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1.
Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule
J?rg Haasenritter Stefan B?sner Paul Vaucher Lilli Herzig Monika Heinzel-Gutenbrunner Erika Baum Norbert Donner-Banzhoff 《The British journal of general practice》2012,62(599):e415-e421
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. 相似文献2.
Hannah V Thornton Peter S Blair Andrew M Lovering Peter Muir Alastair D Hay 《The British journal of general practice》2015,65(631):e69-e81
Background
Antibiotic prescribing decisions for respiratory tract infection (RTI) in primary care could be improved if clinicians could target bacterial infections. However, there are currently no evidence-based diagnostic rules to identify microbial aetiology in children presenting with acute RTIs.Aim
To analyse evidence of associations between clinical symptoms or signs and detection of microbes from the upper respiratory tract (URT) of children with acute cough.Design and setting
Systematic review and meta-analysis.Method
A literature search identified articles reporting relationships between individual symptoms and/or signs, and microbes detected from URT samples. Associations between pathogens and symptoms or signs were summarised, and meta-analysis conducted where possible.Results
There were 9984 articles identified, of which 28 met inclusion criteria. Studies identified 30 symptoms and 41 signs for 23 microbes, yielding 1704 potential associations, of which only 226 (13%) have presently been investigated. Of these, relevant statistical analyses were presented for 175 associations, of which 25% were significant. Meta-analysis demonstrated significant relationships between respiratory syncytial virus (RSV) detection and chest retractions (pooled odds ratio [OR] 1.9, 95% confidence interval [CI] = 1.6 to 2.3), wheeze (pooled OR 1.7, 95% CI = 1.5 to 2.0), and crepitations/crackles (pooled OR 1.7, 95% CI = 1.3 to 2.2).Conclusions
There was an absence of evidence for URT pathogens other than RSV. The meta-analysis identified clinical signs associated with RSV detection, suggesting clinical presentation may offer some, albeit poor, diagnostic value. Further research is urgently needed to establish the value of symptoms and signs in determining microbiological aetiology and improve targeting of antibiotics in primary care. 相似文献3.
Elizabeth A Shephard Richard D Neal Peter Rose Fiona M Walter Emma J Litt William T Hamilton 《The British journal of general practice》2015,65(631):e106-e113
Background
Patients with myeloma experience the longest diagnostic delays compared with patients with other cancers in the UK; 37% are diagnosed through emergency presentations.Aim
To identify and quantify the risk of myeloma from specific clinical features reported by primary care patients.Design and setting
Matched case–control study using General Practice Research Database primary care electronic records.Method
Putative clinical features of myeloma were identified and analysed using conditional logistic regression. Positive predictive values (PPVs) were calculated for the consulting population.Results
A total of 2703 patients aged ≥40 years, diagnosed with myeloma between 2000 and 2009, and 12 157 age, sex, and general practice-matched controls were identified. Sixteen features were independently associated with myeloma: hypercalcaemia, odds ratio 11.4 (95% confidence interval [CI] = 7.1 to 18), cytopenia 5.4 (95% CI = 4.6 to 6.4), raised inflammatory markers 4.9 (95% CI = 4.2 to 5.8), fracture 3.1 (95% CI = 2.3 to 4.2), raised mean corpuscular volume 3.1 (95% CI = 2.4 to 4.1), weight loss 3.0 (95% CI = 2.0 to 4.5), nosebleeds 3.0 (95% CI = 1.9 to 4.7), rib pain 2.5 (95% CI = 1.5 to 4.4), back pain 2.2 (95% CI = 2.0 to 2.4), other bone pain 2.1 (95% CI = 1.4 to 3.1), raised creatinine 1.8 (95% CI = 1.5 to 2.2), chest pain 1.6 (95% CI = 1.4 to 1.8), joint pain 1.6 (95% CI = 1.2 to 2.2), nausea 1.5 (95% CI = 1.1 to 2.1), chest infection 1.4 (95% CI = 1.2 to 1.6), and shortness of breath 1.3 (95% CI = 1.1 to 1.5). Individual symptom PPVs were generally <1%, although were >10% for some symptoms when combined with leucopenia or hypercalcaemia.Conclusion
Individual symptoms of myeloma in primary care are generally low risk, probably explaining diagnostic delays. Once simple primary care blood tests are taken, risk estimates change. Hypercalcaemia and leucopenia are particularly important abnormalities, and coupled with symptoms, strongly suggest myeloma. 相似文献4.
