Barriers to effective primary health care for adolescents.

OBJECTIVES: To assess general practitioners' (GPs') perceptions of barriers in the health care system that hinder provision of effective adolescent health care; and to assess the training needs of GPs for a future education program in adolescent health issues. DESIGN: Retrospective questionnaire survey. METHODS: A 66-item questionnaire was mailed during May and June 1995 to a random stratified sample of 997 rural and urban Victorian GPs. A Practice Assessment Task enabling respondents to fulfil Royal Australian College of General Practitioners' quality assurance requirements was mailed on return of completed questionnaires if requested. RESULTS: The response rate was 72.4%. After adjusting for stratified sampling, 77% (95% confidence interval [CI], 73%-81%) of respondents favoured individual Medicare cards for adolescents from the age of 16. Thirty-eight per cent (95% CI, 34%-43%) were less willing to charge for longer consultations because they feared Health Insurance Commission (HIC) investigation. Most respondents indicated that their undergraduate training in adolescent mental health issues was inadequate and 64% (95% CI, 61%-68%) found it difficult to obtain advice about complex mental health problems. An interest in continuing medical education in adolescent health issues was expressed by 82% (95% CI, 79%-86%) of respondents. CONCLUSIONS: Individual Medicare cards should be automatically issued to adolescents from the age of 16 to improve their ability to access health care. Revision of the Medicare rebate system and clarification of HIC's investigative functions may improve GP's effectiveness in adolescent consultations. Undergraduate medical and GP training should include curriculum relevant to adolescent health care.

Adolescent health care: perspectives of Victorian general practitioners.

OBJECTIVES: To assess general practitioners' (GPs') views of adolescents as a discrete patient group with specific developmental health care needs; to document GPs' perceived knowledge of and competence in adolescent health care; and to clarify the barriers GPs perceive to effective delivery of such care. DESIGN: Qualitative research. METHODS: Stratified sampling generated a sample of 57 GPs from rural and urban divisions of general practice. Focus group discussions and individual interviews were recorded and transcripts were analysed. RESULTS: Thirty-three GPs (62%) reported that adolescents made up 10% or more of their weekly consultations. Although 10 GPs defined adolescents by developmental criteria, 47 had an incomplete understanding of the developmental aspects of adolescence. Most GPs (43) had some concerns about their knowledge of and competence in delivering adolescent health care and 52 stated that they had had little or no formal training in adolescent health. The participants perceived a range of barriers to effective health care provision, including issues of confidentiality, communication and cost. CONCLUSIONS: Changes are needed in the Medicare card and rebate systems to ensure improved access to affordable, confidential care for adolescents. Our results also support the incorporation of important adolescent health care issues in undergraduate and postgraduate medical training.

Assessment of blood pressure during naproxen therapy in hypertensive patients treated with nicardipine.

Nonsteroidal antiinflammatory drugs (NSAIDs) are known to attenuate the antihypertensive effects of a variety of antihypertensive agents including diuretics, beta-blockers, and vasodilators. Because of their unique mechanisms of actions, calcium channel blockers may not be subject to this interaction. This multicenter, double-blind, randomized, placebo-controlled study was designed to assess the effect of NSAID therapy on blood pressure control in stable hypertensive patients treated with a calcium channel blocker. One hundred patients with stable blood pressure control on 30 mg nicardipine three times a day were treated with 375 mg naproxen twice a day or placebo for 4 weeks. The mean diastolic blood pressures and estimated mean arterial pressures in both groups changed < 1 mm Hg during the 4 weeks of study drug treatment. None of the changes was significantly different from baseline and the two treatment groups were not significantly different from each other. Body weight in the placebo-treated patients did not change significantly whereas body weight in the naproxen-treated patients increased significantly, from 90.3 +/- 3.2 kg to 91.0 +/- 3.2 kg (mean = 0.7, P = .0003). At 4 weeks there was a mean loss of 0.1 kg in the placebo group and a mean gain of 0.4 kg in the naproxen group compared to baseline weights, neither of which was statistically significant (P = .60 and P = .071, respectively). These results indicate that despite a significant increase in body weight, the antihypertensive action of the calcium channel blocker nicardipine is not significantly affected by cotreatment with naproxen.

