Not so simple cystitis: how should prescribers be supported to make informed decisions about the increasing prevalence of infections caused by drug-resistant bacteria?

Trimethoprim is a safe, effective, and inexpensive treatment for cystitis. However, at least 25% of bacteria isolated from urine samples in general practice are now resistant to trimethoprim in the laboratory. The relationship between laboratory resistance and clinical outcome is complex. Cephalexin appears to be more active than trimethoprim in the laboratory but has been consistently less effective in clinical trials. There is little point in collecting data about the prevalence of drug resistance in urinary bacteria unless it is linked to evidence about the impact of resistance on clinical outcomes. Pragmatic clinical trials are required to provide practices with clear thresholds for managing their antibiotic policies; for example, 'Change from trimethoprim to drug X when the probability of trimethoprim resistance reaches Y%.' Prescribers should be aware that trimethoprim resistance is most likely to occur in patients who have been exposed to trimethoprim or other antibiotics in the previous six months, and that the risk increases with age. This information could be used to stratify women according to risk of infection by trimethoprim-resistant bacteria. Health education leaflets are an effective method for reducing the frequency of recurrent cystitis. Symptomatic treatment can control symptoms and allow time for microbiological investigation. Both of these strategies may help to reduce unnecessary prescribing of antibiotics in general and quinolones in particular.

Pneumothorax during CPR training: case report and review of the CPR literature

Cardiopulmonary resuscitation is taught widely to both lay persons and health care workers. It is a challenging psychomotor skill. Concerns about its safety to the rescuer have centered around the risk of infectious disease exposure. A young nursing assistant developed a minimally symptomatic pneumothorax during CPR training. This case is the first reported example of this complication for a CPR trainee or provider. The literature is reviewed for complications for CPR provider and recipient and the relevant issues regarding the current status and future direction of this intervention.

Evidence-based education: development of an instrument to critically appraise reports of educational interventions

OBJECTIVES

Educational interventions may ultimately impact on patient care as well as affecting individuals' learning. Critical evaluation of educational literature by those involved in designing and developing educational interventions is therefore important. A checklist instrument for critically appraising reports of educational interventions is described.

DESIGN

The instrument was developed by an iterative process and piloted. The instrument consists of nine questions: 1. Is there a clear question which the study seeks to answer? 2. Is there a clear learning need which the intervention seeks to address? 3. Is there a clear description of the educational context for the intervention? 4. Is the precise nature of the intervention clear? 5. Is the study design able to answer the question posed by the study? 6. Are the methods within the design capable of appropriately measuring the phenomena which the intervention ought to produce? 7. Are the outcomes chosen to evaluate the intervention appropriate? 8. Are there any other explanations of the results explored in the study? 9. Are any unanticipated outcomes explained? A worked example is given to illustrate how the instrument can be used in practice.

SETTING

The Department of General Practice in Glasgow.

SUBJECTS

Young general practitioners and the Educational Journal Club.

RESULTS

The instrument was feasible.

CONCLUSIONS

The use of the checklist allows the reader to critically appraise reports of educational interventions and helps in the practice of evidence-based education.

An information retrieval service to support clinical decision-making at the point of care

The information retrieval systems currently available in general practice, such as Medline, and web search engines are passive and relatively difficult to access during consultations. Emergent technologies, including the National Electronic Library for Health, offer opportunities for more active decision support. We examine the extent to which information retrieval could support primary care consultations by examining the impact of the new technology at different stages of the consultation. We advocate a system whereby professional organisations concerned with quality of care, such as the Royal College of General Practitioners, might contribute the the process.

The Westdoc Internet Questionnaire--a survey of the use of "on-line" resources by West Lothian general practitioners

OBJECTIVE

To investigate the extent to which a representative sample of Scottish GPs used on-line resources for medical applications and their attitudes to various aspects of the technology at a time just prior to the introduction of the Scottish Office Computers offering Internet access to the majority of Scottish practices.

DESIGN

Questionnaire survey.

SETTING

"Out of hours" GP emergency service cooperative.

SUBJECTS

All the (106) GP principals in practice in the Scottish District of West Lothian in June 1997. Locums and Registrars were excluded.

