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R H Jones

Publications and source records attributed to R H Jones.

At least 109 records · Page 6Linked to original sources
PubMed1994

Provider perceptions in using outcomes data to improve clinical practice.

In this article we report on the perceptions of health care providers concerning the use of health care outcomes. These perceptions were identified during two afternoon workshops at the symposium on outcomes data held in Keystone, Colorado, in June 1994. The overall goal of these workshops was to explore the potential use of outcomes data within the clinical practice setting. The attitudes and concerns of several key providers formed the framework for the workshop discussions. The strengths and weaknesses associated with using risk-adjusted outcomes data, both to assess and to improve quality of patient care, were debated within the workshop groups. Overall, conference participants agreed that the risk-adjusted outcomes of cardiac care could be used both to assess and to improve the quality of patient care. The research to date, however, represents only a first step toward this goal. The meeting participants challenged the research community to improve on the measures currently available, with the goal of providing clinicians better information to improve the "art" of medicine.

Attitude of Health Personnel↗
PubMed1994

Short-term effects of mepacrine on serum lipids, lipoproteins, and apolipoproteins in patients with non-insulin-dependent diabetes mellitus.

We investigated the effects of 7 days' treatment with oral mepacrine hydrochloride 100 mg three times daily on fasting serum levels of glucose, insulin, lipids, lipoproteins, and apolipoproteins in 16 patients with non-insulin-dependent diabetes mellitus (NIDDM) in a double-blind placebo-controlled study. Mepacrine treatment decreased fasting levels of total cholesterol (7.0 +/- 0.6 to 5.6 +/- 0.4 mmol/L, P < .01), low-density lipoprotein (LDL) cholesterol (4.7 +/- 0.5 to 3.5 +/- 0.3 mmol/L, P < .01), and apolipoprotein (apo) B (1.20 +/- 0.14 to 1.02 +/- 0.08 g/L, P < .05), and the ratio of LDL cholesterol to high-density lipoprotein (HDL) cholesterol (P < .05). There was no change in fasting levels of serum glucose, insulin, C-peptide, nonesterified free fatty acids, triglycerides, or lipoprotein(a). In conclusion, a short course of oral mepacrine treatment has a potentially beneficial effect on LDL cholesterol and apo B levels in patients with NIDDM and warrants further investigation in this situation.

Adult↗
PubMed1994

A simulation study to determine optimal insulin priming during glucose clamp studies.

Computer simulation of hyperinsulinaemic euglycaemic clamp studies (HECS) using a novel model of insulin kinetics shows that a priming dose of insulin should be in the form of a 10-min-long infusion at a rate six-fold higher than the intended insulin infusion rate in patients with non-insulin-dependent diabetes mellitus. Using this priming regimen, glucose uptake attains equilibrium within 90 min. Two alternative priming regimens: a priming bolus and a monoexponential-decay priming infusion, also result in equilibrium of glucose uptake within 90 min, but give higher transients of plasma insulin concentration. However, with no priming, or if a conventional priming regimen is used, glucose uptake at 90 min rises to only around 80% of its equilibrium value. We conclude that priming of insulin is essential to attain steady state of glucose uptake within 90 min of HECS and that conventionally used priming regimens result in an underestimation of glucose uptake.

Blood Glucose↗
PubMed1994

Effects of insulin-like growth factor-I (IGF-I), insulin and combined IGF-I-insulin infusions on protein metabolism in dogs.

The effect of infusions of recombinant insulin-like growth factor-I (IGF-I) (34, 103 or 688 pmol min-1 kg-1), insulin (3.4, 10.3 or 68.8 pmol min-1 kg-1) or combined infusions (34 pmol IGF-I + 3.4 pmol min-1 kg-1 insulin or 103 pmol IGF-I + 3.4 pmol min-1 kg-1 insulin) on protein metabolism, using an infusion of [1-14C]leucine was investigated in anaesthetized fasted dogs. Leucine concentration, production rate (measure of protein degradation), oxidation rate and non-oxidative disappearance rate (measure of protein synthesis) were decreased in a similar dose dependent manner by the IGF-I and insulin infusions (P < 0.01). The decrease in these measurements of leucine metabolism were greater following 34 pmol IGF-I + 3.4 pmol insulin than with either component infused alone (P < 0.05). Free fatty acid concentrations were decreased by all insulin doses (P < 0.01) but only by 103 and 688 pmol min-1 kg-1 insulin-like growth factor (P < 0.05, P < 0.01). These data demonstrate that IGF-I, like insulin, has a dose dependent effect on protein metabolism and that combined insulin and IGF-I infusions have additive effects on protein metabolism.

