[The place of the clinic in primary case--the TOPIC study]

We know very little about the importance of history and physical examination compared to the importance of paraclinical tests in the diagnostic process in primary care. To answer this question, we examined prospectively 672 consecutive patients with chest pain in primary care. We recorded the timing and the clinical characteristics of the most frequent diagnosis. The resort to laboratory or other clinical tests and reference to specialist were influenced by: emergency consultation, potentially life-threatening aetiology, personal characteristics of the general practitioners' (GP) and patients' anxiety. GPs attributed the diagnosis to history and physical examination alone in 66% and to the association of history, physical examination and tests in 31% cases. This, clinical strategy remains the most important factor in the diagnostic process; even when they are insufficient, they allowed to generate hypotheses and guide investigations.

Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial

OBJECTIVE

To determine the subjective response to iron therapy in non-anaemic women with unexplained fatigue.

DESIGN

Double blind randomised placebo controlled trial.

SETTING

Academic primary care centre and eight general practices in western Switzerland.

PARTICIPANTS

144 women aged 18 to 55, assigned to either oral ferrous sulphate (80 mg/day of elemental iron daily; n=75) or placebo (n=69) for four weeks.

MAIN OUTCOME MEASURES

Level of fatigue, measured by a 10 point visual analogue scale.

RESULTS

136 (94%) women completed the study. Most had a low serum ferritin concentration; <or= 20 microg/l in 69 (51%) women. Mean age, haemoglobin concentration, serum ferritin concentration, level of fatigue, depression, and anxiety were similar in both groups at baseline. Both groups were also similar for compliance and dropout rates. The level of fatigue after one month decreased by -1.82/6.37 points (29%) in the iron group compared with -0.85/6.46 points (13%) in the placebo group (difference 0.95 points, 95% confidence interval 0.32 to 1.62; P=0.004). Subgroups analysis showed that only women with ferritin concentrations <or= 50 microg/l improved with oral supplementation.

CONCLUSION

Non-anaemic women with unexplained fatigue may benefit from iron supplementation. The effect may be restricted to women with low or borderline serum ferritin concentrations.

[Occupational anamnesis in primary care medicine: presentation of a screening questionnaire for health problems related to work]

A brief screening questionnaire has been administered to 791 patients consulting a primary health care physician, to discover job-related health problems. Among the 791 patients, 43 percent estimate subjectively that their job has an unfavorable influence on their health. The study participants were patients from the general consultation of the outpatient department of the medical universitary policlinic of Lausanne and from 10 private medical practices in the french part of Switzerland. Among the 791 patients, 401 were interviewed seconderly in a more detailed questionnaire. These questionnaires were evaluated by 3 reviewers of the Institute of Occupational Health Sciences. 25 percent (one of four patient) was identified for having a job-related health problem. For the primary health care physician, the question is: how to manage such job-related problems and how to orient patient to use the adequate services and institutions.

Community-acquired pneumonia. A prospective outpatient study

We initiated a prospective study with a group of practitioners to assess the etiology, clinical presentation, and outcome of community-acquired pneumonia in patients diagnosed in the outpatient setting. All patients with signs and symptoms suggestive of pneumonia and an infiltrate on chest X-ray underwent an extensive standard workup and were followed over 4 weeks. Over a 4-year period, 184 patients were eligible, of whom 170 (age range, 15-96 yr; median, 43 yr) were included and analyzed. In 78 (46%), no etiologic agent could be demonstrated. In the remaining 92 patients, 107 etiologic agents were implicated: 43 were due to "pyogenic" bacteria (39 Streptococcus pneumoniae, 3 Haemophilus spp., 1 Streptococcus spp.), 39 were due to "atypical" bacteria (24 Mycoplasma pneumoniae, 9 Chlamydia pneumoniae, 4 Coxiella burnetii, 2 Legionella spp.), and 25 were due to viruses (20 influenza viruses and 5 other respiratory viruses). There were only a few statistically significant clinical differences between the different etiologic categories (higher age and comorbidities in viral or in episodes of undetermined etiology, higher neutrophil counts in "pyogenic" episodes, more frequent bilateral and interstitial infiltrates in viral episodes). There were 2 deaths, both in patients with advanced age (83 and 86 years old), and several comorbidities. Only 14 patients (8.2%) required hospitalization. In 6 patients (3.4%), the pneumonia episode uncovered a local neoplasia. This study shows that most cases of community-acquired pneumonia have a favorable outcome and can be successfully managed in an outpatient setting. Moreover, in the absence of rapid and reliable clinical or laboratory tests to establish a definite etiologic diagnosis at presentation, the spectrum of the etiologic agents suggest that initial antibiotic therapy should cover both S. pneumoniae and atypical bacteria, as well as possible influenza viruses during the epidemic season.

