Implementation of RCGP guidelines for acute low back pain: a cluster randomised controlled trial.

BACKGROUND: The Royal College of General Practitioners (RCGP) has produced guidelines for the management of acute low back pain in primary care. AIM: To investigate the impact on patient management of an educational strategy to promote these guidelines among general practitioners (GPs). DESIGN OF STUDY: Group randomised controlled trial, using the health centre as the unit of randomisation. SETTING: Primary care teams in north-west England. METHOD: Twenty-four health centres were randomly allocated to an intervention or control arm. Practices in the intervention arm were offered outreach visits to promote national guidelines on acute low back pain, as well as access to fast-track physiotherapy and to a triage service for patients with persistent symptoms. RESULTS: Twenty-four centres were randomised. Two thousand, one hundred and eighty-seven eligible patients presented with acute low back pain during the study period: 1049 in the intervention group and 1138 in the control group. There were no significant differences between study groups in the proportion of patients who were referred for X-ray, issued with a sickness certificate, prescribed opioids or muscle relaxants, or who were referred to secondary care, but significantly more patients in the intervention group were referred to physiotherapy or the back pain unit (difference in proportion = 12.2%, 95% confidence interval [CI] = 2.8% to 21.6%). CONCLUSION: The management of patients presenting with low back pain to primary care was mostly unchanged by an outreach educational strategy to promote greater adherence to RCGP guidelines among GPs. An increase in referral to physiotherapy or educational programmes followed the provision of a triage service.     

Predicting persistent disabling low back pain in general practice: a prospective cohort study

BACKGROUND: Patients may adopt active and/or passive coping strategies in response to pain. However, it is not known whether these strategies may also precede the onset of chronic symptoms and, if so, whether they are independent predictors of prognosis. AIM: To examine, in patients with low back pain in general practice, the prognostic value of active and passive coping styles, in the context of baseline levels of pain, disability and pain duration. DESIGN OF STUDY: Prospective cohort study. SETTING: Nine general practices in north west England. METHOD: Patients consulting their GP with a new episode of low back pain were recruited to the study. Information on coping styles, pain severity, disability, duration, and a brief history of other chronic pain symptoms was recorded using a self-completion postal questionnaire. Participants were then sent a follow-up questionnaire, 3 months after their initial consultation, to assess the occurrence of low back pain. The primary outcome was persistent disabling low back pain, that is, low back pain at 3-month follow-up self-rated as >or=20 mm on a 100 mm visual analogue scale, and >or=5 on the Roland and Morris Disability Questionnaire. RESULTS: A total of 974 patients took part in the baseline survey, of whom 922 (95%) completed a follow-up questionnaire; 363 individuals (39%) reported persistent disabling pain at follow-up. Persons who reported high levels of passive coping experienced a threefold increase in the risk of persistent disabling low back pain (relative risk [RR] = 3.0; 95% confidence interval [CI] = 2.3 to 4.0). In contrast, active coping was associated with neither an increase nor a decrease in the risk of a poor prognosis. After adjusting for baseline pain severity, disability, and other measures of pain and pain history, persons who reported a high passive coping score were still at 50% increased risk of a poor outcome (RR = 1.5; 95% CI = 1.1 to 2.0). CONCLUSION: Patients who report passive coping strategies experience a significant increase in the risk of persistent symptoms. Further, this risk persists after controlling for initial pain severity and disability. The identification of this low back pain subgroup may help target future treatments to those at greatest risk of a poor outcome.     

