General Medicine Practice Research Articles

Gender, obesity, alcohol use, hyperlipidemia, hypertension and decline of renal endothelial barriers

Background Raised body weight and hypertension are locally relevant risk factors. Patients were examined in a Bavarian General Medicine Practice to investigate the relationship between raised body weight, hypertriglyceridemia and alcohol misuse with raised blood pressure or abnormal morning urines. Methods The risk factors evaluated in this study of primary care patients were obesity, overweight, hypertriglyceridemia, self-reported alcohol misuse, raised blood pressure and proteinuria and/or hematuria in men ( n = 86, 31 ± 12 years) and women ( n = 160, 30 ± 10 years). Results Men or women with obesity (BMI 2) or alcohol misuse (AHA 1) had significantly higher systolic or diastolic blood pressure and significantly lower HDL levels ( p < 0.05) compared with men or women of normal weight or without alcohol problems and the ratio of serum albumin to triglycerides was significantly lower with obesity or alcohol misuse ( p = 0.001, p = 0.001, respectively). Men with hypertriglyceridemia tended to be overweight and showed significantly higher blood pressure than men with normal triglyceride levels ( p < 0.05). Obese men showed significantly higher diastolic blood pressure compared to obese women ( p = 0.049). An increase in systolic ( p = 0.0026) or diastolic ( p = 0.0002) blood pressure was significantly associated with raised body weight (BMI 1 + BMI 2), while a rise in diastolic blood pressure was linked with alcohol misuse ( p = 0.0005) using multivariate modelling. Proteinuria and/or hematuria in men's morning urine samples were significantly associated with misuse of alcohol or nicotine ( p = 0.041, p = 0.045, respectively). Conclusion The data showed significant associations between raised systolic or diastolic blood pressure and raised body weight. Raised diastolic blood pressure or proteinuria and/or hematuria were associated with misuse of alcohol and indicated a decline in renal endothelial barriers.

Assessment of obstructive sleep apnoea/hypopnoea syndrome and its role in preventing stroke

To date stroke prevention has concentrated mainly on weight reduction, healthy diet, control of cholesterol levels and increased exercise. Obesity also contributes to obstructive sleep apnoea/hypopnoea syndrome (OSAHS), a sleep disorder which can be treated effectively with nasal continuous positive airway pressure (CPAP). It is a disorder which is now being recognized more often in general practice and respiratory medicine. Although it is not proven unequivocally that OSAHS causes stroke, some of the symptoms would suggest that it may be a contributory factor. Both general and specialist nurses play a role in the prevention of stroke and those in hospital care are uniquely placed to observe sleeping patterns, respond to patients' questions and work with other professionals to ensure that OSAHS is treated successfully. Therefore an understanding of the recognition and management of OSAHS and its possible association with stroke is important for nurses working on medical wards and in general practice as well as specialist respiratory nurses and neuroscience nurses.

The PEX study – Exercise therapy for patellofemoral pain syndrome: design of a randomized clinical trial in general practice and sports medicine [ISRCTN83938749

BackgroundPatellofemoral complaints are frequently seen in younger and active patients. Clinical strategy is usually based on decreasing provoking activities as sports and demanding knee activities during work and leisure and reassuring the patient on the presumed good outcome.Exercise therapy is also often prescribed although evidence on effectiveness is lacking.The objective of this article is to present the design of a randomized clinical trial that examines the outcome of exercise therapy supervised by a physical therapist versus a clinically accepted "wait and see" approach (information and advice about the complaints only).The research will address to both effectiveness and cost effectiveness of supervised exercise therapy in patients with patellofemoral pain syndrome (PFPS).Methods/design136 patients (adolescents and young adults) with patellofemoral pain syndrome are recruited in general practices and sport medicine centers. They will be randomly allocated receiving either 3 months of exercise therapy (or usual care.The primary outcome measures are pain, knee function and perception of recovery after 3 months and 12 months of follow up and will be measured by self reporting.Measurements will take place at baseline, 6 weeks, and 3 monthly until 1 year after inclusion in the study.Secondary outcome measurements include an economic evaluation.A cost-utility analysis will be performed that expresses health improvements in Quality Adjusted Life Years (QALYs) and incorporates direct medical costs and productivity costsDiscussionThis study has been designed after reviewing the literature on exercise therapy for patellofemoral pain syndrome. It was concluded that to merit the effect of exercise therapy a trial based on correct methodological concept needed to be executed.The PEX study is a randomized clinical trial where exercise therapy is compared to usual care. This trial started in April 2005 and will finish in June 2007. The first results will be available around December 2007.

