Factors identifying higher risk rectal bleeding in general practice

BACKGROUND: Rectal bleeding is a common symptom. The ability to distinguish those patients having serious underlying pathology from those with self-limiting conditions is a continuing dilemma in general practice. AIM: To determine the factors affecting the predictive and diagnostic value of rectal bleeding for bowel cancer in primary care. DESIGN OF STUDY: One-year prospective observational study. SETTING: Three large general practices. METHOD: Three hundred and nineteen consecutive patients over the age of 34 years consulting their GPs with rectal bleeding were included in the study. Investigation was by flexible sigmoidoscopy or a questionnaire and review of all patients took place after 18 months. The main outcome measures were consultation rates; the prevalence of cancer, colitis and significant polyps in patients presenting with rectal bleeding; its diagnostic value when occurring with or without a change in bowel habit, perianal symptoms and abdominal pain. RESULTS: The consultation rate for rectal bleeding in patients over the age of 34 years was 15 per 1000 per year; 3.4% had colorectal cancer. The prevalence of cancer increased to 9.2% when the rectal bleeding was associated with a change in bowel habit, and to 11.1% when it was without perianal symptoms. Thirty-six per cent of cancer patients had a palpable rectal mass. CONCLUSION: Over 96% of the patients who present to their GPs with rectal bleeding do not have cancer. Greater awareness of the diagnostic value of the different symptom combinations of rectal bleeding could help GPs adopt different management strategies for patients at higher and very low risk of cancer.     

Incidence and causes of rectal bleeding in general practice as detected by colonoscopy.

BACKGROUND: Rectal bleeding is common, but it is still unclear which patients require investigation to exclude serious pathology, although it is known that colectoral cancer is very rare under the age of 40 years. Few studies have examined all patients presenting to their primary health physician rather than screening whole populations. AIM: The aim of this study was to investigate the view that all patients over the age of 40 who present to their general practitioner with rectal bleeding should undergo investigation by colonoscopy to rule out serious pathology, regardless of symptomatology. METHOD: A prospective study was carried out of 99 consecutive patients over 40 years presenting with rectal bleeding to 17 general practices in Newcastle upon Tyne. RESULTS: Serious pathology was detected by colonoscopy in 44.4% of patients. The diagnoses were: colorectal carcinoma, eight cases (two Dukes' grade A, two Dukes' grade B, four Dukes' grade C); one or more polyps, 25 cases (in 17 cases at least one polyp was 5 mm or greater in diameter); inflammatory bowel disease, 11 cases. In the remaining 55 patients, bleeding was associated with diverticular disease (16 cases) and haemorrhoids (28 cases). No cause was found in 11 patients. This high rate of pathology may be partly caused by selection of cases for referral by the general practitioner, despite efforts to minimize this. Three symptoms as elicited by the colonoscopist were found to be significantly associated with serious disease: blood mixed with stool (P < 0.001); change in bowel habit (P < 0.005); and the presence of abdominal pain (P < 0.025). However, symptoms elicited on primary presentation were less helpful and symptoms changed significantly between consultation with the general practitioner and colonoscopy. CONCLUSION: All patients over the age of 40 years presenting with rectal bleeding should be referred for flexible sigmoidoscopy or colonoscopy. Symptoms are unhelpful in deciding who requires investigation.     

Telling “the truth” in dementia-Do attitude and approach of general practitioners and specialists differ?

OBJECTIVE: The prevailing opinion in the literature that disclosing the diagnosis of dementia to patients is important is not always put into practice. The purpose of this study was to investigate differences between GPs and specialists (neurologists and psychiatrists) in the German ambulatory care system concerning the disclosure of the diagnosis of dementia. METHODS: Thirty in depth interviews with randomly selected GPs were conducted. On this basis a standardised questionnaire was developed and sent to 389 GPs and 239 neurologists and psychiatrists. RESULTS: The postal survey revealed only minor differences between GPs and specialists, both groups being equally in favour of a timely disclosure. For example, 70% of the GPs and 77% of the specialists strongly agreed that "patients with dementia should be informed early because of the possibility to plan their lives". This positive attitude is pronounced among younger physicians, but is somewhat contradicted by difficulties in the communication with patients expressed in the interviews. In the interviews, what may be described as a "double taboo" emerges, in that GPs describe taboo topic areas related to dementia for them and for their patients. CONCLUSION: The postal survey shows the two professional groups to be very much in favour of a timely disclosure--an attitude that is pronounced among younger physicians. These findings can be interpreted as a recent change of attitudes regarding the disclosure of the diagnosis of dementia in the medical profession. PRACTICE IMPLICATIONS: Training opportunities are needed in order to overcome communication obstacles in the doctor-patient-communication about dementia.     