Community-acquired pneumonia in patients with bacterial meningitis: a prospective nationwide cohort study

ObjectivePneumonia is considered a focus of infection in patients presenting with community-acquired bacterial meningitis but the impact on disease course is unclear. The aim was to study presenting characteristics, clinical course and outcome of meningitis patients with co-existing pneumonia on admission.MethodsWe evaluated adult patients with community-acquired bacterial meningitis with pneumonia on admission in a nationwide, prospective cohort performed from March 2006 to June 2017. We performed logistic regression analysis to identify clinical characteristics predictive of pneumonia on admission, and to quantify the effect of pneumonia on outcome.ResultsPneumonia was diagnosed on admission in 315 of 1852 (17%) bacterial meningitis episodes and confirmed by chest X-ray in 256 of 308 (83%) episodes. Streptococcus pneumoniae was the causative organism in 256 of 315 episodes (81%). Pneumonia on admission was associated with advanced age (OR 1.03 per year increase, 95% CI 1.02–1.04, p < 0.001), alcoholism (OR 1.96, 95% CI 1.23–3.14, p 0.004), cancer (OR 1.54, 95% CI 1.12–2.13, p 0.008), absence of otitis or sinusitis (OR 0.44, 95% CI 0.32–0.59, p < 0.001) and S. pneumoniae (OR 2.14, 95% CI 1.55–2.95, p < 0.001) in the multivariate analysis. An unfavourable outcome defined as a score of 1–4 on the Glasgow Outcome Scale was observed in 172 (55%) episodes and 87 patients (28%) died. Pneumonia on admission was independently associated with unfavourable outcome and mortality in the multivariate analysis (OR 1.48, 95% CI 1.12–1.96; p 0.005).ConclusionPneumonia on admission in bacterial meningitis is a frequent coexisting infection and is independently associated with unfavourable outcome and mortality.     

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

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.     

Successful GP intervention with frequent attenders in primary care: randomised controlled trial.

BACKGROUND: Frequent attenders to GP clinics can place an unnecessary burden on primary care. Interventions to reduce frequent attendance have had mixed results. AIM: To assess the effectiveness of a GP intervention to reduce frequent-attender consultations. DESIGN OF STUDY: Randomised controlled trial with frequent attenders divided into an intervention group and two control groups (one control group was seen by GPs also providing care to patients undergoing the intervention). SETTING: A health centre in southern Spain. METHOD: Six GPs and 209 randomly-selected frequent attenders participated. Three GPs were randomly allocated to perform the new intervention: of the 137 frequent attenders registered with these three GPs, 66 were randomly allocated to receive the intervention (IG) and 71 to a usual care control group (CG2). The other three GPs offered usual care to the other 72 frequent attenders (CG1). The main outcome measure was the total number of consultations 1 year post-intervention. Baseline measurements were recorded of sociodemographic characteristics, provider-user interface, chronic illnesses, and psychosocial variables. GPs allocated to the new intervention received 15 hours' training which incorporated biopsychosocial, organisational, and relational approaches. After 1 year of follow-up frequent attenders were contacted. An intention-to-treat analysis was used. RESULTS: A multilevel model was built with three factors: time, patient, and doctor. After adjusting for covariates, the mean number of visits at 1 year in IG was 13.10 (95% confidence interval [CI]=11.39 to 14.94); in the CG1 group was 19.37 (95% CI=17.31 to 21.55); and in the CG2 group this was 16.72 (95% CI=4.84 to 18.72). CONCLUSION: The new intervention with GPs resulted in a significant and relevant reduction in frequent-attender consultations. Although further trials are needed, this intervention is recommended to GPs interested in reducing consultations by their frequent attenders.     

The effectiveness of long-term psychoanalytic psychotherapy--a meta-analysis of randomized controlled trials

