A clustered randomized trial of the effects of feedback using academic detailing compared to postal bulletin on prescribing of preventative cardiovascular therapy

Background. Interventions to promote prescribing of preventivetherapies in patients with cardiovascular disease (CVD) or diabeteshave reported variable success. Objective. (i) To evaluate the effect of prescribing feedbackon GP practice using academic detailing compared to postal bulletinon prescribing of CVD preventive therapies in patients withCVD or diabetes at 3 and 6 months post intervention and (ii)to evaluate the intervention from a GP's perspective. Methods. Volunteer GP practices (n = 98) were randomized toreceive individualized prescribing feedback via academic detailing(postal bulletin plus outreach visit) (n = 48) or postal bulletin(n = 50). The proportion of CVD or diabetic patients on statinsand antiplatelet agents/warfarin pre- and post-interventionwas calculated for each GP practice. Multivariate regressionwith a random effects model was used to compare differencesbetween the groups adjusting for GP clustering and confoundingfactors. ß-Coefficients and 95% confidence intervals(CIs) are presented. Results. There was a 3% increase in statin prescribing in CVDpatients at 6 months post-intervention for both randomized groups,but there was no statistical difference between the groups (ß= 0.004; 95% CI = –0.01 to 0.02). Statin and antiplatelet/warfarinprescribing also increased in the diabetic population; therewas no significant differences between the groups. GPs participatingin the project expressed a high level of satisfaction with bothinterventions. Conclusion. Prescribing of preventive therapies increased inboth randomized groups over the study period. But academic detailingdid not have an additional effect on changing prescribing overthe postal bulletin alone. Keywords. Academic detailing, feedback, prescribing, primary care.     

Prevalence of distress and symptom severity from the lower urinary tract in men: a population-based study with the DAN-PSS questionnaire

Background. Lower urinary tract symptoms (LUTS) are a commonand costly public health issue. The prevalence varies greatlyin published reports. The distress caused by each symptom isimportant to assess the primary care required before therapeuticdecisions or a referral to an urologist are made. Objectives. LUTS are highly prevalent in men, but less is knownregarding the distress caused by each symptom. The aim of thisstudy was to examine symptom severity and different levels ofdistress using the Danish Prostatic Symptom Score (DAN-PSS)questionnaire in men affected by symptoms from the lower urinarytract. Methods. The study included all men aged 41–81 years (n= 504) that, 12 months earlier in a population-based survey,had reported stress incontinence, urgency or post-micturitiondribbling in a postal questionnaire. The DAN-PSS questionnairewas used to measure severity and distress from LUTS. Results. In total, 311 (80%) of the 387 responders who reportedat least one symptom experienced some level of distress. Themost distressing symptom overall was urinary incontinence. Nineof 10 men with storage symptoms (stress, urge and ‘other’urinary incontinence) reported distress even if the symptomoccurred only seldom. Moreover, two-thirds of the men with themost frequent symptom, post-micturition dribbling, characterizedtheir symptom as moderate or severe; the most distressing voidingsymptom was weak stream. In general, LUTS were well tolerated. Conclusion. Urge incontinence was the most distressing LUTSeven when occurring only seldom. The DAN-PSS questionnaire maybe a potentially useful tool for health professionals to identifypatients with pronounced distress from LUTS to offer therapeuticand nursing care on the relevant level. Keywords. DAN-PSS, distress, LUTS, population-based, postal questionnaire.     

Which agents cause reactive airways dysfunction syndrome (RADS)? A systematic review

Aim To identify those agents reported as being associated withreactive airways dysfunction syndrome (RADS). Methods A systematic review was undertaken. Abstracts were screenedand those selected reviewed against pre-determined diagnosticcriteria for RADS. Results Significant information gaps were identified for allmeasures of interest. In some articles, even the causative agentwas not reported. The most commonly reported agents were chlorine(nine subjects), toluene di-isocyanate (TDI) (n = 6) and oxidesof nitrogen (n = 5). Most exposures occurred in the workplace(n = 51) and affected men (60%). Dyspnoea (71%) and cough (65%)were the commonest symptoms. Median symptom duration was 13months (interquartile range = 6.5–43.5) for RADS. Conclusions Although the most commonly reported agent associatedwith RADS was chlorine, the main finding of a general lack ofadequate information on exposure, investigation and outcomesuggests that to better explore RADS a more structured approachto gathering information is required. A minimum data set forreporting RADS cases is proposed.     

