http://www.biomedcentral.com/bmcfampract/ The most accessed research articles published by BMC Family Practice 2009-11-17T00:00:00Z This is an RSS newsfeed from BioMed Central It is intended to be used with an RSS reader. For more information about RSS newsfeeds from BioMed Central, visit http://www.biomedcentral.com/info/about/rss/ Background: Two simples scoring systems for a self-completed postal respiratory questionnaire were developed to identify adults who may have obstructive airways disease. The objective of this study was to validate these scoring systems.MethodA two-stage design was used. All adults in two practice populations were sent the questionnaire and a stratified random sample of respondents was selected to undergo full clinical evaluation. Three respiratory physicians reviewed the results of each evaluation. A majority decision was reached as to whether the subject merited a trial of obstructive airways disease medication. This clinical decision was compared with two scoring systems based on the questionnaire in order to determine their positive predictive value, sensitivity and specificity. Results: The PPV (positive predictive value) of the first scoring system was 75.1% (95% CI 68.6–82.3), whilst that of the second system was 82.3% (95% CI 75.9–89.2). The more stringent second system had the greater specificity, 97.1% (95% CI 96.0–98.2) versus 95.3% (95% CI 94.0–96.7), but poorer sensitivity 46.9% (95% CI 33.0–66.8) versus 50.3% (95% CI 35.3–71.6). Conclusion: This scoring system based on the number of symptoms/risk factors reported via a postal questionnaire could be used to identify adults who would benefit from a trial of treatment for obstructive airways disease. http://www.biomedcentral.com/1471-2296/4/5 Timothy Frank Peter Frank Jennifer Cropper Michelle Hazell Philip Hannaford Roseanne McNamee Sybil Hirsch Charles Pickering BMC Family Practice 2003, 4:5 2003-04-25T00:00:00Z doi:10.1186/1471-2296-4-5 BMC Family Practice 1471-2296 4 5 2003-04-25T00:00:00Z XML Background: Previous studies indicate that clinical guidelines using combined risk evaluation for cardiovascular diseases (CVD) may overestimate risk. The aim of this study was to model and discuss implementation of the current (2007) hypertension guidelines in a general Norwegian population. Methods: Implementation of the current European Guidelines for the Management of Arterial Hypertension was modelled on data from a cross-sectional, representative Norwegian population study (The Nord-Trøndelag Health Study 1995-97), comprising 65,028 adults, aged 20-89, of whom 51,066 (79%) were eligible for modelling. Results: Among individuals with blood pressure ≥120/80 mmHg, 93% (74% of the total, adult population) would need regular clinical attention and/or drug treatment, based on their total CVD risk profile. This translates into 296,624 follow-up visits/100,000 adults/year. In the Norwegian healthcare environment, 99 general practitioner (GP) positions would be required in the study region for this task alone. The number of GPs currently serving the adult population in the study area is 87 per 100,000 adults. Conclusion: The potential workload associated with the European hypertension guidelines could destabilise the healthcare system in Norway, one of the world's most long- and healthy-living nations, by international comparison. Large-scale, preventive medical enterprises can hardly be regarded as scientifically sound and ethically justifiable, unless issues of practical feasibility, sustainability and social determinants of health are considered. http://www.biomedcentral.com/1471-2296/10/70 Halfdan Petursson Linn Getz Johann Sigurdsson Irene Hetlevik BMC Family Practice 2009, 10:70 2009-10-30T00:00:00Z doi:10.1186/1471-2296-10-70 BMC Family Practice 1471-2296 10 70 2009-10-30T00:00:00Z XML Background: Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies. Methods: Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded. Results: Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms. Conclusion: Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions. http://www.biomedcentral.com/1471-2296/10/72 Beth Costa Kristine Fitzgerald Kay Jones Trisha Dunning BMC Family Practice 2009, 10:72 2009-11-17T00:00:00Z doi:10.1186/1471-2296-10-72 BMC Family Practice 1471-2296 10 72 2009-11-17T00:00:00Z XML Background: Efficacy research has shown that intensive individual lifestyle intervention lowers the risk for developing type 2 diabetes mellitus and the metabolic syndrome. Translational research is needed to test real-world models of lifestyle interventions