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PubMed1984

[5 years' general drug prevention of thromboembolism in general surgery. Comparison of personal experiences with results from the literature].

Despite wide use of physical methods the number of fatal postoperative pulmonary embolisms in surgical patients increased in Kiel until 1976. Because of these results, additional general prophylaxis with 2-3 X 5000 i U of heparin-dihydroergotamine was introduced in 1978. The rate of fatal pulmonary embolism in general surgery proven by autopsy decreased to 0,3% between 1979 and 1983. It should be noted that six of the nine patients who died from pulmonary embolism had also suffered from an infaust disease. This is an excellent result since our study also includes high risk patients after emergency surgery, cases which Kakkar and Gruber did not include in their studies. Due to the extensive analysis of medical records and the pertinent post-mortem reports, the high effectivity of drug induced prophylaxis with 2-3 X 5000 i U of heparin-dihydroergotamine in order to reduce fatal pulmonary embolism in general surgery could be proven.

Adolescent↗

PubMed1994

Are general practitioners really prepared? An audit of emergency equipment in general practice.

AIM: To determine what medical equipment is available in general practice surgeries in the greater Wellington region and the guidelines available for providing this equipment. METHOD: A 23 item questionnaire was completed by general practices in the greater Wellington region between March and June 1993. RESULTS: Sixty-three percent of the study practices did not have all the required items the authors considered essential. CONCLUSION: There is a clear need for guidelines on required emergency equipment for those working in or wishing to set up in general practice.

Emergency Medicine↗

PubMed1994

[Information for quality assurance and self-evaluation in general practice. Use of data from the EDP medical records in general practice].

A project was carried out to study the usefulness of ordinary data from computer-based journals for comparing practices. 20 general practitioners from four municipalities participated for four months in 1992. The computer-based journal provides accurate information on the number and kind of contacts with patients, and on who visits the general practitioner. It also tells what is done at each contact, such as a referral, prescription or laboratory tests. Using the International Classification of Primary Care (ICPC) even the most common diagnoses do not account for more than 3% of the consultations. The practice of the different doctors varies considerably as regards classifying consultations on a symptom level (ICPC 1-29) or a diagnosis level (ICPC 70-99). The results brought to light marked differences with regard to what general practitioners do, and what kind of problems their patients present. The patient populations differed to a lesser degree with respect to sex, age and social status. The findings provided an interesting and useful platform for group discussions among the participating doctors.

Drug Utilization↗

PubMedDate not supplied

[Neurological education of general practitioners. Results of a survey carried out among 196 general practitioners].

We have carried out a survey among professional general practitioners in our province with the aim of getting to know their opinion concerning their own training in Neurology. The survey included questions about the adequacy of training, the nature of any deficiency therein (be it theoretical and/or practical) and ability to analyse and attend a neurological patient. The percentage of replies was 78% out of a total of 196 surveys. 78.8% of those questioned consider that their neurological training has not been sufficient either for clinical or general practice; while 43.8% believe that this insufficiency is due to a lack of practical training, 1.8% think the fault lies in a lack of theoretical training, and 54.32% consider that it is due to a lack of both practical and theorectical training. 61.2% of those questioned claim to have difficulties with neurological explorations, and 55.6% claim they have greater difficulties attending a neurological patient than other patients classified within other internal medical specialties. 76% consider that it is either partially or totally false to claim that these difficulties are unimportant due to the lack of treatment for neurological illnesses, although 69.4% consider it to be partially or totally true that they will never be able to achieve diagnosis of a neurological patient due to a lack of the required complementary investigations. 43.9% consider that continued training in Neurology is not useful because it is a repetition of training received at university. As a consequence, there is an imbalance between neurological training and the need to attend the patient at the level of general practice, which should be set right by making the theoretical training given during graduation more suitable, and by increasing and improving practical credits.

Data Collection↗

PubMed1995

The carrot, the stick and the general practitioner: how have changes in financial incentives affected health promotion activity in general practice?