Assessment of blood pressure during treatment with naproxen or ibuprofen in hypertensive patients treated with hydrochlorothiazide.

This study determined the effect of nonsteroidal anti-inflammatory drug (NSAID) administration on blood pressure in hypertensive patients taking hydrochlorothiazide (HCTZ). Ninety-seven patients with mild essential hypertension and a musculoskeletal indication for NSAID use were studied in a three-phase, multi-center, double-blind, randomized, parallel study based in 15 academic and community clinics. Patients served as their own controls. Patients with stable hypertension, not taking antihypertensive or NSAID medications, were treated with HCTZ 50 mg/day. After 4 to 5 weeks of treatment and documented stable blood pressure, naproxen 375 mg twice a day or ibuprofen 800 mg three times a day was added. Blood pressure was measured at 2 and 4 weeks of NSAID therapy. The average diastolic blood pressure was 97.5 +/- 2.4 mm Hg and the average of the mean arterial pressure (MAP) was 116.8 +/- 6.04 before treatment with HCTZ. Hydrochlorothiazide treatment decreased diastolic blood pressure to 83.1 +/- 5.6 mm Hg, and MAP to 101.1 +/- 6.5 mm Hg. With naproxen or ibuprofen treatments, mean diastolic blood pressure increased less than 3 mm Hg. At 2 weeks, ibuprofen increased diastolic blood pressure by 2.6 mm Hg (P = .004) and naproxen increased diastolic blood pressure 0.7 mm Hg (P = .40). Both ibuprofen and naproxen significantly increased diastolic pressure at 4 weeks (2.1 mm Hg, P = .042; and 1.8 mm Hg, P = .043, respectively). There was no correlation between the pre-NSAID blood pressure and the magnitude of change after 2 or 4 weeks of treatment. Changes in MAP reflected a pattern similar to diastolic pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of naproxen on renal function in older patients with mild to moderate renal dysfunction.

We have evaluated 45 elderly patients with both musculoskeletal problems and mild to moderate renal dysfunction. We treated these patients with a non-steroidal anti-inflammatory drug (NSAID) for 2 weeks. The serum creatinine, urinary creatinine clearance and blood pressure were monitored before and after therapy. In some patients serum levels of thromboxane B2 (TxB2) and the urinary prostaglandins E2 (PGE2) and I2 (prostacyclin) measured as 6-keto-PGF1 alpha were also monitored before and after therapy and correlated with the clinical measurements. This study has demonstrated that in the entire patient group, the trial drug was tolerated extremely well. There were no changes in the serum creatinine or in the urinary creatinine clearance after 2 weeks of therapy. There was also no change in the early morning diastolic blood pressure. In the 11 patients in whom the serum and urinary prostaglandins were measured, the serum thromboxane levels fell with therapy to a level of 1.5% of the initial value. The urinary levels of PGE2 also fell but not to the same degree. The urinary PGE2 levels fell to 28% of the baseline values. There was no significant change in the levels of urinary 6-keto-PGF1 alpha (prostacyclin). These observations suggest that prostacyclin may be the important prostaglandin in maintaining normal renal haemodynamics when patients are treated with NSAIDs.

Survival, prognosis, and causes of death in rheumatoid arthritis.

The factors associated with mortality were examined in a prospective longitudinal study, over an average of 12 years, with 94% followup of patients diagnosed as having rheumatoid arthritis. Of 805 patients, 233 died during the period of the study. Survivorship of rheumatoid arthritis patients was approximately 50% less than that of population controls. Survivorship was decreased by the traditional demographic variables of greater age and male sex; however, a significant independent effect of variables reflecting disease severity (American Rheumatism Association functional class, rheumatoid factor titer, number of involved joints) was identified by multivariate analysis. Seventy-nine excess deaths (i.e., those that would not have been expected in a control population) were due in part to disease-related causes, to infections, and to gastrointestinal complications of therapy. Treatment with gold or prednisone did not seem to affect survivorship or cause of death, except for the clustering of deaths of patients with vasculitis within the prednisone group. Our findings indicate that rheumatoid arthritis, a chronic disabling disease, is also associated with a major decrease in survivorship.