Perception of “Healthy” Body Weight by Patients With Diabetes

Although weight management is important to diabetes treatment (1–3), obesity remains common among adults with diabetes (4). This may reflect the difficulty of promoting weight loss (5) or inattention to obesity management during routine clinical practice (6). Since self-management is a major tenet of diabetes care (4), patient understanding of weight-related health risk may be an important step toward setting healthy lifestyle goals and effective weight management. We sought to understand how well patients with diabetes who receive care in primary care practices could identify healthy body weight. During a diabetes education initiative, a survey was mailed to 2,607 patients with diabetes from three university-based general medicine practices in a single urban area. It included questions on knowledge (diabetes knowledge test, general knowledge subscale [7]) and behaviors related to diabetes. Patients were also asked to report their current height and weight, and “the healthiest weight for your height.” To ensure privacy, patients with diabetes were identified anonymously from the practices’ electronic medical records. Participant responses were anonymous; to avoid undue burden on nonresponders uninterested in participating, the University’s Institutional Review Board precluded multiple mailings. Each participant’s current BMI (weight in kilograms divided by the square of height in meters [kg/m2]) was calculated. Likewise, perceived healthiest BMI was calculated from reported current height and “healthiest” weight. If the current BMI was higher …

Medical students and literature: are we expecting too much?

Medical EducationVolume 40, Issue 2 p. 187-187 Medical students and literature: are we expecting too much? Jill Thistlethwaite, Jill ThistlethwaiteSearch for more papers by this author Jill Thistlethwaite, Jill ThistlethwaiteSearch for more papers by this author First published: 01 February 2006 https://doi.org/10.1111/j.1365-2929.2005.02383.xCitations: 2 Dr Jill Thistlethwaite, Department of General Practice and Rural Medicine, James Cook University, Townsville, Queensland 4811, Australia. E-mail: Jill.thistlethwaite@jcu.edu.au Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume40, Issue2February 2006Pages 187-187 RelatedInformation

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Medical care practitioners Consultation on the medical care pracitioner (MCP) role, which is an assistant role to doctors in general practice, A&E and general medicine, is now available on the Department of Health website at www.dh.gov.uk/Consultations/LiveConsultations/LiveConsultationsArticle/fs/en?CONTENT_ID=4122583&chk=phYuK1.

Screening the soul: Communication regarding spiritual concerns among primary care physicians and seriously ill patients approaching the end of life

The purpose of this study was to explore the spiritual concerns of seriously ill patients and the spiritual-care practices of primary care physicians (PCPs). Questionnaires were administered to outpatients (n=65, 90 percent response rate) with end-stage illness and to PCPs (n=67, 87 percent response rate) in a diverse general medicine practice. Most patients (62 percent) and PCPs (68 percent) considered it important that physicians attend to patients 'spiritual concerns. However, few patients reported receiving such care, and most (62 percent) did not think it was the PCP's job to talk about spiritual concerns. Although both seriously ill outpatients and PCPs assert the importance of spiritual concerns, PCPs often do not provide spiritual care. Appropriate provision of spiritual care within a diverse population of seriously ill outpatients is complex, necessitating appropriate and attentive screening.

Bipolar Depression in a Low-Income Primary Care Clinic

This study estimated the proportion of patients attending an urban general medical practice with current major depression and a history of bipolar disorder and compared the history, presentation, and treatment of patients with unipolar and bipolar depression. A group of 1,143 patients was assessed with measures of past and current mental health and treatment. Patients were partitioned into bipolar and unipolar groups based on a predefined cutoff on the Mood Disorder Questionnaire. The groups were compared on sociodemographic characteristics, depressive symptoms, comorbid mental disorders, and mental health treatment. Approximately one-quarter of the patients with major depression had lifetime bipolar depression. Patients with unipolar and bipolar depression did not significantly differ on background or health characteristics. Patients with bipolar depression were significantly more likely to report hallucinations, current suicidal ideation, and low self-esteem than patients with unipolar depression but less likely to report disturbed appetite. Patients with bipolar depression were significantly more likely to have an alcohol use disorder and to report inpatient psychiatric care and antipsychotic treatment during the past month than patients with unipolar depression. Nearly one-half of the patients with bipolar depression had taken an antidepressant in the last month, but most were not also being treated with an antipsychotic or mood stabilizer. Bipolar depression is common in urban general medicine practice. When patients took antidepressants, they seldom received concurrent antimanic medications. Because of the risks of treating bipolar disorder with antidepressant monotherapy, physicians should assess their depressed patients for mania before prescribing antidepressants.

