SEARCH · Search PubMed
Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.
Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.
In light of the emphasis on community care for schizophrenia and the increasing role likely to be played by general practitioners, this paper describes some of the general principles involved in the treatment of this disorder and provides a set of practical guidelines to assist general practitioners.
BACKGROUND: When general practitioners (GPs) act contrary to their own standards of good practice, they usually cite patient demands as the main reason. However, up until now, studies have relied on doctors' recollections of departures from their own norms, which may be unreliable. AIM: To systematically explore GPs' motives for deliberate departures from their own conception of good practice. METHOD: Forty-nine GPs, over five days, registered to what extent they had deviated from their own norms, and recorded the motives underlying any deviation. RESULTS: Of the 6087 consultations registered, 10% contained some departure from 'good' general practice, the majority (75%) of which was perceived by the doctor concerned as 'slight'. Doctors underpinned their departures mostly by referring to the doctor-patient relationship: the wish to be nice was used, on average, in 42% of deviations, and the wish to prevent a conflict in 30%. The most important non-relational motive was clinical uncertainty, which doctors used in 11% of their cases. DISCUSSION: Contrary to common belief, GPs often comply with patient requests because they wish to, and not because they feel forced to. Whether or not this behaviour affects the quality of care is largely dependent on the model of 'good' general practice used.
Generalized periodontitis is a polyetiological disease, pathogenetically bound with internal pathology. The study was made to reveal common somatic mechanisms of generalized periodontitis pathogenesis. The examination of 574 patients has established immunological unbalances, mineral deficiencies and high activity of free radical oxidation of lipids and proteins. The usage of systemic multienzyme remedies, replacement mineral therapy, antioxidants, had correcting effects. This evidences for the presence of close links between pathogenetic mechanisms of generalized periodontitis, functioning according to the mobile's principle.
INTRODUCTION: We investigated to which degree a sample of 143 general practitioners in the County of Copenhagen would screen their patients for problem drinking by using The Alcohol Use Disorders Identification Test (AUDIT). Furthermore, among users of AUDIT, we aimed to describe the doctors' perception of using it. METHODS: Eighty-one out of the 143 doctors requested AUDIT. However, after they had had the possibility of using AUDIT, only 38 had handed an AUDIT to at least one patient. These 38 doctors were asked to answer a questionnaire on which this study is based. RESULTS: Thirty-two percent (12/38) of the doctors handed out an AUDIT in more than 14 days, and 21% (8/38) gave at least 100 patients an AUDIT. The general practitioners worked a median of 20 days in their practice during the study period. Only 14% (5/36) would screen all their patients in the future, and 42% (15/36) only when they suspected problem drinking. Sixty-four percent (22/34) of the doctors stated that handing all patients an AUDIT was much too time-consuming, 50% (17/34) stated that financial incentives are necessary, and 53% (18/34) questioned whether the patients wanted an AUDIT. Sixty-six percent (23/35) of the doctors judged that they had improved in detecting patients with alcohol related problems. CONCLUSION: The participating general practitioners were not interested in handing all patients an AUDIT. Major barriers were lack of time and financial incentives and furthermore the doctors questioned whether the patients wanted an AUDIT. However, half of the doctors would use AUDIT for certain patients, especially when they suspected problem drinking.
OBJECTIVES: To investigate the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of a random population of patients. STUDY DESIGN: A population-based, randomized, controlled, 5-year follow-up trial conducted in a primary care setting. POPULATION: The study group consisted of 2000 patients, randomly selected middle-aged men and women aged 30 to 50 years from family practices in the district of Ebeltoft, Denmark. Of these patients, 1507 (75.4%) agreed to participate. Patients were randomized into (1) a control group who did not receive health screenings, (2) an intervention group that received 2 health screenings, (3) an intervention group that received both the 2 screenings and a 45-minute follow-up consultation annually with their general practitioner. OUTCOMES MEASURED: Cardiovascular risk score (CRS), body mass index (BMI), blood pressure, serum cholesterol, carbon monoxide in expiratory air, and tobacco use. RESULTS: After 5 years, the CRS, BMI, and serum cholesterol levels were lower in the intervention groups compared with the control group. The improved outcome was greater in the baseline risk groups. The number of patients with elevated CRS in the intervention groups was approximately half the number of patients with elevated CRS in the control group. The difference was not a result of medication use. There was no difference between the group that received consultations after the screenings and the group that had health screenings alone. CONCLUSIONS: Health screenings reduced the CRS in the intervention groups. After 5 years of follow-up, the number of persons at elevated cardiovascular risk was about half that expected, based on the prevalence/proportion in a population not receiving the health checks (the control group). The impact of intervention was higher among at-risk individuals. Consultations about health did not appear to improve the cardiovascular profile of the study population.
