Regional nerve blockade prior to direct injection to achieve anaesthesia of the nasal ala.

BACKGROUND: Dermatological surgical procedures involving the nasal alae are commonplace in clinical practice. Direct infiltration of local anaesthetic into the nasal ala is extremely uncomfortable. OBJECTIVES: In this prospective clinical study, we investigate the effectiveness of alar anaesthesia provided by an infraorbital nerve block (IOB). METHODS: We recruited 100 consecutive patients requiring dermatological surgical procedures involving the nasal ala (or other sites necessitating an IOB). Following topical mucosal anaesthesia, an IOB was administered via the intraoral route. Effectiveness of anaesthesia was assessed after 10 min by testing the perception of a sharp stimulus at five standardized reference points on the nasal ala. If the ala was not completely anaesthetized, blockade of the external nasal branch of the anterior ethmoidal nerve (external nerve block, ENB) was performed. Sensation of the nasal ala was re-assessed after 10 min using the above method. RESULTS: Complete anaesthesia of the nasal ala was achieved with an IOB in 66 of 100 (66%) patients. Of the remaining 34 patients, the addition of an ENB achieved complete anaesthesia in 15 (44%). CONCLUSIONS: An IOB provides effective alar anaesthesia in the majority of patients. In those where it is ineffective for complete anaesthesia, an ENB is a useful adjunct. We recommend using an IOB (and ENB if required) prior to direct infiltration of local anaesthetic into the nasal ala to reduce patient discomfort.

Do Australian family physicians screen smokers for lung cancer?

STUDY OBJECTIVES: To determine family physicians' perceptions of the effectiveness of chest radiographs (CXRs) in reducing premature mortality from lung cancer and their self-reported levels of screening asymptomatic heavy smokers. DESIGN: National postal survey of 1,271 family physicians, obtaining 855 completed questionnaires (67% response rate). SETTING AND PARTICIPANTS: Random sample of Australian family physicians. MEASUREMENTS AND RESULTS: One in five (n = 169, 20%) indicated that an annual CXR was an effective screening test. Older physicians were significantly more likely to hold this view (p < 0.0001). Nearly 25% (n = 190, 22.5%) reported that they recommend an annual CXR as a screening test for asymptomatic heavy smokers. Three variables independently predicted such a practice: increasing physician age (p = 0.0085), being in solo practice (p = 0.0068), and the aforementioned belief in its effectiveness (p < 0.0001). CONCLUSIONS: A substantial minority of family physicians recommends an annual CXR as a screening test despite contradictory evidence from randomized controlled trials. These significant variations in the absence of epidemiologic evidence invite further research to develop effective, efficient, and affordable preventive care in family practice.

Skin cancer screening by Australian family physicians: variation with physician beliefs and geographic locality.

INTRODUCTION: Australian national policies do not recommend skin cancer screening. We measured family physicians' beliefs, self-reported practices, and predictors of using clinical skin examination for skin cancer screening. METHOD: Random self-administered postal survey of 1271 Australian family physicians (FPs) performed during 1996, obtaining 855 completed questionnaires (67% response rate). RESULTS: Eighty-six percent of FPs surveyed indicated that they thought clinical skin examination was effective in reducing premature death from skin cancer; 72% indicated that they should be performed annually; and 60% indicated that all adults should be screened. Only 3% indicated correctly that screening has not been tested to determine its effectiveness. Although most FPs were unlikely to adopt an opportunistic approach to screening, 64% indicated that they would recommend clinical skin examination during a health check-up. FPs in northern (high incidence) latitudes were 3 to 4 times more likely to adopt opportunistic screening, and twice as likely to discuss clinical skin examination in a dedicated check-up. FPs were more likely to advocate screening in male rather than female patients. Half of respondents were unaware of relevant guidelines. CONCLUSION: Although Australian policies do not recommend clinical skin examination because of insufficient evidence as yet of effectiveness, FPs show considerable support for screening. Geographic location, patient gender, and physician beliefs predict the self-reported provision of clinical skin examination by family physicians, suggesting that factors other than published guidelines affect clinical practice.

How many GP referrals to dermatology outpatients are really necessary?

