The Incidence and Outcome of Rectal Bleeding in General Practice

The objective of the studies reported in this paper was to determinethe incidence as well as the final diagnostic outcome of rectalbleeding presenting in general practice. Because of the widevariety observed in incidence rates among 83 general practitioners(GPs) in the first study (A) an additional study (B) was undertaken.In study B with 10 GPs special efforts were made to maximizethe catchment rate. The mean ‘consultation incidence rate’was 7 per 1000 people per year. A follow-up period of at least1 year was applied to establish the final diagnostic conclusion.Occurrence of colorectal cancer was found in 3% of patientswith rectal bleeding. This may represent an overestimation ofthe prior probability since there was a selection in favourof patients with clinically relevant rectal bleeding. In about90% of patients rectal bleeding was related to minor ailmentsor self-limiting disorders. Further study on predictive valuesof (combinations of) other signs and symptoms is necessary todevelop clinical recommendations.     

Delay in consulting a medical practitioner about rectal bleeding.

STUDY OBJECTIVE--The aims were to estimate the incidence of rectal bleeding in the community, and to determine the proportion of individuals who delay or fail to seek medical advice after a first episode of rectal bleeding. DESIGN--The data were collected as part of a large scale general population survey of the health practices and attitudes of individuals in a randomly selected sample of 2121 households. SETTING--The survey was conducted in the Newcastle and Lake Macquarie areas of New South Wales, Australia, during 1987-88. PARTICIPANTS--Information about rectal bleeding was collected from 1213 individuals aged 40 years and over. MEASUREMENTS AND MAIN RESULTS--Of the 1213 people aged 40 years and over, 239 (20%) reported noticing rectal bleeding at some time in their life. However, since an estimated 4.5% had noticed rectal bleeding for the first time in the past year the true lifetime incidence of rectal bleeding is likely to be much higher. Of the 77 individuals who had noticed a first occurrence of rectal bleeding more than three months but less than five years prior to the interview, 23 (30%) had either not sought medical advice or had only done so after a period of delay. The most commonly reported reason for delay or failure to consult was thinking that the bleeding was not serious and would clear up by itself. CONCLUSIONS--The data suggest that prompt investigation of rectal bleeding is not occurring in a relatively large proportion of cases. However, in the absence of firm evidence that early detection improves prognosis, and considering the costs of screening, it would be premature to initiate programmes which encourage people to seek care promptly for this symptom.     

Consider colonoscopy for young patients with hematochezia

BACKGROUND: Hematochezia is a common complaint in adult patients aged <50 years. Most studies of lower endoscopy for rectal bleeding have concentrated on older patients or have failed to mention the location of lesions. OBJECTIVE: To determine the findings of complete colonoscopy in adults younger than 50 years with rectal bleeding. METHODS: Data were retrieved from medical records and included demographics, indications, endoscopic findings, and histology. Lesions were labeled according to location: proximal to the splenic flexure or distal to (and including) the splenic flexure. Excluded were those with a history of colitis, colorectal cancer, polyps, anemia, significant weight loss, severe bleeding, or strong family history of colorectal cancer. RESULTS: The study included 223 patients with rectal bleeding aged <50 years who had undergone a colonoscopy. Normal findings were recorded for 48 (21.5%). Four (1.8%) were diagnosed with cancer in the distal colon, and 22 (9.9%) were found to have colon adenomas, 6 of whom had proximal adenomas only. Hemorrhoids were present in 135 patients (60.5%). Other findings included colitis, angiodysplasia, diverticulosis, anal fissures, and rectal ulcers. CONCLUSIONS: Colon neoplasms may be present even in younger adults with nonurgent rectal bleeding. Though most findings were benign and located in the distal colon, colonoscopy should be strongly considered for this patient group.     

Predictive value of signs and symptoms for colorectal cancer in patients with rectal bleeding in general practice

The aim of the study is to determine the diagnostic value of(combinations of) signs, symptoms and simple laboratory testresults for colorectal cancer in patients with rectal bleedingpresenting in general practice. Initial complaints and findingswere compared with the final diagnoses based on clinical follow-upafter at least 1 year. Patients studied were those presentingovert rectal bleeding to the general practitioner (83 GPs inthe South of the Netherlands). Outcome measures are sensitivity,specificity, predictive values, odds ratios and a predicitionmodel derived from multiple logistic regression analysis. Age,change in bowel habit and blood mixed with or on stool showa statistically significant independent value in the discriminationbetween patients with a low and those with a high probabilityof colorectal cancer. Many other variables did not show predictivevalue. The prediction model has a sensitivity of 100% and aspecificity of 90%. Although the number of patients with colorectalcancer is small (n=9) it was possible to identify three characteristicswhich can be helpful in the prediction of presence or absenceof colorectal cancer in general practice. Application of themodel presented might prevent 90% of ‘unnecessary’invasive diagnostic procedures for patients with rectal bleedingwho do not have colorectal cancer (true negative). Testing theperformance of the model in other general practice populationsis recommended.     

