Complaints In General Practice Research Articles

Acute abdominal pain in general practice

Acute abdominal pain (AAP) represents the 9th most common complaint in general practice. The etiologies are multiple: a third are non-specific, but around 10% require hospital treatment. An accurate history enables a correct diagnosis in 76% of cases, and abdominal palpation can detect a possible surgical abdomen. This article summarizes the intra- and extra-abdominal causes of AAP, the diagnostic strategies, and the most appropriate complementary examinations. It lists the most common causes in general practice, as well as their management and reviews the warning signs not to be missed.

Why do children under 5 years go to the GP in Lambeth: a cross-sectional study

ObjectivesThis study identifies the most common recorded reason for attendance to primary care for children under 5 years old, including a breakdown via age, ethnicity, deprivation quintile and sex.DesignCross-sectional.Setting39 of...

Referral Patterns for People With Musculoskeletal Complaints in General Practice: An Analysis From an Australian Primary Care Database.

Our objective was to examine referral patterns for people with musculoskeletal complaints presenting to Australian general practitioners (GPs). This longitudinal analysis from the Population Level Analysis Reporting (POLAR) database includes 133,279 patients with low back (≥18 years old) or neck, shoulder, and/or knee (≥45 years old) complaints seen by 4,538 GPs across 269 practices from 2014 through 2018. Referrals to allied health and medical and/or surgical specialists were included. We determined the number of patients with referrals and GPs who made referrals and examined their timing, associations, and trends over time. A total of 43,666 patients (33%) received and 3,053 GPs (67%) made at least one referral. Most referrals were to allied health (n=25,830, 19%), followed by surgeons (n=18,805, 14%). Surgical referrals were higher for knee complaints (n=6,140, 24%) compared with low back, neck, and shoulder complaints (range 8%-15%). The referral category varied predominantly by body region followed by gender, socioeconomic status, and primary health network. Time to allied health referral ranged between median (interquartile range [IQR]) 14 days (0-125 days) for neck complaints and 56 days (5-177 days) for knee complaints. Surgical referrals occurred sooner for those with knee complaints (15 days, IQR 0-128 days). There was a 2.2% (95% confidence interval [CI] 1.9%-2.4%) annual increase in the proportion of allied health referrals and a 1.9% (95% CI 1.6%-2.1%) decrease in surgical referrals across all sites. One-third of patients receive, and two-thirds of GPs make, referrals for musculoskeletal complaints. Understanding the reasons for referral and differences between GPs who refer more and less frequently may identify factors that explain variations in practice.

SupportPrim—a computerized clinical decision support system for stratified care for patients with musculoskeletal pain complaints in general practice: study protocol for a randomized controlled trial

BackgroundMusculoskeletal disorders represented 149 million years lived with disability world-wide in 2019 and are the main cause of years lived with disability worldwide. Current treatment recommendations are based on “one-size fits all” principle, which does not take into account the large degree of biopsychosocial heterogeneity in this group of patients. To compensate for this, we developed a stratified care computerized clinical decision support system for general practice based on patient biopsychosocial phenotypes; furthermore, we added personalized treatment recommendations based on specific patient factors to the system. In this study protocol, we describe the randomized controlled trial for evaluating the effectiveness of computerized clinical decision support system for stratified care for patients with common musculoskeletal pain complaints in general practice. The aim of this study is to test the effect of a computerized clinical decision support system for stratified care in general practice on subjective patient outcome variables compared to current care.MethodsWe will perform a cluster-randomized controlled trial with 44 general practitioners including 748 patients seeking their general practitioner due to pain in the neck, back, shoulder, hip, knee, or multisite. The intervention group will use the computerized clinical decision support system, while the control group will provide current care for their patients. The primary outcomes assessed at 3 months are global perceived effect and clinically important improvement in function measured by the Patient-Specific Function Scale (PSFS), while secondary outcomes include change in pain intensity measured by the Numeric Rating Scale (0–10), health-related quality of life (EQ-5D), general musculoskeletal health (MSK-HQ), number of treatments, use of painkillers, sick-leave grading and duration, referral to secondary care, and use of imaging.DiscussionThe use of biopsychosocial profile to stratify patients and implement it in a computerized clinical decision support system for general practitioners is a novel method of providing decision support for this patient group. The study aim to recruit patients from May 2022 to March 2023, and the first results from the study will be available late 2023.Trial registrationThe trial is registered in ISRCTN 11th of May 2022: 14,067,965.

