Do the beliefs of Australian general practitioners about the effectiveness of cancer screening accord with the evidence?

A national random sample of 855 Australian general practitioners was surveyed about their belief in the effectiveness of cancer screening tests in reducing premature mortality. Responses were then compared with scientific evidence of effectiveness for each test. 92% of respondents believed mammography to be effective compared with only 38% for faecal occult blood testing, despite comparable evidence of effectiveness from randomised controlled trials. Seven tests outranked their belief in faecal occult blood testing, despite weaker evidence. Further efforts are required to align general practitioners' beliefs better with the evidence.

Local implementation of national guidelines on lower urinary tract symptoms: what do general practitioners in Sydney, Australia suggest will work?

OBJECTIVES

Systematic reviews demonstrate that local initiatives are vital to implement nationally developed clinical practice guidelines. Evidence-based guidelines on the management of lower urinary tract symptoms in men were launched by the National Health and Medical Research Council in Sydney in April 1997. A study was conducted through interviews to establish patterns of care in the catchment area before the guidelines were implemented and general practitioners were surveyed in order to ascertain the most useful strategies for local implementation.

DESIGN

A four-page questionnaire asked respondents to rate nine items about guideline dissemination; six items relating to the marketing of the guidelines and 15 implementation strategics: conventional educational activities (six); innovative educational strategies (four); quality improvement approaches (two) and patient-based approaches (three).

SETTING

Sydney, Australia.

STUDY PARTICIPANTS

Eighty-three randomly selected general practitioners (50 males; 33 females).

RESULTS

Eighty-three out of 108 surveys were returned (77%). Respondents placed high value upon endorsement by eminent individuals and organizations other than the organization developing the guidelines; this was likely to gain their initial attention. One hundred per cent of respondents would be encouraged to use the guidelines if they were promoted as improving quality of care. Implementation strategies preferred by respondents included small group continuing education with a urologist and a general practitioner as a facilitator, lectures and patient education materials. Internet access, interactive computer systems, academic detailing' and distance education modules were of least interest.

CONCLUSIONS

Our method is feasible as a first step in planning local dissemination and implementation for national guidelines. While useful in identifying preferred strategies, its longer-term predictive validity for improving patient outcomes through better guideline implementation needs to be established.

Outcome after surgery for perianal fistula: predictive value of MR imaging

OBJECTIVE

The purpose of this study was to determine if MR findings are predictive of long-term outcome in a cohort of patients whose initial surgery was performed without access to the findings of MR imaging.

SUBJECTS AND METHODS

Forty patients with surgically proven perianal fistulas underwent preoperative dynamic contrast-enhanced MR imaging. The MR and surgical findings were independently recorded on an identical anatomic form. Three patients were subsequently lost to follow-up. The outcome for the remaining 37 patients was determined from surgical review, case notes, and questionnaires. Minimum follow-up period was 14 months (range, 14-39 months). Outcome was determined by one observer who was unaware of the initial MR grading and had not been present during surgery. Outcome was considered unsatisfactory if further surgery was required.

RESULTS

MR imaging was better than surgical exploration in predicting outcome (for MR imaging: positive predictive value, 73%; negative predictive value, 87%; sensitivity, 89%; and specificity, 68%; for surgical exploration: positive predictive value, 57%; negative predictive value, 64%; sensitivity, 73%; and specificity, 47%). MR classification of fistulas was significantly associated with outcome (p = .0004), and surgical classification was not significantly associated with outcome (p = .22, chi-square test). Also MR grades differed significantly for patients with satisfactory and unsatisfactory outcomes (p < .001, Mann-Whitney U test).

CONCLUSION

MR imaging is valuable in the management of patients with perianal fistulas. MR imaging accurately reveals surgical anatomy and can be used to make better predictions regarding patient outcome than surgical findings.

Cardiovascular risk factors among Arabic-speaking patients attending Arabic-speaking general practitioners in Sydney, Australia: opportunities for intervention

BACKGROUND

Australia has a high rate of cardiovascular disease mortality and also a significant proportion of migrants. Little is known about the morbidity experience or cardiovascular risk factors among the larger migrant groups, and this is especially true of the Arabic-speaking population.

OBJECTIVES

The objectives of the study were to identify the health profile of Arabic-speaking people in Sydney, Australia, to explore the relationship between level of acculturation and health indicators and to identify the morbidity profile of patients presenting to Arabic-speaking general practitioners (GPs).

