Mode of referral to hospital of patients with heart attacks: relevance to home care and special ambulance services

Out of 1250 consecutive patients brought to hospital with heart attacks 956 (76%) were at home when their symptoms began. Of these, 587 (61%) called their general practitioner, and for the remainder an ambulance was summoned by a member of the public. Of the 294 patients who were away from home when the attack occurred 291 were brought to hospital by ambulance. Of these, only 70 (24%) were attended by a general practitioner. Patients for whom ambulances were called by a general practitioner had had their symptoms significantly longer and had significantly lower prehospital and hospital mortalities than those for whom ambulances were summoned by members of the public. Special "cardiac" ambulances appear to be inappropriate for patients who have been seen by a general practitioner, and for this group home care may well be as effective as hospital admission.     

An overview of dental care for the young patient: 1. Introduction, priorities and disease prevention

The provision of high-quality dental care for children presents a challenge for the general dental practitioner. The aim must be to ensure that young patients reach adulthood with optimal dental health. This series of three articles takes an overview of good practice in the provision of dental care for children, with emphasis on disease prevention, early diagnosis of dental disease and deformity and appropriate treatment measures. This first paper discusses preventive measures and highlights the need to apply them, particularly for patients at high risk of dental disease or with special needs in relation to dentistry.     

The metabolic changes associated with trauma and sepsis

BACKGROUND: Intractable epistaxis has been treated with surgical intervention for many years, including ligation of the internal maxillary artery. As an alternative approach, endovascular therapy has gained increased acceptance. The purpose of our study was to evaluate the efficacy and safety of endovascular treatment of untractable epistaxis. METHODS: Embolotherapy was performed in 26 patients. The indication for embolization was persistent epistaxis even after anterior and posterior nasal packing. In all but two patients, who required general anesthesia, the procedure was performed in local anesthesia. Endovascular embolization of the internal maxillary artery was performed by using microcatheters, which were introduced intraarterially. Particulate embolic agents were used in all but one patient, who was treated by means of minicoils. RESULTS: The embolization of the territory of the internal maxillary artery was possible in all cases, the technical success rate was 96%, the clinical success rate was 100%. No complications were encountered. Because of an acute recurrent bleeding in one case, a second embolization was performed. No delayed hemorrhages were noted. CONCLUSIONS: Endovascular embolotherapy seems to be an excellent, safe, and less invasive alternative to surgery in patients with intractable epistaxis.     

Epistaxis and hypertension

The status of nose bleeding as a symptom of high blood pressure has been studied in patients admitted because of epistaxis. Twenty-six patients with a factor predisposing to nasal bleeding had age- and sex-adjusted systolic and diastolic scores similar to those of the general population. One hundred and sixty-eight patients with no such factor formed a different population with significantly higher age- and sex-adjusted systolic and diastolic scores. It is concluded that epistaxis is a true symptom of hypertension.     

School policy in COMMIT: a promising strategy to reduce smoking by youth

Destructive periodontal disease is found in a significant number of adult patients. At present there is no reliable method of determining the presence of active periodontal disease, other than retrospectively. Tests are being developed that rely on various markers of periodontal disease activity but all of those produced to date have limitations. It is to be hoped that reliable tests that can be used at the chairside will help the general dental practitioner to combat periodontal disease before it progresses too far.     

Role of kinases and G-proteins on arachidonate release induced by zymosan in mouse peritoneal macrophages

Each of the 15 Health Boards in Scotland maintains a computer file of its residents who are registered with a general practitioner; this is known as the Community Health Index or CHI. The CHI allows a variety of demographic data and indicators of health to be analysed on either a geographic or general practice base, or both simultaneously. The considerable potential of the CHI as a public health tool may be of interest to health authorities outside Scotland which are developing wider uses for their own family practitioner registers.     

Children and adolescents with ulcerative colitis and Crohn disease

The diagnosis and treatment of children and young people with ulcerative colitis and Crohn's disease follows the same guidelines as for adults, but several important and unique problems related to the diseases in young age groups deserve attention. Since ulcerative colitis and Crohn's disease are relatively rare at a young age, there is often a lack of awareness among people in general, parents and general practitioners. There is therefore often an unnecessarily long delay before the young patient is seen by a general practitioner and then referred to a specialist centre where the diseases can be properly diagnosed, evaluated and treated. Chronic gastrointestinal symptoms caused by inflammatory bowel disease at an age where physical and mental growth are at a peak could result in serious negative effects not only on young patients' physical and mental development, but also on their self-esteem. The diseases adversely affect the quality of life of many young patients and their families and are a source of anxiety, emotional, behavioural, and psychological morbidity. Patients' organisations can help by providing additional information and support through special groups for young patients with inflammatory bowel disease.     