GP training in the USA

In the United States, after completing four years of medical school, students apply to various residency programmes. General practice (what we call family practice (FP) or family medicine in the US) is a relatively non-competitive programme. There are many programmes, and each year fewer and fewer graduating medical students choose to take that route. The training lasts three years and consists of rotations in virtually every aspect of medicine, including obstetrics and gynaecology, …

Description of a New Hepatitis C Risk Assessment Tool

Because of the low prevalence of hepatitis C virus (HCV) infection in the general population, mass screening would be expensive and of low yield. Some researchers advocate targeted screening of persons at elevated HCV risk. This cross-sectional study aimed to develop a patient-administered tool to assess HCV infection risk. Two hundred seven patients with unknown HCV status from a general medicine practice and 222 HCV-positive patients from a hepatology practice completed a 72-item survey about demographic, social, and clinical risk factors for HCV infection. General medicine patients also underwent HCV serologic testing. Three (1.5%) of 207 general medicine patients had positive HCV antibody test results. These patients plus the 222 hepatology patients were significantly more likely than HCV-negative patients to report an array of factors. In a multivariable model, 7 factors remained significantly associated with HCV infection: sex with a prostitute or an injecting drug user, exposure to blood products, refusal as a blood donor or as a life insurance applicant, witnessing illicit drug use, and self-reported HBV infection. A simplified model that assigned 1 point for each factor present predicted HCV infection as well as a weighted model (based on chi(2) testing and receiver operating characteristic curve comparison). In a population with a 2% prevalence of HCV infection, people who identified 2 risk factors had a 10% chance of HCV infection, whereas those with 4 or more risk factors had a 50% chance. A self-administered 72-item questionnaire can stratify patients into HCV risk groups. If validated in other primary care populations, this instrument could help target HCV screening.

Implementing evidence-based medicine in general practice: a focus group based study

BackgroundOver the past years concerns are rising about the use of Evidence-Based Medicine (EBM) in health care. The calls for an increase in the practice of EBM, seem to be obstructed by many barriers preventing the implementation of evidence-based thinking and acting in general practice. This study aims to explore the barriers of Flemish GPs (General Practitioners) to the implementation of EBM in routine clinical work and to identify possible strategies for integrating EBM in daily work.MethodsWe used a qualitative research strategy to gather and analyse data. We organised focus groups between September 2002 and April 2003. The focus group data were analysed using a combined strategy of 'between-case' analysis and 'grounded theory approach'. Thirty-one general practitioners participated in four focus groups. Purposeful sampling was used to recruit participants.ResultsA basic classification model documents the influencing factors and actors on a micro-, meso- as well as macro-level. Patients, colleagues, competences, logistics and time were identified on the micro-level (the GPs' individual practice), commercial and consumer organisations on the meso-level (institutions, organisations) and health care policy, media and specific characteristics of evidence on the macro-level (policy level and international scientific community). Existing barriers and possible strategies to overcome these barriers were described.ConclusionIn order to implement EBM in routine general practice, an integrated approach on different levels needs to be developed.

Brief report: Health services research in the privacy age

Strengthened regulations concerning privacy of health information are affecting large-scale health outcomes research. To create a data collection system that would facilitate outcomes research, avoid selection bias, and fulfill obligations to protect privacy. We created a web-based system that uses touch-screen computer technology for longitudinal collection of data. The system provides access to information in deidentified form, enables it to be linked to health services and outcomes data, and allows patients to join a research registry project (RRP) and be placed on a prospective subject list (PSL). PARTICIPANTS, MEASUREMENTS, AND RESULTS: Pilot testing in 86 consecutive patients who were seen at a large, urban, university-based general medicine practice and had a mean age of 50 years showed that 81 patients had no difficulty, 5 had some difficulty, and none had considerable difficulty using the computer technology to complete a health survey. No patients refused to complete the survey and all patients completed the entire survey. Forty-seven (55%) joined the RRP and 42 of these 47 (89%) joined the PSL. RRP participants were less likely than RRP nonparticipants to be divorced or widowed (P=.03) and less likely to have hypertension (P=.03) but had no other significant differences in sociodemographic or clinical characteristics. PSL participants did not differ from PSL nonparticipants. The new system ensures privacy and appears to facilitate research recruitment and avoid selection bias.

Can Psychiatry Prevent Suicide? Not Yet!

