Hospital General Practice Research Articles

Factors affecting the outcome of orthograde root canal therapy in a general dentistry hospital practice

The goal of this study was to weigh the impact of patient-related, tooth-related, and treatment-related factors on therapy outcome in a series of consecutive patients. Eighty-four patients were included. Of these, 66 (79%) were available for recall after > or = 30 months (mean = 46 months). Root canal treatments were performed using a standard protocol. At recall, teeth were scored by means of the periapical index (PAI), which was the dependent variable (dichotomized to sound/ unsound). Explanatory variables were patient age, integrity of the nonspecific immune system, smoking status, dichotomized PAI score before treatment, initial treatment versus retreatment, prior exposition of the root canal to saliva, stainless-steel hand versus NiTi rotary instrumentation, and quality of root filling. Unit of observation was the patient-individual. Data were analyzed using univariate tests and backward stepwise logistic regression analysis. After 5 steps with elimination of the least significant independent variable, status of the immune system (P = .05), initial PAI (P = .04), and root filling quality (P = .01) were found to be the indispensable predictors for treatment outcome. Using these 3 explanatory variables, the logistic regression model had a predictive value of 87%, compared to 91% with all 8 variables. Success rate at recall (PAI < or = 2 without symptoms) was 88% (95% CI = 78, 94). The integrity of a patient's nonspecific immune system, which has been neglected in earlier investigations, is a significant predictor for endodontic treatment outcome, and should receive more attention in future studies.

Alcohol high risk drinking, abuse and dependence among tobacco smoking medical care patients and the general population

Background: Little is known about the synergies of smoking and alcohol consumption in medical care patients. The objective, therefore, is to estimate the coincidence of hazardous and harmful alcohol consumption as well as alcohol abuse and dependence with tobacco smoking in a general hospital and general practices. Methods: Three samples of 18–64 year olds include 510 consecutively admitted currently smoking in-patients of a general hospital, 271 patients of a randomized sample of general practices, and 1567 current smokers from a regional population in Germany. Data include the number of cigarettes and a diagnosis of alcohol dependence and abuse (DSM), harmful or hazardous alcohol use. Results: The rates of current daily cigarette smokers with an alcohol dependence or abuse, harmful or hazardous alcohol consumption are 47.1% in the general hospital and 32.1% in the general practice sample compared with 18.4% in the general population. The rates increase from nonsmokers to smokers and with the number of cigarettes. Conclusions: The findings fit into the evidence about alcohol and tobacco interactions in morbidity and mortality. General medical care settings are appropriate for the detection of alcohol dependence or abuse via smoking.

Obesity in type 2 diabetes — local experience in a district general hospital

Obesity, diabetes and glycaemic control are inter-linked. Weight gain is associated with worsening diabetic control and can be exacerbated by therapies aimed at controlling hyperglycaemia. Auditing our practice in a district general hospital, we have examined our diabetic population with regards to age and weight, HbA1C and body mass index (BMI), and for weight gain following conversion to insulin.

One hundred laparoscopic choledochotomies with primary closure of the common bile duct.

Several technical approaches for laparoscopic CBD exploration (LCBDE) exist. Laparoscopic choledochotomy is required in some situations and whenever a transcystic approach fails. Biliary drainage after choledochotomy has a 5% morbidity rate and avoidance of biliary drains might therefore further improve the results of LCBDE. The authors report a prospective multicentric evaluation of laparoscopic choledochotomy with completion choledochoscopy and primary duct closure without any biliary drainage. Between October 1991 and December 1997, 100 patients from four surgical centers underwent this approach for CBD stones. Choledocholithiasis had been demonstrated preoperatively in 35 patients (35%), suspected in 52 and was incidentally found during routine intraoperative cholangiography in 13 patients. External ultrasound was the only preoperative imaging investigation in 87 patients. LCBDE was attempted irrespective of age, ASA score, or the circumstances leading to the preoperative diagnosis or suspicion of CBD stones (acute cholecystitis in 33% of patients, cholangitis in 10%, or mild acute pancreatitis in 6% of all patients). The technique was equally feasible in all participating centers (University hospital, general hospital, or private practices). Vacuity of the CBD was achieved in all patients without mortality. Eleven patients had complications and 3 patients required a laparoscopic reintervention. Median postoperative hospital stay was 6 days (range: 1-26). No patient required additional CBD procedures during follow-up. In case of LCBDE, choledochotomy with primary closure without external drainage of the CBD is a safe and efficient alternative, even in patients with acute cholecystitis, cholangitis, or pancreatitis, provided that choledochoscopy visualizes a patent CBD. This technique is applicable in all types of medical institutions if required laparoscopic skills and equipment are available.

