The influence of an ECG on patient management in family practice

OBJECTIVE: To determine how often electrocardiography, as an addition to history taking and physical examination, leads to changes in non-emergency patient management in general practice. DESIGN: Prospective observational study. SETTING: 18 general practices in Amersfoort and its surroundings, the Netherlands. METHOD: From the end of September, 1996 until the beginning of February 1997, the general practitioners (GPs) filled out two questionnaires each time an ECG was recorded, one before and one after the recording. The patient management planned by the GP before and after the availability of the ECG results was then compared. RESULTS: A total of 119 sets of questionnaires was obtained from 119 patients. In 47 patients (40%; 95% confidence interval: 31-48) the GP's management changed after recording and interpretation of the electrocardiogram. In particular, the decision whether or not to refer patients to a cardiologist was frequently changed (26 patients, 22%). The GPs management changed more often in patients in whom palpitations and dyspnoea had been the reason for taking an ECG. CONCLUSION: The use of electrocardiography in general practice in non-emergency situations would seem a valuable instrument in addition to history taking and physical examination.     

Sumatriptan. An updated review of its use in migraine

Sumatriptan is a selective agonist at serotonin 5-HT1-like receptors, including 5-HT1B/1D subtypes. It is an effective treatment for acute migraine attacks and the injectable form has also shown efficacy in the treatment of cluster headaches. In placebo-controlled clinical trials, sumatriptan, administered subcutaneously, orally, intranasally or rectally was significantly more effective than placebo in relieving migraine headache and in producing resolution or reduction of other symptoms associated with migraine, including nausea, photophobia and phonophobia. Improvements in clinical disability were also significantly greater after sumatriptan than after placebo. Headache recurred in 21 to 57% of patients who received oral or subcutaneous sumatriptan, but most patients responded to a second dose of the drug. Results of comparative trials showed that subcutaneous sumatriptan 6 mg was significantly more effective than either patients' usual antimigraine treatments or intranasal dihydroergotamine mesylate 1 mg in relieving migraine headache. Subcutaneous sumatriptan 6 mg and subcutaneous dihydroergotamine mesylate 1 mg provided similarly effective migraine relief, but the headache recurrence rate was significantly higher after sumatriptan than after this formulation of dihydroergotamine mesylate. Response rates achieved after oral sumatriptan were similar to those reported after treatment with oral naratriptan, rizatriptan or lysine acetylsalicylate plus metoclopramide. Treatment of acute migraine attacks with oral or subcutaneous sumatriptan leads to less loss of workplace productivity than other antimigraine therapies. Several pharmacoeconomic analyses showed that gains in workplace productivity in sumatriptan recipients ranged from 12.1 to 89.8 hours per patient per year. Significant improvements from baseline in overall health-related quality-of-life scores were also experienced by sumatriptan recipients. Sumatriptan is generally well tolerated. Nausea, vomiting, malaise and fatigue are the most common adverse events with oral sumatriptan. Injection site reactions occur in 10 to 40% of patients receiving the drug subcutaneously. A bitter taste at the back of the mouth occurs frequently after intranasal administration. Serious adverse events occur in about 0.14% of patients with migraine treated with sumatriptan. As the drug is associated with the rare development of cardiovascular effects, it is contraindicated in patients with a history of cardiovascular disease. CONCLUSIONS: Despite its relatively high acquisition cost, reductions in lost workplace productivity experienced by patients treated with sumatriptan may result in savings in the overall cost of migraine to society. Thus, sumatriptan is a useful first- or second-line treatment option for patients with moderate or severe migraine.     