The effectiveness of psychoanalysis and long-term psychoanalytic psychotherapy (LTPP) is debated. We evaluated the effectiveness of LTPP, compared to other treatments or no treatment, in patients with clearly defined metal disorders. We selected randomised or quasi-randomised controlled trials on LTPP. Two authors independently identified trials for inclusion. Eleven trials were eligible. The risk difference for recovery (primary outcome) at the longest available follow-up was 0.00 (95% CI: -0.17 to 0.17; p=0.96; I-squared: 58%). The combined Hedges' g, at the longest follow-up for each study, were: for target problems: -0.05 (95% CI -0.55 to 0.46; p=0.86; I-squared=88%); general psychiatric symptoms: 0.69 (95% CI -0.19 to 1.57; p=0.13; I-squared=96%); personality pathology: 0.17 (95% CI: -0.25 to 0.59; p=0.42; I-squared=41%); social functioning: 0.20 (95% CI -0.10 to 0.50; p=0.19; I-squared=53%); overall effectiveness: 0.33 (95% CI -0.31 to 0.96; p=0.32; I-squared=94%); and quality of life: -0.37 (95% CI: -0.78 to 0.04; p=0.08; I-squared=55%). A subgroup analysis of the domain target problem showed that LTPP did significantly better when compared to control treatments without a specialized psychotherapy component, but not when compared to various specialized psychotherapy control treatments. An exploratory meta-regression indicated that there might be a relation between the difference in treatment intensity between the intervention and control group (session ratio) and effect size. We came to conclude that the recovery rate of various mental disorders was equal after LTPP or various control treatments, including treatment as usual. The effect sizes of the individual trials varied substantially in direction and magnitude. In contrast to previous reviews, we found the evidence for the effectiveness of LTPP to be limited and at best conflicting.     

Identifying suspected breast cancer: development and validation of a clinical prediction rule

Background

An evidence-based approach is needed to identify women with breast symptoms who are most likely to have breast cancer so that timely and appropriate referral can take place.

Aim

To report the development and validation of a clinical prediction rule for the diagnosis of breast cancer.

Design and setting

Cohort study with two prospective groups of women: those presenting to a symptomatic breast clinic (derivation cohort) and a separate cohort presenting to 11 general practices (validation cohort) in Tayside, Scotland.

Method

Regression analysis was used to derive a clinical prediction rule from presenting symptoms, personal and family history, and clinical findings. Validation consisted of estimating the number of breast cancers predicted to occur compared with the actual number of observed breast cancers across deciles of risk.

Results

In the derivation cohort of 802 patients, 59 (7%) were diagnosed with breast cancer. Independent clinical predictors for breast cancer were: increasing age by year (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] = 1.07 to 1.13); presence of a discrete lump (AOR 15.20, 95% CI = 4.88 to 47.34); breast thickening (AOR 7.64, 95% CI = 2.23 to 26.11); lymphadenopathy (AOR 3.63, 95% CI = 1.33 to 9.92); and lump ≥2 cm (AOR 5.41, 95% CI = 2.36 to 12.38). All eight patients with skin tethering had breast cancer. The regression model had good predictive power, identifying all five breast cancers in the validation cohort of 97 patients in the top two deciles of risk.

Conclusion

The clinical prediction rule discriminates between patients at high risk of breast cancer from those at low risk, and can be implemented as an evidence-based recommendation to enhance appropriate referral from general practice to a symptomatic breast clinic. Ongoing validation in further populations is required.     

The work hours of GPs: survey of English GPs

BACKGROUND: There is no current information about the hours worked by English GPs. AIM: To compare the reported hours worked by GPs with that of other professions and to explain the variation in GP hours worked and on call. Design of study: National postal survey of 1871 GPs in February 2004. SETTING: English general practice. METHOD: Multiple regression analyses of part-time versus full-time status, hours worked, and hours on call. RESULTS: Full-time male GPs report more hours worked (49.6; 95% CI [confidence interval] = 48.9 to 50.2) than males in other professional occupations (47.9; 95% CI = 47.6 to 48.1) and male managers (49.1; 95% CI = 48.8 to 49.5). Full-time female GPs report fewer hours (43.2; 95% CI = 42.0 to 44.3) than females in other professional occupations (44.7; 95% CI = 44.4 to 45.0) and female managers (44.1; 95% CI = 43.7 to 44.5). The number of hours worked decreased with practice list size, and increased with the number of patients per GP. GPs work longer hours in practices with older patients and with a higher proportion of patients in nursing homes. Fewer hours are worked in practices with higher 'additional needs' payments. Having children under 18 years of age increased the probability that female GPs work part-time but has no effect on the probability of male GPs working part-time. Given full-time/part-time status, having children under 18 years of age reduces the hours of male and female GPs. CONCLUSION: Male English GPs report longer hours worked than other professional groups and managers. The sex differences between GPs in hours worked are mostly attributable to the differential impact of family circumstances, particularly the number of children they have. Perversely, 'additional needs' payments are higher in practices where GPs work fewer hours.     

