Colorectal cancer and advanced adenoma incidence during post-polypectomy surveillance: a national cohort study in the English Bowel Cancer Screening Programme.

BACKGROUND: Improved colonoscopy quality has led to debate about whether all post-polypectomy surveillance is justified. We evaluated surveillance within the English Bowel Cancer Screening Programme (BCSP) to determine the yield of surveillance and identify predictive factors for surveillance outcome. METHODS: We performed a retrospective cohort study of individuals undergoing post-polypectomy surveillance between July 2006 and January 2017. BCSP records were linked to the National Cancer Registration Database to identify interval-type post-colonoscopy colorectal cancers (CRCs). Advanced adenoma and CRC at surveillance were documented. CRC incidence was compared with the general population using standardized incidence ratios (SIRs). Predictors of advanced adenomas at first surveillance (S1), and CRC during follow-up, were identified. RESULTS: 44 151 individuals (23 078 intermediate risk; 21 073 high risk) underwent 64 544 surveillance episodes. Advanced adenoma and CRC yields were, respectively, 10.0 % and 0.5 % at S1, 8.5 % and 0.4 % at S2, and 10.8 % and 0.4 % at S3. S1 yield was lowest in those with one index adenoma ≥ 10 mm (advanced adenoma 6.1 %; CRC 0.3 %). The SIR was 0.76 (95 %CI 0.66-0.88), accounted for by the intermediate risk group (intermediate risk SIR 0.61, 95 %CI 0.49-0.75; high risk SIR 0.95, 95 %CI 0.79-1.15). Adenoma multiplicity, presence of a large nonpedunculated adenoma, and greater villous component were associated with advanced adenoma at S1. Older age and multiplicity were significantly associated with CRC risk. CONCLUSION: This large, national analysis found low levels of CRC in those undergoing surveillance and low advanced adenoma yield in most subgroups. Less intensive surveillance in some subgroups is warranted, and surveillance may be avoided in those with a single large adenoma.

Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed treatment opportunity.

Microscopic colitis (MC) is a treatable cause of chronic, non-bloody, watery diarrhoea, but physicians (particularly in primary care) are less familiar with MC than with other causes of chronic diarrhoea. The colon in patients with MC is usually macroscopically normal. MC can only be diagnosed by histological examination of colonic biopsies (subepithelial collagen band >10 µm (collagenous colitis) or >20 intraepithelial lymphocytes per 100 epithelial cells (lymphocytic colitis), both with lamina propria inflammation). The UK National Health Service exerts downward pressure to minimise colonoscopy referrals. Furthermore, biopsies are often not taken according to guidelines. These factors work against MC diagnosis. In this review, we note the high incidence of MC (comparable to ulcerative colitis and Crohn's disease) and its symptomatic overlap with irritable bowel syndrome. We also highlight problems with the recommendation by National Health Service/National Institute for Health and Care Excellence guidelines for inflammatory bowel diseases that colonoscopy referrals should be based on a faecal calprotectin level of ≥100 µg/g. Faecal calprotectin is <100 µg/g in over half of individuals with active MC, building into the system a propensity to misdiagnose MC as irritable bowel syndrome. This raises important questions-how many patients with MC have already been misdiagnosed, and how do we address this silent burden? Clarity is needed around pathways for MC management; MC is poorly acknowledged by the UK healthcare system and it is unlikely that best practices are being followed adequately. There is an opportunity to identify and treat patients with MC more effectively.

Should heart failure be regarded as a terminal illness requiring palliative care? A study of heart failure patients', carers' and clinicians' understanding of heart failure prognosis and its management.

OBJECTIVES: Communication and planning for heart failure (HF) care near the end of life is known to be complex. Little is known about how the patient experience of palliative assessment and communication needs change over time, and how this might inform management. Our aim was to explore experiences of giving or receiving a prognosis and advanced palliative care planning (ACP) for those with HF. METHODS: We carried out a longitudinal grounded theory study, employing in-depth interviews with 14 clinicians (primary and secondary care) and observations of clinic and home appointments, followed by a series of interviews with 13 patients with HF and 9 carers. RESULTS: Overall, the majority of participants rejected notions of HF as a terminal illness in favour of a focus on day-to-day management and maintenance, despite obvious deterioration in disease stage and needs over time. Clinicians revealed frustration about the uncertain nature of HF prognosis, leading to difficulties in planning. Others highlighted the need to deliver problem-based, individualised care but felt constrained sometimes by the lack of multidisciplinary ACP. Patients reported an absence of prognostic discussions with clinicians. CONCLUSIONS: This is the first study exploring the experiences of prognostic communication at all stages of HF. Findings raise questions regarding the pragmatic utility of the concept of HF as a terminal illness and have implications for future HF care pathway development. Findings support the incorporation of a problem-based approach to management, which recognises the importance of everyday functioning for patients and carers as well as the opportunity for ACP.