Problem in early diagnosis of the loco-regional breast cancer in general hospital

of the loco-regional breast cancer and disease confirmation to help in making decision about surgery treatment (1-6). Physical examination is often unsatisfactory, and mammography and ultrasound are complementary for better detection. However, possibilities for better and more applicable methods based on molecular level in general hospital and general clinical practice are limited. At present, X-ray mammography is the only accepted imaging modality to screen for the early detection of breast cancer tumor (7, 8). The sensitivity of mammography is lower in younger patients with dense, glandular breasts. In older women whose breasts are fatty, sensitivity of X-ray mammography for the detection of malignancy is higher. However, the positive predictive value of mammography is limited. The comparison of positive results of mammography and positive results of biopsy analyses vary in previously reported papers and depend on patients' number as observed in the some studies (8,9). The ultrasound as second method for early tumor detection has been used to characterize breast tumor for over 20 years (10). Introduction of high-resolution ultrasound significantly increases detection of tumor mass presence. Today ultrasound is recommended as important method and complementary procedure for breast cancer detection in young women. However, differentiation between benign and malignant tumor of the breast, and making definitive decision is still difficult (9, 10). False-positive and false negative findings appear up to 11% in USA and Sweden (11, 12), depending on tumor extension, size, histology types, and especially when other abnormalities are simultaneously present. On this basis, analyses obtained by mammography and ultrasound from breast cancer postmenopausal women with family related cancer (breast and gynecological cancer previously extirpated) were compared with ex tempore histology obtained during surgery.

The Excess Cost of Acute Exacerbations of Chronic Bronchitis in Patients Aged 45 and Older in England and Wales

Introduction Chronic Bronchitis is a serious and costly health problem. Prevalence is estimated at 45 per 10,000 persons in the United Kingdom. Approximately £120,000 would be saved for every 100 hospital admissions avoided. A reduction in acute exacerbations of chronic bronchitis (AECB), treatment failures, and subsequent hospital admission could have a significant impact on the burden of AECB borne by secondary care facilities in the UK National Health Service (NHS). Objective The aim of this study is to provide an economic assessment of the direct cost to the health care system associated with the management of chronic bronchitis and its acute exacerbations. Design A prevalence-based, excess-cost-of-illness analysis is undertaken from the perspective of the UK NHS. Disease prevalence data, primary health care resource utilization, hospital inpatient and outpatient resource utilization, and costs of health care were taken from a variety of data sources, including a large UK national survey of general practice (GP) consultations, the General Practice Research Database, a survey from a single NHS hospital trust, and the national health-care resource and cost statistics. Results From 1994 to 1995, approximately 233,000 cases of chronic bronchitis were detected in the persons aged 45 and older in the United Kingdom. Prevalence peaked at 204 per 10,000 in the group of subjects aged 75 to 84 years. During that same period, the total excess cost of primary care associated with AECB was calculated at £35.7 million. The largest component of primary care costs was the excess cost of all prescription medicines, which totaled £27.8 million. The excess cost attributed to antibacterial and respiratory prescription medications alone was estimated at £9 million. Excess costs attributed to GP consultations and hospital emergency room visits were £6.5 million and £1.3 million, respectively. The excess costs arising from inpatient hospital episodes included £8.3 million for hospital admissions, £660,000 for outpatient costs, and £225,000 for day care. Conclusions These results suggest that improving the management of AECB with the objective of reducing the number of AECB treatment failures and the associated hospital admissions could significantly reduce expenditures by the UK NHS.