Animals↗
PubMed1994

Use of a leucine clamp to demonstrate that IGF-I actively stimulates protein synthesis in normal humans.

Insulin-like growth factor I (IGF-I) is thought to mediate the anabolic action of growth hormone. A glucose and amino acid clamp technique was used to investigate the effects of a 3-h intravenous infusion of either 43.7 pmol.kg-1.min-1 (20 micrograms.kg-1.h-1) IGF-I or 3.4 pmol.kg-1.min-1 (0.5 mU.kg-1.min-1) insulin on whole body leucine turnover in five normal human volunteers. During the IGF-I infusion, IGF-I levels increased (P < 0.01; 26.6 +/- 2.8 to 88.9 +/- 14.2 nmol/l) and insulin levels fell (P < 0.05; 0.096 +/- 0.018 to 0.043 +/- 0.009 nmol/l). During the insulin infusion, insulin levels increased (P < 0.01; 0.057 +/- 0.013 to 0.340 +/- 0.099 nmol/l), and there was no change in IGF-I. There was no significant change in leucine production rate (Ra; a measure of protein degradation) during the IGF-I infusion (2.23 +/- 0.17 to 2.13 +/- 0.2 mumol.kg-1.min-1), but there was an increase (P < 0.03) in nonoxidative leucine disposal rate (Rd; a measure of protein synthesis; 1.83 +/- 0.15 to 2.05 +/- 0.21 mumol.kg-1.min-1). In contrast, insulin reduced (P < 0.02) leucine Ra (1.81 +/- 0.24 to 1.47 +/- 0.24 mumol.kg-1.min-1) and had no effect on nonoxidative leucine Rd (1.44 +/- 0.25 to 1.41 +/- 0.22 mumol.kg-1.min-1). We conclude that IGF-I, under conditions of adequate substrate supply, directly increases protein synthesis in contrast to insulin, which exerts its anabolic action by reducing proteolysis.

Adult↗
PubMed1994

Myocardial perfusion and ventricular function measurements during total coronary artery occlusion in humans. A comparison with rest and exercise radionuclide studies.

BACKGROUND: The purpose of this investigation was to compare the magnitude of change in myocardial perfusion and function during exercise with that obtained during total coronary artery occlusion. Radionuclide studies are widely used for the diagnosis and determination of prognosis in patients with suspected or known coronary artery disease. These studies are based on the premise that the relative deficit of coronary blood flow, which is induced by exercise and recognized as increased demand, relates to the jeopardy experienced by the decrease or sudden absolute interruption of coronary blood flow that is recognized as decreased supply and is associated with coronary stenosis or total coronary artery occlusion. The magnitude of exercise-induced perfusion and function abnormalities compared with those induced by total coronary artery occlusion in humans has not been previously reported. METHODS AND RESULTS: We prospectively studied 20 patients with > or = 50% diameter stenosis documented by quantitative coronary angiography in at least one vessel. A same-day rest/exercise sestamibi myocardial function and perfusion study was performed within 24 hours before percutaneous transluminal coronary angioplasty. At 1 minute after balloon inflation, while the vessel was occluded, sestamibi was injected, and a myocardial perfusion and function study was performed. Perfusion defect size was greater during occlusion (28 +/- 3%) than during exercise (13 +/- 2%) (P < .01). Ejection fraction was greater during exercise (53 +/- 3%) compared with values measured during occlusion (41 +/- 2%) (P < .01). CONCLUSIONS: Physiological abnormalities induced by coronary occlusion are greater than those that occur during exercise, thereby indicating that stress-induced ischemia may not reflect the total potential myocardium in jeopardy from a stenotic lesion, if sudden occlusion occurs.

Adult↗
PubMed1994

Continuing evolution of therapy for coronary artery disease. Initial results from the era of coronary angioplasty.