Prevalence and characteristics of musculoskeletal complaints in primary care: an analysis from the population level and analysis reporting (POLAR) database

BackgroundElectronic health record datasets have been used to determine the prevalence of musculoskeletal complaints in general practice but not to examine the associated characteristics and healthcare utilisation at the primary care level.AimTo describe the prevalence and characteristics of patients presenting to general practitioners with musculoskeletal complaints.Design and settingA five-year analysis within three Primary Health Networks (PHNs) in Victoria, Australia.MethodWe included patients with at least one face-to-face consultation 2014 to 2018 inclusive and a low back (≥ 18 years), and/or neck, shoulder or knee (≥ 45 years) complaint determined by SNOMED codes derived from diagnostic text within the medical record. We determined prevalence, socio-demographic characteristics and diagnostic codes for patients with an eligible diagnosis; and number of consultations within one year of diagnosis.Results324,793/1,294,021 (25%) presented with at least one musculoskeletal diagnosis, of whom 41% (n = 133,279) fulfilled our inclusion criteria. There were slightly more females (n = 73,428, 55%), two-thirds (n = 88,043) were of working age (18–64 years) and 83,816 (63%) had at least one comorbidity. Over half had a low back diagnosis (n = 76,504, 57%) followed by knee (n = 33,438, 25%), shoulder (n = 26,335, 20%) and neck (n = 14,492, 11%). Most codes included ‘pain’ and/or ‘ache’ (low back: 58%, neck: 41%, shoulder: 32%, knee 26%). Median (IQR) all-cause consultations per patient within one year of diagnosis was 7 (4–12).ConclusionThe burden of MSK complaints at the primary care level is high as evidenced by the prevalence of people with musculoskeletal complaints presenting to a general practitioner, the preponderance of comorbidities and the numerous consultations per year. Identification and evaluation of strategies to reduce this burden are needed.

804 Accessory Extensor Digitorum Brevis Manus Muscle Presenting as a Painful Dorsal Hand Swelling - a Case Report

Abstract Hand and wrist pain are common presenting complaints in General Practice, Emergency Departments, and plastic surgery clinics across the UK. We present the case of a 43-year-old male who initially presented to his General Practitioner with an 18-month history of progressive pain and intermittent swelling to the dorsum of his right hand and wrist. Magnetic resonance imaging (MRI) and ultrasound (US) performed privately, when his symptoms first presented, were inconclusive, demonstrating generalised tenosynovitis. The patient had previously tried local steroid injections and shockwave therapy prior to being referred, neither of which relieved his symptoms. On examination in clinic, there was subtle fusiform prominence over the radio-dorsal aspect of his right hand, with tenderness on palpation and on extension of the wrist. An up-to-date MRI scan was performed which revealed an accessory extensor digitorum brevis manus (EDBM) muscle at the dorsal aspect of the right hand and wrist. The patient opted for excision of the accessory EDBM muscle, which was performed without complication under general anaesthetic and regional block. He made an unremarkable recovery. Whilst accessory extensor muscles in the hand are not unheard-of, variant EDBM muscles only account for around 1% of these, and only a handful have been documented in literature. When patients present with a painful swelling in the dorsum of the hand or wrist, which is exacerbated with repetitive use, a diagnosis of an accessory EDBM muscle should be considered a differential.

Assessing Medical Student Basic Otolaryngology Knowledge: A questionnaire-based Study

