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Biomedical subjects

C B Del Mar

Publications and source records attributed to C B Del Mar.

At least 37 records · Page 2Linked to original sources
PubMed2000

N of 1 trials. Practical tools for medication management.

BACKGROUND: In single patient (n of 1) trials, a patient acts as his or her own control in a study comparing the effectiveness of a drug with placebo or another drug. The aim of a single patient trial (SPT) is to identify the best treatment for the individual patient, formalising a 'trial of treatment' by using blinding and multiple crossover periods. OBJECTIVE: We have successfully piloted SPTs for osteoarthritis and attention deficit hyperactivity disorder, and several others are currently being piloted. Barriers encountered include: obtaining identical placebos, ethical approval for individual SPTs, standardising doses, determining length of treatment periods, patient withdrawals and cost of the SPTs. DISCUSSION: Only prescribing medications if an individual has been shown to be a responder can greatly benefit general practitioners, patients and the healthcare system. We have established the infrastructure necessary to offer a single patient trial service to GPs and patients anywhere in Australia. This has the potential to revolutionise prescribing for certain chronic conditions.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2000

Managing ADHD in general practice. N of 1 trials can help!

OBJECTIVE: To pilot single patient trials designed to improve decision making about stimulant use for attention deficit hyperactivity disorder (ADHD) in general practice. METHOD: Patients previously stabilised on dexamphetamine were enrolled from a general practice. Each undertook a six week same patient randomised, double blind, placebo controlled crossover comparison of dexamphetamine with placebo for ADHD. Rating scales were completed weekly by self, parent and teacher. RESULTS: Three of the four patients were clear responders to dexamphetamine (including a noncompleter, as his results still demonstrated a clear response). The results were clinically useful in each case. Management was confirmed for three patients and changed for one (who ceased dexamphetamine). DISCUSSION: Prescribing stimulant medications only to children with diagnosed ADHD and who are found to respond, limits use of these worrisome drugs to those who will respond, and minimises their use in those who will not benefit.

Adolescent↗
PubMed1999

Skin cancer screening by Australian family physicians: variation with physician beliefs and geographic locality.

INTRODUCTION: Australian national policies do not recommend skin cancer screening. We measured family physicians' beliefs, self-reported practices, and predictors of using clinical skin examination for skin cancer screening. METHOD: Random self-administered postal survey of 1271 Australian family physicians (FPs) performed during 1996, obtaining 855 completed questionnaires (67% response rate). RESULTS: Eighty-six percent of FPs surveyed indicated that they thought clinical skin examination was effective in reducing premature death from skin cancer; 72% indicated that they should be performed annually; and 60% indicated that all adults should be screened. Only 3% indicated correctly that screening has not been tested to determine its effectiveness. Although most FPs were unlikely to adopt an opportunistic approach to screening, 64% indicated that they would recommend clinical skin examination during a health check-up. FPs in northern (high incidence) latitudes were 3 to 4 times more likely to adopt opportunistic screening, and twice as likely to discuss clinical skin examination in a dedicated check-up. FPs were more likely to advocate screening in male rather than female patients. Half of respondents were unaware of relevant guidelines. CONCLUSION: Although Australian policies do not recommend clinical skin examination because of insufficient evidence as yet of effectiveness, FPs show considerable support for screening. Geographic location, patient gender, and physician beliefs predict the self-reported provision of clinical skin examination by family physicians, suggesting that factors other than published guidelines affect clinical practice.

Adult↗
PubMed1998

Antibiotics for sore throats?

Although not explicit, recommendations in the new edition of Therapeutic Guidelines: Antibiotic have taken a lurch towards an evidence basis. What does this mean, and what is the basis of the recommendation that antibiotics be used for sore throat in very limited circumstances?

Anti-Bacterial Agents↗
PubMed1998

Examination of skin naevi in Australian general practice: dissonance between care and need?

Over 26 months, 223 general practitioners recorded consultations involving the management of skin naevi and some demographic details of the patients. We used data from the Health Insurance Commission and the Australian Bureau of Statistics to estimate population consultation rates. Of 749,171 consultations, 9,729 involved management of naevi. The annual rate per 1,000 of these consultation was 11.3 (95% CI 11.0-11.6) for males and 17.0 (95% CI 16.6-17.5) for females. The rate was significantly higher in the 15-44 year age group, at 21.8 consultations per 1000 individuals annually, compared to 6.3 for younger ages and 16.0, 16.1 and 8.6 for the 45-64, 65-74 and 75+ age groups respectively. There was a seasonal variation, with rates highest in the hot months (of about 16 annual consultations per 1,000 individuals) and lowest in the cooler months (14 for the two years' cooler seasons sampled). There was a significant variation between the rates of different states and territories, but this did not follow a latitude difference. There is a dissonance between the distribution of melanomas (relatively concentrated among older patients and males) and the general practice management of skin naevi (relatively concentrated among younger patients and females). Although melanomas (particularly those with the poorest prognosis) are relatively concentrated in older men, paradoxically, more skin naevi are managed in general practice among younger and female patients.

