Predisposing Factors Associated With Chronic and Recurrent Rhinosinusitis in Childhood

Purpose

There is currently no information regarding predisposing factors for chronic and recurrent rhinosinusitis (RS), although these are considered to be multifactorial in origin, and allergic diseases contribute to their pathogenesis. We evaluated the predisposing factors that may be associated with chronic and recurrent RS.

Methods

In this prospective study, we examined patients with RS younger than 13 years of age, diagnosed with RS at six tertiary referral hospitals in Korea between October and December, 2006. Demographic and clinical data related to RS were recorded and analyzed.

Results

In total, 296 patients were recruited. Acute RS was the most frequent type: 56.4% of the patients had acute RS. The prevalences of other types of RS, in descending order, were chronic RS (18.9%), subacute RS (13.2%), and recurrent RS (11.5%). Factors associated with recurrent RS were similar to those of chronic RS. Patients with chronic and recurrent RS were significantly older than those with acute and subacute RS. The prevalences of allergic rhinitis, atopy, and asthma were significantly higher in patients with chronic and recurrent RS than those with acute and subacute RS.

Conclusions

An association between atopy and chronic/recurrent RS, compared to acute and subacute RS, suggests a possible causal link.     

Clinical Characteristics and Management of Benign Transient Non-Organic Ileus of Neonates: A Single-Center Experience

Purpose

The term benign transient non-organic ileus of neonates (BTNIN) is applied to neonates who present symptoms and plain radiographic findings of Hirschsprung''s disease, but do not have aganglionic bowel and are managed well by conservative treatment. It can often be difficult to diagnose BTNIN because its initial symptoms are similar to those of Hirschsprung''s disease. The aim of this study is to evaluate the clinical characteristics and proper treatment of BTNIN.

Materials and Methods

A retrospective review was made on the clinical data of 19 neonates who were treated for BTNIN between January 2008 and December 2011 at a single facility.

Results

Abdominal distension occurred in every patient (19/19). Other common symptoms included emesis (5/19), explosive defecation (5/19), and constipation (4/19). The vast majority of patients (15/19) experienced the onset of symptoms between 2 and 4 weeks of age. Radiograph findings from all of the patients were similar to Hirschsprung''s disease. A barium study showed a transition zone in 33.4% (6/18) of the patients. However, rectal biopsy revealed ganglion cells in the distal rectum in 88.2% (15/17) of the patients, and anorectal manometry showed a normal rectoanal inhibitory reflex in 90% (9/10). All patients responded well to conservative treatment. Symptoms disappeared at the mean age of 4.9±1.0 months, and the abdominal radiographs normalized.

Conclusion

BTNIN had an excellent outcome with conservative treatment, and must be differentiated from Hirschsprung''s disease. A rectal biopsy and anorectal manometry were useful diagnostic tools in the differential diagnosis.     

When is acute persistent cough in school-age children and adults whooping cough?: A prospective case series study

Background

Pertussis is a vaccine modified disease in most age groups and hence subtle in its presentation. Current diagnostic approaches require relatively invasive sampling.

Aim

To determine the incidence of B. pertussis infection among people aged 5–49 years identified in primary care with acute persistent cough using an oral fluid based diagnostic test.

Design and setting

Active surveillance of acute persistent cough of 2 weeks duration or greater was established in Auckland, New Zealand from May to October 2011. The 15 participating primary care practices provided care for a socioeconomically diverse population.

Method

Recent B. pertussis infection was determined by measurement of IgG antibodies to pertussis toxin (PT) in an oral fluid sample. An IgG antibody titre to PT of ≥70 arbitrary units defined recent infection. Participants reported symptoms at presentation and kept a cough diary.

Results

A total of 226 participants were enrolled: 70 (31%) were children (5–16 years) and 156 (69%) were adults (17–49 years). Oral fluid samples were obtained from 225 participants. Ten per cent (23/225) had recent B. pertussis infection including a larger proportion of children than adults (17% versus 7%, P = 0.003). Neither cough duration nor any individual symptom discriminated between those with and without recent B. pertussis infection.