Background: Otolaryngology is one of the oldest medical specialties that involves the diagnosis and treatment of patients with diseases and conditions of the ears, nose, throat, head, and neck. The commonest ENT cases encountered by physicians are tonsillitis, acute otitis media, pharyngitis, epistaxis, and hay fever. The prevalence of otolaryngologic complaints in general practice is disproportionately high compared to the amount of otolaryngology module provided in medical school. Objectives: The purpose of this study is to assess medical students’ basic otolaryngology knowledge. Additionally, we will check factors that determine the level of knowledge. Methods: A cross-sectional survey was conducted among medical students in clinical years in the Saudi Arabia who studied ENT module. Participating students completed an online questionnaire that included questions related to ENT module. Results: The study included 483 participants, 53.4% were males and 46.6% were females. 43.7% were in the 4th academic year. 16.1% of participants intent to choose ENT as future specialty. 94.6% took ENT module and test. 44.5% reported spending 1-2 days on an ENT service or office, as part of clinical education. The majority of our study participants correctly answered ENT cases. Conclusion: Saudi medical students have appropriate knowledge of basic otolaryngology. With a significant proportion of ENT complaints in general practice, it is critical that all graduating medical students, not just those entering ENT, are adequately trained in basic ENT to perform competently and be confident enough to manage or refer these patients. Keywords: medical, student, basic, otolaryngology, knowledge, Saudi

Breast FNA cytology reporting using new proposed IAC Yokohama reporting system: A single institution retrospective study

Introduction: Breast lumps are a common presenting complaint in general practice. Breast cancers are the most common cancers diagnosed over the world along with unfortunate rise in number of mortality due to them. Proper diagnostic evaluation is necessary. The fine needle aspiration cytology (FNAC) examination of breast lumps is important as it can be used either to differentiate between benign and malignant breast lesion or as an adjunct to core needle biopsy. In 2016 the IAC Yokohama five category reporting system was proposed to allow uniform reporting of breast FNA aspirates. Aim: The current study aims to reclassify breast lump aspirates using the proposed Yokohama reporting system and also to assess the risk of malignancy of each category. Materials and Methods: This single institution retrospective study included female breast lump FNAC cases over 4 year period. Clinical details of included cases were recorded from archives. Cytology slides were reevaluated as per new reporting system and the histopathology correlation was done where available. Statistical analysis was performed. Risk of malignancy of each category was calculated. Results: 649 breast FNAC cases were studied of average age 36.97 years. Maximum cases were in benign category followed by malignant category. Fibroadenoma was most common benign diagnosis. The risk of malignancy was 3.17% in benign category and 95.45% in suspicious for malignancy category. The diagnostic accuracy in current study was 97.83%. Conclusion: Use of a standard categorical cytology reporting system will give improved reports for better patient care.

The incidence and management of shoulder complaints in general practice: a retrospective cohort study.

BackgroundShoulder pain is the third most common musculoskeletal complaint in primary care. The international guidelines for general practitioners (GPs) recommend a stepwise treatment of shoulder pain. Little is known about the actual distribution of these treatments in current practice.ObjectiveTo gain insight in the incidence and current management of shoulder complaints in Dutch general practice.MethodsA retrospective cohort study was conducted using a health care database containing the full electronic medical records of approximately 200 000 patients in Dutch general practice. A search algorithm was constructed to identify incident cases of shoulder complaints from January 2012 to December 2017. Data on the management of shoulder complaints were manually validated in a random sample of 1000 cases.ResultsThe overall incidence of shoulder complaints was 30.3 (95% confidence interval 29.9–30.7) per 1000 person-years. More than half of the patients (58.6%) consulted their GP only once, 44.4% two times or more and 19.7% three times or more. For most patients (58.1%), the GP applied a wait-and-see policy or prescription of oral medication in the first consultation. However, no less than 42.9% of the patients were referred or received an injection already in the first consultation.ConclusionsThere is a wide variety of treatments for shoulder complaints applied by the GP. Some patients are referred or received an injection already in the first consultation. The stepwise approach recommended by the guideline, might not always be applicable due to the diversity of patient- and shoulder characteristics presented in general practice.

Patient complaints in general practice seen through the lens of professionalism: a retrospective observational study.