5.
Ana Ruigómez Elvira L Massó-González Saga Johansson Mari-Ann Wallander Luis A García-Rodríguez 《The British journal of general practice》2009,59(560):e78-e86
Background
Ischaemic heart disease (IHD) can be excluded in the majority of patients with unspecific chest pain. The remainder have what is generally referred to as non-cardiac chest pain, which has been associated with gastrointestinal, neuromusculoskeletal, pulmonary, and psychiatric causes.Aim
To assess morbidity and mortality following a new diagnosis of non-specific chest pain in patients without established IHD.Design of study
Population-based cohort study with nested case-control analysis.Setting
UK primary care practices contributing to the General Practice Research Database.Method
Patients aged 20–79 years with chest pain who had had no chest pain consultation before 2000 and no IHD diagnosis before 2000 or within 2 weeks after the index date were selected from the General Practice Research Database. The selected 3028 patients and matched controls were followed-up for 1 year.Results
The incidence of chest pain in patients without established IHD was 12.7 per 1000 person-years. In the year following the index date, patients who had chest pain but did not have established IHD were more likely than controls to receive a first IHD diagnosis (hazard ratio [HR] = 18.2, 95% confidence interval [CI] = 11.6 to 28.6) or to die (HR = 2.3, 95% CI = 1.3 to 4.1). Patients with chest pain commonly had a history of gastro-oesophageal reflux disease (GORD; odds ratio [OR] = 2.0, 95% CI = 1.5 to 2.7) or went on to be diagnosed with GORD (risk ratio 4.5, 95% CI = 3.1 to 6.4).Conclusion
Patients with chest pain but without established IHD were found to have an increased risk of being diagnosed with IHD. Chest pain in patients without established IHD was also commonly associated with GORD. 相似文献6.
7.
Stefan B?sner J?rg Haasenritter Maren Abu Hani Heidi Keller Andreas C. S?nnichsen Konstantinos Karatolios Juergen R. Schaefer Erika Baum Norbert Donner-Banzhoff 《Croatian medical journal》2010,51(3):243-249
Aim
To estimate how accurately general practitioners’ (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result.Methods
During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients’ visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs’ diagnoses were calculated.Results
GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing.Conclusions
GPs’ evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.When general practitioners (GP) treat patients with chest pain, they have to decide whether there is a serious underlying pathology requiring urgent action or whether a “wait and see” strategy can be applied. Chest pain can be caused by a wide range of different illnesses, among which life-threatening cardiac disease is of the greatest immediate concern (1,2). However, chest pain is caused by coronary heart disease (CHD) in only around 12-15% of primary care patients (3-5). For most of patients with chest pain, the GP remains the main point of entry into the health care system. The effectiveness of GPs’ gatekeeping role, ie, identifying patients with CHD and protecting patients from over-diagnosis and treatment, depends on the accuracy of their provisional diagnosis after taking the patient’s history and performing the basic clinical examination. So far, a limited number of studies have addressed this question (6-10). There is a need for additional data on GPs’ management decisions after assumed CHD diagnosis, derived from a large and consecutively recruited sample of chest pain patients in primary care.In this study, we aimed to investigate how accurately GPs’ assessed the probability of CHD in patients presenting with chest pain and to analyze management decisions taken as a result. 相似文献8.
J?rg Haasenritter Norbert Donner-Banzhoff Stefan B?sner 《The British journal of general practice》2015,65(640):e748-e753
Background
The Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain.Aim
To investigate whether using the rule adds to the GP’s clinical judgement.Design and setting
A comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice.Method
Three diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP’s clinical judgement aided by the MHS. Their accuracy was compared with the GPs’ unaided clinical judgement.Results
Sensitivity and specificity of the GPs’ unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = −2.4 to 19.6) and the specificity was similar (difference −0.4%, 95% CI = −5.3 to 4.5); the sensitivity of the triage was similar (difference −1.5%, 95% CI = −9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = −6.9 to 23.0 and 5.8%, 95% CI = −1.6 to 13.2, respectively).Conclusion
Using the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice. 相似文献9.