Conclusion

Pertussis is a frequent cause of acute persistent cough presenting to primary care. Clinical differentiation of pertussis from other causes of acute persistent cough is difficult. An oral fluid based diagnostic test, which is less invasive than other diagnostic approaches, has high acceptability in primary care.     

Changes in Dynamic Pedobarography after Extensive Plantarmedial Release for Paralytic Pes Cavovarus

Purpose

Plantarmedial release and first ray extension osteotomy are often combined to treat paralytic cavovarus foot deformity. The purpose of this study is to evaluate the effect of additional first ray extension osteotomy in terms of dynamic pedobarography.

Materials and Methods

We reviewed findings of pre- and postoperative plain radiography and dynamic pedobarography for 25 patients in whom the flexibility of the hindfoot was confirmed by the Coleman block test. The results of treatment by extensive plantar medial release with first ray osteotomy (group I) were compared with the results of treatment by extensive plantar medial release alone (group II).

Results

Plain radiographs obtained pre- and postoperatively showed no statistically significant improvement in each group. Only in group I, peak forces at the 1st metatarsal head, 2nd metatarsal head and medial calcaneus were increased after operation.

Conclusion

In paralytic hindfoot flexible cavovarus, extensive plantarmedial release with first ray osteotomy improve foot pressure distribution more than extensive plantarmedial release alone.     

Primary care access to computed tomography for chronic headache

Background

The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services.

Aim

To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care.

Design of study

Prospective observational analysis of GP referrals to an open access CT brain scanning service.

Setting

Primary care, and outpatient radiology and neurology departments.

Method

GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan.

Results

There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period.

Conclusion

An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.     

Development and validation of the Molluscum Contagiosum Diagnostic Tool for Parents: diagnostic accuracy study in primary care

Background

Molluscum contagiosum (MC) is diagnosed by its distinct appearance. Parental diagnosis of MC may reduce anxiety and lead to reductions in healthcare consultations, and may be particularly useful in large-scale epidemiological studies. However, there are currently no published, validated tools allowing parental diagnosis of MC.

Aim

To develop and validate a tool for parental diagnosis of MC.

Design and setting

The Molluscum Contagiosum Diagnostic Tool for Parents (MCDTP) was developed and its diagnostic accuracy was compared with GP diagnosis in 12 GP surgeries in South Wales.

Method

Following development, which involved three phases with dermatologists, nurses, GPs, and parents, parents completed the MCDTP (index test) in the practice waiting room, and rated their confidence in their diagnosis. A GP then examined their child for MC (reference test). Test characteristics were calculated for all responders and for those who expressed being confident or very confident in their diagnosis.

Results

A total of 203 parents completed the MCDTP. The MCDTP showed a sensitivity of 91.5% (95% confidence intervals (CI) = 81.3 to 97.2) and a specificity of 88.2% (95% CI = 81.8 to 93.0) in all parents and a sensitivity of 95.8% (95% CI = 85.7 to 99.5) and a specificity of 90.9% (95% CI = 83.9 to 95.6) in parents who were confident or very confident in their diagnosis. The positive predictive value was 76.1% (95% CI = 64.5 to 85.4) and negative predictive value was 96.2% (95% CI = 91.4 to 98.8) for all parents.

Conclusion

The MCDTP performed well compared with GP diagnosis and is suitable for clinical use by parents and in population-based studies.     

Ultrasonographic Findings in Patients Examined in Cataract Detection-and-Treatment Campaigns: A Retrospective Study

INTRODUCTION:

A cataract is defined as an opacity of any portion of the lens, regardless of visual acuity. In some advanced cases of cataracts, in which good fundus visualization is not possible, an ultrasound examination provides better assessment of the posterior segment of the globe.

OBJECTIVES:

This study aims to evaluate the ultrasonographic records of patients with advanced cataracts who were examined during cataract campaigns.