RESULTS

There was an 87% response rate. Nineteen (21%) respondents used the Internet once a month or more, 12(13%) used it to communicate with colleagues by e-mail and 4(4%) with patients. Only 8% found it useful for medical purposes though more than half thought it would be a significant part of practice in five years time. Younger GPs were more likely to use the Internet. Many users expressed concern about reliability of the information and the ease with which it could be applied.

CONCLUSION

By identifying a mismatch between levels of Internet use and the perceived potential of this new technology this study points to the need for training initiatives. It also forms a benchmark against which the uptake of Internet technology by GPs can be measured in years to come.

Stereochemical course and steady state mechanism of the reaction catalyzed by the GDP-fucose synthetase from Escherichia coli

Recently the genes encoding the human and Escherichia coli GDP-mannose dehydratase and GDP-fucose synthetase (GFS) protein have been cloned and it has been shown that these two proteins alone are sufficient to convert GDP mannose to GDP fucose in vitro. GDP-fucose synthetase from E. coli is a novel dual function enzyme in that it catalyzes epimerizations and a reduction reaction at the same active site. This aspect separates fucose biosynthesis from that of other deoxy and dideoxy sugars in which the epimerase and reductase activities are present on separate enzymes encoded by separate genes. By NMR spectroscopy we have shown that GFS catalyzes the stereospecific hydride transfer of the ProS hydrogen from NADPH to carbon 4 of the mannose sugar. This is consistent with the stereospecificity observed for other members of the short chain dehydrogenase reductase family of enzymes of which GFS is a member. Additionally the enzyme is able to catalyze the epimerization reaction in the absence of NADP or NADPH. The kinetic mechanism of GFS as determined by product inhibition and fluorescence binding studies is consistent with a random mechanism. The dissociation constants determined from fluorescence studies indicate that the enzyme displays a 40-fold stronger affinity for the substrate NADPH as compared with the product NADP and utilizes NADPH preferentially as compared with NADH. This study on GFS, a unique member of the short chain dehydrogenase reductase family, coupled with that of its recently published crystal structure should aid in the development of antimicrobial or anti-inflammatory compounds that act by blocking selectin-mediated cell adhesion.

Shaping the future: a primary care research and development strategy for Scotland

Primary care is at the centre of the National Health Service (NHS) in Scotland; however, its R & D capacity is insufficiently developed. R&D is a potentially powerful way of improving the health and well-being of the population, and of securing high quality care for those who need it. In order to achieve this, any Scottish strategy for primary care R&D should aim to develop both a knowledge-based service and a research culture in primary care. In this way, decisions will be made based upon best available evidence, whatever the context. Building on existing practice and resources within primary care research, this strategy for achieving a thriving research culture in Scottish primary care has three key components: A Scottish School of Primary Care which will stimulate and co-ordinate a cohesive programme of research and training. A comprehensive system of funding for training and career development which will ensure access to a range of research training which will ensure that Scotland secures effective leadership for its primary care R&D. Designated research and development practices (DRDPs) which will build on the work of existing research practices, in the context of Local Health Care Co-operatives (LHCCs) and Primary Care Trusts (PCTs), to create a co-operative environment in which a range of primary care professionals can work together to improve their personal and teams' research skills, and to support research development in their areas. A modest investment will create substantial increases in both the quality and quantity of research being undertaken in primary care. This investment should be targeted at both existing primary care professionals working in service settings in primary care, LHCCs and PCTs, and at centres of excellence (including University departments). A dual approach will foster collaboration and will allow existing centres of excellence both to undertake more primary care research and to support the development of service based primary care professionals in their research. Resources should be distributed equitably, taking into account demography, geography and the health needs of patients in Scotland. The strategy and its components must be seen as a whole. The Scottish School of Primary Care will stimulate and co-ordinate both research and training programmes. DRDPs will become research active and will participate in School-led training and research, and will contribute to research programmes. Comprehensive funding for training and career development will ensure that staff have the skills to participate in both DRDPs and in the School's activities. Thus, inadequate commitment to any one component of the strategy will mean that other components will be less successful. Commitment to all three components will maximise the chances of success.

