Local clinical guidelines: description and evaluation of a participative method for their development and implementation

BACKGROUND: National guidelines are rarely followed by immediate changein clinical behaviour. We present our experience of an activeeducational method for local development and implementationof a guideline. OBJECTIVE: To evaluate the effectiveness of a participative method fordeveloping local clinical guidelines. METHODS: A trial in a district of the effect of guideline developmentincorporating active participation of intended recipients onsubsequent relevant prescribing. It was carried out in WirralFamily Health Services Authority district (the Wirral peninsula)comprising 69 general practices covering a population of 345763. An exemplar guideline on ‘hypertension in the elderly’was developed by the method described. The principal recommendeddrug was bendrofluazide 2.5 mg once daily. The differences inprescribed daily doses (PDD) of bendrofluazide 2.5 mg tabletsper quarter per 1000 prescribing units (age-weighted population)between the intervention district and England as a whole wasmeasured. RESULTS: Comparison of the intervention district with England data demonstratesa median difference of 122.49 PDD before and 206.34 PDD afterguideline production, this change is statistically highly significant(Mann-Whitney two-tailed P < 0.0001; 95% CL = 36.51–104.77).Grouped regression analysis shows no significant difference(0.89) in slope gradients before guideline production (P = 0.35,95% CL = –3.97–5.76), but the difference in slopegradients after (12.95) is statistically highly significant(P < 0.0001; 95% CL = 8.17–17.73). The data suggeststhat the change in clinical behaviour persisted for at leasttwo years. CONCLUSION: Participation of intended recipient general practitioners andlocal specialists in the development of a guideline by an activeeducational method as described was followed by a favourablechange in clinical behaviour which persisted for at least twoyears. Keywords. Clinical guidelines, development, evaluation, implementation, participation.     

Agonist-antagonist properties of fluorescent opioid probes in the guinea-pig myenteric plexus-longitudinal muscle preparation

Summary The behavioral consequences of -adrenoceptor subsensitivity were investigated by determining whether a physiological response that is mediated by -receptors, isoproterenol-induced drinking (IID), would be reduced by subacute antidepressant/ ₂-antagonist treatmentThe coadministration of typical (e.g., imipramine) or atypical (e.g., mianserin) antidepressants with yohimbine or piperoxan twice daily for four consecutive days reduced IID. Both the time course as well as the magnitude of -adrenoceptor subsensitivity could be behaviorally demonstrated. In addition, the reduction in IID observed after coadministration of imipramine with yohimbine was a centrally mediated effect since it was observed after systemic (subcutaneous) and central (intraventricular) administration of isoproterenol. These results provide evidence that IID is an appropriate behavioral model to demonstrate -adrenoceptor subsensitivity following subacute antidepressant/ ₂-antagonist treatment.Paper presented in part at FASEB, St. Louis, MO, USA (Abstract: Fedn Proc 43:941, 1984)     

<Emphasis Type="Italic">In vivo</Emphasis> activity of <Emphasis Type="Italic">Sapindus saponaria</Emphasis> against azole-susceptible and -resistant human vaginal <Emphasis Type="Italic">Candida</Emphasis> species

Background  

Study of in vivo antifungal activity of the hydroalcoholic extract (HE) and n-BuOH extract (BUTE) of Sapindus saponaria against azole-susceptible and -resistant human vaginal Candida spp.     

Digital ischemia due to essential thrombocythemia: a case report

This report describes the case of a 34-year-old patient with essential thrombocythemia who presented with Raynaud's syndrome, was refractory to medical treatment, and developed progressive digital gangrene.     

Management of venomous snakebite injury to the extremities

Pit vipers (subfamily Crotalinae) are responsible for most venomous snakebites in the United States. The mixture of proteins with cytotoxic, proteolytic, and/or neurotoxic enzymes in snake venom varies by species. Treatment in the field consists of safe identification of the species of snake and rapid transport of the patient to the nearest health care facility. Swelling, bruising, and systemic symptoms are seen following snakebite. Most patients respond to elevation of the affected extremity and observation. Some require the administration of antivenin. Crotalidae Polyvalent Immune Fab (Ovine) (CroFab, BTG International, West Conshohocken, PA) antivenin is safe and effective for the management of local and systemic effects of envenomation. Rarely, compartment syndrome may develop in the affected limb because of edema and tissue necrosis. Close monitoring of the extremity via serial physical examination and measurement of compartment pressure is a reliable method of determining whether surgical intervention is required.