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1.
Si Si John R Moss Thomas R Sullivan Skye S Newton Nigel P Stocks 《The British journal of general practice》2014,64(618):e47-e53
Background
A recent review concluded that general health checks fail to reduce mortality in adults.Aim
This review focuses on general practice-based health checks and their effects on both surrogate and final outcomes.Design and setting
Systematic search of PubMed, Embase, and the Cochrane Central Register of Controlled Trials.Method
Relevant data were extracted from randomised trials comparing the health outcomes of general practice-based health checks versus usual care in middle-aged populations.Results
Six trials were included. The end-point differences between the intervention and control arms in total cholesterol (TC), systolic and diastolic blood pressure (SBP, DBP), and body mass index (BMI) were −0.13 mmol/l (95% confidence interval [CI] = −0.19 to −0.07), −3.65 mmHg (95% CI = −6.50 to −0.81), −1.79 mmHg (95% CI = −2.93 to −0.64), and −0.45 kg/m2 (95% CI = −0.66 to −0.24), respectively. The odds of a patient remaining at ‘high risk’ with elevated TC, SBP, DBP, BMI or continuing smoking were 0.63 (95% CI = 0.50 to 0.79), 0.59 (95% CI = 0.28 to 1.23), 0.63 (95% CI = 0.53 to 0.74), 0.89 (95% CI = 0.81 to 0.98), and 0.91 (95% CI = 0.82 to 1.02), respectively. There was little evidence of a difference in total mortality (OR 1.03, 95% CI = 0.90 to 1.18). Higher CVD mortality was observed in the intervention group (OR 1.30, 95% CI = 1.02 to 1.66).Conclusion
General practice-based health checks are associated with statistically significant, albeit clinically small, improvements in surrogate outcome control, especially among high-risk patients. Most studies were not originally designed to assess mortality. 相似文献2.
Una Martin Roger Holder James Hodgkinson Richard McManus 《The British journal of general practice》2013,63(607):e97-e103
BackgroundInter-arm difference in blood pressure of >10 mmHg is associated with peripheral vascular disease, but it is unclear how much of the difference in sequential right and left arm blood pressure measurements might be due to a ‘white-coat’ effect.AimTo use ambulatory blood pressure monitoring (ABPM) to better understand the clinical significance of inter-arm differences in blood pressure.MethodAnonymised clinical data collected from 784 patients attending a single hospital-based hypertension clinic were retrospectively analysed. Each participant had blood pressure measured sequentially in both arms, followed by ABPM over the subsequent 24 hours.ResultData were available for 710 (91%) patients, of whom 39.3% (279) had a blood pressure difference of 10 mmHg or more between each arm. Compared to daytime systolic ABPM, the difference was 25.1 mmHg using the arm with the highest reading, but only 15.5 mmHg if the lower reading was taken (mean difference 9.6 mmHg (95% confidence interval [CI] = 9.0 mmHg to 10.3 mmHg)). However, differences between mean right (20.7 mmHg) or left (19.9 mmHg) arm blood pressure and daytime systolic ABPM were very similar.ConclusionCompared with ABPM, use of the higher of the left and right arm readings measured sequentially appears to overestimate true mean blood pressure. As there is no significant difference in the extent of disparity with ABPM by left or right arm, this is unlikely to be due to arm dominance and may be due to the ‘white-coat’ effect reducing blood pressure on repeated measurement. Where a large inter-arm blood pressure difference is detected with sequential measurement, healthcare professionals should re-measure the blood pressure in the original arm. 相似文献
3.
