Years In General Practice Research Articles

Patient perspective on herpes zoster and its complications: An observational prospective study in patients aged over 50 years in general practice

Understanding the effect of herpes zoster and zoster-related pain should inform care to improve health-related quality of life in elderly patients. A 12-month, longitudinal, prospective, multicenter observational study conducted in primary care in France enrolled patients aged ⩾50 years with acute eruptive herpes zoster. Patient-reported zoster-related pain was assessed by validated questionnaires (Douleur Neuropathique en 4 Questions [DN4], Zoster Brief Pain Inventory [ZBPI], and Neuropathic Pain Symptom Inventory [NPSI]) on days 0 and 15, and at months 1, 3, 6, 9, and 12. Health-related quality of life was assessed by the 12-item short-form health survey (SF-12) and the Hospital Anxiety and Depression scale on day 0 and at months 3, 6, and 12. Of 1358 patients included, 1032 completed follow-up. Mean ± standard deviation age was 67.7 ± 10.7 (range, 50–95) years; 62.2% were women. Most patients (94.1%) were prescribed antiviral drugs. The prevalence of zoster-related pain on day 0 and at months 3, 6, 9, and 12 was 79.6%, 11.6%, 8.5%, 7.4%, and 6.0%, respectively. Patients with persistent pain had lower scores on the physical and mental component summaries of the SF-12 and the ZBPI interference score than those without pain. By logistic regression analysis, main predictive factors on day 0 for postherpetic neuralgia at month 3 were age, male sex, ZBPI interference score, Physical Component Summary score of the SF-12, and neuropathic quality of pain (DN4 score ⩾4). Despite early diagnosis and treatment with antiviral agents, many patients with herpes zoster experience persistent pain and marked long-term reduction in health-related quality of life.

Age differential between outcomes of carotid angioplasty and stent placement and carotid endarterectomy in general practice

Data derived from prospective randomized clinical trials suggest differential comparative benefit between carotid angioplasty and stent (CAS) placement and carotid endarterectomy (CEA) in various age strata. We sought to investigate the impact of age on outcomes of CAS and CEA in general practice. We analyzed the data from the Nationwide Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2008. The primary end point was occurrence of stroke, cardiac complications, or death during the postprocedural period. Outcomes of interest were compared between patients aged ≥70 years and <70 years, undergoing CEA and CAS. Multivariate logistic regression was performed to determine the effect of age on occurrence of postoperative stroke, cardiac complications, or death. Covariates included in the logistic regression were patient's age, gender, comorbid conditions, including hypertension, diabetes mellitus (DM), chronic lung disease, coronary artery disease (CAD), congestive heart failure (CHF), and renal failure; symptom status (symptomatic vs asymptomatic status), and hospital characteristics. Of the total 495,331 estimated patients who received treatment for CAD during the study period, 88% underwent CEA and the remaining 12% underwent CAS. Of the total procedures, 41% of the procedures were performed in patients aged <70 years compared to the remaining 59% that were performed among patients aged ≥70 years. For patients undergoing CAS, age ≥70 years was an important predictor of postoperative stroke (P = .0025; odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.5) and cardiac complications postprocedure (P = .045; OR, 1.3; 95% CI, 1.0-1.6). For patients undergoing CEA, age ≥70 years was associated with higher cardiac complications (P < .001; OR, 1.5; 95% CI, 1.3-1.7) and higher postoperative mortality risk (P = .0008; OR, 1.4; 95% CI, 1.1-1.8) compared to patients aged <70 years. The increased risk of composite end point (postoperative stroke/cardiac complications/mortality) among patients aged ≥70 years was a significant factor for patients undergoing either CAS or CEA (OR of 1.3 for both procedures). Our analysis suggests that most CAS and CEAs are performed in patients aged ≥70 years in general practice, and higher rates of postoperative complications are observed among these patients regardless of procedure choice.

Duncan Martyn Watney

Duncan Martyn Watney came from the third generation of doctors. He never really thought that there was any other career for him, pursuing it to the best of his ability...

