Thrombolytic therapy in acute myocardial infarction: some reservations.
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Age Factors↗
Biomedical subjects
J Froom
Publications and source records attributed to J Froom.
The inventory to diagnose depression (IDD) in primary care patients.
Major depressive disorder (MDD) is highly prevalent in ambulatory primary care patients. Severe functional impairment and risk of suicide are features of the condition. Although treatment can reduce morbidity, detection of MDD by primary care physicians is suboptimal. The aim of this study is to assess the inventory to diagnose depression (IDD) as compared with clinical psychiatric assessment for case finding in primary care patients. Adult members of an Israeli kibbutz (communal settlement), where all psychiatric diagnoses made by the family physician are confirmed by psychiatric consultation, were asked to complete the IDD; a 22 question, self-administered questionnaire. Patients whose scores indicated MDD, if not previously diagnosed, were also referred to psychiatrists. Patients' medical charts were reviewed for the diagnosis of MDD and response to therapy prior to the administration of the IDD. Of the sample of 312 patients, 207 (66.3%) completed the IDD. Refusers were younger (P = 0.04), more likely to be native born Israelis (P = 0.02), and had a higher prevalence of known MDD (P = 0.05) than participants. MDD by IDD scores was present in seven patients, in three of whom the diagnosis had previously been established; the other four were newly diagnosed. In the three previously diagnosed patients, one (metastatic carcinoma) refused treatment and two were receiving psychotherapy; all were clinically depressed. Four additional previously diagnosed patients whose IDD scores were insufficient for MDD had had a successful response to current therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Use of CT scans for the investigation of headache: a report from ASPN, Part 1.
BACKGROUND: Clinicians in the Ambulatory Sentinel Practice Network (ASPN) order computed tomography (CT) scans for approximately 3% of patients with headache. This study was undertaken to provide information about the reasons for ordering CT scans and the results obtained. METHODS: Weekly return cards were used to collect data on every patient for whom a CT scan was ordered to investigate a headache during a 19-month period. Copies of CT reports were reviewed, and a chart audit was performed to collect further clinical information whenever an intracranial tumor, subarachnoid hemorrhage (SAH), or subdural hematoma (SDH) was reported. RESULTS: Clinicians in 58 practices ordered 349 CT scans. Only 52 patients (15%) had abnormalities noted on neurological examination. Most CT scans were ordered because the clinician believed that a tumor (49%) or an SAH (9%) might be present. Fifty-nine (17%) were ordered because of patient expectation or medicolegal concerns. Of the 293 reports reviewed, 14 indicated that a tumor, an SAH, or an SDH was present. Two of the 14 (14%) were false positives. Forty-four (15%) of the reports noted incidental findings of questionable significance. CONCLUSIONS: Because there are no clear guidelines for the use of CT for the investigation of headache, physicians must exercise good clinical judgment in their attempts to identify treatable disease in a cost-effective manner. ASPN clinicians made selective use of CT scans based on a combination of factors that included physician and patient concerns. CT was an imperfect tool in this setting. Most of the positive results represented false positives or incidental findings that could have led to adverse effects and additional costs.
Adolescent↗
Detection of intracranial tumors, subarachnoid hemorrhages, and subdural hematomas in primary care patients: a report from ASPN, Part 2.
BACKGROUND: The initial diagnosis of intracranial tumor, subarachnoid hemorrhage (SAH), and subdural hematoma (SDH) can be difficult. This study was undertaken to determine the incidence and presenting signs and symptoms of these disorders in primary care settings, and to determine whether a more aggressive investigative strategy for patients with headache is justifiable. METHODS: Weekly return cards and a chart audit were used to collect data over a 19-month period on every patient who had a new diagnosis of intracranial tumor, SAH, or SDH. Age and sex reports were collected annually. RESULTS: Twenty-five new tumors, 17 SAHs, and 8 SDHs were reported in 58 practices (a rate of 12/100,000 patients per year). Only one half of these patients had headaches, and no abnormalities were found on neurological examination of many. Diagnosis was delayed in only four patients with headache caused by a brain tumor and in three patients with SAHs. Diagnosis was delayed in two of the latter because of false-negative CT scans. CONCLUSIONS: Although clinical findings and CT scans are not reliable indicators, clinicians are able to detect the majority of these rare conditions without undue delay by selecting a small subset of patients for further investigation. More extensive use of CT scans appears to be a weak strategy to improve detection of these serious disorders, as increased use would lead to increased health care costs and unintended adverse effects, and provide little benefit.