DESIGN

Adult Arabic-speaking patients aged 18-70 years attending 20 Arabic-speaking GPs in Canterbury, Sydney, during the 2-week study period were asked to complete a self-administered questionnaire in Arabic or English while waiting to see the GP. Data on cardiovascular risk factors, level of acculturation and reasons for seeing the GP were collected.

RESULTS

Data were collected from 851 patients (62% response rate). Almost three-quarters (73%) of males and 36% of females were considered overweight or obese (body mass index > 25). Of concern, 37% of males and 28% of females were smokers. Females were significantly less likely to have been tested for diabetes (p < .05) or raised blood pressure (p < 0.05) compared with females in NSW. Respondents consumed less bread per day and more fruits than in NSW overall. Respiratory complaints (flu and colds) were the most frequently reported reasons for patient encounters. Except for the youngest age group, males gave more reasons for encounters than females.

CONCLUSIONS

Consecutive sampling of ethnic patients attending a GP who speaks their language holds promise as a method of needs assessment with migrant populations. Further, our results suggest that smoking and weight reduction programs are priorities in the Arabic-speaking community. These risk factors are ideal for intervention by GPs speaking the same language.

Targeted disruption of the acid alpha-glucosidase gene in mice causes an illness with critical features of both infantile and adult human glycogen storage disease type II

We have used gene targeting to create a mouse model of glycogen storage disease type II, a disease in which distinct clinical phenotypes present at different ages. As in the severe human infantile disease (Pompe Syndrome), mice homozygous for disruption of the acid alpha-glucosidase gene (6(neo)/6(neo)) lack enzyme activity and begin to accumulate glycogen in cardiac and skeletal muscle lysosomes by 3 weeks of age, with a progressive increase thereafter. By 3.5 weeks of age, these mice have markedly reduced mobility and strength. They grow normally, however, reach adulthood, remain fertile, and, as in the human adult disease, older mice accumulate glycogen in the diaphragm. By 8-9 months of age animals develop obvious muscle wasting and a weak, waddling gait. This model, therefore, recapitulates critical features of both the infantile and the adult forms of the disease at a pace suitable for the evaluation of enzyme or gene replacement. In contrast, in a second model, mutant mice with deletion of exon 6 (Delta6/Delta6), like the recently published acid alpha-glucosidase knockout with disruption of exon 13 (Bijvoet, A. G., van de Kamp, E. H., Kroos, M., Ding, J. H., Yang, B. Z., Visser, P., Bakker, C. E., Verbeet, M. P., Oostra, B. A., Reuser, A. J. J., and van der Ploeg, A. T. (1998) Hum. Mol. Genet. 7, 53-62), have unimpaired strength and mobility (up to 6.5 months of age) despite indistinguishable biochemical and pathological changes. The genetic background of the mouse strains appears to contribute to the differences among the three models.

Impact in general practice of the policies of the organised approach to preventing cancer of the cervix

This cross-sectional survey of cancer screening in May 1996 used a national random sample of a specified group of general practitioners (GPs). The survey included items to assess the impact of the Organised Approach to the Prevention of Cervical Cancer (OAPCC). Of the 1,271 GPs who satisfied the eligibility criteria, 855 (67%) returned a completed questionnaire. Fifty-two per cent indicated they would be 'highly' likely to introduce a discussion about cervical smears to a 58-year-old woman who was in good health and had come for a non-gynaecological consultation. Female sex, RACGP affiliation, practising in a metropolitan area and awareness of the OAPCC booklet were independent predictors of an opportunistic orientation. By contrast, 91% indicated that they would be 'highly' likely to include a Pap smear in a general health checkup. Thirty-eight per cent reported that they had found the booklet about the 1991 screening policy 'very' useful, while 38% found the NHMRC guidelines for the management of women with screen detected abnormalities 'very' useful. Around one-fifth of the GPs were not aware of these documents. Overall, 19% still recommended annual or more frequent screening. GPs from NSW and Queensland were less likely to support biennial screening than GPs from other states. Overall, 26% of GPs did not indicate that they would refer a woman who had tested positive for any grade of CIN for colposcopic assessment. Female GPs were more likely to refer women with CIN for colposcopic assessment while older doctors were less likely to do so.

