Screening and genetic counselling for relatives of patients with colorectal cancer in a family cancer clinic.

OBJECTIVE--To introduce and monitor a screening programme for first degree relatives of patients with colorectal cancer based on their calculated lifetime risk. DESIGN--Lifetime risks were calculated for first degree relatives of patients with colorectal cancer and used to offer screening based on estimated risk. SETTING--A family cancer clinic was set up as part of the North East Thames Regional Genetic Service for relatives of patients who had developed colorectal cancer before the age of 45 and members of families in which multiple cancer had occurred. PATIENTS--Self referrals as well as patients referred by general and hospital practitioners. INTERVENTION--Relatives with a lifetime risk of 1 in 10 or greater (high risk group) were offered screening five yearly by colonoscopy, and those whose risk was between 1 in 10 and 1 in 17 were offered yearly screening for faecal occult blood. Women with family histories compatible with Lynch type II cancer family syndrome were offered screening for breast and pelvic tumours. RESULTS--In four years 715 patients were seen. Acceptance of screening was 90% (644 patients). Of 151 patients screened for faecal occult blood, two were found to have polyps. This screening test was unsatisfactory for the high risk group, having a negative predictive value of 78% in 59 patients tested. Regular screening by colonoscopy was offered to 382 high risk patients; 62 patients with polyps and five with colonic cancer were found. One hundred and ten pedigrees were identified with the Lynch type II cancer family syndrome, and four of 35 women screened were found to have breast cancer. Of 14 relatives aged over 65 with a 1 in 2 risk of site specific colonic cancer or Lynch type II cancer family syndrome, seven were found to have polyps, one of whom had carcinoma in situ. CONCLUSIONS--Family history can be used to identify those at risk of colonic cancer and to target appropriate screening. Colonoscopy detected a high number of premalignant colonic polyps, but faecal occult blood testing was unsatisfactory for those at high risk of colorectal cancer.     

Preventing iron deficiency in preschool children by implementing an educational and screening programme in an inner city practice.

OBJECTIVE--To assess the feasibility and acceptability of screening young children for iron deficiency in a deprived inner city practice and to assess the effects of a programme of dietary education. DESIGN--Prospective study of children in general practice, comparison with historical controls. SETTING--A deprived inner city practice. PATIENTS--127 Children aged 13-24 months. Findings were compared with those in 110 children of the same age studied previously. INTERVENTIONS--All mothers received dietary education antenatally and in the first year after giving birth. Screening for iron deficiency (defined as mean cell volume less than 75 fl and haemoglobin concentration less than 105 g/l) and haemoglobinopathy (when appropriate) was offered for all children attending for immunisation against measles, mumps, and rubella over 12 months; capillary blood samples were taken after immunisation. MAIN OUTCOME MEASURES--Uptake of the screening programme expressed as the percentage of all children eligible for immunisation who were screened, and the effectiveness of the dietary education as shown by the prevalence of iron deficiency in the two groups. RESULTS--Altogether, 122 of the 127 (96%) children who attended for immunisation had their haemoglobin concentration and mean cell volume measured; 90% of all children aged 13-24 months in the practice were screened. Dietary education, clinical procedures, and counselling were incorporated successfully into the clinic''s work. Ten children (8%) were iron deficient, all of whom responded to iron supplements, and eight had a haemoglobinopathy trait. In the previous study 110 children (70%) had been screened and 28 children (25%) had been iron deficient. The two groups were similar in terms of sex, social class, and ethnic group. CONCLUSIONS--Screening young children for iron deficiency, sickle cell disease, and thalassaemia when they attended for immunisation was acceptable and successful in a socially deprived inner city practice. Dietary education may have accounted for some of the reduction in the prevalence of iron deficiency that occurred over the two years.     