Prescribing new drugs: qualitative study of influences on consultants and general practitioners

Objective: To explore consultants' and general practitioners' perceptions of the factors that influence their decisions to introduce new drugs into their clinical practice.Design: Qualitative study using semistructured interviews. Monitoring of...

Low mortality in ulcerative colitis and Crohn’s disease in three regional centers in England

OBJECTIVES: Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn’s disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. METHODS: Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. RESULTS: Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79–140] for UC and 94 (95% CI: 59–140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99–439; p = 0.02) and 229 (74–535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD ( p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84–793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108–335; p = 0.02) and 164 (95% CI: 82–335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). CONCLUSIONS: Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.

Low mortality in ulcerative colitis and Crohn's disease in three regional centers in England.

Recent epidemiological studies suggest that mortality rates for inflammatory bowel disease (IBD) are similar to those of the general population. However, most of this work has been done in referred populations or larger urban centers. We intended to estimate mortality rates for ulcerative colitis (UC) and Crohn's disease (CD) in three British district general hospital practices in Wolverhampton, Salisbury, and Swindon. Consecutive patients with CD or UC were identified from 1978 to 1986 and followed prospectively. Demographic data, date and cause of death or health status at December 31, 1993 were used to estimate standardized mortality ratios (SMRs) and 95% confidence intervals. Sixty-four deaths occurred in 552 patients (UC 41 of 356; CD 23 of 196). The overall SMRs were 103 [95% confidence interval (CI): 79-140] for UC and 94 (95% CI: 59-140) for CD. The respective SMRs were higher only in the first year after diagnosis at 223 (95% CI: 99-439; p = 0.02) and 229 (74-535; p = 0.056), and even then, most subjects died from non-IBD causes (5 of 13). Nonsurvivors were significantly older than survivors in both UC and CD (p < 0.01). The SMR was also significantly greater during a severe first attack of UC at 310 (95% CI: 84-793; p = 0.04). Patients with perianal or colonic CD had an increased SMR [396 (95% CI: 108-335; p = 0.02) and 164 (95% CI: 82-335; p = 0.02)] respectively, partly related to the older mean age (52 vs 32 yr, p < 0.001). Mortality rates are not increased in IBD compared with the general population. However, older patients may be at increased risk of dying from other causes early in the disease clinical course.

Undiagnosed tuberculosis as the reason of failure in treatment of critical care patients

Intensive treatment sometimes becomes unsuccessful due to diagnostics mistakes. Tuberculosis — one of the most serious diseases in Russia — also leads to critical status of patients. But in some of such patients tuberculosis remains undiagnosed. Purpose of present study was to analyse why not recognition of pulmonary tuberculosis became the reason of failure in treatment of critical care patients. Thirty-eight cases of patients (28 men and 10 women) treated in emergency departments of general practice hospitals of Tatarstan Republic, Russia, were investigated. Age of patients was from 42 to 77 years. Clinical diagnosis of pneumonia was in 86.8% of them, pleuritis of obscure etiology in 10.5% and one patient had clottage of mesenteric blood vessels. Patients status at entering the hospitals was estimated as serious. Complaints to tussis with a sputum were in 89.5% cases. Average value of ESR was 17.3 mm/h, leukocytosis -16.2 × 109/l. All patients received a complex intensive care. Patient with the surgical pathology was operated. But despite treatment there were not improvement in patients status, and 1–5 days after entering hospitals all patients died. Postmortem examination found out that the reason of failure in complex treatment of patients was undiagnosed pulmonary tuberculosis. Infiltration tuberculosis was in 14 patients, fibro-cavernous in 13 patients and disseminated tuberculosis in 11 patients. Analysis of that cases showed that radiography was done only to 36.8% of patients on the average 2.3 days after entering the hospitals. Sputum microscopy was done only in two cases and also with an appreciable delay. In both cases BK were found out. Radiography and smear microscopy results became accessible to doctors only after patients morses. Investigation showed the necessity of urgent fulfillment of radiography and sputum microscopy in critical patients with suspicion of pulmonary tuberculosis just after entering the hospitals.

