Respiratory medicine curriculum in Portuguese family medicine training: A Delphi study.

BACKGROUND: Respiratory diseases (RD) constitute a significant part of the workload of family physicians. There is no consensus on what family doctors should know in this area but established methods for achieving consensus may help to overcome this. OBJECTIVES: The purpose of the study was to obtain a national consensus on the required knowledge and skills in respiratory medicine for family medicine trainees after vocational training. METHODS: A Delphi study was conducted via e-mail with a diverse panel of experts. We developed a Learning Curriculum Framework (LCF) with 399 items adapted from the Royal Australasian College of Physicians - Respiratory Medicine Advanced Training Curriculum. The LCF was submitted to the experts in two rounds for consensus. Consensus was considered for items that had an agreement of 80% in the classifications above 4 on a scale of importance that ranged from 1 (not important) to 5 (very important). RESULTS: Consensus was obtained for 159 items (38.8%). These included structure and function of the respiratory tract (0.6%), presenting problems (21.4%), diagnosis (7.5%), interventions and prevention (11.3%), COPD-emphysema (12.6%), tumours (3.1%), infections (10.7%), tuberculosis (5.7%), HIV (1.3%), thromboembolic disease (2.5%), pleural-pulmonary disease (3.1%), pregnancy (0.6%) and sleep disorders (3.8%). Items on iatrogenic diseases and respiratory research did not reach consensus. CONCLUSIONS: Consensus on the respiratory medicine curriculum may contribute to further development of the vocational training curriculum in Portugal. This approach may help teachers in other countries in Europe to develop curricula for respiratory medicine and other areas of general practice.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit , and Embase, to July 2007. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. AUTHORS' CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

Steroids for acute sinusitis.

BACKGROUND: Acute sinusitis is a common reason for primary care visits. It causes significant symptoms and often results in time off work and school. OBJECTIVES: We examined whether intranasal corticosteroids (INCS) are effective in relieving symptoms of acute sinusitis. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2006), MEDLINE (January 1966 to December 2006), EMBASE (1990 to June 2006) and bibliographies of included studies. SELECTION CRITERIA: Randomized controlled trials (RCTs) were considered eligible if they compared INCS treatment to placebo treatment of a control group for acute sinusitis; acute sinusitis was defined by clinical diagnosis and confirmed by radiological evidence or by nasal endoscopy. The primary outcome was the proportion of participants with either resolution or improvement of symptoms. Secondary outcomes were any adverse events that required discontinuation of treatment, drop-outs before the end of the study, rates of relapse, complications and return to school or work. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data, assessed trial quality and resolved discrepancies by consensus. MAIN RESULTS: Four studies with 1943 participants met the inclusion criteria. The trials were well designed, double-blind, placebo controlled in which the included participants had acute sinusitis. The treatment assigned was INCS versus control treatment for 15 or 21 days. The rates of loss to follow up in the studies were 7%, 11%, 41% and 10%. When the results from the three trials included in the meta-analysis were combined, participants receiving INCS were more likely to have resolution or improvement of symptoms than those receiving placebo (73% versus 66.4%; RR 1.11; 95% CI 1.04 to 1.18). Higher doses of INCS had a stronger effect on improvement or complete relief of symptoms: for mometasone furoate (MFNS) 400 mcg versus 200 mcg, (RR 1.10; 95% CI 1.02 to 1.18 versus RR 1.04; 95% CI 0.98 to 1.11). No significant adverse events were reported and there was no significant difference in the drop-out and recurrence rate for the two treatment groups and for groups receiving higher doses of INCS. AUTHORS' CONCLUSIONS: For acute sinusitis confirmed by radiology or nasal endoscopy, current evidence is limited, but supports the use of INCS as a monotherapy or as an adjuvant therapy to antibiotics. Clinicians should weigh the modest but clinically important benefits against possible minor adverse events when prescribing therapy.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit, and Embase, to April 2002. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. AUTHORS' CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

Baseline tests or screening: what tests do family physicians order routinely on their healthy patients?

