The experience of a UK General Practice in implementing quality ideas within the context of a UK Government contract to bring in Quality Targets is described. Simple ideas based on a theoretical background from industrial methods are used to make changes in a typical UK general practice. Measurements based on a range of easily available data, from the practice computer system, enables one to see a benefit to patient care and in particular the management of chronic disease. The stress of dealing with potential mistakes in current British healthcare environment is addressed as is the conflicting culture of Targets applied by Government to the Quality culture. The virtue of a Team approach to change is emphasised as is the principle of “blame reduction” so as to allow the Team to flourish. The author has been impressed with the benefits to both the community and the practice staff of applying basic simple quality tools in general practice.

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BACKGROUND: The existence of a gap between research evidence and clinical practice has been described recently. Several drugs are effective in preventing secondary events after acute myocardial infarction (AMI), but it is not certain whether this evidence is employed in daily practice. We investigated the drugs currently employed for patients with a history of AMI in Japan.
METHODS: Medical records of patients who developed AMI during the calendar year of 1999 were retrospectively identified at three teaching hospitals in Japan. We collected data on drugs prescribed at three time points (upon admission for AMI, at the time of discharge, and one year after discharge) for each patient.
RESULTS: Data were available for 149 patients with AM!. Drugs prescribed at the time of discharge were aspirin (77.5%), nitrates (68.3%), and angiotensin converting enzyme inhibitors (52.8%) . β-blockers were prescribed for only 12.0% of patients. The drugs used one year after discharge were to a large extent similar to those at the time of discharge. There were no significant correlations between the use of these drugs and comorbidity.
CONCLUSION: Despite established evidence that β-blockers offer benefits to patients with a history of AMI, they have not been prescribed frequently, for reasons that remain unclear. To improve the quality of clinical care, further systematic effort is needed to bridge this evidence to practice gap.

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An 18-year-old woman was admitted to our hospital because of headache and double vision. One year before, she had experienced similar symptoms which were ameliorated spontaneously. Before admission, she had been experiencing throbbing headaches for 20 days and double vision for 7 days, respectively. A brain magnetic resonance imaging (MRI) study, performed at another hospital 6 days before admission, showed no abnormality. On admission, she had paralysis of the left abducens nerve and papillaedema of the bilateral optic fundi. Magnetic resonance venography (MRV) revealed areas of signal loss expanding from the confluence of sinuses to the right transverse sinus, which confirmed the diagnosis of cerebral sinus thrombosis. Her symptoms improved dramatically with anticoagulation therapy. The present case suggests that the exploration of papillaedema of optic fundi is of paramount importance in the diagnosis of cerebral sinus thrombosis, and MRV can be definitely diagnostic despite the normal findings of conventional MRI.

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We present a case of juvenile type dermatomyositis and severe retinopathy. A 10-year-old girl presented with progressive weakness of proximal muscles, generalized rash, including heliotrope-type eyelid erythema, and bilateral visual disturbance. Laboratory data showed a markedly elevated serum creatine kinase and electromyography revealed a myogenic pathology. Funduscopic examination showed numerous cotton wool spots and macular edema. She developed massive rhabdomyolysis, generalized skin lesions, systemic edema, renal failure, and respiratory failure. After she received steroid pulse therapy, plasma exchange, and high-dose immunoglobulin, her general condition and visual symptoms improved. She remained well when we followed up her condition 5 years after the discharge.

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