INTRODUCTION: We investigated the impact of general health screenings and discussions with general practitioners on the cardiovascular risk profile of the population. MATERIAL AND METHODS: A population-based, randomised, controlled, 5-year follow-up trial conducted in a primary care setting. In total 2000 randomly selected men and women, aged 30-50 years, from family practices in the district of Ebeltoft, Denmark. Of these persons, 1507 (75.4%) agreed to participate, and were randomised into: (1) a control group who did not receive health screenings; (2) an intervention group that received two health screenings; or (3) an intervention group that received both the two screenings and a 45-minute follow-up consultation annually with their general practitioner. All were followed up after 5 years by questionnaires and health screenings. The outcome measures were: cardiovascular risk score (CRS), body mass index (BMI), blood pressure, serum cholesterol, carbon monoxide in expiratory air, and use of tobacco. RESULTS: After 5 years, the CRS, BMI, and serum cholesterol levels were lower in the intervention groups, as compared with the control group. The improved outcome was greater in the baseline risk groups. The number of persons with elevated CRS in the intervention groups was about half the number of persons with elevated CRS in the control group. The difference was not a result of medication use. There was no difference between the group that received consultations after the screenings and the group that had health screenings alone. DISCUSSION: Systematic health screenings reduce the cardiovascular risk score in a middle-aged population. After 5 years of follow-up, the number of persons at elevated cardiovascular risk was about half the expected. The impact of intervention is higher in at-risk individuals. Planned consultations about health did not appear to improve the cardiovascular profile of the study population.
BACKGROUND: The role of divisions of general practice has changed significantly since its inception. Divisions have evolved from simply assisting general practitioners in their practices and providing complementary support to existing health services through project work, to becoming major instruments of organisational change. OBJECTIVE: This article looks at the short history of divisions of general practice and explores options for the future that may help build a better interface between practical medicine and the growing bureaucratic, organisational and managerial demands being placed upon divisions. DISCUSSION: In the process of the change in the role of divisions we have experienced a paradigm clash between the essential work of GPs as effective medical practitioners, and their role in divisions as managers and leaders of the wider health care system change.
With the publication of the Dutch College of General Practitioners' practice guideline 'Examination of the neonate', a discussion which has lasted several decades has been brought to an end. Up to now a second neonatal examination by the general practitioner on the third, fourth or fifth day after a midwife-assisted birth was recommended. The arguments in support of this recommendation were based on the following: (a) the limited expertise of midwives in the past, (b) the experience that general practitioners had in examining children, although this experience was not specifically related to the defects for which neonates should be checked, and (c) the government bodies' wish to restrict the number of hospital deliveries by giving greater structure to the organisation of midwife care, which in practice, did not lead to large changes. Based on three studies, the practice guideline recommends that a second examination is of no added value.