Area-wide diabetes care: the Lanarkshire experience with primary health care teams 1994-1997

In Lanarkshire (population 560,000) an area-wide diabetes database was introduced and process of care was measured. The number of patients with diabetes identified was 11,621 (prevalence = 2.08). In 1997 50% of the diabetic population were reviewed at least once during the year. Compared to those attending hospital clinics, GP patients were significantly older, female and less likely to be on insulin. During 1994-1997 hospital clinics improved the process of care in nearly all areas, but GP patients were much less likely to have any of the process measures carried out. Initiatives are underway to support general practices, and to improve co-ordination between GP and hospital services.

Attitudes of general practitioners who practice in remote island communities

OBJECTIVE

To describe the personal, social and medical attitudes of doctors who practice on the islands off the West coast of Scotland.

DESIGN

Questionnaire survey with a single follow-up.

SUBJECTS

All 65 general practitioners (GPs) who practice on the 17 islands located off the West coast of Scotland.

RESULTS

Fifty-two (80%) responded after a single reminder. The main advantages identified were continuity of care, personal relationships with patients and involvement with the local community. Other important reasons were the opportunity to exercise clinical skills and appreciation of their local environment such as the beauty of the scenery. Disadvantages were associated with isolation, difficulty in obtaining cover, in attending refresher courses and the burden of sole responsibility.

CONCLUSION

The GPs who practice in remote island practices believe that the advantages outweigh the disadvantages. They value continuity of care and their relationships with patients and communities. This survey suggests that the difficulties of staffing remote island communities may partly be addressed by allowing undergraduate students and postgraduate colleagues access to these general practitioners.

The completeness and accuracy of patient record transfer between practices

OBJECTIVES

In addition to the paper record, most general practitioners now use a parallel electronic record system on their practice computer. When a patient changes practice at present, the written records are transferred from the patient's previous practice to the next. An up to date computer generated summary or print out should also be sent. Our aim was determine the completeness and accuracy of this process of patient record transfer.

DESIGN

A survey of an opportunistic sample of one hundred patient records in transit between general practices during a single week. Accuracy of information transferred was assessed by examining the records. Further analysis of discrepancies was conducted by one of the authors (FS) to assess their clinical significance.

SETTING

September 1995, primary care department of Lanarkshire Health Board.

RESULTS

Only 46% of practices transfer the complete record compared to the 85% of practices with computers which would have been expected to do so. Even in those which transferred a paper copy of the electronic record, a total of 51% showed discrepancies between the computer and manual format in recording of some or all of the following: diagnoses, prescribing data and the results of investigations.

CONCLUSION

Practices should ensure all relevant data is transferred when a patient moves from one practice to another. The current arrangements do not ensure that this occurs.

Protection of mitomycin C induced skin extravasation with the nitroxide, 3-carbamoyl-PROXYL (3-CP)

Extravasation tissue injury from chemotherapeutic drugs is a serious clinical problem. A swine model has been useful for studying skin extravasation and evaluating potential antidotes. Mitomycin C (MMC) skin extravasation was studied. Nitroxides, a class of compounds which are protective against a variety of oxidative stresses in vitro, including MMC, were tested as antidotes. Miniature swine were anesthetized and given intradermal (ID) injections of MMC. MMC alone caused skin necrosis and ulceration. Several nitroxides were screened as protectors of MMC induced skin necrosis. 3-carbamoyl-PROXYL (3-CP) was the lone nitroxide which protected if given 5 min after extravasation. Administration of 3-CP 10 min after MMC injection was not protective. In vitro studies with monolayered V79 cells showed that 3-CP had a direct protective effect against MMC cytotoxicity in a concentration-dependent fashion. Therefore, in the swine model doses of 3-CP ranging from 25-100 mM were tested and found to protect against MMC skin necrosis 90 days after injection. Histologic sections of the 3-CP- and MMC-treated pig skin showed a marked reduction in the degree of acute inflammation and the absence of deep dermal scarring when compared to MMC alone.

Confidence in performance of pediatric emergency medicine procedures by community emergency practitioners

OBJECTIVE

To survey a cohort of physicians who work in general community emergency departments (ED) in order to assess their comfort levels in performing urgent and emergent medical procedures on children.

METHODS

One hundred seventeen emergency physicians were surveyed at 23 institutions within the referral base of Hasbro Children's Hospital, a tertiary care pediatric ED. Physicians rated their comfort levels (4-point scale: 1 = comfortable, 2 = moderately comfortable, 3 = uncomfortable but would perform in an emergency, 4 = uncomfortable and would never perform) for all procedures in which the American Academy of Pediatrics recommends competence for pediatric emergency physicians.

