A trial of a self-assessment tool of problems following treatment of colorectal cancer: a prospective study in Australia primary care.

Patients treated for colorectal cancer (CRC) experience considerable physical, social and psychological morbidity. In this study, 66 participants with stages I-III CRC were enrolled in this study. Participants completed the self-assessment tool for patients (SATp) over a 5-month period and visited a general practitioner with a copy of their SATp to assist in the management of any problems associated with CRC treatment. General practitioners' notes were reviewed for management actions. Of the 66 participants, 57 visited a general practitioner over the 5-month study period. A total of 547 problems were identified (median 7; IQR: 3-12.25). Participants with physical problems were more likely to consult their general practitioner (OR: 1.84, CI: 1.05-3.21, P = 0.03) compared to those with psychological problems. The number of problems experienced by participants did not have any influence on the decision to visit a general practitioner. Psychological problems (P < 0.01) significantly reduced over the 5-month study period. Regular use of the SATp facilitates the identification of long-term CRC treatment-related problems. Some of these problems could then be addressed in primary care.

Help-seeking experiences of men diagnosed with colorectal cancer: a qualitative study.

Advanced-stage diagnosis of colorectal cancer (CRC) leads to poor prognosis and reduced survival rates. The current study seeks to explore the reasons for diagnostic delays in a sample of Australian men with CRC. Semi-structured interviews were conducted in a purposive sample of 20 male CRC patients. Data collection ceased when no new data emerged. Interviews were audiotaped, transcribed and thematically analysed using Andersen's Model of Total Patient Delay as the theoretical framework. Most participants (18/20) had experienced lower bowel symptoms prior to diagnosis. Patient-related delays were more common than delays attributable to the health-care system. Data regarding patient delays fit within the first four stages of Andersen's model. The barriers to seeking timely medical advice were mainly attributed to misinterpretation of symptoms, fear of cancer diagnosis, reticence to discuss the symptoms or consulting a general practitioner. Treatment delays were a minor cause for delayed diagnosis. Delay in referral and scheduling for colonoscopy were among the system-delay factors. In many instances, delays resulted from men's failure to attribute their symptoms to cancer and, subsequently, delay in diagnosis.

Patients' perspectives on the role of their general practitioner after receiving an advanced cancer diagnosis.

The aim of this study was to explore patients' perspectives on the role of their general practitioner (GP) after an advanced cancer diagnosis. A qualitative research approach was used. Semi-structured interviews were conducted and data were analysed using a constant comparative methodology. Participants were eligible if they were diagnosed with advanced cancer and referred for palliative radiotherapy. Data saturation was achieved after 21 interviews. Key themes included (1) obtaining diagnosis and referral for advanced cancer treatment; (2) preference for specialist oncology care; (3) a preference for GP to act as an advocate; and (4) obtaining ongoing routine care from their GP. GP involvement in the patients' management was dependent on: time since diagnosis, GP's involvement in diagnosis and referral, doctor/patient relationship, additional chronic conditions requiring management, frequency of seeing oncologist and specialist recommendation to involve GP. Patients want GPs to have varying levels of involvement following an advanced cancer diagnosis. Not all communication between GPs and patients was positive suggesting communication skills training may be a priority. Patients wished to maintain continunity of care for their non-cancer related issues and healthcare of their family members. Future research needs to focus on working with GPs to increase their role in the management of advanced cancer.

An investigation of factors that influence general practitioners' referral of computed tomography scans in patients with headache.

AIM: In assessing patients with headaches, general practitioners (GPs) play an important role in determining which patients require computed tomography (CT) scans. The purpose of this study was to identify factors that influence GPs' decisions to refer CT scans for patients with headaches. MATERIALS AND METHODS: A self-administered survey was presented to GPs in Western Australia. One hundred and twenty-eight vignettes describing patients who may have required CT referral for headache were constructed encompassing six clinical variables. Nine vignettes, selected at random, were presented to each respondent. Respondents were asked if they would refer the patient for diagnostic imaging tests, if so, which imaging modalities would they request, how urgently and the perceived benefits of the requested imaging modality. Multinomial logistic regression was used for the multivariate analysis. RESULTS: We received 105 completed questionnaires (21%). GPs were more likely to refer patients with headaches for diagnostic imaging and CT scans in the following clinical scenarios: patients with a history of colorectal cancer and epilepsy; and patients feeling unwell for the past 6 weeks and headache being exacerbated with valsalva manoeuvrers. Private health insurance and other respondent demographics such as GPs experience and site of care increased imaging referral. CONCLUSION: GP's referral decisions of diagnostic imaging and CT examinations for patients with headaches are dependent on clinical scenarios and the likelihood of a significant pathology. Further research is required to identify the significant clinical findings with regard to the CT referrals and ensure that CT scans are not requested in patients who are unlikely to benefit.