Patterns of practice among older physicians in Ontario

BACKGROUND: Policy-makers interested in the supply of doctors in Canada have recently begun focusing attention on older physicians. This study informs the policy debate by analysing the practice patterns of Ontario physicians aged 65 years and over. METHODS: A cross-sectional and longitudinal analysis of physician claims data for fiscal years 1989/90 through 1995/96 was conducted. The number of full-time equivalent (FTE) physicians by age category, urban or rural status, and specialty was calculated by means of an established method, and differences between older physicians, established physicians and recent graduates (in practice for 5 years or less), in terms of the types of services provided and patients seen, were examined. RESULTS: The proportion of FTE physicians aged 65 or more increased from 5.3% to 7.0% during the study period, whereas the proportion of recent graduates decreased from 19.6% to 16.3%. Of the older physicians, 61.4% practised part time (less than 1 FTE). Half of the physicians aged 75 in 1989/90 were still in practice 6 years later. Older physicians were less likely than those under age 65 to practice obstetrics (4.6% v. 16.9%), provide emergency department services (1.1% v. 14.8%) or house calls (38.7% v. 60.4%), or perform many minor procedures (38.7% v. 62.3%) (p < or = 0.001 for all comparisons). Older physicians tended to be male and had older patients in their practices than did younger physicians. Rural regions had higher proportions of older specialists. INTERPRETATION: Ontario''s physician corps is aging. This may result in decreasing availability of obstetrics and emergency department coverage in the future. Encouraging retirement may create more openings for recent graduates, but if such policies are enacted, special attention should be paid to ensure that rural communities and older patients continue to be served.     

Population-based screening for colorectal cancer using an immunochemical faecal occult blood test: A comparison of two invitation strategies

Background: To date, there is no screening programme for colorectal cancer (CRC) in Flanders, Belgium. However, The European Code Against Cancer (2003) recommends a population-based approach for CRC screening. This study aimed to obtain information about potential participation rates for a population-based screening programme for CRC in Flanders, and to compare two invitation strategies. Methods: In 2009, a trial programme for CRC screening was set up in three Flemish areas for all average-risk people aged 50-74 years, using an immunochemical faecal occult blood test (iFOBT) with a cut-off value set at 75ng/ml of haemoglobin. The faecal sampling set was sent at random by post (mail group) or provided by the general practitioner (GP group). Results: In total, 19,542 people were invited to participate. Of these, 8229 provided a faecal sample, resulting in an overall participation rate of 42.1%. Participation by mail and through the GP was 52.3% (95% CI, 51.3-53.2) and 27.7% (95% CI, 26.7-28.6), respectively. The difference of 24.6% was statistically significant (95% CI, 23.3-25.9, p<0.001). Before the reminder letter was sent and the other invitation strategy was offered, the overall participation rate was 26.5% (n=5176); 36.4% (95% CI, 35.5-37.4) for the mail group and 16.6% (95% CI, 15.8-17.3) for the GP group. The odds of participating in CRC screening was almost three times higher for people invited by mail as opposed to people invited through a GP (OR=2.96, 95% CI, 2.78-3.14, p<0.001). Women were more likely to participate in CRC screening than men (OR=1.22, 95% CI, 1.15-1.30, p<0.001). In addition, we found that inhabitants from residential (OR=1.98, 95% CI, 1.85-2.11) and rural (OR=2.90, 95% CI, 2.66-3.16) areas were more likely to participate than those in urban areas. Of the 8229 people who submitted a faecal sample, 435 (5.3%) had a positive iFOBT, and of those, CRC was diagnosed in 18 (5.7%) individuals. Compliance for follow-up colonoscopy was 72.9%, and did not differ between the mail (72.4%, 95% CI, 67.5-77.3) and GP groups (74.3, 95% CI, 66.2-82.5). Conclusion: Inviting people for CRC screening by means of a direct-mail invitation, and including a faecal sampling set (iFOBT), results in much higher participation rates than inviting people through the GP.     

Increased incidence of faecal Klebsiella pneumoniae in patients with HLA B7 CREG antigen and men with rheumatoid arthritis.