Use of Rome criteria for the diagnosis of irritable bowel syndrome in primary care: a survey among European countries.

BACKGROUND AND OBJECTIVES: The majority of patients with irritable bowel syndrome (IBS) are diagnosed and treated in primary care. The aim of this study was to investigate the implementation of the Rome criteria in daily primary care clinical practice and adherence of general practitioners (GPs) to recommended diagnostic approaches for IBS. PATIENTS AND METHODS: A survey consisting of 18 questions was distributed across 11 European countries and was used to assess GPs' diagnostic approach of IBS, the use of Rome criteria in daily practice and GPs' perspective on the aetiology of the disorder. RESULTS: Overall, 185 GPs completed the survey. In daily clinical practice, 32% of GPs reported that they usually make a positive diagnosis on the basis of symptoms only, whereas 36% of GPs reported regular use of the Rome criteria to diagnose IBS. Furthermore, 62% of the responders reported that they applied additional diagnostics, such as blood tests, 31% found it necessary to perform endoscopy to make a positive diagnosis of IBS and 29% referred patients with IBS to a specialist. Psychological factors were the most frequently selected potential aetiological factor of IBS (88% of GPs). Overall, 52% of GPs reported systematically including questions on psychological symptoms in the assessment of history of IBS. CONCLUSION: Only about one-third of GPs regularly used the Rome criteria to diagnose IBS. In daily primary care practice, IBS largely remains a diagnosis of exclusion. This has implications in terms of GPs' specialty training and questions the applicability of IBS guidelines in daily care, which advocate an early, positive, symptom-based diagnosis.

A multicenter pragmatic study of an evidence-based intervention to improve adenoma detection: the Quality Improvement in Colonoscopy (QIC) study.

BACKGROUND AND STUDY AIMS: Low adenoma detection rates (ADRs) at colonoscopy are linked to significantly higher interval cancer rates, and vary between colonoscopists. Studies demonstrate that lesion detection is improved by: withdrawal time of ≥ 6 minutes; use of hyoscine butylbromide; position change; and rectal retroflexion. We evaluated the feasibility of implementing the above "bundle" of interventions into colonoscopy practice, and the effect on ADR. MATERIALS AND METHODS: A longitudinal cohort design was used. Implementation combined central training, local promotion, and feedback. The uptake marker was change in hyoscine butylbromide use. Comparisons were between the 3 months before and the 9 months after the implementation phase, globally, by endoscopy unit and by quartile when colonoscopists were ranked according to baseline ADR. Chi-squared or Fisher's tests were used to evaluate significance. RESULTS: 12 units participated. Global and quartile analyses included data from 118 and 68 colonoscopists and 17 508 and 14 193 procedures respectively. A significant increase in hyoscine butylbromide use was observed globally (54.4 % vs. 15.8 %, P < 0.001), in all endoscopy units (P < 0.001) and quartiles (P < 0.001). A significant increase in ADR was observed globally (18.1 % vs. 16.0 %, P = 0.002) and in the lower two colonoscopist quartiles (P < 0.001), with a nonsignificant increase in the upper middle quartile and a significant fall to 21.5 %. in the upper quartile. The significant variations in ADR among the upper three quartiles disappeared. CONCLUSION: In routine clinical practice, introduction of a simple, inexpensive, evidence-based "bundle" of measures is feasible and is associated with higher global ADR, driven by improvements amongst the poorest performing colonoscopists.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K).

BACKGROUND: Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H).

BACKGROUND: Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

High prevalence of undetected heart failure in long-term care residents: findings from the Heart Failure in Care Homes (HFinCH) study.

