Acute gastroenteritis diagnostic practices of New Zealand general practitioners

AIMS: A sample of New Zealand general practitioners was surveyed to determine the laboratory referral practices of general practitioners for patients with acute gastroenteritis, with particular reference to viral gastroenteritis. METHODS: A mail questionnaire was sent to 209 general practitioners throughout New Zealand. RESULTS: The most important criteria for laboratory referral of a diarrhoeal specimen were prolonged duration of illness, presence of blood in the stool, a recent history of overseas travel, tramping or camping, shellfish consumption, or if the patient worked in the food, child care, or health care industries. Most general practitioners reported that they would refer diarrhoeal specimens from less than 25% of their patients with acute gastroenteritis. Requests for testing for viruses other than rotavirus were rare. CONCLUSION: The viral agents causing acute gastroenteritis were less likely to receive laboratory confirmation than other causes of gastroenteritis. On the basis of current laboratory investigation practices of general practitioners, foodborne viral gastroenteritis outbreaks are unlikely to be identified as such in New Zealand.     

Screening for colorectal cancer in Catalonia. Results of a population survey

This CT study was designed to assess brain morphology in agoraphobia. 21 patients and 21 normal control subjects matched in age and sex were investigated. Frontal and parietooccipital cortex, temporal cortex, lateral ventricles and third ventricle were evaluated by qualitative assessment on a 3-point scale (normal, questionable, abnormal). Patients showed significant bilateral enlargement of prefrontal cortical cerebrospinal fluid (CSF) spaces (p < .05). The rating "abnormal" was given to none (0%) of the normal controls, but to 6 (28.6%) of the patients in the left hemisphere, and to 4 patients (19%) in the right hemisphere, respectively. No qualitative differences were seen in the temporal cortex, lateral ventricles and third ventricle. These findings support the hypothesis that alterations in brain morphology are involved in the etiology of agoraphobia. The lack of a correlation between CSF enlargement and duration of illness suggests that prefrontal CSF enlargement is a neurobiological vulnerability marker in agoraphobia.     

Screening for colorectal cancer

Second only to lung cancer in mortality, colon cancer is amenable to cure if detected early. Because fecal occult blood testing and flexible sigmoidoscopy are effective individually but have limitations, both are now recommended for screening. However, after successful polyp removal, surveillance colonoscopy does not need to be performed as often as previously thought.     

Obstetric practice amongst Queensland general practitioners: a survey of needs and attitudes

A survey of Queensland general practitioners was carried out to assess their needs and attitudes regarding obstetric practice. Less than half of the respondents now practise obstetrics, and many general practitioners felt a lack of support from specialist obstetricians, paediatricians, and anaesthetists. Many of the respondents expressed needs for further obstetric training, especially in labour ward management and neonatal care; however, few were able to attend extended courses.     

Mass screening of colorectal cancer by general practitioners in France: what is the real target population?

OBJECTIVES: People at high risk of colorectal cancer, due to familial or personal history, or to specific symptoms, are considered not to be concerned by mass screening by Haemoccult test. The aim of this study was to investigate people aged 50 to 74 with high risk of colorectal cancer among general practitioners' practices in the department of Calvados (France). METHODS: A random sample of 200 general practitioners were asked to systematically fill out a questionnaire on Haemoccult II proposal for 50-74 year-old patients for a whole week. RESULTS: Participation rate of general practitioners was 58.5%. According to our findings, 13% of 50-74 years patients are considered not be concerned by mass screening, due to familial or personal history, or to specific symptoms. CONCLUSIONS: Colorectal cancer screening protocol have to be fit to level of risk of colorectal cancer. Involvement of general practitioners in colorectal cancer mass screening allows identification of high risk people who can then be managed with a more suitable screening protocol.     