Clinical features of prostate cancer before diagnosis: a population-based, case-control study

BACKGROUND: Even in areas where screening is available, many prostate cancers are diagnosed after the symptoms begin. However, the risk posed by particular symptoms is largely unknown, especially in unselected populations such as primary care. AIM: To identify and quantify the features of prostate cancer before diagnosis, both individually and in combination. DESIGN OF STUDY: Population-based case-control study. SETTING: All 21 general practices in Exeter, Devon, UK. METHODS: We studied all 217 prostate cancer patients diagnosed between 1998 and 2002, and 1080 male controls, matched by age and general practice. The full medical record for 2 years before diagnosis was coded, using the International Classification of Primary Care. We calculated odds ratios for variables independently associated with cancer, using conditional logistic regression, and calculated the positive predictive values for these, both individually and in combination. RESULTS: Eight features were associated with prostate cancer before diagnosis. Their positive predictive values against a background risk of 0.35% were: urinary retention 3.1% (95% confidence interval [CI] = 1.5 to 6.0); impotence 3.0% (95% CI = 1.7 to 4.9); frequency 2.2% (95% CI = 1.3 to 3.5); hesitancy 3.0% (95% CI = 1.5 to 5.5); nocturia 2.2% (95% CI = 1.2 to 3.6); haematuria 1.0% (95% CI = 0.57 to 1.8); weight loss 0.75% (95% CI = 0.38 to 1.4); abnormal rectal examination, deemed benign 2.8% (95% CI = 1.6 to 4.6); abnormal rectal examination, deemed malignant 12% (95% CI = 5.0 to 37): all P <0.001, except for hesitancy P = 0.032, nocturia P = 0.004 and haematuria P = 0.009. Loss of weight, impotence, frequency and abnormal rectal examination remained associated with cancer after excluding the final 180 days from analysis. CONCLUSION: Most men with prostate cancer present with symptoms. The predictive values for these symptoms will help guide GPs and patients about the value of further investigation.     

Increased mortality among women with Rose angina who have not presented with ischaemic heart disease.

BACKGROUND: Little is known about the clinical importance of disease that is not presented to healthcare services. AIM: To determine the 5-year mortality among those with angina symptoms, known or not known by their general practitioner (GP) to have ischaemic heart disease (IHD). DESIGN: A prospective cohort study. SETTING: The study was conducted in the United Kingdom as part of the Royal College of General Practitioners' Oral Contraception Study. METHOD: In 1994-1995 women (n = 11,797) still under GP observation were sent a questionnaire that inquired about their smoking habits, other lifestyle issues, general health, and selected symptoms (including chest pain, assessed using the Rose angina questionnaire). The main outcome measure was the chances (odds) of dying during the next 5 years, among those with and without exertional chest pain, Rose angina or Rose myocardial infarction (MI), stratified by documented history of IHD. RESULTS: Overall, the lifetime prevalence of any exertional chest pain was 10.1% (95% confidence interval [CI] = 9.5 to 10.8); grade I Rose angina was 6.1% (95% CI = 5.6 to 6.6); grade II Rose angina was 1.3% (95% CI = 1.1 to 1.6); and Rose MI was 4.4% (95% CI = 4.0 to 4.9). The prevalence of each condition tended to increase with age, social class, parity, body mass index, and documented history of IHD. The proportion of women documented as having IHD was 23% among those with any exertional chest pain, 21.7% for grade I Rose angina, 37.7% for grade II Rose angina, and 31.4% for Rose MI. Compared to women without Rose angina, significantly higher odds ratios for all-cause mortality were observed among women with grade I Rose angina and no documented history of IHD (adjusted odds ratio [AOR] = 1.71, 95% CI = 1.05 to 2.79); those with grade II Rose angina and documented IHD (AOR = 3.94, 95% CI = 1.58 to 9.83); and women with grade II Rose angina and no documented history of IHD (AOR = 3.35, 95% CI = 1.47 to 7.62). CONCLUSIONS: Women with angina symptoms that have not been documented by their GP appear to have an increased risk of future mortality. Research is needed to determine the best way of identifying and managing these individuals.     

Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis

Background

Selection of primary care patients for investigation of potential oesophagogastric cancer is difficult, as the symptoms may represent benign conditions, which are also more common.

Aim

To review systematically the presenting features of oesophagogastric cancers in primary care, including open-access endoscopy clinics.

Design and setting

Systematic review and meta-analysis.

Method

MEDLINE^®, Embase, the Cochrane Library, and CINAHL were searched for studies of adults who were symptomatic and presented in primary care or open-access endoscopy clinics. Exclusions were being asymptomatic, screening, or recurrent cancers. Data were extracted to estimate the diagnostic performance of features of oesophagogastric cancers and summarised in a meta-analysis.

Results

Fourteen studies were identified. The strongest summary sensitivity and specificity estimates were for: dyspepsia 0.42 (95% confidence interval [CI] 0.29 to 0.56) and 0.48 (95% CI = 0.31 to 0.65); pain 0.41 (95% CI = 0.24 to 0.62) and 0.75 (95% CI = 0.51 to 0.89); and dysphagia 0.32 (95% CI = 0.17 to 0.52) and 0.92 (95% CI = 0.81 to 0.97). Summary positive likelihood ratios (LR+) and diagnostic odds ratios were: dyspepsia 0.79 (95% CI = 0.55 to 1.15) and 0.65 (95% CI = 0.32 to 1.33); pain 1.64 (95% CI = 1.20 to 2.24) and 2.09 (95% CI = 1.57 to 2.77); and dysphagia 4.32 (95% CI = 2.46 to 7.58) and 5.91 (95% CI = 3.56 to 9.82). Corresponding LR+ were: anaemia 4.32 (95% CI = 2.64 to 7.08); nausea/vomiting/bloating 1.07 (95% CI = 0.52 to 2.19); reflux 0.78 (95% CI = 0.47 to 1.78) and; weight loss 5.46 (95% CI = 3.47 to 8.60).

Conclusion

Dysphagia, weight loss, and anaemia show the strongest association but with relatively low sensitivity and high specificity. The findings support the value of investigation of these symptoms, but also suggest that, in a population of patients who are low risk but not no-risk, investigation is not currently recommended.     

Enhanced treatment for depression in primary care: long-term outcomes of a psycho-educational prevention program alone and enriched with psychiatric consultation or cognitive behavioral therapy

BACKGROUND: The long-term outcome of major depression is often unfavorable, and because most cases of depression are managed by general practitioners (GPs), this places stress on the need to improve treatment in primary care. This study evaluated the long-term effects of enhancing the GP's usual care (UC) with three experimental interventions. METHOD: A randomized controlled trial was conducted from 1998 to 2003. The main inclusion criterion was receiving GP treatment for a depressive episode. We compared: (1) UC (n=72) with UC enhanced with: (2) a psycho-educational prevention (PEP) program (n=112); (3) psychiatrist-enhanced PEP (n=37); and (4) brief cognitive behavioral therapy followed by PEP (CBT-enhanced PEP) (n=44). We assessed depression status quarterly during a 3-year follow-up. RESULTS: Pooled across groups, depressive disorder-free and symptom-free times during follow-up were 83% and 17% respectively. Almost 64% of the patients had a relapse or recurrence, the median time to recurrence was 96 weeks, and the mean Beck Depression Inventory (BDI) score over 12 follow-up assessments was 9.6. Unexpectedly, PEP patients had no better outcomes than UC patients. However, psychiatrist-enhanced PEP and CBT-enhanced PEP patients reported lower BDI severity during follow-up than UC patients [mean difference 2.07 (95% confidence interval (CI) 1.13-3.00) and 1.62 (95% CI 0.70-2.55) respectively] and PEP patients [2.37 (95% CI 1.35-3.39) and 1.93 (95% CI 0.92-2.94) respectively]. CONCLUSIONS: The PEP program had no extra benefit compared to UC and may even worsen outcome in severely depressed patients. Enhancing treatment of depression in primary care with psychiatric consultation or brief CBT seems to improve the long-term outcome, but findings need replication as the interventions were combined with the ineffective PEP program.     

