General Practitioner Offices Research Articles

Comparison of Salmeterol with Beclomethasone in Adult Patients with Mild Persistent Asthma Who Are Already on Low-Dose Inhaled Steroids

Current guidelines on asthma management recommend the early use of inhaled corticosteroids. Recent studies of patients with moderate to severe asthma show that the addition of salmeterol is superior to a further increase of the steroids. In this study with adult, mild persistent asthma patients, we compared the effects of adding salmeterol 50 μg b.i.d. versus beclomethasone dipropionate (BDP) 200 μg b.i.d. (both via Diskhaler dry powder inhaler) to the low-dose inhaled steroids. A double-blind, randomized, parallel-group study was conducted with a run-in period of 2 weeks and a treatment period of 12 weeks. Patients (n = 233) were randomized with a peak expiratory flow (PEF) reversibility of 22 10% (mean ± SD) in the run-in period. The morning PEF was 84 ± 17% predicted and the age was 42 ± 14 years (45% males). The average prestudy inhaled steroid dose was 361 μg daily. Within a week of salmeterol treatment the daily PEF recordings reached maximal levels. At the end of the treatment period the evening PEF remained significantly better in the salmeterol group than in the BDP group (p = 0.036). The PEFs, measured at the general practitioners (GPs) office, were at least 95% of the predicted values and the post-salbutamol values at the end of both treatments. However, the salmeterol group had already obtained this level after 2 weeks and differed significantly from the beclomethasone group (p = 0.003 for percent predicted and p = 0.0007 for post-salbutamol PEF values). The symptom scores and the use of rescue medication showed a similar profile. Quality of life improved with both treatments, but without significant statistical differences between the groups. The frequency of adverse events, typical for beta 2-agonists, was low and showed no differences between the groups. These results showed that the addition of salmeterol is at least as effective as adding beclomethasone in normalizing peak flows and improving asthma control in mild persistent asthma patients. Furthermore, salmeterol has a much faster onset of action.

PMD17 Surveillance of A New Drug in the United Kingdom

Reports of adverse events often surface shortly after a new drug is introduced and in many cases provoke governmental regulatory action. Deaths pose a particular challenge, because drug takers may have excess mortality risk relative to nontakers for reasons unrelated to drug use. Aside from the implications for safety surveillance, a spurious association between drug use and mortality also can confound economic comparisons based on drug use. OBJECTIVE: To investigate, at the request of the U.K. Medicines Control Agency, safety and health-care resource utilization related to use of a new drug. METHODS: A postmarketing surveillance program was implemented at major medical schools in England and Scotland to monitor mortality, morbidity, and healthcare resource utilization associated with use of a new drug for treating gastrointestinal conditions. The study employs a longitudinal design that identified 18,000 drug takers through automated pharmacy listings at 700+ general practitioner offices located within a one-hour drive from the medical schools. In addition to drug taking patterns and adverse event occurrences, use of ambulatory and hospital health-care resources is recorded. Instead of employing a reference group of nontakers, national death rates will serve as “historical controls.” RESULTS: Morbidity and mortality experience among drug takers will be assessed by reviewing whether incidents occurred concomitantly with use of the medicine, by examining relationships with dose and duration of use, and other evidence to establish “biologic plausibility.” These experiences will be related in turn to selected measures of health-care resource utilization. CONCLUSION: This study provides a useful template for future research to establish the safety and health care resource utilization profiles of a new drug.