Prevention in practice: results of a 2-year follow-up of routine health promotion interventions in general practice

BACKGROUND.: The effectiveness of health promotion activity in general practiceon risk factor reduction for coronary heart disease remainsthe subject of active debate. OBJECTIVE.: The study aimed to assess the impact of practice-based healthcheck-ups on health behaviours over a 2-year period. METHOD.: A general practice cohort of 7123 patients from 18 practiceswas surveyed. Eight hundred and forty (12%) patients had beenoffered a heafth check within a 12-month period from September1992 and 621 (9%) received one. Two hundred and fifty patients(40%) were asked back for follow-up after their health check. RESULTS.: Over a 2-year period there was no difference in smoking cessation,alcohol consumption, weight loss nor the amount of exercisetaken between those who attended for a health check and thosewho did not. The food score chosen to assess dietary change(Oxcheck) showed a statistically significant 1.16-point risefor the whole sample over the survey period. There was a significantdifference in mean food score change between heafth check attendersand non-attenders (Mann-Whitney U test: P << 0.002). Maintenanceof dietary improvement over a 2-year period was not affectedby health check attendance. CONCLUSIONS.: This study confirms the low impact of health checks on the selfreported modification of cardiovascular risk factors and showsthat maintenance of appropriate health behaviour change is nomore likely in those who have received a health check. Keywords. Health promotion, general practice.     

Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study

BACKGROUND: Many patients with asthma or chronic obstructive pulmonary diseaseuse their medication inhalers incorrectly. General practitioners,pharmacists and other health care providers do not always havethe opportunity to instruct patients in correct inhaler technique. OBJECTIVE: To find out whether the inhaler technique and respiratory symptomsof patients can be improved after instruction by practice assistants. METHODS: Single blind, randomized intervention study in which 48 patientswho had been using a dry powder inhaler for at least one monthtook part. Their inhaler technique was videotaped on two visitswith a two-week interval between visits. The inhaler techniqueon the videos was subsequently scored by two experts on ninecriteria. At both visits the patients completed a questionnaireabout their respiratory symptoms. After the first video, 25patients were randomly chosen to receive instruction from oneof six practice assistants who had followed a one evening courseabout inhaler instruction, and who had been issued an instruction-set. RESULTS: The patients who received instruction had a significantly greaterreduction in number of mistakes at the second visit than thepatients who did not (P = 0.01). The instructed patients alsoreported less dyspnoea at the second visit (P = 0.03). No effectof instruction was found on wheezing, cough and sputum production. CONCLUSION: The inhaler technique of patients can be improved significantlyby the instruction of patients by trained practice assistants,possibly resulting in less dyspnoea. Keywords. Administration-inhalation, obstructive lung diseases, airways symptoms, patient-education, general practice.     

直肠息肉摘除对直肠癌预防的前瞻性评价

目的 评估直肠镜在人群中筛检效果,验证直肠息肉摘除能否阻断直肠癌的自然史,降低直肠癌的发病率及死亡率。方法 １９７７￣１９８０年间在海宁次对３０岁以上２３余万人群进行１５ｃｍ肠镜筛检,对检出的４０７６例肠息肉进行镜下摘除后定期肠镜随访。结果 肠息肉患者经２０年定期肠镜随访,共计肠镜随访到并摘除肠腺瘤９５２例次,非腺瘤性息肉４１７例次,另外还随检出肠癌２７例。直肠镜筛检验出的直肠癌的生存率显著高于非     