A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds

BACKGROUND: The past seven years have seen rapid changes in general practice in the United Kingdom (UK), commencing with the 1990 contract. During the same period, concern about the health and morale of general practitioners (GPs) has increased and a recruitment crisis has developed. AIM: To determine levels of psychological symptoms, job satisfaction, and subjective ill health in GPs and their relationship to practice characteristics, and to compare levels of job satisfaction since the introduction of the 1990 GP contract with those found before 1990. METHOD: Postal questionnaire survey of all GP principals on the Leeds Health Authority list. The main outcome measures included quantitative measures of practice characteristics, job satisfaction, mental health (General Health Questionnaire), and general physical health. Qualitative statements about work conditions, job satisfaction, and mental health were collected. RESULTS: A total of 285/406 GPs (70%) returned the questionnaires. One hundred and forty-eight (52%) scored 3 or more on the General Health Questionnaire (GHQ-12), which indicates a high level of psychological symptoms. One hundred and sixty GPs (56%) felt that work had affected their recent physical health. Significant associations were found between GHQ-12 scores, total job satisfaction scores, and GPs' perceptions that work had affected their physical health. Problems with physical and mental health were associated with several aspects of workload, including list size, number of sessions worked per week, amount of time spent on call, and use of deputizing services. In the qualitative part of the survey, GPs reported overwork and excessive hours, paperwork and administration, recent National Health Service (NHS) changes, and the 1990 GP contract as the most stressful aspects of their work. CONCLUSIONS: Fifty-two per cent of GPs in Leeds who responded showed high levels of psychological symptoms. Job satisfaction was lower than in a national survey conducted in 1987, and GPs expressed the least satisfaction with their hours, recognition for their work, and rates of pay. Nearly 60% felt that their physical health had been affected by their work. These results point to a need to improve working conditions in primary care and for further research to determine the effect of any such changes.     

Family physician consultation by patients with rheumatoid arthritis or gonarthrosis/coxarthrosis

OBJECTIVE: To determine how often patients with rheumatic joint disease consult their general practitioner (GP), and if there are disease and patient characteristics that influence GP consultation of gonarthrosis/coxarthrosis patients. DESIGN: Prospective record investigation. SETTING: Seven GP centres in the southeast of the Netherlands. METHOD: All patient contacts were registered prospectively in the seven GP centres: 46 concerned patients with rheumatoid arthritis (RA), 122 patients with gonarthrosis/ coxarthrosis. Patient and disease characteristics were collected on intake sheets. RESULTS: Three-quarters of the RA patients were periodically seen (mostly by a specialist), and 47% of the gonarthrosis/coxarthrosis patients (as often by their GP as by a specialist). Of the RA patients and of the gonarthrosis/coxarthrosis patients 74% and 89% respectively consulted their GPs in one year (the average numbers of contacts were 4.7 and 5.0); 50% and 57% did so because of the chronic joint disease (with 2.2 and 1.6 contacts respectively). No disease characteristics and only a few patient characteristics (arthroplasty, chronic use of medication) of patients with gonarthrosis/coxarthrosis influenced GP consultation. CONCLUSION: Patients with rheumatic joint disease often consult their GP, but not always because of this illness. If they consult their GP, they usually do so more than once a year.     

Gender differences in adverse drug reactions

The objective of this study is to identify gender-related differences in the types of symptoms and drugs reported to cause an adverse drug reaction. Patient data from the Sunnybrook Health Science Centre ADR Clinic for the period from April 1986 to May 1996 were reviewed. Of the 2,367 patients assessed, 74.1% were female. The mean age of the patients was 43 +/- 17 years. Drug classes most frequently reported to elicit an adverse event were general antiinfectives (60.4%), nervous system agents (21.5%), and musculoskeletal agents (3.7%). Skin-related reactions accounted for 49.0% of all reported adverse drug reactions. More than one agent was reported to be responsible for the adverse drug reaction(s) in 50% of the female patients, versus 33.1% of all male patients. Of the female patients, 47.6% were referred for skin or oral challenge testing, versus 41.6% of the male patients. Of the female patients, 6.2% tested positive to the agent compared with 6.1% of all male patients. These results support previous findings that female gender is a risk factor for the development of adverse drug reactions. Further work is required to elucidate the mechanisms explaining the differences observed between male and female patients.     