METHODS:

The ultrasonographic findings obtained from 215 patients examined in cataract campaigns conducted by the Hospital das Clínicas Department of Ophthalmology of the Faculdade de Medicina da Universidade de São Paulo between the years of 2005 and 2007 were evaluated, and the utility of this exam in changing the treatment procedures was studied.

RESULTS:

A total of 289 eyes from 215 patients were examined. Of the eyes examined, 77.5% presented with findings in the vitreous cavity and the posterior pole. A posterior vitreous detachment with no other complications was observed in 47.4% of the eyes. The remaining 30.1% presented with eye diseases that could result in a reduced visual function after surgery. The most frequent eye diseases observed were diffuse vitreous opacity (12.1% of the eyes) and detachment of the retina (9.3% of the eyes).

DISCUSSION:

In many cases, the ultrasonographic evaluation of the posterior segment revealed significant anomalies that changed the original treatment plan or contra-indicated surgery. At the very least, the evaluation was useful for patient counseling.

CONCLUSION:

The ultrasonographic examination revealed and differentiated between eyes with cataracts and eyes with ocular abnormalities other than cataracts as the cause of poor vision, thereby indicating the importance of its use during ocular evaluation.     

Accuracy of symptoms and signs for coronary heart disease assessed in primary care

Background

Diagnosing the aetiology of chest pain is challenging. There is still a lack of data on the diagnostic accuracy of signs and symptoms for acute coronary events in low-prevalence settings.

Aim

To evaluate the diagnostic accuracy of symptoms and signs in patients presenting to general practice with chest pain.

Design of study

Cross-sectional diagnostic study with delayed-type reference standard.

Setting

Seventy-four general practices in Germany.

Method

The study included 1249 consecutive patients presenting with chest pain. Data were reviewed by an independent reference panel, with coronary heart disease (CHD) and an indication for urgent hospital admission as reference conditions. Main outcome measures were sensitivity, specificity, likelihood ratio, predictive value, and odds ratio (OR) for non-trauma patients with a reference diagnosis.

Results

Several signs and symptoms showed strong associations with CHD, including known vascular disease (OR = 5.13; 95% confidence interval [CI] = 2.83 to 9.30), pain worse on exercise (OR = 4.27; 95% CI = 2.31 to 7.88), patient assumes cardiac origin of pain (OR = 3.20; 95% CI = 1.53 to 6.60), cough present (OR = 0.08; 95% CI = 0.01 to 0.77), and pain reproducible on palpation (OR = 0.27; 95% CI = 0.13 to 0.56). For urgent hospital admission, effective criteria included pain radiating to the left arm (OR = 8.81; 95% CI = 2.58 to 30.05), known clinical vascular disease (OR = 7.50; 95% CI = 2.88 to 19.55), home visit requested (OR = 7.31; 95% CI = 2.27 to 23.57), and known heart failure (OR = 3.53; 95% CI = 1.14 to 10.96).

Conclusion

Although individual criteria were only moderately effective, in combination they can help to decide about further management of patients with chest pain in primary care.     

Does a decision aid help physicians to detect chronic obstructive pulmonary disease?

Background

Numerous decision aids have been developed recently, but the value they add above that of the initial clinical assessment is not well known.

Aim

To quantify whethera formal decision aid for chronic obstructive pulmonary disease (COPD) adds diagnostic information, above the physician''s clinical assessment.

Design and setting

Subanalysis of a diagnostic study in Dutch primary care.

Method

Sixty-five primary care physicians included 357 patients who attended for persistent cough and were not known to have COPD. The physicians estimated the probability of COPD after short history taking and physical examination. After this, the presence or absence of COPD was determined using results of extensive diagnostic work-up. The extent to which an 8-item decision aid for COPD, which included only symptoms and signs, added diagnostic value above the physician''s estimation was quantified by the increase of the area under the receiver operating characteristic curve (ROC area), and the improvement in diagnostic risk classification across two classes: ‘low probability of COPD’ (<20%) and ‘possible COPD’ (≥20%).