Childhood vulvovaginitis and vaginal discharge in general practice

OBJECTIVE.: This study aims to examine the aetiology, clinical featuresand response to treatment of childhood vulvovaginitis in generalpractice. METHOD.: A longitudinal survey of consecutive premenarchal patients presentingwith vulvovaginitis and/or vaginal discharge in the course ofnormal consultations with a general practitioner was conductedin a a semi-rural, group general practice with 11 000 patientsin Plymouth, UK. Forty-two premenarchal girls with vaginal inflammationor discharge were surveyed, with main outcome measures beingclinical evaluation, microbiological assessment of urine andvaginal swabs, and patients' and parents' assessments of resolutionand relapse of symptoms. RESULTS.: Non-specific vulvovaginitis with mixed bacterial flora, associatedwith poor hygiene and atrophic vaginal mucosa, was the commonestcause; specific bacteria were found in 10 out of 42 cases, includingsix of Streptococcus pyogenes. No candida was isolated. Treatmentwith topical oestrogen cream was effective only with mixed infection,oral antibiotics were effective in both mixed and single organisms.No evidence of sexual abuse nor foreign body was found. CONCLUSIONS.: Childhood vulvovaginitis is not uncommon in general practice,is usually associated with mixed growth of faecal organisms,and is seldom due to serious causes such as sexual abuse orforeign body. Keywords. Vulvovaginitis, vaginal discharge, children, general practice.     

Bowels: Beliefs and Behaviour

A postal questionnaire about knowledge, beliefs, and experiencesof bowel function was returned by 171 patients aged 55 yearsand over from a group general practice in London. Of the respondents,10% reported no predictable frequency of movement, a higherproportion being women than men; 79% believed that a daily movementis important and 90% that ‘regularity’ is necessaryfor good health; 14% were dissatisfied with their bowel habitsand 16% regularly self-treated; 95% gave reasonable definitionsof ‘regular’ and ‘diarrhoea’; a tenthwere unsure about the definition of ‘constipation’.Although 76% believed there were bowel symptoms which requireimmediate medical attention, 98% would in the first instancetreat themselves for constipation, 90% for diarrhoea, and 25%for rectal bleeding. To reduce delay in the diagnosis of colorectal cancer, it issuggested that consultations for disturbance of bowel functionbe encouraged among the middle-aged and the elderly. Doctorsshould examine such patients with the diagnosis of malignancyin mind.     

Secondary depression in weaned alcoholics: implications of Lesch's typology of chronic alcoholism

Schuckit (1983) described two types of alcohol-related depression:(1) the common type, in which secondary depression disappearswithout treatment within the first few weeks of abstinence;(2) a less frequent type, primary depression, requiring specifictreatment. It is difficult to anticipate whether an alcoholicpatient needs antidepressive treatment or whether depressionwill remit spontaneously. A potential guide to differentiatedepressed alcoholic patients who might need specific treatmentfor depression could be the typology of Lesch et al. (1990).Based on . . . [Full Text of this Article]ConclusionFOOTNOTESREFERENCES     

Dietary and exercise assessment in general practice

BACKGROUND: Diet and physical activity are important in many conditionsmanaged in primary care. Dietary and physical activity assessmentis complex, has inherent inaccuracies related to self-reporting,and is only a small part of a larger context of developing effectiveintervention in primary care. However, for personalized assessmentin routine clinical care, and for the assessment of differentintervention strategies in a general practice research setting,validated life-style assessment tools are needed. OBJECTIVE: We aimed to discuss the requirements for assessment tools andto identify feasible validated assessment instruments for usein primary care. METHODS: Potential tools were identified from a Medline search, UK ResearchIntelligence, and contact with groups known to be working inthe area. RESULTS: Several brief instruments assess mainly fat in the US diet butthe limited range of foods covered and the setting of studieslimits their generalizability. Only one tool developed for UKuse—‘DINE’, which scores total fat, fibreand unsaturated fat—was identified which is both feasibleand has documented reasonable validated characteristics. Evenfor this tool there are doubts about the validation ‘standard’.No diet or physical activity validation studies have used bothsubjects and health professionals from general practice settings. CONCLUSION: There are very few feasible and validated dietary or physicalactivity assessment tools for use in clinical care or researchin general practice, and doubts about the design and settingsof published validation studies. Further research is neededto validate and develop a range of feasible life-style assessmenttools with specified time and training requirements for usein primary care. Keywords. Nutrition assessment, primary health care, exercises.     