BACKGROUND: Survival after coronary artery bypass graft surgery (CABG) and medical therapy in patients with coronary artery disease (CAD) has been studied in both randomized trials and observational treatment comparisons. Over the past decade, the use of coronary angioplasty (PTCA) has increased dramatically, without guidance from either randomized trials or prospective observational comparisons. The purpose of this study was to describe the survival experience of a large prospective cohort of CAD patients treated with medicine, PTCA, or CABG. METHODS AND RESULTS: The study was designed as a prospective nonrandomized treatment comparison in the setting of an academic medical center (tertiary care). Subjects were 9263 patients with symptomatic CAD referred for cardiac catheterization (1984 through 1990). Patients with prior PTCA or CABG, valvular or congenital disease, nonischemic cardiomyopathy, or significant (> or = 75%) left main disease were excluded. Baseline clinical, laboratory, and catheterization data were collected prospectively in the Duke Cardiovascular Disease Databank. All patients were contacted at 6 months, 1 year, and annually thereafter (follow-up 97% complete). Cardiovascular death was the primary end point. Of this cohort, 2788 patients were treated with PTCA (2626 within 60 days) and 3422 with CABG (3080 within 60 days). Repeat or crossover revascularization procedures were counted as part of the initial treatment strategy. Kaplan-Meier survival curves (both unadjusted and adjusted for all known imbalances in baseline prognostic factors) were used to examine absolute survival differences, and treatment pair hazard ratios from the Cox model were used to summarize average relative survival benefits. For the latter, a 13-level CAD prognostic index was used to examine the relation between survival and revascularization as a function of CAD severity. The effects of revascularization on survival depended on the extent of CAD. For the least severe forms of CAD (ie, one-vessel disease), there were no survival advantages out to 5 years for revascularization over medical therapy. For intermediate levels of CAD (ie, two-vessel disease), revascularization was associated with higher survival rates than medical therapy. For less severe forms of two-vessel disease, PTCA had a small advantage over CABG, whereas for the most severe form of two-vessel disease (with a critical lesion of the proximal left anterior descending artery), CABG was superior. For the most severe forms of CAD (ie, three-vessel disease), CABG provided a consistent survival advantage over medicine. PTCA appeared prognostically equivalent to medicine in these patients, but the number of PTCA patients in this subgroup was low. CONCLUSIONS: In this first large-scale, prospective observational treatment comparison of PTCA, CABG, and medicine, we confirmed the previously reported survival advantages for CABG over medical therapy for three-vessel disease and severe two-vessel disease. For less severe CAD, the primary treatment choices are between medicine and PTCA. In these patients, there is a trend for a relative survival advantage with PTCA, although absolute survival differences were modest. In this setting, treatment decisions should be based not only on survival differences but also on symptom relief, quality of life outcomes, and patient preferences.

Angioplasty, Balloon, Coronary↗
PubMed1994

Diagnosing and managing unstable angina. Agency for Health Care Policy and Research.

This Quick Reference Guide for Clinicians contains recommendations on the care of patients with unstable angina based on a combination of evidence obtained through extensive literature reviews and consensus among members of an expert panel. Principal conclusions include the following. (1) Many patients suspected of having unstable angina can be discharged home after adequate initial evaluation. (2) Further outpatient evaluation may be scheduled for up to 72 hours after initial presentation for patients with clinical symptoms of unstable angina judged at initial evaluation to be at low risk for complications. (3) Patients with acute ischemic heart disease judged to be at intermediate or high risk of complications should be hospitalized for careful monitoring of their clinical course. (4) Intravenous thrombolytic therapy should not be administered to patients without evidence of ST segment elevation and acute myocardial infarction. (5) Assessment of prognosis by noninvasive testing often aids selection of appropriate therapy. (6) Coronary angiography is appropriate for patients judged to be at high risk for cardiac complications or death based on their clinical course or results of noninvasive testing. (7) Coronary artery bypass surgery should be recommended for almost all patients with left main disease and many patients with three-vessel disease, especially those with left ventricular dysfunction. (8) The discharge care plan should include continued monitoring of symptoms; appropriate drug therapy, including aspirin; risk-factor modification; and counseling.

