Respiratory consultations in asthmatic compared with non-asthmatic children in general practice.

In a retrospective study we found that before a diagnosis of asthma had been made children with asthma had consulted their general practitioner more often with respiratory symptoms than children who were non-asthmatic under the age of four. In the second, third, and fourth years the number of consultations differed significantly between the two groups. Asthma should be suspected in any child who presents often with respiratory symptoms. This should lead to earlier diagnosis in most cases.     

Cost effectiveness of screening for and eradication of Helicobacter pylori in management of dyspeptic patients under 45 years of age.

OBJECTIVE--To assess the cost effectiveness of screening for and eradicating Helicobacter pylori in patients under 45 years of age presenting with dyspepsia. DESIGN--A decision analytic model composed of a decision tree to represent the epidemiology of dyspepsia and a Markov process to model the outcomes of treatment. PATIENTS--Patients under the age of 45 years presenting to their general practitioner with (peptic type) dyspepsia. INTERVENTIONS--Conventional empirical treatment with healing and maintenance doses of cimetidine v eradication treatment solely in patients with confirmed peptic ulcer; and conventional empirical treatment for all dyspeptic patients compared with the use of a serology test to identify patients with H pylori, who then receive endoscopy to investigate the presence of peptic ulcer disease and, when disease is found, are given eradication treatment with a breath test to confirm successful eradication. MAIN OUTCOME MEASURES--Expected cumulative costs over a period of 10 years. The proportion of time patients spend without a recurrent ulcer. RESULTS--After receiving eradication treatment, patients with confirmed ulcer spend an average of 99% of their time free from recurrent ulcer disease compared with 95% after treatment with cimetidine. Eradication treatment costs less than that with cimetidine. When the initial cost of identifying appropriate patients to receive eradication treatment is added to the analysis, however, these cost savings take almost eight years to accrue. CONCLUSIONS--Enthusiasm for introducing testing for and eradication of H pylori for dyspeptic patients in general practice should be tempered by an awareness that cost savings may take many years to realise.     

First-time urea breath tests performed at home by 36,629 patients: a study of Helicobacter pylori prevalence in primary care

Background: The aim of the current study was (1) to describe the use of a ¹³C‐urea breath test (UBT) that was performed by patients at their homes as a part of a test‐and‐treat strategy in primary care and (2) to investigate the prevalence of Helicobacter pylori in patients taking a first‐time UBT. Material and Methods: The patients performed UBTs at home based on the discretion of the general practitioner and mailed the breath bags to a central laboratory for analysis. Each patient was identified by a unique civil registration number. The study was population‐based, and the background population was approximately 700,000 people. Results: From 2003 to 2009, 44,487 UBTs were performed. Of these, 36,629 were first‐time UBTs. In total, 726 of 45,213 breath bags received (1.6%) were unable to be analyzed because of errors with the bags. For both women and men who were ≤45 years of age, positive H. pylori declined over the time course of the study (women: 19.6% in 2003 to 17.6% in 2009, p < .01; men: 20.7% in 2003 to 16.9% in 2009, p < .001). Patients who were older than 45 years had significantly higher positive H. pylori results than younger patients. Conclusions: A test‐and‐treat system was possible to implement that allowed patients to perform UBTs at their homes. The results of the first‐time UBTs demonstrated that approximately one of five patients who presented with dyspepsia in the clinical setting of Danish primary care was infected with H. pylori.     

Early detection of gastric cancer.

OBJECTIVE--To see whether investigation of dyspeptic patients aged over 40 after their first consultation with the general practitioner would increase the proportions with early and operable gastric cancers. DESIGN--Prospective study of gastric cancer in dyspeptic patients aged over 40 from a defined population. SETTING--10 General practices (six in central Birmingham, four in Sandwell); the Queen Elizabeth Hospital, Birmingham; and Sandwell District General Hospital. PATIENTS--2659 Patients aged 40 or over referred with dyspepsia. MAIN OUTCOME MEASURE--Increase in early and operable gastric cancers detected in middle aged patients with dyspepsia. RESULTS--Disease was identified in 1992 patients (75%). Fifty seven were found to have gastric cancer, 36 being treated by potentially curative resection, including 15 with early cancer. CONCLUSIONS--The investigation of dyspeptic patients over 40 at first attendance can increase the proportion of early gastric cancers detected to 26% and the proportion of operable cases to 63%. Such a policy has the potential to reduce mortality from gastric cancer in the population.     