in primary care settings.DesignE-LITE is a three-arm randomized controlled clinical trial aimed at testing the feasibility and potential effectiveness of two lifestyle interventions: information technology-assisted self-management, either alone or in combination with care management by a dietitian and exercise counselor, in comparison to usual care. Overweight or obese adults with pre-diabetes and/or metabolic syndrome (n = 240) recruited from a community-based primary care clinic are randomly assigned to one of three treatment conditions. Treatment will last 15 months and involves a three-month intensive treatment phase followed by a 12-month maintenance phase. Follow-up assessment occurs at three, six, and 15 months. The primary outcome is change in body mass index. The target sample size will provide 80% power for detecting a net difference of half a standard deviation in body mass index at 15 months between either of the self-management or care management interventions and usual care at a two-sided α level of 0.05, assuming up to a 20% rate of loss to 15-month follow-up.Secondary outcomes include glycemic control, additional cardiovascular risk factors, and health-related quality of life. Potential mediators (e.g., treatment adherence, caloric intake, physical activity level) and moderators (e.g., age, gender, race/ethnicity, baseline mental status) of the intervention's effect on weight change also will be examined.DiscussionThis study will provide objective evidence on the extent of reductions in body mass index and related cardiometabolic risk factors from two lifestyle intervention programs of varying intensity that could be implemented as part of routine health care.Trial registrationNCT00842426 http://www.biomedcentral.com/1471-2296/10/71 Jun Ma Abby King Sandra Wilson Lan Xiao Randall Stafford BMC Family Practice 2009, 10:71 2009-11-12T00:00:00Z doi:10.1186/1471-2296-10-71 BMC Family Practice 1471-2296 10 71 2009-11-12T00:00:00Z XML Background: Alkaline phosphatase (ALP) is an important enzyme mainly derived from the liver, bones and in lesser amounts from intestines, placenta, kidneys and leukocytes. An increase in ALP levels in the serum is frequently associated with a variety of diseases. This study was done in order to determine the diseases associated with a high ALP level among Thai adult hospitalized patients.MethodA review was made of medical records of inpatients with high ALP level above 1000 IU/L in King Chulalongkorn Memorial Hospital, Thailand from January 1999 to December 1999. Excluded were cases of (a) patients who have bone involvements with malignancies, (b) pediatric patients younger than 15 years old and c) HIV-seropositive patients. Results: A total of 181 hospitalized patients with eligible medical records were identified (96 males and 85 females, mean age 49.4 ± 16.1 years). Their ALP levels ranging from 1,001 to 3,067 IU/L, these patients were divided into four groups. Conclusion: High serum ALP levels in hospitalized patients were commonly found in three major groups having obstructive biliary diseases, infiltrative liver disease and sepsis. The study results were in accordance with previous reports in developed countries. Nonetheless, cholangiocarcionoma and some tropical diseases unique to our setting were also detected in these cases. where there was a marked elevation of serum ALP. http://www.biomedcentral.com/1471-2296/2/2 Viroj Wiwanitkit BMC Family Practice 2001, 2:2 2001-08-24T00:00:00Z doi:10.1186/1471-2296-2-2 BMC Family Practice 1471-2296 2 2 2001-08-24T00:00:00Z XML Background: Men with spinal cord injury (SCI) appear to have a greater incidence of bacterial colonisation of genital skin as compared to neurologically normal controls. We report a male patient with paraplegia who developed rapidly progressive infection of scrotal skin, which resulted in localised necrosis of scrotum (Fournier's gangrene).Case presentationThis male patient developed paraplegia at T-8 level 21 years ago at the age of fifteen years. He has been managing his bladder by wearing a penile sheath. He noticed redness and swelling on the right side of the scrotum, which rapidly progressed to become a black patch. A wound swab yielded growth of methicillin-resistant Staphylococcus aureus (MRSA). Necrotic tissue was excised. Culture of excised tissue grew MRSA. A follow-up wound swab yielded growth of MRSA and mixed anaerobes. The wound was treated with regular application of povidone-iodine spray. He made good progress, with the wound healing gradually. Conclusion: It is likely that the presence of a condom