Let me begin by saying that I believe psychiatrists can and should play a significant role in the prevention of suicide in Canada. Whether this is currently the case is another question. Dr Lesage has advanced the “pro” opinion on this matter. It is my aim to examine these arguments in terms of scope, accuracy, and future planning. The “pro” part of this debate suggests that psychiatrists can prevent suicide in 3 ways: first, by adopting a shared care model that allows greater collaboration and thus better support for treatment of mental disorders (particularly depression) by general practitioners (GPs); second, by optimizing treatment of depression via the application of clinical management procedures as outlined by the Canadian Psychiatric Association; and third, by collaborating with addiction services, because alcohol and drugs are heavily involved in cases of completed suicide. Scope The merits of these points notwithstanding, they encompass an approach that falls far short of what might be considered comprehensive in regard to suicide prevention. In the first place, all the focus is on treatment of individuals who are actively suicidal and (or) suffer from mental illness. This approach has no room for early detection and intervention, no focus on healthy child development, and no emphasis on community development or ecologic interventions. To be fair, perhaps this is outside the purview of the In Debate section, since the topic refers to what psychiatrists can do, rather than to a comprehensive suicide prevention plan. Second, the focus seems to be on depression, but the evidence shows that virtually all mental disorders are associated with suicidal behaviour (for example, 1). In fact, schizophrenia and bipolar disorder show an equal or higher level of association with suicidal behaviour than does major depression (2,3). Third, it is important to consider suicide–substance abuse comorbidity, but suicide is related to any number of other social problems and conditions, including interpersonal violence, relationship difficulties, unintentional injuries, and being left out of the mainstream (4,5). This suggests that something causal underlies all these conditions, perhaps something social in nature. Finally, although it is reasonable, from the point of view of this journal’s readers, to conceive of a scheme with the medical profession at its centre, not everyone else sees it that way. Other professionals compete with psychiatry and general practice medicine to deliver treatment services—not as team members, but as primary care clinicians. It does not seem sensible either to ignore this or to compete. It should be noted, however, that the primacy of any mental health treatment specialist declines when we consider interventions at the societal level and when we engage in primary prevention with presuicidal children and youth.

Disciplinary action against physicians: Who is likely to get disciplined?

Purpose We sought to determine the characteristics of disciplined physicians at-large and the risk of disciplinary action over time and to report the type and frequency of complaints and the nature of disciplinary actions against allopathic physicians in Oklahoma. Methods Descriptive statistics, Kaplan-Meier analysis, and Cox proportional hazards modeling of publicly available data on physicians licensed by the Oklahoma Board of Medical Licensure and Supervision. Results Among 14 314 currently or previously licensed physicians, 396 (2.8%) had been disciplined. Using univariate proportional hazards analysis, men ( P <0.04), non-whites ( P < 0.001), non-board-certified physicians ( P < 0.001), and those in family medicine ( P < 0.001), psychiatry ( P < 0.001), general practice ( P < 0.001), obstetrics-gynecology ( P < 0.03) and emergency medicine ( P < 0.001) were found to be at greater risk of being disciplined than other medical specialty groups. Foreign medical graduates had a higher risk of disciplinary action compared to US medical graduates ( P < 0.001), although this finding was not confirmed by multivariate analysis. Kaplan-Meier analysis revealed that the proportion of physicians disciplined increased with each successive 10-year interval since first licensure. Complaints against physicians originated most often from the general public (66%), other physicians (5%), and staff (4%), and the complaints most frequently involved issues related to quality of care (25%), medication/prescription violations (19%), incompetence (18%), and negligence (17%). Conclusion To improve physician behavior and reduce the need for disciplinary action, medical schools and residency training programs must continue to emphasize both patient care and medical professionalism as critical core competencies.

Ethnic Differences in Pain Among Outpatients with Terminal and End-Stage Chronic Illness

To explore ethnic and country of origin differences in pain among outpatients with terminal and end-stage chronic illness. Cohort study within a year-long trial of a palliative care consultation. Outpatient general medicine practice in an academic medical center. Ninety patients with advanced congestive heart failure, chronic obstructive pulmonary disease, or cancer, and with a prognosis between 1 and 5 years. Patients' report of pain using the Brief Pain Inventory and analgesic medications prescribed by primary care physicians. Differences in pain report and treatment were assessed at study entry, at 6 and 12 months. The overall burden of pain was high. Patients of color reported more pain than white patients, including measures of least pain (P = 0.02), average pain (P = 0.05), and current pain (P = 0.03). No significant ethnic group differences in pain were found comparing Asian, black, and Latino patients. Although nearly all patients who were offered opioid analgesics reported using them, opioids were rarely prescribed to any patient. There were no differences in pain between patients born in the U.S. and immigrants. Pain is common among outpatients with both terminal and end-stage chronic illness. There do not appear to be any differences in pain with regard to country of origin, but patients of color report more pain than white patients. Patients of all ethnicities are inadequately treated for their pain, and further study is warranted to explore the relative patient and physician contributions to the finding of unequal symptom burden and inadequate treatment effort.