Continuing medical education in mental illness: a paradox for general practitioners

BACKGROUND: In 1992, the Royal College of General Practitioners instituted its fellowship in mental health education, which aimed to provide general practitioner tutors with the skills they need to help general practitioners manage mental illness in general practice. However, the emphasis of the fellowship on pedagogic education may discourage educators wishing to introduce andragogic teaching, a paradox which general practitioners must resolve if the aims are to be realized. AIM: This study set out to follow the difficulties encountered by the regional fellows in managing the fellowship and to understand how the scheme has evolved. METHOD: Data collected for interim evaluation of the fellowship was studied and interviews undertaken with the senior fellow and the regional fellows participating in the scheme. RESULTS: From its beginnings, the project encountered difficulties involving acceptance among general practitioner tutors. In response to the objections raised, the project metamorphosed through three stages, from a (perceived) pedagogic approach to a much more overtly learner-centered one. CONCLUSION: Learner-centred education requires trust and belief in the ability of general practitioners to teach general practitioners; over-protection of the audience from 'non-expert' educators merely perpetuates the status quo. If education in mental health care is to become truly learner-centred, general practitioners must address this paradox.     

Screening for colorectal cancer by immunochemical fecal occult blood testing

Screening for colorectal cancer using the conventional Hemoccult test has been shown to reduce mortality associated with cancer by 33% through a randomized controlled trial. However, the magnitude of effectiveness is small in terms of cost-effectiveness. The recently developed immunochemical fecal occult blood test (IFOBT) provides a potential replacement for the Hemoccult test as a screening test, due to its superior performance characteristics such as higher sensitivity shown in preliminary studies and the fact that it does not require any dietary restriction. The IFOBT method is reviewed, especially in relation to its specificity. In known colorectal cancer subjects, IFOBTs have shown both higher sensitivity and specificity than the Hemoccult test. Similarly, IFOBT has demonstrated a higher sensitivity than Hemoccult for colorectal cancer in an asymptomatic population. A nationwide screening program in Japan has demonstrated the feasibility of this approach for large population screening. However, the positivity rate varied according to the conditions at each screening facility. Therefore, technical factors that influence the positivity rate of IFOBTs in the screening program are discussed. Case-control studies have strongly suggested that screening using IFOBT would reduce mortality from colorectal cancer by 60% or more. Several observational studies have provided support for this estimate. The feasibility and effectiveness of population-based screening by IFOBT are discussed.     

The general practitioner's role in breast cancer screening: a survey in Otago-Southland

AIMS: To study the experience of general practitioners in Otago and Southland with the existing breast cancer screening programme and the reviews on future programmes. METHODS: A questionnaire was sent to all 210 general practitioners in Otago and Southland in June 1996. RESULTS: The response rate was 71%. All the 141 respondents except one encouraged eligible women to take part in the programme; this was done mainly during individual doctor-patient consultations, by pamphlets and posters, and in the work of the practice nurse. Ten percent of practitioners had a practice-based recall system for breast cancer screening. Seventy-five percent of general practitioners currently provide a list of eligible women to the programme, and of these, 52% check the list to exclude ineligible women. Only 24% of practitioners supplying a patient list to the programme reported that a patient had ever requested that their name be excluded from the list. Twenty-five percent of general practitioners providing lists had a notice in the waiting room stating that. Of those who did not provide lists, concerns about logistics, ethical issues and cost were raised, although 40% of these general practitioners intended to provide lists in the future. In a future programme, 57% of general practitioners felt they should be paid for supplying lists defined by age only and 82% felt they should be paid for supplying a list of women eligible by both age and medical history. Most general practitioners felt that general practitioner lists were the preferred source for invitations to the breast screening programme and that general practitioners had an important part in any future programme. Screening at the ages 50-64 (as currently proposed) is supported by 95% of general practitioners; in addition, 64% supported screening at ages 65-69. Only a minority of general practitioners supported screening at ages 40-49 or ages 70-74. Most general practitioners would offer screening to women under age 50 with either a strong or a weak family history, or even with a past history of a fibroadenoma. CONCLUSIONS: These results show that almost all general practitioners support breast cancer screening programmes and feel that they have an important role in future programmes. The majority support extension of the programme to ages 65-69, but not to ages 40-49. The majority support screening women with individual risk factors at ages under 50, although their responses show that better information on the importance of different risk factors is required.     