catheter, increased skin moisture in the scrotum due to urine leakage, compromised personal hygiene, a neurogenic bowel and subtle dysfunction of the immune system contributed to colonisation, and then rapidly progressive infection in this patient. We believe that spinal cord injury patients and their carers should be made aware of possible increased susceptibility of SCI patients to opportunistic infections of the skin. Increased awareness will facilitate prompt recourse to medical advice, when early signs of infection are present. http://www.biomedcentral.com/1471-2296/3/20 Subramanian Vaidyanathan Bakul Soni Peter Hughes Paul Mansour Gurpreet Singh James Darroch Tun Oo BMC Family Practice 2002, 3:20 2002-12-05T00:00:00Z doi:10.1186/1471-2296-3-20 BMC Family Practice 1471-2296 3 20 2002-12-05T00:00:00Z XML Background: Drug formularies have been created by third party payers to control prescription drug usage and manage costs. Physicians try to provide the best care for their patients. This research examines family physicians' attitudes regarding prescription reimbursement criteria, prescribing and advocacy for patients experiencing reimbursement barriers. Methods: Focus groups were used to collect qualitative data on family physicians' prescribing decisions related to drug reimbursement guidelines. Forty-eight family physicians from four Ontario cities participated. Ethics approval for this study was received from the Hamilton Health Sciences/Faculty of Health Sciences Research Ethics Board at McMaster University. Four clinical scenarios were used to situate and initiate focus group discussions about prescribing decisions. Open-ended questions were used to probe physicians' experiences and attitudes and responses were audio recorded. NVivo software was used to assist in data analysis. Results: Most physicians reported that drug reimbursement guidelines complicated their prescribing process and can require lengthy interpretation and advocacy for patients who require medication that is subject to reimbursement restrictions. Conclusion: Physicians do not generally see their role as being cost-containment monitors and observed that cumbersome reimbursement guidelines influence medication choice beyond the clinical needs of the patient, and produce unequal access to medication. They observed that frustration, discouragement, fatigue, and lack of appreciation can often contribute to family physicians' failure to advocate more for patients. Physicians argue cumbersome reimbursement regulations contribute to lower quality care and misuse of physicians' time increasing overall health care costs by adding unnecessary visits to family physicians, specialists, and emergency rooms. http://www.biomedcentral.com/1471-2296/10/69 L. Suzanne Suggs Parminder Raina Amiram Gafni Susan Grant Kevin Skilton Aimei Fan Karen Szala-Meneok BMC Family Practice 2009, 10:69 2009-10-16T00:00:00Z doi:10.1186/1471-2296-10-69 BMC Family Practice 1471-2296 10 69 2009-10-16T00:00:00Z XML Background: General practitioners sometimes base clinical decisions on gut feelings alone, even though there is little evidence of their diagnostic and prognostic value in daily practice. Research to validate the determinants and to assess the test properties of gut feelings requires precise and valid descriptions of gut feelings in general practice which can be used as a reliable measuring instrument. Research question: Can we obtain consensus on descriptions of two types of gut feelings: a sense of alarm and a sense of reassurance? Methods: Qualitative research including a Delphi consensus procedure with a heterogeneous sample of 27 Dutch and Belgian GPs or ex-GPs involved in academic educational or research programmes. Results: After four rounds, we found 70% or greater agreement on seven of the eleven proposed statements. A "sense of alarm" is defined as an uneasy feeling perceived by a GP as he/she is concerned about a possible adverse outcome, even though specific indications are lacking: There's something wrong here. This activates the diagnostic process by stimulating the GP to formulate and weigh up working hypotheses that might involve a serious outcome. A "sense of alarm" means that, if possible, the GP needs to initiate specific management to prevent serious health problems. A "sense of reassurance" is defined as a secure feeling perceived by a GP about the further management and course of a patient's problem, even though the doctor may not be certain about the diagnosis: Everything fits in. Conclusion: The sense of alarm and the sense of reassurance are well-defined