the health care delivered to each patient.

Methods

A cluster randomized trial, with the general practitioner office as the unit of randomization, has been designed to evaluate the effect of a referral intervention on the quality of health care delivered. Referral templates have been developed covering four diagnostic groups: dyspepsia, suspected colonic malignancy, chest pain, and chronic obstructive pulmonary disease. Of the 14 general practitioner offices primarily served by University Hospital of North Norway Harstad, seven were randomized to the intervention group. The primary outcome is a collated quality indicator score developed for each diagnostic group. Secondary outcomes include: quality of the referral, health process outcome such as waiting times, and adequacy of prioritization. In addition, information on patient satisfaction will be collected using self-report questionnaires. Outcome data will be collected on the individual level and analyzed by random effects linear regression.

Discussion

Poor communication between primary and secondary care can lead to inappropriate investigations and erroneous prioritization. This study’s primary hypothesis is that the use of a referral template in this communication will lead to a measurable increase in the quality of health care delivered.

Trial registration

This trial has been registered at ClinicalTrials.gov. The trial registration number is NCT01470963     

1 July 1858: what Wallace knew; what Lyell thought he knew; what both he and Hooker took on trust; and what Charles Darwin never told them

At the Linnean Society on 1 July 1858, Charles Lyell and Joseph Hooker, using only an extract from Charles Darwin's unpublished essay of 1844, and a copy of a recent letter to Asa Gray in Boston, argued successfully that Darwin understood how species originate long before a letter from Alfred Russel Wallace outlining his own version of the theory of evolution arrived at Darwin's home. That letter from Ternate in the Malay Archipelago, however, was not the first letter Darwin received from Wallace. This article will contend that two of the three letters Wallace sent Darwin between 10 October 1856 and 9 March 1858 arrived much earlier than Darwin recorded, thereby allowing him time to assess Wallace's ideas and claim an independent understanding of how the operation of divergence and extinction in the natural world leads strongly marked varieties to be identified as new species. By the time of the Linnean meeting Darwin's new ideas had filtered into his letters and ‘big’ species book, despite the absence of any independent evidence from the natural world to justify his constant insistence to have been guided only by inductive reasoning. © 2013 The Linnean Society of London, Biological Journal of the Linnean Society, 2013, 109 , 725–736.     

Topography of visual event-related potentials during geometric and phonetic discriminations

Event-related potentials (ERPs) were obtained to letters during 3 tasks that involved a SIMPLE RESPONSE (SR) to each letter presentation, a FORM discrimination of the letters that formed a closed loop, and a RHYME discrimination of the letters that rhymed with the letter ‘v’. The first task only required detection of the letters, the FORM task required a visual-spatial analysis. and the RHYME task, a grapheme-phoneme conversion of the letters followed by a determination of rhyming characteristics. The SR ERPs were morphologically different from the discriminative ERPs, notably by the absence of N2 and P3. The difference wave forms between the discrimination and SR conditions and between the targets and non-targets indicated differential topographies of components associated with the FORM and RHYME tasks in the 300 msec latency region. In both of these tasks, components exhibited distributions localized primarily in the occipital regions, whereas in the RHYME task they extended more anteriorly and encompassed temporo-parietal regions. Thus, although the stimulus presentation was visual, the requirement of a visual-auditory conversion in the RHYME task resulted in activity that was more proximal to auditory regions than when only a FORM analysis of the letters was required.     

REAL-TIME PCR方法测定转基因小麦中外源基因拷贝数

采用SYBR GreenⅠ real-time PCR方法检测7株转基因小麦中外源半夏凝集素基因的拷贝数。以小麦蜡质基因（wx012）作为内参基因,以未转基因小麦基因组DNA为内参基因标准品进行5倍梯度稀释得到内参基因CT值与起始模板量的相关性标准曲线：y=-0.2667x+6.98;以含半夏凝集素基因（pta）的质粒DNA为目的基的因标准品同样进行5倍梯度稀释,建立目的基因CT值与起始模板量的相关性标准曲线：y=-0.2118x+4.53。通过SYBR GreenⅠ real-time PCR分别获得每一样本中目的基因和内参基因的CT值,将CT值分别代入标准曲线计算该样本中内参基因和目的基因起始模板量,目的基因与内参基因起始模板量比值即是目的基因在该转基因植株中的拷贝数。计算结果为：单拷贝的有1株,2个拷贝1株,3拷贝和4拷贝的各有2株,其中有1株为假阳性植株。     

Postal workers' perspectives on communication during the anthrax attack

In 2001, the nation experienced its first bioterrorism attack, in the form of anthrax sent through the U.S. Postal Service, and public health professionals were challenged to communicate with a critical audience, U.S. postal workers. Postal workers, the first cohort to receive public health messages during a bioterrorist crisis, offer a crucial viewpoint that can be used in the development of best practices in crisis and emergency risk communication. This article reports results of qualitative interviews and focus groups with 65 postal workers employed at three facilities: Trenton, New Jersey; New York City; and Washington, DC. The social context and changing messages were among the factors that damaged trust between postal workers and public health professionals. Lessons learned from this attack contribute to the growing body of knowledge available to guide communications experts and public health professionals charged with crisis and emergency risk communication with the public.     

