National Consensus Guidelines Research Articles

Therapeutic strategies of urinary disorders in MS. Practice and algorithms

ObjectiveReview the literature on therapeutic strategies and guidelines for the treatment of neurogenic bladder in multiple sclerosis. Material and methodA search on available articles on consensus, recommendations guidelines and algorithm of treatment of urinary tract dysfunction in multiple sclerosis. ResultsFive national consensus guidelines were recently published and proposed guidelines for the first and second line treatments. ConclusionMultiple sclerosis patients suffering from lower urinary tract disorders must benefit from an early diagnosis and simple first line evaluation and treatment. More complex and invasive evaluation in the neuro-urology unit is appropriate for patients who failed to first line treatment or in case of complications.

PC.111 Survey of Sildenafil Use for Treatment of Persistent Pulmonary Hypertension (PPHN) in Tertiary Neonatal Intensive Care Units (NICU) in England and Wales

IntroductionSildenafil is increasingly used to treat PPHN secondary to chronic lung disease in neonates. Severity of PPHN has been linked to increased mortality at two years.1 There is no national...

PFM.18 UK variation in prenatal management of Congenital Adrenal Hyperplasia

IntroductionCongenital adrenal hyperplasia (CAH) is a relatively common condition with a population carrier frequency of 1:50. Antenatal administration of dexamethasone treatment has been used to reduce virilisation in affected female...

G51(P) Dermatitis artefacta: A difficult clinical problem

IntroductionThe term dermatitis artefacta (DA) is used to refer to the skin manifestations of self-inflicted injury that is denied or not acknowledged by the patient. The presentation is variable but...

Diagnosis, treatment, and follow-up of hepatitis C-virus related liver disease. Hungarian national consensus guideline

Approximately 70 000 people are infected with hepatitis C virus in Hungary, more than half of whom are not aware of their infection. Early recognition and effective treatment of related liver injury may prevent consequent advanced liver diseases (liver cirrhosis and liver cancer) and its complications. In addition, it may increase work productivity and life expectancy of infected individual, and can prevent further viral transmission. Early recognition can substantially reduce the long term financial burden of related morbidity from socioeconomic point of view. Pegylated interferon + ribavirin dual therapy, which is available in Hungary since 2003, can kill the virus in 40-45% of previously not treated (naïve), and in 5-21% of previous treatment-failure patients. Addition of two direct acting first generation protease inhibitor drugs (boceprevir and telaprevir) to the dual therapy increased the chance of sustained clearance of virus to 63-75% and 59-66%, respectively. These two protease inhibitor drugs are available and financed for a segment of Hungarian patients since May 2013. Indication of therapy includes exclusion of contraindications to the drugs and demonstration of viral replication with consequent liver injury, i.e., inflammation and/or fibrosis in the liver. For initiation of treatment as well as for on-treatment decisions accurate and timely molecular biology tests are mandatory. Staging of liver damage (fibrosis) non-invasive methods (transient elastography and biochemical methods) are acceptable to avoid concerns of patients related to liver biopsy. Professional decision for treatment is balanced against budget limitations in Hungary, and priority is given to those with urgent need using a national Priority Index system reflecting stage of liver disease as well as additional factors (activity and progression of liver disease, predictive factors and other special circumstances). All naïve patients are given a first chance with dual therapy. Those with genotype 1 infection and with on-treatment or historic failure to dual therapy are eligible to receive protease inhibitor based triple therapy provided, they reach financial cutoff eligibility based on Priority Index. Duration of therapy is usually 48 weeks in genotype 1 with a response-guided potential to reduce duration for non-cirrhotic patients. Patients with non-1 genotypes are treated with dual therapy (without protease inhibitors) for a genotype and response driven duration of 16, 24, 48, or 72 week. Careful monitoring for early recognition and management of side-effects as well as viral response and potential breakthrough during protease-inhibitor therapy are recommended.