OBJECTIVE: The purpose of this study was to survey the attitudes of family doctors to the performance of baseline tests and to determine which doctors perform these tests. SETTING: Family physicians in a continuing medical education programme in Tel Aviv, Israel. METHOD: An anonymous questionnaire was distributed focusing on performance of tests by doctors in healthy patients and not as part of a screening programme. RESULTS: Questionnaires were returned by 147 of 165 physicians surveyed (89% response rate). Baseline tests were performed by 98% of respondents: not routinely by 54%, 7% at the patient's request, and 2% did not perform tests. The decision to perform baseline tests was influenced by the presence of other risk factors of disease (86%), patient age (61%), family history (59%), patient request for tests (24%), and patient sex (20%). The tests performed were blood counts, glucose, renal function tests, urinalysis, liver function tests, and electrocardiograms. Baseline tests were useful in case finding of new illnesses for 49% of physicians and 40% said the tests had proved useful during a subsequent illness. The remainder of the physicians found no use for baseline tests. Physicians from the former Soviet Union were more likely to favour baseline tests. CONCLUSION: Almost all of the physicians in this study reported that they perform baseline tests on most of their patients. Evidence based guidelines for these tests and education of physicians are needed.

Dietary calcium supplementation for preventing colorectal cancer and adenomatous polyps.

BACKGROUND: Several dietary factors have been considered to be involved in the increasing incidence of colorectal cancer in industrialised countries. Experimental and epidemiological evidence has been suggestive but not conclusive for a protective role for high dietary calcium intake. Intervention studies with colorectal cancer as an endpoint are difficult to perform owing to the large number of patients and the long follow-up required; studies using the appearance of colorectal adenomatous polyps as a surrogate endpoint are therefore considered in reviewing the existing evidence. OBJECTIVES: This systematic review aims to assess the effect of supplementary dietary calcium on the incidence of colorectal cancer and the incidence or recurrence of adenomatous polyps. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, the Cochrane Colorectal Cancer Group specialised register, MEDLINE, Cancerlit, and Embase, to April 2002. The reference lists of identified studies were inspected for further studies, and the review literature was scrutinized. SELECTION CRITERIA: Randomised controlled trials of the effects of dietary calcium on the development of colonic cancer and adenomatous polyps in humans are reviewed. Studies of healthy adults and studies of adults at higher risk of colon cancer due to family history, previous adenomatous polyps, or inflammatory bowel disease were considered; data from subjects with familial polyposis coli are excluded. The primary outcomes were the occurrence of colon cancer, and occurrence or recurrence of any new adenomas of the colon. Secondary outcomes were any adverse event that required discontinuation of calcium supplementation, and drop-outs before the end of the study. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data, assessed trial quality and resolved discrepancies by consensus. The outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI). The data were combined with the fixed effects model. MAIN RESULTS: Two studies with 1346 subjects met the inclusion criteria. Both trials were well designed, double - blind, placebo controlled trials, included participants with previous adenomas. The doses of supplementary elemental calcium used were 1200 mg daily for a mean duration of 4 years, and 2000 mg/day for three years. The rates of loss to follow -up were 14 % and 11%. For the development of recurrent colorectal adenoma, a reduction was found (OR 0.74, CI 0.58,0.95) when the results from both trials were combined. REVIEWER'S CONCLUSIONS: Although the evidence from two RCTs suggests that calcium supplementation might contribute to a moderate degree to the prevention of colorectal adenomatous polyps, this does not constitute sufficient evidence to recommend the general use of calcium supplements to prevent colorectal cancer.

A comparison of videotape and audiotape assessment of patient-centredness in family physicians' consultations.

The aim of this study was to compare videotape and audiotape assessments of doctors' patient-centred behaviour in primary care consultations. The patient-centredness scale of Henbest and Stewart was used to measure the quality of 856 doctor-patient interactions in 258 consultations performed by 47 primary care physicians recorded on videotape. Assessments were performed once using only the sound track and a second time using both the sound and video-tracks. On a nominal quality scale of 0-3, the average score for all consultations was 1.94 (S.D. 0.63) by audio assessment, and 1.94 (S.D. 0.59) by video assessment (P<0.8). There was excellent agreement between audio and video scores over a wide range of scores. Little information (<5%) was lost when using audiotape compared to videotape. It was technically easier to assess the video recordings. Audio recording is equivalent to video recording for the assessment of patient-centredness using the scale of Henbest and Stewart in primary care consultations.

Ethiopian parents' perception of their children's health: a focus group study of immigrants to Israel.