Promoting Help-Seeking in Response to Symptoms amongst Primary Care Patients at High Risk of Lung Cancer: A Mixed Method Study

BackgroundLung cancer symptoms are vague and difficult to detect. Interventions are needed to promote early diagnosis, however health services are already pressurised. This study explored symptomology and help-seeking behaviours of primary care patients at ‘high-risk’ of lung cancer (≥50 years old, recent smoking history), to inform targeted interventions.MethodsMixed method study with patients at eight general practitioner (GP) practices across south England. Study incorporated: postal symptom questionnaire; clinical records review of participant consultation behaviour 12 months pre- and post-questionnaire; qualitative participant interviews (n = 38) with a purposive sample.ResultsA small, clinically relevant group (n = 61/908, 6.7%) of primary care patients was identified who, despite reporting potential symptoms of lung cancer in questionnaires, had not consulted a GP ≥12 months. Of nine symptoms associated with lung cancer, 53.4% (629/1172) of total respondents reported ≥1, and 35% (411/1172) reported ≥2. Most participants (77.3%, n = 686/908) had comorbid conditions; 47.8%, (n = 414/908) associated with chest and respiratory symptoms. Participant consulting behaviour significantly increased in the 3-month period following questionnaire completion compared with the previous 3-month period (p = .002), indicating questionnaires impacted upon consulting behaviour. Symptomatic non-consulters were predominantly younger, employed, with higher multiple deprivation scores than their GP practice mean. Of symptomatic non-consulters, 30% (18/61) consulted ≤1 month post-questionnaire, with comorbidities subsequently diagnosed for five participants. Interviews (n = 39) indicated three overarching differences between the views of consulting and non-consulting participants: concern over wasting their own as well as GP time; high tolerance threshold for symptoms; a greater tendency to self-manage symptoms.ConclusionsThis first study to examine symptoms and consulting behaviour amongst a primary care population at ‘high- risk’ of lung cancer, found symptomatic patients who rarely consult GPs, might respond to a targeted symptom elicitation intervention. Such GP-based interventions may promote early diagnosis of lung cancer or other comorbidities, without burdening already pressurised services.     

Certificated sickness absence in industrial employees threatened with redundancy

The proposition that workers take less sick leave when threatened by redundancy was examined in a longitudinal, controlled study using information from case records in a general practice. The hypothesis was only partly supported—certificated sickness absence dropped only in employees under the age of 40. Workers fearing job loss reported more illness, and their periods of absence were significantly longer, especially for men and for workers who had previously consulted their general practitioner infrequently.This study provides further evidence that the fear of mass redundancy is stressful to workers so threatened and costly to a society experiencing rising unemployment.     

Self referral to an accident and emergency department for another opinion.

OBJECTIVE--To determine whether patients referring themselves to an accident and emergency department for another opinion after consulting their general practitioner present with serious illness, show any risk factors for being admitted, or are more likely to be patients of particular practitioners. DESIGN--Six month prospective survey. SETTING--District general hospital''s accident and emergency department, receiving 42,000 new patients a year. PATIENTS--180 Patients identified as attending for another opinion having already consulted a general practitioner. INTERVENTIONS--Classified as admission, referral to specialist clinic, follow up in accident and emergency department, or referral back to general practitioner. END POINT--Admission, with an analysis of admitted patients. MEASUREMENTS AND MAIN RESULTS--General outcome, diagnostic category, age, time of attendance, time since seen by general practitioner, and name of general practitioner were recorded. Forty seven patients were admitted, 99 were discharged back to the general practitioner (62 without a letter), and two died. Patients were most likely to be admitted if they attended within 24 hours after seeing a general practitioner, were aged under 5, or presented with respiratory or gastrointestinal complaints. Some general practitioners were overrepresented. CONCLUSIONS--Important disorders present in this way, and therefore these patients should be seen by a doctor. Information about these attendances could be useful to general practitioners in reviewing their performance.     