Effect of Helicobactor pylori eradication therapy on dyspeptic symptoms in primary care

OBJECTIVE: The aim was to explore the effect of eradication therapy ondyspeptic symptoms in patients with known peptic ulcer disease(PUD). METHOD: A total of 164 known dyspeptics and 147 non-dyspeptic attendersat six UK general practices were recruited. The Helisal RapidBlood test was performed in the practices and eradication therapyleft to the preference of the general practitioner. Patientswere followed prospectively by a Likert scaled symptom questionnaireand record review. The symptom questionnaire distinguished betweenpatients known to have dyspepsia and those not. RESULTS: There was a statistically significant decrease in dyspepticsymptoms in patients with known PUD who received eradicationtherapy (n = 43, Z = –2.63, P = 0.009). CONCLUSIONS: Eradication of Helicobacter pylori in primary care can leadto a reduction in consumption of H2 receptor antagonists andhence cost savings. This study demonstrates that dyspeptic symptomsalso decrease. The questionnaire could be used in further studiesto evaluate the effect of management on dyspeptic symptoms inthe primary care setting. Keywords. Dyspepsia, Helicobactor pylori, primary care, therapy, outcome measures.     

Salivary acetylcholinesterase as a biomarker for organophosphate exposure

Background Workers exposed to organophosphate (OP) pesticidesare required to undergo periodic statutory medical surveillancein several countries. Aim To study the relationship between serum, erythrocyte andsaliva acetylcholinesterase (AChE) levels and to explore theuse of salivary AChE as potential biomarker for OP exposure. Methods A cross-sectional study was conducted on 19 healthyadult male lead-exposed workers who were undergoing six monthlystatutory medical examination. Passive drool saliva sampleswere collected from each worker. Each blood sample was testedfor serum and erythrocyte AChE, and each saliva sample was testedfor AChE. Results Among the 19 subjects, the mean (±standard deviation)of salivary, erythrocyte and serum AChE/cholinesterase were22.7 (±17.4), 17171 (±1467), 8861 (±1876)U/l, respectively. There was a moderate correlation betweensalivary and erythrocyte AChE (r = 0.42, P = 0.071), but notsalivary and serum AChE (r = –0.17, P = 0.48). The levelof AChE in saliva was 1820 times lower than AChE in erythrocytes. Conclusion It is probably not feasible to use saliva as a replacementfor blood for the measurement of AChE levels. This is becauseof the much lower levels of AChE in saliva relative to erythrocytes,the weak correlation between the two measurements and the previouslyreported high intra-individual variation of salivary AChE.     

Prevalence of three lower urinary tract symptoms in men-a population-based study

Background. Lower urinary tract symptoms are a common and costlypublic health issue. In earlier studies, the prevalence of urinarysymptoms can be seen to fluctuate because there is no consensusabout how to define and categorize the severity of the symptoms. Objectives. The study was undertaken in order to investigatethe prevalence of three common lower urinary tract symptoms(urgency, stress incontinence and post-micturition dribbling)and analyse health care-seeking behaviour. Methods. A self-administered questionnaire was developed toinvestigate all men aged 40–80 years residing in the communityof Surahammar, Sweden. The questionnaire included items on threespecific urinary symptoms: urgency, stress incontinence andpost-micturition dribbling, and one question about health care-seekingbehaviour. Results. A response rate of 86% was obtained in the questionnairestudy. The overall prevalence of the lower urinary tract symptomswas 24%. The prevalence increased from 20% in the group aged40–49 years to 28% in the group aged 70–80 years(P < 0.01). Post-micturition dribbling (21%) was the mostfrequent symptom, and stress incontinence (2.4%) was the leastfrequent symptom. The number of participants who sought healthcare was low (4%) and increased significantly with age (P <0.001). Conclusions. The present study showed that 24% of the Swedishcohort of men of 40–80 years of age reported at leastone of the following symptoms: urgency, stress incontinenceor post-micturition dribbling. This study is consistent withother research regarding the low consultation frequency forthese symptoms. Moreover, the study is also in accord with thosefindings indicating that for the majority of men with urinarysymptoms, their health care providers are not aware of theirproblem. Keywords. Health care consultation, men, population-based study, prevalence, urinary symptoms.     