[Vitamin B 12 deficiency: early diagnosis in ambulatory care medicine]

Many patients suffer from vitamin B12 deficiency and are thus exposed to irreversible sequelae if diagnosis occurs at a late stage. This prospective study undertaken by eight practitioners over a period of 12 months concerns early diagnosis. Blood vitamin B12 levels were measured in 152 patients presenting macrocytosis detected by systematic MCV analysis at the time of a blood test, a neuropathy or a recent cognitive, affective and behavioural problem, and were found to be lowered (< or = 175 pmol/l) in 54 patients of whom 43 had undergone vitamin B12 test treatment for 6 months. Haematological, neurological and psychiatric evaluation was carried out before and after treatment, and a diagnosis of deficiency was recorded in 24 patients based on unequivocal response to therapy. Improvement was greatest haematologically in 12 patients, neurologically in 6 patients and psychiatrically in 6 other patients, with 4 patients showing a combination of all modes. These 24 patients (mean age 69 years) suffered from numerous pathologies which were liable to complicate diagnosis in some of them: neurological (46%), psychiatric (37%), chronic alcoholism (33%), folic acid deficiency (29%), and diabetes (17%). The only diagnostic element used as a criterion of deficiency was an extremely low level of vitamin B12 (< or = 75 pmol/l). Marked macrocytosis or a combination of haematological and neuropsychiatric signs are strong indicators, but only improvement under treatment allowed a diagnosis to be made in the majority of patients. Macrocytosis was, however, not present in 6 of the 12 neuropsychiatric patients. The study thus identified a high proportion of patients with vitamin B12 deficiency who additionally presented, in equal proportions, both haematological and neuropsychiatric symptoms. Neither the clinical examination nor the vitamin B12 level in general permit early diagnosis based on a high probability index and long-term follow-up. Simpler methods for early diagnosis are therefore needed.

[Seasonal variations of blood pressure in normal subjects and patients with chronic disease]

The characteristics and determining factors of seasonal variations of the blood pressure (BP) were studied in 20 normal subjects and 219 chronic stable chronically all patients, most of whom were ambulatory. The BP was measured repetitively over twelve months and measurements in the lying position repeated after one minute of orthostatism were performed in Winter and in Summer. In normal subjects, the BP decreased from June to reach its lowest value in August to return to the Winter values from October. The mean BP of the three Winter months was 130/79 mmHg and the seasonal lowering averages 5 +/- 5/5 +/- 6 mmHg (m +/- SD) (p < 0.01), with marked individual differences. The Summer decrease in BP was observed both lying down (3/4 mmHg) (p = 0.01) and standing (5/6) (p = 0.0001). In the patient group, the Summer decrease in BP was 4/3 mmHg. During the orthostatic measurements, it was 4/4 mmHg lying down and 6/5 mmHg when upright. Symptoms of orthostatic hypotension were reported spontaneously 10 times during the Winter and 21 times during the Summer months (p = 0.04) and occurred in the upright position in 12 patients (6%) in Winter and 25 patients (12%) in Summer (p = 0.025). The Summer decrease was greater in women than in men. Blood pressure lowering drugs increased this effect and the association of several drugs had an additive effect. It increased with age but disappeared after 70-80 years of age. The very elderly patients on antihypertensive therapy showed a marked decrease in BP during the Summer, especially in the upright position. The Summer decrease in BP is important for the management of elderly patients with hypertension or cardiac failure. It may favorize symptoms of orthostatic hypotension and increase the risk of malaise.

[Seasonal variations in arterial pressure in hypertensive patients]

Blood pressure (BP) was measured once every month during one year in 80 hypertensive outpatients. An orthostatic test was performed in winter and another during summer. The collective was aged 65 +/- 13 years (m +/- SD) and presented an elevated prevalence of diabetes mellitus, cardiac failure, and coronary, cerebral and arterial insufficiency. Diuretics, betablockers, converting enzyme inhibitors and calcium channel blockers were used by 31 patients as monotherapy and by 49 patients in association. During summer a significantly lower seated BP was found (144.1/79.4 mm Hg vs 150.8/82.9 mm Hg in winter, p < 0.001). One fourth of the patients did not show this diminution. On the basis of the WHO criteria of BP definition, 31% of the patients could be considered hypertensive in winter vs 16% in summer and 28% as normotensive in winter vs 43% in summer (p < 0.05). The summer reduction in BP depended on position. It was less marked in seated position (-5.3/-2.7 mm Hg) than in lying (-6/-5.1 mm Hg) or even in standing position (-10.8/-5.1 mm Hg). The orthostatic test induced a greater immediate fall in systolic BP in summer than in winter (-14.4 vs -9.6 mm Hg, p < 0.001), more orthostatic hypotensive episodes defined as a systolic BP fall of 20 mm Hg or more (34% of patients vs 20% in winter, p = 0.05) and more signs of reduced cerebral perfusion (14% vs 7.5% in winter, NS). Diabetic patients and patients treated by diuretic and vasodilator drugs are particularly exposed to orthostatic hypotension in summer. Betablockers can minimize this risk.(ABSTRACT TRUNCATED AT 250 WORDS)

[Arterial blood pressure measurement--which cuff?]