Low levels of ill health among elderly non-consulters in general practice.

The characteristics of random samples of elderly patients (over 65 years of age), designated as consulters (n = 200) and non-consulters (n = 196), in a group general practice were compared using a postal questionnaire that was validated by comparison with findings by general practitioners in a random sample of 58 responders. A response rate of 90% was obtained, and all non-responders were visited by their general practitioner. The questionnaire had a sensitivity of 79% and a specificity of 82% when compared with general practitioner findings. The use of hospital and social services by non-consulters was low in this practice. Measures of disability and state of health showed that non-consulters were a fit group of the aged. Case finding for problems among elderly people should initially be confined to consulters, who have a high prevalence of problems. Non-consulters are a low risk group that can be assessed only with special effort and extra resources. Once an effective case finding system has been developed it might then be reasonable to consider ways of finding the few patients who have problems but do not consult their doctor.     

Irritable bowel syndrome in the general population.

OBJECTIVE--To determine the prevalence of symptoms compatible with a clinical diagnosis of irritable bowel syndrome in the general population. DESIGN--Validated postal questionnaire sent to 2280 subjects randomly selected in 10 year age bands from the lists of eight general practitioners. The Manning criteria were used to define irritable bowel syndrome. SETTING--Urban population in Southampton and mixed urban-rural population in Andover, Hampshire. RESULTS--A response of 71% yielded 1620 questionnaires for analysis, of which 412 (25%) reported more than six episodes of abdominal pain in the preceding year, with 350 (22%) reporting symptoms consistent with the diagnosis of irritable bowel syndrome. The male: female ratio was 1:1.38. More subjects with irritable bowel syndrome had constipation and diarrhoea and 35% with the syndrome reported rectal bleeding compared with an overall prevalence of 20%. Other symptoms and conditions including heartburn, dyspepsia, flushing, palpitations, migraine, and urinary symptoms were significantly more common in the group with irritable bowel syndrome. Abdominal pain in childhood was more common in the subjects with irritable bowel syndrome (12%) than without (3%). One third of the group with irritable bowel syndrome had sought medical advice during the study period (male:female ratio 1:1.21); consultation behaviour was influenced by age and the presence of associated symptoms, varied considerably among patients registered with different general practitioners, and was poorly correlated with symptom severity. CONCLUSION--Symptoms consistent with a diagnosis of irritable bowel syndrome are present in almost one quarter of the general population and tend to be associated with a number of other complaints and conditions, some of which may reflect smooth muscle dysfunction.     

Factors Affecting Admission to a Coronary Care Unit

Of 103 patients with suspected myocardial infarction admitted to an intensive care unit in a general hospital half were admitted within four and a half hours of the onset of symptoms. In general, patients who attended the casualty department were under intensive care sooner than patients who sought attention from their general practitioner before admission. Patients who were seen by a locum from the emergency treatment service at night or weekends were more likely to remain at home until seen the next day by their own general practitioner, compared with patients seen by their own general practitioner initially.     

Endoscopic studies of dyspepsia in a general practice.

In an urban general practice serving 7800 patients, all patients presenting over five and a half years with dyspepsia lasting more than two weeks were investigated by fibreoptic endoscopy and cholecystography, and many by barium meal. Of the 393 patients with dyspepsia, 346 completed the investigation: 180 had specific disease of the oesophagus, stomach, duodenum, or gall bladder, including six with carcinoma. Al further 67 had mucosal disease, and only 99 patients had no abnormality. After the first year the number of patients presenting annually and the percentage of patients with specific lesions remained constant. The annual incidence for patients with dyspepsia was about 1% and for patients with specific lesions 0.4%, suggesting that each year those who became symptom free (either spontaneously or because of treatment) were balanced by a similar number who developed symptoms. In contrast to the conclusions of other workers that an "open-access" endoscopy service could not be justified because the number of patients with specific lesins fell during their survey, we suggest that such endoscopy services are indeed worth while for providing an accurate diagnosis of dyspepsia.     

Contribution of Gardnerella vaginalis to vaginitis in a general practice.

