Persistent presentation of medically unexplained symptoms in general practice

OBJECTIVES: To estimate the prevalence of persistent presentation of medically unexplained physical symptoms (MUPS) in general practice. To assess socio-demographic characteristics, health status and use of health services of patients who frequently present MUPS, compared with reference groups. DESIGN: One-year, nationwide, representative survey of morbidity in general practice in The Netherlands, including 400,000 enlisted patients in 104 general practices. RESULTS: Of all patients (age: 18 years and older), 2.45% who visited their GP at least once a year, presented at least 4 times in 1 year with symptoms which are commonly considered medically unexplained without getting a medical diagnosis during that period, that might explain the symptoms. These patients are significantly older, more often female, less educated, more frequently unemployed and more frequently from a non-Western origin than 'average' patients or patients with a medical diagnosis. CONCLUSION: Although 25-50% of all reasons for visit to a GP concern symptoms that are not medically explained, the frequent presentation of such symptoms is much more rare. Frequent attendance because of MUPS is most common among elderly women with a lower socio-economic status.     

Hypertension management in general practice.

The views of 542 general practitioners (GPs) and 64 consultant physicians about the management of patients with hypertension in general practice were sought by postal questionnaire. 325 (60%) of the GPs and 45 (70%) of the consultant physicians completed the questionnaire. For a 40-year-old man with no other cardiovascular risk factors most general practitioners would intervene with drugs at blood pressure levels specified in published guidelines, whereas many local consultants and older GPs would consider drug treatment at lower levels. About 75% of GPs, compared with 87% of consultants, would suggest drug treatment in a woman of 70 years with a BP of 180/100 mmHg. Although consultants tended to expect GPs to order more tests when investigating a patient with hypertension than the GPs actually did, both GPs and consultants would order similar types of investigations apart from imaging. Consultants had different expectations about the frequency with which general practitioners should record patients' blood pressure and the GPs' ability to prevent cardiovascular events in hypertensive patients. Many older GPs and consultants seem to have unrealistic expectations of the value of treating patients with hypertension.     

Somatic symptoms and depression in general practice in Italy

Among primary care attenders, depression is a common and debilitating disturbance. These patients imply higher medical costs compared with those without depression, even after controlling for comorbid physical illness. A study performed in 15 countries worldwide has shown that ICD-10 mental disorders were present in 24% of primary care attenders. Detection and management of depression in primary care have received increasing attention. Most individuals with depression have been shown to consult their GPs for somatic symptoms rather than psychological ones. In the study mentioned above, 69% of the depressed patients reported only somatic symptoms. Another study found that GPs were able to diagnose a mental disorder in 90% of subjects presenting psychopathological symptoms and in 50% of those with somatic symptoms. In the light of the above, the Italian College of General Practitioners (Società Italiana di Medicina Generale-SIMG) in the area of Varese (north of Italy) organised a course on depression. Then a study was carried out in our setting. The aim was to evaluate the frequency of depression in patients who seek care for somatic symptoms, where tests showed that these symptoms were without an organic cause.     

Acute respiratory symptoms in adults in general practice

BACKGROUND: Community studies have shown that approximately 30% of patients with acute respiratory tract symptoms have no identifiable infective aetiology. This may not be applicable in general practice. OBJECTIVE: The purpose of this study was to determine the infective aetiology in patients who presented to primary care doctors with acute respiratory symptoms. METHODS: A prospective study was carried out in all nine primary care clinics belonging to the National Healthcare Group Polyclinics (NHGPs) in Singapore. The subjects comprised 594 consecutive patients (318 males, 276 females) aged > or = 21 years who presented with complaints of any one of cough, nasal or throat symptoms of <7 days duration. Data collection was through interview using structured questionnaire, physical examination, throat swabs for bacterial culture and nasal swabs for virus identification by immunofluorescence (IF) and polymerase chain reaction (PCR). Additional PCR was performed on a subsample of 100 patients. Patients were followed-up until resolution of symptoms. RESULTS: The aetiological diagnosis by infective agent is as follows: 150 patients (25.2%) had virus infections, of which 90.7% (136/150) were by rhinovirus. Fourteen patients (2.4%) had bacterial infections, of which 10 were due to group G streptococcus. Group A streptococcus was not detected. Nineteen patients with new pathogens were identified by further PCR. These included parainfluenza 4, human coronavirus OC43, adenovirus, enterovirus and Chlamydia pneumoniae. No pathogen could be identified in 49% of patients. There were no differences in clinical presentation and socio-demographic variables between patients who had viral infections and those in whom no pathogen could be identified. CONCLUSION: In about half of patients who presented at NHGPs, no pathogens could be identified even after PCR. A non-infective aetiology could be considered in these patients.     

