The One-Stop Aortic Surveillance Clinic.

BACKGROUND: The principle of interval ultrasound surveillance of small abdominal aortic aneurysms (AAA) is well established. The fundamental principle of surveillance is that repair of AAA is a serious undertaking and the risk of the operation outweighs the risk of rupture in aneurysms less than 5.5 cm. Surveillance is well established but requires multiple visits to both the surgical clinic and the ultrasound department. REPORT: This report presents a system whereby the vascular surgeon is trained in the process of aortic sonography with a view to one-stop clinic assessment. After training of the main investigators in aortic sonography, the surgeons performed scans on the aortas of 80 consecutive patients and compared the scan result with the subsequent formal scan. DISCUSSION: Surgical and radiographer scans correlate very closely. It is believed that the one-stop aortic surveillance model is safe, accurate, and improves both the patient journey and clinic throughput.

Characteristics of family practitioners with large geriatric practices.

Little has been reported on the characteristics of physicians presently serving the health needs of the elderly. In this report, generated from a survey of Florida family practitioners, physicians and with large geriatric practices are compared to physicians with practices composed primarily of younger patients. Family physicians with large geriatric practices are older, and treat more chronic disease than do their peers. However, they consult the same professional journals and texts in caring for their patients, refer patients to specialists at the same rate, and have the same office facilities as do their colleagues who treat chiefly younger patients. The family physician with a large geriatric case load is less likely to have a predominantly outpatient practice and more likely to be involved with hospitalized patients. Data from the census and health manpower studies suggest that family physicians will care for substantial number of elderly patients in the future. Continuing education which addresses issues in geriatrics may help to attain optimal health care for the elderly.

A double-blind comparative study of Otoseptil Ear Drops and Otosporin Ear Drops in otitis externa.

A double-blind comparative study of Otoseptil Ear Drops and Otosporin Ear Drops in otitis externa in fifty-eight patients revealed them both to be equally effective in a series with very few fungal infections. In view of the normally high proportion of infections including fungi, there are obvious advantages in using Otoseptil Ear Drops.

Correlates of asthma morbidity in primary care.

OBJECTIVES: To explore the morbidity of patients diagnosed as asthmatic in general practice, to examine the determinants of this morbidity, and to derive a simple morbidity screening tool for use in primary care. DESIGN: Patient interviews, lung function measurements, and data extraction from general practice case notes. SUBJECTS: 300 asthmatic patients aged 5 to 65 years randomly selected from the repeat prescribing registers of three general practices in the Southampton area. MAIN OUTCOME MEASURES: Reported morbidity using a calculated index based on three questions (Are you in a wheezy or asthmatic condition at least once per week; Have you had time off work or school in the past year because of your asthma; Do you suffer from attacks of wheezing during the night?); mean forced expiratory volume in one second and mean peak expiratory flow (over a seven day period); diurnal variation in peak flow; and the relation of the morbidity index to lung function. RESULTS: Mean forced expiratory volume in one second was 67% predicted (SD 18.4), mean peak expiratory flow was 80% predicted (SD 18.9), and mean diurnal variation was 10% (SD 7.7). 76 subjects were classified as having low morbidity, 95 medium, and 125 high. The morbidity index was significantly associated with forced expiratory volume in one second, mean peak expiratory flow rate, and diurnal variation (p less than 0.05); it was not significantly associated with inhaler technique or use of prophylaxis. CONCLUSIONS: There was a large burden of persisting morbidity across all ages of patients diagnosed as asthmatic in the three well resourced practices studied. The use of the morbidity index may help to target the asthmatic patients needing more attention by concentrating on those reporting medium to high morbidity.

The content of physician/patient communication in family practice.

Observation of a series of office visits by patients to family physicians provide information on physician-patient communication. During interaction on medical matters, the physicians instigated 80 percent of the interview. By way of contrast, when discussion of matters beyond the strictly medical situation occurred, 70 percent of the conversation was initiated by the patients. Irrespective of diagnoses, there were significant differences in the overall content of communications for patients from different socioeconomic groups, with more verbal exchange occurring with upper social class patients than with lower social class patients. Other patient factors which led to an increase in verbal interaction were chronic illness, emotional disorders, and ill-defined conditions. The analysis of categories of verbal interaction between physicians and patients proved to be a practical method of studying the physician-patient relationship, and provided guidelines for those seeking to make objective measurements of communication in family practice.

Acute otitis media in children: diagnostic and therapeutic dilemmas.