BACKGROUND: The recent influx of Ethiopian immigrants to Israel has created challenges for healthcare workers. Qualitative research methods have proven to be of value in providing useful data in cross-cultural medical settings. OBJECTIVE: To learn about Ethiopian immigrants' perception of the health of their children. METHODS: Ethiopian parents of children under age 3 registered with a family medicine clinic in Jerusalem were invited to participate in two focus groups. Transcripts of the group discussions were analyzed to reveal themes relating to children's health. RESULTS: Analysis of the transcripts revealed five themes relating to the health of children in two domains: the intra-familial and the extra-familial. Specific themes that emerged in the intra-familial domain were the role of traditional medicine, gender-specific roles in child care, and decision-making in seeking extra-familial medical help. Themes in the extra-familial domain were recognition of illness and the meaning of symptoms, and notions of prevention and resistance to illness. The collected data found application in the daily clinical work of the researchers and enriched understanding of their patients. CONCLUSIONS: Ethiopian immigrants to Israel share special perceptions of their children's health that differ from prevailing beliefs in Israel. Focus groups provide health workers with a wealth of data on these beliefs that will enable them to offer more culturally sensitive care.

[Continuity of care and hospital admission rates in a rural family practice].

Hospitalization data may be used as an indicator of the quality of care in family practice. There were marked differences between hospitalization rates in a rural family practice and the corresponding national rural rates, which raised questions about the reasons for these differences. All 309 hospital admissions recorded between 1987 and 1990 in a rural family practice were then studied to determine the hospital admission pattern. The crude hospitalization rate of this practice over the period studied was 74/1000 person-years at risk. After indirect standardization with the national Jewish rural hospitalization rate, the actual number of hospitalizations for the family practice (309) was 24% less than would have been expected (407) had the national rural rate applied to the family practice population during the study period. The decreases between actual and expected admissions were greater in the infant, adolescent and elderly age-groups. Continuity-of-care by a single provider in the study practice is presented as an important factor in determining the smaller number of practice hospitalizations recorded.

Hormone replacement therapy and WONCA/COOP functional status: a cross-sectional population-based study of women in Israel.

BACKGROUND: Current indications for hormone replacement therapy (HRT) for menopausal women include symptom relief, but recent studies have raised concerns about the safety of HRT. Little data are available on the effect of HRT on functional status of women taking hormonal preparations after menopause. OBJECTIVE: To assess the association between hormonal replacement therapy and functional status in menopausal women. METHODS: A cross-sectional survey, population-based study of 682 menopausal women between the ages of 50 and 70 years registered with six family physicians in central Israel. The main outcome measure was the functional status measured by the WONCA/COOP charts. RESULTS: A total of 587 women (86%) completed questionnaires. Univariate analysis showed an association between current use of HRT and improved functional status. However this association was diminished in a regression analysis which controlled for sociodemographic status and health variables. The contribution of HRT to functional status was small but was found to be significant in the domains of general health status (1.9%, p<0.002), sleep (0.9%, p<0.044), physical activities (2.1%, p<0.001) and feelings (1.0%, p<0.033). The contribution of HRT to daily activities, social activities, change in health status and pain was not significant. CONCLUSIONS: HRT use had a small contribution to improved functional status in half of the domains measured by the WONCA/COOP charts.

Chart Audit of Mammography in a Family Practice: How to improve screening rates with a chart audit and outreach.

A chart audit was done of women in a family practice aged 50 to 69. Those who had not had a mammogram done opportunistically were then contacted by mail and by telephone. An original screening rate of 49.2% over 2 years rose to 69.7% after outreach. A Pap smear within 2 years and a history of breast lumps were associated with performance of mammography.

The association between funding by commercial interests and study outcome in randomized controlled drug trials.

BACKGROUND: Previous studies limited to specific drugs or journal types have shown an association between the source of funding of research and the published results. OBJECTIVE: The aim of the present study was to determine the association between source of support of research and published outcomes of randomized controlled drug trials in general interest medical journals. METHODS: Randomized controlled drug trials (n = 314) published in five general interest medical journals over a 2-year period were reviewed. Study outcome was classified as positive or negative. Support was classified as pharmaceutical industry or non-industry. Association between source of support and outcome was tested with the chi-squared statistic. RESULTS: Positive findings were found in 77% of studies, negative findings in 20% and an uncertain outcome in 3%. Support from commercial sources was found in 68% of trials. Negative findings were found in 13% of industry-supported studies and in 35% of non-industry-supported studies (chi-squared = 18.36, P < 0.0001, odds ratio = 3.54, 95% confidence interval 1.90-6.62). CONCLUSIONS: An association was found between the source of study support and the published outcome. Though the reason for this association cannot be determined from the data collected, future studies may clarify the importance of this finding for readers concerned with the relationship of funding bodies to the publication of research outcomes.