William Hamilton Jacqueline Barrett Sally Stapley Debbie Sharp Peter Rose 《The British journal of general practice》2015,65(637):e516-e522
Background
How metastatic cancer initially presents is largely unknown.Aim
To identify clinical features of metastatic cancer in primary care.Design and setting
Case–control study in 11 general practices in Devon, UK.Method
Cases of patients who had died with metastatic breast, colorectal, or prostate cancer were selected. In addition, two control groups were formed of patients with the same primary cancer but without metastases (‘cancer controls’) and patients without cancer (‘healthy controls’), matched for age, sex, and practice. All symptoms, signs, and laboratory test abnormalities in the year before metastasis were identified. The primary analysis used conditional logistic regression.Results
In total, 162 cases, 152 cancer controls, and 145 healthy controls were studied. Common symptoms associated with cancer were: vomiting, 40 (25%) cases and 13 (9%) cancer controls (multivariable odds ratio [OR] 3.5, 95% confidence interval [CI] = 1.3 to 9.4, P = 0.011); low back pain, 38 (24%) cases and 17 (11%) cancer controls (OR 2.5, 95% CI = 1.1 to 5.6, P = 0.032); loss of appetite, 32 (20%) cases and nine (6%) cancer controls (OR 4.0, 95% CI = 1.2 to 13.2, P = 0.021); and shoulder pain, 27 (17%) cases and eight (5%) cancer controls (OR 5.3, 95% CI = 1.6 to 18, P = 0.007). Groin pain was uncommon, but strongly associated (16 [10%] cases and one [1%] cancer control [OR 10, 95% CI = 1.2 to 82, P = 0.032]), as was pleural disease (nine [6%] cases and one [1%] cancer control [OR 10, 95% CI = 1.1 to 92, P = 0.038]).Conclusion
These features of disseminated cancer have been reported before in studies from secondary care, but the scarcity of specific symptoms (such as local pain) and the fairly common occurrence of non-specific symptoms (vomiting and loss of appetite) is important and may explain delays in the diagnosis of metastases. 相似文献10.
Rachel M Dommett Theresa Redaniel Michael CG Stevens Richard M Martin William Hamilton 《The British journal of general practice》2013,63(606):e22-e29
Background
Guidelines describing symptoms in children that should alert GPs to consider cancer have been developed, but without any supporting primary-care research.Aim
To identify symptoms and signs in primary care that strongly increase the likelihood of childhood cancer, to assist GPs in selection of children for investigation.Design and setting
A population-based case-control study in UK general practice.Method
Using electronic primary care records from the UK General Practice Research Database, 1267 children aged 0–14 years diagnosed with childhood cancer were matched to 15 318 controls. Clinical features associated with subsequent diagnosis of cancer were identified using conditional logistic regression, and likelihood ratios and positive predictive values (PPVs) were estimated for each.Results
Twelve symptoms were associated with PPVs of ≥0.04%, which represents a greater than tenfold increase in prior probability. The six symptoms with the highest PPVs were pallor (odds ratio, OR = 84; PPV = 0.41% (95% confidence interval [CI] = 0.12% to 1.34%), head and neck masses (OR = 17; PPV = 0.30%; 95% CI = 0.10% to 0.84%), masses elsewhere (OR = 22; PPV = 0.11%; 95% CI = 0.06% to 0.20%), lymphadenopathy (OR = 10; PPV = 0.09%; 95% CI = 0.06% to 0.13%), symptoms/signs of abnormal movement (OR = 16; PPV = 0.08%; 95% CI = 0.04% to 0.14%), and bruising (OR = 12; PPV = 0·08%; 95% CI = 0.05% to 0.13%). When each of these 12 symptoms was combined singly with at least three consultations in a 3-month period, the probability of cancer was between 11 and 76 in 10 000.Conclusion
Twelve features of childhood cancers were identified, each of which increased the risk of cancer at least tenfold. These symptoms, particularly when combined with multiple consultations, warrant careful evaluation in general practice. 相似文献11.