Requests for euthanasia or physician-assisted suicide from older persons who do not have a severe disease: an interview study

OBJECTIVE: To determine how often requests are made for euthanasia and physician-assisted suicide (EAS) in the absence of severe disease and how such requests are dealt with in medical practice in The Netherlands. METHOD: Retrospective interview study. Participants: 125 general practitioners (GPs), 77 nursing home physicians (NHPs), and 208 clinical specialists. RESULTS: In The Netherlands, each year approximately 400 people request EAS, because they are 'weary of life'. Thirty per cent of all physicians have at some time received an explicit request for EAS in the absence of severe disease; 3% of all physicians had granted a request for EAS in such a case. Most requests for EAS to GPs in the absence of severe disease (n = 29) were made by single people aged 80 years and over. While their problems were most frequently of a social nature, 79% had one or more non-severe illnesses. Most GPs refused the request; half of them proposed an alternative treatment, which the patient often refused. Nineteen people who did not receive any treatment persisted in their wish to die; the request for EAS from 5 out of 10 patients who received one or more types of treatment was withdrawn or became less explicit. CONCLUSIONS: Most physicians in The Netherlands refuse requests for EAS in the absence of severe disease. Most patients persist in their request. In an ageing population more research is needed to provide physicians with practical interventions to prevent suicide and to make life bearable and satisfactory for elderly people who wish to die.     

Solitary rectal ulcer syndrome in children and adolescents: a descriptive clinicopathologic study

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder of the rectum. While benign, it can cause concern for patients and affect quality of life. Reported studies on SRUS worldwide are scarce. The aim of this study is to describe the clinicopathologic characteristics of SRUS in a cohort of children based in Saudi Arabia. In this study, children with a confirmed diagnosis of SRUS at King Abdulaziz University Hospital (KAUH) were included, during the period November 2003 to November 2017. Data were collected from hospital medical records. The study comprised twenty-one patients: 17 males (81%) and 4 females (19%); the median age was 11.4 years (range, 5.43-17.9 years). The most common presenting symptoms were rectal bleeding in 21 patients (100%), passage of mucus in 16 (76.1%), abdominal pain in 14 (66.6%), constipation in 13 (61.9%), straining in 9 (42.9%), and rectal prolapse in 5 (23.8%). The most common finding at initial colonoscopy was a single ulcer in 7 patients (33.3%), multiple ulcers in 6 (28.5%), polypoid lesions in 5 (23.8%), and hyperemic mucosa in 3 (14.2%). All patients received medical treatment and 14 (81%) continued to manifest one or more of the symptoms following treatment, which required subsequent modification of the treatment course. None of the patients required surgery. In conclusion, the study found rectal bleeding to be the most common presentation, with a single ulcer being the most prevalent lesion in endoscopy. Treatment response was variable, but almost half of patients reported relief of symptoms following treatment.     

Diagnosing headache in primary care: a qualitative study of GPs’ approaches

Background

Headache is one of the most common symptoms in primary care. Most headaches are due to primary headaches and many headache sufferers do not receive a specific diagnosis. There is still a gap in research on how GPs diagnose and treat patients with headache.

Aim

To identify GPs’ diagnostic approaches in patients presenting with headache.

Design and setting

Qualitative study with 15 GPs in urban and rural practices.

Method

Interviews (20–40 minutes) were conducted using a semi-structured interview guideline. GPs described their individual diagnostic strategies by means of patients presenting with headache that they had prospectively identified during the previous 4 weeks. Interviews were taped and transcribed verbatim. Qualitative analysis was conducted by two independent raters.