Adolescent↗
PubMed1998

Improving general practitioner clinical records with a quality assurance minimal intervention.

BACKGROUND: Although good medical records have been associated with good care, there is considerable room for their improvement in general practice. AIM: To improve the quality of general practice medical records at minimal cost. METHOD: A total of 150 randomly sampled general practitioners (GPs) in suburban Brisbane, Australia, were randomized in a controlled trial to receive or not receive an intervention. The intervention consisted of 6 to 12 one-hour monthly meetings when the pairs of GPs assessed samples of each other's medical records using a 12-item instrument. This was developed previously by a process of consensus of general practice teachers. Mean scores of 10 medical records selected at random from before the intervention started and one year later were compared. RESULTS: After the intervention, the increase in the total score (for which the maximum possible was 18) for the intervention GPs (from a baseline of 11.5 to 12.3) was not significantly greater than for the controls (from 11.4 to 11.7). Legibility and being able to determine the doctor's assessment of the consultation were significantly improved. The post-intervention increase of 1.06 (9.3%) of the total scores of the 47% of intervention GPs who complied with the intervention was significantly greater than that for the controls. CONCLUSION: The quality assurance activity improved some components of the quality of GPs' clinical records. However, the improvement was small, and the search for activities for Australian GPs that demonstrate an improvement in the quality of their practice must continue.

Family Practice↗
PubMed1997

Patterns of excision and referral from primary care of melanocytic lesions.

There is debate about the margin of normal tissue that should be included with excisions of melanocytic lesions of the skin, and about which lesions should be referred for specialist care. We describe the determinants of the margins of excised melanocytic skin lesions and of referral patterns from primary care. Copies of the pathology reports of melanocytic skin lesions excised from two cities in tropical Queensland were obtained; questionnaires about each lesion were administered to the excising doctor. Data about 3275 lesions (2914 naevi, 130 lentigos, 151 melanomas, 51 dysplastic naevi, 21 Hutchinson's melanotic freckles and eight other melanocytic lesions) were analysed. Twenty-one per cent of the treatment sessions involved the excision of more than one lesion; 5% involved three lesions or more. Most lesions were managed by one doctor. The overall mean margin of excision was 2.8 mm. It was greater for longer qualified doctors, surgeons and college-affiliated general practitioners, for lesions excised to address malignancy (3.0 mm) rather than cosmetic appearance (2.4 mm), for Hutchinson's melanotic freckles (5.9 mm) and melanomas (5.1 mm) compared with benign lesions (2.7 mm) (P < 0.001) and for older patients (2.6 mm for those < or = 15, 3.5 mm for those > 40 years) (P = 0.001). Wider excisions of skin melanocytic lesions are performed by older and more experienced doctors, on older patients, and for lesions in which malignancy is being addressed.

Adolescent↗
PubMed1997

The skin cancer workload in Australian general practice.

OBJECTIVE: Skin cancer is common in Australia. It is managed in large portion within general practice, and early excision usually affords cure, therefore, it may form a much greater workload for general practitioners (GPs) than incidence figures would imply. The aim of this study was to describe the skin cancer workload in Australian general practice. METHOD: Analysis of data recorded by 495 randomly selected GPs relating to 113,468 consultations (98,796 weighted for State size), which were collected as part of a national descriptive study. Medicare and census data were used to calculate rates at which GPs were consulted for different conditions. RESULTS: Skin tumours accounted for 2,083 (1.5%) of all 145,799 problems managed in 98,796 encounters. Annual rates at which GPs were consulted were: 13/1,000 people for 'malignant' tumours of the skin; 23/1,000 for 'naevus/mole; and 13/1,000 for 'other benign' lesions. The rates of diagnoses of 'malignant skin neoplasms' increased with age to a maximum among women and men aged 65 years or more of > 80/1,000 and > 100/1,000, respectively. For 'naevus/mole' the rates of maximum diagnoses were 40/1,000 for women and 351/1,000 for men aged 15-24 years. There was no sex difference for the maximal rate (15/1,000) among the 45-64 age groups for 'other benign skin lesions'. The main form of management was procedural for malignant skin lesions (90% of consultations) and naevi/moles (50%). Referral to specialist services was most common during consultations for malignant disease (22% of consultations), in comparison to naevi/moles (15%) and other benign skin neoplasms (9%). Procedures (cryotherapy, diathermy and excision) and referrals were more common for malignant lesions and naevi/moles. CONCLUSIONS: There were important differences in age distribution for rates of management of benign and malignant skin tumours and naevi. Skin tumours usually were managed in conjunction with other problems. Most were managed procedurally. Only a minority were referred. Skin cancer represents a greater workload for Australian GPs than suggested by previous incidence reports.

