Access to specialist gastroenterology care in Canada: the Practice Audit in Gastroenterology (PAGE) Wait Times Program.

BACKGROUND: Canadian wait time data are available for the treatment of cancer and heart disease, as well as for joint replacement, cataract surgery and diagnostic imaging procedures. Wait times for gastroenterology consultation and procedures have not been studied, although digestive diseases pose a greater economic burden in Canada than cancer or heart disease. METHODS: Specialist physicians completed the practice audit if they provided digestive health care, accepted new patients and recorded referral dates. For patients seen for consultation or investigation over a one-week period, preprogrammed personal digital assistants were used to collect data including the main reason for referral, initial referral and consultation dates, procedure dates (if performed), personal and family history, and patient symptoms, signs and test results. Patient triaging, appropriateness of the referral and timeliness of care were noted. RESULTS: Over 10 months, 199 physicians recorded details of 5559 referrals, including 1903 visits for procedures. The distribution of total wait times (from referral to procedure) nationally was highly skewed at 91/203 days (median/75th percentile), with substantial interprovincial variation: British Columbia, 66/185 days; Alberta, 134/284 days; Ontario, 110/208 days; Quebec, 71/149 days; New Brunswick, 104/234 days; and Nova Scotia, 42/84 days. The percentage of physicians by province offering average-risk screening colonoscopy varied from 29% to 100%. DISCUSSION: Access to specialist gastroenterology care in Canada is limited by long wait times, which exceed clinically reasonable waits for specialist treatment. Although exhibiting some methodological limitations, this large practice audit sampling offers broadly generalized results, as well as a means to identify barriers to health care delivery and evaluate strategies to address these barriers, with the goals of expediting appropriate care for patients with digestive health disorders and ameliorating the personal and societal burdens imposed by digestive diseases.

Access to specialist gastroenterology care in Canada: comparison of wait times and consensus targets.

BACKGROUND: Monitoring wait times and defining targets for care have been advocated to improve health care delivery related to cancer, heart, diagnostic imaging, joint replacements and sight restoration. There are few data on access to care for digestive diseases, although they pose a greater economic burden than cancer or heart disease in Canada. The present study compared wait times for specialist gastroenterology care with recent, evidence-based, consensus-defined benchmark wait times for a range of digestive diseases. METHODS: Total wait times from primary care referral to investigation were measured for seven digestive disease indications by using the Practice Audit in Gastroenterology program, and were benchmarked against consensus recommendations. RESULTS: Total wait times for 1903 patients who were undergoing investigation exceeded targets for those with probable cancer (median 26 days [25th to 75th percentiles eight to 56 days] versus target of two weeks); probable inflammatory bowel disease (101 days [35 to 209 days] versus two weeks); documented iron deficiency anemia (71 days [19 to 142 days] versus two months); positive fecal occult blood test (73 days [36 to 148 days] versus two months); dyspepsia with alarm symptoms (60 days [23 to 140 days] versus two months); refractory dyspepsia without alarm symptoms (126 days [42 to 225 days] versus two months); and chronic constipation and diarrhea (141 days [68 to 264 days] versus two months). A minority of patients were seen within target times: probable cancer (33% [95% CI 20% to 47%]); probable inflammatory bowel disease (12% [95% CI 1% to 23%]); iron deficiency anemia (46% [95% CI 37% to 55%]); positive occult blood test (41% [95% CI 28% to 54%]); dyspepsia with alarm symptoms (51% [95% CI 41% to 60%]); refractory dyspepsia without alarm symptoms (33% [95% CI 19% to 47%]); and chronic constipation and diarrhea (21% [95% CI 14% to 29%]). DISCUSSION: Total wait times for the seven indications exceeded the consensus targets; 51% to 88% of patients were not seen within the target wait time. Multiple interventions, including adoption of evidence-based management guidelines and provision of economic and human resources, are needed to ensure appropriate access to digestive health care in Canada. Outcomes can be evaluated by the 'point-of-care', practice audit methodology used for the present study.

In vitro and in vivo effects of formamidines in locust (Locusta migratoria migratorioides).

In vivo and in vitro experiments were used to study the effects of formamidines in the locust, Locusta migratoria migratorioides. In vivo the lethal and the antifeeding effects, in vitro the inhibition of the binding of a selective 3H-ligand to the receptors of octopamine, tyramine, dopamine, serotonin and gamma-amino butiric acid were studied. We have demonstrated that demethylchlordimeform is specific agonist to octopamine receptor, having high affinity to octopamine receptor, a moderate affinitiy to tyramine receptor and a low affinity to dopamine, serotonin and to gamma-amino butiric acid receptors. The demethylated chlordimeform analogoues, demethylchlordimeform and didemethylchlordimeform have higher affinity to the octopamine receptor than the parent compound. The formamidines had a toxic and an antifeeding effects when injected into the locust. The half lethal doses (LD50) and the feeding inhibition were correlated with the affinity of the compounds (Ki). The ring substitutions of the mulecule have alterated the both affinity and in vivo effect of the compounds. The most effective ring substitution pattern is 2,4-disubstitution with a combination of methyl groups or halogens. Our results suggest that the lethal effect of formamidines is mediated through the octopamine receptor.