Management of cases that might benefit from radiotherapy: a standardised patient study in primary care.

The aim of this study was to assess general practitioner (GP) consultations with standardised patients presenting with cancer-related problems that might benefit from radiotherapy. Standardised patient scenarios were constructed with indications for radiotherapy or with side effects of radiotherapy. Six GPs consulted six standardised patients. All consultations were video recorded. Two GPs independently rated the consultation performance using the Leicester Assessment Package (LAP). Each consultation was also assessed by two radiation oncologists to assess specific decisions taken or advice offered to 'patients' in each case. The mean duration of consultations was 13 min and 55 s. Three GPs differed significantly (P < 0.025) in competencies measured by the LAP, but not as assessed by radiation oncologists. There was no significant difference in LAP scores when reviewed by scenario. However, there was significant differences in the management of the case with prostate cancer (P= 0.005) and data suggest that GPs management of different problems presented varied widely. These data are consistent with the published literature which suggests that in practice not all patients are appropriately advised or referred. There is a need for innovations to support GPs to manage patients who would benefit from radiotherapy.

"The doctor will see you now": Direct support professionals' perspectives on supporting adults with intellectual and developmental disabilities accessing health care during COVID-19.

BACKGROUND: It is critical to consider how rapid changes in health care delivery and the rise in use of virtual modalities have impacted adults with intellectual and developmental disabilities and caregivers. OBJECTIVE: The purpose of this paper is to describe direct support professionals' experiences assisting adults with intellectual and developmental disabilities in accessing virtual and in-person health care during COVID-19. METHODS: A content analysis was conducted on responses obtained from an online questionnaire distributed to 942 direct support professionals in Canada. Descriptive statistics were used to report the type of visits that occurred and open text responses describing these visits were coded. RESULTS: Twenty four percent of direct support professionals reported supporting someone at an in-person medical appointment, 22% reported attending at least one video-based virtual appointment and 58% reported supporting at least one phone based virtual appointment in the first 5 months of the pandemic. They identified several barriers and facilitators with each type of visit which suggests there is no "single way" to provide health care to this group, but that optimal care depends on maximizing the fit between the person's abilities, the skill set of direct support professionals and health care providers, and the presenting health care issue. CONCLUSIONS: Study findings provide insight into the experience of health care for this population during COVID-19 and can be used to support direct support professionals and adults with intellectual and developmental disabilities to adapt to safe, supportive and comprehensive virtual and in-person health care during the pandemic and beyond.

Repeat attenders at National Health Service walk-in centres - a descriptive study using routine data.

OBJECTIVES: Whilst numerous studies have examined repeat attendance at general practices or emergency departments, little is known about repeat attenders at walk-in centres. The aim of this study was to examine age, gender, socio-economic status, distance from walk-in centre, day and time of attendance in relation to repeat attendance at walk-in centres. STUDY DESIGN: Descriptive study using routine data from four walk-in centres in England, two of which were located in London and were accessible to local and commuter populations. METHODS: Data for 2 years (2003-2004) were examined. Age, gender, day and time of attendance were obtained from administrative records. Distance was calculated from the census output area of residence to walk-in centre attended. The Index of Multiple Deprivation (Income Domain) was used as an indicator of socio-economic deprivation at the small-area level. RESULTS: Thirty-nine percent of 272,701 attendances by 166,486 patients were repeat attendances. Seventy percent of patients attended once, 27.9% attended two to five times, and 2.2% attended on over five occasions over the 2-year study period. Patients attending the two London walk-in centres lived closer than those attending the two walk-in centres outside London (percentage living 6 km or more from walk-in centre: 9% and 12% compared with 18% and 22%). The London walk-in centres had a higher percentage of single attenders (74.1% and 78%) compared with the other two walk-in centres (63.3% and 64.7%). Repeat attenders lived closer to walk-in centres than single attenders. Adjusted odds ratios for patients living within 3 km of the walk-in centre relative to patients living 6 km or more from the walk-in centre ranged from 1.59 [95% confidence interval (CI) 1.42-1.78] to 3.34 (95% CI 3.12-3.57) for patients attending two to five times, and from 2.37 (95% CI 1.36-4.11) to 14.99 (95% CI 11.30-19.88) for patients with over five attendances. There was substantial variation with significant contrasting patterns in odds ratios across walk-in centres in relation to the other variables. Repeat attenders were older than single attenders at three of the four walk-in centres. Repeat attenders tended to be more likely to be male at two walk-in centres, and less likely to be male at the other two walk-in centres. Socio-economic deprivation tended to be associated with repeat attendance at one of the walk-in centres. There were also significant and contrasting patterns in relation to day and, to a lesser extent, time of attendance. CONCLUSIONS: Users living near walk-in centres are more likely to be repeat attenders. Age, gender, socio-economic deprivation, day and time of attendance had significantly higher or lower odds ratios for repeat attendance at different walk-in centres, suggesting that organizational and other factors may determine patterns of repeat attendance.

