Influence of Royal College of Radiologists' guidelines on referral from general practice. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on general practitioner referrals for radiography of introducing guidelines of good practice together with monitoring and peer review. DESIGN--Collection of referral data during 1 January 1989 to 31 December 1990. Guidelines were introduced on 1 January 1990. SETTING--Open access radiology services provided by one non-teaching district in England. SUBJECTS--144614 registered patients from 22 practices. MAIN OUTCOME MEASURES--Number of referrals per 1000 registered patients for radiography of the chest, skull, spine, abdomen, limbs, and joints and for barium investigation and excretion urography. RESULTS--Overall referrals fell from 88.4/1000 registered patients to 77.2/1000 after the guidelines were introduced. The commonest reasons for referral were for examination of the chest, spine, and limbs and joints and referrals for these fell by 9.4%, 17.5%, and 13.5% respectively. Referrals for skull radiography fell by 30% (from 241 to 168). CONCLUSIONS--By helping general practitioners to be more selective in their use of diagnostic radiology, the guidelines reduced the rate of referral and thus patients'' exposure to radiation.     

Radiography of injured arms and legs in eight accident and emergency units in England and Wales. Royal College of Radiologists Working Party.

The use of radiography of the arms and legs (extremity radiography) in 32936 patients attending eight accident and emergency units was studied. Although extremity radiography was satisfactory in terms of cost per bony injury detected (40 pounds), considerable differences between centres in the predicted and actual yields of bony injury were observed. Guidelines for selection of patients for extremity radiography would reduce variability in its use and improve the quality of present practice.     

Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London,Royal College of Surgeons of England,Royal College of Anaesthetists,Association of Surgeons,the British Society of Gastroenterology,and the Thoracic Society of Great Britain.

Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.     

Patient care and the general practitioner. Joint Working Party of the Welsh Council of the Royal College of General Practitioners and the Welsh General Medical Services Committee.

The role of general practitioners is being redefined in the light of the emphasis on more care in the community, economic factors, and patients'' expectations. The strength of general practice lies in the doctor-patient relationship; this strength must not be lost sight of. Specific tasks of the general practitioner include the responsibility for the care of individuals; the role of gatekeeper; broad knowledge of curative, preventive; and rehabilitative medicine; teamwork; management; and development of population based strategies. Future work patterns include the general practitioner first and foremost as a clinician and an integrator of health services, but they also involve audit, education and training, research, management, and relations with organisations in the public, private, and voluntary sectors. It is important to make changes only when they benefit patients and to maintain the principle of equity of access to care.     

Cefoxitin: a hospital study.

Cefoxitin is a new cephamycin antibiotic that has recently become available for clinical trial. We report here the results of an uncontrolled trial of cefoxitin treatment in 31 hospital patients with various acute infections, 20 of whom were cured. Serum, urine, and bile concentrations of cefoxitin greatly exceeded the minimum inhibitory concentration (MIC) required for clinically important Gram-negative organisms. We conclude that cefoxitin will have a place in the management of serious infections, particularly in the abdominal cavity and renal tracts.     

A study in test reproducibility between laboratories: Report of a Pseudomonas Working Party

The results are reported of a collaborative study in laboratories of 17 tests commonly used for pseudomonads, together with statistical analysis of the results in the form of analyses of variance. The studies involved 59 strains. The following tests showed good or reasonably good consistency between different laboratories: motility if checked by a Craigie tube, growth at 4 C, production of fluorescin, oxidation of glucose and sucrose, gluconate oxidation, hydrolysis of aesculin, arginine and casein, and gelatin hydrolysis by the tube method. The following were less satisfactory: shape, size and arrangement of organismis, growth at 42 C, oxidase, acid from lactose, reduction of nitrate, acetic acid from ethanol, gelatin hydrolysis by the plate method, and the egg yolk reaction. The following showed poor consistency or noticeable difficulties in performing or interpreting results of the test: growth at 37 C, the denitrification test of Stanier, Palleroni and Doudoroff, and hydrolysis of urea. However, with several of the unsatisfactory tests the replicates within a laboratory showed much better reproducibility. This (together with other evidence on the importance of exact control of variables such as temperature, and time of reading, and the occurrence of mutants in some strains) suggests that careful attention to standardization may give much better testing methods. The considerable value of statistical analyses in such work is discussed.     

Adult advanced cardiac life support: the European Resuscitation Council guidelines 1992 (abridged). European Resuscitation Council Working Party.

The European Resuscitation Council, established in 1990, is committed to saving lives by improving standards of cardiopulmonary resuscitation across Europe and coordinating the activities of interested organisations and individuals. In this regard the council has successfully brought together physicians and surgeons from eastern and western Europe and, in addition, has established relations with the American Heart Association and equivalent organisations in Canada, Australia, and South Africa. A main objective of the European Resuscitation Council is to produce guidelines for cardiopulmonary and cerebral resuscitation, and in this paper members of a working party of 14 experts from 11 countries set out an abridged version of the council''s guidelines for adult advanced cardiac life support. The council hopes that the guidelines and accompanying algorithms will serve as a ready use "how to do it" for ordinary practitioners and paramedics inside and outside hospital.     

Medical practice guidelines: lessons from the United States.

Clinical guidelines, or protocols, have been devised by many different groups, often with differing aims. Some aim to reduce variations in care by using guidelines, while others seek to improve outcomes. Guidelines have long been used in the United States to try to control the behaviour of the medical profession--and the cost of health care. The "effectiveness initiative," run by the Agency for Health Care Policy and Research spawned much activity among other groups, including the American Medical Association and the American College of Physicians. The experience of the Americans in analysing data to gauge effectiveness and then in disseminating good practice may help British moves in this direction. In particular, it is often hard to get guidelines adopted in practice; doctors have to be exposed to the same message in different forms. Also guidelines must not be unrealistic: those devised by senior doctors away from the realities of day to day practice are likely to fail.     

Bacteriology of abscesses of the central nervous system: a multicentre prospective study.

Pus from 46 patients with abscesses of the central nervous system (CNS) was examined for bacteria; bacteria were found in all patients. Streptococci were isolated from 36 patients and most isolates were Streptococcus milleri, Lancefield Group F, Ottens and Winkler type O III. Staphylococci were isolated from nine patients, organisms of the bacteroides group from 11, Proteus spp from seven, Klebsiella aerogenes from one, and Haemophilus aphrophilus from one. Pure cultures predominated over mixed cultures. Streptococci were isolated from abscesses of all types, and at all sites, but members of the Enterobacteriaceae and of the bacteroides group were isolated, in mixed cultures, principally from abscesses of the temporal lobe secondary to infection of the middle ear. Staphylococci predominated in abscesses that followed accidental or surgical trauma. Compared with fully sensitive control organisms, microbes infecting half the patients were resistant to penicillin. The prognosis of abscess of the CNS is grave, and the microbiological findings have important consequences for treatment. Prompt inoculation of specimens to culture plates and prompt incubation are mandatory if bacteria are to be cultured. Inhibitors of antimicrobial agents should be added to culture media if antibiotics have been administered. Provided that the site of the abscess and the antecedent history are ascertainable, the neurosurgeon should be able to start appropriate treatment while awaiting the results of culture.