Results

One hundred and four patients (29%) had COPD. Adding the decision aid to the clinical assessment increased the ROC area from 0.75 (95% confidence interval [CI] = 0.70 to 0.81) to 0.84 (95% CI = 0.80 to 0.89) (P<0.005), and improved the diagnostic risk classification of the patients, such that 35 fewer patients needed spirometry testing and eight fewer COPD cases were missed.

Conclusion

A short decision aid for COPD added diagnostic value to the physician''s clinical assessment.     

Clinical Characteristics and Treatment Outcomes of Mycobacterium kansasii Lung Disease in Korea

Purpose

While Mycobacterium kansasii is a common cause of nontuberculous mycobacterial (NTM) lung disease in many developed countries, M. kansasii is infrequently isolated in Korea. We investigated the clinical and radiological features and treatment outcomes of M. kansasii lung disease in Korea retrospectively.

Materials and Methods

We identified 41 patients with M. kansasii lung disease who met the diagnostic criteria for NTM lung disease in two tertiary referral hospitals in Seoul, Korea, between January 1998 and December 2007.

Results

Their median age was 63 years [interquartile range (IQR) 51-75 years] and 33 (81%) were men. Twenty-three patients (56%) were smokers and 13 patients (32%) had previous pulmonary tuberculosis. The most common radiographic findings were nodules (n = 22, 54%) and consolidation (n = 22, 54%). Cavitation was present in 13 patients (32%). Thirty-one patients (76%) were treated with isoniazid, rifampin, and ethambutol. The median treatment duration was 16 months (IQR 9-18 months). The negative conversion rate after 12 months of treatment was 95%.

Conclusion

Clinicians should be aware of the various radiographic manifestations of M. kansasii lung disease. With appropriate treatment, these patients have a good prognosis.     

Accuracy of symptoms,signs, and C-reactive protein for early chronic obstructive pulmonary disease

Background

Guidelines recommend detection of early chronic obstructive pulmonary disease (COPD), but evidence on the diagnostic work-up for COPD only concerns advanced and established COPD.

Aim

To quantify the accuracy of symptoms and signs for early COPD, and the added value of C-reactive protein (CRP), in primary care patients presenting with cough.

Design and setting

Cross-sectional diagnostic study of 73 primary care practices in the Netherlands

Method

Four hundred primary care patients (182 males, mean age 63 years) older than 50 years, presenting with persistent cough (>14 days) without established COPD participated, of whom 382 completed the study. They underwent a systematic diagnostic work-up of symptoms, signs, conventional laboratory CRP level, and hospital lung functions tests, including body plethysmography, and an expert panel decided whether COPD was present (reference test). The independent value of all items was estimated by multivariable logistic regression analysis.

Results

According to the expert panel, 118 patients had COPD (30%). Symptoms and signs with independent diagnostic value were age, sex, current smoking, smoking more than 20 pack-years, cardiovascular comorbidity, wheezing complaints, diminished breath sounds, and wheezing on auscultation. Combining these items resulted in an area under the receiver operating characteristic curve (ROC area) of 0.79 (95% confidence interval = 0.74 to 0.83) after internal validation. The proportion of subjects with elevated CRP was higher in those with early COPD, but CRP added no relevant diagnostic information above symptoms and signs.

Conclusion

In subjects presenting with persistent cough, the CRP level has no added value for detection of early COPD.     

Patients' confidence in their GP before and after being diagnosed with cancer

Background

General practice plays an important role in the cancer care pathway. The initial diagnostic phase may be crucial for the relationship between the patient and the GP.

Aim

The aim was to describe whether patients'' confidence in their GP changed after a cancer diagnosis, and analyse whether the change in confidence was associated with doctor delay.

Design and setting

Population-based cohort study with 1892 questionnaires sent to patients and their GPs in general practices in the former Aarhus County, Denmark.

Method

Information on patients'' confidence in their GP was obtained from the patient questionnaire. Information on doctor delay was obtained from the GPs and defined as a period of 14 days or more from the date of first symptom presentation to the GP until cancer-specific investigation was initiated.