Measuring the quality of referral letters about patients with upper gastrointestinal symptoms.

BACKGROUND: General practitioners state the reason for referring patients in referral letters. The paucity of information in these letters has been the source of criticism from specialist colleagues. OBJECTIVE: To invite general practitioners to set standards for referral letters to gastroenterologists and to apply these standards to actual referral letters to one specialist gastroenterology unit. METHODS: A scoring schedule was designed based on the responses to a questionnaire survey of a large sample of all general practitioners in one locality. Altogether 350 consecutive letters to a district general hospital about patients referred for an upper gastrointestinal specialist opinion were subsequently scored using the schedule. RESULTS: 102 practitioners responded to the survey. Their responses imply that colleagues assess and record findings on 18 potential features of upper bowel disease. In practice most referral letters address fewer than six features of upper bowel disease. The mean number of positive features of upper gastrointestinal disease reported in each letter was one. CONCLUSIONS: This study reported a failure to meet "peer defined" standards for the content of referral letters set by colleagues in one locality. Referral letters serve many purposes, however, encouraging full documentation of specific clinical findings may serve to increase the pre-referral assessments performed in practice.

Prospective multicenter evaluation of the morphometric D-score for prediction of the outcome of endometrial hyperplasias.

Prospective multicenter evaluation of the WHO classification and the morphometric D-score to predict endometrial hyperplasia cancer progression. In 132 endometrial hyperplasias WHO classification was performed by two experienced gynecologic pathologists. The D-score was assessed blindly by technicians in a routine diagnostic setting. Development of endometrial carcinoma during a 1-10-year follow-up was used as the end point. Eleven of 132 patients (8%), 10 of 61 (16%) atypical hyperplasias, and 1 of 71 (1%) nonatypical hyperplasias developed cancer. Twenty-six curettings had a D-score < or = 0 ("unfavorable" or endometrial intraepithelial neoplasia) of which 10 (38%) developed cancer. None of the 86 cases with a D-score > 1 ("favorable") and one of the 20 (5%) cases with 0 < D-score < or = 1 ("uncertain") developed cancer. Sensitivity of the D-score was 100%, specificity 82%, the positive and negative predictive values were 38% and 100%, respectively. These values are similar to those in three prior retrospective D-score studies but higher than the WHO values (which are 91%, 58%, 16%, and 99%, respectively). The D-score in endometrial hyperplasias is a more sensitive and specific marker for cancer prediction than the WHO classification, can be assessed in a routine clinical setting on standard hematoxylin and eosin sections (15-30 minutes per case), and is highly reproducible and cost-effective (U.S. $50 per case).

Application and comparison of silver intensification methods for the diaminobenzidine and diaminobenzidine-nickel endproduct of the peroxidation reaction in immunohistochemistry and in situ hybridization.

