Can brain natriuretic peptide (BNP) be used as a screening tool in general practice?

OBJECTIVE

To investigate plasma brain natriuretic peptide (p-BNP) in consecutive primary care patients for heart failure screening.

DESIGN

Open, descriptive.

SETTING

Three primary care clinics, university hospital.

SUBJECTS

291 consecutive patients, > or =40 years.

MAIN OUTCOME MEASURES

p-BNP and general practitioners estimated probability of CHF.

RESULTS

Median p-BNP was 29 ng/L. In 42% p-BNP was >40 ng/L in the first sample. In 41 patients further investigated, median p-BNP was 98 ng/L, with a correlation between p-BNP and physicians' estimation of probability of heart failure (r=0.469, p<0.0001). New York Heart Association class was correlated to p-BNP (r=0.343, p=0.034). No correlation between ejection fraction and p-BNP was seen.

CONCLUSION

P-BNP concentrations in unselected primary care patients of 40 years of age or above were elevated in a larger proportion of patients than previously reported. Owing to the low specificity, p-BNP concentration limits have to be defined before the test can be used for screening in primary care.

STIs in pregnancy. An update for GPs

BACKGROUND

Pregnancy and sexually transmitted infections (STIs) are both consequences of unprotected vaginal sex. In addition to causing maternal morbidity in their own right, many STIs including human immunodeficiency virus (HIV) can be transmitted to the neonate. Antenatal screening during pregnancy provides an opportunity to minimise or eliminate the antepartum, intrapartum and postpartum consequences of most STIs.

OBJECTIVE

This article discusses the diagnosis, management and treatments available for STIs in pregnancy to minimise morbidity and mortality for both mother and child.

DISCUSSION

HIV testing in antenatal care should be added to routine syphilis and hepatitis B serology, as effective HIV interventions can significantly reduce the risk of mother-child transmission. Consideration should be given to testing in women less than 25 years of age for chlamydia and those women at increased sexual risk. Male partners should not be forgotten and contact tracing, treatment and follow up offered. Due to the very small risk associated with genital warts and genital herpes, normalisation, information and reassurance are appropriate for the majority of women affected.

Giving patients an audiotape of their GP consultation: a randomised controlled trial

BACKGROUND

Providing patients with an audiotape of their medical consultation has been a relatively common practice in oncology clinics for some years. However, broader generalisability of the technique has yet to be examined.

AIMS

To investigate the efficacy of providing patients with an audiotape of their consultation in a general practice setting.

DESIGN OF STUDY

Randomised controlled trial: 95 experimental participants, 85 controls.

SETTING

Routine surgeries run by two general practitioners (GPs) in two different health centres.

METHOD

All patients attending GP appointments were eligible for inclusion. Patients were followed up by telephone 7-10 days later.

RESULTS

More than half (61%) of the patients who received a tape listened to it. Among listeners, 64% rated the tape useful or very useful; 24% noticed information not heard in the consultation. Half of listeners (46%) said that their understanding of the consultation improved after listening to the tape. Half of the listeners (48%) shared the tape with others, of whom 71% found sharing helpful or very helpful. However, 21% of those who shared the information with others found this unhelpful or very unhelpful, suggesting that patients may need to be briefed on the potential risks of sharing. At follow-up a week later, it emerged that being given a tape had no effect on adherence with GPs' advice, nor on anxiety about conditions.

CONCLUSION

Providing patients with an audiotape of their GP consultation was positively rated by many patients. Although there were no detectable clinical effects at follow-up, the technique merits further evaluation in general practice.

Evidence-based medicine in general practice: helping the whole patient

This article is based on a keynote presentation at the 13th Nordic Congress in General Practice in Helsinki, Finland in September 2003. The aim was to demonstrate the strengths and limitations of evidence-based medicine (EBM) in a primary healthcare setting, and to show how and why it also can represent a hindrance to optimal medical care. The presentation comprised two separate lectures. Initially, Marjukka Mäkelä pointed to strengths to underline the need for EBM in general practice. Subsequently, Irene Hetlevik argued that the concept of EBM, on the contrary, could be a hindrance for good general practice.

Relationship between general practitioner certification and characteristics of care

BACKGROUND

The introduction of mandatory or quasimandatory certification processes for general/family doctors has become common in many countries, including Australia. Whether certification effects the care provided is rarely investigated.

OBJECTIVES

The objective of this study was to determine whether certification of general/family physicians is associated with clinical performance.

RESEARCH DESIGN

We conducted a secondary comparative analysis of data from an Australian national cross-sectional survey (April 2000-March 2002).