BACKGROUND: Financial incentives for increasing health promotion activity in primary care, introduced with the 1990 contract for general practitioners, were amended in 1993 and are now focused on cardiovascular disease. Payments for health promotion clinics were abolished and target payments were introduced. AIM: The study aimed to evaluate the effect of the change, in June 1993, in financial incentives for health promotion activity in primary care on the distribution of health promotion payments in two family health services authorities. METHOD: A retrospective study was undertaken in which data from two family health services authorities were used to determine the annual level of health promotion payments per 1000 practice population before and after the contractual amendment. Health promotion clinic payment data were analysed for 78 practices in Bedfordshire Family Health Services Authority and 85 practices in Kensington, Chelsea and Westminster Family Health Services Authority. Changes in health promotion payments were calculated and related to two measures of relative need: all cause standardized mortality ratios, for patients aged 74 years or less, of the electoral ward in which the practice is located; and the Jarman underprivileged area score. High relative need was defined as a standardized mortality ratio of over 100 or more than 25% of the practice population living in electoral wards with a Jarman score of over 30. RESULTS: Health promotion payments were more evenly distributed after the change in June 1993 than before between the two family health services authorities and between general practices. Single-handed practices were carrying out more clinics in 1992 than multi-partner practices and consequently were one of the greatest financial losers as a result of the change. In addition, practices located in electoral wards with high relative needs lost proportionally more than those in electoral wards with lower needs. CONCLUSION: Changes in the general practitioner health promotion contract have created new financial winners and losers. It now appears that health promotion payments are more evenly distributed but that the distribution is unrelated to need or treatment given. More evidence on the effectiveness of health promotion interventions is required before policies aimed at promoting better health through primary care can be fully evaluated.

England↗

PubMed1997

Chronic debilitating fatigue in Irish general practice: a survey of general practitioners' experience.

BACKGROUND: Doctors are called upon to treat chronic debilitating fatigue without the help of a protocol of care. AIMS: To estimate the incidence of chronic debilitating fatigue in Irish general practice, to obtain information on management strategy and outcome, to explore the attitudes of practitioners (GPs) towards the concept of a chronic fatigue syndrome (CFS), and to recruit practitioners to a prospective study of chronic fatigue in primary care. METHOD: A total of 200 names were selected from the database of the Irish College of General Practitioners (ICGP); 164 of these were eligible for the study. RESULTS: Altogether, 118 questionnaires were returned (72%). Ninety-two (78%) responders identified cases of chronic fatigue, giving an estimated 2.1 cases per practice and an incidence of 1 per 1000 population. All social classes were represented, with a male to female ratio of 1:2. Eleven disparate approaches to treatment were advocated. Many (38%) were dissatisfied with the quality of care delivered, and 45% seldom or hardly ever referred cases for specialist opinion. The majority (58%) accepted CFS as a distinct entity, 34% were undecided, and 8% rejected it. Forty-two (35%) GPs volunteered for a prospective study. CONCLUSION: Chronic fatigue is found in Irish general practice among patients of both sexes and all social classes. Doctors differ considerably in their management of patients and are dissatisfied with the quality of care they deliver. Many cases are not referred for specialist opinion. A prospective database is required to accurately assess the scale of this public health problem and to develop a protocol of care.

Adult↗

PubMed1976

A general-practitioner ward in a new district general hospital.

So far there are relatively few general-practitioner wards in district general hospitals in the National Health Service. The work of one such general-practitioner ward at Queen Mary's Hospital, Sidcup, is described and the advantages of this system of care for patients and doctors discussed.

Adolescent↗

PubMed1996

A survey of general anaesthesia, sedation and resuscitation in general dental practice.

The Poswillo Report, published in 1990, made recommendations regarding general anaesthesia (GA), sedation and resuscitation in dentistry. The aims of the present study were to examine the level of provision of GA and sedation by general dental practitioners (GDPs) a few years after the publication of the report, and to estimate the degree of compliance of GDPs with a number of its principal recommendations. In May 1994, a questionnaire was sent to 268 GDPs in two Scottish Health Boards, and a response rate of 80% was achieved. Thirteen per cent of respondents had treated GA cases during 1993-94 while 18% indicated that they had stopped providing a GA service since the immediate pre-Poswillo years. However, 91% had referred some patients elsewhere for treatment under GA. There was very little evidence of a replacement of GA by sedative techniques. The percentages of respondents using inhalation or intravenous sedation during the previous year were 9% and 27%, respectively. Almost all of the respondents reported that they had been trained in cardiopulmonary resuscitation and 60% stated that resuscitation exercises were practised at least once a year. While over 80% of the practitioners indicated that their dental surgeries stocked the emergency drugs recommended in the Poswillo Report, 12% expressed concern regarding the length and content of the drug list.