A'Court C Stevens R Sanders S Ward A McManus R Heneghan C 《The British journal of general practice》2011,61(590):e598-e603
Background
Previous studies identified worrying levels of sphygmomanometer inaccuracy and have not been repeated in the era of digital measurement of blood pressureAim
To establish the type and accuracy of sphygmomanometers in current useDesign and setting
Cross-sectional, observational study in 38 Oxfordshire primary care practicesMethod
Sphygmomanometers were evaluated between 50 and 250 mmHg, using Omron PA350 or Scandmed 950831-2 pressure meters.Results
Six hundred and four sphygmomanometers were identified: 323 digital (53%), 192 aneroid (32%), 79 mercury (13%), and 10 hybrid (2%) devices. Of these, 584 (97%) could be fully tested. Overall, 503/584 (86%) were within 3 mmHg of the reference, 77/584 (13%) had one or more errorof 4-9 mmHg, and 4/584 (<1%) had one or more errorof more than 10 mmHg. Mercury (71/75, 95%) and digital (272/308, 88%) devices were more likely to be within 3 mmHg of the reference standard than aneroid models (150/191, 78%) (Fisher''s exact test P = 0.001). Donated aneroid devices from the pharmaceutical industry performed significantly worse: 10/23 (43%) within 3 mmHg of standard compared to 140/168 (83%) aneroid models from recognised manufacturers (Fisher''s exact test P<0.001). No significant difference was found in performance between manufacturers within each device type, for either aneroid (Fisher''s exact test P = 0.96) or digital (Fisher''s exact test P = 0.7) devices.Conclusion
Digital sphygmomanometers have largely replaced mercury models in primary care and have equivalent accuracy. Aneroid devices have higherfailure rates than other device types; this appears to be largely accounted forby models from indiscernible manufacturers. Given the availability of inexpensive and accurate digital models, GPs could consider replacing aneroid devices with digital equivalents, especially for home visiting. 相似文献4.
Margaret P Astin Tanimola Martins Nicky Welton Richard D Neal Peter W Rose William Hamilton 《The British journal of general practice》2015,65(639):e677-e691
Background
Selection of primary care patients for investigation of potential oesophagogastric cancer is difficult, as the symptoms may represent benign conditions, which are also more common.Aim
To review systematically the presenting features of oesophagogastric cancers in primary care, including open-access endoscopy clinics.Design and setting
Systematic review and meta-analysis.Method
MEDLINE®, Embase, the Cochrane Library, and CINAHL were searched for studies of adults who were symptomatic and presented in primary care or open-access endoscopy clinics. Exclusions were being asymptomatic, screening, or recurrent cancers. Data were extracted to estimate the diagnostic performance of features of oesophagogastric cancers and summarised in a meta-analysis.Results
Fourteen studies were identified. The strongest summary sensitivity and specificity estimates were for: dyspepsia 0.42 (95% confidence interval [CI] 0.29 to 0.56) and 0.48 (95% CI = 0.31 to 0.65); pain 0.41 (95% CI = 0.24 to 0.62) and 0.75 (95% CI = 0.51 to 0.89); and dysphagia 0.32 (95% CI = 0.17 to 0.52) and 0.92 (95% CI = 0.81 to 0.97). Summary positive likelihood ratios (LR+) and diagnostic odds ratios were: dyspepsia 0.79 (95% CI = 0.55 to 1.15) and 0.65 (95% CI = 0.32 to 1.33); pain 1.64 (95% CI = 1.20 to 2.24) and 2.09 (95% CI = 1.57 to 2.77); and dysphagia 4.32 (95% CI = 2.46 to 7.58) and 5.91 (95% CI = 3.56 to 9.82). Corresponding LR+ were: anaemia 4.32 (95% CI = 2.64 to 7.08); nausea/vomiting/bloating 1.07 (95% CI = 0.52 to 2.19); reflux 0.78 (95% CI = 0.47 to 1.78) and; weight loss 5.46 (95% CI = 3.47 to 8.60).Conclusion
Dysphagia, weight loss, and anaemia show the strongest association but with relatively low sensitivity and high specificity. The findings support the value of investigation of these symptoms, but also suggest that, in a population of patients who are low risk but not no-risk, investigation is not currently recommended. 相似文献5.
Hypertension is defined as the persistent elevation of blood pressure above normal limits. It can be classified according to whether the contributing factors are genetics and environmental (primary hypertension) or underlying medical conditions and medications (secondary hypertension). The goal of this review is to increase recognition of the various anatomical etiologies of hypertension. Clin. Anat. 32:678–681, 2019. © 2019 Wiley Periodicals, Inc. 相似文献
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7.