Silver-intensification methods described in the literature for the diaminobenzidine (DAB) and diaminobenzidine-nickel (DAB/Ni) endproduct of the peroxidase reaction were compared in model systems after immunoperoxidase and in situ hybridization. First, these methods were compared in immunohistochemical model systems, using the demonstration of glial fibrillar acidic protein (GFAP) and prostate-specific antigen (PSA) in paraffin sections of human brain and prostate tissue, respectively. When DAB without Ni was used as substrate, tissue argyrophilia caused considerable background staining. Only when this tissue reactivity was quenched with, e.g., CuSO4 with H2O2 or thioglycolic acid, were the results acceptable. A considerable improvement in the signal-to-noise ratio could be obtained when nickel was included in the substrate mixture. The methods that proved to be best for demonstration of GFAP and PSA made use of acid developer solutions. Subsequently, these methods were compared with other sensitive immunostaining methods for demonstration of the gamma-delta T-cell receptor in frozen lymphoid tissue. In this model a considerable increase in the number of positive cells could be obtained using silver intensification. The different methods using DAB/Ni were also compared for use in DNA in situ hybridization (DISH). In this case two model systems were used: human papilloma virus type 11 (HPV-11) DNA in condyloma tissue (abundant target model) and Epstein-Barr virus (EBV) DNA in a mononucleosis lymph node (low target model). For demonstration of HPV-11, all methods gave more or less satisfactory results, which were best with the acid developer solutions. Moreover, for demonstration of EBV DNA, a signal could be obtained only with these developer solutions. Such a method also proved suitable in double immuno-hybrido stainings for the demonstration of EBV DNA in specific antigen-positive Reed-Sternberg cells in paraffin sections of Hodgkin lymph nodes.

Expression of Epstein-Barr virus latent gene products and related cellular activation and adhesion molecules in Hodgkin's disease and non-Hodgkin's lymphomas arising in patients without overt pre-existing immunodeficiency.

Epstein-Barr virus (EBV) recently has been associated with Hodgkin's disease (HD) and the EBV genome was found in CD30-positive Reed-Sternberg cells. Therefore, tissue sections from 25 cases of HD, 35 cases of CD30-positive non-Hodgkin's lymphoma (NHL) (seven CD30-positive anaplastic large cell lymphomas [ALCLs] and 28 CD30-positive non-ALCLs), and 12 cases of CD30-negative NHL that previously had been screened for the presence of EBV by polymerase chain reaction and DNA in situ hybridization were studied by immunohistochemistry for the expression of the latent EBV proteins, latent membrane protein (LMP), and Epstein-Barr nuclear antigen-2 (EBNA-2). We also analyzed the expression of the B-cell activation molecule CD23 and the adhesion molecules LFA-1/CD11a and ICAM-1/CD54 because the upregulation of these molecules by LMP and/or EBNA-2 in vitro has been related to the EBV-induced lymphocyte growth. Latent membrane protein expression was found in Reed-Sternberg cells in nine of 25 cases (36%) of HD and in large, occasionally Reed-Sternberg-like tumor cells in six of 47 cases (12%) of NHL; these six tumors were CD30-positive, histologically high-grade NHL (one CD30-positive ALCL and five CD30-positive non-ALCLs). All the LMP-positive cases were also polymerase chain reaction EBV positive while LMP expression was not found in polymerase chain reaction EBV-negative HD and NHL. No staining for EBNA-2 was detected in our series. In view of the transforming potential of the LMP, these findings suggest that EBV may be associated with the development of some cases of HD and CD30-positive NHL. These findings also suggest a correlation between the expression of LMP and the detection of CD30 in tumor cells of HD and NHL. In contrast, no correlation was found between the expression of LMP and the detection of CD23, LFA-1/CD11a, and ICAM-1/CD54 in tumor cells of HD and NHL.

Three sensitive methods for the detection of cytomegalovirus in lung tissue of patients with interstitial pneumonitis.

Interstitial pneumonia after allogeneic bone marrow transplantation is frequently associated with human cytomegalovirus (HCMV) infection. However, in a considerable proportion of the cases, no infectious agent can be determined and the interstitial pneumonia is then classified as idiopathic. Hypothetically, idiopathic interstitial pneumonia could be caused by HCMV present in such small amounts or such conformation that the virus cannot be detected by routine histopathologic analysis or viral culture techniques. To check this hypothesis, three sensitive methods for HCMV detection (in situ hybridization, the polymerase chain reaction for HCMV-DNA detection, and immunohistochemistry for the detection of HCMV immediate early antigens) have been applied on lung tissue sections of bone marrow transplant patients who died with interstitial pneumonia. Three categories were distinguished: (1) patients with HCMV-related interstitial pneumonia (n = 5); (2) patients with idiopathic interstitial pneumonia (n = 10); and (3) patients with HCMV interstitial pneumonia who had been treated with antiviral therapy (n = 2). In the first category, all three techniques yielded clearly positive results, whereas these techniques indicated that one of the patients of the second category had HCMV-related pneumonia. In the third category no positive signals could be obtained. The presented data indicate that a direct involvement of HCMV in idiopathic interstitial pneumonia is unlikely. However, a PCR performed for Epstein-Barr virus (EBV) was positive in two patients with idiopathic interstitial pneumonia. These data indicate that the introduction of new sensitive techniques such as in situ hybridization, immunohistochemistry, and the polymerase chain reaction revives the interest for HCMV and other causative infectious agents in idiopathic interstitial pneumonia.