Implementation of antithrombotic management in atrial fibrillation

The aim of the study was to assess the extent to which published recommendations on the antithrombotic management of atrial fibrillation had been adopted into clinical practice in a busy...

Clinical training experience in district general hospitals

AIMSTo estimate the nature and quantity of clinical experience available for trainees in paediatrics or general practice in acute general hospitals of differing sizes in the UK. To discuss implications...

The diagnosis of Clostridium difficile-associated disease.

There are well-documented risk factors associated with the development of antibiotic-associated diarrhoea; knowledge of these and of the typical signs and symptoms should alert the clinician to the possibility of Clostridium difficile-associated diarrhoea (CDAD). It is therefore common practice in large general hospitals for clinicians to request, and for laboratories to include, investigations for C. difficile on in-patient stool specimens to confirm a diagnosis of CDAD. The laboratory methods used to investigate for CDAD are divided into two main categories: those that are aimed at detecting the presence of C. difficile or its products, and those that detect either of its two major toxins, A (enterotoxin) and B (cytotoxin). Within each of these broad strategies there are various rationales which are reviewed here.

Recognition of and early intervention in alcohol abusers in general hospital and private practices in Germany

Recognition of and early intervention in alcohol abusers in general hospital and private practices in Germany

Supply of in-patient medical services for elderly people and geographical variation in medical admissions in a health district in England

Geographical variation in the utilisation of in-patient medical services for elderly people in a health district in England was examined in relation to supply of in-patient geriatric medical care and indicators of need. An ecological study design based on electoral wards was used. The health district had a resident population of 67 919 aged 65 y or more and was divided into three localities, each with a different supply of in-patient medical services for elderly people. Locality A had a traditional model of geriatric medical care, Locality B an integrated model and Locality C an age-related model. Localities A and C also had a high provision of general practice hospital beds. The main outcome measure was the age and sex standardised hospital admission ratio for people aged 65 y or more admitted under geriatric medicine, general medicine or general practice in April 1991–March 1992. There were 8829 admissions in 1991/2, 48% in general medicine, 40% in geriatric medicine and 12% in general practice, giving an overall unadjusted admission rate of 130 per 1000 population aged 65 y or more for the three specialties combined. Locality A had the highest, and Locality B the lowest, unadjusted admission rate for the three specialties combined. This rate remained highest in Locality A if second and subsequent admissions in the same period were excluded. Lengths of stay in geriatrics were longest in this locality but lengths of stay for the three specialties combined were similar in the three localities. Multiple regression was used to examine the effect of three indicators of need, the Jarman score, standardised mortality ratio and prevalence of limiting long-term illness, on standardised admission ratios at the electoral ward level. Jarman score had a significant independent association with the standardised admission ratio but adjustment for this factor did not alter the ranking of the three localities, with the standardised admission ratio remaining highest in Locality A. Subject to the limitations of the study, the results suggest that factors related to the supply of in-patient medical services may be associated with geographical variation in medical admissions for elderly people.

Development of a Screening Questionnaire for the General Hospital and General Practices

The purpose of this study was to develop a sensitive as well as brief screening questionnaire by combining the well-known instruments CAGE and the Michigan Alcoholism Screening Test (MAST) in detecting patients with alcohol dependence or abuse in general hospitals and general practices. The number of items was reduced by means of logistic regression and item analysis based on data of 1,167 consecutive admissions of a general hospital who completed both questionnaires. Further data were derived from a sample of 774 patients from 10 randomly selected general practices. A solution with nine items was validated in a second sample of 436 hospital inpatients. In all three samples, cases screening positive were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry to provide ICD-10 and DSM-III-R or DSM-IV diagnosis. In addition, 103 subjects with negative screening results were interviewed in the second general hospital sample. On grounds of the data of all three samples, a solution of seven items was chosen. This instrument comprises two CAGE and five MAST questions (Leubeck Alcohol Dependence and Abuse Screening Test; LAST) and was significantly higher in sensitivity than CAGE and SMAST. Data were robust in all three samples. It is concluded that the LAST is an optimized instrument for use in general hospital and general practice.