Readability of standard appointment letters

Introduction and aims The first contact a clinical service has with a patient is often an appointment letter and thus it is important that this letter is written in a way which is accessible. One concern is to write in language which is easily able to be read by the majority of recipients. A simple initial way to assess this is by using measures of readability of text.Methods We applied measures to examine the readability of appointment and administrative letters sent to young people by clinicians in the Young People's Department at the Royal Cornhill Hospital in Aberdeen.Results Many letters were unlikely to be understood by our youngest patients. We revised the letters to meet an agreed standard of readability, and agreed their routine use within the team. All letters were significantly improved on standard measures of readability and were preferred by patients.Conclusions The methods used are feasible, easily available and may be helpful to clinicians working in other specialties to improve the level of readability of written communication. This will help patients and families in their first contact with any clinical service.     

The filtered Fourier difference spectrum predicts psychophysical letter discrimination in the peripheral retina

We wished to devise a measure of dissimilarity (D) which could predict psychophysical discrimination performance for Snellen letter pairs in peripheral vision. Threshold size for discriminating 33 pairs of Snellen letters was measured at 30 degrees eccentricity in the nasal retina for two subjects. D was computed for each pair by performing an overlap subtraction in the spatial domain, followed by a Fast Fourier Transform on this difference image, and dividing the total power in the resultant 'difference spectrum' by the sum of the powers of the individual letter spectra. A plot of D vs. psychophysical threshold letter size gave a mean correlation of R = -0.81. When D was calculated for letters that were low-pass filtered at different cut-off frequencies, the correlation with psychophysical performance was greatest when cut-off was between 1.25-1.9 cycles/letter (R = -0.85). Conversely, when the difference spectrum was high-pass filtered at different cut-off frequencies, the correlation decreased continuously as the cut-off increased. These results imply that the band of frequencies between zero and 1.25 cycles/letter are most important for letter discrimination in peripheral vision.     

Letter constraints within words in printed English

Summary Due to the manner in which the English language is used, words exhibit strong internal constraints on letters, but some additional constraint may be imposed by the context in which words appear. In order to estimate the internal constraints of words and the overall effect of context, an experiment was carried out using 225 human subjects who predicted letters in each of the first four positions within words, both with and without context prior to the words. It was found that as more letters at the beginning of words are given, prediction of the following letters increases monotonically, but the increase is not smooth. Prediction of the third letter of words given the first two letters is only a little better than prediction of the second letter given only the first. This effect may be explained by the probable combinations of vowels and consonants at the beginning of words. Letters in the first two positions show no improvement due to long context but prediction of later letters is increased by such context so that prediction rises smoothly from the initial letter to the fourth letter. Also, the type of word in which the letters are to be predicted affects the prediction, function words showing more constraint on letters than content words. The difference between function and content words does not take effect, however, until the first two letters of the word are given. Using the prediction data from words preceded by long context, extrapolations of constraint out to the tenth letter were obtained. From the values of constraint at the first ten letter positions it was possible to estimate the maximum unilateral sequential constraint in English. A value of about 48% was obtained which compares with previous estimates of 50%. A further evaluation of the overall effect of context indicates that about 81% of the constraint in English is contained within the words themselves, and the other 19% is due to any additional context.This paper is based on a dissertation submitted to the Department of Psychology, The Johns Hopkins University, in partial fulfillment of the requirements for the Ph. D. degree. The research was done under Contract Nonr-248(55) between the Office of Naval Research and The Johns Hopkins University. This is Report No. 13 under that contract. Reproduction in whole or in part is permitted for any purpose of the United States Government.During the period of this investigation the author was a National Institutes of Health Fellow. The author wishes to thank Wendell R. Garner for his encouragement and advice.     

Genetic mapping of 18s ribosomal RNA-related loci to mouse Chromosomes 5, 6, 9, 12, 17, 18, 19, and X

The organization of ribosomal RNA genes (rDNA) in the genome of the mouse varies significantly from one strain to another, but has been shown to follow the pattern of clusters of tandem repeats located at chromosome ends, often associated with cytological nucleolus organizer regions. The number of copies of the repeat unit at each locus also varies. A probe for the 18S ribosomal RNA sequence on Southern blots reveals both high copy number bands and fainter bands indicative of low repeat number. We have mapped a number of newly identified low-copy-number rDNA loci in C57BL/6J, in addition to placing some of the NOR-associated rDNA repeats on the Jackson interspecific backcross (BSS) map. We suggest that additional low-copy-number loci may remain to be mapped, and that the evolution of rDNA loci in the genome may include the proliferation of single copies by retroinsertion or other mechanisms. Received: 23 February 1996 / Accepted: 29 July 1996     

A tribute to Fritz-Albert Popp on the occasion of his 70th birthday

On May 11, 2008 the German biophysicist Professor Fritz-Albert Popp will celebrate his 70th birthday. This is a welcome occasion to pay tribute to the scientific achievements and human qualities of a scientist whose merits as one of the founders of biophotonics and as a pioneer of quantum biophysics increasingly find appreciation internationally.     