In a study of 154 adult women who presented to their general practitioner with vaginal symptoms 30 (20%) had Gardnerella vaginalis on its own and 51 (33%) had G vaginalis in combination with anaerobes or known pathogens. Thirty one (20%) patients were culture negative. Those who were culture negative had fewer symptoms and signs of vaginitis than those with G vaginalis alone or G vaginalis plus anaerobes. Those with known pathogens had more symptoms and signs than those with G vaginalis alone or G vaginalis plus anaerobes. Those with known pathogens plus G vaginalis had the most severe signs and symptoms of vaginitis. It is concluded that G vaginalis can cause vaginitis on its own, and it makes vaginitis worse when present with other organisms. G vaginalis was also found in 30 (21%) of the 138 control patients who, although they presented "asymptomatically," had worse signs than control patients without G vaginalis. It seems that G vaginalis can occur in a spectrum ranging from the uncomplaining patient to those with severe vaginitis.     

Unemployment and patterns of consultation with the general practitioner.

The relation between unemployment and consultations with the general practitioner was investigated among 13,275 economically active men aged 18-64 by using the British general household surveys. Men who were unemployed but seeking work consulted with doctors significantly more (odds ratio 1.83; 95% confidence interval 1.61 to 2.09) than those in employment, the highest consultation rate being among those who had been out of work for five years or more (odds ratio 2.12; 95% confidence interval 1.12 to 3.78). The high consultation rates persisted even after adjustment for self reported longstanding illness (odds ratio 1.53; 95% confidence interval 1.34 to 1.76). These findings suggest that in areas with high unemployment general practitioner workload is likely to be high.     

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Objective To determine the cost effectiveness of Helicobacter pylori “test and treat” compared with empirical acid suppression in the initial management of patients with dyspepsia in primary care.Design Randomised controlled trial.Setting 80 general practices in the United Kingdom.Participants 699 patients aged 18-65 who presented to their general practitioner with epigastric pain, heartburn, or both without “alarm symptoms” for malignancy.Intervention H pylori ¹³C urea breath test plus one week of eradication treatment if positive or proton pump inhibitor alone; subsequent management at general practitioner’s discretion.Main outcome measures Cost effectiveness in cost per quality adjusted life year (QALY) (EQ-5D) and effect on dyspeptic symptoms at one year measured with short form Leeds dyspepsia questionnaire.Results 343 patients were randomised to testing for H pylori, and 100 were positive. The successful eradication rate was 78%. 356 patients received proton pump inhibitor for 28 days. At 12 months no significant differences existed between the two groups in QALYs, costs, or dyspeptic symptoms. Minor reductions in costly resource use over the year in the test and treat group “paid back” the initial cost of the intervention.Conclusions Test and treat and acid suppression are equally cost effective in the initial management of dyspepsia. Empirical acid suppression is an appropriate initial strategy. As costs are similar overall, general practitioners should discuss with patients at which point to consider H pylori testing.Trial registration Current Controlled Trials ISRCTN87644265.     

Excision biopsy of malignant melanoma by general practitioners in south east Scotland 1982-91.

OBJECTIVE--To examine the management of patients who had a malignant melanoma excised initially by general practitioners in south east Scotland over the past 10 years and to assess the impact of the April 1990 contract on this. DESIGN--A retrospective case-control study. SETTING--South east Scotland. SUBJECTS--All patients in south east Scotland who had malignant melanomas excised by general practitioners in 1982-91. OUTCOME MEASURES--Demographic details of patients; Breslow thickness, clearance of excision. RESULTS--42 patients had malignant melanomas excised by general practitioners in 1982-91: 15 in 1982-9 and 27 in 1990-1. These patients were significantly younger than those who had their tumours excised initially in hospital. Although the longest diameter of melanomas excised by general practitioners was significantly less than of those excised in hospital, the Breslow thicknesses were similar. Completeness of initial excision was doubtful or incomplete in nine (23%) general practitioner excisions compared with 4% of hospital excisions, but the time interval between excision biopsy and wide excision was similar. Pathology requests accompanying excision biopsies mentioned melanoma as a possible diagnosis in 15% (6/40) of general practitioner cases compared with 79% of hospital cases. Thirty nine general practitioners responded to a questionnaire and only 12 had considered melanoma in the differential diagnosis. CONCLUSIONS--General practitioners need to think more often of malignant melanoma when they excise pigmented lesions and when they consider this tumour a possibility should perform an excision biopsy with a lateral clearance of at least 2 mm.     

