The economic and quality-of-life benefits of Helicobacter pylori eradication in chronic duodenal ulcer disease--a community-based study.

A policy of Helicobacter pylori eradication in patients with duodenal ulceration on long-term acid-suppressing therapy was evaluated in a prospective study amongst a general practice population, with particular reference to economic and quality-of-life benefits. One hundred and sixty-eight patients on long-term acid-suppressing therapy had chronic duodenal ulcer disease of whom 88 were eligible for the study; 45 patients attended for review, with 42 testing positive for H pylori (as assessed by 13C-urea breath test). The median duration of acid-suppressing therapy was six years (maximum 15 years); 47.6% of the patients were using additional antacids and 80.9% still experienced epigastric discomfort. Two-thirds (28/42) of the patients eradicated H pylori. Successful eradication was associated with a highly significant reduction in all symptoms. At 12 months follow-up, heartburn had decreased from 28.7% to 7.1%, epigastric discomfort from 75% to 3.6%, nausea from 32.1% to 0% and wind from 50% to 0%. Of the patients that eradicated H pylori 96.4% reported an improvement in their general health compared to none of those that remained H pylori positive. Successful H pylori eradication therapy scored higher on satisfaction ratings than long-term acid-suppressing therapy. Eradication of H pylori resulted in 27/28 patients being able to discontinue acid-suppressing therapy, representing a 5.8% reduction in the use of such drugs per year in the local general practice population. A policy of H pylori eradication in chronic duodenal ulcer disease reduces the use of long-term acid-suppression therapy in general practice. This has important financial implications as well as offering considerable symptomatic benefits to the patients and improving their quality of life.     

北京市非瓣膜心房颤动病人日常抗血栓治疗现况分析

目的 了解北京市非瓣膜心房颤动（房颤）病人日常抗血拴治疗现状,发现房颤病人脑卒中预防存在的问题。方法从北京市城8区（东城区、西城区、海淀区、朝阳区、崇文区、宣武区、石景山区、丰台区）选择8所三级医院和7所二级医院（社区卫生服务中心）。由内科医生对门诊或病房非瓣膜房颤病人采取统一问卷调查。结果 583例病人中75％来源于门诊。其中64．3％来源于三级医院,35．7％来源于社区卫生服务中心。18．9％房颤病人服用华法林,其中39．1％国际标准化测量值（INR）控制在2．0～3．0。68．2％病人华法林服用时间在1年以内。5．7％病人曾经服用华法林。59．3％房颤病人服用阿司匹林,其中85．7％剂量在76～150mg／d,无一例剂量达到325mg／d。18．9％房颤病人未接受任何抗凝治疗。房颤病人不服用华法林的主要原因来自两方面：78．6％病人没有获得抗凝建议,75％以上病人缺乏抗凝知识。房颤病人卒中患病率22．8％,服用华法林者脑卒中患病率22．0％,服用阿司匹林者脑卒中患病率为24．3％,不采取任何措施者脑卒中患病率为21．3％,脑卒中患病率差异无统计学意义（χ^2=1．09,P=0．58）。结论 北京非瓣膜房颤病人抗凝治疗率低于抗血小板治疗率,华法林服用率在我国处于较高水平,但服用时间短,效果欠佳。脑卒中高危房颤病人阿司匹林服用率过高,剂量偏低。提高房颤病人抗凝治疗一方面要改变医生的行为,一方面提高病人抗凝治疗相关知识及治疗依从性。     

Canadian atrial fibrillation anticoagulation study: were the patients subsequently treated with warfarin? Canadian Atrial Fibrillation Anticoagulation Study Group.