Als ‘A’ niet meer als ‘a’ wordt herkend. Een analyse van verworven woordblindheid

A right-handed patient, aged 72, manifested alexia without agraphia, a right homonymous hemianopia and an impaired ability to identify visually presented objects. He was completely unable to read words aloud and severely deficient in naming visually presented letters. He responded to orthographic familiarity in the lexical decision tasks of the Psycholinguistic Assessments of Language Processing in Aphasia (PALPA) rather than to the lexicality of the letter strings. He was impaired at deciding whether two letters of different case (e.g., A, a) are the same, though he could detect real letters from made-up ones or from their mirror image. Consequently, his core deficit in reading was posited at the level of the abstract letter identifiers. When asked to trace a letter with his right index finger, kinesthetic facilitation enabled him to read letters and words aloud. Though he could use intact motor representations of letters in order to facilitate recognition and reading, the slow, sequential and error-prone process of reading letter by letter made him abandon further training.     

Eye Exercises Enhance Accuracy and Letter Recognition,but Not Reaction Time,in a Modified Rapid Serial Visual Presentation Task

Eye exercises have been prescribed to resolve a multitude of eye-related problems. However, studies on the efficacy of eye exercises are lacking, mainly due to the absence of simple assessment tools in the clinic. Because similar regions of the brain are responsible for eye movements and visual attention, we used a modified rapid serial visual presentation (RSVP) to assess any measurable effect of short-term eye exercise in improvements within these domains. In the present study, twenty subjects were equally divided into control and experimental groups, each of which performed a pre-training RSVP assessment where target letters, to which subjects were asked to respond to by pressing a spacebar, were serially and rapidly presented. Response time to target letters, accuracy of correctly responding to target letters, and correct identification of target letters in each of 12 sessions was measured. The experimental group then performed active eye exercises, while the control group performed a task that minimized eye movements for 18.5 minutes. A final post-training RSVP assessment was performed by both groups and response time, accuracy, and letter identification were compared between and within subject groups both pre- and post-training. Subjects who performed eye exercises were more accurate in responding to target letters separated by one distractor and in letter identification in the post-training RSVP assessment, while latency of responses were unchanged between and within groups. This suggests that eye exercises may prove useful in enhancing cognitive performance on tasks related to attention and memory over a very brief course of training, and RSVP may be a useful measure of this efficacy. Further research is needed on eye exercises to determine whether they are an effective treatment for patients with cognitive and eye-related disorders.     

Neural Correlates of Letter Reversal in Children and Adults

Children often make letter reversal errors when first learning to read and write, even for letters whose reversed forms do not appear in normal print. However, the brain basis of such letter reversal in children learning to read is unknown. The present study compared the neuroanatomical correlates (via functional magnetic resonance imaging) and the electrophysiological correlates (via event-related potentials or ERPs) of this phenomenon in children, ages 5–12, relative to young adults. When viewing reversed letters relative to typically oriented letters, adults exhibited widespread occipital, parietal, and temporal lobe activations, including activation in the functionally localized visual word form area (VWFA) in left occipito-temporal cortex. Adults exhibited significantly greater activation than children in all of these regions; children only exhibited such activation in a limited frontal region. Similarly, on the P1 and N170 ERP components, adults exhibited significantly greater differences between typical and reversed letters than children, who failed to exhibit significant differences between typical and reversed letters. These findings indicate that adults distinguish typical and reversed letters in the early stages of specialized brain processing of print, but that children do not recognize this distinction during the early stages of processing. Specialized brain processes responsible for early stages of letter perception that distinguish between typical and reversed letters may develop slowly and remain immature even in older children who no longer produce letter reversals in their writing.     

Visual crowding is correlated with awareness

Crowding by nearby features causes identification failures in the peripheral visual field. However, prominent visual features can sometimes fail to reach awareness, causing scenes to be incorrectly interpreted. Here we examine whether awareness of the flanking features is necessary for crowding to occur. Flankers that were physically present were rendered perceptually absent with adaptation-induced blindness. In a letter identification task, targets were presented unflanked or with up to four flanker letters. On each trial, observers reported both the number of letters they perceived and the identity of a target letter. This paradigm allowed trial-by-trial assessment of awareness and crowding and ensured that both targets and flankers were attended. Target-letter identification performance was correlated with the number of flanking letters that were perceived on a given trial, regardless of the number that were physically present. Our data demonstrate that crowding can be released when flanking elements at attended locations are suppressed from visual awareness.