Diagnosis and treatment of affective disorders

The rates of major depression (5-12%) are considerably higher than for bipolar disorder (ca. 1%). Depressive disorder is most frequent in general practice. Although general practitioners recognise and manage efficiently a large number of depressed patients, at any consultation about half the patients are not diagnosed. Recognising depression is made difficult by the frequency in general practice of presentations with somatic symptoms (masked depression) and of depression related to physical disorder. The best method for the general practitioner to overcome these problems is by using a relatively direct interview for the main specific symptoms of depression. The general practitioner has a key role in the management of depression and as a gatekeeper with a prime responsibility to make appropriate referrals to specialists. Counselling members of the family or friends and recommending self-help groups are important to improve the therapeutic compliance of the patients.     

Fabrication of multiple posts and cores using a thermoplastic material and an indirect technique: a clinical report

The object of this study was to determine whether warfarin could be safely continued in patients with epistaxis if the International Normalized Ratio (INR) was within the suggested therapeutic range. Twenty patients on warfarin treatment were compared with controls, matched for age and sex. Local measures for the control of epistaxis were undertaken appropriately in all the patients. In the warfarin group 17 patients (85%) did not discontinue warfarin as the INR was within the suggested range. There were no additional bleeding complications or failure of epistaxis control due to continuation of warfarin. There was no significant difference in the mean hospital stay between the warfarin and non-warfarin groups. It is concluded that warfarin can be continued safely in patients with epistaxis, in appropriate circumstances, and that the policy of stopping warfarin routinely in all patients with epistaxis should be reconsidered.     

Love in the origin of the therapeutic relationship

The rural community of Dalwallinu found itself without a medical practitioner early in 1995. Believing recruitment of a replacement practitioner would be relatively straightforward, the Shire and the Hospital Board combined for this process. Little did we realise that there would be many factors that would impinge upon our ability to recruit a general practitioner (GP) other than the availability of a suitably qualified practitioner. Locum availability, providing a furnished house, a motor car, becoming the employer of the locum practitioner, community reactions, government regulations on recruiting doctors trained overseas, Health Department restructures and the arbitrary regulations of professions all had a significant impact, not to mention the cost to the local council to provide a community service.     

Perceptions of general practice among homosexual men

BACKGROUND: Primary care has an important role to play in the prevention and management of the human immunodeficiency virus (HIV). It has been suggested that homosexual men experience a variety of problems in relation to primary care. AIM: As part of a larger study, it was decided to examine the extent to which a sample of homosexually active men experienced difficulties in general practice and whether they consulted their general practitioner for problems related to HIV or the acquired immune deficiency syndrome (AIDS). METHOD: Homosexual men were recruited for interview in 1991-92 from a variety of sources including genitourinary clinics and homosexual organizations. RESULTS: Of 623 men registered with a general practitioner 44% had not informed their general practitioner of their sexual orientation and 44% of the 77 men who were HIV antibody positive, as confirmed by the study, had not informed their general practitioner of this fact. Men who viewed their practice as unsympathetic towards homosexual men were less likely to have informed their general practitioner of their sexual orientation or HIV status. The majority of men (87%) nevertheless viewed primary care as an appropriate source of HIV/AIDS advice. CONCLUSION: There is considerable scope for improvement in the acceptability of general practice to homosexual men.     

Acute anxiety and its therapy

Acute anxiety is a quite common event for a general practitioner to solve. Anxiety could be of a various ethiology and the treatment should be based on the ethiology. It is important to differentiate panic attacks from general anxiety so as panic disorder treatment differs specifically. The drug of choice for parenteral application for acute anxiety seems to be diazepam in the Czech republic conditions and the most convenient drug for oral administration is alprazolam.     

Halitosis: causes, diagnosis, and treatment

Halitosis is a major concern to the general public and the source of a multimillion-dollar industry world wide. Although the aetiology may be localised to the oral cavity in up to 90 percent of instances, halitosis may indicate a serious underlying medical condition necessitating medical referral. In general, halitosis of an oral cause can be safely and easily diagnosed and treated by the general dental practitioner.     

