Objective: To describe the complete range of factors which doctors recognise as changing their clinical practice and provide a measure of how often education is involved in change. Design: Interviews using the critical incident technique. Setting: Primary and secondary care. Subjects: Random sample of 50 general practitioners and 50 consultants. Main outcome measures: Categories of reasons for change in clinical practice. Results: Doctors described 361 changes in clinical practice, with an average of 3.0 reasons per change. The three most frequently mentioned reasons were organisational factors, education, and contact with professionals, together accounting for 47.9% of the total number of reasons for change. Education accounted for one sixth (16.9%) of the reasons for change and was involved in one third (37.1%) of the changes. Education was seldom mentioned as a reason for change in referral practice but was more often mentioned in management and prescribing changes. Consultants were influenced by medical journals and scientific conferences, while general practitioners were more influenced by medical newspapers and postgraduate meetings. Conclusions: Education is involved in about a third of changes in clinical practice. The wide range of other factors affecting changes in practice need to be taken into account in providing and evaluating education. The role of education in the numerous changes in clinical practice that currently have no educational component should also be considered.

Arterial stiffness was increased in SCH and improved with l-thyroxine, which may be beneficial, whereas myocardial functional reserve was similar to controls and remained unaltered after treatment.

Altered cardiac function in thyroid disease is well recognized and has been extensively investigated, vascular function has however been less well studied in those with thyroid dysfunction. Thyroid hormones, thyroxine (T(4)) and triiodothyronine (T(3)) are important regulators of cardiac function and cardiovascular hemodynamics. The cardiovascular system responds to minimal but persistent changes in circulating thyroid hormone levels producing changes in vascular reactivity and endothelial function. The detection of endothelial dysfunction and/or arterial stiffness allows early identification of individuals at risk as these occur in both patients with risk factors for coronary artery disease and in those with established disease. This may allow treatment to be targeted at high risk individuals with the aim of slowing the progression of vascular disease. The various methods used to assess arterial function are reviewed and the changes demonstrated in human and animal models of thyroid dysfunction.

Objectives: To describe the presentation of meningococcal disease in primary care; to explore how general practitioners process clinical and contextual information in children with meningococcal disease; and to describe how this information affects management.

No abstract