In a study of the carriage of faecal Klebsiella pneumoniae in 106 patients with rheumatoid arthritis the incidence of carriage was higher in men (28%) than women (14%) (p < 0.001) and klebsiellae were isolated on two or more occasions from a higher proportion of men than women (p < 0.002). The incidence of carriage was increased among patients with rheumatoid arthritis who had B7 cross-reacting (B7 CREG) antigens (32% v 13%--p < 0.001). Carriage of klebsiellae was not associated with clinical disease activity, raised erythrocyte sedimentation rate, drug treatment, or the presence of HLA Dw4 or DRw4 or both. Thus the carriage and prevalence of faecal Klebsiella pneumoniae appear to be partly determined by the sex and HLA state of the host.     

Cervical screening in an inner city area: response to a call system in general practice.

To determine whether a cervical screening call system based in general practice in a deprived inner city area would increase the numbers of women who came forward for cervical smears the response to letters of invitation for screening was monitored for one year in one general practice in the Paddington and North Kensington district of London. Women aged 20-64 were identified from the computerised age-sex register. Only 16% of these women had had a smear test. A total of 750 call letters was sent out. Initially the response was poor (57 women; 22%), and 85 (32%) letters were returned marked "address unknown." After the age-sex register was updated the response to call was 330 women (44%). The response of women aged over 35 was better than the response of women aged 35 and under (229 (53%) v 101 (32%)). In the year of the study the number of women aged 20-64 on the revised register who had been screened rose by 330 (14%). A general practice based call system can improve uptake of cervical screening even in a highly mobile, socially underprivileged population.     

Adolescent smokers seen in general practice: health,lifestyle, physical measurements,and response to antismoking advice.

OBJECTIVE--To compare physical, lifestyle, and health characteristics of adolescent smokers and non-smokers and their initial response to anti-smoking counselling. DESIGN--Adolescents aged 13, 15, and 17 years were identified from age-sex registers and invited by letter for a general practice health check. SETTING--Three general practices in the MRC general practice research framework. MAIN OUTCOME MEASURES--Blood pressure, body mass index, saliva cotinine concentration, peak flow rate, alcohol consumption, exercise, duration of sleep, and stated persistent health problems. RESULTS--73% of the adolescents (491) attended for the health check. A total of 68 (14%) were regular smokers. By age 17 those who smoked regularly had a significantly lower systolic blood pressure than those who had never smoked regularly (by 6 mm Hg; p = 0.025) despite a significantly higher body mass index (by 1.5; p <0.001) [corrected]. Cotinine concentrations increased with smoking exposure, from 0.7 ng/ml when no family member smoked to 155 ng/ml in active smokers of six or more cigarettes a week. Significantly more regular smokers than never regular smokers drank greater than or equal to 8 g alcohol a day (chi 2 = 15.2 adjusted for age and sex p less than 0.001); regular smokers exercised less (1.0 hrs/week in boys and 0.8 hrs/week in girls v 3.4 hrs/week in boys and 2.2 hrs/week in girls; p less than 0.001) and slept less (8.0 hrs/night v 8.5 hrs/night at age 17; p less than 0.005). Persistent health problems, mostly asthma or allergic symptoms, were reported by 25% (17/68) of the smokers and 16% (60/381) of the non-smokers. Of the smokers given counselling, 60% (26/43) made an agreement with the practice doctor or nurse to give up smoking. CONCLUSION--General practice is an appropriate setting for adolescents to receive advice on healthy lifestyle, which should not focus solely on smoking.     

Disturbances of insulin in British Asian and white men surviving myocardial infarction.

