Non-acute abdominal complaints in general practice: diagnostic value of signs and symptoms.

BACKGROUND. Although many patients are evaluated initially by their general practitioner, clinicians' accuracy at diagnosing organic gastrointestinal disease has not been studied in a primary care setting. Different spectra of severity of disease in general practice and hospital populations may lead to different values for diagnostic tests in these two populations. AIM. This study set out to determine the diagnostic value of history and physical and laboratory items for organic and neoplastic disease in general practice patients with nonacute abdominal complaints. METHOD. The one-year prospective, observational study was carried out in 1989 in 80 general practices in Limburg, the Netherlands. The study subjects were 933 patients (aged 18-75 years) presenting to their general practitioner with new non-acute abdominal complaints of minimum duration two weeks, and with whom the doctor had a diagnostic problem. Patients were physically examined by their general practitioner and asked to complete pre-structured questionnaires. Basic laboratory tests were carried out. Patients were followed up for at least one year by researchers and then a diagnosis was determined by an independent panel of three general practitioners using patient records, blinded for the results of the questionnaires. Sensitivity, specificity and odds ratios were calculated for clinical items. Stepwise forward logistic regression analysis was undertaken to identify independent predictors of organic gastrointestinal disease. RESULTS. Of the 933 patients 14% had organic gastrointestinal disease. No clinical item had both high sensitivity and specificity. Logistic regression analysis showed only eight independent predictors of organic disease: male sex, greater age, epigastric pain, no specific character to pain, pain affecting sleep, history of blood in stool, no pain relief after defecation and abnormal white blood cell count. When the model was programmed to predict neoplasms five items were found: male sex, greater age, no specific character to pain, weight loss and erythrocyte sedimentation rate greater than 20 mm hour-1. CONCLUSION. In a general practice population with non-acute abdominal complaints some clinical findings can be used as predictors for organic and neoplastic gastrointestinal disease.     

Health status and management of chronic non-specific abdominal complaints in general practice.

BACKGROUND: While chronic non-specific abdominal complaints are common in general practice, data on patients' perspective and management of these complaints are lacking. Knowledge of these data is important for the development of guidelines for management and assessment of the burden of chronic non-specific abdominal complaints on society. AIM: To draw a comprehensive picture of chronic non-specific abdominal complaints in general practice, including volume, patients' perspective, and health care involvement. METHOD: In a retrospective study, 644 patients were selected in 16 general practices. Patients and general practitioners (GPs) received a questionnaire regarding the nature of complaints and health care management during the previous 12 months. RESULTS: Overall, 619 questionnaires were returned and 291 patients participated. Of the study population, 15% of patients were diagnosed as suffering from non-ulcer dyspepsia, 39% from irritable bowel syndrome, and 45% from other abdominal complaints. Over 50% of patients suffered from chronic non-specific abdominal complaints on a daily or weekly basis. In these patients, general health perception is impaired and above norm scores on SCL-anxiety and SCL-depression scales were recorded. Only 4% of patients showed complete resolution of complaints during the previous 12 months. Fifty-two per cent of patients consulted their GP for abdominal complaints. Diagnostic modalities were used frequently. Medication was prescribed in 83% of patients with abdominal complaints. Twenty per cent of patients were referred to secondary or tertiary care. There was a considerable inter-doctor variation in the management of chronic non-specific abdominal complaints. CONCLUSION: Once non-specific abdominal complaints have become chronic they are mainly managed by the GP. The impact on patients' physiological and psychological well being is large. Diagnostic and therapeutic modalities are frequently used. Given the considerable inter-doctor variation, research into the evidence base of management strategies is recommended.     