Diagnosis and treatment of chronic hepatitis B and D. Hungarian national consensus guideline

Diagnosis and treatment of hepatitis B and D virus infections mean that the patient is able to maintain working capacity, increase quality of life, prevent cancer, and prolong life expectancy, while the society benefits from eliminating the chances of further transmission of the viruses, and decreasing the overall costs of serious complications. The guideline delineates the treatment algorithms for 2014, which is agreed on a consensus meeting of specialists involved in the treatment of the above diseases. The prevalence of hepatitis B virus infection in the Hungarian general population is 0.5-0.7%. The indications of treatment is based upon viral examinations (including viral nucleic acid determination), determinations of disease activity and stage (including biochemical, pathologic, and/or non-invasive methods), and excluding contraindications. To avoid unnecessary side effects and for cost-effective approach the guideline emphasizes the importance of quick and detailed virologic evaluations, the applicability of transient elastography as an acceptable alternative of liver biopsy in this regard, as well as the relevance of appropriate consistent follow up schedule for viral response during therapy. The first choice of therapy in chronic hepatitis B infection can be pegylated interferon for 48 weeks or continuous entecavir or tenofovir therapy. The latter two must be continued for at least 12 months after hepatitis B surface antigen seroconversion. Adefovir dipivoxil is recommended mainly in combination therapy. Lamivudine is no longer a first choice; patients currently taking lamivudine must switch if response is inadequate. Appropriate treatment of patients taking immunosuppressive medications is highly recommended. Pegylated interferon based therapy is recommended for the treatment of concomitant hepatitis D infection.

A palliative care approach for people with advanced heart failure: recognition of need, transitions in care, and effect on patients, family carers, and clinicians

BackgroundDespite international and national consensus guidelines, patients with advanced heart failure have substantial unmet palliative care needs. UK policy recommends that identification of those requiring palliative care should be based on prognosis (last year of life). However, heart failure has an unpredictable course, and clinicians might not discuss a palliative approach for fear of causing alarm and destroying hope. We aimed to explore aspects of a palliative care approach for people with advanced heart failure and assessed recognition of need, transitions in care, and effect on patients, family carers, and clinicians. MethodsThis was a mixed method study with integration of findings. We did a systematic literature review of prognostic variables associated with the last year of life in heart failure, and analysed records from the General Practice Research Database (GPRD) to compare recognition of the need for palliative care between patients with cancer and patients with heart failure. Qualitative semistructured interviews were done with patients receiving a palliative approach to care, with their carers, and with clinicians. FindingsGPRD data showed gross inequity in documented recognition of the need for a palliative care approach between patients with cancer and patients with heart failure: patients with heart failure were poorly represented on the palliative care register, and those who were represented, were registered close to death. Prognostic markers, identified in both the systematic review and the GPRD, had little clinical usefulness for identifying the last year of life. From interview data, clinicians seemed reluctant to discuss a palliative care approach without clear irreversible deterioration of the patient. However, patients welcomed, and some initiated, conversations about the change in focus of care. After such discussion, patients, carers, and clinicians found this approach beneficial, even with subsequent periods of stability or improvement. Other barriers included lack of recognition of symptoms by clinicians and difficulties in delivering proactive care. InterpretationA palliative care approach before the very end of life is beneficial in patients with heart failure. A problem-based flexible approach to recognising the need for palliative care, rather than prognosis, is recommended. FundingHull York Medical School, Medical Research Council, Association for Palliative Medicine.

Abstract T P267: Development of an EMS Interfacility Ground Transport Protocol for Patients During/After IV tPA Administration for Acute Ischemic Stroke

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Evidence-based management of sport-related concussion.

Concussion is not only one of the most common injuries encountered by athletes participating in contact and collision sports, but also among the most complex injuries to manage in a sports medicine setting. Over the past two decades, we have made great progress in advancing the basic and clinical science of concussion. These advances have had enormous clinical translational value for developing evidence-based guidelines for management of concussion in sports. Applied clinical research has clarified the defining characteristics of sport-related concussion (SRC) that support new diagnostic criteria. At the same time, major advancements have been realized in the development and validation of clinical tools that allow a more objective and accurate assessment of concussion and performance-based measures of recovery. These tools provide clinicians with a more informed basis for determining an athlete's cognitive and physical fitness to return to competition after concussion. Standardized injury management protocols that systematically prescribe rest, graded activity, and return to play have been adopted in nearly all clinical settings. Herein, we briefly summarize the findings and recommendations from several national and international consensus guidelines and position statements on best practice in the evaluation and management of SRC.