放置与未放置IUD子宫异常出血患者的子宫内膜病理变化对比分析

目的 探讨放置宫内节育器(IUD)后子宫异常出血患者子宫内膜病理变化.方法 选取2012年4月至2015年12月在青岛市黄岛区妇幼保健计生服务中心治疗的子宫异常出血患者318例,其中放置IUD患者186例,未放置IUD患者132例,比较各患者诊断性刮宫病理结果.结果 放置IUD患者子宫内膜病理示增殖期比例为39.25%,明显高于未放置IUD患者(χ2=23.195,P<0.05);放置IUD患者子宫内膜病理示单纯增生的比例为3.23%,明显低于未放置IUD患者(χ2=10.722,P<0.05);两组子宫肌瘤、子宫内膜息肉、子宫内膜炎及子宫内膜癌的比例比较差异无统计学意义(χ2值分别为0.011、0.828、1.550和0.030,均P>0.05);放置IUD组>40岁和≤40岁患者子宫内膜病理示增殖期、单纯增生、子宫肌瘤、子宫内膜息肉、子宫内膜炎及子宫内膜癌的比例比较差异无统计学意义(χ2值分别为0.776、0.095、0.035、0.037和0.923,均P>0.05);IUD放置年限≥5年和<5年患者子宫内膜病理示增殖期、单纯增生、子宫肌瘤、子宫内膜息肉、子宫内膜炎及子宫内膜癌的比例比较差异无统计学意义(χ2值分别为0.371、0.775、1.600、0.322和0.002,均P>0.05).不同类型IUD患者子宫内膜病理示增殖期、单纯增生、子宫肌瘤、子宫内膜息肉、子宫内膜炎及子宫内膜癌的比例比较差异无统计学意义(χ2值分别为0.019、2.386、0.401、0.746和2.386,均P>0.05).结论 IUD不会增加子宫内膜炎、子宫内膜息肉、子宫内膜异常增生、子宫肌瘤等的发病率;IUD是一种安全的避孕措施.     

The effect of a computer-generated patient-held medical record summary and/or a written personal health record on patients' attitudes, knowledge and behaviour concerning health promotion

OBJECTIVE: The aim of the study was to examine the effect of a computer-generatedpatient-held medical record summary (CHR) and/or a written personalhealth record (PHR) on patients' attitudes, knowledge and behaviourconcerning health promotion. METHOD: It was conducted in five general practices in Oxfordshire. Patientsaged 25–65 years in each practice were randomly assignedto receive either a CHR plus PHR, CHR only, PHR only, or nopersonal record. Patients were recruited by mail (one practice)or opportunistically by nurses (four practices). Health checkswere carried out using the randomly assigned record, which thepatient retained. Attitudes to patient-held records, and pre-and post-intervention knowledge and behaviour concerning healthpromotion, were assessed using questionnaires. Only those whoresponded to ‘before’ and ‘after’ questionnaireswere included in the analysis. RESULTS: A sample of 261 patients was obtained from mail recruitmentand 103 from opportunistic nurse recruitment. Patients receivinga CHR as part of mail recruitment were significantly more likelyto attend for a health check (P = 0.016). Those receiving bothPHR and CHR were more likely to keep (P = 0.014) and use (P= 0.029) the record. Those receiving PHR as part of the packageimproved their knowledge of health promotion and became moreaware of and more likely to change their life-style (P = 0.022). CONCLUSIONS: The effectiveness of a computer-generated patient-held healthsummary and an explanatory booklet together is greater thaneither separately in changing patients' knowledge attitudesand behaviour concerning health promotion. Keywords. Patient-held record, primary care, health promotion, computerized medical record.     

A general practice-based recruitment strategy for colorectal cancer screening

OBJECTIVE: To determine whether a screening recruitment strategy for first degree relatives of people with colorectal cancer is effective in enabling eligible relatives to request screening from their general practitioner (GP) and to assess acceptability to GPs and patients. METHODS: Thirty GPs, from 26 practices, and 303 of their patients aged over 50 who were first degree relatives of a person with colorectal cancer, participated in a randomised controlled trial of a GP-based recruitment strategy, in the Newcastle Area of New South Wales, Australia. RESULTS: The proportion of relatives requesting screening was statistically significantly higher in the intervention group than in the control group (18% compared to 4%, respectively; p = 0.01). CONCLUSIONS: Interest in the study by GPs was low, however for GPs who were involved, the recruitment strategy did prompt first degree relatives to discuss screening. The strategy may be even more effective when combined with other interventions such as a media campaign. The results may be generalizable to feasibility studies of general population screening for colorectal cancer in Australia. IMPLICATIONS: The results of this work are potentially informative to public health practice in Australia given the ensuing pilot programs of colorectal cancer screening.     

