Primary Catchment Area Research Articles

Cost effective management programme for heart failure reduces hospitalisation

ObjectiveTo study the effects of a management programme on hospitalisation and health care costs one year after admission for heart failure.DesignProspective, randomised trial.SettingUniversity hospital with a primary catchment area of...

Pain is temporally related to eating but not to defaecation in the irritable bowel syndrome (IBS). Patients' description of diarrhea, constipation and symptom variation during a prospective 6-week study.

To study the intensity and variation of pain and its temporal relation to eating and defaecation. Furthermore, what irritable bowel (IBS) patients mean by constipation and diarrhea and how bowel symptoms vary. Prospective daily symptom recording over 6 weeks. The primary catchment area of University Hospital of Linköping. Eighty consecutive patients fulfilling the Rome criteria; 63 finished the study. Fifty-nine of 63 patients recorded an average of 29 pain periods and 24 days with pain during the 6 weeks. Over-all pain burden decreased slightly over the study period. At inclusion 38 (64%) patients claimed that pain was relieved by defaecation. However, on average, only 10% of each patient's recorded pain periods were relieved by defaecation. At inclusion 29 (49%) patients claimed postprandial worsening of pain. On average, 50% of each patient's recorded pain periods worsened postprandially. The patients defined constipation as hard stools and diarrhea as loose stools and urgency. Stool frequency did not differ. Bowel symptoms varied within, but not between, fortnightly periods. Postprandial worsening of pain should be included as a criterion in the clinical definition of IBS while the criterion 'pain relieved by defaecation' should be re-evaluated. IBS patients can probably be divided into subgroups based on stool consistency, not frequency. Daily records are superior to structured clinical interviews or questionnaires for a detailed study of symptoms in IBS.

Low Symptomatic Load in Crohn's Disease with Surgery and Medicine as Complementary Treatments

Background: The treatment of Crohn's disease has changed owing to the recognition of its chronicity. Medical maintenance treatment and limited resections have evolved as major concepts of management, regarded as complementary, and both aim at reducing the symptoms. Methods: We investigated the symptomatic load in Crohn's disease as reflected in a cross-sectional study of the symptom index, physicians' assessment, and the patients' perception of health. A cohort of 212 patients from the primary catchment area and 125 referred patients were studied. Results: Of catchment area patients, 83% were receiving medication, and the annual rate of abdominal surgery was 5.7%. Corresponding figures for the referred patients were 82% and 10.3%. According to the symptom index, 87% of catchment area patients were in remission or had only mild symptoms; according to the physicians' assessment, 90% were. The patients' median perception of health was 90% of perfect health according to the visual analogue scale. The figures were similar for referred patients, except that referrals were considered more diseased by the physician. Conclusion: The great majority of patients with Crohn's disease are able to live in remission or experience only mild symptoms.

An evaluation of paramedic activities in prehospital trauma care

The object of the study was to identify the effect paramedics have on prehospital trauma care and evaluate their influence on outcome compared to that of ambulance technicians. A prospective review of ambulance and hospital records was conducted over 2 years from 1 August 1993 to 31 July 1995. The setting for the study was the Royal Infirmary of Edinburgh and its primary response catchment area served by the South-East Region of the Scottish Ambulance Service central control room. The study involved 1090 patients brought to hospital by ambulance who met the entry criteria for the Scottish Trauma Audit Group study. The results show that paramedics spend significantly longer at scene than the ambulance technicians; however, there was no difference in total prehospital times between the groups. Paramedics direct a significantly higher proportion of patients to the resuscitation room and significantly more of these patients go to theatre, intensive care or the mortuary. There is no reduction in mortality or length of stay in intensive care in the paramedic group. The authors conclude that paramedics deliver an improved process of care but their activities do not significantly reduce mortality or length of stay in intensive care.

Left ventricular atrioventricular plane displacement: an echocardiographic technique for rapid assessment of prognosis in heart failure.

OBJECTIVE: To assess the prognostic value of atrioventricular plane displacement in heart failure patients. DESIGN: Patients were followed prospectively for one year after atrioventricular plane displacement determination. SETTING: Malmö University...