Choice of age cut-off for endoscopy in dyspepsia in developing countries according to incidence of gastric cancer

Endoscopic examination of all patients with dyspepsia is hard to perform, because of high annual prevalence of dyspepsia and limited resource availability, especially in developing countries. Aim was to establish age cut off for upper endoscopy in dyspeptic patients without alarming features according on incidence of gastric cancer in western Herzegovina in Bosnia and Herzegovina. Group of 2697 (1536 males, 1161 females) patients over 15 with chronic dyspepsia without alarming features and symptoms of gastroesophageal reflux disease, had been referred for a diagnostic upper endoscopy during 4 years. Study was prospective. All 34 gastric cancers were diagnosed in male patients above 55 years, and in female ones above 60. In the same age groups two thirds of gastric ulcers were found out. If the age cut off for dyspeptic patients had been 55 years for male and 60 for female gender, the workload could be decreased by 50%. The choice of alternative approaches is possible, depending on the level of diagnostic uncertainty, the patient and his physician are prepared to accept. Age cut off determines diagnostic approach in chronic dyspepsia, and greatly decreases the endoscopy workload.     

Signs of illness preceding sudden unexpected death in infants.

OBJECTIVE--To determine whether signs of illness reported by parents can be used to identify babies at risk from the sudden infant death syndrome. DESIGN--A two year prospective case-controlled study based in a geographically defined area. SETTING--Four health districts in Avon and north Somerset. SUBJECTS--Babies who had died suddenly and unexpectedly aged between 1 week and 2 years (index babies) and two control babies for each index baby selected from the same health visitor''s list and matched for age, time of year of the interview, and area of residence. MAIN OUTCOME MEASURES--Major and minor signs of illness during two weeks before the index babies'' death, or before the interview for control babies, and consultations with the general practitioner during the same period. RESULTS--Parents reported major and minor signs of illness in the previous week in 66 of the 95 index babies compared with 77 of the 190 controls. No significant difference was found in the incidence of major signs reported (34 out of 95 index babies and 44 out of 190 controls), but a higher proportion of the index babies had been seen by their general practitioner during the previous week (17/95 v 11/190). CONCLUSION--Major and minor signs of illness are neither a sensitive nor a specific indicator of sudden unexpected death of infants and have no predictive value. Better understanding of the reasons why a higher proportion of parents of babies who died took them to their general practitioners may help to identify babies at risk before death.     

Prevalence of symptoms of Raynaud's phenomenon in general practice.

OBJECTIVE--To investigate the prevalence of Raynaud''s phenomenon in the populations of five general practices. DESIGN--Two populations studied. A questionnaire was given to all new patients attending five general practices over four weeks, and the same questionnaire was sent by post to a random sample of adults from two of the practices. SETTING--General practices in inner London, Merseyside, and Cheshire. SUBJECTS--1532 Patients who completed questionnaires (1119 who attended the surgeries (response rate unknown) and 413 respondents to the postal survey (response rate 69%)). MAIN OUTCOME MEASURES--Response to questionnaire on symptoms of Raynaud''s phenomenon: patients were regarded as having the disease if they had episodes of blanching of the fingers that were precipitated by cold and accompanied by sensory symptoms (pins and needles or numbness). Subsequent interview and clinical appraisal of patients with the disease according to their responses to the questionnaire. RESULTS--The prevalence of Raynaud''s phenomenon was 11% (26/231) and 19% (34/182) respectively in men and women who completed the postal questionnaire and 16% (56/357) and 21% (157/762) respectively in those who completed the questionnaire when attending their general practice. Thus the overall rates were slightly higher in women, but there was no effect of age even after adjustment of the rates for practice and method of survey. CONCLUSION--The prevalence of Raynaud''s phenomenon is high compared with the low number of patients who seek treatment for the disease.