Expression and localization of angiotensin II type 1 receptor mRNA in rat ocular tissues

OBJECTIVE: Hereditary hemorrhagic telangiectasia (HHT) is an inherited abnormality passed down as a dominant autosomal feature. Recurrent epistaxis usually constitutes the major clinical manifestation of this disease. The unsatisfactory results of conservative therapy have stimulated a research interest for the role of laser photocoagulation in telangiectatic vessels associated with this clinical entity. METHOD: The Nd:YAG laser was used to treat a group of 11 individuals suffering from HHT, all of whom had been previously treated using other modalities. RESULTS AND CONCLUSION: The excellent results of Nd:YAG laser irradiation are addressed in view of all treatment modalities proposed for the treatment of recurrent epistaxis in HHT.     

The rapid access proctology clinic: an appraisal of one year's experience

A walk-in, once-a-week clinic was established in May 1993. In the first year, 1268 patients (954 new and 314 follow up) were seen with a reduction in waiting time, high patient and general practitioner satisfaction, and raised awareness of colorectal disease.     

The health project Ebeltoft: health check ups and discussions in general practice. Basic data from a 5-year, prospective, randomized, controlled population study

A study was carried out to investigate people's interest in participating in health check-up and in discussions about health with their own general practitioner, participants' health status, the proportion who received health advice following health check-up, and the lifestyle goals they set following discussion with their general practitioner. This study reports the baseline data from a five-year randomized, controlled, prospective, population-based study in general practices in Ebeltoft, Denmark. All general practitioners from the four practices in Ebeltoft and a random sample of 2,000 people aged between 30 and 50 years were invited to participate. Participants were randomly divided into three groups-one control group and two intervention groups. One intervention group was given a health check-up which included a range og tests (Table 2 and 3); this group received written feedback from the general practitioner. The other intervention group was also given a health check-up and written feedback, in addition, they were given the opportunity to attend their general practitioner to discuss health-promoting measures. A total of 1370 people participated in the study (69% response rate). Health advice was given to 76% of 905 participants following health check-up. Almost all of the 456 participants (96%) who were offered the opportunity of discussing their health with their general practitioner took up the offer: 64% of the 456 participants reported that they had decided to undertake lifestyle changes. Eleven of those who discussed their health with the doctor were referred to a specialist (2%). There was considerable interest in participating in health promotion. Three out of four of those who had a health check-up were given health advice. Two out of three of those who were offered a health talk with the general practitioner appeared willing to make relevant lifestyle changes. Longterm follow up is needed to determine effects and side effects of health check-up and health talks.     

Pentobarbital modulatory effect on GABA binding sites in developing chick optic lobe

The care for elderly patients is traditionally a task of the general practitioner and will be of increasing importance in the future. Medical considerations focus on the patient's functional abilities which should play a primary role. These should, however, not neglect the patient's resources for the development of social and mental competence. Medical interventions so far will also need social indications evaluating their importance in the every day life context of the individual patient. Based on scientific knowledge of geriatrics and gerontology there should be a wide-spread introduction of standardized instruments into geriatric diagnostics and evaluation. Geriatric screening may be one example. This will support the development of a special geriatric quality management in general practice. There is a need for further development of ambulatory rehabilitation for the elderly. The general practitioner in this field will have to control the teamwork with rehabilitation-professionals and professionals from the social support services.     

An instrument for assessment of videotapes of general practitioners' performance

OBJECTIVES: To identify those important characteristics of doctors' and patients' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners' performance in their own consultations. DESIGN: Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING: All vocational training schemes for general practice in the Northern region of England. SUBJECTS: First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES: Trainers' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS: 6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION: The instrument produced is reliable for assessing general practitioners' performance in their own consultations.     

Nephrology in general practice

Hints for the practitioner concerning the management of patients with renal disease are presented. Important facts relating to history, physical, laboratory and radiological findings are stressed and diagnostic assessment is briefly described. Although the general practitioner will refer such patients in most instances to a nephrologist, he should know what kind of further examinations and studies are necessary for correct diagnosis and adequate treatment. The present therapeutic possibilities have greatly improved, but one still disappointing aspect is the treatment of certain forms of glomerulonephritis. The cumulative survival rates in patients undergoing hemodialysis and renal transplantation are assessed and compared with the survival rates in patients suffering from myocardial infarct and carcinoma of the breast, colon and the lung. Essential preventive measures are avoidance of toxic substances like analgesics and consistent antihypertensive therapy even in patients with a renal ailment. The dosage of drugs which are mainly eliminated by the kidneys must be adapted to renal function (serum creatinine or clearance of endogenous creatinine).