Elizabeth A Shephard Richard D Neal Peter W Rose Fiona M Walter William T Hamilton 《The British journal of general practice》2015,65(634):e281-e288
Background
Non-Hodgkin lymphoma (NHL) is the sixth most common cancer in the UK; approximately 35 people are diagnosed and 13 die from the disease daily.Aim
To identify the primary care clinical features of NHL and quantify their risk in symptomatic patients.Design and setting
Matched case–control study using Clinical Practice Research Datalink patient records.Method
Putative clinical features of NHL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs).Results
A total of 4362 patients aged ≥40 years, diagnosed with NHL between 2000 and 2009, and 19 468 age, sex, and general practice-matched controls were studied. Twenty features were independently associated with NHL. The five highest risk symptoms were lymphadenopathy, odds ratio (OR) 263 (95% CI = 133 to 519), head and neck mass not described as lymphadenopathy OR 49 (95% CI = 32 to 74), other mass OR 12 (95% CI = 10 to 16), weight loss OR 3.2 (95% CI = 2.3 to 4.4), and abdominal pain OR 2.5 (95% CI = 2.1 to 2.9). Lymphadenopathy has a PPV of 13% for NHL in patients ≥60 years. Weight loss in conjunction with repeated back pain or raised gamma globulin had PPVs >2%.Conclusion
Unexplained lymphadenopathy in patients aged ≥60 years produces a very high risk of NHL in primary care. These patients warrant urgent investigation, potentially sooner than 6 weeks from initial presentation where the GP is particularly concerned. 相似文献12.
Sarah Walker Chris Hyde William Hamilton 《The British journal of general practice》2013,63(614):e643-e648
Background
Uterine cancer is the fourth most common cancer in women in the UK, with approximately 7700 new diagnoses and 1700 deaths annually.Aim
To identify and quantify features of uterine cancer in primary care.Design and setting
Case–control study using electronic primary care records in primary care in the UK.Method
Putative features of uterine cancer were identified in the year before diagnosis, and odds ratios (ORs) calculated using conditional logistic regression. Positive predictive values (PPVs) were calculated for women who consulted.Results
A total of 2732 women aged ≥40 years with uterine cancer between 2000 and 2009, and 9537 age-, sex- and practice-matched controls were selected from the General Practice Research Database. The median age at diagnosis was 67 years. Nine features were significantly associated with uterine cancer: postmenopausal bleeding (OR = 160; 95% confidence interval [CI] = 100 to 240), excessive vaginal bleeding (OR = 22; 95% CI = 12 to 42), irregular menstruation (OR = 42; 95% CI = 27 to −63), vaginal discharge (OR = 14; 95% CI = 10 to 21), haematuria (OR = 8.7; 95% CI = 5.0 to 15), abdominal pain (OR = 2.0; 95% CI = 1.4 to 2.8), low haemoglobin (OR = 2.1; 95% CI = 1.5 to 2.9), raised platelets (OR = 1.5; 95% CI = 1.0 to 2.3), and raised glucose (OR = 1.4; 95% CI = 1.1 to 1.8); all P<0.01, other than raised platelets, P = 0.05 and raised glucose, P = 0.02. In the year before diagnosis, 1725 (63%) cases had a record of abnormal vaginal bleeding compared to 135 (1%) controls. The PPV of uterine cancer with postmenopausal bleeding was 4%, and was higher in women with multiple or repeated symptoms.Conclusion
This study confirms the importance of several features, particularly postmenopausal bleeding, for uterine cancer. Haematuria is an important risk marker. The results of this study may inform GPs in the selection of women for investigation and should assist the NICE in their update of GP referral guidance. 相似文献13.