BackgroundProfessionalism is a key competence for physicians. Patient complaints provide a unique insight into patient expectations regarding professionalism. Research exploring the exact nature of patient complaints in general practice, especially focused on professionalism, is limited.AimTo characterise patient complaints in primary care and to explore in more detail which issues with professionalism exist.Design & settingA retrospective observational study in which all unsolicited patient complaints to a representative out-of-hours general practice (OOH GP) service provider in The Netherlands were analysed over a 10-year period (2009–2019).MethodComplaints were coded for general characteristics and thematically categorised using the CanMEDS Physician Competency Framework (CanMEDS) as sensitising concepts. Complaints categorised as professionalism were subdivided using open coding.ResultsOut of 746 996 patient consultations (telephone, face-to-face, and home visits) 484 (0.065%) resulted in eligible complaint letters. The majority consisted of two or more complaints, resulting in 833 different complaints. Most complaints concerned GPs (80%); a minority (19%) assistants. Thirty-five per cent concerned perceived professionalism lapses of physicians. A rich diversity in the wording of professionalism lapses was found, where ' not being taken seriously ' was mentioned most often. Forty-five per cent related to medical expertise, such as missed diagnoses or unsuccessful clinical treatment. Nineteen per cent related to management problems, especially waiting times and access to care. Communication issues were only explicitly mentioned in 1% of the complaints.ConclusionMost unsolicited patient complaints were related to clinical problems. A third, however, concerned professionalism issues. Not being taken seriously was the most frequent mentioned theme within the professionalism category.

Antibiotic prescribing patterns of general practice registrars for infective conjunctivitis: a cross-sectional analysis

INTRODUCTION Over-prescription of antibiotics for common infective conditions is an important health issue. Infective conjunctivitis represents one of the most common eye-related complaints in general practice. Despite its self-limiting nature, there is evidence of frequent general practitioner (GP) antibiotic prescribing for this condition, which is inconsistent with evidence-based guidelines. AIM To investigate the prevalence and associations of GP registrars' (trainees') prescription of antibiotics for infective conjunctivitis. METHODS We performed a cross-sectional analysis of the Registrar Encounters in Clinical Training (ReCEnT) ongoing prospective cohort study, which documents GP registrars' clinical consultations (involving collection of information from 60 consecutive consultations, at three points during registrar training). The outcome of the analyses was antibiotic prescription for a new diagnosis of conjunctivitis. Patient, registrar, practice and consultation variables were included in uni- and multivariable logistic regression analyses to test associations of these prescriptions. RESULTS In total, 2333 registrars participated in 18 data collection rounds from 2010 to 2018. There were 1580 new cases of infective conjunctivitis (0.31% of all problems). Antibiotics (mainly topical) were prescribed in 1170 (74%) of these cases. Variables associated with antibiotic prescription included patients' Aboriginal or Torres Strait Islander status, registrar organisation of a follow up (both registrar and other GP follow up), and earlier registrar training term (more junior status). DISCUSSION GP registrars, like established GPs, prescribe antibiotics for conjunctivitis in excess of guideline recommendations, but prescribing rates are lower in later training. These prescribing patterns have educational, social and economic consequences. Further educational strategies may enhance attenuation of registrars' prescribing during training.

Rural\u2013urban disparities and factors associated with delayed care-seeking and testing for malaria before medication use by mothers of under-five children, Igabi LGA, Kaduna Nigeria

BackgroundFever in under-five children (U5) is the commonest presenting complaint in general practice and mothers’ recognition is an entry point for fever treatment, including malaria. This study describes rural–urban disparity in fever prevalence in U5, mothers’ malaria knowledge, care-seeking, testing for malaria before anti-malarial medication and the associated factors.MethodsA cross-sectional survey was conducted among 630 mother–child pairs [rural (300) and urban (330)] selected randomly using a multi-stage sampling from 63 villages in Igabi LGA, Kaduna State, Nigeria. Trained female data collectors administered a pre-tested structured questionnaire to collect information on mother–child demographic profiles, malaria knowledge, fever episodes in birth order last child in two weeks prior to survey, blood testing before anti-malarial use, and delayed care-seeking defined as care sought for fever > 48 h of onset. Malaria knowledge was categorized into good, average, and poor if the final scores were ≥ 75th, 50th–74th, and < 50th percentiles, respectively. Frequency, proportions, and odds ratio were calculated. Statistically significant was set at p-value < 0.05.ResultsThe median age (interquartile range) of rural mothers was 30 (IQR, 10) years compared to 27 (IQR, 6) years in urban. Of the 70.0% (441/629) U5 children with fever, 58.5% (258/441) were in rural settlements. A third of the mothers whose child had fever sought care. Mothers in rural settlements were 2.8 (adjusted OR: 2.8, CI 1.8–4.2, p < 0.01) times more likely to delay care-seeking for fever. Other significant factors were poor or no knowledge of malaria transmission, poor perception of malaria as a major health problem, and household size > 5. Also, mothers who had no formal education were four times more likely to receive anti-malarial medications without testing for malaria compared to their educated counterpart (adjusted OR: 4.0, 95% CI 1.6–9.9, p < 0.000).ConclusionsRural–urban disparities existed between fever prevalence in U5 children, care-seeking practices by their mothers, and factors associated with delayed care-seeking and testing the fever for malaria before anti-malarial medication. Fever treatment for high impact malaria elimination in Nigeria needs a context-specific intervention rather than ‘one-size-fits-all’ approach.

