Chronic obstructive pulmonary disease in Brazilian primary care: Diagnostic competence and case-finding.

AIMS: The developing world is particularly at risk of an increasing health burden due to an increased prevalence of Chronic Obstructive Pulmonary Disease (COPD) secondary to increasing tobacco consumption. However, research is scarce. The objectives of this study were to assess the current competence for diagnosing COPD in primary care in a resource-limited setting in Brazil, and to develop a local patient profile for case-finding. METHODS: 34 general practitioners (GPs) in five areas of northern Brazil recruited adult patients with principal complaints of cough and/or shortness of breath who then had spirometry (n = 142). RESULTS: For the dichotomous variable 'COPD' the degree of agreement between GP diagnosis (n = 64, 18.3%) and spirometric outcome (n = 36, 25.4%) was poor, with Kappa = 0.055 (SE 0.087) and DOR = 1.35. False-positive and false-negative diagnosis proportions were 19.8% and 75%, respectively. Independent risk factors were 'smoking history of more than five pack years' and 'presence of both dyspnoea and cough'. It requires the testing of 2.2 smokers with more than five pack years to detect one patient at risk. CONCLUSIONS: COPD is a common yet underdiagnosed disease in Brazilian primary care. Spirometry improves diagnostic competence and case-finding substantially. If applied in a pre-selected high-risk population, we believe spirometry can be a cost-effective diagnostic tool for case-finding in the resource-limited setting. This study provides important baseline information for effective guideline implementation.     

312例活动性肺结核延误诊断的临床分析

本文报告1986年12月至1988年5月在我科门诊确诊的312例新发现活动性肺结核延误诊断情况。结果表明,新发现活动性肺结核的及时诊断率为67.1％,总延误率为32.9％,平均延误时间为75天。提示我区肺结核的延误诊断情况较严重。如能采取多方面综合性措施,结核病的发现问題可望有所好转。     

目标考核对提高肺结核病人转诊和追踪效果的评价

目的了解湖北省肺结核病人转诊和追踪工作实施的进展和效果。方法将肺结核病人转诊和追踪工作纳入各市州政府结核病防治工作目标责任书考核内容，每半年现场考评1次，同时抽查市、县级综合医院肺结核疫情登记、报告和转诊情况，以及结防专业机构对网络直报病人的追踪情况。考评资料经审核后；12总，采用SAS8．1软件处理。结果实施目标考核1年后，市级综合医院肺结核疫情报告率由71．1％提高到92，1％（P〈0．01），转诊率由36．3％提高到81．3％（P〈0．0001）。县级综合医院报告率由65．5％提高到97．2％（P〈0．001），转诊率由47．5％提高到94．9％（P〈0.0001）。全省结防机构追踪率由78．6％提高到92．2％（P〈0．0001），追踪到位率45．9％。2006年1—6月，全省由转诊和追踪发现的肺结核病人数，占病人发现总数的34．2％。结论实施目标考核后，有力促进医疗机构和结防机构之间的协调与合作，极大地提高病人的发现。     

对不同人群采用不同方法肺结核病人检出率的研究

目的 了解我国目前肺结核可疑症状者在全人口中的比例和不同人群不同方法肺结核病人检出率。方法 对无肺结核可疑症状者和有肺结核可疑症状者，分别采用胸透筛选、直接摄片、直接痰菌检查等不同方法对照研究。结果 有肺结核可疑症状者占全人口的1．27％；无症状者采用胸透筛选法检出活动性病人数、菌阳病人数和涂阳病人数分别仅占无症状者人数(受检人数)的0．13％、0．04％和0．03％，有症状者检出活动性病人数、菌阳病人数和涂阳病人数分别占有症状者人数(受检人数)的16．82％、7．98％和6．。76％。有肺结核可疑症状者采用：直接摄片的活动性肺结核病人、菌阳病人和涂阳病人检出率，分别为17．92％、8．37％和6．83％；直接痰培养的菌阳病人检出率为8．95％。直接痰涂片：2个痰标本与3个痰标本的涂阳病人检出率分别为6．17％和7．08％。结论 1．27％的全人口肺结核可疑症状者是评价可疑症状者就诊率的指标；对咳嗽、咳痰≥3周或有咯血的肺结核可疑症状者进行检查是最符合成本效益原则的结核病人发现方法。对有肺结核可疑症状者应当采用直接摄片法和3个痰标本进行病人发现；直接痰培养的菌阳病人检出率最高，有条件的单位可开展痰培养检查。     