Results

Regarding GPs’ general diagnostic approach to patients with headache, four broad themes emerged during the interviews: ‘knowing the patient and their background’, ‘first impression during consultation’, ‘intuition and personal experience’ and ‘application of the test of time’. Four further themes were identified regarding the management of diagnostic uncertainty: ‘identification of red flags’, ‘use of the familiarity heuristic’, ‘therapeutic trial’, and ‘triggers for patient referral’.

Conclusion

GPs apply different strategies in the early diagnostic phase when managing patients with headache. Identification of potential adverse outcomes accompanied by other strategies for handling uncertainty seem to be more important than an exact diagnosis. Established guidelines do not play a role in the diagnostic workup.     

Abdominal pain,diarrhea, constipation-which symptom is more indispensable to have a colonoscopy?

Background: Doctors perform colonoscopies when presented with various symptoms, including unexplained weight loss, rectal bleeding, changes in bowel habits, however many other symptoms such as abdominal pain, diarrhea and constipation may be more popular in outpatient department. As a result, we want to evaluate the three symptoms which is more need to have a colonoscopy. Abdominal pain, diarrhea and constipation are the main reasons for patients to visit the outpatient department of gastroenterology. And the colonoscopy is regularly recommended for outpatients with the above symptoms in China. The aim of this study was to evaluate the value of colonoscopy on the diagnosis of each single symptom of the three above and answer the question of my title-which symptom is more indispensable to have a colonoscopy? Methods: Colonoscopic findings of 580 outpatients with a single of these three common lower gastrointestinal symptoms were systematically analyzed in retrospect. Results: In this study, no significant difference was found in the positive rate of colon polyps, cancer and ulcerative colitis among these three groups divided by symptoms. The incidence of colon polyps, cancer and colitis for the chronic abdominal pain, chronic diarrhea and constipation group are 20.8%, 57.1%, 42.9% respectively. The incidence of colon polyps and cancer increases with age. Among the age groups 13-39 years old, 40-59 years and > 60 years, the incidence is 7.9%, 13.6%, 22.4% respectively. There is no significant difference in the incidence of colon polyps and colon cancer in our groups of symptoms. Conclusion: The results show the prevailing opinion that the indications of colonoscopy just refer to symptom and physical sign nowadays in China is inappropriate and it is best to take a full consideration of patient’s age, auxiliary examinations, family diseases history and other factors.     

`There's a lot of it about': clinical strategies in family practice

Is there a difference in the way family physicians and specialists deal with clinical problems? Family physicians, in contrast to specialists, work in a practice environment in which there is a high prevalence of symptomatic discomfort, but a low prevalence of frank disease. These circumstances result in clinical strategies that are very different to those used in secondary and tertiary levels of care, and which run counter to what are usually accepted as medical norms. The primary care physician must often diagnose what things are not, rather than what they are, must make management decisions prior to, or instead of, diagnostic decisions and must resist the temptation to be `thorough'' These imperatives are reflected in the language family physicians sometimes use in their conversations with patients. Clinical reasoning in primary care involves important but poorly understood intellectual processes which may be of significance to all levels of medicine.     

Remote medical consultation for vestibular disorders: technological solutions and case report.

Complaints of vertigo and imbalance are common presentations to primary care physicians, yet there are few specialists who diagnose and treat these problems as a significant part of their practices. We demonstrated the feasibility of remote consultation for a patient presenting with vertigo using a two-way digital video and audio network. It was possible to take an appropriate history, examine the patient, and provide a diagnosis and treatment. The patient had a common problem that causes dizziness: benign positional vertigo (BPV). An essential component of the examination was the use of a head-mounted display with embedded cameras. The cameras allowed viewing of the patient's eye movements, which were diagnostic.     

Coping with patients with medically unexplained symptoms: work-related strategies of physicians in primary health care

General practitioners (GPs) often meet patients with medically unexplained symptoms (MUS). From a patient perspective, MUS is a well-acknowledged problem within the primary health care services today, but less is known about the GPs' perceptions. This study aims to elucidate GPs' perceptions of patients with MUS, focusing on stressing situations, emotional reactions and coping strategies. Twenty-seven physicians participated in focus-group discussions. In the analysis, where a phenomenographic approach was used, six situations were identified as being especially stressful in the encounter with these patients. The GPs described how they used both problem-focused and emotion-focused strategies, but with emotion-focused strategies slightly dominating, indicating that the GPs had difficulties in managing their own stress when working with patients with MUS.     

