Audit of chest X-rays in general practice--a case for local guidelines?

OBJECTIVE: To investigate the use of the chest X-ray (CXR) in a typical urban practice with reference to the Royal College of Radiology (RCR) guidelines. DESIGN: A retrospective review of all requests over a two-year period. SETTING: Urban general practice with 9,463 registered patients. RESULTS: A total of 569 CXRs were performed in 482 patients. Thirty per cent of the CXRs were assessed as being "not indicated" and a significant percentage of requests did not come within the RCR guidelines. The guidelines advise a six weeks' delay following onset of chest wall pain prior to chest X-ray. We assessed the application of the rule in this patient group. A large percentage of those X-rayed were referred at less than the recommended six weeks' interval from time of presentation and the vast majority of CXRs were entirely normal. The "six weeks rule" was developed further in patients with cough, differentiating between simple and productive cough. Those with productive cough who were otherwise well had no significant findings in contrast to the unwell group where several abnormalities were noticed. Radiology-recommended follow-up films were further studied. Where the CXR was carried out after a time interval of less than three weeks, several showed incomplete resolution and a further film was required. CONCLUSION: The RCR guidelines might be adapted to apply to those with simple cough or to those with productive cough who are otherwise well. This simple recommendation, in addition to the RCR guidelines, we feel would reduce the number of unnecessary CXRs performed in general practice.

Prophylactic use of human endotoxin-core hyperimmune gammaglobulin to prevent endotoxaemia in colostrum-deprived, gnotobiotic lambs challenged orally with Escherichia coli.

The efficacy of human IgG polyclonal antibody to endotoxin-core in preventing endotoxaemia and subsequent disease was studied in colostrum-deprived gnotobiotic lambs challenged orally at about 5 h old with 10(9) cfu Escherichia coli. Human endotoxin-core hyperimmune gammaglobulin was given intravenously to 5 lambs at 1.9 g IgG/kg bodyweight prior to challenge. Human albumin was given intravenously to 3 control lambs. Bacteraemia was observed in all lambs, but the incidence was lower (P < 0.01) and the onset later (P < 0.05) in gammaglobulin pre-treated lambs. These lambs showed no signs of disease, whereas clinical endotoxaemia, manifesting as watery mouth disease, was diagnosed in 2 of the 3 control lambs which were killed between 18 and 22 h after challenge. Thus, prophylactic treatment of colostrum-deprived lambs with human IgG enriched in endotoxin-core antibodies was effective in reducing the degree of bacteraemia and preventing endotoxaemia, leukopenia and clinical disease following oral challenge with E. coli.

The effect of chlamydial infection on the initiation of premature labour: serial measurements of intrauterine prostaglandin E2 in amniotic fluid, allantoic fluid and utero-ovarian vein, using catheterised sheep experimentally infected with an ovine abortion strain of Chlamydia psittaci.

The initiation of premature labour by an ovine abortion strain of Chlamydia psittaci was studied in relation to Prostaglandin E2 (PGE2), which plays a major role in parturition. The local intrauterine concentration of PGE2 was monitored after experimental infection with C. psittaci, during late gestation, using a catheterised sheep model. Indwelling catheters were implanted into the amniotic and allantoic cavities of six control sheep, and into six sheep infected with an ovine abortion of C. psittaci. The release of PGE2 into the utero-ovarian vein of these sheep was also monitored. Infection with C. psittaci was associated with a premature rise in PGE2 in the amniotic fluid between days 122 and 135 of gestation (P less than 0.01). A premature increase in PGE2 was defected between days 127 and 136 of gestation (P less than 0.05) in the allantoic fluid of sheep infected with C. psittaci, but not in the control uninfected sheep. Chlamydial infection significantly decreased the secretion of PGE2 into the utero-ovarian vein. The mean concentration of PGE2 in the utero-ovarian vein of infected sheep was 68.8 +/- 5.2% of the PGE2 concentration of control sheep between days 122 to 141 of gestation (P less than 0.01). The release of PGE2 into the utero-ovarian vein increased between days 126 to 136 of gestation in infected and control sheep (P less than 0.01). The results from the catheterised sheep model indicated that C. psittaci infection is associated with a local intrauterine release of PGE2. The magnitude of this release was similar to the PGE2 release in control sheep prior to parturition.(ABSTRACT TRUNCATED AT 250 WORDS)

Biochemical and haematological evidence of endotoxic shock in gnotobiotic lambs with watery mouth disease.

Eight gnotobiotic lambs deprived of colostrum were infected by mouth when two hours old with nonenterotoxigenic strains of Escherichia coli. All developed clinical signs of watery mouth disease and seven died within 24 hours. The mean concentrations of several blood constituents were determined in samples taken at intervals until 24 hours after infection in infected lambs and in four control lambs. The biochemical and haematological changes observed in the lambs developing watery mouth disease were those characteristic of endotoxic shock.

Immune exclusion of Haemonchus contortus larvae in sheep: dose dependency, steroid sensitivity and persistence of the response.

Naive and immune sheep, treated with anthelmintic, challenged directly into the abomasum and killed 48 hours later were used to examine the steroid sensitivity, persistence and dose dependency of immune mechanisms which result in the failure of incoming Haemonchus contortus larvae to establish (immune exclusion). Immune exclusion was almost totally abolished by corticosteroid treatment, the mean percentage of larvae establishing in the mucosa of immune sheep was 1.4 per cent of the challenge infection whereas in those treated with dexamethasone it was 24.4 per cent and in naive sheep 27.3 per cent. Immune animals challenged after seven and 42 days without antigenic experience excluded more than 90 per cent of the challenge larvae from their mucosae, whereas those challenged after 84 days without antigenic experience were as susceptible as naive animals. Immune exclusion was dose dependent, animals challenged with 10(6) and 10(5) larvae excluded 93 per cent and 82.5 per cent of the challenge dose whereas those challenged with 10(4) larvae failed to exclude larvae.