Computer-generated correspondence for patients attending an open-access chest pain clinic

AIM: To determine whether general practitioners (GPs) prefer structured computer-generated or standard dictated outpatient clinic letters. DESIGN: Questionnaire survey of all GPs referring patients to an open-access chest pain clinic at a district general hospital in London. The GPs were asked to compare three twinned examples of structured computer-generated and unstructured dictated letters. RESULTS: Of 93 respondents (response rate 77.5%), 75 (80.6%) preferred the computer-generated letter and 16 (17.2%) preferred the dictated letter (p < 0.0005). The preferred features of the computer-generated letter were its clear presentation, subheadings, and concise information. The computer-generated letter scored significantly higher than the dictated letter: for clarity, mean 8.2 vs 6.5 (p < 0.0005); content, mean 8.5 vs 6.9 (p < 0.0005); and readability, mean 8.2 vs 6.8 (p < 0.0005). The GPs in the survey considered a mean delay of 3.4 days to be acceptable for receiving the letter from the chest pain clinic. CONCLUSION: GPs prefer structured computer-generated letters to unstructured dictated letters for patients referred to an open-access chest pain clinic. Computer-generated correspondence allows rapid feedback of information to the referring GP, one of the key requirements of open-access clinics.     

Exogenous adenosine potentiates hypnosis induced by intravenous anaesthetics

AIMS: To determine whether adverse drug reactions (ADRs) to herbal remedies would be reported differently from similar ADRs to conventional over-the-counter (OTC) medicines by herbal-remedy users. METHODS: Face-to-face interviews (using a structured questionnaire) with 515 users of herbal remedies were conducted in six pharmacy stores and six healthfood stores in the UK. The questionnaire focused on the likely course of action taken by herbal-remedy users after experiencing an ADR associated with a conventional OTC medicine and a herbal remedy. RESULTS: Following a 'serious' suspected ADR, 156 respondents (30.3%) would consult their GP irrespective of whether the ADR was associated with the use of a herbal remedy or a conventional OTC medicine, whereas 221 respondents (42.9%) would not consult their GP for a serious ADR associated with either type of preparation. One hundred and thirty-four respondents (26.0%) would consult their GP for a serious ADR to a conventional OTC medicine, but not for a similar ADR to a herbal remedy, whereas four respondents (0.8%) would consult their GP for a serious ADR to a herbal remedy, but not for a similar ADR to a conventional OTC medicine. Similar differences were found in attitudes towards reporting 'minor' suspected ADRs. CONCLUSIONS: Consumers of herbal remedies would act differently with regard to reporting an ADR (serious or minor) to their GP depending on whether it was associated with a herbal remedy or a conventional OTC medicine. This has implications for herbal pharmacovigilance, particularly given the increasing use of OTC herbal remedies. The finding that a high proportion of respondents would not consult their GP or pharmacist following ADRs to conventional OTC medicines is also of concern.     

Adverse reactions to trimethoprim-sulfamethoxazole among children with human immunodeficiency virus infection

BACKGROUND: The clinical course of HIV infection is frequently different among infants and children from that in adults. In adults among the most common sources of morbidity related to therapy are adverse drug reactions, notably to trimethoprim-sulfamethoxazole. Although there are case reports of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection, the precise rate and clinical characteristics of these adverse reactions among HIV-infected children are unknown. METHODS: We reviewed the clinical records of all children referred to a regional HIV clinic in a 6-year period. Therapy and suspected adverse drug reactions to therapy were reviewed by one of the investigators not involved in patient care. Adverse drug reactions were identified and characterized according to previously established criteria. RESULTS: During this time 78 children were referred for assessment of possible HIV infection, 45 of whom were ultimately determined to have the infection. Twenty-five were treated with trimethoprim-sulfamethoxazole, 15 (60%) of whom tolerated therapy and 10 (40%) of whom had adverse reactions. The most common type of adverse reaction was erythema multiforme (70%), followed by neutropenia (20%) and Stevens-Johnson syndrome (10%). In two patients a serious adverse reaction to trimethoprim-sulfamethoxazole led to the diagnosis of HIV infection. CONCLUSIONS: The overall incidence and type of serious adverse reactions to trimethoprim-sulfamethoxazole among infants and children with HIV infection appear to be similar to those among adults.     