Impact of 7-valent pneumococcal conjugate vaccine (PVC-7) on the incidence and treatment of pneumonia diagnosed in primary care in children and adolescents in UK

BackgroundStreptococcus pneumonia is the main cause of bacterial pneumonia in children in the UK. In September 2006, a 7-valent pneumococcal conjugate vaccine (PCV7) was introduced into the UK childhood immunisation...

A complexity perspective on health care improvement and reform in general practice and primary health care

Health care improvement is always on the planning agenda but can prove frustrating when 'the system' seems to have a life of its own and responds in unpredictable ways to reform initiatives. Looking back over 20 years of general practice and primary health care in Australia, there has been plenty of planning and plenty of change, but not always a direct cause and effect relationship between the two. This article explores in detail an alternative view to the current orthodoxy of design, control and predictability in organisational change. The language of complexity is increasingly fashionable in talking about the dynamics oforganisational behaviour and health care improvement, but its popular use often ignores challenging implications. However, when interpreted through human sociology and psychology, a complexity perspective offers a better match with everyday human experience of change. As such, it offers some suggestions for leaders, policy makers and managers in health care: that uncertainty and paradox are inherent in organisational change; that health care reform must pay attention to the constraints and politics of the everyday; and that change in health systems results from the complex processes of relating among those involved and that neither 'the system' nor a few individuals can be accountable for overall performance and outcomes.

Edmund James Raffle

As a medical student, Edmund James Raffle had a tuberculous kidney which necessitated a nephrectomy. After a spell at Alder Hey Children’s Hospital, he spent time in general medicine/cardiology at...

Bernard Vincent Lee

Bernard Vincent Lee came from a well-known Manchester family, which had given two Lord Mayors to the city. He began his medical career by undertaking ear, nose, and throat surgery,...

Farewell to the handmaiden? Profile of nurses in Australian general practice in 2007

Objective: To describe the characteristics of nurses working in Australian general practice, including their backgrounds, working environments, tasks and duties. Design: National cross‑sectional survey. Setting: General practices in all regions of Australia. Subjects: 104 registered and enrolled nurses working as practice nurses (PNs). Results: Participants were predominantly registered nurses (93%); all female; and had been in general practice for an average of 6.2 years. They were generally working part time (average 26.2 hours per week), with pay ranging from $18 to $45 per hour. Registered nurses had higher rates of pay but there was no clear relationship between rate of pay and years in general practice. The majority (86%) had completed one or more short courses, and one in six (16%) held or were undertaking postgraduate studies in practice nursing. PNs in the sample worked in practices where there was an average of one PN for every 2.43 GPs. Almost half (47%) worked in practices which employed allied health professionals, and 90% employed practice managers. All undertook duties relating to direct patient care, coordination of care, and management of the clinical environment. 90% undertook practice management and administration tasks, including 57% who provided some reception or secretarial support. Conclusions: Although some differentiation of roles within the PN workforce was apparent, there were few discernable differences in nurse or practice characteristics associated with these different profiles, and they were unrelated to experience and remuneration. Findings highlight the need for development of career pathways and better monitoring of the PN workforce.

Rise in psychotropic drug prescribing in children and adolescents during 1992–2001: a population-based study in the UK

The trend towards increased psychotropic drug prescribing in children and adolescents is well recognised in North America and continental Europe. However, it is unclear to what extent these studies are applicable to clinical practice in the United Kingdom (UK). This study was conducted to estimate the prevalence of psychotropic drug prescribing in children and adolescents aged <19 years in general practice in the UK from January 1992 to December 2001. Data were obtained from the General Practice Research Database (GPRD). Annual age- and sex-specific prevalence of psychotropic drug prescribing was calculated. A total of 143,079 prescriptions were issued to 34,398 study subjects. Stimulant prescriptions rose significantly from 0.03 per 1,000 (95% confidence interval 0.02-0.04) in 1992 to 2.9 per 1,000 (2.52-3.32) in 2001; a 96-fold increase. Methylphenidate accounted for the majority of stimulant prescriptions; 2.4% (349/14,370) of stimulant prescriptions were prescribed to children aged <6 years. Increased prescribing was also noted for antidepressants (1.6-fold), hypnotics/anxiolytics (1.3-fold), antipsychotics (1.3-fold) and anticonvulsants (1.3-fold), whilst the prevalence of clonidine and lithium prescribing remained fairly stable throughout the study period. The use of antidepressant, hypnotic/anxiolytic and anticonvulsant increased with increasing age. A high proportion of boys received stimulants, whereas antidepressants and hypnotics/anxiolytics were more likely prescribed to girls. There is an increased trend of psychotropic drug use in children and adolescents in the UK practice. Since most psychotropic drugs are not licensed for use in children at this time, research is needed to investigate the efficacy and long-term safety in this population.