Tanya Ali Haj-Hassan Matthew J Thompson Richard T Mayon-White Nelly Ninis Anthony Harnden Lindsay FP Smith Rafael Perera David C Mant 《The British journal of general practice》2011,61(584):e97-e104
Background
Symptoms are part of the initial evaluation of children with acute illness, and are often used to help identify those who may have serious infections. Meningococcal disease is a rapidly progressive infection that needs to be recognised early among children presenting to primary care.Aim
To determine the diagnostic value of presenting symptoms in primary care for meningococcal disease.Design of study
Data on a series of presenting symptoms were collected using a parental symptoms checklist at point of care for children presenting to a GP with acute infection. Symptom frequencies were compared with existing data on the pre-hospital features of 345 children with meningococcal disease.Setting
UK primary care.Method
The study recruited a total of 1212 children aged under 16 years presenting to their GP with an acute illness, of whom 924 had an acute self-limiting infection, including 407 who were reported by parents to be febrile. Symptom frequencies were compared with those reported by parents of 345 children with meningococcal disease. Main outcome measures were diagnostic characteristics of individual symptoms for meningococcal disease.Results
Five symptoms have clinically useful positive likelihood ratios (LR+) for meningococcal disease: confusion (LR+ = 24.2, 95% confidence interval [CI] = 11.5 to 51.3), leg pain (LR+ = 7.6, 95% CI = 4.9 to 11.9), photophobia (LR+ = 6.5, 95% CI = 3.8 to 11.0), rash (LR+ = 5.5, 95% CI = 4.3 to 7.1), and neck pain/stiffness (LR+ = 5.3, 95% CI = 3.5 to 8.3). Cold hands and feet had limited diagnostic value (LR+ = 2.3, 95% CI = 1.9 to 3.0), while headache (LR+ = 1.0, 95% CI = 0.8 to 1.3), and pale colour (LR+ = 0.3, 95% CI = 0.2 to 0.5) did not discriminate meningococcal disease in children.Conclusion
This study confirms the diagnostic value of classic ‘red flag’ symptoms of neck stiffness, rash, and photophobia, but also suggests that the presence of confusion or leg pain in a child with an unexplained acute febrile illness should also usually prompt a face-to-face assessment to exclude meningococcal disease. Telephone triage systems and primary care clinicians should consider these as ‘red flags’ for serious infection. 相似文献14.
Elizabeth A Shephard Richard D Neal Peter W Rose Fiona M Walter William T Hamilton 《The British journal of general practice》2015,65(634):e289-e294
Background
In the UK, approximately five people are diagnosed with Hodgkin lymphoma (HL) daily. One-tenth of diagnoses are in those aged >75 years.Aim
To establish a symptom profile of HL and quantify their risk in primary care patients aged ≥40 years.Design and setting
Matched case–control study using Clinical Practice Research Datalink patient records.Method
Putative clinical features of HL were identified in the year before diagnosis. Results were analysed using conditional logistic regression and positive predictive values (PPVs) calculated for the consulting population.Results
Two-hundred and eighty-three patients aged ≥40 years, diagnosed with HL between 2000 and 2009, and 1237 age, sex, and general practice-matched participants were studied. Six features were independently associated with HL: lymphadenopathy (OR 280, 95% confidence interval [CI] = 25 to 3100), head and neck mass not described as lymphadenopathy (OR 260, 95% CI = 21 to 3200), other mass (OR 12, 95% CI = 4.4 to 35), thrombocytosis (OR 6.0, 95% CI = 2.6 to 14), raised inflammatory markers (OR 5.2, 95% CI = 3.0 to 9.0), and low full blood count (OR 2.8, 95% CI = 1.6 to 4.8). Lymphadenopathy per se has a positive predictive value (PPV) of 5.6% for HL in patients aged ≥60 years.Conclusion
Consistent with secondary care findings, lymphadenopathy is the clinical feature with the highest risk of HL in primary care and warrants urgent investigation. 相似文献15.