The general practitioner, the drug misuser, and the alcohol misuser: major differences in general practitioner activity, therapeutic commitment, and 'shared care' proposals

BACKGROUND: The primary care setting has been regarded in government policy and the scientific literature as an ideal setting for the work needed to meet the Health of the Nation drug and alcohol targets. Although studies have pointed to the negative attitudes held by general practitioners (GPs) towards alcohol- and drug-misusing patients, there has been no direct comparison of the work and attitudes of the GP towards these patients. AIM: To compare the work and attitudes of GPs towards alcohol- and drug-misusing patients. METHOD: All GPs in an outer London area (157 doctors) were surveyed, using an eight-page postal questionnaire, collecting clinical and attitudinal data alongside demographics and practice information. A response rate of 52% was achieved. RESULTS: General practitioners reported working with only 3.5 patients drinking above recommended guidelines in the previous four working weeks, and even fewer drug-using patients (0.75). While they viewed the alcohol-misusing patients negatively, the drug misuser elicited substantially more negative attitudes. The primary care setting was seen as appropriate to work with the alcohol-misusing patient but not with drug users. Training and support from local services would encourage substantially more GPs to work with alcohol misusers but not with drug misusers. CONCLUSIONS: Our findings indicate that there are some cautious grounds for optimism that GPs are willing to work with alcohol misusers; however, with regard to drug misusers, we find a GP workforce that is only minimally involved with this group and would not be greatly encouraged by the provision of additional training, support, or incentives. The Health of the Nation targets are not being met, and GPs are not detecting adequate numbers of the patients at whom these targets are aimed. Emphasis has been placed on the role of primary care, but the real achievements that can be made require detection of the less severe drinkers and injecting drug misusers.     

General practitioner involvement in hospital in the home. The hospital's view

INTRODUCTION: Programs involving hospitals and general practitioners (GPs) have become more commonplace, with a greater emphasis on integration of health services emerging over the last generation. Hospital in the home (HIH) refers to the delivery of acute hospital services such as intravenous therapy, anticoagulation and wound care to patients in their own homes. This study sought to determine the extent to which HIH units had involved urban GPs, issues related to GP involvement, and the likely future of such involvement. METHOD: Telephone administered structured survey to all urban HIH coordinators/directors in Melbourne, Australia. RESULTS: All 14 identified HIH coordinators were interviewed. Five units reported a direct role for GPs, six reported no role and three reported a limited role in managing intercurrent illnesses. Coordinators felt that variability of GP response and skills, GP availability and patient control were significant issues. An increase in future GP involvement was uncertain and conditional. DISCUSSION: One-third of urban hospitals surveyed have involved GPs in their programs. However, issues such as variability in skills, enthusiasm and availability threaten expansion of such involvement. This calls for a review in the way GPs are involved in hospital programs, and for better relationships with hospital nursing staff. Limiting the number of involved GPs in any hospital-GP program may offer advantages to both groups. Despite the movement of hospital work into the community, GP involvement in such work is not guaranteed.     

Chlamydia pneumoniae in coronary and iliac arteries of Japanese patients with atherosclerotic cardiovascular diseases

OBJECTIVE: This pilot study was undertaken to assess the need and acceptability of a theoretically based audit model to assist GPs improve their asthma care. METHOD: Seventeen GPs from two GP divisions conducted a chart audit and patient survey of asthma patients presenting during the 8 week audit period. Audit results were discussed at a workshop providing a forum for GP peer groups to review their asthma care against current guidelines. This workshop allowed the GPs to develop strategies to improve their asthma care in the context of the resources of their individual practice, GP division, local community and health services. RESULTS: Of the 243 asthma patients audited 177 (72.8%) had a review of their asthma recorded in the past 12 months, 138 (56.8%) were prescribed regular preventive therapy and 118 (48.2%) had been given an asthma action plan. Despite the time commitment required to participate in the activity, 16 respondents who answered the audit evaluation questionnaire reported that the audit was a useful process and 15 (93.8%) stated that it had motivated them to change their practice. CONCLUSION: The results confirmed the need for improved asthma care in general practice and demonstrated the feasibility of the GP-peer led, regionally coordinated, audit-workshop model.     