RESULTS

Sixty (51%) physicians completed the survey. Residency training included internal medicine, family practice, surgery, general practice, pediatrics, and emergency medicine, while only 32 (53%) were Board certified in emergency medicine. All respondents treated pediatric patients. Over 25% were uncomfortable (level 3 or 4) with performing certain potentially life-saving pediatric procedures. These included cardioversion, defibrillation, external pacing, nasal intubation, needle cricothyrotomy, rapid sequence intubation, laryngoscopy, tracheostomy replacement, chest tube placement, vascular cutdowns, emergency childbirth, pericardiocentesis, intraosseous line placement, infant subdural and ventriculoperitoneal (V-P) shunt taps, and upper airway foreign body removal. Over 25% of respondents were also uncomfortable with non-life-saving procedures such as temperomandibular joint (TMJ) reductions, tooth reinsertions, rape evaluations, suprapubic taps, tympanocentesis, retrograde urethrograms, thoracentesis, paraphimosis reduction, ear foreign body removal, and pain management.

CONCLUSION

While emergency physicians within the catchment area of a tertiary care children's hospital feel comfortable with most pediatric procedures, they express a significant degree of discomfort with many potentially life-saving skills. Because of the infrequent need for many of these interventions in children, the high levels of discomfort are not surprising. These procedures may most comfortably be performed at pediatric centers but can be accomplished well at all EDs if personnel are adequately trained. A strong working relationship with pediatric emergency centers and an enhanced teaching of these procedures may increase comfort levels with these potentially life-saving measures.

Has general practitioner computing made a difference to patient care? A systematic review of published reports

OBJECTIVE

To review findings from studies of the influence of desktop computers on primary care consultations.

DESIGN

Systematic review of world reports from 1984 to 1994.

SETTING

The computerised catalogues of Medline, BIDS, and GPlit were searched, as well as conference proceedings, books, bibliographies, and references in books and journal articles.

SUBJECTS

30 papers met the inclusion criteria and were included for detailed review.

INTERVENTIONS

A validated scheme for assessing methodological adequacy was used to score each paper.

MAIN OUTCOME MEASURES

Papers were rated on sample formation, baseline differences, unit of allocation, outcome measures, and follow up. Differences in outcomes were also recorded.

RESULTS

Four of the six papers dealing with the consultation process showed that consultations took longer. Doctor initiated and "medical" content of consultations increased at the expense of a reduction in patient initiated and "social" content. Each of the 21 studies which looked at clinician performance showed an improvement when a computer was used (from 8% to 50%, with better results for single preventive measures). Only one of the three studies looking at patient outcomes showed an improvement (diastolic blood pressure control 5 mm Hg better after one year, with fewer doctor-patient consultations).

CONCLUSIONS

Using a computer in the consultation may help improve clinician performance but may increase the length of the consultation. More studies are needed to assess the effects on patient outcomes of using a computer in consultations.

Examination of the effects of emotional disturbance and its detection on general practice patients' satisfaction with the consultation

BACKGROUND

A patient's satisfaction with a consultation may be influenced by many factors relating to both patient and doctor.

AIM

This study set out to examine the effects of emotional disturbance and its detection on general practice patients' satisfaction with the consultation.

METHOD

A prospective study involving 893 adult patients attending 12 general practitioners in Glasgow was carried out. Questionnaires were completed by general practitioners after consecutive surgery consultations. Patients completed forms assessing mental state and satisfaction with inter-personal aspects of the consultation.

RESULTS

Patients reporting frank psychological disturbance tended to express more dissatisfaction with the inter-personal aspects of the consultation. This effect was alleviated in the majority by recognition of the disturbance by the general practitioner. General practitioners differed markedly in their assessment of the psychological component of consultations. Fewer dissatisfied patients were found in the surgeries of doctors who tended to rate the psychological component of consultations more highly. In contrast, the general practitioner's overall accuracy of diagnosis of psychological distress was a poor predictor of the proportion of dissatisfied patients.