Risk Factors for Lower Limb Complications in Diabetic Patients

Diabetic lower extremity complications may be influenced by a number of factors, including those related to the interaction between patients and the health-care system. Our objective is to identify risk factors for the development of lower limb complications, by looking for classical clinical variables and those related to quality of care. A case-control study was carried out between December 1993 and June 1994 by interviewing 348 patients with lower-limb diabetic complications and 1050 controls enrolled from 35 diabetes outpatient clinics and 49 general practitioner's offices in Italy. Among sociodemographic characteristics associated with increased risk of lower limb complications were male gender [odds ratio (OR) = 2.5, confidence interval (CI) 1.6–3.9], age between 50 and 70 years as opposed to younger than 50 (OR = 3.6, CI 2.1–6.3) and being single as opposed to married (OR = 1.4, CI 1.1–1.8). Among clinical variables, treatment with insulin for IDDM and NIDDM patients was an important predictor of lower extremity complications compared to NIDDM patients not being treated with insulin. Cardio-cerebrovascular disease and presence of diabetic neuropathy were associated with a higher risk of being a case (OR = 1.4, CI 1.2–1.8 and OR = 3.0, CI 2.1–4.2, respectively). Patients who needed help to reach the health facility before the onset of the complications and those who did not attend health facilities regularly were more liable to develop complications (OR = 1.5, CI 1.1–2.2 and OR = 2.0, CI 1.3–3.0, respectively). Patients who had never received educational intervention had a threefold risk of being a case as compared to those who received health information regularly. The study identifies factors most likely to be related to adverse outcome and permits to discriminate between avoidable and unavoidable factors.

Self-evaluation of health: Elder outpatients, general practitioner and geriatric assessment

The self-evaluation of health status, as well as the well documented increasing prevalence of physical diseases and cognitive or affective disorders, are the most significant outcomes of health programs for elders. As the self-evaluation is less examined, with a sample of 100 elderly outpatients (48 males, 52 females, age range: 66–89 years) attending general practitioner (GP) offices, this study aimed to evaluate the pattern of self-appraisal health, the degree of congruence between patient appraisal and GP reports on both health status and drug protocols, by means of a 12-items general health questionnaire (GHQ). In the group of dissatisfied patients, the relationships between appraisals and the outcomes of psychometric cognitive and affective evaluations were assayed. The findings indicate that more than 1/3 of the patients were unsatisfied with their health status, regardless of social and demographic conditions, and inconsistently with their GP reports. The latter proved to be correlated only with positive appraisals of patients. The negative evaluation of patients correlated with both affective symptoms collected by means of psychometric tests and GP reports on psychiatric disorders. The latter were also correlated with cognitive performance scores, which did not correlate with the patients' appraisals. This suggests that the high prevalence of health status insatisfaction among elders requires from the GP a more in-depth consideration and assessment with selected screening tools.

Albuminuria in normotensive and hypertensive individuals attending offices of general practitioners.

To investigate the rate of albumin excretion and the prevalence of albuminuria in hypertensive individuals relative to the normotensive population, and to clarify the quantitative importance of confounding variables. We examined the morning urines of all consecutive non-diabetic and diabetic hypertensive patients (n = 631; 371 women, 260 men) attending the offices of five general practitioners in a circumscribed geographical area during a 4-month period. To obtain a normotensive control population, all consecutive visitors (n = 375; 217 women, 158 men) were also examined. Urinary albumin excretion was assessed by kinetic nephrelometry in morning urine samples. The median albumin excretion rate was 4.3 micrograms/ml (range 1.9-112) in normotensive individuals; 3.4 micrograms/ml (1.9-1440) in hypertensive and 3.6 micrograms/ml (1.9-2790) in diabetic patients (n = 189; 115 women, 74 men). The overall prevalence of albuminuria above 20 micrograms/ml was 4% in normotensive individuals, 10% in hypertensive patients and 17% in diabetic patients. The proportion of patients with higher-grade albuminuria (> 50 micrograms/ml) was 1% among the normotensive subjects aged below 60 years and 2% in those aged above 60 years; the respective values in hypertensive patients were 3 and 6% and in diabetic patients 8 and 13%. The multivariate regression analysis showed a significant correlation between albuminuria and smoking (P < 0.0001), the presence of hypertension (P < 0.001), the current level of systolic blood pressure (P < 0.01) and age (0.031), but not sex or body mass index. The present study confirms a higher prevalence of albuminuria above 20 micrograms/ml in individuals with primary hypertension and diabetes mellitus compared with that in normotensive subjects, despite similar median albumin excretion rates. However, the excess of prevalence is moderate. Smoking, advanced age and current level of systolic blood pressure are the important determinants.

Health care for persons with non-insulin-dependent diabetes mellitus. The German experience.