General practitioners miss disability and anxiety as well as depression in their patients with osteoarthritis.

BACKGROUND: General practitioners (GPs) integrate physical, psychological, and social factors when assessing patients, particularly those with chronic diseases. Recently, the emphasis has been on assessment of depression but not of other factors. AIM: To determine functional disability, psychological morbidity, social situation, and use of health and social services in patients with osteoarthritis and examine GP knowledge of these factors. METHOD: Two hundred patients completed a validated postal questionnaire about functional disability (Health Assessment Questionnaire [HAQ]), mood (Hospital Anxiety and Depression Scale [HAD]), employment status, who they lived with, welfare benefits received, and use of health and social services. A similar questionnaire was completed by the patient's GP, including a HAQ. However, a three-point scale was used to assess depression and anxiety. RESULTS: Forty-seven per cent of patients were moderately or severely disabled (HAQ > 1). GPs underestimated functional disability: mean patient HAQ = 1.04 (95% confidence interval [CI] = 0.92-1.16), mean GP HAQ = 0.74 (95% CI = 0.65-0.83), and there was low correlation between patient and GP scores (kappa = 0.24). There was moderate prevalence of depression and high prevalence of anxiety, which the GP often did not recognise: patient depression = 8.3% (95% CI = 4.1%-12.8%), GP depression = 6.0% (95% CI = 2.4%-9.6%), kappa = 0.11; patient anxiety = 24.4% (95% CI = 17.8%-31.0%), GP anxiety = 11.9% (95% CI = 6.9%-16.9%), kappa = 0.19. Only 46% of severely disabled patients (HAQ > 2) were receiving disability welfare benefits. GPs were often unaware of welfare benefits received or the involvement of other professionals. CONCLUSION: GPs frequently lack knowledge about functional disability, social factors, and anxiety as well as depression in their patients with osteoarthritis.     

Prediction of complicated lower respiratory tract infections in older patients with diabetes

BACKGROUND: Patients with diabetes have an elevated risk of developing complicated lower respiratory tract infections (LRTIs). However, up until now, GPs have not had the tools to assess individual risks. AIM: To assess the applicability of an existing prediction rule for complicated LRTI among patients with diabetes. DESIGN OF STUDY: Retrospective cohort study. SETTING: The Utrecht GP Research Network. METHOD: An existing rule that was used estimates the risk of 30-day hospitalisation or death following an episode of LRTI. Predictors were exacerbation of chronic obstructive pulmonary disease, or pneumonia, increasing age, heart failure, number of hospitalisations in the previous year, use of antibiotics in the previous month, diabetes medication, and prednisone use. Discriminative capacity of the rule was estimated in patients with diabetes. Other potential predictors from the original study were examined, to test for a potentially improved model. RESULTS: Of 445 episodes of LRTI in patients with diabetes, 68 had an outcome of hospitalisation or death within 30 days of diagnosis of LRTI (15.3%). Results showed good reliability of the model (goodness of fit test P=0.16) and discriminative properties (area under the receiver operating characteristic curve: 0.79, 95% confidence interval=0.73 to 0.86). No other predictors could be added. Patients with a lower-risk assignment (scoreor=7) had a probability of 36.6% for the composite endpoint of hospitalisation or death within 30 days of diagnosis of LRTI. CONCLUSION: The use of a prediction rule may help GPs to assess the risk of hospitalisation or death in patients with diabetes who have an episode of LRTI.     