Determination of structure-activity relationships of Annonaceous acetogenins by inhibition of oxygen uptake in rat liver mitochondria.

A new group of natural compounds, the Annonaceous acetogenins, have recently been determined to inhibit ATP production at a similar site of action and higher levels of potency as rotenone, i.e., at NADH-ubiquinone oxido-reductase, complex I of the mitochondrial electron-transport chain. The acetogenins had earlier been determined to be pesticidal, antimalarial, antimicrobial, anti-parasitic, cytotoxic, and in vivo active as potentially new antitumor agents. In order to determine structural activity relationships (SARs) among these compounds, at the subcellular level, several available acetogenins have been tested. Data obtained, from the inhibition of oxygen consumption by rat liver mitochondria, demonstrated that all of the twenty acetogenins tested are active with IC50 values in the range of 15-800 nM/mg protein. The IC50 value of rotenone was 17 nM/mg protein. The bis-adjacent THF ring acetogenins and the bis-nonadjacent THF ring compounds are about ten times more active than the mono-THF ring acetogenins. Overall, 30-OH and 31-OH-bullatacinone were the most active and were slightly more active than rotenone. The least active were the 4-deoxy bis-adjacent THF ring compounds followed by the mono-THF ring group. There was some variation between the groups, e.g., within the bis-adjacent and mono-THF ring groups, the alpha, beta-unsaturated-gamma-lactones were less active than the keto-lactones, but this observation was reversed for one of the pairs of bis-nonadjacent THF ring acetogenins. Additional hydroxylations, to a maximum of three, seemed to increase activity within all of the groups. Before final decisions on SARs can be made, additional comparisons of the results of this subcellular assay (as an in vitro assay) with the results of in vivo assays should be made. Also, future investigations into the exact site of action within complex I and other possible sites of action (such as the NADH oxidase of plasma membranes) need to be conducted for a more. complete understanding of the utility and potential of this new group of very potent compounds.

Mode of action of bullatacin: a potent antitumor and pesticidal annonaceous acetogenin.

Bullatacin, a compound isolated from plants of the Annonaceae, and its analogues show in vivo potential as antitumor agents based on their efficacy in normal mice bearing L1210 murine leukemia and athymic mice bearing A2780 conventional ovarian cancer xenografts. These compounds also have interesting potential as insecticides and inhibit respiration in insect-derived Sf9 cells with high potency. Their toxicity in both cases probably arises from their strong inhibition of mitochondrial electron transport with a specific action at complex I.

Characterization of the pH-mediated solubility of Bacillus thuringiensis var. san diego native delta-endotoxin crystals.

Native crystals of Bacillus thuringiensis var. san diego, a coleopteran-specific delta-endotoxin, were metabolically labelled with [35S]methionine. Specific activity was 82,000 CPM/micrograms (2.44 Ci/mmol). Using a universal buffer formulated with the same ionic strength at every pH, we determined that native crystals dissolve above pH 10 and below pH 4. At the acidic pH, the rate of solubilization was substantially slower than at the alkaline pH. Recrystallization rates for the toxin were similar regardless of solubilization conditions. The banding patterns in denatured polyacrylamide gel electrophoresis were unaffected by solubilization conditions. Toxicity was higher for soluble toxin compared to crystal toxin, but virtually identical for the acidic and alkaline produced solutions. Acid solubilization is significant because of the acidic midgut of susceptible Coleoptera.

Inhibition of insect acetylcholinesterase by the potato glycoalkaloid alpha-chaconine.

Homogenates from several insect species were assayed for inhibition of acetylcholinesterase by the potato glycoalkaloid alpha-chaconine. Colorado potato beetle acetylcholinesterase was up to 150-fold less sensitive than other species tested. Acetylcholinesterase from an insecticide-resistant strain of Colorado potato beetles was more sensitive to inhibition than the susceptible strain. Most insect species tested had inhibitory concentrations causing a 50% reduction in activity in the 5 to 40 microM range. Sensitive insect acetylcholinesterases were similar to mammalian cholinesterases in their response to alpha-chaconine. The results indicate that pesticides and host plant resistance factors may interact at the same target. Changes in the target due to selection pressure from either pesticides or host plant resistance factors could affect the efficacy of both control strategies.

XAMI and DCDM, agonists at cAMP-associated octopamine receptors in cockroach nerve cord, produce centrally mediated antinociception in mice.