OBJECTIVE: To determine the effect of the results of clinical trials on the behaviour of patients and physicians, the authors ascertained the proportion of patients participating in the Canadian Atrial Fibrillation Anticoagulation (CAFA) study who started or continued warfarin therapy at the end of the study and identified factors affecting the decision to use or not use warfarin. The CAFA study was a double-blind, randomized, placebo-controlled, multicentre study to evaluate the efficacy of warfarin in preventing stroke among patients with nonrheumatic atrial fibrillation. Recruitment and follow-up were stopped early because two other similar studies had shown a decrease in the rate of stroke among patients treated with warfarin. DESIGN: Mail survey 21 months after the end of the study. PARTICIPANTS: The personal physicians of 336 patients who had participated in the CAFA study. OUTCOME MEASURES: Type of antithrombotic therapy the patients had received since the CAFA study ended for patients who were not receiving warfarin, the reasons they were not. RESULTS: Questionnaires concerning 254 (76%) of the patients who had participated in the study were returned. Since the end of the CAFA study, 153 (60%) of these patients had been treated continually with warfarin, 14 (6%) had been treated with warfarin but had subsequently stopped taking it, 59 (23%) had taken acetylsalicylic acid (ASA) continually, 5 (2%) had been taking ASA but had subsequently stopped taking it, and 23 (9%) had not taken either drug. The responding physicians stated that 58 (67%) of the patients who were not treated with warfarin did not wish to take the drug. The patients who had received warfarin during the CAFA trial were more likely to be treated with warfarin after the trial (75%) than were those who had received a placebo (56%) (p = 0.001). The probability of the patients' being treated with warfarin also depended on which study centre they had been treated in (p = 0.001). CONCLUSIONS: Of the patients in the CAFA study for whom questionnaires were received, only 167 (66%) had been treated with warfarin after the end of the study. The patients were more likely to have been treated with warfarin after the study if they had received warfarin during the study. The positive results of clinical trials, on their own, are not enough to fully change the behaviour of patients and physicians.     

胃镜下药物喷洒配合抑酸抗炎对消化性溃疡的效果观察

目的探讨胃镜下药物喷洒配合抑酸抗炎类药物对消化性溃疡的治疗效果。方法选取该院2008年8月—2009年7月门诊或住院部收治的消化性溃疡患者102例,随机分为对照组与观察组,对照组采取抑酸抗炎类药物治疗,观察组在此基础上于胃镜下喷洒云南白药和珍珠粉,观察两组患者临床治疗效果。结果观察组有效率为96.08%,明显高于对照组（P〈0.05）;观察组治疗后3年复发率均明显低于对照组,两组比较差异有统计学意义（P〈0.05）。结论胃镜下药物喷洒配合抑酸抗炎类药物治疗消化性溃疡疗效确切,可有效降低复发率,值得临床推广和应用。     

Patterns of medical drug use - a community focus.

The pattern and extent of medical use of drugs was examined by survey in a rural Ontario community (Smithville) and a suburban (Burlington) family practice. Changes in established patterns of drug use that occur after the introduction of a nurse practitioner were also examined in the suburban practice. In both surveys 60% of respondents were using at least one medication and 30% were taking at least one medication prescribed or suggested by a doctor. There were consistently high rates of use of nonprescribed drugs at all ages, especially among females. Vitamins and tonics were the most commonly used drugs, and were taken by 25 to 28% of the respondents, 40% of whom used them on the advice of a physician. From 8.8 to 10.5% of respondents used sedatives or tranquillizers, and reduction in the prescribed use of these drugs was found among patients managed by the nurse practitioners. Self-medication is apparently unrelated to the frequency of medical consultation.     

Prescription information leaflets: a pilot study in general practice

Leaflets containing information about medicines were issued to 56 patients prescribed penicillins and 43 patients prescribed non-steroidal anti-inflammatory drugs. The patients were interviewed between four and 10 days later and their responses compared with those of 65 patients prescribed penicillin and 33 prescribed nonsteroidal anti-inflammatory drugs who did not receive a leaflet. Patients who received a leaflet were more likely to be completely satisfied with their treatment and with the information they had been given. They were also more likely to know the name of their medicine and much more aware of potential unwanted effects. Although there was no evidence that knowledge increased the incidence of adverse effects, when these did occur they were more likely to be recognised as being due to the medicine. Further studies of other leaflets are warranted, including leaflets for drugs that are taken long term.     

Findings of a national survey of the role of general practitioners in the treatment of opiate misuse: dealing with the opiate misuser

Because there has been a substantial increase in the scale of drug misuse general practitioners have become increasingly concerned in responding to this problem. Little is known, however, about how general practitioners manage drug misusers. The findings from a national survey carried out in mid-1985 of a 5% random sample of general practitioners in England and Wales show the extent to which various actions were undertaken by general practitioners who reported on the consultation with the opiate misuser whom they last attended. In more than half of the cases the opiate misuser had been under the care of the general practitioners for this problem for at least six months. The findings indicate that most general practitioners refer these patients to specialist drug dependence clinics or to general psychiatric services but rarely to other agencies. Opiate drugs had been prescribed in nearly a third of cases. The rate of notification to the Home Office conforms with that in other studies and indicates a high degree of undernotification. More detailed study of general practitioners' activities in managing drug misusers is needed.     

Clinical contact preceding suicide.