Predicting colorectal cancer risk in patients with rectal bleeding

BACKGROUND: Rectal bleeding is an important symptom of colorectal cancer but has low predictive value in primary care. AIM: To determine which characteristics of rectal bleeding, along with other factors, are predictive of colorectal cancer. DESIGN OF STUDY: Observation study of patients with rectal bleeding referred to an open-access diagnostic clinic. SETTING: Primary care, southern England. METHOD: Symptom data were collected, using a self-completed questionnaire. Logistic regression techniques were used to determine predictors of colorectal cancer. RESULTS: There were 604 patients in the study and 22 (3.6%, 95% confidence interval [CI] = 2.0% to 5.2%) were diagnosed with colorectal cancer. Significant predictors of colorectal cancer were found to be age (<50 years: odds ratio [OR] = 1; 50-69 years: OR = 5.1, 95% CI = 1.4 to 18.6; > or = 70 years: OR = 8.2, 95% CI = 2.1 to 31.8) and blood mixed with the stool (Likelihood ratio [LR] 1.5; adjusted OR = 3.8; 95% CI = 1.4 to 10.5). Presence of haemorrhoids associated with bright red bleeding not mixed with stool reduced the likelihood of cancer (OR = 0.4, 95% CI = 0.1 to 1.2) but did not eliminate it--a cancer was present in 2% of patients with these symptoms. CONCLUSION: Patient-reported type of rectal bleeding as an isolated symptom has insufficient diagnostic value to be useful in general practice. By studying referred patients, we may even have overestimated its value. At best, it could be useful as a component of a composite symptom score to guide referral decisions.     

结直肠活检HGCIN与手术切除病理标本对比研究

目的：分析结直肠高级别上皮内瘤变(high grade colorectal intraepithelial neoplasia,HGCIN)术前结肠镜活检与手术切除病理标本的诊断效果。方法：选取本院2012年4月至2015年4月收治的HGCIN患者52例,所有病例均接受术前结肠镜活检检查以及手术切除标本病理检查,回顾性分析两种诊断方式的临床特点,总结结直肠HGCIN合理诊断方式,并探讨术前活检与手术切除病理检查的差异原因。结果：52例患者术前结肠镜活检均确诊为HGCIN,手术切除标本病理检验诊断为HGCIN共4例,同术前诊断的符合率为7.7%(4/52),另48例患者均诊断为腺癌,术前活检与术后病理检验结果比较存在统计学差异(P<0.05);同时,直肠位置病变误诊率约为97.2%(35/36),结肠位置病变误诊率约为81.3%(13/16),直肠病变误诊机率显著高于结肠,具有统计学意义(P<0.05)。结论：结直肠HGCIN术前活检与手术切除标本病理检查的差异性较为显著,临床针对疑似病理务必严密评估其病变分化程度等相关情况,积极同病理医师进行沟通,以缓解术前误诊情况,确保给予患者更为合理的临床诊治方案。     

Randomised controlled trial of tailored strategies to implement guidelines for the management of patients with depression in general practice.

BACKGROUND: Various methods are available for implementing change in the clinical behaviour of general practitioners (GPs). Although passive dissemination of information is generally ineffective, other methods can be variably effective. Few studies have investigated the impact of tailored methods. AIM: To determine whether methods tailored to overcome obstacles to change using psychological theories are more effective than dissemination alone in the implementation of guidelines for depression among GPs. DESIGN OF STUDY: Randomised controlled trial. SETTING: Sixty general practices in England; 30 GPs in the control group, 34 in the intervention group. METHOD: Practitioners identified patients presenting with depression before and after the implementation of guidelines (control group n = 192 in the first data collection, n = 181 in the second; intervention group n = 210 in the first data collection and n = 197 in the second). The main outcome measures were: record of adherence to guideline recommendations in clinical records; proportion of patients with Beck Depression Inventory (BDI) score less than 11 at 16 weeks after diagnosis. RESULTS: In comparison with the control group, in the group of GPs receiving tailored implementation, there were increases in the proportions of patients assessed for suicide risk. In the intervention group, the proportion of patients with BDI scores of less than 11 at 16 weeks increased. CONCLUSION: Obstacles to implementation can be identified and strategies tailored to address them. The findings indicate a new approach for research to understand and develop methods of implementation.     