Accuracy of body mass index in detecting an elevated alanine aminotransferase level in adolescents

AIM: We evaluated the accuracy of body mass index (BMI) in detecting an elevated alanine aminotransferase (ALT) level in adolescents, taking into account the effects of gender, age, ethanol intake, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, and drug consumption. SUBJECTS: A representative sample of 454 adolescents (11-17 years) from two cities in northern Italy was studied (the Dionysos Study). METHODS: z-BMI was calculated as the z-score of BMI using national growth charts. Logistic regression was used to quantify the contribution of the variables of interest to an elevated ALT (> 30 UL(-1)). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated, and areas under receiver-operator characteristic curves (AUC) were used to evaluate accuracy. RESULTS: An elevated ALT was detected in 21 adolescents (4.6%). Among the studied variables, only male gender (OR=6.7, 95% CI 2.0-23.2) and z-BMI (OR=2.1, 95% CI 1.4-3.2) were significant predictors of elevated ALT. The accuracy of the prediction was 0.69 (95% CI 0.59-0.79) for gender and 0.71 (95% CI 0.59-0.81) for z-BMI. By combining gender and z-BMI, the accuracy rose to 0.80 (95% CI 0.71-0.89). CONCLUSION: BMI is a good predictor of elevated ALT in Italian adolescents and gender adds to the accuracy of the prediction.     

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.     

Screening for left ventricular systolic dysfunction using GP-reported ECGs

BACKGROUND: Diagnostic echocardiography has poor access for patients with suspected heart failure. Pre-echocardiography screening with electrocardiograms (ECGs) is recommended as a means of targeting this scarce resource. There are data to support this policy when ECGs are interpreted by cardiologists but not by GPs. AIM: To assess the value of GP-reported ECGs as a pre-echocardiography screening test for left ventricular systolic dysfunction (LVSD). DESIGN OF STUDY: Cross-sectional study of GPs' ECG reporting skills. SETTING: General practice, NHS in Scotland. METHOD: A randomly selected, stratified sample of 123 Scottish GPs reviewed 180 ECGs (100 abnormal, 50 normal and 30 duplicate) from 150 patients with suspected heart failure. Forty-one patients had LVSD on echocardiography. GPs were required to categorise ECGs as normal or abnormal. RESULTS: Mean sensitivity was 0.94 (95% CI = 0.92 to 0.95). Mean specificity 0.58 (95% CI = 0.56 to 0.60). Mean positive predictive value (PPV) was 0.47 (95% CI = 0.46 to 0.48). Mean negative predictive value (NPV) was 0.96 (95% CI = 0.95 to 0.97). Mean likelihood ratio was 2.39 (95% CI = 2.28 to 2.50). Seventy of 123 (57%) GPs achieved sensitivity of 0.9 and specificity of 0.5 for the detection of LVSD. CONCLUSION: Most Scottish GPs have the skills to perform pre-echocardiography screening ECGs in patients with suspected LVSD. However, differences in ECG reporting performance between individual GPs will result in widely varying referral rates for echocardiography and differences in the detection rate of LVSD. The implications of these findings need to be considered when heart failure diagnostic services are being developed.     

Retention of young general practitioners entering the NHS from 1991-1992.