AIMS: Diagnosis of heart failure in older people in long-term care is challenging because of co-morbidities, cognitive deficit, polypharmacy, immobility, and poor access to services. This study aimed to ascertain heart failure prevalence and clinical management in this population. METHODS AND RESULTS: A total of 405 residents, aged 65-100 years, in 33 UK care facilities were prospectively enrolled between April 2009 and June 2010. The presence of heart failure was determined using European Society of Cardiology guidelines, modified where necessary for immobility. Evaluation of symptoms and signs, functional capacity, and quality of life, portable on-site echocardiography, and medical record review were completed in 399 cases. The point prevalence of heart failure was 22.8% [n = 91, 95% confidence interval (CI) 18.8-27.2%]; of these, 62.7% (n = 57, 95% CI 59.6-66.5%) had heart failure with preserved ejection fraction and 37.3% had left ventricular systolic dysfunction (n = 34, 95% CI 34.8-40.5%). A total of 76% (n = 61) of previous diagnoses of heart failure were not confirmed, and up to 90% (n = 82) of study cases were new. No symptoms or signs were reliable predictors of heart failure. CONCLUSION: Heart failure was diagnosed in almost a quarter of residents: the prevalence was substantially higher than in other populations. The majority of heart failure cases were undiagnosed, while three-quarters of previously recorded cases were misdiagnosed. Common symptoms and signs appear to have little clinical utility in this population. Early, accurate differential diagnosis is key to the effective management of heart failure; this may be failing in long-term care facilities.

Hormone replacement therapy is associated with gastro-oesophageal reflux disease: a retrospective cohort study.

BACKGROUND: Oestrogen and progestogen have the potential to influence gastro-intestinal motility; both are key components of hormone replacement therapy (HRT). Results of observational studies in women taking HRT rely on self-reporting of gastro-oesophageal symptoms and the aetiology of gastro-oesophageal reflux disease (GORD) remains unclear. This study investigated the association between HRT and GORD in menopausal women using validated general practice records. METHODS: 51,182 menopausal women were identified using the UK General Practice Research Database between 1995-2004. Of these, 8,831 were matched with and without hormone use. Odds ratios (ORs) were calculated for GORD and proton-pump inhibitor (PPI) use in hormone and non-hormone users, adjusting for age, co-morbidities, and co-pharmacy. RESULTS: In unadjusted analysis, all forms of hormone use (oestrogen-only, tibolone, combined HRT and progestogen) were statistically significantly associated with GORD. In adjusted models, this association remained statistically significant for oestrogen-only treatment (OR 1.49; 1.18-1.89). Unadjusted analysis showed a statistically significant association between PPI use and oestrogen-only and combined HRT treatment. When adjusted for covariates, oestrogen-only treatment was significant (OR 1.34; 95% CI 1.03-1.74). Findings from the adjusted model demonstrated the greater use of PPI by progestogen users (OR 1.50; 1.01-2.22). CONCLUSIONS: This first large cohort study of the association between GORD and HRT found a statistically significant association between oestrogen-only hormone and GORD and PPI use. This should be further investigated using prospective follow-up to validate the strength of association and describe its clinical significance.

Systematic review: Patterns of proton pump inhibitor use and adherence in gastroesophageal reflux disease.

BACKGROUND & AIMS: Variation in how proton pump inhibitors (PPIs) are taken likely influences their clinical effectiveness, and must be considered when estimating PPI failure rates. This review aimed to systematically investigate the literature on patterns of PPI use in patients with gastroesophageal reflux disease (GERD). METHODS: PubMed and Embase were searched (1989-May 2010) to identify observational studies providing information on patterns of PPI use in patients with GERD. RESULTS: Of 902 studies identified, 13 met prespecified selection criteria. Across 2 database studies, 53.8%-67.7% of patients with GERD had a medication possession ratio (MPR) of >0.80. Across 2 more database studies, the mean MPR for the study population was 0.68 to 0.84. Across 3 surveys, 70%-84% of patients reported daily PPI use. In 2 surveys, the presence and severity of reflux symptoms increased PPI adherence, as did Barrett's esophagus in another 2 studies. Across 3 surveys, 11%-22.2% of patients reported twice daily PPI use, and across 6 studies 11.0%-44.8% of patients took GERD medication in addition to a PPI. CONCLUSIONS: The results of this systematic review suggest that the majority of patients with GERD are relatively adherent to their PPI, although substantially different estimates were obtained using MPR data compared with surveys. Severe symptoms and the presence of Barrett's esophagus may increase PPI adherence, and other GERD medication is frequently taken in addition to a PPI. Limitations of studies in this area include inferring adherence from indirect MPR data, and recall bias associated with patient surveys.

Screening for diabetes in unconventional locations: resource implications and economics of screening in optometry practices.