The beneficial impact of regular exercise on cardiovascular health is partly mediated by psychobiological mechanisms. However, the effect of acute exercise on psychobiological responses is unclear. Thus, we performed a systematic review of randomised controlled trials (RCTs) that examined the effect of acute aerobic exercise on blood pressure (BP) responses (the change from baseline to stress) to psychosocial laboratory tasks. Fifteen RCTs met inclusion criteria of which ten demonstrated significant reductions in post-exercise stress related BP responses compared with control (mean effect sizes for systolic and diastolic BP, 0.38 and 0.40). Studies involving greater exercise doses tended to show larger effects, with the minimum dose to show a significant effect being 30 min at 50% VO2max. No other moderators emerged from the examination of participant characteristics, research designs and stressor characteristics. In conclusion, an acute bout of aerobic exercise appears to have a significant impact on the BP response to a psychosocial stressor. 相似文献
8.
Corine den Engelsen Paula S Koekkoek Merijn B Godefrooij Mark G Spigt Guy E Rutten 《The British journal of general practice》2014,64(627):e616-e626
Background
Many programmes to detect and prevent cardiovascular disease (CVD) have been performed, but the optimal strategy is not yet clear.Aim
To present a systematic review of cardiometabolic screening programmes performed among apparently healthy people (not yet known to have CVD, diabetes, or cardiometabolic risk factors) and mixed populations (apparently healthy people and people diagnosed with risk factor or disease) to define the optimal screening strategy.Design and setting
Systematic review of studies performed in primary care in Western countries.Method
MEDLINE, Embase, and CINAHL databases were searched for studies screening for increased cardiometabolic risk. Exclusion criteria were studies designed to assess prevalence of risk factors without follow-up or treatment; without involving a GP; when fewer than two risk factors were considered as the primary outcome; and studies constrained to ethnic minorities.Results
The search strategy yielded 11 445 hits; 26 met the inclusion criteria. Five studies (1995–2012) were conducted in apparently healthy populations: three used a stepwise method. Response rates varied from 24% to 79%. Twenty-one studies (1967–2012) were performed in mixed populations; one used a stepwise method. Response rates varied from 50% to 75%. Prevalence rates could not be compared because of heterogeneity of used thresholds and eligible populations. Observed time trends were a shift from mixed to apparently healthy populations, increasing use of risk scores, and increasing use of stepwise screening methods.Conclusion
The optimal screening strategy in primary care is likely stepwise, in apparently healthy people, with the use of risk scores. Increasing public awareness and actively involving GPs might facilitate screening efficiency and uptake. 相似文献9.
10.
Ruth A Lewis Richard D Neal Nefyn H Williams Barbara France Maggie Hendry Daphne Russell Dyfrig A Hughes Ian Russell Nicholas SA Stuart David Weller Clare Wilkinson 《The British journal of general practice》2009,59(564):e234-e247
Background
Cancer follow-up has traditionally been undertaken in secondary care, but there are increasing calls to deliver it in primary care.Aim
To compare the effectiveness and cost-effectiveness of primary versus secondary care follow-up of cancer patients, determine the effectiveness of the integration of primary care in routine hospital follow-up, and evaluate the impact of patient-initiated follow-up on primary care.Design of study
Systematic review.Setting
Primary and secondary care settings.Method
A search was carried out of 19 electronic databases, online trial registries, conference proceedings, and bibliographies of included studies. The review included comparative studies or economic evaluations of primary versus secondary care follow-up, hospital follow-up with formal primary care involvement versus conventional hospital follow-up, and hospital follow-up versus patient-initiated or minimal follow-up if the study reported the impact on primary care.Results
There was no statistically significant difference for patient wellbeing, recurrence rate, survival, recurrence-related serious clinical events, diagnostic delay, or patient satisfaction. GP-led breast cancer follow-up was cheaper than hospital follow-up. Intensified primary health care resulted in increased home-care nurse contact, and improved discharge summary led to increased GP contact. Evaluation of patient-initiated or minimal follow-up found no statistically significant impact on the number of GP consultations or cancer-related referrals.Conclusion
Weak evidence suggests that breast cancer follow-up in primary care is effective. Interventions improving communication between primary and secondary care could lead to greater GP involvement. Discontinuation of formal follow-up may not increase GP workload. However, the quality of the data in general was poor, and no firm conclusions can be reached. 相似文献11.