Anesthesia, Dental↗

PubMed2004

Do referrals from primary dental care for treatment using general anaesthesia comply with General Dental Council guidelines?

OBJECTIVES: To investigate the quality of information in referrals for patients aged under 16 years referred for dental extraction under general anaesthesia (GA), to ascertain the knowledge and expectations of the parents of these patients, and to determine whether the number of teeth extracted in secondary care coincides with that of the referring dentist. DESIGN: Retrospective study of referrals of all patients aged under 16 years referred to community dental clinics in Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire over a 26-day period. RESULTS: The majority (62.2%) of the 251 referrals examined were for extractions under GA. Of these, 125 were by letter and 117 using a pro forma. Significantly more pro formas (33) than letters (8) contained a full medical history (P < 0.001). A treatment plan was included in significantly more pro formas (76) than letters (49) (P < 0.01). Few referrals contained a note about the discussion of alternatives to a GA procedure and only 37% (58/156) of parents reported that the referring general dental practitioner had discussed alternative treatments with them. A total of 551 primary teeth were indicated for removal but 846 teeth were eventually removed. CONCLUSIONS: Our findings indicate a need for parents of patients referred for GA procedures to be better informed about alternatives. Improvement in the quality of referrals, perhaps with the aid of standard pro formas, would also facilitate more effective management of referred patients.

Adolescent↗

PubMed1978

Changes of sensitivity to the cuing properties of narcotic drugs as evidenced by generalization and cross-generalization experiments.

With a discrete-trial, food-reward, two-lever procedure, rats were trained to discriminate 0.04 mg/kg fentanyl from saline. Individual threshold doses for generalization of fentanyl and for cross-generalization of morphine were determined repeatedly during a 17-week posttraining period. Threshold doses of both drugs almost continuously shifted in both the up- and downward direction. Shifts of fentanyl threshold doses covaried with those of morphine threshold doses. These shifts can best be described by a sustained oscillation, the mean amplitude of which amounts to a factor 3.65 of the dose-range for fentanyl, and to a factor 1.85 for morphine. The upper and lower limits of oscillation were symmetrical with respect to baseline. The oscillation can be described by a function expressing that the more distant a point along the function is from the baseline, the more it is susceptible to (positive/negative) acceleration along the intensity (i.e., dose) axis.

Animals↗

PubMedDate not supplied

Endocrine-metabolic response to abdominal aortic surgery: a randomized trial of general anesthesia versus general plus epidural anesthesia.

The influence of epidural anesthesia on the endocrine-metabolic response following abdominal aortic reconstruction was studied in a prospective randomized trial. Cortisol and catecholamine responses and nitrogen balance were measured in two groups of five patients receiving general anesthesia only (group 1) or general anesthesia combined with epidural bupivacaine (group 2). The study lasted from preoperatively until the first postoperative day. At 2100 hours on the day of surgery serum cortisol concentrations were higher in group 1 than in group 2 (1.41 versus 0.82 mumol/L; p < 0.01). Likewise the total perioperative hypercortisolemia, expressed as the area under the curve, was significantly higher in group 1 (11.7 versus 5.7 mumol/L/hr, p < 0.01). Intraoperative urinary excretion of epinephrine and postoperative norepinephrine excretion were significantly higher in group 1 than in group 2. Urinary excretion of free cortisol and cumulative nitrogen balance were not different between the groups. Although the number of patients was limited and the sensory nerve block level was not measured perioperatively, this study suggests that epidural anesthesia attenuates the stress response to aortic surgery.

Aged↗

PubMed1994

[No better vigilance after general anesthesia with propofol in colonic surgery. A comparison of three procedures for general anesthesia (propofol, halothane and midazolam/fentanyl) in combination with catheter epidural anesthesia].