The causes of acute cough: a tertiary-care hospital study in Japan

Objectives Cough is the most frequent presenting complaint in general practice and has an adverse effect on an individual’s well-being. Understanding the causes of cough is critical for appropriate patient management. According to its duration, cough is classified as acute, subacute, and chronic. While acute respiratory infection is considered to be the major cause of acute cough, there is little evidence. Methods We retrospectively assessed the prevalence of acute cough in all patients presenting with cough to the respiratory clinic of Japanese Red Cross Wakayama Medical Center from May 2018 to April 2019. We subsequently assessed the causes of acute cough, after stratifying patients with acute cough into two subgroups based on the chest X-ray findings. Results Among 685 patients (329 males; mean age, 61.8 ± 18.6 years) who presented with cough as a chief complaint, 274 (125 males; mean age, 57.6 ± 20.9 years) reported to have acute cough; chest X-ray abnormalities were detected in 113 of these patients. The most frequent cause of acute cough among 113 patients with chest X-ray abnormalities was pneumonia (55.8%), followed by lung cancer (9.7%) and pneumonia exacerbating asthma (7.1%). Among the 161 patients with acute cough without chest X-ray abnormalities, the most frequent cause was upper respiratory tract infection (57.1%), followed by asthma (23.6%) and cough variant asthma (6.2%). Conclusions Cough is the most frequent presenting complaint in general practice. Infections are the most frequent causes of acute cough regardless of the chest X-ray findings.

Evaluating the effects of probiotics in pediatrics with recurrent abdominal pain.

Background Recurrent abdominal pain (RAP) is one of the frequent complaints in general practice, particularly in pediatrics and is among the common cause of referral to gastroenterology clinics.Purpose This study is designed to investigate the effects of probiotics for the treatment of RAP and desired therapeutic outcomes.Methods One hundred twenty-five children with the diagnosis of RAP according to Rome III criteria for irritable bowel syndrome (IBS), functional abdominal pain (FAP), functional dyspepsia (FD), and abdominal migraine (AM), were enrolled in this double-blind randomized controlled trial.Results Sixty-five subjects received probiotics, and others received placebo treatment for 4 weeks. Lactobacillus reuteri was therapeutically effective in 32 patients compared to 8 patients, responding to the placebo treatment. Compared to baseline, all pain-related variables showed a significant reduction for the IBS and FD at the end of the 4th week. However, it did not respond well in FAP and AM groups. Pain-related outcomes such as, frequency of the pain, severity, and duration of the pain were decreased following the probiotic treatment. No therapeutic response was seen in AM group after the administration of probiotics. L. reuteri significantly led to pain relief in the overall population, and also in FAP, FD, and IBS subgroups.Conclusion L. reuteri probiotics are likely to lead to RAP relief and can be recommended for the treatment of functional gastrointestinal disorders.

A systematic review of patient complaints about general practice.

Health care complaints are an underutilized resource for quality and safety improvement. Most research on health care complaints is focused on secondary care. However, there is also a need to consider patient safety in general practice, and complaints could inform quality and safety improvement. This review aimed to synthesize the extant research on complaints in general practice. Five electronic databases were searched: Medline, Web of Science, CINAHL, PsycINFO and Academic Search Complete. Peer-reviewed studies describing the content, impact of and motivation for complaints were included and data extracted. Framework synthesis was conducted using the Healthcare Complaints Analysis Tool (HCAT) as an organizing framework. Methodological quality was appraised using the Quality Assessment Tool for Studies with Diverse Designs (QATSDD). The search identified 2960 records, with 21 studies meeting inclusion criteria. Methodological quality was found to be variable. The contents of complaints were classified using the HCAT, with 126 complaints (54%) classified in the Clinical domain, 55 (23%) classified as Management and 54 (23%) classified as Relationships. Motivations identified for making complaints included quality improvement for other patients and monetary compensation. Complaints had both positive and negative impacts on individuals and systems involved. This review highlighted the high proportion of clinical complaints in general practice compared to secondary care, patients' motivations for making complaints and the positive and negative impacts that complaints can have on health care systems. Future research focused on the reliable coding of complaints and their use to improve quality and safety in general practice is required.