Liam G Glynn Andrew W Murphy Susan M Smith Knut Schroeder Tom Fahey 《The British journal of general practice》2010,60(581):e476-e488
Background
Patients with high blood pressure (hypertension) in the community frequently fail to meet treatment goals: a condition labelled as ‘uncontrolled’ hypertension. The optimal way to organise and deliver care to hypertensive patients has not been clearly identified.Aim
To determine the effectiveness of interventions to improve control of blood pressure in patients with hypertension.Design of study
Systematic review of randomised controlled trials.Setting
Primary and ambulatory care.Method
Interventions were categorised as following: self-monitoring; educational interventions directed to the patient; educational interventions directed to the health professional; health professional- (nurse or pharmacist) led care; organisational interventions that aimed to improve the delivery of care; and appointment reminder systems. Outcomes assessed were mean systolic and diastolic blood pressure, control of blood pressure and proportion of patients followed up at clinic.Results
Seventy-two RCTs met the inclusion criteria. The trials showed a wide variety of methodological quality. Self-monitoring was associated with net reductions in systolic blood pressure (weighted mean difference [WMD] −2.5mmHg, 95%CI = −3.7 to −1.3 mmHg) and diastolic blood pressure (WMD −1.8mmHg, 95%CI = −2.4 to −1.2 mmHg). An organised system of regular review allied to vigorous antihypertensive drug therapy was shown to reduce blood pressure and all-cause mortality in a single large randomised controlled trial.Conclusion
Antihypertensive drug therapy should be implemented by means of a vigorous stepped care approach when patients do not reach target blood pressure levels. Self-monitoring is a useful adjunct to care while reminder systems and nurse/pharmacist -led care require further evaluation. 相似文献12.
13.
Mansell G Shapley M Jordan JL Jordan K 《The British journal of general practice》2011,61(593):e821-e835
Background
Reducing delay in the primary care part of the cancer care pathway is likely to improve cancer survival. Identifying effective interventions in primary care would allow action by primary healthcare professionals and local commissioners to reduce delay.Aim
To identify interventions that reduce primary care delay in the referral of patients with cancer to secondary care.Design and setting
Systematic review in primary care.Method
Eight electronic databases were searched using terms for primary care, cancer, and delay. Exclusion criteria included screening and the 2-week-wait referral system. Reference lists of relevant papers were hand searched. The quality of each paper was assessed using predefined criteria, and checked by a second reviewer.Results
Searches identified 1798 references, of which 22 papers were found to meet the criteria. Interventions concerning education, audit and feedback, decision support software and guideline use, diagnostic tools, and other specific skills training were identified. Most studies reported a positive effect on their specified outcomes, although no study measured a direct effect on reducing delay.Conclusion
There was no evidence that any intervention directly reduced primary care delay in the diagnosis of cancer. Limited evidence suggests that complex interventions, including audit and feedback and specific skills training, have the potential to do so. 相似文献14.
BackgroundLong-term use of benzodiazepines (BZDs) is common. Not only is such use ineffective, but it also has several risks in addition to dependence, and remains a significant problem among the older populationAimTo systematically review randomised controlled trials that evaluate the effectiveness of minimal interventions to reduce the long-term use of BZDs in primary care.MethodCochrane Central, MEDLINE, and Embase (1967–2010) were searched for trials of minimal interventions (such as a single letter or one consultation from a GP) for patients in primary care with long-term (>3 months) BZD use. Pooled risk differences were calculated with 95% confidence intervals.ResultsFrom 646 potentially relevant abstracts, three studies (615 patients) met all the inclusion criteria. The pooled risk ratio showed a significant reduction/cessation in BZD consumption in the minimal intervention groups compared to usual care (risk ratio [RR] = 2.04, 95% confidence interval [CI] = 1.5 to 2.8, P<0.001; RR = 2.3, 95% CI = 1.3 to 4.2, P = 0.008) respectively. Two studies also reported a significant proportional reduction in consumption of BZD from baseline to 6 months in intervention groups compared to the control group. The secondary outcome of general health status was measured in two studies; both showed a significant improvement in the intervention group.ConclusionA brief intervention in the form of either a letter or a single consultation by GPs, for long-term users of BZD, is an effective and efficient strategy to decrease or stop their medication, without causing adverse consequences. 相似文献
15.
