[Guideline for the joint swelling symptom--primary physician problem management and referral indications. German Society of Rheumatology "Quality Assurance" Committee]

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.

[The DEGAM-concept--development, dissemination, implementation and evaluation of guidelines for general practice]

The German Society for General Practice/Family Medicine (DEGAM) has launched a project to develop and implement national guidelines for general practice accordingly to international models. Guidelines are seen as statements to assist practitioners and patients in deciding about appropriate, effective and efficient health care. They should be evidence-based, feasible for primary care practices, and purposefully addressing to physicians as well as practice staff and patients. The development follows a comprehensive and well-structured programme (10 stages) which requires the appraisal of medical evidence, the involvement of experienced general practitioners on various stages (primary review, feasibility testing), and comments of concerned specialists, before a guideline is promulgated. Implementation of each guideline is promoted by at least five tools (full text, quick reference guide, telephone card for practice staff; patient leaflet, and information-prescription--"infozept"). Methodological quality is checked for the first time in Germany according to the standards of the German Agency for Quality Assurance. Different targets and criteria for evaluation of guidelines in primary care are mandatory part of the DEGAM-concept.

[Evaluation of scientific publication: a recommendation (not only) for general medicine]

A Proposal (not only) for General Practice/Family Medicine: Medical faculties and other institutions increase their pressure on scientific societies and colleges to present and set standards to evaluate publications from their discipline. After discussing the quality of different literature and publication indices the authors take a critical look at the impact factor which arouses much controversy among medical faculties. The evaluation standard presented for general practice comprises three categories of quality to which (A) Top Journals, (B) Standard Journals and (C) other Journals (but also books and book contributions) are allocated. Assessment criteria are mainly based on indexation (Index Medicus) and independent peer review. Within that system original papers are valued higher than reviews and editorials or comments. The impact factor is not considered to be helpful for judgement. The authors are convinced that any numerical point system would not be likely to lead to a reasonable assessment of an individual publication. Furthermore, there could be an increased risk that members of committees would prefer the point system for their judgement rather than to read papers in detail. The suggested standard could serve as an aid for referees from disciplines other than general practice. However, their expert decision regarding the quality of publications could not be replaced by even the most sophisticated valuation system.

Cancer incidence on a small island--research opportunities in general practice

OBJECTIVE

To test the impression of an increased cancer incidence on the island of Pellworm (in the far North of Germany) and to illustrate the feasibility of a general practice-based approach in epidemiological research.

DESIGN

Cancer incidence on Pellworm was prospectively registered in the only general practice on the island from 1986 to 1992. Age-standardized rates and expected rates were calculated on the basis of the Saarland cancer registry, the only registry in Germany. Standardized incidence ratios and 95% confidence intervals (CI) for Poisson-distributed events were also calculated. The cancer data were summed up over a seven-year period.

SETTING

The only general practice on the island of Pellworm, a North Frisian marshland-island.

SUBJECTS

The total practice population between 1986 and 1992 (N = 1172)

RESULTS

The crude annual cancer incidence rate for Pellworm was, according to the impression, unexpectedly high: 634/100 000 for men and 502/100 000 for women. After age standardization, however, this increased rate of cancer incidence was even lower than in the Saarland (ratios: 0.86 for men and 0.95 for women). Only the incidence of neoplasms of the lymphatic and haematopoietic tissue in men exceeded the limits of statistical likelihood (ratio: 3.21; 95% CI: 1.17-7.10).

CONCLUSION

The impression of an increased rate of cancer on Pellworm could not be validated. The overall incidence rate was even lower than expected. Only the rate of leukaemia/lymphoma (men) was significantly higher. Reasons for this result could not be detected by a descriptive approach. General practice is a suitable place for studies in cancer epidemiology, especially in such ideal circumstances as a clearly limited area and complete and reliable documentation.

[Screening for toxoplasmosis in pregnancy: more harm than good]

Using data from international literature makes it possible to calculate for Germany benefit and harm of a screening for toxoplasmosis in pregnancy. On the basis of these data harm of such a screening is much greater than benefit. Taking the reported number of congenital toxoplasmosis in Germany as the base for such a calculation of harm and benefit makes the ratio of benefit and harm even worse.

Prophylaxis of constipation by wheat bran: a randomized study in hospitalized patients

To evaluate the efficacy of wheat bran in preventing constipation, 200 hospitalized patients were randomly allocated to groups receiving either a dietary supplement of 40 g bran daily or no dietary supplement at all. A quarter of the bran group patients refused to take their bran from the very beginning (refusers), one third stopped bran consumption during the study (dropouts), and only 42% of the patients continued on bran until discharge or death (participants). Independent of a previous history of constipation, neither the hospital incidence of constipation nor the average percentage of days on laxatives was significantly different between the bran group and the control group. Only the dropouts were significantly more constipated than the control patients, whereas no such difference could be demonstrated in the refusers or participants. It is concluded that the administration of bran as a prophylactic laxative confers no benefit in patients hospitalized for a relatively short time.