Implausibility of an aetiological association between cytomegalovirus and Kaposi's sarcoma shown by four techniques.

The presence of cytomegalovirus (CMV) was analysed in either lymph node or skin and lung tissue necropsy specimens affected by Kaposi's sarcoma, from 10 patients who had died of AIDS. The different detection techniques used were: (i) immunohistochemical demonstration of CMV immediate early antigen (IEA); (ii) in situ hybridisation with a biotinylated CMV DNA probe; (iii) Southern blot hybridisation of DNA extracted from sequential tissue sections; and (iv) polymerase chain reaction (PCR) with CMV specific primers on the DNA samples. The results of these analyses were compared with the postmortem data on CMV obtained by infectious particle assays and histological examination, especially of adrenal glands of the same patients. The results of the various detection methods correlated very well, yielding a combined score of six of 10 patients positive for CMV; there did not seem to be any association between the presence of CMV and the occurrence of Kaposi's sarcoma in our patients.

Presence of Epstein-Barr virus latency type III at the single cell level in post-transplantation lymphoproliferative disorders and AIDS related lymphomas.

AIMS: To investigate the expression pattern of Epstein-Barr virus (EBV) latent genes at the single cell level in post-transplantation lymphoproliferative disorders and acquired immunodefiency syndrome (AIDS) related lymphomas, in relation to cellular morphology. METHODS: Nine post-transplantation lymphoproliferative disorders and three AIDS related lymphomas were subjected to immunohistochemistry using monoclonal antibodies specific for EBV nuclear antigen 1 (EBNA1) (2H4), EBNA2 (PE2 and the new rat anti-EBNA2 monoclonal antibodies 1E6, R3, and 3E9), and LMP1 (CS1-4 and S12). Double staining was performed combining R3 or 3E9 with S12. RESULTS: R3 and 3E9 anti-EBNA2 monoclonal antibodies were more sensitive than PE2, enabling the detection of more EBNA2 positive lymphoma cells. Both in post-transplantation lymphoproliferative disorders and AIDS related lymphomas, different expression patterns were detected at the single cell level. Smaller neoplastic cells were positive for EBNA2 but negative for LMP1. Larger and more blastic neoplastic cells, sometimes resembling Reed-Sternberg cells, were LMP1 positive but EBNA2 negative (EBV latency type II). Morphologically intermediate neoplastic cells coexpressing EBNA2 and LMP1 (EBV latency type III), were detected using R3 and 3E9, and formed a considerable part of the neoplastic population in four of nine post-transplantation lymphoproliferative disorders and two of three AIDS related lymphomas. All samples contained a subpopulation of small tumour cells positive exclusively for Epstein-Barr early RNA and EBNA1. The relation between cellular morphology and EBV expression patterns in this study was less pronounced in AIDS related lymphomas than in post-transplantation lymphoproliferative disorders, because the AIDS related lymphomas were less polymorphic than the post-transplantation lymphoproliferative disorders. CONCLUSIONS: In post-transplantation lymphoproliferative disorders and AIDS related lymphomas, EBV latency type III can be detected by immunohistochemistry in a subpopulation of tumour cells using sensitive monoclonal antibodies R3 and 3E9. Our data suggest that EBV infected tumour cells in these lymphomas undergo gradual changes in the expression of EBV latent genes, and that these changes are associated with changes in cellular morphology.

Interaction with host stroma as a promotional factor in tumor malignancy.

Cells of a Yoshida sarcoma implanted subcutaneously in the rat are heterogeneous. Nuclei vary microscopically from regularly vesicular to irregular and hyperchromatic. Cells with hyperchromatic nuclei are in remarkably close association with stromal elements. This finding is consistent with the theory that stromal influences have a promotional effect on tumor cells. The nature of the hypothetical factor is conjectural.

The possible role of stromal influences in tumor cell heterogeneity. Histology and fibronectin pattern of the Yoshida sarcoma of the rat.