In a survey of patients referred to the dermatology outpatients department of a British teaching hospital, 26% of referrals were considered unnecessary by a senior house officer with three months practical dermatological experience. We conclude that better undergraduate and postgraduate education in dermatology is essential. A period spent in dermatology should be included in all vocational training schemes for general practice.

How do general practitioners manage rectal bleeding?

OBJECTIVE: To determine how general practitioners (GPs) in northern Tasmania manage rectal bleeding in terms of examination, referral, and patient investigation and estimate the value of early diagnosis of colorectal cancer (CRC). METHOD: Self reported postal questionnaire survey sent to 100 randomly selected GPs in northern Tasmania. RESULTS: Sixty-eight per cent of GPs responded. The clinical action proposed by GPs varied considerably according to patient age and type of rectal bleeding. The proportion of GPs who would refer a patient to a specialist varied from 15 to 100% depending on the specific scenario. Responses were not consistent with the available consensus guidelines and evidence. Most GPs believed that early diagnosis of CRC through screening and the early detection of rectal bleeding improved outcomes. However, fewer than half the respondents believed that there were clear guidelines about the management of a patient with rectal bleeding, emphasising the need for evidence-based guidelines which are effectively disseminated and clinically evaluated. Rural GPs indicated that distance from specialist investigation and referral centres would influence patient management. CONCLUSIONS: There is a wide variation in the way GPs manage rectal bleeding and inconsistent knowledge about the existence of guidelines for managing rectal bleeding. Evidence-based education about the management of this common clinical problem, which is effectively disseminated and clinically evaluated, would seem appropriate.

Rectal bleeding in general practice patients.

OBJECTIVE: To determine the prevalence of observed rectal bleeding in general practice patients, the health seeking behaviour of those with rectal bleeding, and what rectal bleeding 'means' to patients in terms of perceived health risk. METHOD: Self administered questionnaire survey of general practice patients aged 50 years and over in northern Tasmania recruited as they visited their general practitioner (GP). RESULTS: The reported lifetime prevalence of rectal bleeding in our sample was 33% (299 of 903 respondents). It was more common in younger people, becoming less common with increasing age. Many respondents do not examine for bleeding. Only 45% of respondents with rectal bleeding consulted their GP about the most recent bleed. Patients were more likely to consult if they reported blood in the toilet pan and if they sought advice from a family member. There were significant differences between the meaning of bleeding for GP consulters and non consulters. This may have important implications for health education. CONCLUSION: Colorectal cancer (CRC) is a common problem managed by a combination of screening and case finding. With the high prevalence of rectal bleeding and low consultation rates for this problem there is potential to enhance the effectiveness of early detection of CRC through general practice based public health and education campaigns.

Toxic epidermal necrolysis: current evidence, practical management and future directions.

Toxic epidermal necrolysis (TEN) is a rare disorder characterized by extensive epidermal death. Almost all cases appear to be caused by an idiosyncratic drug reaction. Proposed pathogenic mechanisms are conflicting, and the evidence for the benefits of individual treatments is inadequate, and in some cases contradictory. The mortality rate remains high. We review the literature pertaining to the pathogenesis of TEN and drug reactions in general. The rationale for therapeutic interventions, together with reported evidence of efficacy, are considered. We present a composite model of TEN, based on previous work and suggested pathogeneses of TEN, mechanisms of drug reactions and reported cytotoxic lymphocyte (CTL) cytolytic pathways. In this system, TEN, like some other cutaneous drug eruptions, is an HLA class I-restricted, specific drug sensitivity, resulting in clonal expansion of CD8+ CTLs. Cytotoxicity is mediated by CTL granzyme and possibly death receptor (DR) ligand (DR-L), probably Fas ligand (FasL). Particular to TEN, there is then an amplification sequence involving further DR-L expression. FasL is likely to be particularly important but tumour necrosis factor (TNF) may well contribute, via the TNF receptor 1 (TNF-R1) death pathway. Alternatively, we suggest the possibility of upregulation of an antiapoptotic TNF-R1-nuclear factor kappaB pathway, which would proscribe treatments which downregulate this pathway. None of the published data on individual treatment efficacies is sufficiently strong to suggest a definitive single treatment. Currently a multifaceted regimen appears indicated, targeting various likely intermediary mechanisms, including elimination of residual drug, immunosuppression, inhibition of DR pathways, general antiapoptotic strategies, and aggressive supportive care. Particular attention has been directed at avoiding potential conflicts between different treatments and avoiding agents that theoretically might have a net proapoptotic rather than antiapoptotic effect. Nursing on a specialized unit is of paramount importance.