Effect of work with visual display units on musculo-skeletal disorders in the office environment

Background The increase in computer and mouse use has been associatedwith an increased prevalence of disorders in the neck and upperextremities. Furthermore, poor workstation design has been associatedwith an increased risk of developing these symptoms. Aim The aims of this study were (i) to estimate the prevalenceof musculo-skeletal disorders among full-time visual displayunit (VDU) users; (ii) to examine how the prevalence variesby work environment; and (iii) to explore the association withwork factors. Method A survey was carried out on the effect of work with VDUson musculo-skeletal disorders in workers in the office environmentof 56 workplaces. Office workers (n = 298), customer serviceworkers (n = 238) and designers (n = 247) were studied. Results For all the occupations combined, the 12 month prevalencesof musculo-skeletal symptoms in the neck, shoulders, elbows,lower arms and wrists, and fingers were 63, 24, 18, 35 and 16%,respectively. The study indicated that musculo-skeletal painis common among computer workers in offices. There was no strongassociation between the duration of computer work and pain orbetween the duration of mouse use and pain, but workers' perceptionof their workstation as being poor ergonomically was stronglyassociated with an increased prevalence of pain. Conclusions Musculo-skeletal symptoms are common, but the durationof daily keyboard and mouse use had no connection with musculo-skeletalsymptoms. Instead, more consideration should be paid to theergonomics of workstations, the placing of the mouse, the posturesof the upper extremities and the handling of the mouse.     

Can we measure the ankle-brachial index using only a stethoscope? A pilot study

Background. Ankle-brachial index (ABI) is an excellent methodfor the diagnosis of peripheral arterial disease (PAD) whenit is performed with Doppler. However, this device is not alwaysavailable for primary care physicians. The ABI measured withstethoscope is an easy alternative approach, but have not beenproved to be useful. Objective. To assess the accuracy of the ABI measured usinga stethoscope comparatively to that of the current eligiblemethod for the diagnosis of PAD, the Doppler ABI, and describethe characteristics of this new approach. Methods. We conducted a diagnostic study of ABI measured witha stethoscope and a Doppler probe and compared the results.Eighty-eight patients were accessed by both methods. Results. Mean stethoscope ABI, 1.01 ± 0.15, and meanDoppler ABI, 1.03 ± 0.20, (P = 0.047) displayed a goodcorrelation. Measurements of stethoscope ABI diagnostic accuracyin recognizing a Doppler ABI are described. The comparison ofthis data with the current gold standard method results gavea sensitivity of 71.4% [95% confidence interval (CI), 41.9–91.6]and specificity of 91.0% (95% CI, 81.5–96.6), with predictivepositive value of 62.5% (95% CI, 38.6–81.5) and negativepredictive value of 93.8% (95% CI, 85.2–97.6). The studyaccuracy was 87.7%. The area under the ROC curve was 0.895 (95%CI, 0.804–0.986, P < 0.0001). Conclusions. According to our study, the stethoscope ABI isa useful method to detect PAD and it may be suitable for itsscreening in the primary care setting. Keywords. Ankle-brachial index, peripheral arterial disease, stethoscope.     