Identifying knowledge-translation opportunities in the treatment of locally advanced breast cancer.

47 Background: Guidelines are usually developed using systematic literature reviews. Expert opinion plays a key role but can be difficult to incorporate. The objective of this study was to develop a national consensus of expert opinion on the management of Locally Advanced Breast Cancer (LABC) and subsequently identify gaps in knowledge translation in current practice. Methods: 361 Canadian oncologists were subdivided into LABC experts (n = 83) and non-experts (n = 278). Experts were surveyed with a modified Delphi protocol to establish consensus. A systematic literature review was performed and compared to expert opinion. Non-experts were then surveyed with a 29-item questionnaire to determine current practice patterns. Z test was used to assess discordance. Results: Response rate for the expert survey was 61% (51/83). Consensus was achieved in all key aspects of care and was concordant to published literature in areas of: clinical assessment with caliper at each cycle, option of lumpectomy if good clinical response, radiotherapy to loco-regional lymph nodes, and no further adjuvant chemotherapy outside of clinical trial if residual disease found at time of surgery. Response rate for the non-expert survey was 50% (140/278). Areas of discordance are highlighted below. Conclusions: A national practice consensus guideline reflective of current evidence and expert opinion has been developed on the management of LABC. Differences in expert opinion and current practice have been identified as targets for knowledge translation interventions (KTIs) that may improve quality of care and resource utilization. Further exploration of KTIs to address identified gaps is warranted. [Table: see text]

Distribution of human papillomavirus genotypes, assessment of HPV 16 and 18 viral load and anal related lesions in HIV positive patients: A cross‐sectional analysis

Natural history of anal intraepithelial neoplasia and anal cancer is not fully understood. Factors associated with cytological abnormalities and predictors of progression to high-grade anal intraepithelial neoplasia still deserve investigation. The aim of this cross-sectional study was to assess the prevalence of HPV types, the relationship between HPV genotypes, HPV 16/18 viral load and cytological abnormalities in male and female HIV-infected patients. One hundred and twenty-two (72.6%) patients were infected with HPV, 75 (61%) had multiple HPV infection, and 94 (77%) had high-risk HPV infection. The most frequently identified HPV types were HPV 16 (64%), HPV 6 (39%), HPV 18 (31%), HPV 53 (14.7%), HPV 33 (10.6%), HPV 11 (8.2%), HPV 70 (5.7%), and HPV 61 (4.9%). The HPV types which were most frequently found in combination were HPV 6 + 16 (9.8%), 6 + 16 + 18 (8.2%), 16 + 18 (6.6%), 6 + 18 (4.9%), 16 + 33 (3.3%), 16 + 53 (3.3%). Median HPV16 and 18 viral loads were 6.1 log10 copies/10(6) cells [IQR 5.0-7.3] and 6.1 log10 copies/10(6) cells [IQR 5.7-6.0], respectively. Male gender (P = 0.03, OR: 1.2 [1.0-1.4]) and homo/bisexual transmission routes (P = 0.044, OR: 1.4 [1.0-1.9]) were associated with HPV 16 infection. An HPV 16 viral load cut-off ≥5.3 log10 copies/10(6) cells and a CD4+ cell count ≤200/µl were independent factors associated with abnormal cytology. In the absence of national consensus guidelines, a strict regular follow-up at shorter intervals is recommended for HIV-infected patients with abnormal cytology, especially low grade squamous intraepithelial lesions, an HPV 16 viral load ≥5.3 log/10(6) cells and a CD4+ cell count ≤200/µl.