A structured treatment and education program for patients with non-insulin-dependent diabetes mellitus (NIDDM) who are not taking insulin was developed, evaluated, and implemented at the primary health care level throughout Germany. The program is based on the definition of individual and pragmatic therapeutic goals for each patient, primarily using nondrug treatment, which includes systematic glycosuria self-monitoring by the patients and four structured sessions of group education held in a general practitioner's office. After documentation of the program's efficacy in a randomized, controlled trial and several pilot projects, the program has been officially incorporated into the general German health care scheme and includes payment to practicing physicians for each patient treated. More than 12,500 primary health care physicians have participated in special 2-day postgraduate courses given by diabetologists; these courses are a precondition to participating in the program. As part of the primary health care scheme, the NIDDM program will be continuously monitored for quality control and efficiency. Currently, similar structured treatment and education programs targeted to primary health care physicians are being introduced for both insulin-treated NIDDM and arterial hypertension.

Letters to the Editor

A rural general practitioner (GP) from Tasmania Australia objects to several points raised in the earlier article Family Planning Practices among Lebanese Turkish and Vietnamese Women in Sydney. The authors include hysterectomy as a sterilizing operation yet hysterectomies are not done in Australia for sterilization purposes but rather for medical indications. The authors mention contraceptive methods as those that do and do not need a medical consultation yet do not indicate what criteria they use to divide the methods into the two groups. They conclude that an unmet need for culturally sensitive family planning information and services exist but their study does not support this. Specifically the results show that the women are pleased with the family planning information that they receive. Most women depend on their physicians for contraceptive advice. These physicians tend to have a private practice or work in hospital clinics. Half of the women do not complain about the source of their contraceptive advice. The study does not determine whether women who have complaints attend family planning clinics or private practices. It also does not indicate how many staff from non-Australian cultures work in family planning clinics or GP offices. It is likely that most Australian cities have physicians from the same cultural background as the women in the study. Since GPs know the womens medical surgical social and family history properly trained and informed GPs are better prepared to provide women appropriate contraceptive advice. In fact in rural areas GPs are often the only source of contraceptive information. Time patience and written information in other languages can surmount cultural differences which can help women choose their family planning method with the advice of someone they know and trust.

Nicotine Inhaler for Smoking Cessation

To the Editor. —In a recent article, Tonnesen et al 1 suggest that a nicotine inhaler in smoking cessation could be implemented in general practitioner offices with high success rates and that it would be acceptable to patients. In addition, the program is described as low intervention. Results their study do not support such statements. Their study involved volunteers who were recruited through newspaper advertisements and who were motivated to quit smoking. Furthermore, subjects came to the clinic for a total of eight visits within 1 year, with each visit lasting from 30 to 60 minutes. Subjects saw videotapes on smoking cessation, had group instructions about the use of the nicotine inhaler, had assessments with fiscal and biological parameters, and received individual counseling. Such broad and expensive interventions are admirable, but in my practice as well as that of most primary care physicians, I don't think they would be

Microelectronic and nanoelectronic interfacing techniques for biological systems

A variety of electronic and opto-electronic interfacing techniques for the transduction of biological signals is available which utilise technology normally accessed for microelectronic and nanoelectronic semiconductor device fabrication. Correct interfacing of electronics to biological systems leads to the possibility of creating a range of devices which are capable of being used as biosensors or as monitoring units for individual biological cells. This can be thought of as 'bioelectronic interfacing'. Fabrication of these devices at the microelectronic scale leads to the creation of multi-analyte sensors or electrode arrays 'on chip'. There are many application areas for these devices, ranging from disposable multi-analyte sensors for use in the general practitioner's office to novel research tools allowing the monitoring of networks of neural cells in vitro. The Bioelectronics Research Group at the University of Glasgow has fabricated and tested multi-microelectrode devices for monitoring biological cells in culture. Electrical signals have been recorded extracellularly from individual neural and cardiac cells in vitro; the adhesion and movement of individual cells have been monitored on microelectrodes via electrical impedance techniques. The devices can be adapted as multi-analyte biosensors by immobilising a range of biological molecules on the electrode array. It is possible to further utilise micro- and nano-fabrication techniques to provide patterned molecular arrays for sensors, cell guidance or molecular electronic applications on planar surfaces. One important future application of this might be in nerve repair where guidance cues could be provided for nerve regrowth on surfaces and some examples of this will be shown. At the smallest scale, we are now trying to image and interact with biological molecules on these surfaces using scanning tunnelling microscopy. Possible benefits of this might be better fabrication and immobilisation of molecules for biosensors and the optimisation of surface biocompatibility treatment.