concepts. These descriptions enable us to operationalise the concept of gut feelings in further research. http://www.biomedcentral.com/1471-2296/10/66 Erik Stolper Paul Van Royen Margje Van de Wiel Marloes Van Bokhoven Paul Houben Trudy Van der Weijden Geert Jan Dinant BMC Family Practice 2009, 10:66 2009-09-17T00:00:00Z doi:10.1186/1471-2296-10-66 BMC Family Practice 1471-2296 10 66 2009-09-17T00:00:00Z XML Background: Persistent presentation of medically unexplained symptoms (MUS) is troublesome for general practitioners (GPs) and causes pressure on the doctor-patient relationship. As a consequence, GPs face the problem of establishing an ongoing, preferably effective relationship with these patients. This study aims at exploring GPs' perceptions about explaining MUS to patients and about how relationships with these patients evolve over time in daily practice. Methods: A qualitative approach, interviewing a purposive sample of twenty-two Dutch GPs within five focus groups. Data were analyzed according to the principles of constant comparative analysis. Results: GPs recognise the importance of an adequate explanation of the diagnosis of MUS but often feel incapable of being able to explain it clearly to their patients. GPs therefore indicate that they try to reassure patients in non-specific ways, for example by telling patients that there is no disease, by using metaphors and by normalizing the symptoms. When patients keep returning with MUS, GPs report the importance of maintaining the doctor-patient relationship. GPs describe three different models to do this; mutual alliance characterized by ritual care (e.g. regular physical examination, regular doctor visits) with approval of the patient and the doctor, ambivalent alliance characterized by ritual care without approval of the doctor and non-alliance characterized by cutting off all reasons for encounter in which symptoms are not of somatic origin. Conclusion: GPs feel difficulties in explaining the symptoms. GPs report that, when patients keep presenting with MUS, they focus on maintaining the doctor-patient relationship by using ritual care. In this care they meticulously balance between maintaining a good doctor-patient relationship and the prevention of unintended consequences of unnecessary interventions. http://www.biomedcentral.com/1471-2296/10/68 Tim olde Hartman Lieke Hassink-Franke Peter Lucassen Karel van Spaendonck Chris van Weel BMC Family Practice 2009, 10:68 2009-09-24T00:00:00Z doi:10.1186/1471-2296-10-68 BMC Family Practice 1471-2296 10 68 2009-09-24T00:00:00Z XML Background: High utilising primary care patients with medically unexplained symptoms (MUS) often frustrate their primary care providers. Studies that elucidate the attitudes of these patients may help to increase understanding and improve confidence of clinicians who care for them. The objective of this study was to describe and analyze perceptions and lived experiences of high utilising primary care patients with MUS. Methods: A purposive sample of 19 high utilising primary care patients for whom at least 50% (69.6% in this sample) of visits for two years could not be explained medically, were encouraged to talk spontaneously about themselves and answer semi-structured questions. Verbatim transcripts of interviews were analyzed using an iterative consensus building process. Results: Patients with MUS almost universally described current and/or past family dysfunction and were subjected to excessive testing and ineffective empirical treatments. Three distinct groups emerged from the data. 1) Some patients, who had achieved a significant degree of psychological insight and had success in life, primarily sought explanations for their symptoms. 2) Patients who had less psychological insight were more disabled by their symptoms and felt strongly entitled to be excused from normal social obligations. Typically, these patients primarily sought symptom relief, legitimization, and support. 3) Patients who expressed worry about missed diagnoses demanded excessive care and complained when their demands were resisted. Conclusion: High utilising primary care patients are a heterogeneous group with similar experiences and different perceptions, behaviours and needs. Recognizing these differences may be critical to effective treatment and reduction in utilisation. http://www.biomedcentral.com/1471-2296/10/67 Francesca Dwamena Judith Lyles Richard Frankel Robert Smith BMC Family Practice 2009, 10:67 2009-09-21T00:00:00Z doi:10.1186/1471-2296-10-67 BMC Family Practice 1471-2296 10 67 2009-09-21T00:00:00Z XML