OBJECTIVES: To determine the elements taken into account by French general practitioners to establish the initial diagnosis of benign prostatic hyperplasia (BPH) and to estimate the prevalence of BPH. MATERIAL AND METHODS: 1,698 doctors answered a questionnaire on their medical practice, and kept a register for two consecutive weeks comprising all men between the ages of 55 and 70 years seen in their practice. Men with no known BPH completed the IPSS (International Prostate Symptoms Score) questionnaire. The doctors described the management of the first three patients with an IPSS score > 8. RESULTS: The prevalence of BPH in the population of 33,077 men between the ages of 55 and 70 years consulting their general practitioner was 57.5%: 40.8% of patients had known BPH at the time of the visit and 29.9% of patients without known BPH reported voiding disorders (IPSS > or = 8). For the diagnosis of BPH, clinical interview was not systematically followed by digital rectal examination and urinalysis was rarely performed. Laboratory tests and ultrasound were the complementary investigations most frequently performed. CONCLUSION: BPH is a frequent disease whose prevalence is underestimated. This diagnosis should be considered more frequently when patients over the age of 55 consult their general practitioner.
A transient ischaemic attack (TIA) can be seen as an attack of angina of the brain. In the first weeks following a TIA there is a sizeable risk of subsequent stroke. After this period, this increased risk tapers off and an elevated risk of cardiovascular disorders remains, with the emphasis on its cardiac component. The management of a patient with a TIA in general practice focuses on these two risk periods. The long-term cardiovascular risk can easily be reduced by prescribing aspirin, an established procedure in general practice. The immediate threat of obstruction of the carotid artery may, as was only recently firmly established, be averted by a timely referral for additional diagnostics and, when needed, carotid desobstruction. This part of TIA management in general practice, however, is hampered by the current waiting periods for these procedures.
The new guidelines from the Dutch College of General Practitioners on sexually transmitted diseases (STDs) replace three existing practice guidelines covering a number of sexually transmitted diseases. In the Netherlands the general practitioner treats almost 75% of all patients with an STD. These include patients with symptoms, patients who are worried or anxious, and patients at high risk of an STD. STD-risk assessment should be regarded as a high priority. Chlamydia-infection remains the most prevalent STD. It is easily diagnosed by DNA-diagnostic amplification techniques. The new guidelines recommend more proactive and wider testing. There is much emphasis on counselling, prevention and notifying partners. General practice is the ideal setting for this.
The Dutch College of General Practitioners recently published an update of the practice guideline on urinary-tract infections. This guideline provides a clear overview of the medical history, the diagnostic methods and the treatment options. Sixteen management modalities are presented in relation to specific patient characteristics. However, this revised guideline warrants some minor comments. According to the guideline, the dipstick (nitrite) test and dipslide form the two cornerstones of the diagnosis of urinary-tract infections. The value of the dipslide, however, seems to have been overestimated and that of microscopic examination of the urine by skilled physicians to have been underestimated. New in this guideline compared to that of 1999 is that nitrofurantoin (the treatment of first choice in uncomplicated infections) should be given for five instead of three days. The guideline motivates this change in policy on the basis of the numerous treatment failures seen in practice. The most convincing type of evidence, however, is not available due to the lack of relevant randomised clinical trials. The introduction of the prescription of phosphomycin, which is unusual in the Netherlands, as an alternative treatment for uncomplicated infections requires supportive evidence before it will be accepted by general practitioners. This well-documented guideline provides clear guidance for the general practitioner faced with patients with urinary-tract symptoms that could be caused by infection.
The recently revised version of the practice guideline 'Problematic alcohol consumption' from the Dutch College of General Practitioners offers realistic advice to general practitioners on how to manage problem drinkers. The number of patients with alcohol problems tends to increase among women of middle age. The proportion of patients that report an alcohol problem themselves is larger than is usually assumed. Questionnaires are oflimited value in the detection of an alcohol problem. The general practitioner should look at problem drinking as a chronic disease that demands structured disease management and monitoring. This perspective will lead to less frustration in handling both the problem and the patients.