A prospective comparison of four study designs used in assessing safety and effectiveness of drug therapy in hypertension management

The objective of the study was to compare prospectively the impact of study design on drug therapy safety and effectiveness data obtained in hypertension management. The main study was a randomized controlled clinical trial of four different prospective study designs used in postmarketing assessment involving 1008 primary care practices in nine Canadian provinces. Two thousand nine hundred sixty-four patients with mild to moderate hypertension received an angiotensin converting enzyme (ACE) inhibitor daily for 14 weeks in one of four postmarketing studies--a randomized double-blind clinical trial (RCT) (10 to 40 mg fosinopril daily v 5 to 20 mg enalapril daily), two structured open label trials of 10 to 40 mg fosinopril daily (one with free drugs), or an unstructured open label trial of 10 to 40 mg fosinopril daily. Patient demographic and baseline characteristics, systolic and diastolic blood pressures, adverse events reported, and data quality were recorded as the outcome measures. The results showed that the RCT patients were titrated to higher doses of ACE inhibitor than patients in the open studies, P < .008; patients in the open studies were more likely to receive adjuvant diuretic therapy, P < .008. The decrease in blood pressure was similar for patients in all four studies, mean decrease in systolic BP was between 18 and 20 mm Hg, mean decrease in diastolic BP was between 11 and 13 mm Hg. Fewer patients in the unstructured open trial reported adverse events than patients in the RCT; a 55% relative reduction in reported adverse events (P < .008) was associated with the unstructured trial. There were also fewer drug-related adverse events per patient reported in the unstructured study (17 per 100 patients) than in the other studies (27 to 41 per 100 patients), P < .008. Physician preference for rounding off blood pressure measurements to 0 or 5 occurred most often in the unstructured open trial (P < .008). In conclusion, despite differences in dose titration and in the use of adjuvant therapy, antihypertensive drug therapy effectiveness observed in an RCT may be similar to uncontrolled postmarketing studies. Open trials with scheduled follow-up visits are as effective in detecting severe adverse events as RCT, but postmarketing studies with unstructured schedules of follow-up are insufficient in identifying drug-related adverse events and have poorer quality data.     

How common is medical training in palliative care? A postal survey of general practitioners

BACKGROUND: General practitioners (GPs) have a central role in palliative care, yet research continues to reveal room for improvement in symptom control at home. There is a need to evaluate how well-prepared GPs are for this task of caring for the dying at home. AIM: To evaluate the training in palliative care GPs have received throughout their careers. METHOD: Postal survey of 450 randomly selected East Anglian GP principals, investigating training in five areas of palliative care (pain control, control of other symptoms, communication skills, bereavement care, use of syringe driver), as clinical students, junior hospital doctors, GP trainees (registrars), and GP principals. RESULTS: A response rate of 86.7% was obtained. While GPs were clinical students, training was uncommon, (32% reported no training in pain control, and 58% no training in bereavement care), although there has been a significant increase in more recent years. Training as junior doctors was particularly uncommon (over 70% report no training in communication skills or bereavement care); there was some evidence of an increase in more recent years. During the GP trainee year, training was much more common. For GP principals, most areas had been covered, although over 20% reported no training in communication skills and bereavement care. During the community-based years as trainee and principal, training was significantly more common than during the hospital-based years of training as clinical student and junior doctor. CONCLUSIONS: There is a continuing need for medical education in palliative care. Particular attention should be paid to the basic medical education of clinical students and the training of junior doctors, especially regarding communication skills and bereavement care.     

Safety of oral terbinafine: results of a postmarketing surveillance study in 25,884 patients

OBJECTIVE: To broaden the safety database for oral terbinafine by determining the incidence of adverse events, particularly rare risks, that accompany its uncontrolled use in actual clinical practice. DESIGN: Four open, prospective, uncontrolled, postmarketing surveillance studies were conducted in unselected patients in 4 countries. No exclusion criteria were applied. The only treatment instructions participating physicians received were the manufacturer's product information. Physicians monitored patients for adverse events at baseline, during treatment, and at the end of treatment. Serious events were identified according to study protocol, which was consistent for all 4 studies, allowing data to be pooled and analyzed collectively. SETTING: Patients were recruited from dermatology, general, and family practices in the United Kingdom, the Netherlands, Germany, and Austria. PATIENTS: Of the 25884 patients who entered the study, 38.6% had concomitant diseases, 42.8% were taking other medications, and 22.7% were older than 60 years. The predominant indication for terbinafine treatment was onychomycosis (72.2%). INTERVENTIONS: Data on treatment duration was available for 25091 patients. Median duration of treatment was 12 weeks (mean, 13.2 weeks). Treatment extended beyond 6 weeks in 76.0% of patients and for at least 12 weeks in 59.3%. MAIN OUTCOME MEASURES: The incidence of adverse events as reported by physicians, with their opinions regarding relationship to terbinafine therapy. RESULTS: The incidence of adverse events was 10.5%; the majority involved the gastrointestinal system (4.9%) or skin (2.3%). These tended to be mild, transient, and reversible. Terbinafine was considered a possible or probable cause of 11 (0.04%) serious adverse events. No drug interactions were reported, even in patients taking oral antidiabetic agents, astemizole, terfenadine, or cimetidine hydrochloride. CONCLUSIONS: The positive safety profile established during controlled clinical trials of oral terbinafine extends to its uncontrolled use in clinical practice. No previously unrecognized risks were identified.     