The ability of XAMI (2,3-xylylaminomethyl-2'-imidazoline), the most potent agonist of cAMP-associated octopamine-sensitive adenylate cyclase in cockroach (Periplaneta americana) nerve cord yet reported, and DCDM (N-demethylchlordimeform), a partial octopamine agonist in this preparation, to produce centrally mediated antinociception in mice was evaluated. The antinociception produced by these compounds was compared to that previously reported for p-octopamine, a phenylethylamine and endogenous mammalian hydroxyphenolic analog of norepinephrine. Consonant with the reported greater agonistic activity of XAMI on octopamine-sensitive adenylate cyclase, XAMI was more potent than p-octopamine by spinal or supraspinal administration in the abdominal constriction test (E50 = 0.013 micrograms i.t., 1.45 micrograms i.c.v.) and in the 48 degrees C hot-plate test (ED50 = 0.06 micrograms i.t., 0.4 micrograms i.c.v.), but was inactive in the tail-flick test (up to 4.0 micrograms i.c.v. or i.t.). Unlike p-octopamine, both XAMI and DCDM were active by peripheral routes of administration. DCDM was orally active in the mouse acetylcholine-induced abdominal constriction test (ED50 = 9.98 mg/kg p.o.) and was active via the s.c. route in this test (ED50 = 2.36 mg/kg), the 48 degrees C hot-plate test (ED50 = 5.40 mg/kg) and the tail-flick test (ED50 between 15 and 30 mg/kg). It appeared to be a full agonist against these endpoints. XAMI produced dose-related antinociception in the abdominal constriction test (ED50 = 0.10 mg/kg s.c.) and in the 48 degrees C hot-plate test (ED50 = 3.71 mg/kg p.o. and 0.46 mg/kg s.c.), where the antinociceptive response persisted for at least 60 min following subcutaneous or oral administration. Both compounds were less potent via peripheral routes than clonidine (as reference) in these tests. Mechanistically, XAMI-induced antinociception was antagonized by yohimbine and idazoxan, but not the opiate antagonist naloxone.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution and pharmacological characterization of muscarinic-cholinergic receptors in the cockroach brain.

The binding of [3H]quinuclidinyl benzilate to a cockroach brain preparation was investigated. Specific binding was saturable with a Kd of 0.25 nM and Scatchard analysis indicated a Bmax of 604 pmol/mg protein. Kinetic analysis indicated that the ligand is binding in a complex fashion while dissociation followed a simple kinetic process. The pharmacology of the site was typical of muscarinic receptors but the site cannot be characterized in terms of vertebrate muscarinic-receptor subtypes. Affinity of the receptor for agonists was modulated by Mg2+ and guanylylimidodiphosphate but not by pertussis toxin indicating the involvement of a pertussis-toxin insensitive G-protein. Carbamylcholine did not inhibit basal or forskolin-stimulated adenylate cyclase activity. The binding site was localized autoradiographically and was restricted to the median and lateral calyces of the brain.

Octopamine uptake and metabolism in the insect nervous system.

Several insect tissues were examined for their ability to take up octopamine in the presence and absence of sodium ions. The cockroach Malpighian tubules, ovary, and ventral nerve cord showed the highest level of sodium-dependent uptake. The adult firefly lantern exhibited substantial sodium-independent uptake. Some of these tissues were also examined for their ability to metabolize octopamine by N-acetylation. Measurable N-acetyltransferase activity was present in the cockroach ventral nerve cord, tobacco hornworm CNS, and firefly light organ. N-Acetylation is proposed to be the major metabolic pathway for octopamine in the cockroach (Periplaneta americana) nervous system. Several classes of compounds, including octopamine receptor agonists, tricyclic antidepressants, amphetamines, chloroethylbenzylamines, and some experimental insecticides, were tested for their ability to inhibit octopamine uptake and metabolism. The sodium-insensitive component of uptake was not inhibited by most compounds tested, but the sodium-sensitive component was strongly inhibited by xylamine, N-ethyl-N-chloroethyl-o-bromobenzylamine, and their aziridinium ions (60-100%). These compounds also effectively inhibited N-acetyl-transferase (IC50 values at or below 1 microM). Other good inhibitors of N-acetyltransferase included desipramine, synephrine, and an experimental insecticide, CGA 132427. Formamidine pesticides had limited effect on both processes, and neither action seems likely to be involved in their octopaminergic actions in vivo. Cocaine was unique in stimulating N-acetyltransferase activity. When inhibition of sodium-sensitive uptake is compared with inhibition of N-acetyltransferase in the cockroach ventral nerve cord, two groups of inhibitors are discernible. Type 1 compounds inhibit uptake without an effect on N-acetyltransferase, whereas type 2 compounds inhibit both processes. These results suggest a functional linkage between the uptake and acetylation of octopamine.