Advanced glycation end-products in patients with chronic alcohol misuse

Aims: The aim of our study was to determine serum levels ofadvanced glycation end-products (AGE) in patients with chronicalcohol misuse and to examine their relationship to markersof nutrition and inflammation. Methods: The study group consistedof 23 heavy alcohol drinkers treated for chronic alcohol misuseand 22 healthy controls. Studied parameters included AGE (fluorescence,CML – carboxymethyllysine and pentosidine), lipids, glucose,albumin, leptin, prealbumin, C-reactive protein (CRP) and pregnancy-associatedplasma protein A (PAPP-A). Results: AGE fluorescence was significantlyhigher in chronic alcoholic patients than in healthy subjects(4.3 ± 0.7 x 10³ vs 3.7 ± 0.5 x 10³ AU/g protein,P < 0.005), while CML was only slightly but not significantlyelevated (569.1 ± 106.6 vs 545.5 ± 85.8 µg/l)and pentosidine levels did not differ (105.4 ± 29 vs102.2 ± 23 nmol/l). In alcoholics, AGE correlate significantlynegatively with leptin (r = –0.46, P < 0.05) and pentosidinewith prealbumin (r = –0.43, P < 0.05), otherwise therewas no relationship between AGE and other biochemical parameters(glucose, cholesterol, albumin, CRP, PAPP-A). Conclusion: Ourfindings suggest a more complex relationship among advancedglycation, oxidative stress and metabolism of ethanol and theirlink to nutrition and nutrition-associated parameters. AGE asa result of oxidative stress might be similarly linked to increasedcardiovascular risk of heavy alcohol drinkers, as are malnutritionand inflammation; however, further studies are needed to confirmthis hypothesis.     

Doctors, their mental health and capacity for work

Background Information about doctors’ mental ill-healthis limited. This study looks at doctors’ careers followingmental illness and the strategies that helped them return towork. Aim To examine the effect of mental ill-health on doctors’careers. Methods Questionnaire survey of members of the Doctors SupportNetwork (DSN). The DSN is a peer support group for doctors whohave experienced, or are experiencing, mental ill-health. Results One hundred and sixteen doctors (35% response rate)returned completed questionnaires (n = 116, 63% female, 37%male). Prior to their ill-health, 80% worked full time, 15%part-time, 2% were not working and 3% were medical students.Following illness, 33% worked full time (P < 0.05), 36% part-time(P < 0.05) and 29% were not working (P < 0.01). Flexibleworking practices were the most helpful reported strategy forenabling a doctor to return to work. Conclusions Following mental ill-health, a doctor’s capacityto work full time is reduced. Most doctors return to full-timeor part-time work. With improved support, more doctors may beable to return to work.     

Screening campaign of hepatitis C among underprivileged people consulting in health centres of Lyon area, France

Background: A screening campaign for hepatitis C virus (HCV)infection was carried out in eight health centres of Lyon fromJune 2003 until March 2004. The population targeted for screeningwas underprivileged individuals without any social insurance,protected by Couverture Mutuelle Universelle or Aide MédicaleEtat (AME), to estimate the prevalence of anti-HCV antibodiesin this population and to identify associated risk factors.Methods: After training in HCV infection and screening, 43 generalpractitioners participated in the campaign. Information aboutpatient socio-demographics and risk factors was collected priorto proposing screening serology. Blood samples were often takenin health centres. Follow-up of positive cases was organisedvia the Reference Centre of HCV Infection in Lyon with possiblespecialised consultations in health centres. Results: The averageage of the 988 individuals in the campaign was 37 years; 51%were women; 54% had a foreign nationality; 21% lived in shelteredaccommodation; 19% were lodged in third-party accommodation;9% were homeless; and 57% possessed less than 562 (Revenu Minimumd'Insertion level). Screening was not proposed to nine patientsbecause of medico-psychological problems. The acceptance ratefor screening was 98.8% (967/979), and testing was carried outon 97.6% of these subjects (944/967). The prevalence of anti-HCVantibodies in the sample was 4.7% (44/944) (95% CI = 3.4–6.2).Nearly 80% of positive cases were unknown prior to the campaign.Multivariate logistic regression modelling identified lifetimeinjection drug use [odds ratios (OR) = 15.99; P < 0.0001],lifetime medical care in a foreign country (OR = 4.46; P = 0.001),and wearing tattoos (OR = 2.75; P = 0.048) as significant riskfactors for carrying anti-HCV antibodies. Characteristics independentlyassociated with HCV seropositivity were age between 40 and 49years, AME benefits, and no social insurance. Conclusion: Wideacceptance of screening, high prevalence of anti-HCV antibodies(much higher than in the French population in general), a highproportion of positive cases unknown beforehand, and satisfactoryfollow-up of seropositive patients are all factors which supportthe need for a screening campaign targeting HCV infection inunderprivileged persons living in France.     

