Clinical guidelines online: do they improve compliance?

BACKGROUND: The introduction of intranet services in a district general hospital provided an opportunity to put evidence based national guidelines online to facilitate access and promote application of best practice in acute medical care. This study evaluated the effectiveness of this approach. METHOD: Local guidelines were made available online at ward terminals after they had been distributed in paper form. An interrupted time series design was used to evaluate the impact on compliance with three preselected guidelines, which addressed the management of suspected deep vein thrombosis, upper gastrointestinal bleeding, and stroke. This was supplemented by a qualitative assessment of the views of medical staff. RESULTS: There was a significant increase in the adherence to the guidelines for stroke when they were made available online, but this was not demonstrable for deep vein thrombosis or upper gastrointestinal bleeding. Qualitative interviews with junior medical staff and consultants after the study was completed revealed that there was confusion regarding the application of the guidelines for deep vein thrombosis and little active support from the gastroenterologists for the guidelines for upper gastrointestinal bleeding. The stroke guidelines were actively promoted by their author and widely supported. CONCLUSION: Making guidelines available online will not be effective unless they are actively promoted and represent a consensus view.

Ileitis due to Yersinia pseudotuberculosis in Crohn's disease.

We present the case of a young woman with fulminating terminal ileitis due to Yersinia pseudotuberculosis, in whom Crohn's disease was subsequently diagnosed. Serological testing was prompted by radiological, macroscopic and histological changes which were atypical of Crohn's disease. We speculate that Y. pseudotuberculosis ileitis may occasionally produce an acute exacerbation of Crohn's disease, but that its occurrence may not be diagnosed if the atypical features are not recognised. In this case, the classical features of Y. pseudotuberculosis may have been modified by pre-existing Crohn's disease. We propose that, because of defects in mucosal barrier function and immunological function, patients with Crohn's may have increased susceptibility to infection by Yersinia sp.

Objective evaluation of ERCP procedures: a simple grading scale for evaluating technical difficulty.

BACKGROUND: and objective: Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding endoscopic procedure that varies from a simple diagnostic to a highly complex therapeutic procedure. Simple outcome measures such as success and complication rates do not reflect the competence of the operator or endoscopy unit, as case mix is not taken into account. A grading scale to assess the technical difficulty of ERCP can improve the objectivity of outcome data. METHODS: A I to IV technical difficulty grading scale was constructed and applied prospectively to all ERCPs over a 12 month period at a single centre. The procedures were performed by two senior trainees and two experienced consultants (trainers). The grading scale was validated for construct validity and inter-rater reliability at the end of the study using the chi(2) test and kappa statistics. RESULTS: There were 305 ERCPs in 259 patients over the 12 months study period (males: 112, females: 147, age range 17-97, mean 70.3 years). There was overall success in 244 (80%) procedures with complications in 13 (4%): bleeding in five (1.6%), cholangitis in one (0.3%), pancreatitis in five (1.6%), and perforation in two (0.7%). Success rate was highest for grade I, 49/55 (89%), compared with grade IV procedures, 8/11 (73%). There was a significant linear trend towards a lower success rate from grade I to IV (p=0.021) for trainees, but not for trainers. Complications were low in grade I, II, and III procedures, 12/295(4%), compared with grade IV procedures, 1/11(9%). The inter-rater reliability for the grading scale was good with a substantial agreement between the raters (kappa=0.68, p<0.001). CONCLUSION: Success and complications of ERCP by trainees are influenced by the technical difficulty of the procedure. Outcome data incorporating a grading scale can give accurate information when auditing the qualitative outcomes. This can provide a platform for structured objective evaluation.

Hepatocellular carcinoma arising in non-cirrhotic liver in genetic haemochromatosis.

The occurrence of primary hepatocellular carcinoma (HCC) in patients with genetic haemochromatosis (GH) with cirrhosis is well known. In the past it has been suggested that patients with GH without cirrhosis have the same risk of HCC and life expectancy as the general population. However, recently there have been cases of HCC arising in non-cirrhotic livers, and we report another such case. A review of the literature has been included.

Diffuse esophageal leiomyomatosis: another cause of pseudoachalasia.

The patient was a 22-year-old woman who had presented in early childhood with gastroesophageal reflux and who subsequently underwent surgery. It was commented upon by the surgeons at that time that the esophagus was abnormally thickened. The patient subsequently presented during her first pregnancy with a vulval tumor, which proved histologically to be a leiomyoma. She was also found to have a grossly dilated esophagus and was thought to have achalasia. However, endoscopic ultrasound imaging showed gross hypertrophy of the mid- and distal esophageal wall, with only mild symptoms of dysphagia, which had been long-standing. The appearance of the esophagus was consistent with diffuse esophageal leiomyomatosis. In view of the associated vulval leiomyoma, the patient demonstrated esophagovulvar syndrome.

The relationship between nutritional status and serum soluble interleukin-2 receptor concentrations in patients with Crohn's disease treated with elemental diet.

Serum soluble interleukin-2 receptor concentrations (sIL-2R) were measured and correlated with indices of disease activity and nutrition in 13 patients with active Crohn's disease treated with an elemental diet. The initial serum sIL-2R concentrations were raised, 1121 +/- 181 U/ml (mean +/- SEM) compared to controls, 177 +/- 22.9 U/ml (n = 18) (p < 0.001). Four weeks' treatment resulted in significant improvement in disease activity (Harvey-Bradshaw index) and 4-day faecal (111)Indium-leucocyte excretion. Serum sIL-2R concentrations did not change significantly after treatment, 789 +/- 79.8 U/ml (p > 0.05). Serum sIL-2R concentrations were inversely correlated with albumin, pre-albumin, creatinine-height index and total body potassium. Only those patients with markedly elevated sIL-2R concentrations (>800 U/ml) and severe nutritional depletion prior to treatment, showed significant reductions in sIL-2R levels with elemental dietary treatment. These results demonstrate an association between nutritional impairment and immune activation in Crohn's disease.