Paul Little FD Richard Hobbs David Mant Cliodna AM McNulty Mark Mullee 《The British journal of general practice》2012,62(604):e787-e794
Background
Management of pharyngitis is commonly based on features which are thought to be associated with Lancefield group A beta-haemolytic streptococci (GABHS) but it is debatable which features best predict GABHS. Non-group A strains share major virulence factors with group A, but it is unclear how commonly they present and whether their presentation differs.Aim
To assess the incidence and clinical variables associated with streptococcal infections.Design and setting
Prospective diagnostic cohort study in UK primary care.Method
The presence of pathogenic streptococci from throat swabs was assessed among patients aged ≥5 years presenting with acute sore throat.Results
Pathogenic streptococci were found in 204/597 patients (34%, 95% CI = 31 to 38%): 33% (68/204) were non-group A streptococci, mostly C (n = 29), G (n = 18) and B (n = 17); rarely D (n = 3) and Streptococcus pneumoniae (n = 1). Patients presented with similar features whether the streptococci were group A or non-group A. The features best predicting A, C or G beta-haemolytic streptococci were patient’s assessment of severity (odds ratio [OR] for a bad sore throat 3.31, 95% CI = 1.24 to 8.83); doctors’ assessment of severity (severely inflamed tonsils OR 2.28, 95% CI = 1.39 to 3.74); absence of a bad cough (OR 2.73, 95% CI = 1.56 to 4.76), absence of a coryza (OR 1.54, 95% CI = 0.99 to 2.41); and moderately bad or worse muscle aches (OR 2.20, 95% CI = 1.41 to 3.42).Conclusion
Non-group A strains commonly cause streptococcal sore throats, and present with similar symptomatic clinical features to group A streptococci. The best features to predict streptococcal sore throat presenting in primary care deserve revisiting. 相似文献16.
Chadambuka A Chimusoro A Maradzika JC Tshimanga M Gombe NT Shambira G 《African health sciences》2011,11(4):535-542
Background
Sexually transmitted infections (STIs) remain a major public health problem in Zimbabwe. In Zvishavane, STI increased from 66 per 1,000 in 2002 to 97 per 1,000 in 2005, a 31% increase in cases.Objective
To determine the factors associated with contracting sexually transmitted infections (STI) among patients in Zvishavane.Methods
A frequency matched case control study was conducted. Cases were persons above 15 years diagnosed with STI at three health facilities in Zvishavane urban. Controls were patients who visited the same facilities for other ailments. We interviewed 77 cases and 154 controls.Results
Both cases and controls were knowledgeable about STI. Risk factors for men included sex under the influence of alcohol OR=7.11 (95% CI 2.42–20.85), relationships less than one year, OR= 9.33 (95% CI 3.53–24.70), no condom use at first intercourse OR=5.17 (95% CI 1.64–16.25) and paying for sex OR= 23.65 (95% CI 6.23–89.69). For females the risk factors were non-use of condom at first intercourse OR=2.49 (95% CI 1.02–6.04) and relationships less than one year OR=3.19 (95% CI 1.41–7.23).Significant differences in attitudes were evident among cases and controls.Conclusion
Knowledge of STI did not provide protection from STI diagnosis. Limiting the number of partners, consistent condom use, and fidelity are important for both men and women. 相似文献17.
Jamie Brown Robert West Colin Angus Emma Beard Alan Brennan Colin Drummond Matthew Hickman John Holmes Eileen Kaner Susan Michie 《The British journal of general practice》2016,66(642):e1-e9
Background
Brief interventions have a modest but meaningful effect on promoting smoking cessation and reducing excessive alcohol consumption. Guidelines recommend offering such advice opportunistically and regularly but incentives vary between the two behaviours.Aim
To use representative data from the perspective of patients to compare the prevalence and characteristics of people who smoke or drink excessively and who receive a brief intervention.Design and setting
Data was from a representative sample of 15 252 adults from household surveys in England.Method
Recall of brief interventions on smoking and alcohol use, sociodemographic information, and smoking and alcohol consumption patterns were assessed among smokers and those who drink excessively (AUDIT score of ≥8), who visited their GP surgery in the previous year.Results
Of 1775 smokers, 50.4% recalled receiving brief advice on smoking in the previous year. Smokers receiving advice compared with those who did not were more likely to be older (odds ratio [OR] 17-year increments 1.19, 95% confidence interval [CI] =1.06 to 1.34), female (OR 1.35, 95% CI =1.10 to 1.65), have a disability (OR 1.44, 95% CI = 1.11 to 1.88), have made more quit attempts in the previous year (compared with no attempts: one attempt, OR 1.65, 95% CI = 1.32 to 2.08; ≥2 attempts, OR 2.02, 95% CI =1.49 to 2.74), and have greater nicotine dependence (OR 1.17, 95% CI =1.05 to 1.31) but were less likely to have no post-16 qualifications (OR 0.81, 95% CI = 0.66 to 1.00). Of 1110 people drinking excessively, 6.5% recalled receiving advice in their GP surgery on their alcohol consumption in the previous year. Those receiving advice compared with those who did not had higher AUDIT scores (OR 1.17, 95% CI =1.12 to 1.23) and were less likely to be female (OR 0.44, 95% CI = 0.23 to 0.87).Conclusion
Whereas approximately half of smokers in England visiting their GP in the past year report having received advice on cessation, <10% of those who drink excessively report having received advice on their alcohol consumption. 相似文献18.