OBJECTIVE--To examine the role of insulin as a cardiovascular risk factor in British Asian and white men. DESIGN--Case-controlled study of survivors of first myocardial infarction. SETTING--District general hospital. PATIENTS--Consecutive series of 76 white and 74 Asian men who survived first myocardial infarction compared with 58 white and 61 Asian male controls without coronary artery disease who were randomly sampled from the community. RESULTS--More Asians than white subjects had impaired glucose tolerance or overt diabetes as measured by the two hour glucose tolerance test (23/74 (32%) v 11/76 (15%) (p less than 0.001) among patients; 17/61 (28%) v 3/58 (6%) (p less than 0.001) among controls). Insulin and C peptide concentrations were higher in both patient groups than in respective controls (p less than 0.001) and higher in Asian than in white subjects, irrespective of their glucose tolerance. Triglyceride concentrations were higher in patients than in controls (1.92 (SD 1.05) v 1.43 (0.82) mmol/l among Asian men; 1.65 (0.83) v 1.3 (0.61) mmol/l among white subjects; p less than 0.001). Total cholesterol concentrations were lower in both groups of Asians than in respective white subjects (5.78 (0.99) v 6.22 (1.04) mmol/l (p less than 0.01) among patients; 5.54 (1.01) v 5.65 (1.11) mmol/l (p less than 0.6) among controls). High density lipoprotein cholesterol concentrations were lower in Asian than in white subjects. The ratio of total cholesterol to high density lipoprotein cholesterol was significantly higher (p less than 0.001) in both patient groups (6.69 (1.81) in Asian patients and 6.31 (1.91) in white patients) than in respective controls (5.24 (1.19) and 4.77 (1.43)). Regression analysis identified C peptide concentration and the ratio of total to high density lipoprotein cholesterol as powerful independent predictors of myocardial infarction in Asian and white men. Total cholesterol concentration predicted infarction in white but not in Asian men. CONCLUSIONS--Secretion and hepatic extraction of insulin are high in survivors of myocardial infarction and especially high in British Asians. Tissue resistance to the action of insulin, giving rise to increased pancreatic secretion, may be an important risk factor for coronary artery disease in both ethnic groups and may be partly responsible for the high incidence of diabetes and coronary artery disease in Asian populations.     

Metabolic and growth response of mink (Neovison vison) kits until 10 weeks of age when exposed to different dietary protein provision

Growth performance and metabolism were investigated in mink kits (n = 210) exposed to the same dietary treatment as their dams (n = 30), i.e. high (HP; 61% of metabolisable energy, ME), medium (MP; 48% of ME) or low (LP; 30% of ME) protein supply, from birth until 10 weeks of age. The kits were weighed weekly, and were measured by means of balance experiment and indirect calorimetry, in weeks eight and nine post-partum (p.p.). At weaning (seven weeks p.p.) and 10 weeks p.p. one kit per litter was killed and blood, liver and kidneys were collected. Plasma amino acid profiles, and hepatic abundance of mRNA for phosphoenolpyruvate carboxykinase (PEPCK), fructose 1,6-biphosphatase, pyruvate kinase and glucose-6-phosphatase (G-6-Pase) by q-PCR, were determined. There were no differences in live weights among kits the first four weeks of life when kits solely consumed milk, but male LP kits were the heaviest. After transition to solid feed MP kits weighed most at nine weeks of age (p < 0.05). At eight weeks of age, the kits fed the LP diet retained less (p < 0.05) N than HP and MP kits. Heat production did not differ among kits, although protein oxidation was higher (p < 0.001) in HP kits than in LP kits. Kits fed the LP diet had lower (p < 0.05) plasma concentrations of lysine, methionine and leucine than MP kits. Dietary treatment was not reflected in the relative abundance of any of the studied mRNAs, but kits had significantly lower abundance of all studied mRNA than their dams, ranging from 83% less PEPCK abundance to 40% less for G-6-Pase. The kidney mass was smallest (p < 0.01) in kits fed the LP diet, and liver masses were largest (p < 0.001) in HP kits. The results indicate that the LP diet did not meet the protein requirements for mink kits in the transition period from milk to solid feed. The capacity to regulate the rate of gluconeogenesis was even more limited in young mink kits than in adult dams. However, young mink kits can regulate protein oxidation in response to dietary protein supply, probably by adapting the size of the liver and kidneys to the level of protein supply.     

A study of patients attending without appointments in an urban general practice.