Of the 400 consecutive completed suicides investigated over a 5-year period, 114 (28.5%) who had consulted a doctor in the week preceding death were specifically reviewed and compared with those who did not. The study comprised an analysis of the medical history, the scene of death and a complete autopsy with histological and toxicological examination and the identification of features which occurred more frequently in this group when compared with other suicides not contacting their doctors. Suicide-associated factors include psychiatric illness (58.8%), deteriorating health (16.7%), and a loss of spouse (7.0%); all these features were manifested by this group of suicides more frequently than by those who made no clinical contact (P < 0.001). A pre-indication of suicidal intention was made by 45% of these patients. This feature, as with previous attempts, occurred more commonly in patients who consulted a doctor (P < 0.001). Drug overdose was the most common suicidal method chosen (50.9%) and anti-depressants predominated (35%); 78% of those who overdosed ingested prescribed drugs. Poisoning was more common in this group (P < 0.001). Half of the victims committed suicide within 24 hours following consultation; of these, 51% overdosed on drugs with 61% of them ingesting their prescribed drugs. Of these 114 cases, the final consultation in 43% was to collect more drugs. All suicidal threats should be taken seriously, and particular care should be taken in prescribing and dispensing medication which may be fatal in overdose.     

"Not thrush again!" Women's experience of post-antibiotic vulvovaginitis

OBJECTIVES: To examine the frequency of post-antibiotic vulvovaginitis (PAV); describe how women prevent and treat PAV; and determine whether concern about PAV affects their decisions about taking antibiotics. DESIGN: Cross-sectional survey using a written questionnaire. SETTING AND PARTICIPANTS: Five general practice waiting rooms in north-western Melbourne, in February 2000. 1298 women aged 18-70 years were surveyed. MAIN OUTCOME MEASURES: Self-reported symptoms and management of vulvovaginitis and PAV. RESULTS: The response rate was 86%. Thirty-five per cent of women reported ever having PAV and 73% reported ever having symptoms suggestive of vulvovaginal candidiasis. Antifungal medications and lactobacillus products or yoghurt were most popular for both prevention (49%, 40%) and treatment (63%, 43%) of PAV. Other home remedies such as tea tree oil, vinegar, and dietary and clothing modification were infrequently used by the women surveyed. Twenty-three per cent of women who had taken antibiotics in the previous month had experienced symptoms of vulvovaginitis. Of women who had ever had vulvovaginitis, 35% were moderately to very concerned about developing PAV when prescribed antibiotics. Because of this concern, around a fifth of these women would not take prescribed antibiotics. CONCLUSIONS: Concern about PAV affects women's decision-making regarding antibiotic use. Many women use unproven complementary therapies to prevent or treat PAV. When prescribing antibiotics, doctors should discuss the risks of PAV and its management with patients.     

Follow-up care after acute myocardial infarction.

OBJECTIVE: To examine the medical care received by patients following discharge from hospital after acute myocardial infarction (AMI). SETTING AND DESIGN: Community-based cross-sectional survey. PATIENTS: 2836 consecutive patients aged 25-64 years living in the Perth Statistical Division who were admitted to hospital with AMI during 1984-1988. After one reminder the response rate was 71%. RESULTS: Half of all respondents were in full-time employment at the time of their AMI. At follow-up this had fallen to a third. Over 80% of patients visited a cardiologist after AMI, with half remaining under consultant care to the time of survey. However, one in five patients reported no follow-up care at the time of survey. Seventy-three per cent of patients reported undergoing at least one exercise stress test after AMI, with 61% undergoing angiography, 16% angioplasty and 24% coronary bypass surgery. Large proportions of the patients accurately reported being prescribed beta-blockers and antiplatelet agents. The pattern of prescribing at discharge corresponded closely with the use of cardioactive agents at the time of survey and with drugs reported to have been taken continuously since discharge to the time of survey. CONCLUSIONS: These data suggest that follow-up care after AMI is both comprehensive and widespread. Such care may have contributed significantly to the overall decline in mortality from ischaemic heart disease.     

Detection and management of hypertension in general practices in north west London

An examination of the practice notes and attached correspondence of 900 patients aged 30 to 65 years in a random sample of 18 general practice in north west London showed that 340 (47%) of 716 patients consulting in a 10 year period had no blood pressure readings in their records. The blood pressure was equal to or above 160 mm Hg systolic or 95 mm Hg diastolic, or both, in 115 (31%) of those whose blood pressures were recorded; 18 (16%) of these were not followed up. Seventy four patients were being treated for hypertension. Diuretics were the most commonly prescribed drugs. Treatment was started after one blood pressure reading in 34 (46%). Nine of those who had an initial raised blood pressure reading were normotensive on follow up. A further 14 patients had subsequent raised blood pressure readings but were not treated. Sixty one (69%) of the 88 patients with hypertension did not have a blood pressure recording after diagnosis for one or more periods exceeding 12 months. Of 84 hypertensive patients with complete records, 62 (74%) apparently had had no physical examination performed by the general practitioner and 61 (72%) did not seem to have had any investigations initiated by the general practitioners. Fifteen (35%) of 43 patients taking oral contraceptive pills apparently had no blood pressure recordings during the time they were taking these. The results of this study suggest that there are still deficiencies in the detection and management of hypertension in general practice.     

