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Many rheumatologists are concerned at the number of return visits being made to their out-patient clinics. This study investigates the outcome of 179 general practitioner referrals to two rheumatology clinics during 1987. Forty-one (34%) of the rheumatoid arthritis patients and six (10%) of the osteoarthritis patients made four or more visits. Junior staff discharged far fewer (11-18%) of patients than did consultants (34%). Multiple linear and multiple logistic regression analyses were performed for the demographic and clinical variables which seemed (on univariate analyses) to predict continuing attendance. The maximum disease severity, diagnosis of rheumatoid arthritis, male sex, patient's perceived reason for referral and the hospital clinic only explained 21% of the variation in the number of visits made. Most of the factors influencing hospital clinic doctors are not easily apparent. The data suggested only one method of reducing unnecessary out-patient attendances, namely to increase the number of patients seen by a consultant. Differences in 'clinic policies' and individual doctor's decision-making strategies will require further study.

A case of a duodeno-ureteric fistula in a man of 46 years is described. This is a rare condition, only 2 previous cases having been reported. The patient did not agree to operation and no tissue is available for histological examination. However, reasons are given for believing this to be the first case in which the primary pathology is in the duodenum.

Summary A randomized trial has compared the results of brush cytology before or after biopsy in patients with solitary gastric lesions. One hundred and eleven carcinomas were identified in 324 patients. False positive histological reports were recorded in 2 patients but there were no false positive cytology results. The cumulative accuracy of biopsy and cytology in patients with carcinoma was 97 per cent, which was significantly better than biopsy alone (83 per cent, P < 0.001) or cytology alone (87 per cent, P < 0.001). The cumulative results of brushing before biopsy were significantly better than results obtained by brushing after biopsy (P < 0.05) and indicate that brush cytology should normally be performed before biopsy.

The effect of local controlled cooling on the digital systolic blood pressure in the hand was studied in 25 healthy volunteers and 25 patients with Raynaud's syndrome. Arterial systolic pressure was indirectly measured using a digital cuff over the proximal phalanx and a photoplethysmographic probe over the digital pulp to detect pulsation. Pressures were measured after occlusion of the circulation (cuff at 180 mmHg) for 5 minutes with water circulating initially at 30°C and then at 10°C. An airfilled cuff was used simultaneously on a control finger. The digital systolic pressure at 10°C in the patients was significantly lower (P < 0·001 Mann–Whitney U test) than in the normal volunteers whilst calculation of the percentage change in pressure induced by cooling the digit to 10°C allowed complete separation between both groups. The range in the controls was +2 per cent to −26 per cent and in the patients, −33 per cent to −100 per cent. The test gives reproducible results (coefficient of variation 5–11 per cent) and offers an objective method of identifying patients with excessive vasospasm due to a cold stimulus. It may prove useful in studying natural history and the effect of drug therapy.