OBJECTIVE--To ascertain which social and psychological characteristics are associated with patients attending surgeries without appointments. DESIGN--Prospective study of patients attending an urban centre group practice. SETTING--Urban health centre group practice with five doctors and 12,000 patients in an area of high (greater than 20%) unemployment and social deprivation. PATIENTS--All attenders at the open access surgery and one in four consecutive attenders by appointment, selected sequentially from the first three appointments, during 10 days in January 1989. Patients participating in the pilot study, reattending during the study period, or attending antenatal clinics were excluded. MAIN OUTCOME MEASURES--Patients'' attitude to making appointments and reasons for attending, including perception of urgency, with respect to sociodemographic and psychosocial data obtained from a self completed questionnaire before the consultation. Doctors'' diagnosis and perception of urgency obtained from a separate questionnaire. RESULTS--86% (141/172) Of patients attending without appointments and 96% (139/145) with appointments responded to the questionnaire. The need for consultation was considered to be "very urgent" or "fairly urgent" in significantly more of the open access group than the appointments group (89%, 124/139 v 66%, 91/138; chi 2 = 27.04, df = 3; p less than 0.001), although the doctors did not share the same views. Significantly more patients had self limiting conditions of recent onset in the open access than in the appointments group (75%, 101/135 v 48%, 59/123: p less than 0.001). Overall, open access attendance was significantly linked with social support (39%, 48/124 v 26%, 32/123; p less than 0.05) and with marital separations or intentions to separate (10%, 9/87 v 0/92; 47%, 32/87 v 22%, 20/92 respectively; both p less than 0.001), but the doctors recorded significantly fewer psychological and social problems in these patients (p less than 0.05). Although almost half those in the appointments group considered that making appointments was inconvenient, more of those in the open access group agreed with this view (47%, 60/129 v 61%, 80/131). CONCLUSIONS--There was an important link between social support problems and a negative attitude to making appointments. In our previous experience encouraging patients to make appointments has been unsuccessful; practices serving areas with a high prevalence of social deprivation providing a mixed open access and appointments system may better serve patients'' needs.     

Doctor-patient communications revisited

To test a new approach to detecting and managing hypertension, 34 family practices in southwestern Ontario that comprised 32 124 patients aged 20 to 65 years were randomly assigned in a 5-year study to either undertake a system of care in which a medical assistant oversaw screening and attended to education, compliance and follow-up (experimental group) or continue their usual practices (control group). The 17 physicians in the experimental practices (15 659 patients) were matched with the 17 in the control practices (16 465 patients) according to size of the community, sex, level of practice activity and length of time in practice. Hypertension was defined as at least two diastolic blood pressure readings over 90 mm Hg. More patients in the experimental group than in the control group were screened at least once (91% v. 80%); the former were more likely to have lower systolic blood pressure (p less than 0.02), to be compliant (p less than 0.05) and to be very satisfied with care (p less than 0.01). There were no significant differences between the two groups in the rates of illness and death due to cardiovascular disease for all patients or for hypertensive patients. The unassisted family physician can provide effective care for hypertensive patients. However, minor modifications in the physician''s practices can improve care.     

Comparison of immunisation rates in general practice and child health clinics.

OBJECTIVE--To compare immunisation uptake rates in general practice surgeries and community child health clinics. DESIGN--Cohort study using data from a computerised child health system. SETTING--Four health districts of North East Thames Regional Health Authority. SUBJECTS--3616 children born January to March 1990 and resident in the four districts at the end of January 1991. MAIN OUTCOME MEASURES--Immunisation uptake rates at 10-12 months of age, age at immunisation, scheduling performance at the two locations, and odds ratios of outstanding immunisations. RESULTS--80% of children registered at general practices had completed their third dose of pertussis immunisation compared with 68% of those at health clinics. Median ages at the third dose were 24 weeks and 29 weeks at the two locations respectively. Scheduling was more effective at general practice surgeries. Unscheduled immunisations were more likely to be given after the recommended age. Overall, children resident in rural and suburban areas had greater uptakes than those in inner cities. Odds ratios for not being fully immunised among children registered at health clinics were 1.4 times those among children immunised in general practice and 3.0 times greater among children resident in inner cities than among those in rural and suburban districts. Children who moved into a district, however, were no less likely to be fully immunised than children who were born there. CONCLUSIONS--The immunisation uptake rate was better in general practices than in child health clinics in both inner city and rural and suburban areas. Uptake may be increased with additional support to enable general practitioners to undertake immunisations, especially in inner cities.     

Uptake of cystic fibrosis testing in primary care: supply push or demand pull?