Labour-saving strategies to maintain survey response rates: a randomised trial

To evaluate response-aiding strategies feasible in large surveys, we randomly allocated general practitioners (GPs) to one of four intervention groups: Group 1 received 'exhaustive' telephone prompts by a medical peer in advance of a questionnaire; Group 2, inclusion of an embossed pen with the questionnaire; Group 3, an advance letter prompt; and Group 4, a 'single attempt' advance telephone prompt by a non-medical research assistant. Follow-up procedures were identical. Response rates by group were not significantly different overall (chi 2 = 4.59, df = 3, p = 0.20) although advance prompts by a medical peer were significantly more effective than other strategies for male GPs. The difference in overall response rates between males (63%) and females (74%) was significant (chi 2 = 15.40, df = 1, p < 0.01). No other response bias was evident. Our demonstration of a significant interaction between respondent sex and response-aiding strategy invites further research.

Australian general practitioners' views and use of tests to detect early prostate cancer

To describe general practitioners' current beliefs, knowledge and self-reported practices in prostate cancer screening, we conducted a national survey of 1,271 general practitioners, obtaining 855 completed questionnaires (67% response rate). Available tests for prostate cancer screening, namely DRE and PSA alone and in combination, were indicated to be effective by 49%, 43% and 68% of respondents respectively, with older GPs significantly more likely to hold these views. The effect of guidelines was mixed. Less than 8% of respondents indicated they did not recommend screening. Although the majority of GPs were unlikely to adopt an opportunistic approach to prostate cancer screening, 63%, 57% and 46% indicated they would recommend DRE, PSA or both respectively during a dedicated health check up. Awareness of relevant guidelines was low, with nearly half of respondents unable to recall publications from the RACGP or ACS. Counter-intuitively, awareness of ACS guidelines for prostate cancer screening (which advise against screening) was significantly associated with the converse behaviour. Findings from this first national study behove proactive and highly targeted dissemination in general practice of the AHTAC policy announced by the Commonwealth Health Minister in August 1996.

A novel protein complex that interacts with the vitamin D3 receptor in a ligand-dependent manner and enhances VDR transactivation in a cell-free system

Nuclear receptors transduce hormonal signals by binding directly to DNA target sites in promoters and modulating the transcription of linked genes. Receptor-mediated transactivation appears to be potentiated in response to ligand by a number of coactivators that may provide key interactions with components of the transcription preinitiation complex and/or alter chromatin structure. Here, we use the vitamin D3 receptor ligand-binding domain (VDR LBD) as an affinity matrix to identify components of a transcriptionally active nuclear extract that interact with VDR in response to ligand. We describe the purification of a complex of at least 10 VDR interacting proteins (DRIPs) ranging from 65 to 250 kD that associate with the receptor in a strictly 1,25-dihydroxyvitamin D3-dependent manner. These proteins also appear to interact with other, but not all, nuclear receptors, such as the thyroid hormone receptor. The DRIPs are distinct from known nuclear receptor coactivators, although like these coactivators, their interaction also requires the AF-2 transactivation motif of VDR. In addition, the DRIP complex contains histone acetyltransferase activity, indicating that at least one or more of the DRIPs may function at the level of nucleosomal modification. However, we show that the DRIPs selectively enhance the transcriptional activity of VDR on a naked DNA template utilizing a cell-free, ligand-dependent transcription assay. Moreover, this activity can be specifically depleted from the extract by liganded, but not unliganded, VDR-LBD. Overexpression of DRIP100 in vivo resulted in a strong squelching of VDR transactivation, suggesting the sequestration of other limiting factors, including components of the DRIP complex. These results demonstrate the existence of a new complex of novel functional nuclear receptor coactivators.

Rational engineering of the TOL meta-cleavage pathway

The meta-cleavage pathway of Pseudomonas putida mt-2 was simulated using a biochemical systems simulation developed by Regan (1996). A non-competitive inhibition term for catechol-2,3-dioxygenase (C23O) by 2-OH-pent-2,4-dienoate (Ki = 150 μM) was incorporated into the model. The simulation predicted steady state accumulation levels in the μM range for metabolites pre-meta-cleavage, and in the mM range for metabolites post-meta-cleavage. The logarithmic gains L[V-i, Xj] and L[X-i, Xj] clearly indicated that the pathway was most sensitive to the concentration of the starting substrate, benzoate, and the first enzyme of the pathway, toluate-1, 2-dioxygenase (TO). The simulation was validated experimentally; it was found that the amplification of TO increased the steady state flux from 0.024 to 0.091 (mmol/g cell dwt)/h. This resulted in an increased accumulation of a number of the pathway metabolites (intra- and extracellularly), especially cis-diol, 4-OH-2-oxovalerate, and 4-oxalocrotonate. Metabolic control analysis indicated that C23O was, in fact, the major controling enzymic step of the pathway with a scaled control coefficient of 0.83. The amplification of TO resulted in a shift of some of the control away from C23O. Catechol-2,3-dioxygenase, however, remained as the major controling element of the pathway. Copyright 1998 John Wiley & Sons, Inc.