Trends in colorectal cancer incidence and histologic findings in Maori and Polynesian residents of New Zealand

BACKGROUND: The aim of this study was to combine an epidemiologic survey of colorectal cancer among Maori, Polynesian, and white inhabitants of New Zealand with a detailed analysis of tumor subsite and histopathology. METHODS: Data were obtained from the New Zealand National Cancer Registry and included all registrants from 1970 to 1984. Sections of histologic specimens of colorectal cancer of Maori and non-Maori were retrieved from three Auckland hospitals. RESULTS: The annual age-adjusted incidence rates of large intestinal cancer among male and female Maoris and male and female Polynesians were 40%, 40%, 39%, and 29%, respectively, of the total population incidence. Time-trend analysis showed the incidence of large intestinal cancer to be increasing among all racial groups. The relative proportion of rectal cancers was higher in male and female Maoris and female Polynesians than in the general population, whereas male Polynesians had a relatively high proportion of right colonic cancers. High-grade carcinoma and mucinous carcinoma occurred more frequently in young individuals regardless of race. Carcinomas were diagnosed at a more advanced stage in Maoris. CONCLUSION: Given the similar environmental characteristics of the three racial groups, the findings indicate the presence of powerful protective factors in Maoris and Polynesians. These could be constitutional or mediated by unrecognized dietary constituents.     

Familial aggregation of colorectal cancer in the general population

To investigate the familial aggregation of colorectal cancer in Denmark, parents and siblings of colorectal cancer patients diagnosed below age 60 years in the years 1982-1984 were identified through population registries. For 1,470 probands with families eligible for tracing, 1,376 mothers, 1,303 fathers and 3,259 siblings were identified. They contributed 222,634 person-years, and 325 cases of colorectal cancer were observed during the follow-up period 1943-1992. All data were retrieved from population registries and consequently were free from any reporting bias. The overall standardized morbidity ratio (SMR) compared with the Danish population was 2.02 (95% confidence interval [CI] 1.81-2.25), significantly different between the parents (1.78, 95% CI 1.55-2.04) and the siblings (2.65, 95% CI 2.21-3.17). A strong dependence on the proband's age at diagnosis was seen for the sibling risk; siblings of probands less than 50 years old at diagnosis had a 5-fold risk compared with the general population. This dependence was not seen for parents, but the risk tended to be higher for parents of younger ages. No other factor was seen to influence the relative risk. The observation of an 80% increased risk among the parents and a 170% increased risk among the siblings indicates that the genetic component is one source, but probably not the only one, of familial aggregation of colorectal cancer. The cost benefit of screening siblings of colorectal cancer patients is substantially higher than that for the total population.     

Screening for colorectal cancer with the Haemoccult test (author's transl)

Results are reported of a 5 year trial with the Haemoccult stool-test in a diagnostic center (DKD), and of a 1 year trial in the offices of 110 physicians. In the DKD 8 000 patients were tested: In a non-selected group 2,4% and in a selected one 3,8% of tests performed turned out to be positive; the diagnosis of carcinoma of the colon or rectum was established in 32 of these cases and 45 large polyps were traced. In most of the offices the test was positive in less than 3% of the patients tested, 57 of these patients had a carcinoma and 26 polyps. In 54 of all 89 cases with carcinoma and in 46 out of 71 polyps the lesions could not be found by digital or rectoscopic examination, due to a higher localization; 17 of the cancer patients were asymptomatic except for a positive Haemoccult test. Using only 3 tests per patients, 7 out of 96 colorectal cancers and 27 out of 98 large polyps were negative. 6 haemoccult tests to be done on three successive stools (as originally proposed by Greegor) are recommended as a yearly routine procedure in all persons about 40 years of age for early detection of carcinoma or polyps of the colon.     

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.