BACKGROUND: The supply of general practitioners (GPs) in the National Health Service (NHS) is dynamic and there are fears that there will be an inadequate number of doctors to meet the needs of the NHS. There are particular concerns about changes in the career trajectory of young GPs and what they mean for overall supply. AIM: To identify predictors of retention among young, new entrant GPs entering the NHS between 1 October 1991 and 1 October 1992. METHOD: Two-year retention rates of young (35 years of age or less) new entrant GPs have been modelled using a multilevel logit model. Retention is defined as young, new entrant GPs remaining in their initial health authority for two years or more. RESULTS: Two hundred and fifty-two (13.0%) members of the study group left general practice within two years of entry (i.e. were not retained). Sex (females had lower retention [95% CI = 0.43-0.75]), practice size (young GPs in larger practices had higher retention [95% CI = 1.10-1.29]), and belonging to a practice in one of 16 Greater London Health Authorities (which had lower retention [95% CI = 0.39-0.82]) were identified as major predictors of retention. Deprivation, measured at the individual GP patient list level, had a very slight association with retention (P = 0.097; 95% CI = 1.00-1.02). Deprivation measured at the health authority level (95% CI = 0.99-1.01) was not found to be a statistically significant predictor of retention (P = 0.83). CONCLUSION: None of the statistically significant predictors of retention suggest any policy panacea to end this phenomenon. The challenge for policy is to learn to deal with the dynamic nature of the GP workforce with a non-crisis mentality.     

Prediction of Neurological Outcomes in Out-of-hospital Cardiac Arrest Survivors Immediately after Return of Spontaneous Circulation: Ensemble Technique with Four Machine Learning Models

BackgroundWe performed this study to establish a prediction model for 1-year neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients who achieved return of spontaneous circulation (ROSC) immediately after ROSC using machine learning methods.MethodsWe performed a retrospective analysis of an OHCA survivor registry. Patients aged ≥ 18 years were included. Study participants who had registered between March 31, 2013 and December 31, 2018 were divided into a develop dataset (80% of total) and an internal validation dataset (20% of total), and those who had registered between January 1, 2019 and December 31, 2019 were assigned to an external validation dataset. Four machine learning methods, including random forest, support vector machine, ElasticNet and extreme gradient boost, were implemented to establish prediction models with the develop dataset, and the ensemble technique was used to build the final prediction model. The prediction performance of the model in the internal validation and the external validation dataset was described with accuracy, area under the receiver-operating characteristic curve, area under the precision-recall curve, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Futhermore, we established multivariable logistic regression models with the develop set and compared prediction performance with the ensemble models. The primary outcome was an unfavorable 1-year neurological outcome.ResultsA total of 1,207 patients were included in the study. Among them, 631, 139, and 153 were assigned to the develop, the internal validation and the external validation datasets, respectively. Prediction performance metrics for the ensemble prediction model in the internal validation dataset were as follows: accuracy, 0.9620 (95% confidence interval [CI], 0.9352–0.9889); area under receiver-operator characteristics curve, 0.9800 (95% CI, 0.9612–0.9988); area under precision-recall curve, 0.9950 (95% CI, 0.9860–1.0000); sensitivity, 0.9594 (95% CI, 0.9245–0.9943); specificity, 0.9714 (95% CI, 0.9162–1.0000); PPV, 0.9916 (95% CI, 0.9752–1.0000); NPV, 0.8718 (95% CI, 0.7669–0.9767). Prediction performance metrics for the model in the external validation dataset were as follows: accuracy, 0.8509 (95% CI, 0.7825–0.9192); area under receiver-operator characteristics curve, 0.9301 (95% CI, 0.8845–0.9756); area under precision-recall curve, 0.9476 (95% CI, 0.9087–0.9867); sensitivity, 0.9595 (95% CI, 0.9145–1.0000); specificity, 0.6500 (95% CI, 0.5022–0.7978); PPV, 0.8353 (95% CI, 0.7564–0.9142); NPV, 0.8966 (95% CI, 0.7857–1.0000). All the prediction metrics were higher in the ensemble models, except NPVs in both the internal and the external validation datasets.ConclusionWe established an ensemble prediction model for prediction of unfavorable 1-year neurological outcomes in OHCA survivors using four machine learning methods. The prediction performance of the ensemble model was higher than the multivariable logistic regression model, while its performance was slightly decreased in the external validation dataset.