Doctors'' views on anxiety management in general practice.

Various guidelines have been issued to doctors concerning the treatment of anxiety in primary care and particularly on the use of benzodiazepines. Little has been reported about how this advice has influenced doctors' opinions and practice. This paper describes results of interviews with 15 general practitioners and 15 general practitioner trainees on their management of anxiety problems. Most respondents admitted prescribing benzodiazepines for anxiety but reported doing so only in cases of severe distress and for short periods of time. Trainees appeared more cautious in their use of benzodiazepines than the experienced practitioners. Most doctors agreed that counselling could be as effective as benzodiazepines in treating moderate anxiety but several respondents felt it too demanding of their time. Two-thirds of doctors were in favour of employing counsellors in general practice though many foresaw practical difficulties in doing so. Increased availability of clinical psychology services was the development which most respondents felt would improve their management of anxiety problems in primary care.     

Specialist and general practice views on routine follow-up of breast cancer patients in general practice

The practice of routinely following-up breast cancer in hospitalclinics is of widespread concern: studies have shown that itis not an effective way of detecting recurrent disease and itplaces great strain on cancer services which are already overstretched.A general practice centred system of routine follow-up may bea solution to this problem in those countries which have a strongprimary care base. Such a system would have other benefits suchas continuity of care for the patient. The objective of thisstudy was to determine the views of general practitioners andspecialists on follow-up of patients with breast cancer in remission,with special emphasis on their views on the transfer of routinefollow-up from the hospital to general practice. A postal questionnairesurvey of British breast cancer specialists (response rate 77.0%)and a personal interview survey of British general practitioners(response rate 81.8%) were conducted. The results show thatBritish general practitioners are willing to take on greaterresponsibility for the routine follow-up care of their patientswith breast cancer. However, there was frequently a mis-matchbetween specialists' and general practitioners' views on thissubject.     

Delay in the presentation of breast symptoms for consultant investigation

Summary Women referred to hospital outpatients with breast symptoms were interviewed to ascertain the interval between first noticing a breast symptom and first consulting a doctor (patient delay). Later, the hospital notes of each patient were examined to determine the intervals between this first consultation and referral by a doctor (doctor delay) and between referral and outpatient attendance (hospital delay), as well as the diagnosis (benign or malignant). The study found that the largest component of delay between noticing symptoms and outpatient attendance was patient delay, with 20 per cent of the women delaying for more than 12 weeks. Analysis of this group revealed that long delays were related to both age and subsequent diagnosis, but that these two variables were not independent of each other. The findings that there were longer delays in older women and that symptoms other than lumps, which could indicate breast cancer, were associated with long delays, have implications for health education. Generally, doctors in the community distinguished between benign and malignant cases, with 86 per cent of the latter referred within a week. Most women waited 2 weeks or less for an outpatient appointment, with none of those subsequently found to have breast cancer waiting more than 4 weeks. This study was supported by a grant from the Department of Health and Social Security through the Wessex Regional Cancer Organisation.     

TIAs - management in general practice

From April 2005 to March 2010 in the BEACH (Bettering the Evaluation and Care of Health) program, transient ischaemic attack (TIA) was managed in general practice at a rate of 2 per 1000 encounters, about 170,000 times per year nationally.