Ambulatory Care↗
PubMed1994

Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development.

BACKGROUND: In 1991, the General Medical Council suggested the development of a new undergraduate curriculum, on a 'core plus electives' basis. The combination of National Health Service reforms and the rising profile of academic departments of general practice had led to a consideration of general practice as an alternative teaching environment. These departments now face escalating expectations from their medical schools of their ability to provide additional community based teaching. AIM: The aim of this study was to investigate the present contribution of academic departments of general practice to undergraduate teaching and their plans for curriculum development, including the introduction of community-based clinical skills teaching. METHOD: A questionnaire was circulated in June 1993 to all academic departments of general practice in the United Kingdom and Eire. RESULTS: Twenty seven out of 28 questionnaires were returned. Twenty two departments provided pre-clinical teaching and all provided a clinical practice attachment. Eight medical schools were organizing community-based clinical skills teaching, and in two this formed the basis for a community-based medical attachment. Eight planned to reduce the factual content of their curricula and introduce problem-based learning while nine were contemplating a 'core plus electives' option. Fourteen medical schools had primary care input in teaching basic clinical skills and an additional seven planned to introduce this. Problems encountered by the general practitioner tutors in teaching clinical skills included insufficient time and resources and poor self-esteem; they identified a need for good central and peripheral organization. CONCLUSION: Compared with a 1988 study, academic departments of general practice are increasingly involved in teaching both general practice and general medical skills at undergraduate level. Curriculum change is occurring rapidly, with an increasing trend towards community teaching; the implications for both academic departments and general practitioner tutors are discussed.

Curriculum↗
PubMed1994

A compartmental model for simulation of IGF-I kinetics and metabolism.

A compartmental model for the simulation of in-vivo insulin-like growth factor one (IGF-I) kinetics and metabolism is presented. The model is based on the concept that IGF binding proteins (IGFBPs) act as a reservoir for IGF-I in plasma, thereby restricting its access to the extravascular space. The model is divided into two subsystems; a binding model for IGF-I and IGFBP, and an IGF-I clearance model, which includes the binding of IGF-I to IGF-I receptors. The non-linear differential equations describing the model are based on the law of mass action. Given the steady state condition, the linearized form of the model, describing tracer kinetics of IGF-I and IGFBPs is developed. It is demonstrated that using the available data, it is possible to assign values to the model parameters, thereby allowing simulation of the model to obtain information not accessible by direct observation.

Animals↗
PubMed1993

Ethnic differences in risk factors associated with the prevalence of non-insulin-dependent diabetes mellitus. The San Luis Valley Diabetes Study.

Non-insulin-dependent diabetes mellitus is 2-5 times more common in Hispanics than in non-Hispanic whites in the United States. The authors conducted this case-control study in two Colorado counties from 1984 to 1986 to determine whether known risk factors for non-insulin-dependent diabetes mellitus explained the excess incidence in Hispanics. There were 279 subjects with prevalent diabetes and 488 subjects with normal glucose tolerance who were eligible for this analysis. After adjustment for age and sex, results showed that Hispanics were 3.5 times more likely than non-Hispanic whites to have non-insulin-dependent diabetes mellitus (95% confidence interval 2.4-4.9). The excess risks of diabetes associated with body mass index, subscapular and triceps skinfold thickness, family history of diabetes, and income were similar in Hispanics and non-Hispanic whites, after adjustment for age and sex. However, 1-unit increases in subscapular/triceps skinfold ratio and waist/hip ratio were associated with greater increases in risk among non-Hispanic whites than among Hispanics. When risk factors were entered into logistic regression models simultaneously, higher subscapular skinfolds, a higher waist/hip ratio, family history of diabetes, older age, male sex, and lower income were independently associated with non-insulin-dependent diabetes mellitus in both ethnic groups. No association was found with skin reflectance, a marker for Amerindian admixture. While the excess risk of diabetes in Hispanics was reduced, a significant 1.9-fold excess risk in Hispanics remained. Further studies are needed to understand factors contributing to the excess prevalence of diabetes in Hispanic Americans.

Adult↗
PubMed1993

The effect of diabetes and dietary ascorbate supplementation on the oxidative modification of rat lens beta L crystallin.