Sylvia Todd (née Dennison)

After junior hospital posts at Otley and Bradford, Sylvia Todd (nee Dennison) spent five years in general practice, mainly in Hawes, North Yorkshire, before she became a CMO (clinical medical...

An overview of study design

An overview of study design

The Tooke report: good news for general practice?

During the 1960s — when it was still possible to enter general practice immediately after completion of the pre-registration house officer year — the Royal College of General Practitioners (RCGP) sought to improve standards of care for patients by introducing vocational training for general practice. Although the RCGP proposed a 5-year period of vocational training at that time, resource constraints within the NHS meant that only 3-year programmes could be developed, and with only 1 year in general practice itself. Initially voluntary, there was no requirement to undertake any training until 1978 when primary legislation was introduced making it mandatory to complete 12 months in general practice. Subsequent changes to the legislation in 1983 required completion of 3 years' training to become a principal and in 1990 required completion of training to work in any capacity within general practice. Although the majority of trainees took the MRCGP examination, there was no requirement to demonstrate satisfactory completion of training until 1996 when summative assessment became mandatory. The changes brought about by the Postgraduate Medical Education and Training Board (PMETB) gave us the opportunity to develop specialty training for general practice, ensuring that doctors have the competences necessary to provide high standards of medical care for patients. The PMETB set explicit standards for both the training curriculum and the assessment of completion of training that needed to be met by all medical specialties including general practice. The curriculum for general practice1 was given unconditional approval by PMETB. Although the curriculum is competence-rather …

William Keith Davidson

Keith Davidson was born in Partick, Glasgow, in 1926. He began his medical education at St Mungo's College, which two years later was absorbed into Glasgow University, and after graduation...

Guidelines for the vaccination of dogs and cats

Guidelines for the vaccination of dogs and cats

The prognosis of depression in older patients in general practice and the community. A systematic review

Little is known about the prognosis of depression in older patients in general practice or the community. To summarize available evidence on the course and prognostic factors of depression in older persons. We conducted a systematic, computerized search of Medline and PsycINFO. Manual search of references of included studies were done. Studies potentially eligible for inclusion were discussed by two reviewers. Methodological quality was independently assessed by two reviewers. Data regarding selection criteria, duration of follow-up, outcome of depression and prognostic factors were extracted. We identified 40 studies reporting on four cohorts in general practice and 17 in the community. Of all, 67% were of high quality. Follow-up was up to 1 year in general practice and up to 10 years in the community. Information on treatment was hardly provided. About one in three patients developed a chronic course. Five cohorts used more than two measurements during follow-up, illustrating a fluctuating course of depression. Using a best evidence synthesis we summarized the value of prognostic indicators. General practice studies did not provide strong evidence for any factor. Community studies provided strong evidence for an association of baseline depression level, older age, external locus of control, somatic co-morbidity and functional limitations with persistent depression. Within the older population, age seems to be a negative prognostic factor, while older people are more likely to be exposed to most of the other prognostic factors identified.

"All changed, changed utterly": recollections of 40 years in general practice.

Medical Journal of AustraliaVolume 181, Issue 1 p. 21-22 The Profession – 90th Anniversary “All changed, changed utterly”: recollections of 40 years in general practice Eva Szego MB BS, Eva Szego MB BS General Practitioner MedicalOne, Elwood, VIC.Search for more papers by this author Eva Szego MB BS, Eva Szego MB BS General Practitioner MedicalOne, Elwood, VIC.Search for more papers by this author First published: 05 July 2004 https://doi.org/10.5694/j.1326-5377.2004.tb06152.xCitations: 2Read 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 onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume181, Issue1July 2004Pages 21-22 RelatedInformation