Results

Before the cancer diagnosis, 88.4% of the patients had confidence in their GP, which decreased to 80.0% after the diagnosis (P<0.001); 15.8% of the patients who experienced no doctor delay reported a decrease in confidence after the cancer diagnosis, compared with 29.1% of the patients with a doctor delay (P<0.001). Patients presenting with alarm symptoms and experiencing doctor delay were 3.8 times more likely to lose confidence compared with those presenting with alarm symptoms who experienced no doctor delay (P = 0.048).

Conclusion

The majority of the patients had high levels of confidence in their GP before, as well as after, the cancer diagnosis. Nevertheless, a substantial amount had low confidence in the GP, especially when experiencing doctor delay in the initial phase of the pathway.     

Management of first-episode pelvic inflammatory disease in primary care: results from a large UK primary care database

Background

Prompt and effective treatment of pelvic inflammatory disease (PID) may help prevent long-term complications. Many PID cases are seen in primary care but it is not known how well management follows recommended guidelines.

Aim

To estimate the incidence of first-episode PID cases seen in UK general practice, describe their management, and assess its adequacy in relation to existing guidelines.

Design of study

Cohort study.

Setting

UK general practices contributing to the General Practice Research Database (GPRD).

Method

Women aged 15 to 40 years, consulting with a first episode of PID occurring between 30 June 2003 and 30 June 2008 were identified, based on the presence of a diagnostic code. The records within 28 days either side of the diagnosis date were analysed to describe management.

Results

A total of 3797 women with a first-ever coded diagnosis of PID were identified. Incidence fell during the study period from 19.3 to 8.9/10 000 person-years. Thirty-four per cent of cases had evidence of care elsewhere, while 2064 (56%) appeared to have been managed wholly within the practice. Of these 2064 women, 34% received recommended treatment including metronidazole, and 54% had had a Chlamydia trachomatis test, but only 16% received both. Management was more likely to follow guidelines in women in their 20s, and later in the study period.

Conclusion

These analyses suggest that the management of PID in UK primary care, although improving, does not follow recommended guidelines for the majority of women. Further research is needed to understand the delivery of care in general practice and the coding of such complex syndromic conditions.     

Undetected chronic obstructive pulmonary disease and asthma in people over 50 years with persistent cough

Background

Chronic obstructive pulmonary disease (COPD) and asthma are underdiagnosed in primary care.

Aim

To determine how often COPD or asthma are present in middle-aged and older patients who consult their GP for persistent cough.

Design of study

A cross-sectional study in 353 patients older than 50 years, visiting their GP for persistent cough and not known to have COPD or asthma.

Setting

General practice in the Netherlands.

Method

All participants underwent extensive diagnostic work-up, including symptoms, signs, spirometry, and body plethysmography. All results were studied by an expert panel to diagnose or exclude COPD and/or asthma. The reproducibility of the panel diagnosis was assessed by calculation of Cohen''s κ statistic in a sample of 41 participants.

Results

Of the 353 participants, 102 (29%, 95% confidence interval [CI] = 24 to 34%) were diagnosed with COPD. In 14 of these 102 participants, both COPD and asthma were diagnosed (4%, 95% CI = 2 to 7%). Asthma (without COPD) was diagnosed in 23 (7%, 95% CI = 4 to 10%) participants. Mean duration of cough was 93 days (median 40 days). The reproducibility of the expert panel was good (Cohen''s κ = 0.90).

Conclusion

In patients aged over 50 years who consult their GP for persistent cough, undetected COPD or asthma is frequently present.     

Comparison of seven diagnostic tests to detect Trypanosoma cruzi infection in patients in chronic phase of Chagas disease

Objective:

To compare the diagnostic performance of seven methods to determine Trypanosoma cruzi infection in patients with chronic Chagas disease.