Comparison of dyspnea ratings during submaximal constant work exercise with incremental testing

PURPOSE

The purpose of this study was to determine whether dyspnea ratings would be similar during submaximal (as used for training) and incremental (as used in testing) exercise at specific intensities in patients with chronic obstructive pulmonary disease (COPD).

METHODS

We studied 20 patients with COPD. Age was 66 +/- 9 yr (mean +/- SD); FEV1 was 43 +/- 14% pred. At Visit 1 patients provided dyspnea ratings (0 to 10 scale) each minute during incremental exercise on the cycle ergometer. At Visit 2 patients rated dyspnea during production of submaximal exercise for 10 min at two intensities.

RESULTS

Peak oxygen consumption (VO2) was 13.9 +/- 3.2 mL.kg-1.min-1. At visit 2 VO2 was stable, but dyspnea ratings increased slightly. Dyspnea ratings (2.0 +/- 1.2) during submaximal exercise were higher than during incremental exercise (1.1 +/- 0.7) at 55 +/- 8% of peak VO2 (P = 0.02) but were similar (4.3 +/- 1.5 vs 3.9 +/- 1.5) at 77 +/- 8% of peak VO2 (P = 0.40).

CONCLUSIONS

In patients with COPD, dyspnea ratings were similar during steady state compared with equivalent levels of incremental exercise at a "high" intensity, but were slightly higher at the "low" exercise intensity. These data support the potential use of dyspnea ratings obtained during incremental exercise as a target for exercise training in patients with respiratory disease.

Postcard reminders from GPs for influenza vaccine: are they more effective than an ad hoc approach?

All persons 65 years and older are recommended to be immunised against influenza each autumn. As immunisation rates remain low, we conducted a randomised control trial in a three-partner urban general practice to evaluate the differential effectiveness of a single postcard reminder in a general practice setting compared to usual care. All non-residential patients aged 65 years and over were identified from the age/sex/disease register. After exclusions, 325 patients were stratified by sex (125 men and 200 women) and randomised to receive either a postcard reminder in large print mailed in April or usual care. General practitioners (GPs) were blind to the randomisation. A blinded record audit performed in July demonstrated that the postcard was effective in increasing immunisation for men (chi(2)1df = 3.85; p = 0.05) but not for women (chi(2)1df = 0.45; p = 0.50). After adjusting for 1995 immunisation status, the effect of the postcard on immunisation rates was even stronger in men (Wald chi(2)1df = 6.20; p = 0.01) but remained non-significant in women (Wald chi(2)1df = 1.38; p = 0.24). With this adjustment, the odds of having the 1996 flu vaccine for men sent the postcard reminder were three times that of men in the control group (OR = 3.0; 95% CI 1.3-6.9). In a general practice setting, a single postcard reminder appears to be a promising way to boost influenza immunisation rates among ageing men. Replication of the study is recommended.

Assessment of resectability of pancreatic cancer with dynamic contrast-enhanced MR imaging: technique, surgical correlation and patient outcome

The aim of our work was to investigate the use of a dynamic contrast-enhanced MR (DCEMR) technique for staging apparently localised pancreatic cancer, and to determine the patterns of tumour and vascular enhancement with this technique. Thirty-five consecutive patients were examined. The MR findings were correlated with surgical findings in 13 patients and with clinical outcome in 22 patients. Breath-hold gradient-echo fast low angle shot (TR = 100, TE = 4, flip angle 80 degrees ) acquisitions were obtained at 10 and 40 s (right anterior coronal oblique plane) and at 90 s (axial plane) following intravenous gadolinium. Mean contrast-to-noise ratio was higher on the first than the second acquisition (p < 0. 001) and higher on the second acquisition than the third (p < 0.005). Tumour conspicuity was greatest and arterial anatomy was best demonstrated on the first acquisition and the portal venous anatomy on the second. Small tumours were isointense by the third acquisition. Maximal intensity projections were helpful. The MR findings correctly predicted the surgical findings in 11 of 13 cases (85 %) and the clinical course in the other 22 patients. The DCEMR imaging technique is valuable in the staging of patients with pancreatic cancer. Capillary and portal venous phase images are both required for complete local staging.