Yoshida tumors implanted subcutaneously in the rat are conspicuously heterogeneous. A definite zoning can be discerned. Cell nuclei range from uniform epitheloid (type I) via pleomorphic (type II) to compact (type III). Type III is seen to detach at the rim of the tumor and to infiltrate the dermis. Type I is characterized by positive pericellular fibronectin staining, type II and III are fibronectin-negative. A marked spatial relationship was seen between types II and III on one hand and the presence of collagenous stroma on the other. It is conjectured that stromal components play a role in tumor promotion or progression.

The management of Type 2 diabetes: a survey of Australian general practitioners.

OBJECTIVE: To explore how clinical and demographic variables impact on the management of diabetes mellitus in general practice. DESIGN: A structured vignette survey was conducted in Australia. This included nine vignettes chosen at random from 128 developed around seven clinical variables. Respondents were asked to recommend a change in treatment and make specific recommendations. A random sample of general practitioners (GPs) were recruited. Two diabetologists involved in the development of national guidelines also participated. RESULTS: 125 (13.8%) GPs participated. Statistical analyses were used to generate outcome measures. GPs recommended a change in treatment for most (81.1%) cases; were less likely to prescribe a statin (68.5% GPs vs. 76.3% diabetologists), less likely to treat hypertension (66.7% vs.89%) and less likely to refer for lifestyle modification (82.3% vs. 96.5%). Significant disagreement occurred around prescribing or changing oral hypoglycaemics. No GP characteristics showed significant impact. The proportion of GPs who agreed with diabetiologists on dose and choice of drugs was 35.7% for statins, 49.6% for antihypertensives and 39.6% for oral hypoglycaemics. CONCLUSIONS: There were significant differences between diabetologists and GPs on the management of diabetes. The survey suggests significant under-dosing by GPs. These findings warrant further investigation.

Increases in asthma hospital admissions associated with the end of the summer vacation for school-age children with asthma in two cities from England and Scotland.

In school-age asthmatics, an increase in hospitalizations has been reported in early autumn. This increase in admissions is conjectured to be associated with the return back to school. In the UK schools in England complete their summer vacations 2 weeks later than in Scotland and so there should be a lag between the two countries in the increase in asthma episode. Daily hospital asthma admission data from Aberdeen (in Scotland) and Doncaster (in England) for the period July 23rd to October 8th for years 1999-2004 were included in the analysis. There are peaks in hospitalization after the return back to school for both Aberdeen and Doncaster with the peak for Doncaster appearing 2 weeks after Aberdeen. This study has demonstrated peaks in admissions in school-age children around the return back to school in two cities where different school return dates were reflected in a 2-week lag effect. These data therefore provide strong evidence that peaks in admissions are associated with the end of the summer holidays.

Frequent attenders in general practice: an attempt to reduce attendance.

BACKGROUND: 'Frequent attenders' in general practice are known to include patients with a variety of problems. Most studies of frequent attenders have not assessed the impact of providing GPs with detailed summaries of the clinical records of these patients on consultation rates. Good medical records are associated with good care. If it is not relatively easy or quick for GPs to ascertain which chronic illness or psychosocial problems the patient has from the records, it will be difficult to manage the patient proactively. OBJECTIVE: The aim of this study was to investigate the impact on the consultation rate of providing a detailed and accessible summary of patients' problems including physical, social and psychological data based on information already recorded in the patients' records. METHOD: A prospective controlled study was made of frequent attenders at one UK general practice comprising four full-time GPs. A total of 104 frequent attenders were identified by examining the lists of patients attending the surgery and by including the names of patients identified by GPs from memory. The final study groups were patients who consulted a GP 11 times or more in a year. The sample was divided into two groups. In both groups, the clinical notes were summarized for data relating to physical, social and psychological problems. In the intervention group, summaries were displayed prominently in the notes which were marked with a distinctive label. GPs were asked to read and initial the available summaries in these notes. In the control group, summaries were not included in the notes and the notes were not highlighted in any way. The consultation rate of these 104 patients was recorded for 5 months after the availability of the summaries in the notes. RESULTS: Summarizing the notes in the style described in this study failed to reduce the consultation rate of the identified frequent attenders (Kruskal-Wallis H = 2.75, P = 0.1) Furthermore, in the intervention group, patients for whom there was evidence that the summaries had been consulted by their GP (24; 46%) continued to attend as frequently as those whose summaries were not endorsed as consulted (mean attendance 4.8 consultations compared with 4.2 in 5 months). CONCLUSION: Frequent attenders often have multiple problems, but prominently displayed summaries of their history for use by GPs during consultations do not reduce the frequency of consultations.