SUBJECTS

Subjects consisted of a random sample of 1982 general practitioners (GPs)

METHODS

Each participant provided demographic details and information about 100 consecutive patient encounters (total 197,500). We compared characteristics of certified and uncertified general practitioners (GPs), their patients, encounters, problems, management actions, and tested 34 performance indicators. We investigated whether differences identified in descriptive analyses were explained by other factors.

RESULTS

Of 1975 GPs who indicated certification status, 659 (33.4%) were vocationally certified. Certificants were more likely to be female, younger, Australian graduates, working fewer sessions, in larger practices, in accredited practices, and using computers for clinical purposes. Their patients were younger, more often female, and less likely to hold a healthcare concession card. Their consultations were longer; they prescribed fewer medications and more clinical treatments and procedures, ordered more pathology tests, and referred more to other health professionals. After adjustment for GP/practice, patient and morbidity differences, certificants had longer consultations, did more therapeutic procedures, prescribed less overall, prescribed fewer nonsteroidal antiinflammatory drugs in the elderly, and fewer antibiotics for upper respiratory infections.

CONCLUSION

Certification of general practitioners has a significant association with consultation behavior and patient management.

[Use of the Goldberg General Health Questionnaire (GHQ-28) to detect psychosocial problems in the family physician's office]

OBJECTIVE

To analyze the usefulness of the 28-item Goldberg General Health Questionnaire (GHQ-28) in identifying psychosocial problems, and to determine how the questionnaire scores are related to stressful life events (SLE), use of health services, and individual variables (age, sex, employment status, socioeconomic group, and educational level).

DESIGN

Cross-sectional study.

SETTING

Almanjayar Health Center in the city of Granada, Southern Spain.

PARTICIPANTS

314 patients more than 18 years of age, selected by systematic sampling at an on-demand health center.

MAIN MEASURES

Each patient completed the GHQ-28 during the course of a personal interview, and scores of 8 or higher were considered to indicate psychosocial problems. Score on the Social Readjustment Rating Scale of Holmes and Rahe (stressful life events during the previous year) was also recorded, as were socioeconomic group, educational level, employment status and use of services (number of visits to the doctor during the previous year). All variables were subjected to descriptive analysis and their associations with the GHQ-28 score were tested with the chi-squared test. Multivariate analysis was used to identify categories that showed an independent association with high scores on the GHQ-28.

RESULTS

The variables associated with a greater likelihood of psychosocial problems were female sex (OR, 2.15; CI, 1.14-4.04) and high levels of stress (OR, 2.65; CI, 1.50-4.68). Both showed a statistically significant association with the GHQ-28 score after multivariate analysis.

CONCLUSIONS

The GHQ-28 is a potentially useful instrument to detect psychosocial problems in the family physician's office, and can aid in the subsequent identification and qualitative evaluation of patients.

Family medicine: its core principles and impact on patient care and medical education in the United States

The specialty of family medicine arose out of a combination of American public and professional concerns regarding fragmentation of health care and was intended to foster a type of physician with a scope of clinical competence that would allow the patient, not the disease, to be the focus. Family physicians serve as the patient's personal physician and provide entry to the health care system, provide comprehensive care, maintain continuing responsibility for the patient including necessary coordination of care and referral, and provide care appropriate to the patient's physical, emotional, and social needs in the context of family and community. The specialty is currently second only to internal medicine in size, and makes a significant contribution to patient care and medical education. As family medicine looks to the future, some of its challenges include continuing to attract medical students to the specialty, refine research themes, and gain further acceptance in academic medical centers.

Does my patient have capacity to consent to treatment?

A competent adult patient has an ethical and legal right to give or withhold consent to an examination, investigation or treatment. Depending on the nature and complexity of an intervention, a patient with a developmental disability may be capable of consenting to their own medical treatment. In circumstances in which an adult patient does not have the capacity to consent, there is specific guardianship legislation enacted in each state that provides for valid consent by a substitute decision maker.

Children and adolescents with developmental disabilities. The GP's role

BACKGROUND

General practitioners play a central role in the health care for families of children with disabilities, but may feel inadequately trained or resourced for this role.

OBJECTIVE

This article highlights the important issues arising for children and their families as the child grows--from birth through to adolescence and adulthood. It also provides some key resources for the GP, patient and their family during this transition.

DISCUSSION

Families need GPs to provide primary and preventive health care, and referral to and coordination of other health care services. The families of children with disabilities are no different. They need their GP to provide care to all family members and to work as a part of a health care team for children with complex needs relating to developmental disabilities.

Adults with intellectual disability and the GP

BACKGROUND

General practitioners are the health professionals most commonly consulted by people with intellectual disability. This group of patients can provide unique but not insurmountable challenges to the GP.

OBJECTIVE

This article outlines the management of this group of patients, and provides strategies for treatment using a case vignette.