Depression and glycemic control in Hispanic primary care patients with diabetes.

Maintaining optimal glycemic control is an important goal of therapy in patients with diabetes mellitus. Patients of Hispanic ancestry have been shown to have high rates of diabetes and poor glycemic control (PGC). Although depression is common in adults with diabetes, its relationship to glycemic control remains unclear, especially among Hispanics. To assess the association of depression with PGC in Hispanics. Data from a cross-sectional mental health survey in primary care were crosslinked to the hospital's computerized laboratory database. Urban general medicine practice at a teaching hospital. Two hundred and nine patients (mean [standard deviation] age, 57.1 [10.3] years; 68% females) with recent International Classification of Diseases, Ninth Revision (ICD-9) codes for diabetes mellitus, and 1 or more hemoglobin A(1c) (HbA(1c)) tests. Probability of PGC (HbA(1c)>or=8%). Probability for PGC steadily increased with severity of depression. Thirty-nine (55.7%) of the 70 patients with major depression had HbA(1c)>or=8%, compared with 39/92 (42.4%) in the minimal to mild depression group, and 15/47 (31.9%) in the no depression group (P(trend)=.01; adjusted odds ratio, 3.27; 95% confidence interval, 1.23 to 8.64, for moderate or severe depression vs no depression). Only 29 (41.4%) of the patients with major depression received mental health treatment in the previous year. In this primary care sample of Hispanic patients with diabetes, we found a significant association between increasing depression severity and PGC. Yet, less than one half of the patients with moderate or severe depression received mental health treatment in the previous year. Improving identification and treatment of depression in this high-risk population might have favorable effects on diabetic outcomes.

Respiratory Medicine in general practice: what is the role of the pulmonary specialist?

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Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial.

Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations. Inner-city academic general internal medicine practice. Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls. DATA EXTRACTION/COLLECTION METHODS: Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires. During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed. Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease.

A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes

To assess the efficacy of a pharmacist-led, primary care-based, disease management program to improve cardiovascular risk factors and glycated hemoglobin (A(1C)) levels in vulnerable patients with poorly controlled diabetes. A randomized controlled trial of 217 patients with type 2 diabetes and poor glycemic control (A(1C) level >or=8.0%) was conducted at an academic general medicine practice from February 2001 to April 2003. Intervention patients received intensive management from clinical pharmacists, as well as from a diabetes care coordinator who provided diabetes education, applied algorithms for managing glucose control and decreasing cardiovascular risk factors, and addressed barriers to care. Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider. Outcomes were recorded at baseline and at 6 and 12 months. Primary outcomes included blood pressure, A(1C) level, cholesterol level, and aspirin use. Secondary outcomes included diabetes knowledge, satisfaction, use of clinical services, and adverse events. For the 194 patients (89%) with 12-month data, the intervention group had significantly greater improvement than did the control group for systolic blood pressure (-9 mm Hg; 95% confidence interval [CI]: -16 to -3 mm Hg) and A(1C) level (-0.8%; 95% CI: -1.7% to 0%). Change in total cholesterol level was not significant. At 12 months, aspirin use was 91% in the intervention group versus 58% among controls (P <0.0001). Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients. There were no significant differences in use of clinical services or adverse events. Our comprehensive disease management program reduced cardiovascular risk factors and A(1C) levels among vulnerable patients with type 2 diabetes and poor glycemic control.

Leitlinie „Kreuzschmerzen”

Chronic back pain is one of our society's most important health problems, causing long periods of sick leave and early retirements. Recently the German Society of General Practice and Family Medicine (DEGAM) published an evidence-based guideline for low back pain. It has been developed according to the 10-step concept of guideline development of the DEGAM, aiming for early detection of complicated clinical conditions, avoidance of unnecessary diagnostic tests and prevention of chronicity. Complicated, uncomplicated and radicular pain are defined by patient history and a short clinical examination. Imaging and further diagnostic tests are reserved for patients at risk. Basic therapy consists of structured advice. The aim of the guideline is to get patients back to their usual activity supported by effective pain relief. Psychosocial factors which are important for the prognosis should be evaluated already during the first consultation. Manual therapy might help in acute pain. Patients with persistent pain symptoms and long periods of sick leave should be transferred to multiprofessional management including pain treatment, behavioural therapy and physiotherapy. A randomised controlled trial has been set up to study the efficacy of guideline implementation.