A Quality Improvement Initiative to Reduce Unnecessary Follow-up Imaging for Adnexal Lesions

Our objective was to improve the quality of pelvic ultrasound reports and decrease the number of physiologic and benign adnexal lesions unnecessarily referred for follow-up. We performed a prospective cohort study of 2 quality improvement interventions: academic detailing with education for the ultrasound radiologists and sonographers, and implementation of a national consensus guideline on adnexal cysts. Our primary quality outcome measure was the proportion of pelvic ultrasound exams in which follow-up was recommended for an adnexal lesion. Baseline data collection in January 2006 identified 252 pelvic ultrasound exams, of which 58 (23%) reported an adnexal lesion and 31 (12%) recommended follow-up. Retrospective review revealed that 17 of 31 (55%) reported adnexal lesions with follow-up recommended were physiologic or benign. After intervention 1, 59 of 214 (28%) pelvic ultrasound exams from January 2008 reported an adnexal lesion, with 18 (8%) recommending follow-up. After intervention 2, 64 of 296 (22%) pelvic ultrasound exams from January 2011 reported an adnexal lesion, with 16 (5%) recommending follow-up. Follow-up recommendations decreased 58% (12% versus 5%, P = .004), with significant increase in the proportion characterized as physiologic or benign (P = .001). Through a quality initiative aimed at appropriate description and follow-up recommendations for adnexal cystic lesions identified at ultrasound, we effectively reduced unnecessary imaging referrals. We conclude that: (1) acceptance of an expert consensus guideline was important to add credibility, (2) accessible image-rich charts are invaluable tools at point of use, and (3) elimination of some unnecessary imaging is under the control of the radiologist.

Fortschritt, Limitationen und Zukunft der onkologischen Leberchirurgie

Modern oncological liver surgery continues to push the limits of resectability by incorporating an array of new developments in the fields of surgery, anaesthesia and intensive care, oncology, radiology and transplantation medicine. New criteria for determining the resectability of primary and secondary liver tumours have been developed and introduced into national consensus guidelines. Modern tools for improving oncological outcome include the rapid induction of liver hypertrophy prior to major liver resection, downstaging of tumours with advanced chemotherapy protocols, minimally invasive local therapies like radiofrequency ablation and chemo- or radioembolisation, and liver transplantation for non-resectable hepatocellular carcinoma.

‘Thinking on my feet’: an improvisation course to enhance students’ confidence and responsiveness in the medical interview

Effective patient-centred communication requires physicians to respond 'in the moment' to comments and questions. It is a valuable skill to be able to react to unexpected patient utterances with empathy and support, and these surprises may be most common in general practice where patients are encouraged to speak to their doctor about anything. We developed an elective for medical students to learn and practise improvisational skills that would optimise their communications with patients during medical encounters. Nineteen second-year medical students during two consecutive years (n =38) participated in a four-session elective that introduced and allowed them to practise the principles and skills of improvisation, and reflect on the role of those skills in their communication with patients. Specific skills that were practised and emphasised included listening, affirmation, vocal tone modulation, nonverbal communication, agreement, collaboration, acceptance and validation. In addition to previously developed 'Improv' exercises, students created their own improvisation exercises targeted at specific communication skills. Twenty-seven (71%) of all participating students completed the post-curriculum assessment survey. Twenty-two (81%) rated their enjoyment as 'tremendous'. The desire to experience something new and different from the standard medical curriculum served as the motivation for many of the students (67%) to sign up for the course. Most students (23/27; 85%) thought that the concepts that were addressed were either 'very much' or 'tremendously' relevant to the care of patients. We have found that an improvisational workshop geared towards enhancing medical student communication skills has the potential to impart valuable skills that are essential to providing empathic, supportive patient-centred care. Communication skills training programmes have become a cornerstone in medical student and postgraduate medical education over the past 20 years. Both national accreditation and expert panel consensus guidelines have stressed the importance and framed the structure for best communication practices. Exemplary curricula for teaching medical trainees in core communication strategies to use with patients have been published; many emphasise patient-centred and/or relationshipcentred strategies. Simulated patient technologies with video review can allow learners to practise their skills through both self-assessment and feedback from others. However, despite these newer learning resources, frameworks and behavioural checklists, learners naïve to clinical patient encounters must still learn how to function and adapt within the interpersonal communicative space that is created by the learner and patient. At its core, this is an iterative, spontaneous process created by the dyad and yielding, from moment to moment, to unique and unanticipated outcomes. Thus, repetitive practice will improve confidence but may miss the mark in learning the essential skills of intuitive and improvised interpersonal responsiveness. One could argue that existing approaches in teaching medical learners communication skills may promote rigid and stereotyped responses. Haidet proposes that there are significant parallels between the patient-physician dialogue (when a physician attempts to learn details about a patient and their illness) and improvisational jazz. 11 He contends that effective clinicians who are committed to relationship-centred practice depart from overarching principles of biomedical inquiry when necessary to respond spontaneously and without script to the particular circumstances of each encounter. It is believed that successful doctor-patient relationships are founded upon trusting and open communication, as well as genuine respect that can be shown by a willingness to listen or respond to the issues raised by patients. 12 The nature of the comprehensive care in family medicine makes it likely that GPs will regularly be surprised by concerns raised by patients such that they must be adept at improvising. Because of the gap that currently exists in interview skills training programmes, we hypothesised that the field of improvisational theatre would effectively supplement the traditional curriculum. Improvisation relies on listening, confidence and responding instinctively and spontaneously. 13,14 In this paper, we describe our efforts to develop a brief curriculum for medical students providing training in the art of theatre improvisation, with the goal of enhancing students' confidence and performance in clinical encounters. We hoped that this innovative curricular experience would establish a venue where secondyear medical students could learn and practise improvisational skills that might prove helpful in their communications with patients during medical encounters.