Sarah Walker Chris Hyde William Hamilton 《The British journal of general practice》2014,64(629):e788-e793
Background
Breast cancer is the most common cancer in the UK. GPs are encouraged to refer all women whose symptoms may represent cancer, rather than selecting those at highest risk.Aim
To identify and quantify features of breast cancer in primary care.Design and setting
A UK case–control study using the Clinical Practice Research Database (CPRD).Method
Possible features of breast cancer were identified in the year before diagnosis, and odds ratios calculated using conditional logistic regression. Positive predictive values (PPVs) were estimated for consulting women.Results
A total of 3994 women aged ≥40 years with breast cancer between 2000 and 2009, and 16 873 age-, sex-, and practice-matched controls were studied. Median age at diagnosis was 63 years (interquartile range 55–74 years). Four features were significantly associated with breast cancer: breast lump (odds ratio [OR] 110; 95% confidence interval [CI] = I88 to150), breast pain (OR = 4.2; 95% CI = 3.0 to 6.0), nipple retraction (OR = 26; 95% CI = 10 to 64), nipple discharge (OR = 19; 95% CI = 8.6 to 41): all P-values <0.01. In the year before diagnosis, 1762 (44%) of cases had a breast lump compared with 132 (0.8%) controls. The PPV of breast cancer with a breast lump was 4.8% in women aged 40–49 years, rising to 48% in women aged >70 years. PPVs were lower in women who also reported breast pain.Conclusion
Generally, the figures support current referral practice. However, the low likelihood of cancer for all the non-lump symptoms means that the current guidance recommends investigation for possible cancer at a more liberal risk threshold than for other cancers. Although supported by patients, this may not meet current NHS criteria for cost–benefit. 相似文献19.
Alex Dregan Henrik M?ller Judith Charlton Martin C Gulliford 《The British journal of general practice》2013,63(617):e807-e812
Background
Alarm symptom presentations are predictive of cancer diagnosis but may also be associated with cancer survival.Aim
To evaluate diagnostic time intervals, and consultation patterns after presentation with alarm symptoms, and their association with cancer diagnosis and survival.Design and setting
Cohort study using the Clinical Practice Research Database, with linked Cancer Registry data, in 158 general practices.Method
Participants included those with haematuria, haemoptysis, dysphagia, and rectal bleeding or urinary tract cancer, lung cancer, gastro-oesophageal cancer, and colorectal cancer.Results
The median (interquartile range) interval in days from first symptom presentation to the corresponding cancer diagnosis was: haematuria and urinary tract cancer, 59 (28–109); haemoptysis and lung cancer, 35 (18–89); dysphagia and gastro-oesophageal cancer, 25 (12–48); rectal bleeding and colorectal cancer, 49 (20–157). Three or more alarm symptom consultations were associated with increased odds of diagnosis of urinary tract cancer (odds ratio [OR] 1.84, 95% CI = 1.50 to 2.27), lung cancer (OR = 1.76, 95% CI = 1.07 to 2.90) and gastro-oesophageal cancer (OR = 2.17, 95% CI = 1.48 to 3.19). Longer diagnostic intervals were associated with increased mortality only for urinary tract cancer (hazard ratio 2.23, 95% CI = 1.35 to 3.69). Patients with no preceding alarm symptom had shorter survival from diagnosis of urinary tract, lung or colorectal cancer than those presenting with a relevant alarm symptom.Conclusion
After alarm symptom presentation, repeat consultations are associated with cancer diagnoses. Longer diagnostic intervals appeared to be associated with a worse prognosis for urinary tract cancer only. Mortality is higher when cancer is diagnosed in the absence of alarm symptoms. 相似文献20.
Margaret P Astin Tanimola Martins Nicky Welton Richard D Neal Peter W Rose William Hamilton 《The British journal of general practice》2015,65(639):e677-e691