5-HT1A Receptors in the Frontal Cortical Brain Areas in Cloninger Type 1 and 2 Alcoholics Measured by Whole-Hemisphere Autoradiography

Aims: The Cloninger type 1 alcoholics are prone to anxiety,and in many cases patients have begun to use alcohol in orderto relieve their anxiety. We have previously reported a decreaseof the serotonin transporter density in the perigenual anteriorcingulate cortex (pACC) in type 1 alcoholics. The 5-HT_1A receptorsare the binding sites for anxiolytic drug buspirone. We aimedto investigate the alteration in the density of 5-HT_1A receptors,that may also alter the effect of serotonin in the pACC in alcoholics.Methods: The density of the serotonin receptor 5-HT_1A amongCloninger type 1 and 2 alcoholics (nine and eight subjects,respectively) and 10 control subjects were determined by postmortemwhole-hemisphere autoradiography with WAY-100635. Results: Substantiallysparser 5-HT_1A (by –31%, P = 0.010) density was observedin the pACC of alcoholic subjects in relation to non-alcoholiccomparison subjects. In a secondary analysis for the differencebetween the alcoholic subtypes and controls, the 5-HT_1A densitywas decreased significantly by –32% (P = 0.015) in theupper level of pACC in type 1 alcoholics. Conclusions: The detecteddecrease of 5-HT_1A receptor density on the pACC suggests furtherthat the serotoninergic system is defected in the so-calledaffect region, especially in the type 1 alcoholics.     

The A1 allele of the D2 dopamine receptor gene is associated with high dopamine transporter density in detoxified alcoholics

The A1 allele of TaqI A restriction fragment length polymorphism(RFLP) in the D₂ receptor (DRD₂) gene locus has been suggestedto be associated with low D₂ receptor density in man. Striataldopamine transporter (DAT) densities were studied with [¹²³I]2-ß-carbometoxy-3ß(4-iodophenyl)tropaneand single-photon emission tomography in 29 detoxified alcoholics,who were also genotyped for the two alleles of TaqI A RFLP atthe DRD2 receptor gene locus. Alcoholics with the A1/A2 genotypes(n = 10) had statistically significantly higher DAT densitiesthan subjects with the A2/A2 genotypes [n = 19; 8.0 ±1.2 (mean ± SD) vs 6.9 ± 1.1, P = 0.035]. We suggestthat the TaqI A RFLP is in linkage disequilibrium with a genevariant modifying DAT density in alcoholics.     

A study of South Korean casino employees and gambling problems

Background Casino employees are exposed to disproportionatelyhigh levels of gambling, drinking and smoking compared to otheroccupations. Because of their occupation, they have the opportunityto detect and prevent pathological gambling (PG). Aims To identify differences in the mental health status andsocial attitudes towards PG among casino workers in South Koreadepending upon whether they report any gambling problems. Methods Data were collected from 388 full-time casino employees.This data provided information about the prevalence of gamblingproblems, alcohol and tobacco use and depression. Employeeswere grouped according to their scores on the Korean versionof South Oaks Gambling Screen (SOGS), and those employees whogambled without experiencing any gambling problems (Group NP:SOGS = 0) and those who reported any gambling problems (GroupP: SOGS > 0) were compared. An exploratory factor analysesidentified the domains of casino employee social attitudes towardsgambling. Results Employees who reported gambling problems (Group P) reporteda higher prevalence of smoking, alcohol problems and depression(P < 0.01) compared to employees who did not report gamblingproblems (Group NP). The primary employee social attitude towardsgambling was identified by the factor of ‘Disease concept/socialawareness’. Group NP reported more positive attitudesin this domain than Group P (P < 0.01). Conclusions Employees who reported any gambling problems reporteda less positive attitude towards developing the public healthsystem to be responsive to gambling problems. These findingsindicate a need to develop health education programmes thatfocus more specifically on casino employees with gambling problems.     