The level of characteristic markers of protein oxidative modification (tryptophan oxidation and sulfhydryl group loss as well as carbonyl and bityrosine formation) and glycation (AGEP formation) have been measured in beta L crystallin purified from the lenses of control, diabetic, and ascorbate-supplemented diabetic animals. These markers were also determined following the application of an in vitro graded oxidative insult. Prior to the application of stress, diabetic lens crystallins, in comparison with control, exhibited a higher content of bityrosine and AGEPs, a lower level of nonoxidized tryptophan, and a loss of sulfhydryl groups. After exposure to the oxidative insult there was a stress-proportional increase of the parameters in all beta L crystallins, irrespective of their source. The effects were most pronounced in the diabetic, in which the already-elevated indicators of oxidative damage were further increased. Dietary supplementation of the diabetic group with ascorbate had a marked effect in preventing beta L crystallin modification in vivo, alleviating the loss of sulfhydryl groups and the oxidation of tryptophan, partially preventing the formation of AGEP and carbonyl groups, but not affecting the formation of bityrosine. Supplementation also inhibited the increase in susceptibility of diabetic beta L crystallin to in vitro oxidative stress, preventing sulfhydryl group loss as well as carbonyl and AGEP group formation. The results are discussed in relation to the proposal that diabetes renders lens crystallins more susceptible to oxidative stress and that this may be a causative factor in cataractogenesis. The possible role of ascorbate in the inhibition, or attenuation, of cataractogenesis is examined.

Animals↗
PubMed1993

Increased susceptibility to metal catalysed oxidation of diabetic lens beta L crystallin: possible protection by dietary supplementation with acetylsalicylic acid.

The effect of dietary supplementation with acetylsalicylic acid on the increased modification, and susceptibility to modification, of lens crystallins from the streptozocin diabetic rat, has been determined. This was done by the measurement of characteristic markers of protein post-translational oxidative modification and glycation, in beta L crystallins purified from the lenses of control, diabetic and acetylsalicylic acid-supplemented diabetic animals, with no further manipulations, and again following the application of an in vitro graded oxidative insult. Crystallins prepared from the diabetic, in comparison with control animals, exhibited a higher level of bityrosine- and AGEP-like fluorescence as well as a loss of tryptophan fluorescence and sulphydryl groups. Exposure to an oxidative insult (in the form of CuSO4 and ascorbate) increased all parameters in beta L crystallins, irrespective of their source. However, the effects were most pronounced in the diabetic in which the effects of oxidative stress were always greater than the control crystallin. Dietary supplementation of the diabetic group with acetylsalicylic acid (100 mg kg-1 body weight day-1) had a marked effect in decreasing the level of modification induced in diabetic crystallins, by in vitro metal catalysed oxidative stress, lowering the levels of AGEP- and bityrosine-like fluorescence and carbonyl group formation. Increasing the oxidative stress by addition of increasing concentrations of H2O2, induced stress proportional increases in the indicators of protein modification in all beta L crystallins, irrespective of source. The increase in damage in relation to H2O2 concentration was greater in those crystallins from diabetic animals, revealing a greater susceptibility to such oxidative stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1993

Coronary artery bypass in patients with severely depressed ventricular function.

This study evaluates whether patients with coronary artery disease and severely depressed left ventricular ejection fraction benefit from coronary artery bypass grafting. From 1981 to 1991, 118 consecutive patients with ejection fraction less than or equal to 0.25 underwent isolated coronary artery bypass grafting at Duke University Medical Center. Operative mortality was 11%. Ventricular arrhythmia requiring treatment was the most common postoperative complication (27%), followed by low cardiac output state (22%). Median length of postoperative hospitalization was 9 days. Kaplan-Meier estimate of survival at 1 year and 5 years was 77.2% and 57.5%, and was better than estimated survival with medical therapy alone. Survivors experienced significant improvement in angina class (p < 0.0001), congestive failure class (p < 0.0001), and follow-up ejection fraction (p < 0.005). Of 22 preoperative factors evaluated by univariate survival analysis, five were associated with significantly greater mortality: other vascular disease (p < 0.005), female sex (p < 0.005), hypertension (p < 0.005), elevated left ventricular end-diastolic pressure (p < 0.05), and depressed cardiac index (p < 0.05). Considering length of hospitalization, three factors showed significant adverse effect in a multivariate Cox model: time on cardiopulmonary bypass (p < 0.005), acute presentation (p < 0.005), and female sex (p < 0.01). These data and review of the literature suggest that patients with coronary artery disease and severely depressed ejection fraction benefit from coronary artery bypass grafting, and specific preoperative factors may help determine optimal treatment.