N016 Development and Implementation of National Patient Education Resources for Atrial Fibrillation: Translating the CCS 2010/2012 Guidelines for Patient Use

In 2010, the Canadian Cardiovascular Society (CCS) published the most comprehensive national consensus guidelines for the management of atrial fibrillation (AF) which were further updated in 2012. The guidelines highlight the importance of evidence-based patient education and the pivotal role of self-care management to optimize outcomes. CCS initiated the development of a national initiative to offer patients, AF clinics and multidisciplinary healthcare providers the patient education resources required to facilitate the knowledge translation of the CCS AF guidelines.

Implementation of a hypertension clinic using a streamlined treatment algorithm

The implementation of a pharmacist-managed clinic based on the Simplified Treatment Intervention to Control Hypertension (STITCH) algorithm is described, with insights on physician acceptance and implementation challenges. After a medical records review indicating gaps in the follow-up care of emergency department (ED) patients found to have elevated blood pressures (BPs), the ED of a large public hospital sought to create a "bridge" to ongoing primary care by applying a modified version of the STITCH algorithm, which aims to address compliance barriers to adequate BP control through a streamlined stepped-care approach derived from national consensus guidelines. Following the guidelines of the STITCH algorithm, the goals of the clinic implemented in this project were to (1) coordinate initial pharmacotherapy, (2) monitor patients pending their first primary care clinic appointment, (3) assess for potential antihypertensive-related complications, and (4) provide comprehensive and ongoing patient education. Physician support for the clinic (staffed by one pharmacist one day weekly) was cultivated through both broad and individually targeted education to allay concerns about initiating BP-lowering therapy in the ED setting, especially given patients' typical one- to six-month wait time for a primary care clinic appointment. Early experience at the clinic indicated increased physician willingness to initiate hypertension treatment in the ED due to the availability of appropriate follow-up services within a shorter time frame (about two weeks). One hospital's experience suggests that a hypertension-focused clinic using a streamlined treatment algorithm can serve as a bridge from urgent care to ongoing primary care, facilitating adequate BP control in a transient, low-income patient population.

Abstract P331: Secondary Prevention After Acute Coronary Syndrome with Microsize Myocardial Infarctions in the Reasons for Geographic and Racial Differences in Stroke-Myocardial Infarction (REGARDS-MI) Study