Management of acute neck pain in general practice: a prospective study

BACKGROUND: Research on neck pain in primary care is sparse. The role of GPs in taking care of patients with neck pain has not been described so far. This study focused on interested in the interaction between patients and GPs in their first contact on a new episode of neck pain. AIM: To describe GPs' management of acute neck pain in patients and to detail the diagnostic and therapeutic procedures undertaken by GPs and self-care by patients. DESIGN OF STUDY: A prospective cohort study with 1-year follow up. SETTING: General practice in The Netherlands. METHOD: Patients consulting their GP for non-specific acute neck pain lasting no longer than 6 weeks were invited to participate. Questionnaires were collected from patients at baseline and after 6, 12, 26, and 52 weeks. Patients rated their recovery on a 7-point ordinal scale. RESULTS: In total 187 patients were included. At baseline GPs prescribed medication for 42% of patients, mostly non-steroidal anti-inflammatory drugs (56%) or muscle relaxation medication (20%); 51% were referred to a physiotherapist. Seventy-four per cent of referred patients reported recovery at the end of the follow-up year, whereas 79% of non-referred patients reported recovery. Frequently-given advice by the GP was to 'wait and see' (23%), 'improve posture' and 'stay active' (22%) or to 'take a rest' (18%). Self-care by patients included different sources of heat application (79%) and exercises (57%). Complementary medicine was used in 12% of cases and 39% of patients visited their GP again during follow up. Consultation of a medical specialist and ordering of X-rays rarely occurred. CONCLUSION: Management by GPs included a strategy to 'wait and see' for an expected favourable natural course supported by medication, or referral to a physiotherapist.     

Discriminating ability of the erythrocyte sedimentation rate: a prospective study in general practice.

Despite its frequent use, little is known about the ability of the erythrocyte sedimentation rate to discriminate between 'pathology' (inflammatory diseases and malignancies) and 'no pathology' in general practice. This has been studied by following 362 patients who presented to their general practitioner with a new complaint, for which the general practitioner considered determination of the erythrocyte sedimentation rate to be indicated. The test was performed at the local hospital laboratory and the patients were seen again after three months, in order to establish the follow-up diagnoses. By comparing the test results with the follow-up diagnoses, combined with receiver operating characteristic curves and regression analysis, the erythrocyte sedimentation rate was found to have a reasonable discriminating ability with respect to malignancies and inflammatory diseases (sensitivity 53%, specificity 94%, positive predictive value 48%, negative predictive value 91%, odds ratio 15.1). The upper limit for the normal erythrocyte sedimentation rate should be set at approximately 12 mm hour-1 for men and 28 mm hour-1 for women, and needs no correction for age. It is concluded that the erythrocyte sedimentation rate still deserves a place in the general practitioner's daily routine.     

Childhood swine flu vaccination uptake in a Welsh general practice: a prospective study

Background

Immunisation of infants is effective and benefits the health of the children immunised as well as the community where uptake is high. Any social inequality in uptake will worsen any social inequalities that already exist.

Aim

To investigate the demographic characteristics of families attending for swine flu vaccination.

Design and setting

A prospective study in a semi-rural general practice in South Wales.

Method

Data were collected by questionnaire, and logistic regression models were used to test for associations between potential risk factors (including family demographic characteristics and the child''s previous vaccination history) and swine flu vaccination uptake.

Results

No evidence was found of any significant associations between potential risk factors and the outcome.

Conclusion

This suggests that social inequality did not affect vaccination uptake in this sample.     

Formal complaints against general practitioners: a study of 1000 cases.

This study was carried out to determine the reasons given by patients in making formal complaints against general practitioners. A sample of 1000 complaints made by UK patients about general practitioner principals over the period 1982-89 was randomly selected from the computer database of the Medical Protection Society and retrospectively analysed. Thirteen categories of criticism were identified. The most common circumstance in which patients complained was when they believed there had been failure to visit. In nearly one third of cases the complaints were associated with the death of a patient. In a quarter of the letters it was clear that the patient's motive for complaining was concern to protect other patients. General practitioners should bear in mind that in declining to visit they could be inviting criticism, particularly if the patient dies.     

Nocturnal asthma: a study in general practice.