General practitioners' attitudes to screening for prostate and testicular cancers.

OBJECTIVE: To assess general practitioners' (GPs') perceptions of the effectiveness of screening for prostate and testicular cancers, and their self-reported levels of screening for these conditions in the light of the conflicting advice available to GPs, and a lack of evidence to support testing for either of these cancers. DESIGN: A questionnaire sent to all 101 GPs in the Division of General Practice, southern Tasmania. RESULTS: There was an 82% response rate to the questionnaire. GPs had an accurate knowledge of the epidemiology of these cancers. Of 57 GPs who thought that digital rectal examination was an effective screening test for prostate cancer, 56 said they should screen asymptomatic patients but only 37 said they actually did screen. The corresponding results for prostate-specific antigen screening were 45, 26 and 13, respectively. For testicular cancer screening, 59 GPs thought that clinical examination of the testes was an effective screening test, 55 said they should screen asymptomatic patients but only 21 said they actually did screen. Corresponding results for testicular self-examination were 56, 57 and 21, respectively. CONCLUSIONS: Many GPs are uncertain about the tests available for screening for prostate and testicular cancers. Some think they should screen, but few do so consistently. Clear and precise evidence-based guidelines for screening for these conditions are necessary.

An evaluation of a surveillance system for patients discharged from the acute psychiatry unit in southern Tasmania.

OBJECTIVES: The aim is to evaluate the current community follow-up, or health surveillance, system for patients discharged from the acute psychiatry unit into the community in southern Tasmania. METHOD: We developed a conceptual model which considered community mental health follow-up as analogous to an epidemiological surveillance system. The surveillance system was evaluated by prospectively following recorded contacts between the system and a cohort of 100 patients consecutively discharged from the acute psychiatry unit. Main outcome measures were attendance at follow-up appointments, patient re-engagement and hospital readmission. RESULTS: There is no formal system of follow-up and no policy relating to non-attenders of follow-up appointments after psychiatric hospitalisation. There is no defined role for private medical practitioners and agencies in the community. Of the 97 patients considered to need community follow-up, 11 patients were lost to follow-up after 3 months, while another 15 remained in the system because of hospital readmission. A further seven patients returned to the system during the following 2 years (six in year 1 and one in year 2) due to readmission. There is appropriate policy about the content and timing of discharge summaries; most summaries were sent promptly. CONCLUSIONS: After discharge from the acute psychiatric unit, there was inadequate community follow-up of those patients for whom follow-up was considered necessary. Research is needed to determine whether increased patient follow-up is beneficial. Stakeholders should decide whether formal follow-up or health surveillance is necessary.

Australian general practitioners' views and use of colorectal cancer screening tests.

OBJECTIVES: To determine general practitioners' (GPs) current beliefs, knowledge and self-reported practices of screening for colorectal cancer. DESIGN AND SETTING: Postal survey of national random sample of 1271 GPs in 1996. OUTCOME MEASURES: GP views on effectiveness of faecal occult blood testing (FOBT) and flexible sigmoidoscopy in reducing premature death from colorectal cancer in "average-risk" patients (asymptomatic with no family history); views on frequency of tests and target group; use of these tests; and independent predictors of views and use. RESULTS: Response rate was 67%. FOBT and flexible sigmoidoscopy were said to be effective as screening tests by 38% and 61% of GPs, respectively, but 30% and 25% were unsure. Independent predictors of belief in screening effectiveness were State of practice (for FOBT), male sex and awareness of Gut Foundation guidelines (for flexible sigmoidoscopy) and increasing age (for both). Most often chosen screening frequencies were every year for FOBT (29%), and five-yearly for flexible sigmoidoscopy (24%), although 19% and 26%, respectively, were unsure of the appropriate screening interval. Most often cited target group was people aged over 40 years with first-degree relatives with colorectal cancer: 63% of GPs would offer FOBT and 74%, flexible sigmoidoscopy. Fewer than 3% of GPs were likely to adopt an opportunistic approach to screening, yet 15% would be highly likely to recommend FOBT during a dedicated health check-up for a 58-year-old male patient, and 9% for a female patient. CONCLUSION: The absence to date of a coherent national policy on colorectal cancer screening is associated with wide variations in views and practice that are inconsistent with the available evidence. If GPs are to be involved in implementing population screening, national policy must be widely and effectively promulgated.