OBJECTIVE--To determine the acceptability and feasibility of screening for carriers of cystic fibrosis in a primary care setting. DESIGN--Follow up study over 15 months of patients offered carrier testing by mouthwash. SETTING--A general practice in inner London. SUBJECTS--5529 patients aged 18-45 invited by various methods and combinations of methods (letter, booklet, personal approach) for testing. MAIN OUTCOME MEASURES--Uptake of screening, anxiety, and knowledge of test. RESULTS--957 (17%) invitees were screened over the 15 months. 28 carriers and no carrier couples were detected. Uptake rates were 12% (59/502 patients) among patients invited by letter and tested by appointment; 9% (47/496) among patients invited by letter, with leaflet, and tested by appointment; 4% (128/2953) among patients invited by letter six weeks before the end of the study and tested by appointment; 17% (81/471) among patients offered passive opportunistic testing; 70% (453/649) among patients offered active opportunistic testing; and 25% (22/88) among patients offered active opportunistic testing by appointment. A short term rise in anxiety among those given a positive test result had dissipated by three months. At three months about one fifth and one third of those given positive and negative results respectively did not understand their results correctly. CONCLUSION--These results suggest that the strongest variable in determining uptake of screening is the active approach by a health professional offering immediate testing. It remains to be resolved whether the high uptake rates achieved by active recruitment indicate a supply push for this new test rather than a demand from the population.     

Impact of an educational video-based strategy on the behavior process associated with colorectal cancer screening: A randomized controlled study

Background: Low public awareness is an important barrier for colorectal cancer screening participation. Aim: To evaluate the impact of educational intervention on the health behavior process, patient knowledge and compliance with colorectal cancer screening in the average-risk population. Methods: 158 subjects (aged 50–79 years) were randomly assigned either to watch a non-medical video or a colorectal cancer educational video. Before and after watching the experimental or control videotape, participants completed a five-item questionnaire that assessed their knowledge about risk factors for colorectal cancer, age of risk, warning symptoms, 5-year prognosis, and incidence. Subjective risk perception for developing colorectal cancer, barriers or benefits of screening, and intention to be screened were also investigated. Finally, subjects received a faecal occult blood test kit and were requested to use and return it within 2 weeks. Results: Participants in the video-based intervention group showed significant improvement in knowledge of colorectal cancer scores (P < 0.001) and decreased barrier scores. The intervention group returned significantly more faecal occult blood tests than controls (69.6% vs. 54.4%, P = 0.035). The intervention had a positive effect on modifying attitudes and intention to take part in screening. Additionally, the intervention was a predictor of compliance (OR 2.0; 95% CI = 1.02–3.84, P = 0.044). Conclusion: Video-based intervention significantly reduced barriers to screening and improved participant awareness and compliance with colorectal cancer screening with faecal occult blood test.     

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns.

OBJECTIVES: To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training. DESIGN: Mail survey conducted in 1985-86. SETTING: Province of Quebec. PARTICIPANTS: A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%). MAIN RESULTS: Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice. CONCLUSION: Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.     

Prophylaxis against hepatitis A for travel.

OBJECTIVE--To develop a rational practice policy for prophylaxis against hepatitis A for travellers to high risk areas. DESIGN--18 Month prospective study of consecutive patients who requested prophylaxis against hepatitis A. SETTING--Inner city general practice. SUBJECTS--104 Patients aged 15-61 (mean 30) assessed for risk factors for hepatitis A and put into groups depending on predictions from the risk factors of their immunity. MAIN OUTCOME MEASURES AND RESULTS--All patients were screened for antibody to hepatitis A virus. Of 52 patients with no risk factors 47 had no antibody and were thus susceptible to hepatitis A. All 27 patients with major risk factors (having been brought up in an endemic area or with a history of jaundice) were immune. Of 25 patients with minor risk factors (a history of previous travel in high risk areas, drug abuse, having lived in a squat or travelled rough, or having lived with someone who had jaundice) 12 were immune (p less than 0.001, chi 2 test). CONCLUSIONS--All travellers requesting prophylaxis against hepatitis A should be assessed for risk factors for previous exposure to hepatitis A. Those with no risk factors could be immunised with human normal immunoglobulin without screening. The remainder should be tested for hepatitis A antibody and those found to be susceptible should be immunised.     

