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Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice.
OBJECTIVES: To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses. DESIGN: Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course. SETTING: Group general practice in Newcastle upon Tyne. DATA SOURCES: The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified. DATA EXTRACTION: Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence. RESULTS: 114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI -1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% (-3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library. CONCLUSIONS: Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.
Diabetes care in general practice: meta-analysis of randomised control trials.
OBJECTIVE: To assess the effectiveness of care in general practice for people with diabetes. DESIGN: Meta-analysis of randomised trials comparing general practice and shared care with follow up in hospital outpatient clinic. IDENTIFICATION: Trials were identified from searches of eight bibliographic and research databases. RESULTS: Five trials identified included 1058 people with diabetes, overall mean age 58.4 years, receiving hospital outpatient follow up for their diabetes. Results were heterogeneous between trials. In shared care schemes featuring more intensive support through a computerised prompting system for general practitioners and patients, there was no difference in mortality between care in hospital and care in general practice (odds ratio 1.06, 95% confidence interval 0. 53 to 2.11); glycated haemoglobin tended to be lower in primary care (weighted difference in means of -0.28%, -0.59% to 0.03%); and losses to follow up were significantly lower in primary care (odds ratio 0.37, 0.22 to 0.61). However, schemes with less well developed support for family doctors were associated with adverse outcomes for patients. CONCLUSIONS: Unstructured care in the community is associated with poorer follow up, worse glycaemic control, and greater mortality than in hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good as or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of selected people with diabetes by willing general practitioners. This can be achieved if suitable organisation is in place.
Changes in Injection‐site Blood Flow and Plasma Free Insulin Concentrations in Response to Stress in Type 1 Diabetic Patients
In order to test the effect of stress on injection‐site blood flow and blood glucose control, 16 C‐peptide negative patients were studied on a stress day, when a 30‐min Stroop Colour‐Word Test was completed, and a control day, when a cartoon was shown. Unmodified insulin was injected subcutaneously into the thigh before the test, and injection‐site blood flow measured throughout the experiment with a thermal clearance probe. Blood glucose and plasma free insulin, glucagon, growth hormone, cortisol, and catecholamines were measured at intervals before, during, and after stress. Patients showed a significant overall rise in injection‐site blood flow with the Stroop test from 4.1 (SD 1.6) to 5.2 (1.8) ml 100‐g−1 min−1 (increase 38.1 (37.8) %, p < 0.001). There was no overall significant difference between stress and control days in blood glucose or plasma free insulin levels, with differences in mean blood glucose levels during stress between the 2 days varying from −4.2 mmol l−1 to +6.3 mmol l−1 in individual patients. The increase in injection‐site blood flow with stress correlated significantly with the increase in plasma free insulin concentration both during (r = 0.55) and after stress (r = 0.71). Differences in blood glucose concentration between stress and control day for each patient showed strong correlation with differences in plasma free insulin both during (r = −0.73) and after stress (r = −0.79). Differences in counter‐regulatory hormones occurred but correlated poorly with blood glucose difference. Thus, stress affects the blood flow at the injection site, and this in turn affects insulin absorption. Most of the blood glucose response to stress is explained by changes in free insulin concentration. 1992 Diabetes UK
From Kafka to Casualty: Doctors and medicine in popular culture and the arts - A special studies module
This paper describes and reflects on the content and teaching methods of a two-week medical humanities special studies module (SSM) taken by third-year students at the Royal Free & University College Medical School. It aims to add to the common pool of knowledge, and will be of use to people who are considering setting up something similar.
RCGP quality team development programme: An illuminative evaluation
Background: There is increasing interest in quality initiatives that are locally owned and delivered, team based, multiprofessional, and formative. The Royal College of General Practitioners' Quality Team Development (QTD) programme is one such initiative aimed at developing primary healthcare teams and their services. Aims: To evaluate QTD from the perspective of participants and assessors. Setting: UK primary health care. Design and method: Twelve of 14 practices and all four primary care organisations (PCOs) approached agreed to participate. Thirty four semi-structured interviews were conducted with key stakeholders. The interviews were taped, transcribed, and analysed using the constant comparative method. Results: The QTD programme appears to be highly valued by participating organisations. Practice based respondents perceived it as acceptable and feasible, and reported positive changes in teamwork and patient services. They valued its formative, participative, and multiprofessional nature, especially the peer review element. PCOs saw QTD as a method of delivering on prevailing national policies on clinical quality and modernisation agendas as well as promoting interorganisational collaboration. The main concerns raised were the workload, particularly for assessors, and maintaining the quality of the assessments and the programme. Conclusion: This qualitative study suggests positive benefits for participants in the QTD programme. However, such practices are a self-selecting innovative minority. Further research is needed on more typical practices to identify barriers to their participation in QTD or other formative, team based quality improvement programmes.
Randomized trial of inhaled fluticasone propionate in chronic stable pulmonary sarcoidosis: a pilot study
Pulmonary sarcoidosis is a disease in which the pathological processes are distributed along lymphatic pathways, particularly those around the bronchovascular bundles. Delivery of disease-modulating drugs by the inhaled route is therefore an attractive option. The aim of this study was to determine the efficacy of inhaled fluticasone propionate 2 mg x day(-1) in adults with stable pulmonary sarcoidosis. Forty-four adult patients (22 from each centre) were enrolled from outpatient clinics in two London teaching hospitals in a two centre, double-blind, randomized, placebo-controlled trial. Primary end points were home recordings of peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), and forced vital capacity (FVC). Secondary end points were symptom scores, use of rescue bronchodilator medication, and clinic values for PEFR, FEV1, FVC, forced mid-expiratory flow (FEF25-75%), diffusion capacity of the lung for carbon monoxide (DL,CO), and total lung capacity (TLC). Symptom scores of cough, breathlessness and wheeze were lower in the active treatment group, but this did not reach statistical significance, and a general health perception assessment (Short Form (SF)-36) showed a difference between active and placebo treatment. No significant differences were found between the two groups in any physiological outcome measure. No new adverse reactions were detected. The results of this pilot study do not show an objective benefit of inhaled fluticasone propionate in pulmonary sarcoidosis where the disease is stable and is controlled without the use of inhaled corticosteroids.