OBJECTIVES: Unconventional locations outwith general medical practice may prove opportunities for screening. The aim was to determine the resource implications and economics of a screening service using random capillary blood glucose (rCBG) tests to detect raised blood glucose levels in the "at risk" population attending high street optometry practices. METHOD: A screening service was implemented in optometry practices in North East England: the cost of the service and the implication of different screening strategies was estimated. RESULTS: The cost of a screening test was £5.53-£11.20, depending on the screening strategy employed and who carried out the testing. Refining the screening strategy to target those ≥40 years with BMI of ≥25 kg/m(2) and/or family history of diabetes resulted in a cost per case referred to the GP of £14.38-£26.36. Implementing this strategy in half of optometric practices in England would have the potential to identify up to 150,000 new cases of diabetes and prediabetes a year. CONCLUSIONS: Optometry practices provide an effective way of identifying people who would benefit from further investigation for diabetes. Effectiveness could be improved further by improving cooperation and communication between optometrists and medical practitioners.

Screening for diabetes in optometry practices: acceptability to users.

PURPOSE: Diabetes is a leading cause of blindness in the working age population. While optometrists have an established role in screening people with known diabetes for eye disease, their role in screening for diabetes has not been evaluated. For diabetes screening in optometry practices to be successful it must be acceptable to both optometrists and to the public. The purpose of this study was to determine acceptability to people attending optometry practices of using random capillary blood glucose (rCBG) tests to detect raised blood glucose levels in optometry practices. METHODS: A screening service offering people with risk factors or symptoms of diabetes rCBG tests was piloted in five high street opticians' practices in North East England. One thousand and two people used the screening service during a 20 week period. Each was given a questionnaire to complete and return following a rCBG test. RESULTS: Nine hundred and thirty-nine questionnaires were returned (return rate 93.7%). The mean age of participants was 54.5 years, 63.3% were female and 75.0% had not been screened for diabetes previously. 99.1% agreed or strongly agreed that the location was convenient for them and 98.0% would recommend others to use the screening service. 83.8% of the participants would not have gone elsewhere to have any tests done and 148 (16.2%) responded that they would have sought a test elsewhere; 14.2% at the GP, 0.8% at a pharmacy and 0.5% elsewhere. Only 3.2% reported that the test procedure was uncomfortable. CONCLUSIONS: To those attending opticians' practices, screening using rCBG tests is acceptable in terms of convenience and test comfort, and they would recommend the test to others. Screening in optometry practices provides an opportunity to identify people at risk of diabetes in a hitherto unutilised setting.

Combined superoxide dismutase mimetic and peroxynitrite scavenger protects against neointima formation after endarterectomy in association with decreased proliferation and nitro-oxidative stress.

OBJECTIVE: Reactive oxygen and nitrogen species (e.g., peroxynitrite) may trigger neointima formation leading to restenosis. In a rat carotid endarterectomy (CEA) model, we investigated the effects of the manganese(III)tetrakis(4-benzoic acid)porphyrin (MnTBAP), a superoxide dismutase (SOD) mimetic and peroxynitrite scavenger on neointima formation. METHODS: CEA was performed in male Sprague-Dawley rats. Animals received either vehicle (control group; n=15) or 15 mg kg(-1) day(-1) MnTBAP intraperitoneally for 3 weeks (treatment group; n=13). Four groups of carotids were analysed: the left, uninjured carotids (sham) and the right, injured carotids (control CEA) from the control group, the right, injured carotids from the treatment group (CEA+MnTBAP) and an additional group of carotids that were harvested 1h following endarterectomy. The analysis of carotid arteries was performed by histology, immunohistochemistry and real-time polymerase chain reaction (PCR). Plasma malondialdehyde (MDA) levels were measured by lipid hydroperoxidase assay. RESULTS: Stenosis rate (10.5+/-8.1% vs. 45.4+/-28.3%), the percentage of proliferating cell nuclear antigen-positive cells (13.4+/-7.1% vs. 23.3+/-11.0%) and nitrotyrosine immunoreactivity (5.8+/-1.9 vs. 8.0+/-2.0) were significantly reduced in the vascular wall of the CEA+MnTBAP group compared with control CEA group. Ratio of Terminal deoxynucleotidyl transferase-mediated dUTP-biotin nick end labelling (TUNEL)-positive nuclei was significantly lower after antioxidant therapy (41.7+/-26.7% vs. 64.9+/-18.5%). Plasma MDA levels increased after endarterectomy (11.7+/-4.8 vs. 4.1+/-2.0 micromol l(-1)) and reduced in the treatment group (3.2+/-2.1 micromol l(-1)). No significant gene regulation after MnTBAP treatment could be noted. CONCLUSIONS: MnTBAP decreased neointima formation, which was associated with reduced vascular smooth muscle cell proliferation and attenuated local and systemic nitro-oxidative stress.