Symptoms of nocturnal asthma were studied using questionnaires returned by 1199 general practitioners throughout the United Kingdom. Of 7729 asthmatic patients seen consecutively and prescribed a bronchodilator aerosol, 73% woke with asthma at least once a week and 39% woke nightly. The percentage of asthmatics waking at night at least once a week in this population, where 48% were prescribed corticosteroid aerosols, was very similar to the 74% found to have asthma attacks at night in an earlier study of new hospital referrals at a time when such medication was not available. While sampling bias cannot be excluded, the clinical characteristics and profile of medications found in this study are similar to other reports and the evidence suggests that the general practitioners were managing these patients carefully. There was an overall association between the patients' perception of the severity of their asthma and frequency of waking at night (P less than 0.001). However, 26% of 2928 patients waking every night regarded their asthma as mild. These patients were taking significantly less medication than those also waking nightly but assessing their asthma as severe (P less than 0.001). The seriousness of nocturnal symptoms may be underestimated by asthmatics and they should be asked specifically about the frequency of nocturnal waking. Those with nocturnal asthma had a generally higher frequency of allergic and non-allergic provoking factors, but no single factor distinguished these patients from those without nocturnal symptoms. There was a strong correlation between the frequency of nightly waking and the number of medications used (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cost effectiveness of minor surgery in general practice: a prospective comparison with hospital practice.

The cost effectiveness of general practitioners undertaking minor surgery in their practices was determined in a prospective comparison of patients having minor surgery undertaken in five general practices over a 12 week period in 1989, and in the departments of dermatology and general surgery in Rotherham District General Hospital over a contemporaneous eight week period. There were no differences between the settings in the reported rates of wound infection or other complications and only one general practice patient was subsequently referred to hospital for specialist treatment. General practitioners sent a smaller proportion of specimens to a histopathology laboratory than hospital doctors (61% versus 90%, P less than 0.001); incorrectly diagnosed a larger proportion of malignant conditions as benign (10% versus 1%, P less than 0.05) and inadequately excised 5% of lesions where this never happened in hospital (difference not significant). General practice patients had shorter waiting times between referral and treatment, spent less time and money attending for treatment and more of them were satisfied with their treatment. The cost of a procedure undertaken in general practice was less than in hospital--pounds 33.53 versus pounds 45.54 for the excision of a lesion and pounds 3.00 versus pounds 3.22 for cryotherapy of a wart (1989-90 prices). Performing minor surgery in general practice would seem cost effective compared with a hospital setting. However, the risk of general practitioners inadequately excising a malignancy and not sending it to a histopathology laboratory must be addressed and the conclusion regarding cost effectiveness only applies where general practice is a substitute for the hospital setting and not an additional activity.     

Predicting persistent disabling low back pain in general practice: a prospective cohort study

BACKGROUND: Patients may adopt active and/or passive coping strategies in response to pain. However, it is not known whether these strategies may also precede the onset of chronic symptoms and, if so, whether they are independent predictors of prognosis. AIM: To examine, in patients with low back pain in general practice, the prognostic value of active and passive coping styles, in the context of baseline levels of pain, disability and pain duration. DESIGN OF STUDY: Prospective cohort study. SETTING: Nine general practices in north west England. METHOD: Patients consulting their GP with a new episode of low back pain were recruited to the study. Information on coping styles, pain severity, disability, duration, and a brief history of other chronic pain symptoms was recorded using a self-completion postal questionnaire. Participants were then sent a follow-up questionnaire, 3 months after their initial consultation, to assess the occurrence of low back pain. The primary outcome was persistent disabling low back pain, that is, low back pain at 3-month follow-up self-rated as >or=20 mm on a 100 mm visual analogue scale, and >or=5 on the Roland and Morris Disability Questionnaire. RESULTS: A total of 974 patients took part in the baseline survey, of whom 922 (95%) completed a follow-up questionnaire; 363 individuals (39%) reported persistent disabling pain at follow-up. Persons who reported high levels of passive coping experienced a threefold increase in the risk of persistent disabling low back pain (relative risk [RR] = 3.0; 95% confidence interval [CI] = 2.3 to 4.0). In contrast, active coping was associated with neither an increase nor a decrease in the risk of a poor prognosis. After adjusting for baseline pain severity, disability, and other measures of pain and pain history, persons who reported a high passive coping score were still at 50% increased risk of a poor outcome (RR = 1.5; 95% CI = 1.1 to 2.0). CONCLUSION: Patients who report passive coping strategies experience a significant increase in the risk of persistent symptoms. Further, this risk persists after controlling for initial pain severity and disability. The identification of this low back pain subgroup may help target future treatments to those at greatest risk of a poor outcome.     