Determining the Value of a Periodontal Diagnostic Test

The purpose of this analysis is to present a method to determine the value of diagnostic tests for evidence of bacterial activity related to periodontal disease. Five population studies are discussed: 1) screening the general population; 2) screening the patients of a general practice; 3) diagnosing initial patients referred to a periodontist; 4) monitoring periodontal maintenance patients; and 5) monitoring postsurgical refractory patients. A decision tree is constructed in which the primary decision branches are test and no test. Chance branches after the test branch were test positive and test negative. The treatment alternatives in the treatment branches were prophylaxis and oral hygiene, scaling and root planing, and advanced periodontal therapy (including surgical intervention and/or antibiotics or chemotherapies). Probabilities for the prevalence of disease in each population were obtained from epidemiological surveys. Disease activity and outcome states were estimated from clinical studies of periodontal treatment. For initial periodontal patients, using a sensitivity of .87 and a specificity of .84 the value of the test branch is .851 versus .566 for the no test branch. Assumptions on the diagnostic test's sensitivity and specificity and the utility of outcomes were tested with the decision analysis techniques of sensitivity and 2-way threshold analyses. These analyses show that using a test had a greater value than no test for older patients in the general practitioner's office, and for the 3 types of periodontal treatment patients. In contrast, using the test had a lower value than not using the test in younger dental patients in the general practitioner's office and for screening the general population. The diagnostic and treatment schemes proposed here are amendable to rigorous testing to evaluate their reliability and usefulness.

Prevalence and Incidence of Diabetes in a Swedish Community 1972–1987

The prevalence and incidence of diabetes mellitus were studied from 1972 to 1987 in Laxå, a rural community with 8500 inhabitants located in mid-Sweden. Data were collected from clinical records at the primary health care centre in Laxå, from departments of internal medicine and paediatrics and from a general practitioner's office in the area. In addition, a case finding procedure involving 85% of the residents aged 35-79 years was performed in 1983-1987. The age-standardized prevalence of diabetes rose significantly (p less than 0.001) from 26 per 1000 in 1972 to 43 per 1000 in 1987. The largest rise in prevalence for males occurred in the age group 45-54 years and for females in the age group 65-74 years. The age-standardized mean annual incidence of diabetes was 3.46 per 1000 population. A small (non-significant) increase in incidence of Type 2 diabetes over time was seen in men which may in part be an effect of the case finding strategy. The overall incidence rates thus appeared to be rather stable while the prevalences tended to increase, probably mainly due to earlier detection of diabetic individuals in recent years, leaving a larger number of patients with a longer duration of diabetes to be cared for in the future.

The Pedodontic Patient with Heart Disease

The child with congenital heart disease and acquired heart disease can have dental treatment done in the general practitioner's office. It is important that the dentist be familiar with the inherent risk of bacterial endocarditis that is always present when treating the child with cardiac disease. Some knowledge of the type of congenital heart disease and the forms which are more susceptible to bacterial endocarditis is advantageous to the dentist when treating these children. The child with a history of rheumatic heart disease who is on regular chemoprophylaxis for recurrent streptococcal infections requires additional coverage when undergoing dental treatment. The controversy that exists in regard to rendering dental treatment for this type of patient should be appreciated by the dentist, and a method of antimicrobial prophylaxis for these children should be formulated in consultation with the child's physician. Most dental procedures can be done for the child with cardiac disease if the following suggestions are observed: 1. Obtaining a proper history to uncover any previous episodes of rheumatic fever or presence of congenital heart defects. 2. A close professional relationship between the dentist and the child's physician in order that optimal treatment of the child with heart disease will be accomplished. 3. Elimination of all oral infection by the removal of all abscessed teeth and other foci of infection. 4. Maintenance of good oral hygiene, preservation of all carious teeth by the placement of good restorations. 5. Adequate antimicrobial chemotherapy for dental procedures that require prophylaxis.

