Are dyspepsia management guidelines coherent with primary care practice?

BACKGROUND: Spontaneous physician behaviour can affect guideline applicability, implementation strategies and application costs, particularly in relation to widespread pathologies chiefly managed by general practitioners (GPs). Of the array of dyspepsia management guidelines, the closest to general practice, partly owing to proposing committee composition, are the European Society for Primary Care Gastroenterology (ESPCG) guidelines. METHODS: To evaluate variability in dyspepsia management among GPs in Padua and divergence in spontaneous prescriptive behaviour from the ESPCG dyspepsia guideline, we prospectively studied the behaviour of 39 GPs over a 3-month period of outpatient activity, through questionnaires on each consultation. Test-group representativeness was preliminarily defined in terms of antisecretory drug expenditure. RESULTS: 1790 forms on dyspepsia-related consultations were studied in a population of 51,193 registered patients; 1264 patients with a history of dyspeptic pathology consulted their GP (19% duodenal ulcer (DU), 9% gastric ulcer (GU), 54% gastro-oesophageal reflux disease (GERD), 32% non-ulcer dyspepsia (NUD), 1% cholelithiasis), while 526 patients presented with symptoms of dyspepsia with no previous gastroscopy (EGDS) (42% were aged <45 years), of whom 42% had twice consulted their GP. Empirical management by prescription of symptomatic drugs was the most common procedure in DU (33%), GU (73%) and NUD (74%) relapses. Helicobacter pylori eradication therapy was prescribed in only 2% of patients with a history of organic or functional dyspepsia. 145 patients with uninvestigated dyspepsia were referred for second-level endoscopy and 43 for H. pylori testing. Forty-four percent of endoscopies prescribed for uninvestigated patients did not comply with the ESPCG guideline; full compliance would have determined a 105% rise in endoscopies. Prescriptive variability between GPs was high (based on the Goodman-Kruskal (0.41, P < 0.001) and Cramer tests (V = 0.51, P < 0.005)) and agreement between observed and expected prescriptions according to ESPCG criteria was as low as V = 0.11. On the basis of the most frequently observed behaviours, we developed three options of the ESPCG guideline and compared them to spontaneous prescriptions. CONCLUSIONS: Highest compliance emerged where the clinical approach for all patients with uninvestigated dyspepsia was symptomatic therapy at first presentation followed by a different attitude at second presentation, setting a higher cut-off age than in the guideline (which in our case proved, on mathematical calculation, to be 55 years).

[Interferon-alpha. Results of a pharmaco-epidemiologic study]. / Interferone alfa. Risultati di uno studio farmaco-epidemiologico.

In the present study we evaluated the use of alpha-IFN in the ULSS 21 of Veneto Region. All outpatients treated with interferon during the period June-July 1992 (114 subjects) were interviewed using a standard questionnaire which was meant to collect information about therapy, side effects and quality of life. Alpha-IFN was mostly prescribed for chronic non-A non-B hepatitis (as approved by the FDA in the USA and by the Ministero della Sanità in Italy), while 35% of the patients were suffering from diseases for which interferon use is approved by Ministero della Sanità but not by FDA. In most cases, independently of the specific disease, a standard dose of 9 MU/week was used, which often resulted to be below the recommended doses reported in the literature. Adverse effects were frequently reported. The most common include fever, chills, headache, fatigue, myalgia. Mild mental disturbances (irritability and/or depression) and thyroid dysfunction were also reported but were less frequent. Finally, a negative influence of alpha-IFN therapy on the quality of life was reported by about half of the interviewed patients.

Prostaglandin E1 diluted solution: preparation technique and stability evaluation.

The authors describe their prostaglandin E1 dilution method for the treatment of male erectile dysfunction. Preparation stability was investigated. Results suggest that PGE1 diluted solution can last as long as 90 days, while decreased concentrations of PGE1 are detected after three months.

Modulation of cholinergic profile of acetylcholine through its cyclovinylogues.

The o-, m- and p-acetoxymethyl-N,N,N-trimethylbenzenemethanaminium iodide (2a-c) as cyclovinilogues of acetylcholine are described. This structural modification allows to modulate the cholinergic activity of the natural neurotransmitter along the sequence: agonist----partial agonist----antagonist, which is referred to meta (2b), para (2c) and ortho (2a) regioisomers, respectively.

Low- and medium-dose diltiazem in chronic atrial fibrillation: comparison with digoxin and correlation with drug plasma levels.

The safety and efficacy of diltiazem were compared with digoxin maintenance therapy for control of ventricular response in 19 patients with chronic atrial fibrillation. The relationship between drug plasma levels and cardiovascular effects was also investigated. After 7 days of combined therapy with diltiazem (60 mg three times a day in 10 patients and four times a day in nine patients) and digoxin (0.125 mg/day in two patients and 0.250 mg/day in 17 patients), the 24-hour mean heart rate derived from ambulatory ECG recording was reduced by 16.3% in comparison with digoxin therapy alone; the serum digoxin level was not significantly changed (1.06 +/- 0.43 vs 1.05 +/- 0.61 ng/ml). After a standardized bicycle exercise test (50 watts for 3 minutes), maximal heart rate was reduced by 19.9%, diastolic blood pressure was decreased by 8.9%, and systolic pressure-rate product was decreased by 12.5%. Diltiazem plasma levels (mean 120.9 +/- 63.3 ng/ml) were linearly correlated with percentage variations in maximal heart rate, diastolic blood pressure, systolic blood pressure, and pressure-rate product during exercise. Eighteen patients in succession discontinued digoxin therapy; after 14 days of diltiazem alone, the 24-hour mean heart rate returned to control values of digoxin therapy, whereas maximal heart rate and pressure-rate product during exercise were significantly reduced (-17.2% and -14.1%, respectively), with no changes in blood pressure. Diltiazem plasma levels (135.0 +/- 83.2 ng/ml) showed a linear correlation with the percentage of reduction in maximal heart rate.(ABSTRACT TRUNCATED AT 250 WORDS)