Otitis media is still a condition with a level of diagnostic confidence lower than physicians fresh from hospital training are accustomed to. Even with improved diagnostic criteria, there will still be other influences which will affect the physician's prescribing habits, especially in the treatment of early signs of otitis media. This study shows that the determinants of prescribing behavior by ambulatory care physicians are more complex than traditional teaching of students implies. The appropriate use of antibiotics is discussed, and the importance of limiting additional medication is stressed. It is the author's contention that the outcome of care is frequently being measured without attempting to examine closely the dilemmas facing ambulatory care physicians in their day-to-day decisions. Otitis media has been used as the model in this report, but the complexities of clinical judgment are equally applicable to other common infections presenting to the primary care physician.

Patient mobility and consulting behavior: a comparative study between the United Kingdom and the United States.

A study of consulting patterns of patients in the United Kingdom and the United States who had recently moved house and settled in a new environment shows that the act of moving has a notable effect on patients' health. Despite the radically different structure of the medical services in the United Kingdom and the United States, the consulting behavior of patients in contrasting settings was remarkably similar. During the first year in a new community, adults will consult twice as often as established patients with emotional illness; and during the same period of time, children will be seen twice as often with respiratory illness. The settling in period in a new environment is a time of stress, and such times of stress will be reflected by higher consulting rates and greater demand on physicians' services.

Nitrogen isotopes as indicators of NO(x) source contributions to atmospheric nitrate deposition across the midwestern and northeastern United States.

Global inputs of NO(x) are dominated by fossil fuel combustion from both stationary and vehicular sources and far exceed natural NO(x) sources. However, elucidating NO(x) sources to any given location remains a difficult challenge, despite the need for this information to develop sound regulatory and mitigation strategies. We present results from a regional-scale study of nitrogen isotopes (delta15N) in wet nitrate deposition across 33 sites in the midwestern and northeastern U.S. We demonstrate that spatial variations in delta15N are strongly correlated with NO(x) emissions from surrounding stationary sources and additionally that delta15N is more strongly correlated with surrounding stationary source NO(x) emissions than pH, SO4(2-), or NO3- concentrations. Although emission inventories indicate that vehicle emissions are the dominant NO(x) source in the eastern U.S., our results suggest that wet NO3- deposition at sites in this study is strongly associated with NO(x) emissions from stationary sources. This suggests that large areas of the landscape potentially receive atmospheric NO(y) deposition inputs in excess of what one would infer from existing monitoring data alone. Moreover, we determined that spatial patterns in delta15N values are a robust indicator of stationary NO(x) contributions to wet NO3- deposition and hence a valuable complement to existing tools for assessing relationships between NO3- deposition, regional emission inventories, and for evaluating progress toward NO(x) reduction goals.

Practice research. Training for general practice: clinical behaviour in trainers and trainees.

A study of 20 trainers and their trainees in general practice showed that trainees had a statistically significant improvement in their diagnosis of otitis media during their trainee year and also became quicker in the time taken for history taking and examination. There was a fall in trainees' prescribing of antibiotics for otitis media during the study but this was accompanied by a notable rise in prescribing of decongestant-antihistamine mixtures to a level similar to that of the trainers. Trainees seemed to accept readily their trainers' prescribing policies and were hesitant to challenge them. An important finding was that trainees had little influence on trainers' prescribing, the latter showing no appreciable changes during the study.

Deputising services: the portsmouth experience.

An analysis of the deputising service in the city of Portsmouth showed that the workload of doctors was not excessive and there was no evidence that the number of calls was higher than in areas where no deputising service exists. Sixty seven per cent of patients were seen within one hour of requesting a call and 93% within two hours. Seven per cent of patients were admitted to hospital and 88% of these were seen within one hour of requesting medical care. Drugs were prescribed at 65% of all contacts between doctor and patient which compares favourably with prescribing rates for consultations in general practice. A notable feature of the Portsmouth scheme is that all subscribers who use the deputising service have to agree to participate as a deputy, with 90% of deputies being practising general practitioners or eligible to be principals in general practice. This has probably conserved costs and hospital resources.

Prescribing psychotropic drugs for children.

The prescribing of psychotropic drugs was studied in a Scottish general practice of five doctors and 8,300 patients; one third of the patients were aged 12 years or less. In 1971, 336 prescriptions for psychotropic drugs were issued to 172 children and 2,583 to the adults. Most children were given only one prescription, but some needed up to ten in one year.The drugs consisted of sedatives (43 per cent), tranquillisers (41 per cent), and hypnotics (17 per cent). Most were given for behaviour disorders and enuresis. The analysis of drugs given by each doctor showed that one had given about one third of the total. This demonstration of comparative over-prescribing was useful in discussing self-audit.

