Rabeprazole test for the diagnosis of gastro-oesophageal reflux disease: results of a study in a primary care setting.

AIM: To determine the diagnostic value of the rabeprazole test in patients seen by general practitioners. METHODS: Eighty-three patients with symptoms suggestive of GERD were enrolled by general practitioners in this multi-centre, randomized and double-blind study. All patients received either rabeprazole (20 mg bid) or a placebo for one week. The diagnosis of GERD was established on the presence of mucosal breaks at endoscopy and/or an abnormal esophageal 24-h pH test. The test was considered to be positive if patients reported at least a "clear improvement" of symptoms on a 7-point Likert scale. RESULTS: The sensitivities of the test for rabeprazole and the placebo were 83% and 40%, respectively. The corresponding specificity, positive and negative predictive values were 45% and 67%, 71% and 71%, and 62% and 35%, respectively. A receiver operating characteristics (ROC) analysis confirmed that the best discriminatory cut-off corresponded to description of "clear improvement". CONCLUSION: The poor specificity of the proton-pump inhibitor (PPI) test does not support such an approach to establish a diagnosis of GERD in a primary care setting.

Validation of the Self-Assessment of Melanoma Risk Score for a melanoma-targeted screening.

Melanoma is nowadays a major public health problem because of its increasing incidence. Targeted screening for patients at a high risk for melanoma is being promoted. The aim of our study was to assess the effectiveness of a targeted screening on the basis of the self-selection of high-risk individuals with the Self-Assessment of Melanoma Risk Score (SAMScore). Our main objective was to prove that this score allows the selection of a group of patients who are at a higher risk and in whom more melanomas may be detected. This prospective study was carried out in France in 2009. Consecutive patients, while visiting their doctor's office, filled out a melanoma risk factor questionnaire. Patients were assessed as being at high risk or not according to the SAMScore, and patients at a high risk were examined both by their general practitioner and by a dermatologist. The efficiency of the selection tool corresponded to the ratio of the prevalence of melanoma in a population selected with the SAMScore to the prevalence in the general population. A logistic model with a random effect was used. A total of 7977 patients filled out the questionnaire. Among the 2404 patients at high risk, histologically proven melanoma was screened in 10 cases: two in-situ and eight invasive melanomas. The SAMScore efficiency assessed was equal to 11.54 (P=0.0016). In conclusion, in this strategy, to detect a new case of melanoma, it is necessary to screen 11 times fewer patients than with a nontargeted screening. This is the first study to confirm the efficiency of a targeted screening on the basis of self-selection of high-risk individuals.

Development of an individual score for melanoma risk.

Melanoma is one of the fastest growing cancers worldwide. We need to have tools to identify patients with high risk of melanoma. We carried out a case-control study and tested three methods to develop an individual score of melanoma risk, usable in routine practice. All cases included newly diagnosed invasive cutaneous melanoma of stage I or II (6th American Joint Committee on Cancer) seen in 2007 at the Skin Cancer Unit of Nantes Hospital, France. Controls included 1500 consecutive patients consulting their general practitioners. A self-administrated questionnaire was used for assessment of melanoma risk factors. Three methods of scoring were used and compared: one with common relative risks reported in the literature, one with odds ratios estimated by logistic regression, and a combinatorial analysis. The method based on combinatorial analysis permitted one to obtain a simple rule to define individuals at risk: the association of the rule 'presence of at least three risk factors or presence of more than 20 naevi on the arms' for the patients aged under 60 years and 'presence of at least three risk factors or presence of freckles' for the patients aged 60 years and above (sensitivity: 63.2% and specificity: 68.8%). The tool we propose is easy to use every day in routine health care to select patients with high risk of melanoma. It can be assessed without any computer or calculator and is based on the self-assessment of the melanoma risk factors by the patient and thus is not medical time consuming.

Creation and test of a questionnaire for self-assessment of melanoma risk factors.

The objective of this study was to create a self-administrated questionnaire for people to enable them to assess their own melanoma risk factors. To test the validity of this questionnaire in a large prospective study, the answers given by the patient were systematically checked by his or her general practitioner. In this prospective study, the choice of questions was based on a review of the literature. The validity of the questionnaire was assessed by testing 1500 consecutive patients attending a consultation with their general practitioner. Considerable variations concerning the prevalence of different melanoma risk factors were noticed in the population: 44.1% had a phototype I or II, 41% had severe sunburn during infancy, 29.9% had freckling tendency, 22% had more than 50 naevi and 1.4% a personal history of melanoma. In total, 45% had more than one melanoma risk factor. The accuracy of the answers given by the patients was assured by the correction given by their general practitioners. The percentage of correct answers given by the patients was 79.9% for the phototype, 90.6% for freckling tendency, 86.6% for the number of naevi, 96.5% for severe sunburn during infancy and 98.1 and 95.8% for personal and familial history of melanoma. This study confirms that individuals with multiple risk factors for melanoma are common among patients consulting their general practitioners. Furthermore, self-screening with the self-assessment questionnaire is easily feasible and is accurate for identifying high-risk individuals. This tool might be useful for carrying out melanoma-targeted screening.

Impact of a campaign to train general practitioners in screening for melanoma.

Melanoma is a serious cancer whose incidence is growing. At this time, its prognosis is dependent on the Breslow index and therefore on early screening. The objective of the study was to evaluate the impact of a campaign to train general practitioners based, in particular, on learning the ABCDE rule. The training, performed by Réseau Mélanome Ouest, involved 210 general practitioners from the Pays de la Loire (Loire region) in France. Eight identical 2-h sessions were held between 2004 and 2006, conducted by a hospital dermatologist, a dermatologist in private practice, and a general practitioner as a moderator. The training was evaluated in two stages, with a self-administered questionnaire followed by a telephone survey. Thirty-six percent of the doctors stated that they had detected melanomas since the training over a median period of 27 months (2-39 months); 15% sent in the corresponding pathological anatomy reports on 37 confirmed melanomas from 30 doctors. The Breslow index scores of the melanomas detected ranged from 0.16 to 4 mm. Therefore, our training promoted the screening of a large number of melanomas, most of them with a low Breslow index. As a result, after a short prior training, the ABCDE rule clearly seems to be a valuable tool. Dermatologists retain an important role both in the diagnostic confirmation of melanomas and in the training of general practitioners.