DISCUSSION

While people with intellectual disability frequently have unidentified and/or sub-optimally managed conditions, improvement in their health care can be made through a variety of strategies. These include maximising communication and cooperation with all those involved and ensuring adequate information from support staff. Regular health assessments, which specifically target the commonly associated comorbidity and health screening activities, are also a useful approach. Through collaboration and proactive health care, the quality of life of patients with an intellectual disability can be substantially improved.

Home medication review. A personal experience in rural Tasmania

The Home Medical Review (HMR) was introduced into the Medical Benefits Scheme in October 2001, presuming teamwork and a holistic approach to treatment to be paramount in patient management at the primary health care level.

When the child with ADHD grows up

BACKGROUND

There is significant controversy surrounding attention deficit hyperactivity disorder (ADHD). While the existence of this disorder is generally accepted, debate continues in relation to aspects of assessment, as well as the effectiveness and choice of treatment options and their continuation into adult life. Management is further complicated as people with ADHD often have chaotic lives which impedes medication compliance and motivation to continue treatment vacillates. Concern also exists over the misuse of amphetamine-like medications by some patients.

OBJECTIVE

This case study does not provide comprehensive information on current diagnosis and ADHD treatment guidelines, but explores the issues and management role of general practitioners treating patients with ADHD.

DISCUSSION

The diagnosis of ADHD is common, and many patients are managed using a range of social and behavioural interventions that are commonly combined with pharmacotherapies (provided in the main by psychiatrists and paediatricians). However, while specialists may appropriately choose not to treat where a diagnosis is unclear, or discontinue treatment for reasons such as doubtful response to treatment, possible medication misuse, concurrent illicit drug use or poor motivation, GPs frequently continue to manage ongoing care and the impact of ADHD on the rest of the family. When the specialist formulation suggests there is little to gain from further treatment, the GP is likely to be the sole health professional remaining engaged in support and ongoing management.

Quinine associated blindness

BACKGROUND

Quinine is commonly prescribed to the elderly for the treatment of benign nocturnal cramps, yet its use is not without complications.

OBJECTIVE

This article presents a case of quinine toxicity producing bilateral blindness, followed by a review of the adverse reactions associated with quinine use and its efficacy in treating benign nocturnal muscular cramps.

DISCUSSION

Visual loss has been associated with quinine serum concentrations above 10 microg/mL (therapeutic range 2-5 microg/mL). Other adverse reactions include neurological symptoms, haemolysis, acute renal failure and arrhythmia. There is conflicting evidence for the efficacy of quinine for leg cramps in randomised controlled studies, however, meta-analysis of these studies suggests some benefit. Although severe side effects are rare at therapeutic doses, the possibility of overdose needs to be considered when prescribing and an individual risk benefit analysis needs to be made. Benefits and adverse reactions should be closely monitored and medication ceased if appropriate.

Prognostic factors for neck pain in general practice

Prognostic studies on neck pain are scarce and are typically restricted to short-term follow-up only. In this prospective cohort study, indicators of short- and long-term outcomes of neck pain were identified that can easily be measured in general practice. Patients between 18 and 70 years of age, suffering for at least 2 weeks from neck pain were recruited by 42 general practitioners (GPs). Perceived recovery, pain intensity and neck dysfunction after 7 and 52 weeks were considered as outcome measures. Indicators of prognosis were identified by means of logistic regression analyses (perceived recovery) and linear regression analyses (pain intensity and neck dysfunction). In total, 183 patients were included. After 1 year, 63% had recovered. The prognostic models showed differences between short- and long-term indicators. At the short term, besides the baseline values of the respective outcome measurements, only older age (> or =40) and concomitant low back pain and headache were associated with poor outcome. At the long term, in addition to age and concomitant low back pain, previous trauma, a long duration of neck pain, stable neck pain during the 2 weeks prior to baseline measurement, and previous neck pain predicted poor prognosis. The predictive power of the models was weak: the explained variance (R(2)) varied from 24 to 36%. Patient history and physical examination give GPs little handholds to predict the prognosis for patients with sub-acute and chronic neck pain. A few indicators of a less favourable prognosis of neck pain were identified, of which older age and concomitant low back pain was the most consistent.

Patients with disabilities and complex communication needs. The GP consultation

BACKGROUND

People with complex communication needs vary in terms of their underlying disability and the methods and strategies they use to communicate.

OBJECTIVE

This article describes the varied communication profiles that a general practitioner is likely to encounter in patients with disabilities, and the various types of augmentative and alternative forms of communication that might be used in such consultations.

DISCUSSION

This article provides strategies to facilitate doctor-patient communication involving patients with complex communication needs, some of which are illustrated in a case study of a young woman with an intellectual disability.