Incidence, prevalence, and management of plantar heel pain: a retrospective cohort study in Dutch primary care.

Plantar heel pain (PHP) is a common cause of foot complaints in general practice. However, information on the occurrence and practical management is scarce. The aim of this study was to determine the incidence and prevalence of PHP in Dutch primary care and to gain insight into the types of treatments provided to patients with PHP in primary care. A cohort study was conducted using a healthcare database containing the electronic general practice medical records of approximately 1.9 million patients throughout the Netherlands. A search algorithm was defined and used to identify cases of PHP from January 2013 to December 2016. Descriptive statistics were used to obtain the incidence and prevalence. Data on the management of PHP were manually validated in a random sample of 1000 patients. The overall incidence of PHP was 3.83 cases (95% confidence interval [CI] = 3.77 to 3.89) per 1000 patient-years, the incidence in females was 4.64 (95% CI = 4.55 to 4.72), and 2.98 (95% CI = 2.91 to 3.05) in males. The overall prevalence of PHP was 0.4374% (95% CI = 0.4369 to 0.4378%). Incidence of PHP peaked in September and October of each calendar year. The most commonly applied strategies were a wait-and-see policy (18.0%, n = 168), use of non-steroidal anti-inflammatory drugs (NSAIDs) (19.9%, n = 186), referral to a paramedical podiatric specialist (19.7%, n = 184), and advice to wear insoles (16.4%, n = 153). Treatment strategies varied greatly among GPs. There was large variation in treatment strategies of GPs for patients with PHP. GPs should be aware of conflicting evidence for interventions, such as insoles, and focus more on exercises for which there is evidence for effectiveness.

Predicting no return to sports after three months in patients with traumatic knee complaints in general practice by combining patient characteristics, trauma characteristics and knee complaints

Background: It remains unclear to what extent patients with traumatic knee complaints aged 18–45 years seen in general practice experience difficulties with return to sports.Objectives: This study aims to determine the proportion of patients with a knee trauma that return to sports at six weeks and three months follow-up. Also examined were associations between no return to sports and baseline patient/trauma characteristics, knee complaints and MR (magnetic resonance) findings, as well as the additive value of MR findings.Methods: Included were patients with traumatic knee complaints participating in a randomized controlled trial assessing the cost-effectiveness of an MR scan in general practice. Patients were classified as ‘no return to sports’ or ‘return to sports’ (sports on pre-injury or adapted level). Potential baseline predictors for no return to sports were assessed using logistic regression analyses. The area under the curves (AUC) was compared.Results: At six weeks and three months follow-up, 147 (59%) and 175 (74%) patients, respectively, reported return to sports. Combining patient characteristics, trauma characteristics and knee complaints predicted no return to sports with an AUC of 0.86 (95%CI: 0.81–0.90) at six weeks and of 0.82 (95%CI: 0.76–0.88) at three months follow-up. After adding MR findings, the AUC was 0.79 (95%CI: 0.71–0.87) at six weeks and 0.79 (95%CI: 0.70–0.88) at three months follow-up.Conclusion: Three out of four patients with a knee trauma in general practice reported return to sports at three months follow-up. A combination of patient/trauma characteristics and knee complaints predicted no return to sports, whereas MR findings had no additive value. Trial registration: Dutch trial registration: registration number: NTR3689. registration date: 7 November 2012.

Assessing Medical Student Basic Otolaryngology Knowledge: A Multi-Institutional Study.