Context: Sleep has been assessed as a risk factor for health consequences. Among adults, excessively longer and shorter sleep durations are associated with high blood pressure (BP), but knowledge of the association between sleep duration and high BP among adolescents is limited.Objectives: To estimate the associations between sleep duration and high BP in adolescents.Methods: PubMed, Web of Science, and Cochrane databases were searched for eligible publications up until 20 November 2017. This study reviewed the reference lists from retrieved articles to search for relevant studies. Pooled odds ratios (ORs) were calculated using a random-effects meta-analysis. Sub-group and sensitivity analyses were conducted to identify heterogeneity. Publication bias was evaluated using Egger’s test.Results: Seven studies involving 21,150 participants were included, with ages ranging from 10–18 years. For primary analysis, compared with the reference sleep duration, the pooled OR for high BP was 1.51 (95% confidence interval [CI]?=?1.04–2.19) for the short sleep duration overall. For long sleep duration, the pooled OR was 1.04 (95% CI?=?0.78–1.38). Further sub-group analysis showed that short sleep duration had a higher risk of incident high BP in males (OR?=?1.55, 95% CI?=?1.24–1.93) than in females (OR?=?1.23, 95% CI?=?0.47–3.22).Conclusions: Among adolescents, and particularly male adolescents, short sleep duration may be a risk factor for high BP. More attention should be given to this lifestyle factor. 相似文献
16.
Lorenzo Villa Diana Sun Kris Denhaerynck Stefaan Vancayzeele Heidi Brié Christine Hermans Ann Aerts Michael Levengood Karen MacDonald Ivo Abraham 《The British journal of general practice》2015,65(630):e9-e15
BackgroundPatient adherence is often not monitored because existing methods of evaluating adherence are either burdensome or do not accurately predict treatment outcomes.AimTo examine whether two simple, single-item physician-administered measures of patient adherence to antihypertensive medication are predictive of blood pressure outcomes.MethodUsing pooled data from five observational studies, a sample was identified of 9725 patients who were assessed using two single-item physician-administered measures of adherence to antihypertensive medication: the first item of the Basel Assessment of Adherence Scale (BAAS) and the Visual Analogue Scale (VAS). These two assessment tools were administered by GPs during regular appointments with patients. Systolic blood pressure (SBP), diastolic blood pressure (DBP), and combined SBP/DBP were measured at baseline and at 90 days.ResultsBAAS-identified adherent patients achieved lower mean SBP and DBP compared with non-adherent patients at 90 days (P<0.001), and had odds ratios of achieving blood pressure control of 0.66 (95% confidence intervals (CI) = 0.61 to 0.73, P<0.001) for SBP, 0.69 (95% CI = 0.62 to 0.76, P<0.001) for DBP, and 0.65 (95% CI = 0.59 to 0.72, P<0.001) for combined SBP/DBP. For VAS-identified adherent patients, the odds ratios of achieving blood pressure control were 0.93 (95% CI = 0.86 to 1.00, P<0.001) for SBP, 0.79 (95% CI = 0.73 to 0.85, P<0.001) for DBP, and 0.91 (95% CI = 0.84 to 0.99, P<0.001) for combined SBP/DBP.ConclusionsThe first item of the BAAS and the VAS are independent predictors of blood pressure control. These methods can be integrated seamlessly into routine clinical practice by allowing GPs to quickly evaluate a patient’s adherence and tailor treatment recommendations accordingly. 相似文献
17.