Methods:

Analytical study, using the case-control design, which included 205 people (patients with Chagasic cardiomyopathy, n= 100; control group, n= 105). Three enzyme linked immunosorbent assays, one indirect hemagglutination assay and one immunochromatographic test were assessed. Additionally, DNA amplification was performed via the PCR method using kinetoplast and nuclear DNA as target sequences. For the comparative analysis of diagnostic tests, the parameters used were sensitivity, specificity, positive and negative predictive values, Receiver Operator Characteristic (ROC), positive and negative likelihood ratio, as well as κ quality analysis.

Results:

The commercial Bioelisa Chagas test showed the highest sensitivity (98%), specificity (100%), and positive and negative predictive values; ​​additionally, it had the highest discriminatory power. Otherwise, the amplification of T. cruzi DNA in blood samples showed low values of sensitivity (kinetoplast DNA = 51%, nuclear DNA = 22%), but high values of specificity (100%), and moderate to low discriminatory ability.

Conclusion:

The comparative analysis among the different methods suggests that the diagnostic strategy of T. cruzi infection in patients with chronic Chagas disease can be performed using ELISA assays based on recombinant proteins and/or synthetic peptides, which show higher diagnosis performance and can confirm and exclude the diagnosis of T. cruzi infection. The molecular methods show poor performance when used in the diagnosis of patients with chronic Chagas disease.     

Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule

Background

The Marburg Heart Score (MHS) aims to assist GPs in safely ruling out coronary heart disease (CHD) in patients presenting with chest pain, and to guide management decisions.

Aim

To investigate the diagnostic accuracy of the MHS in an independent sample and to evaluate the generalisability to new patients.

Design and setting

Cross-sectional diagnostic study with delayed-type reference standard in general practice in Hesse, Germany.

Method

Fifty-six German GPs recruited 844 males and females aged ≥35 years, presenting between July 2009 and February 2010 with chest pain. Baseline data included the items of the MHS. Data on the subsequent course of chest pain, investigations, hospitalisations, and medication were collected over 6 months and were reviewed by an independent expert panel. CHD was the reference condition. Measures of diagnostic accuracy included the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, likelihood ratios, and predictive values.

Results

The AUC was 0.84 (95% confidence interval [CI] = 0.80 to 0.88). For a cut-off value of 3, the MHS showed a sensitivity of 89.1% (95% CI = 81.1% to 94.0%), a specificity of 63.5% (95% CI = 60.0% to 66.9%), a positive predictive value of 23.3% (95% CI = 19.2% to 28.0%), and a negative predictive value of 97.9% (95% CI = 96.2% to 98.9%).

Conclusion

Considering the diagnostic accuracy of the MHS, its generalisability, and ease of application, its use in clinical practice is recommended.     

Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study

Background

In developed countries, primary health care increasingly involves the care of patients with multiple chronic conditions, referred to as multimorbidity.

Aim

To describe the epidemiology of multimorbidity and relationships between multimorbidity and primary care consultation rates and continuity of care.

Design of study

Retrospective cohort study.

Setting

Random sample of 99 997 people aged 18 years or over registered with 182 general practices in England contributing data to the General Practice Research Database.

Method

Multimorbidity was defined using two approaches: people with multiple chronic conditions included in the Quality and Outcomes Framework, and people identified using the Johns Hopkins University Adjusted Clinical Groups (ACG®) Case-Mix System. The determinants of multimorbidity (age, sex, area deprivation) and relationships with consultation rate and continuity of care were examined using regression models.

Results

Sixteen per cent of patients had more than one chronic condition included in the Quality and Outcomes Framework, but these people accounted for 32% of all consultations. Using the wider ACG list of conditions, 58% of people had multimorbidity and they accounted for 78% of consultations. Multimorbidity was strongly related to age and deprivation. People with multimorbidity had higher consultation rates and less continuity of care compared with people without multimorbidity.

Conclusion

Multimorbidity is common in the population and most consultations in primary care involve people with multimorbidity. These people are less likely to receive continuity of care, although they may be more likely to gain from it.