A randomised controlled trial of joint consultations with general practitioners and cardiologists in primary care.

BACKGROUND: Joint consultation sessions of a small group of general practitioners (GPs) and a specialist in orthopaedics proved to be an effective way of decreasing the referral rate of orthopaedic patients. Cardiac complaints comprise an important category of health problems with high referral rates. AIMS: To study the effects of joint consultation on the quality of care and referrals for patients with cardiac complaints. DESIGN OF STUDY: Randomised controlled trial. SETTING: Forty-nine GPs participated in 16 consultation groups, each with one of 13 cardiologists, in monthly joint consultations over a period of about 18 months. METHOD: The GPs selected patients about whom they were uncertain, and those needing urgent referral were excluded. Patients were randomly assigned to joint consultation or to usual care. After a follow-up period all patients had a joint consultation for outcome assessment. Referral data were provided by two regional health insurance companies and questionnaires were given to the patients, GPs, and cardiologists to gauge their opinion of the trial. RESULTS: One hundred and forty-eight patients in the intervention group and 158 patients in the control group fulfilled the whole protocol. The quality of care was similar in both groups. In the intervention group, 34% of the patients were referred, compared with 55% in the control group (P = 0.001), and fewer patients underwent further diagnostic procedures (7% compared with 16%, P = 0.013). Referrals to cardiology as a proportion of all referrals decreased in the practices of the participating GPs, compared with their reference districts (P = 0.024). CONCLUSION: Joint consultation is an effective method that provides a quality of care that at least equals usual care and that contributes to a better selection of patients who need specialist care.     

Rectal and postmenopausal bleeding: consultation and referral of patients with and without severe mental health problems

BACKGROUND: People with severe mental health problems receive less effective care for some physical conditions. There is concern that this could apply to rectal bleeding or postmenopausal bleeding. Published estimates of consultation rates and outcomes for these symptoms vary widely. AIM: To estimate rates of first-ever consultation for rectal bleeding and postmenopausal bleeding in general practice, together with subsequent referrals and outcomes. To identify inequalities for patients with severe mental health problems. DESIGN OF STUDY: Cohort study. SETTING: Primary care. METHOD: Patients with first-ever consultations for rectal or postmenopausal bleeding were identified among more than 3 million patients from 328 practices contributing routine data to the QRESEARCH database. Their records were followed for 2 years. RESULTS: There were 30 175 first consultations for rectal bleeding (2.6 per thousand patients per year at age 25-29 years, rising to 4.8 over age 85 years) and 10 142 for postmenopausal bleeding (highest at 7.4 per thousand per year aged 55-59 years). Overall, 2.2% of those with rectal bleeding and 1.7% of those with postmenopausal bleeding went on to have a relevant cancer diagnosis within 2 years. Cancer risk was strongly related to age, and was higher for males with rectal bleeding than females with rectal bleeding. Recorded referrals were at similar rates among patients with and without severe mental health problems. CONCLUSION: The rate of first consultations for rectal bleeding or postmenopausal bleeding is relatively low. Less than 2.5% overall have a relevant cancer diagnosis within 2 years. There is no evidence of inequality in referral for patients with severe mental health problems.     

Specialist outreach clinics in general practice: what do they offer?