Development of a Screening Questionnaire for the General Hospital and General Practices

Development of a Screening Questionnaire for the General Hospital and General Practices

Kidney failure and transplantation in China

The incidence of chronic renal failure in China is approximately 120,000 cases per year; the vast majority of these new cases will die within a very short time because of the shortage of funds, dialysis machines, and organs for transplantation. This paper focuses on the reasons behind the organ shortage and the strategies proposed by the Chinese medical profession to increase the supply of transplantable kidneys. The data were gathered on multiple trips to China, Hong Kong and Taiwan between August 1993 and January 1995. During these trips the author spoke formally with nephrologists, urologists, dialysis and transplant nurses, and other individuals active in the field of organ procurement, and informally with others familiar with general hospital practice. The author also draws heavily on articles published in leading Chinese journals. The kidney shortage in China is produced by the same sorts of problems as exist in other countries, but the shortage is aggravated by certain beliefs and practices specific to Chinese populations. Live donation is hampered by traditional beliefs about the function of the kidney, while cadaver donation is hampered by reluctance to cut a body and a host of beliefs about ghosts, labeled “feudal superstitions” by the authorities. Cadaver donation is further restrained by the lack of legal recognition of “brain death”. In response to the organ shortage, the Chinese medical community has expanded the range of eligible sources to include those condemned to death as criminals, a practice itself usually condemned by the wider international community. At the same time it has advocated: (1) enhancing corpse donation through propaganda work, administrative work, legal work, and incentives; (2) encouraging live donation; (3) familiarizing the public with the benefits of organ transplantation, and (4) pursuing the development of artificial organs.

Telemedicine and teleconferencing: the SAVIOUR project

Providing high-quality cost-effective healthcare to patients in `remote&apos; locations is an important requirement for today&apos;s health service. In an area such as Scotland, a significant proportion of the population live in rural areas, in many cases at a considerable distance from the nearest major hospital. Local health centres or general practice hospitals can provide effective care for many medical problems. However, patients may require urgent or specialist treatment that cannot be provided locally. Telemedicine can help solve this problem by providing local medical practitioners the means to consult with specialists based in the major hospitals via communications technology. This article introduces the concept of telemedicine and describes the components which make up a telemedicine system. It describes the SAVIOUR telemedicine project which involves the establishment of a telemedicine link between two hospitals in the North East of Scotland, discusses the technical and clinical issues highlighted by this project and examines some of the areas which must be addressed if telemedicine is to become an integrated part of the healthcare system.

Does the doctors' professional experience reduce referral rates? Evidence from the Finnish referral study.

To examine hospital referral rates in Finnish health centres according to doctors' and health centres characteristics. Survey of all general practice hospital referrals over one week. Central and northern part of Finland, in a region comprising 72% of the area of the country and one-third of the population. 851 health centre doctors. Referral rates in terms of characteristics of doctors and health centres. During the study period, the 851 health centre doctors had 58 760 consultations (mean 69 patients/week), and 2 921 (5%) patients were referred to secondary care. The variation between the highest and lowest referral quintile of the doctors was almost 17-fold, and of the health centres 2.4-fold. Relatively more referrals were made by locums, young, not yet graduated and female doctors than by specialized, more experienced and male doctors. A low referral rate is closely connetected with the extent of the general practitioners' professional experience and specialist training. Investing in specialist training and continuing medical education seems to be the best way to reduce high referral rates.