Ethnic differences in the pattern of skin disease seen in a dermatology department--atopic dermatitis is more common among Asian referrals in Leicestershire.

The Leicester Royal Infirmary serves a large immigrant community from the Indian subcontinent. We surveyed referrals to the Dermatology Department over the months of November 1986 and September 1987. In both surveys atopic dermatitis (AD) was significantly more common among the Asian patients.

Community study of uncomplicated lower urinary tract symptoms among male Italien immigrants in Sydney, Australia.

OBJECTIVE: To determine the prevalence, levels of bother and self-reported management of lower urinary tract symptoms (LUTS) in Italian-born men aged 40-80 years. METHOD: 305 randomly selected men aged 40-80 years (72% response rate) participated in a community-based study (computer-assisted telephone survey) in early 1997 in Sydney, Australia. RESULTS: LUTS are common: 41% of men needed to wake up at least once at night to urinate; 35% indicated they had terminal dribbling 'sometimes' or 'frequently'; 31% experienced urgency although few (3%) had urge incontinence; 19% could retain urine in their bladder during the day for no more than 2 h, and 19% experienced hesitancy. Urinary symptoms correlated moderately/poorly with self-rated bother. The prevalence of bothersome frequency and urgency was significantly age-related. Only half (n = 49, 52%) of the men bothered by urinary symptoms had seen a general practitioner (GP) about these symptoms in the last 5 years: of these three quarters had been referred to a urologist and half of these had received surgical treatment. Anxiety about prostate cancer, but not the degree of bother from urinary symptoms, independently predicted attendance at a GP (adjusted odds ratio 6.4, p = 0.006). CONCLUSIONS: Although LUTS are common in Italian-born men, their experiences of bother do not correlate well with symptoms and do not appear to influence referral and treatment. Education is needed to improve men's understanding of the importance of 'bother' as an indicator for urological surgery.

A community study of lower urinary tract symptoms in older men in Sydney, Australia.

BACKGROUND: The aim of the present paper was to determine the prevalence, bother attributable to and self-reported management of uncomplicated lower urinary tract symptoms (LUTS) in men aged 40-80 years in Sydney, Australia. METHODS: A total of 340 randomly selected men aged 40-80 years (65% response rate) participated in a community-based study (computer-assisted telephone survey). RESULTS: Lower urinary tract symptoms are common: 54% of men needed to wake up at least once at night to urinate; 47% indicated they had terminal dribbling 'sometimes' or 'frequently'; 30% experienced urgency although few (4%) had urge incontinence; 21% experienced hesitancy; and 19% could retain urine in their bladder during the day for no more than 2 hours. Urinary symptoms correlated poorly with self-rated bother and there was no increase in age-specific prevalence of bothersome symptoms with increasing age. Only 37 (26%) men inconvenienced by urinary symptoms had seen a general practitioner (GP) about these symptoms in the last 5 years: of these, two-thirds had been referred to a urologist and half of these received surgical treatment. Independent predictors of attending a GP were increasing age (adjusted odds ratio (AOR) = 12.3; P = 0.0015); place of birth outside Australia (AOR = 3.8; P = 0.0036) and anxiety about prostate cancer (AOR = 2.6; P = 0.0318), but not the degree of worry due to urinary symptoms. CONCLUSION: Lower urinary tract symptoms are common in men, but their experiences of bother correlate weakly with symptoms and do not appear to influence referral and treatment. Public and professional campaigns might increase wider understanding of the benefits of surgery for bothersome symptoms, not symptoms per se.