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National Guideline Clearinghouse. URL: www.guideline.gov/index.asp.

Emory University School of Medicine, VA Medical Center, 1670 Clairmont Rd., Decatur, GA 30033
Section of Biochemistry, University of Ottawa, 501 Smyth Rd., Ottawa ON K1H 8L6, Canada
3453 Tupper Hall, Medical Pathology, School of Medicine, University of California Davis, Davis, CA 95616, E-mail gjkost{at}ucdavis.edu

Viral hepatitis is one of the current "hot topics" in medical circles, among clinical laboratory professionals, and even among the general public. Newly heightened awareness of the magnitude of the problem of hepatitis C viral infections in the United States population, together with the availability of new therapies for hepatitis C, have stimulated initiatives designed to identify and treat the large numbers of patients infected with this agent. At the same time, demands for the elimination of hepatitis viruses from the blood supply in the United States have led over the past year to the onset of nucleic acid-based testing of blood products and the appearance of solvent-detergent-treated plasma. Still more recently, press reports of the discovery of a new viral agent, Sen V, which is being touted as the long-sought agent responsible for most cases of non-A, non-E hepatitis have stirred both excitement and controversy within the medical and laboratory communities. Thus, the appearance of a new book devoted to the known hepatitis viruses and the diagnosis, therapy, and prevention of viral hepatitis is both topical and timely.

This book begins with a short introduction by the editor, Steven Specter, which summarizes the major characteristics of the known hepatitis viruses and the diseases they cause. The next six chapters, each written by internationally recognized experts in their respective fields, provide detailed discussions of the biology, pathogenesis, epidemiology, clinical description, and diagnosis of hepatitis viruses A through E and the GB viruses (including the hepatitis G agent). The eighth chapter, which should be of particular interest and value to clinical chemists and other laboratory professionals, provides a comprehensive discussion of the laboratory procedures currently available for the diagnosis of viral hepatitis. The final three chapters are devoted to the currently available antiviral chemotherapies for viral hepatitis as well as vaccines for hepatitis A and hepatitis B. A useful index completes the book. Each chapter includes a fairly comprehensive list of appropriate references. A minor quibble is that references for some chapters are numbered alphabetically, whereas others are numbered in order of appearance. Of more concern, particularly as regards the more recently discovered agents such as the GB viruses, is that only a few of the references are more recent than 1996. Such recent important developments as the success of combination chemotherapy for hepatitis C are not included in the book.

Clinical chemists and other laboratory professionals, physicians, educators, and scientists needing an update on viral hepatitis should find this book a useful, detailed, and readily accessible source of information on all of the major hepatitis viruses. The specialist seeking the latest information on treatment protocols or disease prevention strategies will undoubtedly need to augment this information by consulting the current literature.

This superb, inexpensive pocket book provides answers to a wide variety of the most common questions in pathology and laboratory medicine. Most aspects of the discipline are covered, including principles of pathology such as cell injury, inflammation, immunopathology, nutrition, genetics, environmental pathology, and neoplasia. Systematic pathology is described under the usual headings, as is clinical pathology: clinical chemistry (I wish books would stop using mEq/L for electrolytes), hematopathology, and immunohematology. Some microbiology is included in relation to the above sections, but this discipline does not command a section of its own. The book is intended as a study guide to the larger Saunders pathology text, which is also a very affordable book (1). Most Commons in Pathology and Laboratory Medicine provides common questions and answers in table format. A multiple choice question is included at the end of each section, followed by a brief discussion of the correct answer. It places a heavy emphasis on pathophysiology and mechanisms of disease.

I found this booklet surprisingly comprehensive and very useful. As in any synopsis, corners are cut, and the obsessive reader may challenge some of the conclusions, but I found it accurate in the areas in which I have special expertise. Readers who require more depth must read the parent text. "The proof of the pudding is in the eating thereof"; I keep it by me and read a few pages each day and have learned a great deal in a short time. If I were preparing for exams, I would find it invaluable.