A retrospective analysis of lingual nerve sensory changes after mandibular bilateral sagittal split osteotomy

PURPOSE: The purpose of this retrospective study was to determine the patient-reported incidence, duration, and perceived deficit in daily activities associated with lingual nerve (LN) sensory changes after bilateral sagittal split osteotomy (BSSO) of the mandible and to compare them with inferior alveolar nerve (IAN) sensory changes in the same study population. MATERIALS AND METHODS: Questionnaires were mailed to 316 patients who had undergone BSSO procedures between 1980 and 1993. The patients were queried for perceived sensory changes in the distribution of the IAN and LN; duration of these sensory changes; and alteration in daily activities caused by these sensory changes. The same questionnaire was mailed to 47 patients who had undergone isolated genioplasty (GP) to control for the normal variance of non-BSSO surgery on perceived LN sensory changes. RESULTS: Forty-three percent of the BSSO patients and 38% of the GP patients returned the questionnaires. Within the BSSO group, 19.4% reported LN sensory changes, of which 69.3% reported that these changes resolved within 1 year; 88% reported altered daily activities. By comparison, 95.5% reported a perceived IAN sensory change, of which 27.3% reported that these changes resolved within 1 year; 57% reported altered daily activities. Within the GP control group, 11% reported LN sensory changes; none of the reported sensory changes lasted longer than 1 month. CONCLUSIONS: A small percentage of patients report LN sensory changes after BSSO. When compared with IAN reported sensory changes, LN sensory changes resolve more frequently and sooner, but they are associated with greater perceived deficits in daily activity. The interpretation of the reported incidence of LN change must be critically reviewed because control subjects also responded positively.     

Pharmacological therapy in progressive supranuclear palsy

BACKGROUND: To our knowledge, previous reports on drug treatment in progressive supranuclear palsy have not evaluated autopsy-confirmed cases. OBJECTIVE: To evaluate pharmacological treatment responses from detailed clinical records in patients with autopsy-confirmed progressive supranuclear palsy. SUBJECTS AND METHODS: We reviewed medical records for clinical presentation and pharmacological response in 12 patients with autopsy-confirmed progressive supranuclear palsy diagnosed using the National Institute of Neurological Disorders and Stroke pathologic criteria. For each drug class, exposure, global positive response, and specific positive response (parkinsonism, other movement disorders, or gaze dysfunction) were recorded. RESULTS: Drug classes examined were dopaminergics (all patients), tricyclics (3 patients), methysergide maleate (3 patients), 5-hydroxytryptophan (2 patients), and anticholinergics and selective serotonin inhibitors (1 patient). Positive clinical response was detected in 7 of the patients receiving dopaminergic drugs and in 1 patient each receiving tricyclics, methysergide, and 5-hydroxytryptophan, respectively. None of the patients responded markedly however, and there was no persistent beneficial effect. Use of dopaminergic drugs most frequently improved parkinsonian features, but disabling adverse effects included orthostatic hypotension (6 patients), hallucinations and delusions (3 patients), gastrointestinal complaints (3 patients), and dizziness (1 patient). Only 1 patient developed dyskinesia. CONCLUSION: Use of antiparkinsonian medications and other neurotransmitter replacement therapies was largely ineffective and caused frequent adverse effects in this series of patients with autopsy-confirmed with progressive supranuclear palsy.