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

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

A randomized controlled trial of electromagnetic therapy in the primary care management of venous leg ulceration

OBJECTIVE: The aim was to establish the potential efficacy, tolerabilityand side-effect profile of electromagnetic therapy as an adjunctto conventional dressings in the treatment of venous leg ulcers. METHOD: A prospective, randomized, double blind controlled clinicaltrial was carried out in a dedicated leg ulcer clinic basedin one urban general practice. Nineteen patients with leg ulcersof confirmed venous aetiology were assessed. The main outcomemeasures were rate and scale of venous leg ulcer healing, changesin patient-reported pain levels, quality of life, degree ofmobility, side effect profile and acceptability to patientsand staff. RESULTS: Sixty-eight per cent of patients attending this dedicated clinicachieved improvements in the size of their ulcer (4, 21%, healedfully) and in reduced pain levels (P < 0.05) during the trial,despite the chronicity of ulcer histories. Patients treatedwith electromagnetic therapy at 800 Hz were found at day 50to have significantly greater healing (P < 0.05) and paincontrol (P < 0.05) than placebo therapy or treatment with600 Hz. All patients reported improved mobility at the end ofthe study. The electromagnetic therapy was well tolerated bypatients, with no differences between groups in reporting adverseevents, and proved acceptable to staff. CONCLUSION: Despite the small numbers in this pilot study, electromagnetictherapy provided significant gains in the healing of venousleg ulcers and reduction in pain. Keywords. Electromagnetic therapy, RCT, leg ulcers, primary care.     

Colorectal polyps in children. A study of 34 patients

AIM: To assess the frequency and the clinical features of polyps of the colon and rectum in children. METHODS: A total of 34 patients (20 boys and 14 girls, mean age: 5.4 years) were enrolled in this 14-years retrospective study. Diagnosis was done for almost all patients by colonoscopy (n=8) or recto-sigmoidoscopy (n= 19). After endoscopic polypectomy, polyp's type is determined by histological examination. RESULTS: Minimal and relapsing rectal bleeding was the most frequent finding of polyps of the colon and rectum (85.3%) followed by spontaneous emission of polyp (n=3), rectal prolapses (n=2), chronic constipation (n=1) and abdominal pain (n=1). The polyp was unique in all cases and with a mean size of 12 mm. The majority of polyps were localized in the rectum or sigmoid (97%) and were pediculate (81.2%). Endoscopic polypectomies concerned 26 polyps while two small polyps were left. Most of the polyps corresponded histologically to juvenile polyps (96.2%). The immediate post-op course was uneventful for 26 children. CONCLUSION: Our study suggests that rectal bleeding is the most frequent finding of polyps of the colon and rectum in childhood. Outcome after endoscopic polypectomy is good.     

Clinical features of colorectal cancer before emergency presentation: a population-based case-control study

OBJECTIVE: To identify the clinical features of colorectal cancer presenting as a surgical emergency. DESIGN: Population-based case-control study. SETTING: All general practices in Exeter Primary Care Trust, Devon, UK. Participants. 349 patients with colorectal cancer, 62 of these having an emergency presentation. Five randomly selected controls matched by age, sex and general practice for each case. DATA: The entire primary care record, from 24 months to 30 days before diagnosis, was coded using the International Classification of Primary Care-2. MAIN OUTCOME MEASURES: Symptom reporting by patients with emergency presentation of colorectal cancer compared with matched controls and non-emergency presentations. RESULTS: Eight features of colorectal cancer were associated with the 62 emergency presentations of colorectal cancer. 39 (63%) of patients had reported at least one symptom to their doctors a minimum of 30 days before the diagnosis. In multivariable analysis, three features remained independently associated with cancer: abdominal pain, odds ratio 6.2 (95% CI 2.8-14), P<0.001; loss of weight 3.4 (1.3-8.5), P=0.01; and diarrhoea 3.4 (1.2-5.7), P=0.02. When emergency presentations were compared with elective cases, abdominal pain was more common [interaction odds ratio 2.3 (1.6-3.3); P=0.047] and rectal bleeding less common [0.30 (0.08, 1.0); P=0.040]. CONCLUSION: The majority of patients destined to have an emergency presentation of colorectal cancer have reported symptoms of their cancer to their doctor well before the emergency. Some emergency presentations should therefore be preventable.