The prevalence of otolaryngologic complaints in general practice is disproportionate to the extent of otolaryngology teaching in undergraduate medical education. This is the first multi-institutional validated study used to assess basic otolaryngology knowledge among medical students in order to understand their abilities to recognize and manage these cases. A 9-question, psychometrically validated, multiple-choice quiz was distributed in June 2017 to medical students of 9 US allopathic institutions as an assessment of basic otolaryngology knowledge. A total of 547 medical student responses were used to assess basic otolaryngology knowledge, comfort levels, amount of exposure to otolaryngology, and number of times the head and neck physical examination was taught formally. Comfort in managing otolaryngologic conditions correlated positively with knowledge ( P < .001, R2 = 0.266), in addition to otolaryngology exposure correlating positively with knowledge ( P < .001, R2 = 0.284). Students intending to enter otolaryngology had higher scores ( P = .002), higher comfort levels in managing otolaryngologic cases ( P < .001), and higher comfort levels performing the head and neck examination (χ2 = 21.324, P < .001), compared with students intending to enter primary care or another surgical specialty. Clinical students in third and fourth years entering any surgical specialty (including otolaryngology), more often than students entering primary care ( P = .007), recognized the obturator as the instrument used to guide the insertion of the tracheotomy tube. Additionally, the number of times the head and neck examination was taught correlated positively with comfort in performing the examination ( rs = 0.095, P = .022). Our findings support the need for increased otolaryngologic education and training among all medical students, not only those entering otolaryngology.

Causes of Chronic Hip Pain Undiagnosed or Misdiagnosed by Primary Physicians in Young Adult Patients: a Retrospective Descriptive Study.

BackgroundHip pain is a common musculoskeletal complaint in general practice. Although comprehensive diagnostic approach on hip pain is mandatory for adequate treatment, un- or mis-diagnosis is not rare in primary care. The aim of this study was to analyze descriptively un- or mis-diagnosed hip pain cases referred from primary care to a tertiary hospital, especially in young adults ≤ 50 years old.MethodsWe retrospectively analyzed a consecutive cohort of 150 patients (≤ 50 years old) with chronic hip pain (≥ 6 weeks), which was not diagnosed or misdiagnosed based on the information provided on the referral form.ResultsOverall an average 32 cases/month were referred due to hip pain without a diagnosis or with an incorrect diagnosis. Among them, 150 patients were enrolled in this study and 146 (97.3%) could be allocated to a specific disease by using data from routine clinical practice. Four common final diagnoses were femoroacetabular impingement (FAI) syndrome (55.3%), hip dysplasia (HD, 13.3%), referred pain from the lumbar spine (9.3%), and spondyloarthritis (SpA, 7.3%). In patients with FAI syndrome, 37 (44.0%) had pincer-type FAI and 33 (39.8%) had combined-type. Although the pain site or gender was not tightly clustered, the distribution of final diagnosis was significantly different according to hip pain location or gender. Especially, SpA or HD was not observed in younger women subgroup or elder men subgroup, respectively, when stratified by the mean age of participants.ConclusionMost (> 80%) young patients with hip pain, a difficult issue to diagnosis for many primary physicians, had FAI syndrome, HD, spine lesions, and SpA. This study could give a chance to feedback information about cases with un- or mis-diagnosed hip pain, and it suggests that primary physicians need to be familiar with the diagnostic approach for these 4 diseases.

Genome-wide association analysis of insomnia complaints identifies risk genes and genetic overlap with psychiatric and metabolic traits.

Persistent insomnia is among the most frequent complaints in general practice. To identify genetic factors for insomnia complaints, we performed a genome-wide association study (GWAS) and a genome-wide gene-association study (GWGAS) in 113,006 individuals. We identify three loci and seven genes of which one locus and five genes are supported by joint analysis with an independent sample (n=7,565). Our top association (MEIS1, P<5×10-8) has previously been implicated in Restless Legs Syndrome (RLS). Additional analyses favor the hypothesis that MEIS1 shows pleiotropy for insomnia and RLS, and that the observed association with insomnia complaints cannot be explained only by the presence of an RLS subgroup. Sex-specific analyses suggested different genetic architectures across sexes in addition to common genetic factors. We show substantial positive genetic overlap with internalizing and metabolic traits and negative overlap with subjective well-being and educational attainment. These findings provide novel insight into the genetic architecture of insomnia.