Cinnamyl derivatives and monoterpenoids as nonspecific ovipositional deterrents of the onion fly.

Laboratory dose-response choice tests and discriminate-dosage bioassays revealed wide variation in the effectiveness of cinnamyl, cinnamoyl, monoterpene, and phenethyl alcohol derivatives as ovipositional deterrents toDelia antiqua (Meigen), the onion fly. (E)-Cinnamic acids were not detectably deterrent. When formulated in particles of polyethylene glycol, (E)-cinnamaldehyde had a BR90 (concentration eliciting 90% deterrency) of 1.0% and (E)-4-methoxycinnamaldehyde had a BR90 of 0.38%. Among nine monoterpenoids tested,p-cymene was inactive, citronellal had a BR90 of 3.7%, and terpinene-4-ol had a BR90 of 0.46%. Para-substituted phenethyl alcohols gave increasing deterrence in the order: -NO2, CH3O-, -Cl, -CH3, -H. Wide varieties of structures were deterrent: C-8 to C-13, intermediate in polarity, and possessing either oxygen-containing or nitrile functional groups. The air concentration of (E)-cinnamaldehyde at its BR90 was 1.7 ng/ml. This relatively high concentration, the diversity in deterrent structures, and the lack of differences in deterrency among positional and optical isomers suggest that ovipositional deterrency in onion flies is mediated by receptors broadly tuned for detecting phenylpropenoid, phenolic, monoterpenoid, and perhaps other classes of allelochemicals.

The bradycardic and mydriatic effects of chlordimeform and its demethylated analogs in the rat: antagonism by idazoxan but not by prazosin.

Pupillary and cardiac responses to i.v. injections of chlordimeform (CDM, 0.3-10 mg/kg), a formamidine insecticide, and its metabolites demethylchlordimeform (DCDM, 0.03-1 mg/kg) and didemethylchlordimeform (DDCDM, 0.1-3 mg/kg) were studied in rats anesthetized with pentobarbital. Both CDM and DCDM induced a dose-dependent mydriasis and bradycardia and DCDM was 10 times more potent than CDM in causing these effects. In contrast, DDCDM did not induce a mydriasis or bradycardia. The alpha 2-adrenoreceptor antagonist, idazoxan (0.2 mg/kg, i.v.) abolished or reduced CDM- and DCDM-induced mydriasis and bradycardia, whereas the alpha 1-adrenoreceptor antagonist, prazosin (1.5 mg/kg, i.v.) did not change these effects of CDM and DCDM. SKF 525-A (50 mg/kg, i.p.), an inhibitor of enzymatic demethylation, administered 10 min before the first dose of CDM, failed to reduce the effects of CDM. The results suggested: 1) the mydriatic and bradycardic effects of CDM and DCDM are mediated by alpha 2-adrenoreceptors, 2) the monodemethylation of CDM increases its alpha 2-adrenoreceptor agonistic activities, but the didemethylation of CDM abolishes these activities, and 3) CDM can exert alpha 2-adrenoreceptor agonistic activities without undergoing a demethylation process.

Receptors for 3H-octopamine in the adult firefly light organ.

3H-Octopamine binds reversibly and with high affinity to sites on adult firefly light organ membranes. The binding is characterized by multiple affinities. Scatchard analysis supported a two site binding model with a tentative Kd value of about 1 nM for the high affinity component. The more abundant lower affinity site had a Kd value of about 60 nM. Guanyl nucleotides (Gpp(NH)p and GTP) greatly reduced the apparent number of octopamine binding sites. Competition studies with known octopaminergic agonists including the formamidine pesticides chlordimeform (CDM) and N-demethyl chlordimeform (DCDM) showed the following rank order of potencies in displacing octopamine: DCDM greater than octopamine = synephrine greater than naphazoline greater than clonidine greater than CDM. It was also observed that phentolamine was much more active than propranolol in antagonizing OA-binding. These relative activities are similar to the abilities of the same compounds to alter adenylate cyclase activity in light organ homogenates. Together with the effect of GTP on binding, these results suggest that the binding sites are functional octopamine receptors of the light organ.

Formamidine pesticides: octopamine-like actions in a firefly.

The formamidine pesticide chlordimeform and its N-demethylated metabolites cause the light organ of the firefly Photinus pyralis L. to glow brightly. Monodemethyl chlordimeform is active at doses as low as 5 nanograms per insect when applied topically. This action is postsynaptic and probably involves membrane-bound receptors since cyproheptadine blocks the glows induced by both monodemethyl chlordimeform and octopamine, the putative neurotransmitter in the light organ. The pesticidal and pestistatic properties of the formamidines may result from actions on octopaminergic systems.