CONCLUSION

This preliminary study suggests that a tendency among doctors to assign importance to the psychological component of consultations may enhance elements of patient satisfaction. It is not clear whether this [psychological-mindedness' is an attribute which can be learnt. To resolve this uncertainty, studies are needed of the effects on patients of educational interventions designed to increase general practitioners' sensitivity to psychological distress.

Intruders in the consultation

A confidential consultation is the essence of family practice. That confidentiality is currently under attack from a number of disruptive influences. Several of these are physical intruders: telephone calls, undergraduate and postgraduate students, video recorders, computers, guidelines, protocols and health promotion activities. The potential benefits of each of these is analysed to elucidate why they have been allowed into consultations. Their drawbacks in the light of current published evidence is presented. Conditions which make intrusions permissible are proposed and practical suggestions are made about how to minimise their impact.

Assessment and management of manual traumatic enucleation

BACKGROUND

Gouging injuries represent a rare, severe form of orbital trauma. We report a case of manual traumatic enucleation.

METHOD

Records of the patient were reviewed.

RESULTS

The outcome of this case was loss of the globe with an uncomplicated recovery.

CONCLUSIONS

Without attention to the particular principles of assessment and management outlined in this report, a satisfactory outcome is not assured.

The productive use of threat in primary care: behavioural responses to health promotion

The importance of a scientific understanding of the behavioural change processes involved in certain health promotion interventions is stressed. A model for guiding the behavioural dimensions in health promotion in primary care is presented. This distinguishes between information-giving and -providing skills to facilitate behavioural change. The social factors which impinge upon processes of behaviour change are highlighted. It is suggested that health promotion clinics in primary care may produce a situation with which the client has to cope. The manner of their coping will be a critical factor in determining outcome. Some key organizational issues are underlined.

Patient controlled analgesia: the relation of psychological factors to pain and analgesic use in adolescents with postoperative pain

OBJECTIVE

To examine the relationship of psychological variables to pain and patient-controlled analgesia (PCA) use in adolescents undergoing orthopedic surgeries.

DESIGN

Cohort.

PATIENTS

Fifty adolescents and their parents.

MAIN OUTCOME MEASURES

Visual analogue scales of pain, the McGill Pain Questionnaire, and questionnaires that assessed overall psychological distress, anxiety, and family environment.

RESULTS

Correlations of the psychological variables with measures of pain and PCA use showed that high levels of anxiety and distress in adolescents were related to higher postoperative pain. Adolescents from controlling and conflicted families also had higher pain ratings and made more frequent PCA demands during the lockout interval when drug was unavailable. Parent anxiety and distress were also related to adolescent pain and PCA use.

CONCLUSIONS

The psychological status of adolescents and their parents can significantly influence postoperative pain and PCA use.

Children seen frequently out of hours in one general practice

OBJECTIVE

To identify reasons why some children receive more out of hours visits than most.

DESIGN

A one year prospective study to identify the study group. This was followed by a case-control study involving a record search and personal interviews.

SETTING

One three doctor urban general practice in West Lothian with 4812 patients.

SUBJECTS

40 children aged under 10 years identified as high users of the out of hours service (more than two visits a year) and 40 age and sex matched controls.

MAIN OUTCOME MEASURES

Numbers of visits; social factors such as lone motherhood, low educational attainment; score for management response to clinical vignette.

RESULTS

147/756 (19%) out of hours visits in the study year were to children aged under 10 years; 109 (74%) to 41 children (6%). Problems seen were mainly minor, and little active management was required. Family and social factors which were significantly more common for the cases than for the controls included a lone mother (15 v 4), low educational attainment by the mother (25 v 14), receipt of income support (22 v 7), and non-ownership of the home (45 v 22) or a car (19 v 9). Mothers of the cases were more likely to choose to contact a doctor when presented with vignettes describing common childhood illnesses (median score for 16 vignettes 16.5 for cases v 14.5 for controls, Wilcoxon signed rank test, p = 0.01).

CONCLUSIONS

Children seen more frequently than expected out of hours came from more socially disadvantaged families and their mothers were more likely to seek medical advice about minor childhood illness. Maternal education, to promote confidence in managing minor illness, may reduce their use of the out of hours service.