Adolescent↗
PubMed1997

Do public media campaigns designed to increase skin cancer awareness result in increased skin excision rates?

We report on an observational study of one city in Queensland over a 30-month period to evaluate the effects of two public skin cancer campaigns on the excision rates of melanocytic skin lesions. The numbers of melanomas, the numbers of potentially malignant melanocytic lesions (Hutchinson's melanotic freckles and dysplastic naevi) whose excision might have benefited the patient, and the total number of melanocytic skin lesions submitted to pathology services were recorded. A total of 3221 melanocytic skin lesions were excised. More lesions were excised during summer than non-summer periods (rate ratio 1.22, 95% CI 1.06, 1.40) and, independently, during campaign periods than non-campaign periods (rate ratio 1.24, 95% CI 1.11, 1.37). There were 145 melanomas (4%), of which 116 were < 0.76 mm thick, and an additional 53 (2%) other potentially malignant lesions. During campaigns, proportions of neither type increased significantly, nor was there a significant reduction in excised melanoma thickness. Doctors reported more often that the reason for excision was to exclude malignancy during the campaigns, although they felt themselves to be under less pressure from patients to excise lesions. There may be considerable cost associated with primary prevention campaigns in the form of increased excision of benign skin lesions, which should be addressed in future skin cancer public awareness campaigns.

Australia↗
PubMed1996

Effect of a public awareness campaign on the appropriateness of patient-initiated skin examination in general practice.

The aim of the study was to describe the appropriateness of patient-initiated skin examinations, and assess whether an awareness program leads to a greater proportion of inappropriate patient-initiated skin examinations. General practitioners (n = 27, response rate 71 per cent) from a regional town in Queensland recorded details of consultations involving a skin examination over a five-week period straddling the 1991 National Skin Cancer Awareness Week. The outcome measure was the clinical impression (benign, suspicious or malignant) of the most serious skin lesion presented by each general practice patient (n = 1183). Thirty-six per cent of patient-presented lesions were clinically suspicious or malignant. Lesions were more likely to be clinically suspicious or malignant if they were presented as the primary reason for the consultation (odds ratio OR = 1,219.95 per cent confidence interval (CI) 1.01 to 1.48); if the patient was aged over 35 years (OR = 5.594, CI 1.08 to 7.66); or male (OR = 1.634, CI 1.35 to 2.00). Following a public skin cancer awareness campaign, there was a slight nonsignificant decrease (OR 0.938, CI 0.91 or 1.25) in the proportion of clinically suspicious and malignant lesions detected. An increase in the number of skin examinations following an awareness campaign did not result in an increase in the proportion of inappropriate skin examinations. Patient-initiated skin examinations have an important role to play in the early detection of skin cancer.

Adult↗
PubMed1996

What use do people make of physicians in checking their skin for cancer?

We administered a questionnaire to 995 people selected randomly from the electoral roll in one coastal region of subtropical Australia. Three-quarters (739) indicated their skin was checked by a physician, by themselves, or both. Among the 15% who were taught to check their skin, 59% learned to do so from physicians. A family physician would be consulted immediately by 40% who found something suspicious, and by 58% after a period of delay. Several factors associated with other indicators of health-seeking behavior, including being told by a physician that there was a special risk of skin cancer, were related to an increased proportion of respondents who were checked by their physicians as well as themselves. In addition to being the main focus of help should a suspicious lesion be found, physicians may have an important role in introducing the public to the process of early detection of skin cancer as well as providing an important function in its actual conduct.

Adult↗
PubMed1995

Aid to diagnosis of melanoma in primary medical care.

OBJECTIVE: To evaluate an intervention designed to reduce the number of benign melanocytic lesions excised from the skin. DESIGN: A randomised controlled field trial based in the medical practices of two cities. Examination of histopathological reports of 5823 melanocytic skin lesions excised over the intervention period and in the preceding six months. INTERVENTION: Medical practitioners were offered an algorithm and use of an instant developing camera. SETTING AND SUBJECTS: Over 50 medical practitioners, mostly in general practice, in each of two cities in tropical Queensland, Australia. MAIN OUTCOME MEASURES: Percentages of benign (neither malignant nor potentially malignant) melanocytic lesions excised during the two year intervention period. RESULTS: There were no significant differences in the percentages of benign lesions reported in the intervention and control cities before the intervention started (93.6% and 94.0%, respectively), but there was a significant difference afterwards (88.8% and 93.8%, P < 0.001). There was no difference in the percentage of invasive melanomas excised per month in the intervention city (3.4%) compared with control city (3.4%). CONCLUSION: Clinical diagnostic accuracy may be enhanced by offering to clinicians managing suspicious melanocytic skin lesions a simple algorithm and a camera with which to record the appearance of lesions objectively.

Adult↗