Background: Studies have shown increased mortality after myocardial infarction (MI) with low level elevations of cardiac troponin (“microsize MI”) and subsequent risk reduction with intensive medical management. However, non-standard reporting and highly sensitive assays of cardiac troponin can make the clinical recognition of microsize MI difficult, creating barriers to the implementation of appropriate secondary prevention. Methods: REGARDS follows 30,239 community-dwelling participants of the 48 continental states age ≥45 years recruited from 2003-7; 41% of the sample was African American and 55% female by design. Following national consensus guidelines, experts adjudicated cases of acute coronary syndrome (ACS), defined as an admission for acute signs or symptoms of ischemia, and MI from hospital records. We studied first cases of ACS, classified as: 1) ACS without MI, 2) ACS+microsize MI (peak troponin <0.5), and 3) ACS+usual MI (peak troponin ≥0.5), to compare whether secondary prevention medications were prescribed at hospital discharge among these 3 groups. We used multivariable logistic regression to examine odds ratios for receipt of medications at discharge associated with microsize MI and no MI relative to usual MI. Results: The 1,238 cases of ACS were mean age 68.0+/-8.7 years, 59% male, and 66% white. Of these, 917 had discharge medications available. Compared to those with ACS+usual MI, individuals with ACS+microsize MI had lower odds of receiving beta-blockers and statins at discharge in a similar range as those without MI ( Table ). Conclusion: Individuals hospitalized for ACS and microsize MI were less likely to receive guideline appropriate secondary prevention measures than those with usual MI.

Antidotes for toxicological emergencies: A practical review

Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use. Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability. Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.

Physicians′ perceptions of a national consensus guideline on insulin therapy: Data from the IMPACT study

Introduction:The effectiveness and impact of the Indian insulin guideline in clinical practice was evaluated by the Improving Management Practices and Clinical Outcomes in Type 2 Diabetes (IMPACT) Study. The study also evaluated the participating physicians’ perceptions on the use of IIG versus RCP for management of diabetes.Materials and Method:This 26 week multicenter, open label, randomized, prospective study aimed to evaluate effectiveness of Indian insulin guideline (IIG) versus routine clinical practice (RCP) in patients with type 2 diabetes (T2D).Results:Out of 426 physicians who completed the physicians’ perception questionnaire, 189 (44.4%) felt that it was “easy” to initiate insulin in their patients using IIG. Cost of therapy (52.3%), followed by poor adherence (40.3%), and lack of motivation among physicians (40.4%) were the most important reasons cited for delay in initiation of insulin therapy. Two hundred and thirty three (54.7%) physicians felt that insulin titration was made “easy” in their patients using IIG, while 104 (24.4%) had a neutral approach. A total of 222 physicians (52.1%) felt it was “convenient” applying IIG in their practice, and 239 (67.8%) physicians felt “satisfied” with using IIG for achieving the targeted HbA1c <7%. One hundred and seventy seven (41.5%) physicians felt that there was scope for improving the IIG further by simplifying and revising the titration charts [117 (27.5%)].Conclusion:Primary care physicians in India have perceived the IIG to be easy algorithm to initiate and titrate insulin therapy. These results will encourage the use and facilitate future revision of the guideline.

Range of NICU Practice in England and Wales Regarding Thresholds for Neonatal Conjugated Hyperbilirubinaemia and Relevant Investigations

Background: Conjugated jaundice is a common problem in a neonatal intensive care. However, several investigations are performed to exclude underlying liver disease. Opinion differs on their diagnostic value. Aim: To evaluate practice related to investigation of conjugated jaundice Method: Questionnaire survey of lead neonatal consultants from all neonatal units in England and Wales. Results: 102/194 neonatal units (52%), responded to the survey of which 33 were level 3 units, 50 level 2 and 19 level 1 units. 96 units (94%) performed conjugated jaundice screen and 6 units (6 %) did not. 77 units (75%) had a written policy. 49% of responders defined conjugated jaundice as conjugated bilirubin >20% of total bilirubin and 46% as >15% of total bilirubin and 5% of units did not have a clear definition. Conjugated bilirubin levels that prompted investigations varied between units with 28 (30%) using conjugated bilirubin >20% of total, 33(36%) a conjugated bilirubin >15% of total and 20 (21%) with no definite threshold. Majority (>76%) of units performed liver and thyroid function tests, Galactosaemia screen, α-1 antitrypsin and liver ultrasound. 65% of units performed urine culture and hepatitis serology, 32% performed urine organic acids, NH3 and lactate. 19 units performed CF genetics and 23 HIDA scan. 71% of responders thought ‘diagnostic yield’ was ‘poor’ and 44% based this on their personal view, 29% on local data and 27% on anecdotal evidence. Conclusion: Our study identified a wide variation in definition and investigation of neonatal conjugated jaundice. National consensus guidelines are required to standardize practice.