Criteria for mutation analysis in MEN 1-suspected patients: MEN 1 case-finding

BACKGROUND: Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal, dominantly inherited cancer syndrome, with tumours in various endocrine glands. In 1997 the responsible tumour suppressor gene was identified. MEN1 gene germ-line mutations are detected in the vast majority of MEN 1 patients, however, with regard to case-finding, unfortunately only at a very low frequency in patients with apparently sporadic MEN 1-related tumours. In order to increase the detection rate of disease gene carriers among patients with apparently sporadic MEN 1-related tumours, clinical criteria were needed. DESIGN AND RESULTS: In this study MEN1 gene germ-line mutations were revealed in 16/16 MEN 1 patients/families (100%). Based on our clinical experience with MEN 1 patients/families we formulated clinical criteria to identify disease gene carriers among patients with apparently sporadic MEN 1-related tumours. The criteria for MEN 1-suspected patients are: young age at onset (< 35 years) and/or multiple MEN 1-related lesions in a single organ or two distinct organs affected. Application of these criteria yielded MEN1 gene germ-line mutations in nine of 15 MEN 1-suspected patients (60%), thus identifying novel MEN 1 families. Follow up was also guaranteed for patients not fulfilling these criteria. CONCLUSIONS: The clinical criteria for MEN 1-suspected patients increase the detection rate of germ-line MEN1 gene mutations among patients with apparently sporadic MEN 1-related tumours. These criteria may be used for (presymptomatic) identification of MEN 1 disease gene-carriers, thus enabling early detection of tumour development and timely treatment, as well as genetic counselling.     

Prevalence and incidence rate of diabetes mellitus in a Swedish community during 30 years of follow-up

Aims/hypothesis

Increasing diabetes prevalence has been reported in most European countries in the last 20 years. In this study we report on the development of prevalence and incidence of diabetes from 1972 to 2001 in Laxå, a rural community in central Sweden.

Materials and methods

A diabetes register was established at the primary healthcare centre (PHCC) in Laxå, beginning in 1972 and based on data from clinical records at the PHCC, nearby hospitals and private practitioners in the area. In addition, case-finding procedures involving 85% of the residents aged 35 to 79 years old was performed from 1983 onwards.

Results

During the study period a total of 776 new diabetes cases was found, 36 type 1 diabetes mellitus and 740 type 2 diabetes mellitus. The age-standardised incidence rates for type 1 diabetes mellitus and type 2 diabetes mellitus were 0.15 and 3.03 cases per 1,000 population, respectively. No increase in incidence over time was detected for either forms of diabetes. Age-standardised prevalence for women and men increased from 28.3 and 25.9, respectively, per 1,000 in 1972 to 45 and 46.3 per 1,000 in 1988 (p?

Conclusions/interpretation

The prevalence of diabetes mellitus in Laxå is high, but has not increased during the last 13 years. The incidence rate was relatively stable over the whole 30-year period.

     

The influence of alcohol abuse as a hidden contributor to mortality

Although only about 2-3 percent of annual deaths are attributed to one of the four underlying causes linked to chronic alcohol use, research results suggest that the impact of alcohol is much greater. The recent issue of mortality multiple cause of death tapes from National Center for Health Statistics permit exploration of associations of chronic alcohol abuse with conditions coded as underlying cause of death and provide leads for case-finding. Data analysis is reported from certificates of resident deaths in the United States in 1978. There are 12 groups of underlying causes for which the percentage of pairings with chronic alcohol abuse ranges from 4-16 percent of the number of deaths from the underlying cause. Age, sex, and metropolitan status of residence are associated with a listing of chronic alcohol abuse among decedents of liver cancer, varicose veins, symptomatic heart disease, septicemia, and respiratory system disease. Planners concerned with secondary prevention can use these clues provided by logistic regression modelling as an aid in case-finding.     

Medicaid Patients at High Risk for Frequent Hospital Admission: Real-Time Identification and Remediable Risks

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm’s positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

石家庄市提高肺结核病人发现措施的效果评价

[目的]评价石家庄市提高肺结核病人发现措施的效果。[方法]对石家庄市2002～2007年结核病门诊季报资料进行分析。[结果]采取措施后肺结核病人的发现率大大提高:2003～2007年涂阳新登记率都超过了40/10万;不同的就诊方式涂阳检出率不同,转诊的涂阳检出率较其他方式高为34.3%,其次是日常推荐为20.8%、主动就诊为12.2%。[结论]加大对综合医院结核病人的报告、转诊、追踪力度和加强对乡镇基层医务人员进行结核病防治政策和防治知识的培训,来提高病人发现是行之有效的措施,并能起到事半功倍的效果。     

宾阳县2008年肺结核病人报告/转诊及追踪情况分析

目的评价2008年宾阳县非结防机构网络直报肺结核病人转诊和追踪工作。方法对2008年宾阳县非结防机构的网络报告和转诊以及县结防机构追踪资料进行分析。结果转诊率100%(1006/1006),转诊到位率为68.29%(687/1006),到位的687例中临床复诊为活动性肺结核510例(占74.24%).其中180例肺结核检出涂阳(占35.29%),占总数687例的26.20%;追踪到位率为76.18%(243/319),追踪到位的243例,在结防门诊检查临床复诊为活动性肺结核112例(占46.09%),其中,查痰112例,检出涂阳病人35例(占31.25%,占追踪到位总数的14.40%)。追踪未到位的病人中,有46.05%属于辖区外病人。结论进一步加强结核病防治机构与非结核病防治机构的合作和协调,加强转诊和追踪力度,提高总体到位率;加强流动人口的管理,要充分利用网络的共享功能,进一步加强与各地疾控中心间的沟通与合作,采取切实有效的措施对流进流出的疑似肺结核病人进行管理。