Thoracic gunshot wounds in children under 17 years of age

Over the past decade there has been a significant increase in the incidence of gunshot wounds (GSW) among Americans under 19 years of age. Despite the increase, pediatric GSW have received little attention in the literature, and no study has focused on pediatric victims of thoracic GSW. In the present study, the authors performed a retrospective review of the records of 51 patients under 17 years of age who were treated for thoracic GSW at adjoining level I pediatric and adult trauma centers between July 1987 and June 1995. The primary catchment area for these institutions is a lower socioeconomic, urban tenancy. The study population was 80.4% male and 86.3% black; the mean age was 12.4 years. The mean injury severity score and trauma score were 13.6 and 13.4, respectively. Although statistically significant differences could not be demonstrated with this population size, trends were evident when the group was subdivided by age group (≤12 years and >12 years of age). The younger group was more likely to require a thoracic operation after injury (35.3% v 23.5%), to have unstable vital signs (41.2% v 26.5%), to have a higher total abbreviated injury score (AIS) for the chest (4.8 v 4.0); however, their total extrathoracic AIS was lower (2.1 v 3.1). The younger group spent more time in the hospital and in the intensive care unit (7.6 v 4.6 days and 2.0 v 0.9 days, respectively). The younger children were more likely to have sustained injury by unintentional crossfire (35.3% v 14.7%) and were never injured by intentional assault (0% v 47.2%). Overall, 50% of the patients required surgery, including 93.8% of the patients who had unstable vital signs at the time of arrival. All six deaths (11.8%) owing to the thoracic injury occurred in patients who had mediastinal injury that required an emergency-department thoracotomy (EDT). The authors conclude that among this predominantly black male population, there are different trends with respect to treatment, circumstances, and pattern of injury between the younger and older subpopulations.

Major Differences in Cardiovascular Risk Indicators by Educational Status

All people aged 30-59 years living in one primary health care center's catchment area were invited to participate in a population based screening program. A total of 2642 people (68%) participated. An overall risk index for having a heart attack within 5 years (Ps) was calculated based on diastolic BP, smoking status, total cholesterol, and age. Other risk indicators registered were Body Mass Index, and physical activity. A highly significant association between education level and age-adjusted overall risk index for both men (p = 0.001) and women (p < 0.001) was found. Also Body Mass Index, total cholesterol, smoking status, and, for women, diastolic blood pressure showed similar significant variation with education level with higher education associated to lower risk. These findings imply the possibility of a great variation in the "risk" of receiving pharmacological treatment for one's CVD risk factors.

Prevention of cardiovascular disease within the primary health care system--feasibility of a prevention programme within the Sollentuna primary health care catchment area.

To integrate prevention of cardiovascular disease within the primary health care. A prevention programme which combines population and individual high-risk strategy. The Primary Health Care in Sollentuna, Stockholm, Sweden. Characteristics of, and risk factor prevalence among, persons registered in the prevention programme. During the first year more than 2000 persons, representing every tenth visitor and 6% of the population aged 15-60 years, were registered in the prevention programme. 90% were < or = 60 years and 62% were women. A large proportion (70%) had risk factors that required advice, treatment, and follow up. 24% of the men and 27% of the women were smokers, 68% and 62% respectively, had serum cholesterol > or = 5.2 mmol/l, and 33% and 22% had a diastolic blood pressure > or = 90 mmHg. The present study implies that it is possible to integrate a large scale prevention programme in the existing primary health care organization. The prevalence of risk factors in those who enter the prevention programme is high, which places great demands for treatment and follow up.

Patient-number-based computerized medical records in Crete. A tool for planning and assessment of primary health care

Primary Health Care (PHC) in Crete is in a state of rapid development. The strategy for introducting PHC involves an orientation towards the population and the creation of possibilities for evaluation. A case records system, “EginO”, was installed in the University of Heraklion and at the Health Centre in Spili in 1988, and was further developed according to local needs during 1989, when also a Greek version of the statistical system, “DoIt”, was installed. The main reasons for establishing a computerized medical information system were (i) to assess the health needs in Crete, (ii) to monitor activities of the primary health care organizations, and (iii)_ to introduce epidemiological research into primary health care in Greece. The information system was based on specially assigned patient numbers containing several pieces of information about the individual; the system was developed at the Dalby Health Sciences Centre in Sweden. Each month, data were extracted in Spili Health Centre, and these data were regularly used to present incidence and prevalence indices. Some of the data extracted were reported to the health authorities in Greece. “EginO” and “DoIt” gave possibilities to evaluate health services by following the morbidity, while also making it possible to describe and analyse health needs in the population of Spili and other primary health care catchment areas in Greece.

Open access gastroscopy: too much to swallow?