Early mental and psychomotor recovery was studied in 67 patients undergoing colorectal surgery under continuous epidural anaesthesia and light general anaesthesia using propofol, halothane, and midazolam/fentanyl. The study was approved by the local ethics committee. All patients received epidural anaesthesia with 0.25% bupivacaine and were then randomly allocated to one of three groups. In group I (halothane), light general anaesthesia was induced with thiopental 3-5 mg/kg and maintained with halothane. The propofol group (II) received 2 mg/kg for induction and a mean continuous infusion of 1.7 mg/kg.h. In group III (Mi/Fe), midazolam and fentanyl were used for induction and maintenance. All patients were intubated, received non-depolarising muscle relaxants, and were manually ventilated with nitrous oxide-oxygen (2:1.2). For postoperative analgesia, 0.05 mg/kg morphine was administrated epidurally 30 min before the end of the operation; 30, 60, 90, and 120 min after arriving in the recovery room, vigilance was assessed using a modified Steward score, the Trieger test, the ability to recall a column of numbers (KAI test), and symbol counting (CI test). Heart rate, blood pressure, arterial oxygen saturation, and blood gases were recorded. RESULTS. The three groups were comparable with regard to age, sex, ASA classification, and duration of anaesthesia and operation (Table 3). There was no difference between the groups in performance of the recovery tests (Figs. 2-5), blood pressure, heart rate, arterial blood gas analysis (Fig. 6), or oxygen saturation. Comparing pre- and postoperative values, we found severe psychomotor and mental impairment in all groups. pCO2 was slightly elevated in all groups, but only 3 patients in the propofol group and 6 in the midazolam/fentanyl group developed hypercapnia above 50 mm Hg. Patients receiving propofol or midazolam/fentanyl had significantly less postoperative nausea and vomiting than those receiving halothane (Table 5). CONCLUSION. It is concluded that propofol offers no advantage over halothane or midazolam/fentanyl where early postoperative recovery is concerned. Intraoperatively, all three techniques provided good anaesthesia. Propofol and midazolam/fentanyl caused less postoperative nausea and vomiting than halothane anaesthesia.

Adult↗

PubMed1983

Care of cancer patients in thirty-one Italian general hospitals. Methodological aspects and general findings.

A large sample of cancer patients was reviewed over a two-year period (1978-1979) in 31 general and community hospitals representing five Italian regions, differing in terms of health care organization. Two thousand four hundred and six patients had breast cancer, 1692 lung cancer, 303 non-Hodgkin's lymphomas, 277 ovarian cancer and 235 Hodgkin's lymphoma. Relevant information was collected from medical records through specific pre-standardized and tested forms. The paper discusses the results obtained with respect to (a) general descriptive data of the population; (b) completeness and reliability of recorded data (e.g. staging, histological classification, therapy); and (c) accuracy and completeness of the follow-up. Consistency of the information obtained on selected items with published series of patients suggests that this methodology is worth a wider testing as a simple, inexpensive tool for routinely monitoring the care of cancer patients and the impact on it of organizational and educational interventions.

Adolescent↗

PubMedDate not supplied

The perception of problem drinkers by general hospital staff, general practitioners and alcoholic patients.

A sample of 275 subjects (general hospital staff, general practitioners and alcoholic patients) was investigated regarding their perception of problem-drinkers. A set of semantic differential scales was used, and subjects were asked to evaluate the concepts of "problem drinker," "self" and "ideal self." Psychological distance was measured in terms of bipolar personality constructs between each of the above concepts. Significant differences were found between the groups in terms of concept evaluation and psychological distance. The implications of these findings for both research and treatment are discussed.

Alcoholism↗

PubMedDate not supplied

Combined general and epidural anesthesia versus general anesthesia for major abdominal surgery: postanesthesia recovery characteristics.

BACKGROUND AND OBJECTIVES: Outcome studies comparing general anesthesia combined with epidural anesthesia (GEN-EPI) to general anesthesia (GEN) for major abdominal surgery have been equivocal. However, many believe that patients anesthetized with GEN-EPI fair better than GEN. This study tests the hypothesis that there are favorable recovery characteristics associated with GEN-EPI as compared with GEN following abdominal surgery. METHODS: A prospective randomized double-blind trial, consisting of 30 patients ages 18-74 undergoing abdominal surgery was undertaken. Patients received either GEN-EPI or GEN by standardized protocol. At the end of surgery the epidural catheter was removed and psychological testing was performed over 24 hours to determine recovery characteristics. These included the modified Slater test, the Self-Assessment Manikin, the Kendrick Digital Copying Test, the Hospital Anxiety and Depression Scale, as well as visual analog scales for pain and appearance. RESULTS: Patients receiving GEN-EPI emerged from anesthesia faster (P < .03) with less pain on awakening (P < .04 at rest; P < .01 on coughing), had better psychomotor function at 2 hours (P < .04), and were less drowsy at 4 hours (P < .04), than patients with GEN. There was no difference in pain intensity after the initial assessment, morphine usage, mood, anxiety, and depression at any other measurement period. CONCLUSION: Transient quantifiable differences in recovery characteristics exist between patients receiving GEN-EPI and GEN.