Thomas John (Jock) Murray, OC, MD, FRCP(C), MACP, LLD(Hon), DSC(Hon), FRCP(Lon): A Conversation with the Editor

Dr. Jock Murray (Figure ​(Figure11) was born in Pictou, Nova Scotia, Canada, on May 30, 1938. He attended St. Francis Xavier University in Antigonish and Dalhousie University School of Medicine in Halifax, graduating with honors in 1963. After 2 years in general practice, Dr. Murray returned to Halifax to train in internal medicine and then in neurology in Halifax, London, and Toronto, before joining the Dal housie medical faculty in 1970. He professor of medicine (neurology), professor of medical humanities, and dean of medicine, with professional appointments also in the departments of family medicine, community health and epidemiology, and history at Dalhousie University. He founded and has been director of the Dalhousie Multiple Sclerosis Research Unit for the past 23 years.

Graduates' evaluation of a postgraduate diploma course in family medicine.

Postgraduate programmes offer an opportunity to learn family medicine for physicians in practice who were unable to obtain formal training in the immediate postgraduate phase of their career. Since 1985, the Chinese University of Hong Kong has provided a part-time 1-year diploma course at hours convenient for private practitioners. The curriculum has evolved, reducing public health components and increasing family medicine concepts. Between six and 16 students took the course each year until 1999, when formal recognition led to increased popularity. The aim of this study was to evaluate the components and outcomes of the course as a prelude to further development. Evaluation comprised a structured telephone interview conducted with two enrollees from each year of the course (total 28), selected randomly from class lists. Participants were mostly young doctors, with an average of 5 years in general practice. Many graduates are now prominent in training and development of family medicine in Hong Kong. Graduates rated most components favourably, but found the original research components too demanding, and not useful subsequently for most. Counselling, family dynamics, consultation and practice organization skills were valued. Conventional continuing education components, such as lectures by specialists, were evaluated poorly. This course has proved useful in the Hong Kong context, being practical for physicians, and allowing them to study ideas they would not otherwise encounter. Critical appraisal and evidence-based medicine exercises now replace the former research components.

Additional value of spirometry in risk assessment of acute respiratory disease in winter among patients with mild to moderate asthma or COPD

Spirometry is frequently performed by Dutch general practitioners to diagnose and monitor asthma or COPD. However, its additional value to anamnestic data in predicting the occurrence of acute respiratory disease (ARD) is unknown. We developed a clinical prediction model, assessing the additional value of spirometry, for the risk of asthma/COPD exacerbation or pneumonia during an influenza epidemic. Data were used from a case-control study among patients with asthma or COPD aged 18-64 years in general practice. During the influenza epidemics of 1998-1999 and 1999-2000, data on demographics, prior health care use, medical consumption, type of lung disease and comorbidity were collected from 87 patients with an exacerbation or pneumonia and 363 controls matched on age en sex using computerized medical records. Additionally, FEV1 and PEF were measured before and after inhalation of a β-agonist. Conditional multivariate logistic regression analysis and receiver-operator curve (ROC) analysis was used to assess the discriminative value of anamnestic data and spirometry. Independent predictors of the occurrence of ARD were ‘prior exacerbation’ (OR 6.3 95% CI 3.3-12.3), ‘use of bronchodilators’ (OR 2.0, 95% CI 1.3-3.8), ‘treatment by pulmonologist’ (OR 2.0, 95% CI 1.2-3.4) and ‘COPD’ (OR 1.7, 95%CI 0.9-3.0). The fit of the model was good (Hosmer-Lemeshow goodness-of-fit-test p=0.36) and discrimination satisfactory (AUC =0.75). Both FEV1 %predicted and PEF%predicted were significant predictors, but did not improve discriminative power of the model. Subgroup analyses showed no effect modification by age, type of lung disease, or risk classification on the additional discriminative value of spirometry. Using routinely available information, a reliable estimation of the risk of ARD in patients with mild to moderate lung disease aged 18-64 years during an influenza epidemic can be made. There is no additional value of lung function to history taking in this patient group.

Where there is a will

You have been so kind to me, doctor. I shall be remembering you in my will.” After many years in general practice, I have learned never to take such declarations at face value. Promises of bequests are not uncommon from elderly patients, but there is usually some hidden motive.