Waist circumference home measurement--a device to find out patients in cardiovascular risk

Background: New strategies are needed to prevent the globalepidemic of diabetes and subsequent rise in cardiovascular diseases.We describe a community-based, two-stage screening strategyusing home waist circumference measurement and a risk factorquestionnaire as a primary screening tool. Methods: We maileda tape for measurement of waist and a risk factor questionnaireto every inhabitant aged 45–70 years living in the ruraltown of Harjavalta in Finland. Thereafter we performed an oralglucose tolerance test, anthropometric variables and blood pressureof subjects having at least one risk factor for type 2 diabetesor cardiovascular disease. People with previously known diabetesor vascular disease were excluded. Results: Seventy-three percent(2085/2856) of the invited inhabitants participated, and 84%of the respondents had at least one pre-specified risk factor.Waist circumference 80 cm in women and 94 cm in men (n = 1168),positive metabolic syndrome criteria of the International DiabetesFederation (n = 681) or the Finnish Diabetes Risk Score questionnaire12 points (n = 697) identified 95, 92 and 63% of the new casesof type 2 diabetes and 84, 75 or 62% of pre-diabetes, respectively.Conclusion: The International Diabetes Federation criteria forelevated waist circumference are very sensitive but lack specificityin diagnosing glucose disorders. The criteria for metabolicsyndrome and the Finnish Diabetes Risk Score questionnaire aremore efficient tools for the selection of patients for furtherrisk stratification in general practise.     

BMI, lipid profile, physical fitness and smoking habits of young male adults and the association with parental education

Background: Few studies have focused on the potential relationshipbetween parental educational level and cardiovascular risk factorsamong young male adults. The aim of this study was to investigatecardiovascular disease risk factors among young men and whetherbody mass index (BMI), serum lipids, physical fitness and smokinghabits were related to paternal and maternal education. Methods: In this cross-sectional study 750 18- to 26-year-oldmale recruits participated. Results: Linear regression analyses showed that the paternaleducation was inversely associated with BMI (P = 0.035) andthe concentration of total cholesterol (P = 0.003) and low-densitylipoprotein (LDL) (P = 0.014). Running performance was inverselyrelated to cigarette smoking (P = 0.022) and the concentrationof triacylglycerol (P = 0.001). BMI was positively related tothe concentration of LDL (P = 0.002), total cholesterol/high-densitylipoprotein (HDL) ratio (P < 0.001) and inversely relatedto the concentration of HDL (P < 0.001), running performance(P < 0.001) and muscular strength (P = 0.011). Recruits withlow BMI, both high and low fitness, had a significantly betterlipid profile than recruits with high BMI and low fitness (P 0.016). A lower concentration of triacylglycerol (P 0.001)and a higher concentration of HDL (P = 0.034) were further shownamong recruits with high BMI/high fit compared to recruits withhigh BMI/low fit. Conclusions: High paternal educational level was associatedwith a lower BMI and a better lipid profile among young adultmen. Furthermore, men with low BMI, both high and low fit, hada better lipid profile than those with high BMI/low fit. Menwith high BMI/high fit had a better lipid profile that thosewith high BMI/low fit.     

Who in Brazil has a personal doctor?

Background. Continued medical care (including having a personaldoctor) is regarded as an essential aspect of a good healthservice. Objectives. The objectives of the present study were to investigatethe reasons for not having a personal doctor, and the satisfactionwith the care received by patients with and without a personaldoctor. Methods. We conducted a cross-sectional study with data collectedduring 20 days over 6 months in the Emergency Service of theConceição Hospital, the busiest emergency servicein Porto Alegre. The subjects were 553 patients selected throughsystematic random sampling. The main outcome measure was havinga personal doctor. Patients who reported usually to see thesame doctor and remembered their physician's name were regardedas having a personal doctor. Results. Patients who usually use primary care service represented23% of the sample, and were four times more likely to have apersonal doctor (OR = 3.83, CI 95% = 2.41–6.11). Independent,statistically significant variables associated with having apersonal physician were: usually receiving care from a primaryhealth care service (OR = 3.8, CI 95% = 2.39–6.00) andfrom a physician in the private sector (OR = 2.16, CI 95% =1.15–4.00). Patients who had a personal doctor reportedhigher satisfaction with their access to health care. The personaldoctors' specialties were: internal medicine (37%), cardiologist(17%), gynaecologist-obstetrician (13%), family physician (8%)and pneumologist (6%). Conclusions. For patients who attend emergency services in Brazil,primary health care and private medical care provide betteraccess to continuity of patient care. Patients with personaldoctors report higher satisfaction with access to consultations. Keywords. Continued medical care, personal doctor.