Database of patients' experiences (DIPEx): a multi-media approach to sharing experiences and information.

The Database of Individual Patients' Experience of illness (DIPEx) is a multimedia website and CD-ROM that links patients' experiences with evidence-based information about treatments and the illness itself and with a range of other resources that may be useful, including support groups and links to other websites. DIPEx aims to identify the questions that matter to people when they are ill and it has potential for informing patients, educating healthcare professionals, and providing a patient-centred perspective to researchers and those who manage health services.

Adolescent preventive health visits: a comparison of two invitation protocols.

BACKGROUND: Adolescent health care in family practice at times creates conflicting responsibilities for parents and their teenagers. In the context of a new adolescent preventive health program in a family practice setting, we compared attendance rates using two invitation protocols, the protocols differing in their emphasis on adolescent autonomy vs parental responsibility. METHODS: One hundred six teenagers in the seventh and tenth grades were invited for preventive health visits with the family nurse and physician using two protocols. Protocol 1 involved obtaining parental consent before approaching the adolescent. With protocol 2, an invitation letter and parental consent form were mailed to the teenager, while a letter of explanation was sent concurrently to the parents. In each case, the letter of invitation was followed up by a telephone call for those who did not respond. The spontaneous response rate (a positive response after receiving the letter), agreement to attend rate (a positive response after receiving the letter or being telephoned), and the attendance rate were determined according to grade, sex, and protocol. RESULTS: The spontaneous response rate was 21%, the agreement to attend rate was 75%, and the attendance rate was 44%. Attendance rates were higher for the girls compared with the boys (54% vs 35%, P = .08) and for the seventh graders compared with the tenth graders (53% vs 31%, P = .03). The spontaneous response rate was lower among the tenth graders using protocol 2 (8% vs 37.5% with protocol 1, P = .04), while the agreement to attend rate and attendance rate did not differ for the two protocols. CONCLUSIONS: Nearly one half of this population of adolescents attended preventive health visits at the family nurse's and physician's initiative. A follow-up telephone call after the initial written invitation resulted in increased participation, while approaching the teenager or parent initially did not make a difference in attendance. This pilot study shows the potential for initiating an adolescent health program in the family practice setting.

Use of hormone replacement therapy by menopausal women in six family-practice teaching clinics in Israel.

BACKGROUND: The necessity of hormone replacement therapy (HRT) remains a controversial subject, but guidelines suggest that the subject be discussed with all menopausal women. AIM: To determine the rate of HRT use among women cared for in family-practice, university-affiliated teaching clinics. METHODS: Physicians from six family-practice teaching clinics enrolled all menopausal patients, aged between 50 and 70 years, registered in their practice. A detailed questionnaire was completed regarding demographic and health variables, gynecological history and the nature of HRT use. RESULTS: In total, 682 women were invited to participate in the study; 587 (86%) participated. Some 74% of the women were married, 64% were secular and 43% stated that they performed regular exercise. Current HRT use was reported by 156 women (26.6%). Most women (83%) had been treated for over 1 year. Common indications for starting treatment were hot flushes (75%), and routine recommendation by their physician (68%). Eighty-three (14%) women were past HRT users. It was stated by 45% of never-users that HRT had never been offered to them. Current users of HRT were found to be younger than non-users (mean age 58.2 years vs. 61.5 years, p < 0.0001), more secular than traditional or religious (p < 0.0001) with more years of formal education (p < 0.0001), and more likely to be of Western or European ("Ashkenazi") origin (p < 0.0001). Current HRT users reported fewer chronic illnesses than did non-users (p = 0.001); they were more likely to report being engaged in regular exercise (p < 0.002) and were less likely to be obese (p < 0.005). In a multiple regression model, HRT use was associated with more years of formal education and a secular identity. CONCLUSION: Our study found a higher proportion of women using HRT than in other Israeli studies. HRT use was more prevalent among women with improved health status and higher socioeconomic status. The most common reason given for not using HRT was that a physician had not raised the subject, indicating that physician-related factors might contribute to using HRT. Thus, comparing HRT prescribing rates in non-teaching clinics should clarify this factor.