Elizabeth J Shaw Daniel Sutcliffe Terence Lacey Tim Stokes 《The British journal of general practice》2013,63(610):e309-e317
BackgroundDepression is a major cause of chronic ill-health and is managed in primary care. Indicators on depression severity assessment were introduced into the UK Quality and Outcomes Framework (QOF) in 2006 and 2009. QOF is a pay-for-performance scheme and indicators should have evidence to support their use; potential unintended consequences should also have been considered.AimTo review the effectiveness of routine assessment of depression severity using structured tools in primary care, and to determine the views of GPs and patients regarding their use.DesignSystematic review.MethodStudies were identified by searching electronic databases; study selection, data abstraction, and quality assessment were carried out by one reviewer, with checks from other authors and GRADE (grading of recommendations, assessment, development and evaluation) tables completed for included effectiveness studies.ResultsEight studies met the eligibility criteria. There was very low-quality evidence that assessing severity in a structured way at diagnosis using a validated tool led to interventions that were appropriate to the severity of depression. Patients and GPs had different perceptions of the assessment of depression at diagnosis, with patients being more positive. GPs highlighted unintended consequences. There was low-quality evidence that structured assessment at follow-up led to increased rates of remission and response, but changes to management were not seen. Patients used this assessment to measure their own response to treatment.ConclusionAny estimate of the effect of structured assessment of depression severity in UK general practice is uncertain. GPs consider routine use of questionnaires as incentivised by the QOF has unintended consequences, which could adversely affect patient care. 相似文献
18.
《Expert Review of Clinical Immunology》2013,9(10):1105-1113
ABSTRACTBackground: Common variable immunodeficiency (CVID) is the most common clinically significant primary immunodeficiency (PID) disorder characterized by variable clinical manifestations including recurrent infections, autoimmune disorders, enteropathy, lymphoproliferative disorders, and malignancy. The aim of this study is to estimate the overall prevalence of malignancy in patients with CVID.Methods: PubMed, Web of Science and Scopus were searched systemically to find eligible studies from the earliest available date to March 2019 with standard keywords. Pooled estimates of the malignancy prevalence and the corresponding 95% confidence intervals (CI) were calculated using random effects models.Results: Forty-eight studies with a total of 8123 CVID patients met the inclusion criteria and were finally included in the meta-analysis. Overall prevalence of malignancy was 8.6% (95% CI: 7.1–10.0; I2 = 79.2%). The prevalence of lymphoma, gastric cancer, and breast cancer in CVID patients were 4.1% (95% CI: 3.3–4.9; I2 = 62.6%), 1.5% (95% CI: 0.78–2.2; I2 = 68.9%), and 1.3% (95% CI: 0.64–1.9; I2 = 54.9%), respectively. Moreover, autoimmunity and malabsorption were more frequent in patients with malignancy than those without malignancy.Conclusion: The prevalence of malignancy has increased in CVID patients due to recent improvement in survival rate and the lymphoma is the most common type. This research highlighted the significance of malignancy screening and management in CVID patients. 相似文献
19.
Margaret Kay Geoffrey Mitchell Alexandra Clavarino Jenny Doust 《The British journal of general practice》2008,58(552):501-508
BACKGROUND: The need to improve doctors' access to health care by reducing the barriers they experience has been regularly described in the literature, yet the barriers experienced are not well defined, despite the volume of expert opinion in this area. AIM: To define what is known about doctors' access to health care from the data within the current literature. DESIGN OF STUDY: A systematic review of studies of doctors' health access. METHOD: A systematic search of MEDLINE and CINAHL, supplemented by citation searches and searches of the grey literature, identified both quantitative and qualitative studies. Two reviewers used specific criteria for inclusion of studies and quality assessment. The data were tabulated and analysed. RESULTS: Twenty-six articles met the inclusion criteria. The paucity of data and the overall poor quality of those data are highlighted. Despite this, many doctors appear to have a GP, but this does not ensure adequate health access. Systemic barriers to healthcare access (long hours and cultural issues) are more significant than individual barriers. CONCLUSION: Expert opinion in this field is supported by poor-quality data. The current knowledge reveals important similarities between doctors and the general population in their healthcare access, especially with mental health issues. Understanding this may help the medical profession to respond to these issues of 'doctors' health' more effectively. 相似文献
20.
Hugh Gallagher Simon de Lusignan Kevin Harris Christopher Cates 《The British journal of general practice》2010,60(575):e258-e265