Adolescent↗
Selection bias in using data from one population to another: common pitfalls in the interpretation of medical literature.
The prevalence, course and prognosis of diseases in patients referred to tertiary medical centers frequently differ from those treated in primary care settings. Extrapolation of findings from one population to another may therefore be unwarranted. Other factors that contribute to misinterpretation of medical literature include failure to distinguish statistical from clinical significance and advocacy of medical interventions prior to adequate clinical trials.
Epidemiology↗
"Prudence" in disease prevention.
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Aged↗
Selections from current literature: hormone therapy in postmenopausal women.
The articles reviewed for this issue of 'Selections' concern potential therapies to prevent osteoporosis and cardiovascular disease in postmenopausal women. Each therapy is controversial and provokes more questions than answers. The most benign intervention is the administration of calcium to postmenopausal women whose daily calcium intake is less than 400 mg. Although there have been reports that calcium administration failed to demonstrate benefit in this group, the treatment is unlikely to do harm. Etidronate can increase bone mineralization in women with osteoporosis, but will it be useful for prophylaxis? Oestrogens can prevent bone loss, but is the increased risk of breast cancer sufficient to preclude their use? Do oestrogens increase or decrease the risk of cardiovascular disease? A combination of oestrogen and progesterone may avoid the increased risk of uterine cancer but what are the effects of long term administration? Do the potential benefits of hormone therapy justify the costs and treatment of large numbers of women who without therapy would never have developed complications attributable to oestrogen lack? (Herman J: Fam Phys 1990; 18: 39-40) Given these uncertainties, is postmenopausal administration of hormones reasonable or prudent? The current literature does not provide adequate answers to these questions. Uncertainty, however, is not new for clinicians, who will weigh the evidence, evaluate the multiple variables in the individual patient that influence therapy, and with their patients decide whether the risks outweigh the benefits.
Calcium, Dietary↗
Otitis media in day-care children. A report from the International Primary Care Network.
The relationship between day care and acute otitis media and its adverse consequences was analyzed as part of a collaborative multinational study. Data from primary care research networks in eight countries were collected on 1335 children, aged 0 to 60 months, at the time of initial visits to their primary care physicians for acute otitis media. A history of recurrent acute otitis media, poor hearing, and tonsillectomy or adenoidectomy were all more frequent in day-care children aged 25 to 60 months, compared with those cared for at home. Day-care children were brought to their physicians more promptly after the onset of symptoms and received more referrals to otolaryngologists at the time of the index visit for acute otitis media. Day care may pose a significant risk for otitis media and its adverse consequences.
Acute Disease↗
Diagnosis and antibiotic treatment of acute otitis media: report from International Primary Care Network.
STUDY OBJECTIVE: The relation between a history of disorders suggestive of acute otitis media, symptoms, and findings of an examination of the tympanic membrane and doctors' certainty of diagnosis. Also, to examine differences in prescribing habits for acute otitis media among doctors from different countries. DESIGN: Questionnaires were completed by participating doctors for a maximum of 15 consecutive patients presenting with presumed acute otitis media. SETTING: General practices in Australia, Belgium, Great Britain, Israel, The Netherlands, New Zealand, Canada, Switzerland, and the United States. PATIENTS: 3660 Children divided into the three age groups 0-12 months, 13-30 months, and greater than or equal to 31 months. MAIN OUTCOME MEASURES: General practitioners' responses to questions on their diagnostic certainty and resolution of patients' symptoms after two months. RESULTS: The diagnostic certainty in patients aged 0-12 months was 58.0%. This increased to 66.0% in those aged 13-30 months and 73.3% in those aged greater than or equal to 31 months. In all age groups diagnostic certainty was positively associated with the finding of a tympanic membrane that was discharging pus or bulging. Redness of the membrane and pain were also associated with certainty in patients aged 13-30 months, and a history of decreased hearing or recent upper respiratory infection was positively associated in patients aged greater than or equal to 31 months. The proportion of patients prescribed antibiotics varied greatly among the countries, from 31.2% in The Netherlands to 98.2% in both Australia and New Zealand, as did the duration of treatment. Patients who did not take antibiotics had a higher rate of recovery than those who did; the rate of recovery did not differ between different types of antibiotic. CONCLUSIONS: Doctors' certainty of diagnosis of acute otitis media was linked to patient's age. Improved criteria or techniques for diagnosing acute otitis media, especially in very young children, need to be developed. Antibiotic treatment did not improve the rate of recovery of patients in this study.