Influence of non-steroidal anti-inflammatory drugs on the outcome of faecal occult blood tests in screening for colorectal cancer.

Non-steroidal anti-inflammatory drugs have been accused of causing false positive results in faecal occult blood tests for colorectal cancer. A study was therefore performed in 10,931 people undergoing faecal occult blood screening tests to assess the effect of these drugs on the predictive value of a positive test result. Those with a positive result were interviewed and a full drug history was taken before they underwent a full colorectal examination. Of the 455 people with a positive result, 50 were taking non-steroidal anti-inflammatory drugs: 10 (20%) had colonic neoplasia. Of the 405 who were not taking non-steroidal anti-inflammatory drugs, 129 (32%) had colonic neoplasia. These detection rates were not significantly different, and the predictive value of a positive result for an adenoma larger than 1 cm was 14% in the group not taking anti-inflammatory drugs and 26% in the group taking them (not significant). These results suggest that a finding of occult faecal blood cannot be attributed to upper gastrointestinal tract bleeding caused by non-steroidal anti-inflammatory drugs and should be followed by a thorough colorectal examination.     

Job stress,satisfaction, and mental health among general practitioners before and after introduction of new contract.

OBJECTIVE--To compare measures of job stress, job satisfaction, and mental health among general practitioners before and after the introduction of the new contract in April 1990. DESIGN--Cross sectional postal questionnaire survey in July 1990. Comparison of results with those obtained in previous survey in November 1987. SETTING--General practice in United Kingdom. SUBJECTS--1500 general practitioners randomly selected from general medical services lists, 917 of whom (61%) returned questionnaires usable for statistical analysis. MAIN OUTCOME MEASURES--Aspects of job causing stress, job satisfaction (Warr, Cook, and Wall scale), and mental health (Crown-Crisp experiential index). RESULTS--Compared with 1987, in 1990 doctors experienced more stress from night calls (mean score 3.83 in 1990 v 3.45 in 1987), emergencies during surgery hours (3.72 v 3.48), and interruption of family life by telephone (3.58 v 2.73; p less than 0.001 for all three variables). Scores for somatic anxiety and depression were higher in both men and women in 1990 (men: somatic anxiety 3.12 v 2.36; depression 3.80 v 2.94; women: somatic anxiety 3.56 v 2.65; depression 4.02 v 3.37; p less than 0.001). Job satisfaction had also decreased in 1990 (5.23 v 4.26; p less than 0.001). CONCLUSIONS--Doctors experienced more stress, less job satisfaction, and poorer mental health in 1990 than in 1987. These changes may have resulted from the introduction of the new contract.     

Dipstick haematuria and bladder cancer in men over 60: results of a community study.

OBJECTIVE--To investigate the prevalence and relevance of dipstick haematuria in a group of men in the community. DESIGN--Prospective study of elderly men invited to attend a health centre for urine screening as part of a health check. SETTING--An inner city health centre in Leeds. SUBJECTS--578 Of 855 men aged 60-85 responding to an invitation to participate. INTERVENTIONS--The subjects had their urine tested with a dipstick (Multistix) for the presence of blood and then tested their urine once a week for the next 10 weeks. Those with one or more positive test results were offered full urological investigation. MAIN OUTCOME MEASURE--The prevalence of urological disease in those subjects with dipstick haematuria. RESULTS--78 Men (13%) had dipstick haematuria on a single test and a further 54 (9%) had evidence of dipstick haematuria when testing their urine once a week during a subsequent 10 week period. Investigation of 87 men disclosed urological disease in 45, including four with a bladder tumour and seven with epithelial dysplasia. CONCLUSION--Dipstick haematuria is a common incidental finding in men over 60 and is associated with appreciable urological disease. The introduction of less invasive methods of investigation, particularly flexible cystoscopy and ultrasonography, has made investigation of these patients simple and safe and makes screening for bladder cancer in the community more feasible.