In order to evaluate the influence of cuff size on blood pressure (BP) measurement, we compared values obtained with a standard cuff of 12 x 23 cm with those obtained with a large cuff of 15 x 28 cm in a group of 554 consecutive outpatients. Higher values were obtained with the standard cuff (systolic/diastolic 133.9 +/- 22/80.5 +/- 12 mm Hg) compared to the large cuff (128 +/- 21/76.5 +/- 11.6 mmHg (m +/- SD). This difference reached an average of 10/7 mm Hg for the large arm circumferences (AC) and for high blood pressure values. With the standard cuff, hypertensive values were found twice as often as with the large cuff. Thus the choice of a cuff adapted to AC is of great importance in identifying and treating hypertensive patients. In 77 subjects with a range of AC from 16 to 48 cm, the values measured with the standard and the large cuffs were then compared to those obtained with a reference triple cuff fitting to AC of 8.5 x 26-12 x 36-15 x 46 cm. The measurement of BP was most accurate when the ratio between cuff breadth and AC was between 0.42 and 0.44. The error increased by 0.6-0.7% per centimeter of AC above and below this ratio for the short inflatable bladders (twice as long as broad) of the standard and large cuffs. However, the use of long bladders (3 times as long as broad) combined with the triple cuff appreciably decreased this error.(ABSTRACT TRUNCATED AT 250 WORDS)

[Internal medicine: problems and perspectives]

The professional status of the internist is changing. For instance, subspecialists and general practitioners are conducting more and more the traditional activities of internists. The number of certifications in general internal medicine in Switzerland over recent years has decreased. The same phenomenon is observed in other countries and particularly the USA, where surveys show unquestionable disappointment among internists with the quality of their working life arising from concerns over a private life-invading profession, low income, increasing administrative burdens and loss of clinical decision-making autonomy. Has the internist still a place in our health care system, and what would be the effect of disappearance of internists on the quality and the costs of medicine? The Swiss Society of Internal Medicine seems unable to solve this disaffection problem unaided, since it also interests general practitioners and consequently all the disciplines oriented toward primary care and family medicine.

[Left-sided pectobrachialgia]

Left pectorobrachialgia, described here in 41 patients, is a frequent rheumatoid affection seen in general practice. It causes anterior chest pain with irradiation into the left arm, and patients often interpret it as being of coronary origin. The latter, however, is characterized by its different clinical presentation. Two forms can be distinguished: the typical form, which is an isolated entity, and the second, associated with and modified by fibromyalgia. It may coexist with angina pectoris and occur after myocardial infarction.

[Acid production and the need for bicarbonate in diabetic acidosis]

In a study of 54 patients with diabetic keto-acidosis with pH on admission less than or equal to 7.1, the amount of bicarbonate (HCO3-) necessary to correct the acidosis is compared to the amount predicted by the formula HCO3- (MEq) = 0,3 X body weight (kg) KG) X delta base excess (mEq/l). HCO3- requirements vary widely among patients. In addition, whenever HCO3- is given within 1-2 h the requirement may be inferior to the value calculated, whereas with slow HCO3- infusion it can be twice or three times the amount calculated. Variable HCO3- needs among subjects, and increased needs with time, are due to acid production which may exceed 100 mEq/h, especially in young patients. The amount of HCO3- required is determined not only by the severity of acidosis but also by net acid production, which may vary widely. The assessment of acid-base balance during treatment is useful in evaluating the amount of acid produced and hence the precise need for HCO3- replacement.

[The value of alkalizing treatments in severe diabetic keto-acidosis]

In 37 diabetic patients with severe acidosis (pH less than 7.0; [HCO3-] less than 5.0 mMol/l), administration of insulin was preceded by a rapid infusion of molar sodium bicarbonate in order to obtain partial correction of acidosis (pH approximately 7.20). 31 patients survived (83,8%); 6 patients died in cardio-circulatory failure associated in two cases with acute pulmonary edema. Initial administration of bicarbonate appears to be beneficial in preventing the deleterious effects of prolonged severe acidosis, such as cardiac arrhythmias, shock or acute pulmonary edema. Furthermore, partial correction of acidosis decreases the total dose of insulin necessary to compensate hyperglycemia and thereby reduces the danger of late hypoglycemia. This treatment calls for frequent checks on acid-base status and serum potassium. In most cases hypokalemia develops, but can be easily corrected by administration of potassium chloride. Normalization of arterial pH by bicarbonate infusion is not recommended in view of the development of late hypernatremia and metabolic alkalosis.

[Rennet as a source of Salmonella occurrence in various dairy products]

During a microbiological examination of foodstuffs, frequent occurrence of salmonellas of S. agona serotype was found in milk products, namely in ewe's milk cloddy cheese, ewe's milk curd and hard cheeses. The rennet produced by one enterprise was a source of salmonella spreading. To solve this problem, 1268 different samples were examined in which salmonellas were isolated in 69 cases. The Veterinary Service worked out and in cooperation with other bodies took steps to liquidate the occurrence of salmonellas in a short time; the level of that serotype in the population was not increased.