Acute Disease↗
Glycemic control in elderly people with diabetes.
Hyperglycemia is only one of several metabolic derangements that are prevalent in diabetes mellitus. Of these, hyperlipidemia, obesity, and co-existent hypertension may make more important contributions to complications than persistently elevated blood sugars. The role of hyperglycemia in the genesis of diabetic complications is uncertain and there is little evidence from prospective randomized controlled studies to support rigorous hypoglycemic treatment. Adverse consequences of pharmacologic therapy can be severe, including death, and are most frequent in the elderly. The group of elderly diabetic ambulatory patients is markedly heterogeneous and individualization of therapy is required. Obese persons require dietary therapy, and additional dietary manipulations are needed for patients with the complications of hyperlipidemia, hypertension, and nephropathy. Pharmacologic hypoglycemic therapy may be required to control symptoms, but its use in asymptomatic diabetic persons is for the most part unwarranted.
Age Factors↗
Consequences of the National Cholesterol Education Program.
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Adult↗
Selections from current literature: the cholesterol controversy.
This issue of 'Selections' focuses on studies of cholesterol reduction in asymptomatic adults. Treatment of persons with coronary heart disease involves other issues and the need to consider additional evidence from other studies. Elevated blood cholesterol levels are associated with increased coronary heart disease in young adults. The real question is whether or not lowering cholesterol levels with diet and drugs is possible and if possible, whether it reduces the risk of morbidity and mortality. Even if the relative risk can be reduced it is necessary to consider the absolute risk reduction. Reduction of the risk of fatal myocardial infarction from 2.0% to 1.6% over a seven year period while at the same time increasing the risk for gallbladder surgery from 1.3% to 1.9% may not be an attractive gamble. There is little evidence that elevated cholesterol levels are a risk factor in adults over the age of 60 years. Intervention trials have not been conducted in women or in the aged, and overall mortality has not been reduced in any of the studies. The Department of Health and Human Services of the United States recommends an approach that if implemented could have initial costs that exceed 10 billion dollars. Yearly costs are likely to exceed the initial cost. In a recent editorial Professor Joseph Herman expresses concern that the Israel Society for Research on Atherosclerosis and the European Atherosclerosis Society have adopted similar recommendations to those recently announced in the United States. He also points to large variations reported from 5000 laboratories given standard samples to be tested for total cholesterol. Currently blood cholesterol levels are available to shoppers at a supermarket in Florida (New York Times 1989, January 3). The end of this controversy is not yet in sight.
Adult↗
Mental disorder in primary care.
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Family Practice↗
Classifying family/household problems.
To investigate how family/household problems could be classified 186 problems recorded in 55 families by 14 Israeli family physicians were studied. Four major categories were used which included health problems in one family member affecting others in the household, relationship problems, social problems and health problems in more than one family member. Over half of the 186 problems were psychological or physical problems in the individual which affected other household members. Specific diagnostic titles from the International Classification of Health Problems in Primary Care (ICHPPC-2-Defined) were suitable to classify virtually all identified family/household problems. More problems were identified in mothers than in fathers or children and mothers were perceived as being affected most by social and relationship problems. Additional studies are suggested.
Adult↗
Radical therapy?
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Attitude of Health Personnel↗
Sensitivity of the high-power field method in detecting red blood cells in the urinary sediment.
The red blood cell (RBC) content of urine specimens was determined both by direct counts by a hemocytometer and by the number of RBCs per high-power field (HPF) in the sediment by routine urine analysis. The sensitivity of a finding of 1 to 3 and 2 to 4 RBCs/HPF in detecting greater than or equal to 2,000 RBCs/ml unspun urine was 63% (73/116) and 54% (63/116), respectively. There was a wide range of values of RBCs/ml determined by direct counts for each degree of microscopic hematuria as defined by the HPF method. We conclude that examination of the urinary sediment by the HPF method is not sufficiently sensitive to be used as a screening test for the detection of microhematuria in asymptomatic subjects.
Adult↗
Adjusting for selection biases in referral populations.
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Adult↗