Abdomen↗

PubMed2000

Contacts to the health care system prior to suicide: a comprehensive analysis using registers for general and psychiatric hospital admissions, contacts to general practitioners and practising specialists and drug prescriptions.

OBJECTIVE: The purpose of this study was to describe suicides' contacts with various parts of the health-care system. METHOD: Data on 472 people who committed suicide in a Danish County (Funen) in the period of April 1 1991 to December 31 1995 were searched in the Danish Psychiatric Central Register, the National Patient Register, the National Health Insurance and Odense Pharmacoepidemiologic Database. RESULTS: In total, 97.5% of the suicides were recaptured in at least one of these registers. Forty-two per cent had been hospitalized in psychiatric departments. Within the last month before death, 66% consulted a general practitioner, 13% and 7%, respectively, were discharged from a psychiatric hospital and general hospital. CONCLUSION: The registers used provided a comprehensive registry-based description of suicides' contacts with the health-care system. The most prominent features were the high prevalence of psychiatric morbidity and the high rate of contacts with GPs close to suicide.

Age Factors↗

PubMed1998

A report of an evaluation of the pilot peer review scheme for general dental practitioners working in the general dental services in England.

OBJECTIVE: To evaluate the pilot peer review scheme for general dental practitioners, working in the general dental services in England. DESIGN: A retrospective analysis of a 50% random sample of end of project résumés. SETTING: The scheme was piloted from August 1991 to April 1996. At the end of each project a résumé was completed. METHODS: The random sample of résumés was subjected to content analysis by three reviewers who had previously undergone consistency training. MAIN OUTCOME MEASURES: The range of topics reviewed, the choice of single or multiple topics, the direct relevance of projects to patient care and the comments of the scheme's participants. RESULTS: 332 résumés were analysed, 89% included positive comments. Overall 42% of projects reviewed single topics, with participants in 4 out of 13 regions favouring this approach. 61% of topics related directly to patient care. CONCLUSIONS: The pilot peer review scheme was enthusiastically welcomed by the participants and achieved its objectives of encouraging initiatives to improve patient services and testing different types of peer review.

Dental Audit↗

PubMed2004

The prevalence and nature of recent self-reported changes in general dental practice in a sample of English general dental practitioners.

OBJECTIVE: To determine the extent and types of change in seven domains of dental practice in a sample of English general dental practitioners (GDPs). METHODS: A postal questionnaire was sent to 561 GDPs on the dental lists of three health authorities in diverse regions of England. Information collected included demographic details on personal and practice characteristics, self-rating of amount of change in the seven domains of practice and factors influencing change. RESULTS: The response rate was 60%. Fifty-six per cent of the sample were under 40 years old. Over a third of respondents reported "changing a lot or completely" certain clinical activities, practice management arrangements and practice amenities. The highest self-reported level of change was in clinical activities. Of the GDPs who reported changing their clinical activities, 56% reported an increase in preventive care, followed by crown and bridge (44%), periodontics (44%) and endodontics (43%). Practice management rated second in the mean rank scores for self-reported change. The main changes reported were the introduction of computer systems and employment of practice managers. A sizeable percentage (66%) reported increasing the amount of information they provided to patients and the time spent discussing care. Quality assurance activities were the area of practice least likely to have changed over a 5-year period. Over half the sample reported not being involved in any quality assurance activities in the previous 5 years. Those respondents who were younger, had a postgraduate qualification and earned more than 20% of their income from private practice reported higher levels of change. CONCLUSIONS: General dental practitioners' work patterns are dynamic and appear to be responding to changing needs and demands on their service. The main changes were in the types of clinical procedures being carried out. The low prevalence of changes reported in auditing and peer review activities needs to be investigated further.

Adult↗