Persistent polyclonal B lymphocytosis with Epstein-Barr virus antibodies and subsequent malignant pulmonary blastoma

Persistent polyclonal B lymphocytosis (PPBL), a rare benign lymphoproliferative disorder, occurred in a 25 year old woman. The lymphocytes showed the phenotype cIgM+, FMC7+, CD19+, CD20+, which was similar to that seen in Waldenstrom's macroglobinaemia, but the proliferation was repeatedly shown to be polyclonal both immunologically and by immunoglobulin gene rearrangement studies. Eleven years after presentation the patient developed a malignant pulmonary blastoma, a rare pulmonary tumour of combined epithelial and mesenchymal origin. The failure to develop a lymphoid malignancy over 11 years together with immunological and genetic evidence of polyclonality confirms that PPBL is a benign lymphoproliferative disorder. The subsequent occurrence of a nonhaemopoietic malignancy suggests that benign lymphoid proliferations, like their malignant counterparts, may predispose to the development of neoplasia. A role for Epstein-Barr virus in the pathogenesis of one or both of these rare conditions is suggested by the finding of raised Epstein-Barr viral capsid antigen titres.

The Medical Outcomes Study Instrument (MOSI)--use of a new health status measure in Britain

The Medical Outcomes Study Instrument (MOSI), a 20 item functional health status measure was sent to all women aged 30-40 years (n = 486) in a General Practice (list size 6447). There was a 73% response rate to two mailings. Lower scores on all six dimensions of the MOSI were associated with the number of diagnoses and identified mental illness on the patient summaries, unemployment and with positive scores on the Nottingham Health Profile. In two categories, General Health Perceptions and Mental Health, the scores were lower for those on long-term medication. The paper suggests that the MOSI may be a candidate for Health Status measurement in research and audit in primary care, but further research is required.

Chronic hypothermia in multiple sclerosis

Two patients with clinically definite multiple sclerosis presented with acute hypothermia and on recovery were found to be chronically hypothermic. Thermoregulatory studies indicated a central, hypothalamic defect which is presumed to be due to a plaque of demyelination.

Multiple antibiotic resistance plasmids in Enterobacteriaceae isolated from diarrhoeal specimens of hospitalized children in Indonesia

We studied the plasmid and antibiotic resistance characteristics of 35 strains of Enterobacteriaceae recovered from faecal specimens of children with diarrhoea in Central General Hospital, Bandung, Indonesia. Twenty three Escherichia coli, three Providencia, three Proteus, three Klebsiella, two Enterobacter and one Citrobacter were examined. All strains were multiply resistant, many carrying six to nine antibiotic resistances. Most of these resistances were transferable to a laboratory E. coli strain and were carried on large-sized plasmids. All recently-described tetracycline resistance determinants (Classes A----D) were represented; the most common was the Class B, or TN10 type. The TEM-1 beta-lactamase was detected in 17 out of 21 ampicillin-resistant strains examined. The OXA-1, PSE-1, and SHV-1 enzymes were also found. Of 23 plasmids tested, all could be classified into one of eight different incompatibility groups: IncFII, IncN, IncB, IncF1, IncI1, IncI2, IncH2 and IncT. These studies demonstrate the existence of large multiresistant transferable plasmids representing common incompatibility groups and bearing common tetracycline and ampicillin resistance determinants in enteric strains isolated from children hospitalized in Indonesia.

Treatment of severe aplastic anaemia with anti-thymocyte globulin

Ten patients (9 adults, 1 child) with severe aplastic anaemia (SAA) were treated with anti-thymocyte globulin (ATG). All patients developed serum sickness. No long-term adverse sequelae attributable to ATG were noted. Fifty percent of patients are alive at 1 year post-ATG. One patient received an allogeneic bone marrow transplant because of failure to respond to ATG. One long-term survivor is severely thrombocytopenic and requires support, and one patient has mild thrombocytopenia requiring oxymetholone therapy.

PSRO: advantages, risks, and potential pitfalls

The authors propose that active physician participation in current review methodologies, including PSRO, can lessen the potential for such problems as the development of unrealistic standards, emphasis on review and record keeping as ends rather than means, and ineffectuality of the systems themselves. Potential advantages of PSRO are seen in areas of quality assessment and improvement, economy, and enhancement of the continuing learning processess of physicians. The authors suggest that physicians should resist pressures toward separation of reviewing authority from clinical competence.