Vestibular neuronitis: a review of a common cause of vertigo in general practice.

Vestibular neuronitis is an interesting condition characterized by the acute onset of vertigo, nausea and vomiting, in the absence of hearing loss or tinnitus. There is often evidence of a recent or concurrent upper respiratory tract infection. The disease follows a benign course of between two days and six weeks. It often occurs in epidemics. Following the acute attack, mild transitory episodes of dizziness may recur over a period of 12 to 18 months. Clinical and histopathological evidence suggests that it is caused by an isolated lesion of the vestibular nerve, although the exact aetiology remains obscure. Vestibular neuronitis is a relatively common condition in general practice, but has lacked clear definition, partly as a result of confusion over its nomenclature. Current knowledge of vestibular neuronitis is reviewed. Clinical diagnostic criteria are described, and the diagnosis and differential diagnosis of the syndrome in general practice are outlined. There remains a need to describe the occurrence of vestibular neuronitis in general practice in greater detail.     

Coxsackie B viruses and the post-viral syndrome: a prospective study in general practice

In a prospective study sera from 140 patients with symptoms suggesting a post-viral syndrome and sera from 100 controls were tested for neutralizing antibodies to Coxsackie B viruses. Sixty-five of the patients (46%) and 25 of the controls (25%) had significant antibody titres. The 65 positive cases who had presented with symptoms were followed up and retested six months later and again after one year. Of these 65 patients 36 (55%) were still unwell after one year and high antibody titres persisted in all but two of the patients. Recovery was not found to correlate with a fall in antibody level, but was more rapid in patients whose presenting symptoms were paraesthesiae, anorexia or dyspnoea. The importance of correctly identifying patients with the post-viral syndrome, who may otherwise be labelled neurotic, is emphasized.     

One-year prospective study of cases of suspected acute myocardial infarction managed by urban and rural general practitioners.

BACKGROUND: The role of the general practitioner in the management of patients with suspected acute myocardial infarction is important and specific. It has been recommended that eligible patients should receive thrombolysis within 90 minutes of alerting medical or ambulance services. The administration of prehospital thrombolysis by general practitioners is controversial. Most research into the management of acute myocardial infarction has been hospital based and has not explored differences between urban and rural general practice. AIM: In 1993-94 a one-year prospective survey was undertaken of samples of urban and rural general practitioners to examine their management of cases of suspected acute myocardial infarction and to determine whether differences in management existed between the two settings. METHOD: General practitioners were recruited through the continuing medical education faculty network of the Irish College of General Practitioners. Participating general practitioners completed a report form for cases of suspected acute myocardial infarction. Six-week follow-up forms were also completed. RESULTS: A total of 113 general practitioners (54 urban and 59 rural) participated in the study. A total of 57 general practitioners contributed 195 cases, 49 from urban and 146 from rural areas. The mean number of cases of suspected acute myocardial infarction per participant for urban and rural doctors was 0.9 and 2.5, respectively. Median delay time from onset of symptoms to contacting the general practitioner was 90 minutes for both urban and rural patients. Median general practitioner response times for urban and rural doctors were 10 and 15 minutes, respectively. Median estimated journey times from location of the patient to hospital for urban and rural patients were 10 and 40 minutes, respectively (P<0.001). Rural doctors were more likely, in comparison with their urban counterparts, to administer aspirin (given to 40% of patients versus 16%, P<0.01) but less likely to administer intravenous morphine (26% versus 41%, P<0.05). Twenty one patients (11%) died at the scene; follow-up forms were received for 94% of the remaining patients. Of these 163 patients, 99% were admitted to hospital; 49% were discharged with a diagnosis of acute myocardial infarction and a further 25% had final diagnoses consistent with acute coronary heart disease. CONCLUSION: This study suggests that the management of patients with suspected acute myocardial infarction differs in urban and rural settings. Delay times suggest that in order to meet current guidelines, prehospital thrombolysis must become a reality in rural areas.     