The National Guideline Clearinghouse (NGC) is a public resource for evidence-based clinical practice guidelines. The web site is intended to make guidelines and related materials available to health professionals. To be included in this comprehensive database, a clinical practice guideline must meet multiple criteria (1), which are available on the web site. Among the required criteria is the performance of a verifiable systematic literature search and review of scientific evidence published in peer-reviewed journals. NGC is sponsored by the Agency for Health Care Policy and Research (AHCPR), a part of the US Department of Health and Human Services, in partnership with the American Medical Association and the American Association of Health Plans. Components of the NGC web site include an index, tools for comparing guidelines, summaries, links to full-text versions, an electronic forum, and various references.

Web site content.

Currently, the NGC web site posts close to 600 guidelines. These guidelines are drawn from numerous sources, including, for example, the AHCPR, professional medical academies, professional associations, NIH/CDC and other governmental agencies, hospitals, private foundations, service organizations, and more. Representation from laboratory medicine is scant. For example, the College of American Pathologists lists only three guidelines (examination of the placenta, practice parameter for red blood cell transfusions, and preoperative bleeding time lack of benefit). Of course, there are literally thousands of guidelines in existence, so one can expect the content of this web site to expand. Some guidelines are reviewed, which is useful but perhaps not timely because of delays since the year of guideline publication.

I tested the search engine. A search of "laboratory tests" yielded 149 related guidelines, mostly general ones, but a few tightly focused guidelines, such as "Tests of glycemia in diabetes" (American Diabetes Association, 1997/99), "Guidelines for laboratory evaluation in the diagnosis of Lyme disease" (American College of Physicians, 1996), and "Cervical cancer screening" (American College of Preventive Medicine, 1996). A search for "point-of-care testing" generated 76 related guidelines covering topics such as sampling for arterial blood gas analysis, hyperbilirubinemia, anemia of chronic renal failure, urinary tract infections in febrile infants, and fibrinolysis. These results at least provide avenues for exploration to determine the relevance and impact of point-of-care testing in the individual guideline publications. However, very few of the guidelines carried 1999, or even 1998, publication dates. A search for "acute myocardial infarction" produced 37 guidelines, several of which were important position statements useful for their clinical content.

Web site organization.

Generally, the web site is clear and effective. Download times are minimal, and there is an option for non-frames text only. Graphics are used sparingly. Vertical scrolling is minimal, but some horizontal scrolling may be necessary, depending on viewable area. Navigation is aided by "home", "help", "what’s new", "map", "contact", and other buttons at the bottom of each screen. The guideline search engine is adequate. Results are clustered in groups of 10. Selection of an individual guideline from a search list yields a convenient summary, citation of source, release date, review (if done), links to the electronic version (if available), and information on hard copies and companion documents. At this point, a bookmark is useful because access to the complete text of the guideline may lead the browser off the web site. The help feature, "How to access full-text guidelines", is vital for obtaining guidelines of interest. "What’s new" lists guidelines entered each week. A total of four guidelines were entered the week of September 26, 1999, when I visited the site. The e-mail address (info@guideline.gov) is buried at the bottom of the "What’s new this week" page. The web site is not interactive in terms of on-line dialogue or similar features.

Summary and recommendations.

The NGC web site is a good starting point because it provides a wealth of clinically oriented guidelines from respected sources. The content can be searched in a reasonable length of time. The yield for the laboratorian will depend on the area of interest. If the specific guideline is accessible electronically, then relevance to diagnostic testing and/or diagnostic strategies, such as point-of-care testing, can be ascertained quickly. If not, then manual retrieval may be necessary, slowing down the process and stressing one’s attention span. The destiny of this web site will depend on timely entry of new, fresh guidelines and on perpetual updating of the electronic database to maintain viable links to other vital related web sites. Future inclusion of more expert reviews, live dialogue, and on-line graphics (e.g., algorithms) would be helpful to both practitioners and students.

References

1. Goljan EF. Pathology. Philadelphia, PA: WB Saunders, 1998:527pp..

1. Fed Regist 1998;63(70):18027..

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