外周血淋巴细胞亚群检测在系统性硬化症治疗中的应用

目的: 检测免疫抑制剂治疗中系统性硬化症 (systemic sclerosis, SSc) 患者外周血T淋巴细胞、B淋巴细胞及自然杀伤 (natural killer,NK) 细胞的表达水平,分析其与临床实验室指标之间的相关性,进而探讨外周血淋巴细胞亚群检测在SSc治疗中的意义。方法: 采用流式细胞术检测使用免疫抑制剂的32例SSc患者(SSc组)和 30例健康对照(healthy control,HC)组外周血T、CD4⁺T、CD8⁺T、B、NK细胞数量及比例,比较SSc组与HC组外周血淋巴细胞亚群的差异,分析外周血淋巴细胞亚群与SSc其他实验室及临床指标之间的相关性。结果: 与HC组相比,SSc组中T、CD4⁺T、CD8⁺T、B、NK细胞数量均明显减少 (P<0.05), 同时,NK细胞占淋巴细胞的百分比也明显降低(P=0.004); 此外,使用免疫抑制剂的SSc患者中65%以上外周血存在各淋巴细胞亚群细胞数量减少。CD4⁺T淋巴细胞数量降低组与正常组相比,其出现雷诺现象的比例明显升高(P=0.024), 红细胞沉降率和C-反应蛋白也明显升高(P<0.001,P=0.018); CD8⁺T淋巴细胞数量降低组与正常组相比,红细胞沉降率明显升高(P=0.022);B淋巴细胞数量降低组与正常组相比,发生指尖溃疡的风险明显增高(P=0.019); NK细胞数量降低组与正常组相比,发生指尖溃疡的风险明显增高(P=0.033),而体内免疫球蛋白(immunoglobulin,Ig)M水平明显降低(P=0.049)。相关性分析可见,红细胞沉降率与总T淋巴细胞(r=-0.455,P=0.009)、CD4⁺T淋巴细胞(r=-0.416,P=0.018)、CD8⁺T淋巴细胞(r=-0.430,P=0.014)、B细胞(r=-0.366,P=0.039)数量呈负相关。结论: ⁺T、CD8⁺T、B及NK细胞数量明显减少,某些淋巴细胞亚群的变化可能与雷诺现象、指尖溃疡的发生有关,与红细胞沉降率、C-反应蛋白呈明显负相关,使用免疫抑制剂治疗SSc中应定期检测外周血淋巴细胞亚群的细胞数量。     

Anticoagulant prophylaxis against stroke in atrial fibrillation: effectiveness in actual practice