To ascertain the proportion of endoscopic examinations with normal findings in patients referred for gastroscopy through hospital medical staff or directly by their general practitioner and to assess the likely effect of targeting endoscopy in older patients. Retrospective audit of the gastroscopy practice of one consultant from 1986 to 1988 from information recorded on a standard form completed at the time of the examination, which contained details of patients, their endoscopic findings, and mode of referral (open access or clinic). One district general hospital. 1545 Consecutive patients from primary catchment area attending for their first gastroscopy; 454 were referred through the outpatient clinic or by hospital colleagues (clinic group) and 1091 were accepted for endoscopy solely on their general practitioner's clinical diagnosis (open access group). Similar numbers (about 40%) of examinations with normal findings were performed in each group, although in patients aged over 40 the proportion with normal findings was significantly higher in the clinic group (p less than 0.03). Endoscopic evidence of gastro-oesophageal reflux disease, peptic ulceration, and gastroduodenal inflammation was equally common in each group; upper gastrointestinal malignancy, however, was significantly more common in patients referred through hospital doctors (5%, 23/454 v 2%, 22/1091 respectively; p less than 0.005) (although many of these patients had already been extensively investigated). Open access gastroscopy does not increase the number of unnecessary examinations and should become more widely available. Targeting this service to patients aged over 40 would reduce the number of requests but increase the diagnostic yield.

Comparison of mastectomy with tamoxifen for treating elderly patients with operable breast cancer.

Comparison of tamoxifen and mastectomy in treatment of breast cancer in elderly patients. Randomised trial of treatment of operable breast cancer by wedge mastectomy or tamoxifen, with median follow up 24 and 25 months respectively (range 1-63). University hospital; most patients from primary catchment area. 135 consecutive patients with breast cancer aged over 70 with operable tumours (less than 5 cm maximum diameter); 68 were allocated to tamoxifen group and 67 to mastectomy group. Histological diagnosis by biopsy. Two incorrect randomisations in each group. Patient characteristics similar in the two groups and all under care of one surgical team. Mastectomy group received wedge mastectomy plus excision of symptomatic axillary lymph nodes. Tamoxifen group received continuous treatment with tamoxifen 20 mg twice daily. Patients in tamoxifen group received wedge mastectomy if there was sign of local progression. Those in mastectomy group received further excision or radiotherapy for locoregional recurrence and when local treatments had been exhausted or metastatic disease diagnosed they received tamoxifen. Treatment efficacy was assessed by local control of disease and by survival. Mortality from metastatic cancer in tamoxifen group was 7 (10.6%) and in mastectomy group 10 (15.3%) (NS). There was no difference in survival between the two groups. In mastectomy group 70% remained alive and free of local recurrence at 24 months; in tamoxifen group only 47% remained alive and free of local progression. In mastectomy group locoregional recurrence occurred in 16 patients and metastatic disease in 13; in tamoxifen group locoregional progression occurred in 29 patients and metastatic disease in seven. As a high proportion of patients treated with tamoxifen eventually required surgery treatment of elderly patients with breast cancer should include mastectomy. Optimum treatment may include both mastectomy and tamoxifen.

Temperature activity of serum cholinesterases.

<h3>Objectives</h3> Previous studies have investigated the association between socioeconomic characteristics and fractures among children, producing different results. In a population-based study, we previously found an increased risk of fractures among children living in an urban municipality compared with rural municipalities. This study aimed to evaluate the importance of socioeconomic variables for the incidence of fractures among 0–17 year olds. <h3>Setting, design and outcome measure</h3> We present a longitudinal, observational study of a population 0–17 years of age. Data from an injury database were linked with additional socioeconomic data for the population at risk. These were 55 758 individuals residing within the primary catchment area of a regional hospital in northern Sweden. Using the number of fractures as the outcome, we fitted a generalised linear mixed model for a Poisson response with socioeconomic variables at the family level as independent variables while controlling for age, sex and place of residence. <h3>Results</h3> We found a significant association between higher levels of family income and the risk of fracture, rate ratio 1.40 (1.28–1.52) p&lt;0.001 when comparing the highest income quintile to the lowest as well as the number of siblings and the risk of fracture. Children with one or two siblings had a rate ratio of 1.28 (1.19–1.38) p&lt;0.001 when compared with children with no siblings. Parents’ educational level and having a single parent showed no significant association with fractures. The previously observed association between municipalities and fracture risk was less pronounced when taking family-level socioeconomic variables into account. <h3>Conclusion</h3> Our results indicate that children from families with higher income and with siblings are at greater risk of sustaining fractures.