BACKGROUND: Specialist outreach clinics in general practice, in which hospital-based specialists hold outpatient clinics in general practitioners' (GPs) surgeries, are one example of a shift in services from secondary to primary care. AIM: To describe specialist outreach clinics held in fundholding general practices in two specialties from the perspective of patients, GPs, and consultants, and to estimate the comparative costs of these outreach clinics and equivalent hospital outpatient clinics. METHOD: Data were collected from single outreach sessions in fundholding practices and single outpatient clinics held by three dermatologists and three orthopaedic surgeons. Patients attending the outreach and outpatient clinics, GPs from practices in which the outreach clinics were held, and the consultants all completed questionnaires. Managers in general practice and hospital finance departments supplied data for the estimation of costs. RESULTS: Initial patient questionnaires were completed by 83 (86%) outreach patients and 81 (75%) outpatients. The specialist outreach clinics sampled provided few opportunities for increased interaction between specialists and GPs. Specialists were concerned about the travelling time resulting from their involvement in outreach clinics. Waiting times for first appointments were shorter in some outreach clinics than in outpatient clinics. However, patients were less concerned about the location of their consultation with the specialist than they were about the interpersonal aspects of the consultation. There was some evidence of a difference in casemix between the dermatology patients seen at outreach and those seen at outpatient clinics, which confounded the comparison of total costs associated with the two types of clinic. However, when treatment and overhead costs were excluded, the marginal cost per patient was greater in outreach clinics than in hospital clinics for both specialties studied. CONCLUSION: The study suggests that a cautious approach should be taken to further development of outreach clinics in the two specialties studied because the benefits of outreach clinics to patients, GPs and consultants may be modest, and their higher cost means that they are unlikely to be cost-effective.     

Changes in attainment of lipid goals by general practitioners and specialists in patients at high cardiovascular risk in Hungary during 2004-2008

Introduction

Lipid-lowering therapy should achieve target levels. We assessed the change of the achievement of targets and the mean low-density lipoprotein cholesterol (LDL-C) levels in high-risk Hungarian patients.

Material and methods

Six studies performed with patients of general practitioners (GPs) and specialists between 2004 and 2008 were evaluated: 9,508 patients from GPs and 2809 from specialist practices (total 12,317).

Results

During this 4-year period the LDL-C level decreased by 0.73 mmol/l and the LDL-C goal achievement rate increased from 14 to 32% in patients treated by GPs. LDL-C showed a decrease of 0.48 mmol/l and the goal achievement rate changed from 20 to 43% in patients treated by specialists. In the majority of the patients not achieving the LDL-C goal (57% for specialists and 89% for GPs) there was no modification in the current therapy. In addition to emphasizing the priority of LDL-C lowering, we should also strive for residual risk reduction, which means raising high-density lipoprotein cholesterol (HDL-C) and lowering triglyceride levels. There was no significant improvement in HDL-C or triglyceride levels during the examined period.

Conclusion

More attention needs to be paid to changing treatment of patients to achieve target levels.     

Safety of Gastrointestinal Endoscopy in Korea: A Nationwide Survey and Population-Based Study

BackgroundAttention should be paid to endoscopy-related complications and safety-related accidents that may occur in the endoscopy unit. This study investigated the current status of complications associated with diagnostic and therapeutic endoscopy in Korea.MethodsA questionnaire survey on endoscopy-related complications was conducted in a total of 50 tertiary or general hospitals in Korea. The results were compared to the population-level claims data from the Health Insurance Review & Assessment Service (HIRA), which analyzed endoscopy procedures conducted in 2017 in Korea.ResultsThe incidences of bleeding associated with diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and with diagnostic and therapeutic colonoscopy were 0.224% and 3.155% and 0.198% and 0.356%, respectively, in the 2017 HIRA claims data, compared to 0.012% and 1.857%, and 0.024% and 0.717%, in the 50 hospitals surveyed. The incidences of perforation associated with diagnostic and therapeutic EGD and with diagnostic and therapeutic colonoscopy were 0.023% and 0.613%, and 0.007% and 0.013%, respectively, in the 2017 HIRA claims data compared to 0.001% and 0.325%, and 0.017% and 0.206%, in the 50 hospitals surveyed. In the HIRA claims data, the incidence of bleeding/perforation after diagnostic colonoscopy in clinics, community hospitals, general hospitals, and tertiary hospitals was 0.129%/0.000%, 0.088%/0.004%, 0.262%/0.009%, and 0.479%/0.030% respectively, and the corresponding incidence of bleeding/perforation after therapeutic colonoscopy was 0.258%/0.004%, 0.401%/0.007%, 0.408%/0.024%, and 0.731%/0.055%.ConclusionThe incidences of complications associated with diagnostic and therapeutic EGD or colonoscopy tended to increase with the hospital volume in Korea.Trial RegistrationClinical Research Information Service Identifier: KCT0001728