BACKGROUND: Randomized trials have shown a beneficial effect of anticoagulation with warfarin to prevent stroke in atrial fibrillation. It is not known whether the same effect will be obtained in actual practice. The authors conducted a prospective observational study to evaluate the effect of preventive anticoagulation in patients with atrial fibrillation in 2 practice settings in Montreal. METHODS: Of the 1725 outpatients screened between October 1990 and September 1993 at a community hospital and a university-affiliated hospital, 221 with documented atrial fibrillation were enrolled and followed up for a mean of 27 months. Most (75%) of the patients excluded did not meet the inclusion criteria (because of, for example, an artificial heart valve, mitral stenosis, cardiac transplantation or transient atrial fibrillation); the remainder had not completed enrollment before the end of the study. Following the baseline visit, patients were interviewed by telephone every 6 months, and reported events were confirmed through review of the patients' charts. Hazards for stroke and for stroke and transient ischemic attack (TIA) combined were calculated for each of 4 treatment groups: ASA, warfarin, blended treatment and no treatment, based on the type of anticoagulation therapy patients received during the entire observation period. The blended-treatment group consisted of patients who started on one active therapy and switched to the other or who switched treatments more than once. Corresponding rate ratios (RRs) and 95% confidence intervals (CIs) were calculated with reference to the no-treatment group. Cox proportional hazards analysis was used to adjust for differences in patient characteristics. The rates of bleeding episodes were also analysed. RESULTS: On average, the study patients were older (71.6 [standard deviation 9.3] years) and had a higher prevalence of underlying heart disease (52.0%) than those in the randomized trials. Nineteen patients had a first stroke: 4 in the ASA group, 4 in the warfarin group, 4 in the blended-treatment group and 7 in the no-treatment group, for rates of 5.2, 1.8, 5.3 and 5.9 per 100 person-years, respectively. Only warfarin was associated with a significantly lower risk of stroke compared with no anticoagulant therapy (RR 0.31, 95% CI 0.09-1.00). A similar protective effect of warfarin was found for stroke and TIA combined (2.3 v. 6.7 per 100 person-years; RR 0.34, 95% CI 0.12-0.99); the effect of ASA and blended treatment was not significantly different from no treatment. The rate per 100 person-years of any bleeding was not significantly higher for any treatment group (ASA 2.5, warfarin 3.4 and blended treatment 3.5) compared with the no-treatment group (1.9). Patients receiving warfarin had a significantly greater risk of any bleeding event than patients not receiving anticoagulant therapy (RR 1.79, 95% CI 1.07-3.00). INTERPRETATION: The relative effect of anticoagulant therapy with warfarin in preventing stroke in these practice settings was equivalent to that in the randomized trials, although these patients were older and sicker. This preventive treatment is likely to confer additional benefit as it is more widely prescribed.     

Is cimetidine being prescribed indiscriminately? An analytic survey of patients who present with symptoms of peptic ulcer disease.

An analytic survey was done to determine the influence of previously documented peptic ulcer disease (PUD) on the frequency of prescribing cimetidine to patients who present at a family medicine centre with symptoms of PUD. It was found that of 293 patients who presented with such symptoms over 1 year cimetidine was prescribed to 57 (19%). From the 236 patients who did not receive cimetidine 57 patients were selected at random for comparison. Information on these two groups of patients was obtained by chart review. The patients who received cimetidine were found to be significantly more likely (p less than 0.001) to have previously documented PUD than those who did not receive cimetidine. In patients in whom subsequent confirmation of PUD was not obtained, either because the results of investigations were negative or because the investigations were not ordered, cimetidine was prescribed to 63% of those who had previously documented PUD, compared with only 6% of those who did not. Of the patients who were investigated 73% of those with previously documented PUD had positive results, compared with 8% of those without previously documented PUD. The positive results were obtained by endoscopic examination in 88% of the patients with previously documented PUD, whereas upper gastrointestinal tract roentgenography was the definitive test in 73% of the patients without previously documented PUD. These findings suggest that previously documented PUD influences both the frequency of prescribing cimetidine and the investigations that are carried out.     

Quality of care in managing hypertension by case finding in north west London

The records of patients who were registered with general practice in inner London and outer London (both training and non-training practices) were examined for details of blood pressure recordings. A blood pressure recording was found in the past five years in only 22% of the notes of inner London practices but in 43% of notes in outer London practices, there being no difference between training and non-training practices. In 31% of the notes with a blood pressure recording the blood pressure had been raised (greater than or equal to 160/90) at some time: in 62% of these notes for patients aged 65 or more and in 52% of these notes for patients aged under 65 treatment had been given at some time. Thirty eight per cent of patients in the older group and 33% in the younger group were being treated at the time of the survey, thiazides being the most commonly used drugs. Thirty four per cent of all those with a raised blood pressure at some time had a latest recording of under 90 mm Hg diastolic. There seems to be a continuing need for general practitioners to detect and treat hypertension, and it is suggested that general practitioners should consider using systematic case finding for hypertension in their practices.     

Prescribing patterns in agoraphobia with panic attacks

Although medication is used commonly in the treatment of agoraphobia with panic attacks, the actual drug-prescribing patterns of the medical profession have not been well studied in this condition. The present study compares the prescribing patterns of general practitioners and psychiatrists in their treatment of agoraphobia with panic attacks. The medical records of 111 agoraphobic patients with panic attacks were analysed and divided into those who were referred by general practitioners and those who were referred by psychiatrists. Over all, in the treatment of agoraphobia with panic attacks, general practitioners prescribed drugs less often than did psychiatrists. They used fewer combinations of drugs and tended to prescribe tricyclic antidepressant agents in doses which generally are considered to be below the therapeutic range. This finding would suggest that general practitioners are less effective than are psychiatrists in prescribing for this condition as judged by current practice, although they are less likely to prescribe combinations of drugs--a practice which might well be to their credit.