Educational Value of the Free Clinic

To the Editor.— An interesting point not emphasized in the recent special communication Free Medical (219:603, 1972) is that of the educational possibilities of the Free Clinic, particularly in the field of venereal disease and drug education. The Free Clinic can act to educate the local physicians in the proper treatment of venereal disease and drug abuse. This type of opportunity is not available elsewhere, for the most part, to the interested physician. This is due mainly to the fact that the volume of cases seen in the average general practitioner's office or even in the average specialist's office relating to venereal disease or drug abuse is extremely limited, while the case load in these categories at the Free Clinics is considerably greater. A physician can learn all about venereal disease and learn all about these conditions at a Free Clinic within a few days, while it would

Glaucoma Screening : In offices of General Practitioners and Internists A Study of 10,090 Patients

Glaucoma Screening : In offices of General Practitioners and Internists A Study of 10,090 Patients

PSYCHIATRY IN THE MEDICAL-SURGICAL EMERGENCY CLINIC. THE INCIDENCE AND MANAGEMENT OF PSYCHIATRIC PROBLEMS IN PATIENTS IN THE MEDICAL-SURGICAL CLINIC OF A GENERAL HOSPITAL.

It is a commonly held opinion that a large percentage of the patients seeking help in the offices of general practitioners suffer from emotional problems of one kind or another, solely or concomitant with the somatic problems they present. We were interested in exploring this proposition with regard to the incidence of emotional problems in patients coming to the Medical-Surgical Emergency Clinic of a large municipal general hospital. This project was a natural outcome of our commitment to the idea that emotional problems of all kinds deserve the opportunity for immediate attention. Based on this idea, the Trouble Shooting Clinic had been started by the senior author (LB) in November, 1958, offering psychiatric first-aid around the clock. 1,2 It was as one facet of this project that we decided, in July of 1962, to assign, routinely a psychiatrist, psychologist, or social worker to the Medical-Surgical Emergency Clinic at City Hospital

A Manual of Bandaging, Strapping and Splinting. Fourth edition.

This manual, with the use of pen and ink illustrations (which make up more than three-quarters of the content), admirably presents the commonly used techniques. The illustrations are sufficiently clear so that the inexperienced intern, after careful reading, should be able to apply dressings, bandages, splints, and casts. Subject material has been chosen with discrimination and is limited to the commoner injuries seen in a hospital emergency department or in a general practitioner's office. A concise text complements the illustrations. The brief bibliography provides useful references; an index adds to the usefulness of the book. This manual is recommended to medical students, interns, and all persons concerned with first aid practice and education. The experienced general practitioner and surgeon will find it elementary and of little use.

Is a fluoroscope useful to the general practitioner.

Recent concern over the amount of ionizing radiation to which the public is exposed raises the question of the safety and utility of the fluoroscope in the general practitioner's office. There is evidence that the amount of exposure during fluoroscopy varies widely, as does the output of the fluoroscopes actually found in use. The busy practitioner does not always take time for his eyes to achieve maximal dark adaptation, and optimal filtration and other safety precautions have often been neglected. Fluroscopy is most valuable in observing abnormal movements. It therefore supplements the data obtained from roentgenography, which is otherwise more precise, yields permanent records, and gives more diagnostic information in proportion to the amount of radiation involved.

Preventive medicine in the general practitioner's office.

Preventive Medicine in the General Practitioner's Office Affiliation John S. DeTar CopyRight*Presented at a Joint Session of the Academy of Medicine of Cleveland, the Cuyahoga County Medical Society, and the Health Officers and Medical Care Sections of the American Public Health Association at the Eightieth Annual Meeting in Cleveland, Ohio, October 22, 1952. https://doi.org/10.2105/AJPH.43.2.125 Published Online: August 29, 2011

Fertile fields for the general practitioner.

In 1948 Dr. Eric Royston 1 read a paper entitled Renaissance of the General Practitioner at the Annual Session of the American Medical Association. In 1949 Dr. Winfred Harm 2 stated that every general practitioner's office should be a cancer detection center. I hope to present other phases of the work of the physician who engages in many fields of medical practice. His position is unique, both in the community and in organized medicine. It is my purpose to continue in the same tenor as Dr. Harm, the former chairman of the Section on General Practice, in presenting fields of usefulness and influence of the family physician. HOME AND FAMILY CONTACTS The general practitioner is the only man in America today who is ready to answer any and all emergency calls in the home. These emergencies range from ruptured gastric ulcer, acute coronary occlusion, fractured bones, uterine hemorrhage, circulatory