Aged↗
PubMed1993

Effects of chloroquine on the dyslipidemia of non-insulin-dependent diabetes mellitus.

The effects of 3-day oral chloroquine phosphate treatment administered at a dosage of 250 mg four times daily on fasting serum levels of lipids, lipoproteins, and apolipoproteins were studied in 20 patients with non-insulin-dependent diabetes mellitus (NIDDM). Chloroquine reduced the fasting serum concentrations of total cholesterol (6.16 +/- 0.31 to 5.67 +/- 0.31 mmol/L, P < .05), low-density lipoprotein (LDL) cholesterol (4.38 +/- 0.35 to 3.93 +/- 0.32 mmol/L, P < .05), and apolipoprotein (apo) B (1.46 +/- 0.08 to 1.24 +/- 0.06 g/L, P < .01), and the ratio of apo B to apo A-I (0.81 +/- 0.05 to 0.71 +/- 0.03, P < .05). Chloroquine also caused a decrease in fasting plasma glucose levels (11.1 +/- 0.5 to 9.2 +/- 0.4 mmol/L, P < .01) and an increase in fasting plasma insulin levels (0.12 +/- 0.01 to 0.14 +/- 0.01 nmol/L, P < .01). The decrease in total cholesterol and apo B levels correlated with the increase in fasting plasma insulin levels (r = .35, P = .04 and r = .33, P = .03, respectively), but not with changes in plasma levels of glucose or nonesterified fatty acids (NEFA). This study demonstrates that 3 days of oral chloroquine treatment improves abnormalities of lipoprotein metabolism in patients with NIDDM. This may be due to an increase in insulin levels, but there also appears to be a more direct effect of the drug on apo B metabolism.

Adult↗
PubMed1993

The effects of growth hormone on protein metabolism in adult growth hormone deficient patients.

OBJECTIVE: Growth hormone treatment given to adult growth hormone deficient patients leads to an increase in lean body mass by an unknown mechanism. The aim of this study was to investigate the actions of growth hormone treatment on protein metabolism in adult growth hormone deficient patients. DESIGN: Double-blind, placebo controlled trial of recombinant human growth hormone (0.018 U/kg/day for 1 month followed by 0.036 U/kg/day for 1 month) with isotopic whole body protein turnover studies at 0 and 2 months. PATIENTS: Eighteen adult growth hormone deficient patients (nine male, nine female of mean age 46.6 (range 30-56). MEASUREMENTS: Whole body isotopic leucine turnover using L-1-13C-leucine measuring leucine Ra (a measure of protein degradation), non-oxidative leucine Rd (a measure of protein synthesis) and leucine oxidation rate. RESULTS: Lean body mass (P < 0.02), circulating insulin-like growth factor I (P < 0.01) and insulin (P < 0.02) were significantly increased at 2 months in the treatment group but there was no change in the placebo group. When expressed in relation to body weight, leucine Ra and non-oxidative leucine Rd increased (P < 0.01) and leucine oxidation decreased (P < 0.02) after 2 months growth hormone treatment. When expressed in relation to lean body mass non-oxidative leucine Rd increased (P < 0.02) and leucine oxidation decreased (P < 0.02) but there was no significant change in leucine Ra after 2 months growth hormone treatment. In the placebo group there were no significant changes in leucine metabolism expressed as lean body mass or body weight after 2 months. changes in leucine metabolism expressed as lean body mass or body weight after 2 months. CONCLUSION: These results indicate that the increase in lean body mass resulting from growth hormone treatment in adult growth hormone deficient patients is due to an increase in protein synthesis.

Adult↗
PubMed1993

Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia.

OBJECTIVE: To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN: Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING: Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS: 179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES: Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS: Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION: Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.

Data Collection↗