Doctor-patient communication in general practice consultations.

Detailed study of a series of tape-recorded interviews enabled the author to carry out a critical self-audit of his consultations. The analysis of categories of verbal interaction in doctor-patient consultations proved to be a practical and reliable method of studying the doctor-patient relationship. The methods and techniques used in this research could, with advantage, be employed in the fields of undergraduate and postgraduate teaching. Since a satisfactory doctor-patient relationship is of great value, study in depth of the verbal interaction between doctor and patient in general practice consultations can provide guide lines to those who seek an improvement in doctor-patient communication.

Child care in the new towns in the UK.

New towns with large populations of children present ideal opportunities to study and implement extended primary care services for children. It appears that workload in most new towns is higher than in established communities. Often, the demanding nature of new town practice seems to have precluded innovations in primary care services for children. This report, which is general-practice orientated, can only indicate some aspects of child care in new towns which require further scrutiny. General practitioners are strongly divided in their views as to how they can act most effectively in child health, but there is no doubt that there is a chance in our new towns to nurture the idea of expanding the general practitioner's role in child care.

Methods used by general practitioners in developmental screening of preschool children.

A study of the methods used by 20 general practitioners to perform developmental screening examinations of preschool children showed that routine physical examination was adequately performed but at the expense of additional tests of child development. A total of 348 children were examined by either a doctor (144 cases) or a health visitor (90), or both (114). The degree of participation by health visitors suggests that developmental screening need not necessarily be the sole responsibility of doctors, and health visitors should have training opportunities as they have an important contribution to make in this area of child care. Some omissions in testing hearing, vision, and language were clearly due to conflicting demands on the general practitioners' time, but some tests were not performed because the doctors doubted their value. Nevertheless, too many children still enter school with hearing, visual, and speech handicaps that could have been easily identified. If preventive medicine is to become an increasing component of general practice, the methods used by doctors and health visitors must be scrutinised before attempting to evaluate the outcome of large-scale screening programmes.

A year's study of drug prescribing in general practice using computer-assisted records.

A year's drug prescribing by five family doctors working in a new town is reviewed. The records were computerised and some of the problems which this involved are mentioned.The range of different preparations which were used over the year was high but 76 per cent of prescriptions were accounted for by 117 preparations; 30 per cent of total prescribing was for antibiotics and psychotropic drugs. The lessons to be learned from ;self-audit' have been shown and areas for future study are discussed.

Going to the doctor--attendances by members of 100 families in their first year in a new town.

A study of 100 families' first year in a new town has shown that consulting rates are high, especially for psychiatric illness. Some reasons for this are discussed. If mobility has an effect on the health of individuals, with a consequent increase in the workload of general practitioners, then this must be taken into account in planning primary medical care services.

The practice characterization model: the importance of organizational life cycles and targeted interventions in general medical practice.

In response to a climate of constant change and increasing demand for services, general practice in the UK has undergone significant modification over the last 10 years. It has become a multi-disciplinary organisation encouraged by funding bodies to plan for service delivery using a more structured team based approach. In Tayside in 1996, practices were charged with producing formal Practice Development Plans (PDPs) which would focus on priority areas aligned with the Health Boards own strategic plan--those were teamwork, information management and technology, and clinical service delivery. The University of Dundee's Department of General Practice successfully applied for funding to develop ways of facilitating practices so that they could a) identify their own development priorities, and b) plan and implement action and learning to see these priorities through. Using action research methodology, the project attempted to create a climate for change, provide support and training to see the changes implemented, and ensure commitment to the changes from all members of the practice team. The Facilitator adopted a flexible style varying her role between expert, guide and support. Analysis of progress made by different practices, coupled with the Facilitator's in depth knowledge of them, suggested the importance of certain key aspects of practice organisation and culture. A practice characterisation model identified practices which were stable, currently coping, proactive and ready to face the challenge of change as best placed to engage in a full scale development programme. Other profiles suggested a range of alternative interventions as more likely to be acceptable and productive.

Practice factors that influence antibiotic prescribing in general practice in Tayside.

A cohort design was used to evaluate antibiotic prescribing in relation to patient and general practice characteristics. The study included prescribing to all subjects resident in Tayside, from January to December 1994 and found 215217 antibiotic prescriptions dispensed to 118596 people. Training status of general practitioners (GPs) was found to be the characteristic most associated with prescribing. Adjusting for other GP characteristics had little effect on these results. Training practice status was the dominant factor associated with significant differences in rates of antibiotic prescribing, in class of antibiotic prescribed and in performance indicators of antibiotic prescribing.