How effective is systematic care of diabetic patients? A study in one general practice.

A method of systematic diabetic care compatible with personal lists, the 'diabetic day', was introduced into a seven partner inner city general practice. The effect on glycosylated haemoglobin levels and the recording of six process measures (fundoscopy, visual acuity, weight, blood glucose levels, glycosylated haemoglobin levels and blood pressure) was assessed. Of the 111 known registered diabetic patients, 64 entered the diabetic day and fulfilled the eligibility criteria. General practice records were analysed retrospectively over a period of four years--the two years before entry into the diabetic day were compared with the subsequent two years. Mean glycosylated haemoglobin levels fell from 10.52% in the year before entry to the diabetic day to 9.71% in the second year after entry (P < 0.01, 95% confidence intervals 0.19 to 1.39). There was a significant increase in all process measures recorded in the general practice notes after entry into the diabetic day. The introduction of systematic care for diabetic patients led to an improvement in recorded process measures and a reduction in patients' glycosylated haemoglobin levels in a general practice which had made previous efforts to improve diabetic care and was already well staffed, organized and motivated.     

The inflammatory cervical smear: a study in general practice.

This study set out to determine whether the term 'inflammatory' in a cervical smear report implies underlying infection or whether it could be masking cancerous or precancerous changes. Of 826 smears taken in one practice over one year, 42 demonstrated some degree of inflammatory change. Thirty four of these women presented for swabs and almost half (47%) had a microbiologically proven infection. This group was further subdivided, and of those whose smears were reported as simple 'inflammation', just over one third (35%) were infected but of those whose smears were reported as 'severe inflammation', over two thirds were infected (73%). The commonest organisms isolated were Gardnerella vaginalis and Candida albicans. It would therefore appear to be worthwhile to treat patients who report severe inflammation with metronidazole and with anti-fungal pessaries before the smear is repeated. Following treatment two women went on to show dyskaryosis within five months. On colposcopy one of these women was found to have invasive cervical squamous cell carcinoma. It is concluded that whether women with inflammatory smears are treated or not, it is mandatory to repeat the smear, ideally within five months.     

Lay beliefs of patients using domiciliary oxygen: a qualitative study from general practice.

BACKGROUND: Oxygen, given for 15 hours a day to certain patients with chronic obstructive pulmonary disease, is known to reduce mortality and improve morbidity. There is, however, an apparent mismatch in provision--some patients who would potentially benefit are not receiving it and, conversely, other patients may be receiving it 'inappropriately'. AIM: To investigate lay beliefs about oxygen therapy of patients receiving domiciliary treatment. METHOD: Twenty-four patients receiving domiciliary oxygen therapy from three general practices in Middlesbrough were interviewed using qualitative, semi-structured interviews. RESULTS: There were two contradictory approaches to oxygen use. On the one hand, oxygen helped the individual maintain mastery and self-control over illness by relieving symptoms, thus enabling daily activities and roles to continue, and by the reassurance that it was available, even if not used. In addition, self-control over the illness was maintained by individual experimentation with the best ways to use oxygen, which increased personal involvement in treatment. On the other hand, there were concerns that oxygen should not master the individual through inducing dependency on its use. CONCLUSIONS: These ambivalent ideas about oxygen should be considered when assessing patients for use of domiciliary oxygen and by general practitioners maintaining treatment. Some patients who according to medical criteria would benefit from domiciliary oxygen may wish to restrict its use because of worries about dependency and these worries may need addressing. Other patients using domiciliary oxygen who do not meet medical criteria for long-term use may nevertheless gain benefits, including improved self-control over their illnesses.