Effects of the M1 agonist xanomeline on processing of human beta-amyloid precursor protein (FAD, Swedish mutant) transfected into Chinese hamster ovary-m1 cells

Complementary DNA (cDNA) encoding human beta-amyloid precursor protein familial Alzheimer's disease (FAD) Swedish mutant (beta APPSM) form was cloned into a mammalian expression vector (PK255) containing the CMV promoter. The vector was transfected into Chinese hamster ovary cells containing human muscarinic m1 receptors (CHO-m1), and clonal cells stably expressing beta APPSM were isolated. The effects of m1-receptor activation by the selective m1 agonist xanomeline and the non-selective muscarinic agonist carbachol on processing of beta APPSM to release soluble APP (APPs) and beta-amyloid peptide (A beta) were compared. Xanomeline stimulated APP release with a potency 1000-fold greater than that observed for carbachol. Concentrations of carbachol and xanomeline producing maximal effects on APPs release reduced the secretion of A beta by 28 and 46%, respectively. These results extend previous studies with xanomeline and suggest that cholinergic replacement therapy for Alzheimer's disease may reduce amyloid deposition.

Dynamic contrast-enhanced MR imaging of perianal fistulae

We describe the normal magnetic resonance (MR) anatomy of the perianal region and relate this to the surgical anatomy of perianal fistulae. We illustrate the surgical classification of perianal fistulae and the range of complications of fistulous disease encountered in clinical practice.

Smoking-cessation strategies observed in videotaped general practice consultations

BACKGROUND

This study describes opportunistic smoking-cessation counseling and compares strategies used in general practice to experts' recommendations.

METHODS

In this observational study we analysed 157 videotaped consultations with self-reported smokers, visiting 70 Australian general practitioners (GPs) who were randomly enrolled in the Victorian General Practice Study. Smoking-cessation strategies were analysed using a rating form assessed for intrarater reliability and compared to recommendations of 20 experts surveyed to ascertain effective and feasible strategies.

RESULTS

GPs identified smokers in 32% of consultations and counselled them in 29%. Median counselling time was 44 seconds in encounters typically lasting 10 minutes. When smoking was raised, advice to quit, personalising risks, discussing health risks, and quantifying consumption were the most commonly used strategies (46%-54%). Assessment of motivation to quit, individualised education, practical hints to stop, written materials, and follow-up were observed in a third or less of interventions. Quit dates and nicotine replacement were never proposed.

CONCLUSIONS

GPs miss many opportunities to advise smokers to quit and rarely use effective smoking-cessation techniques as recommended. Medical education has failed to provide GPs with skills to counsel smokers routinely and effectively. We recommend better training of GPs in effective smoking-cessation strategies and incentives to facilitate their implementation in practice.

Applying a health outcomes approach in a health service unit

An explicit focus on health outcomes has the potential to improve health if applied at the local level. However, clinical services require clear and practical support in the measurement and analysis of health outcome indicators. This paper suggests 12 steps for departments or services to take in promoting an outcomes orientation, based on our experiences in the Central Sydney Area Health Service. These include determining commitment at the service level, setting up a working group, specifying service consumers, their health problems and intervention processes, specifying desired health changes, consulting the literature and peers, identifying existing resources, pilot-testing and refining outcome measures, collecting data and responding to sub-optimal results with evidence-based interventions. The paper also reviews common criticisms of the health outcomes approach and key issues which have arisen in the course of applying these steps at the local level.

The vaccinia virus I1 protein is essential for the assembly of mature virions

The product of the vaccinia virus I1 gene was characterized biochemically and genetically. This 35-kDa protein is conserved in diverse members of the poxvirus family but shows no homology to nonviral proteins. We show that recombinant I1 binds to both single-stranded and double-stranded DNA in a sequence-nonspecific manner in an electrophoretic mobility shift assay. The protein is expressed at late times during infection, and approximately 700 copies are encapsidated within the virion core. To determine the role of the I1 protein during the viral life cycle, a inducible viral recombinant in which the I1 gene was placed under the regulation of the Escherichia coli lac operator/repressor was constructed. In the absence of isopropyl-beta-D-thiogalactopyranoside, plaque formation was abolished and yields of infectious, intracellular virus were dramatically reduced. Although all phases of gene expression and DNA replication proceeded normally during nonpermissive infections, no mature virions were produced. Electron microscopic analysis confirmed the absence of mature virion assembly but revealed that apparently normal immature virions accumulated. Thus, I1 is an encapsidated DNA-binding protein required for the latest stages of vaccinia virion morphogenesis.