Upper gastrointestinal endoscopy or not, and in whom?

Despite progress in knowledge and effective therapies for acid-sensitive problems the indications for gastroscopy seem even more confusing than before. The primary care physician, faced with the patient with undifferentiated symptoms, is now less sure when to seek an endoscopy which is actively discouraged in many health care settings. Management guidelines, based essentially on maximizing the yield from endoscopy, may define the direction of travel but do not sit comfortably in the consultation setting.

Urgent cancer referral guidelines: a retrospective cohort study of referrals for upper gastrointestinal adenocarcinoma.

Dyspepsia in primary care is common and guidelines indicate that patients with alarm symptoms, as defined by the urgent cancer referral guidelines, should be investigated by gastroscopy. The specificity and sensitivity of alarm symptoms is poor and only a small percentage of patients will turn out to have malignant disease. This primary care study shows that employing current guidelines will identify only 72% of patients at their initial visit to a general practitioner, but this figure could be increased to 86% if the guidelines included patients with weight loss or anaemia in the absence of dyspepsia. Past performance indicates that the majority of patients with the commonest symptom complex were not referred quickly and less than half were seen within 4 weeks.

Managing gastro-oesophageal reflux disease in the older patient.

Gastro-oesophageal reflux disease (GORD) in older patients presents particular problems for the clinician. Older patients may present with complications rather than with symptoms, which may be less marked than in younger patients. Extraoesophageal symptoms are also more common in this group, and this may lead to confusion over the exact diagnosis. The increased likelihood of co-pathologies and concomitant medication complicate diagnosis and management further. GORD tends to be more severe for any level of symptom severity in the older patient. Erosive oesophagitis is more common among older people with GORD, meaning that this group is more likely to require aggressive therapy for both symptom relief and oesophagitis healing - full or high doses of acid suppression therapy may be necessary.

Short-term treatment of gastroesophageal reflux disease.

OBJECTIVE: To investigate the efficacy of acid suppressant drugs in the empirical treatment of gastroesophageal reflux disease (GERD) and in the treatment of endoscopy-negative reflux disease (ENRD). DESIGN: medline, embase, and the Cochrane Controlled Trials Register were searched. Bibliographies were reviewed. SETTING: Studies were eligible that compared the short-term use of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) with each other or with placebo in adults with GERD who were enrolled irrespective of endoscopic findings (empirical cases) or in whom endoscopy showed no signs of esophagitis (endoscopy-negative cases). MEASUREMENTS: Of 1,408 studies, only 13 could be included for meta-analysis. Data on 3,433 patients empirically treated for GERD and 2,520 patients treated for ENRD were extracted. The primary endpoint was relief of heartburn. MAIN RESULTS: In the empirical treatment of GERD, the summary relative risk (sRR) for symptom relief from H2RAs versus placebo was 0.77 (95% confidence interval [95% CI], 0.60 to 0.99). RR in the only placebo-controlled PPI trial was 0.35 (95% CI, 0.26 to 0.46). The sRR for standard dose PPIs versus H2RAs was 0.55 (95% CI, 0.44 to 0.68). In treatment of ENRD, both PPIs (sRR, 0.64; 95% CI, 0.52 to 0.79) and H2RAs (sRR, 0.78; 95% CI, 0.62 to 0.97) were superior to placebo, and PPIs were superior to H2RAs (sRR, 0.81; 95% CI, 0.70 to 0.95). CONCLUSIONS: Acid suppressant therapy (with a PPI or an H2RA) is more effective than placebo for short-term relief of heartburn in patients with persistent symptoms who are treated empirically for GERD and in those in whom esophagitis was excluded after endoscopy. The benefit of PPIs compared with H2RAs is more pronounced in patients treated empirically.

Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study.

OBJECTIVE: To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care. DESIGN: A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of "pragmatic variant" grounded theory. SETTING: North east England. RESULTS: Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, beta blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care. CONCLUSIONS: The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies--for example, the provision of guidelines--are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.

[A case of Bamberger-Marie syndrome]. / Bamberger-Marie-syndroma esete.

Authors describe their case of Bamberger-Marie-syndrome, in which symptoms of the locomotor system were observed independently, without joined or basic disease. The relating literature is reviewed together with the pathological process in this rare disease.