The aim of this study was to describe the types of drugs prescribed by general practitioners in a sample of initial (rather than repeat) prescriptions, the additions and deletions made to a doctor's repertory and the factors influencing these changes. The method used here enabled repeat prescriptions to be excluded as these are an inaccurate reflection of the current habits of the prescriber. A total of 201 (74%) of the principal general practitioners in the Grampian region participated. Data were obtained by substituting special prescription pads containing duplicate forms which allowed additional data to be recorded at the time of prescribing, including perceived influences that had resulted in changes from established choices of drug therapy. A sample of 100 forms were collected on seven occasions from each doctor over a one year sample period. Prescribers on average selected a preparation that they had only started to use within the last 12 months (that is newly adopted to their repertory) in 5.4% of initial prescriptions. These changes mostly involved antibiotics and analgesics and were occasioned mainly by the influence of the 'limited list' regulations, pharmaceutical company representatives and hospital specialists. We conclude that general practitioners were not unduly influenced by commercial sources of information, and that their prescribing habits were stable and conservative. The paper presents a case for the separate analysis of initial and repeat prescriptions as an essential step in producing more informative data on prescribing.
In 1988 a group of Norwegian experts published a programme for treatment of patients with increased cholesterol. The programme recommended dietary counselling when plasma cholesterol exceeded 5 mmol/l. In the autumn 1988 the Norwegian National Health Association started a campaign on cholesterol for health personnel. In order to find out to what extent general practitioners adhered to the recommendations of the programme, a random sample of 100 general practitioners were sent a questionnaire before and after the campaign. The results showed no significant differences in the doctors' attitudes towards diagnosis and treatment of patients with increased plasma cholesterol. Both before and after the campaign the plasma cholesterol levels at which they would initiate follow-up, dietary counselling or drug therapy were 1-2 mmol/l above the levels recommended by the expert group. The attitude of the general practitioners was more conservative than the recommendations of the programme. The interval between the information meeting and the post study was only six months. It is a complicated process to change attitudes and practice routines, and the time required may be longer than six months. Furthermore, the recommendations of the programme were questioned by other doctors, which reduced its impact.
Contact with patients was described retrospectively for a period of five years by means of careful notes from the case records in five general practices in urban and rural areas chosen at random as a representative spot test. A total of 968 persons in group 1 of the Danish National Health Insurance (98-99% of the population), 485 men and 483 women or 9.7% of the group 1 insured persons over the age of 30 years had 10,410 consultations. This corresponds to 2.15 consultations per annum for persons in group 1 insurance. 91% of the patients visited the consultation. 17% of all the patient, twice as many women as men, were responsible for 50% of all the consultations. Women had 45% more consultations than men. Women in the age group 35-54 years constituted the group where most persons of the group visited general practice and this group had also the greatest total number of consultations, viz 30% of the total. Significantly more women than men had many consultations in this age group while significantly more men than women had only few consultations in the age group between 35-44 years. Expressed in percentages, the age group 55-64 years showed greatest similarity between men and women. Half of the men and slightly more than one third of all the women consulted their practitioners once per annum or more rarely. Patients of 75 years or over consulted their general practitioners most frequently.
Cervical smears in the area of "Rhône Alpes" are evaluated through a population examined by general practitioners. Among 10,000 examined women, aged from 15 to 69 years, 20% had never been smeared. In 8% of the remaining 8,000 cases, the smear was realized since more than 5 years. Absence or prolonged delay was more frequently met with more aged women, from unfavorable or rural area; or foreigner (from South of Europe or from North-West Africa). These results are discussed and compared with those of other studies whether inside or outside France. Certainly, they are under-estimated as regards the general population. In fact, this study considers an already mostly medicalized population together with volunteer general practitioners. However, it's always less medicalized than in most of French studies considering this subject.
The American Medical Association Council on Long Range Planning and Development has been publishing a series of reports that assess trends in the environment of medicine and their impact on physicians and health care provision. The Council believes that each specialty in medicine has unique characteristics and will respond differently to changes in the health care arena. This report, developed in cooperation with the American College of Physicians, the American Society of Internal Medicine, and the Society of General Internal Medicine, provides an overview and environmental analysis of the specialty of general internal medicine. The Council first reviews socioeconomic data pertinent to general internal medicine. This is followed by a review of key issues pertinent to internists that relate to such topics as graduate medical education, reimbursement, scope of practice, manpower, and competition. In the conclusions, the Council suggests activities for the medical profession to pursue in response to the identified environmental trends.