A multicenter study of hospitalization in rheumatoid arthritis. Frequency, medical-surgical admissions, and charges.

During 1981, 123 of 816 patients (15.1%) with rheumatoid arthritis were hospitalized 160 times because of the disease. The mean length of hospitalization was 13.1 days, and the cost $7,845. Surgery accounted for 54.4% of admissions, but 69.2% of costs. The average cost for total joint surgery was $12,287. Most medical admissions (46.6%) were for the diagnosis or treatment of articular disease, but 42.5% were for treatment of side effects of therapy, and 11.0% for complications of RA. The most commonly performed surgical procedures included reconstructive surgery of the hand/wrist (n = 35) and foot (n = 22), followed by total knee replacement (n = 18).

The development of disability in rheumatoid arthritis.

Six hundred eighty-one consecutive patients with rheumatoid arthritis were followed for an average of 11.9 years to identify initial factors that predicted subsequent disability. Of 39 potentially predictive variables obtained at study onset and studied by stepwise regression methods, age was found to be the most powerful single predictor of disability, followed by radiologic grade, sex, and initial functional class. The worst prognosis for disability was found in patients who were older women and who showed radiologic worsening and developed functional impairment early in the disease course. Both disability and radiologic progression of disease were found to develop most rapidly during the first years after disease onset and to assume a slow, nearly linear rate of increase after 10 years. Approximately 10% of patients did not develop significant disability. This study suggests that it is possible to identify, early in the disease course, those patients who are likely to develop severe disability, and that "disease-modifying" therapy might well be initiated earlier in such patients and used consistently throughout the subsequent treatment.

A multicenter study of hospitalization in rheumatoid arthritis: effect of health care system, severity, and regional difference.

During 1981, centers in Phoenix, Saskatoon, Stanford and Wichita monitored hospitalizations for 816 patients with rheumatoid arthritis. Admission rates varied 2-fold, and admissions for evaluation and treatment 10-fold across centers. Admissions were related primarily to disease severity, but in US centers, were reduced by a factor of 3 by prepaid health care. Length of stay was shortest in California (7.3 days), and longest in Saskatoon (16.3) where designated arthritis beds and government prepaid health care existed. Average charges for surgery were as high as $10,000 in Phoenix and as low as $4550 in Wichita. Charges and length of stay were unrelated to disease severity, but were responsive to health care delivery system, availability of facilities, and geographic and center variation.

How many joints in the hands and wrists should be included in a score of radiologic abnormalities used to assess rheumatoid arthritis?

Numerous methods for reading abnormalities of rheumatoid arthritis in hand and wrist radiographs have been proposed over the past several decades. There are many differences among these methods, one of the more striking of which is the variation in the number of joints that are scored. In this study, we tested the number of joints that need to be read in order to represent abnormalities accurately and reproducibly, using the scores of multiple observers. Thirteen rheumatologists and radiologists each read a set of 41 hand and wrist films from patients with rheumatoid arthritis. Ten of 13 readers scored 27 joints in each hand and wrist; the other 3 readers scored fewer areas. Fourteen combinations of joints were selected based on the frequency of involvement and the technical adequacy of routine films in assessing a given area. After testing these 14 different combinations, 1 scheme, which included 17 areas read for erosions and 18 areas read for joint space narrowing, was tested further. The correlation coefficients for 10 intraobserver scores derived from this modified scheme compared with the original scores were between 0.981 and 0.997. Seventy-one of 78 interobserver comparisons were better using the new scheme than using the original scheme. These data indicate that the simplified scheme, using a combination of 17 joints to score erosions and 18 to score joint space narrowing, more accurately reflects the extent of abnormalities perceived by a panel of experts than does the original scheme. This abbreviated number of joints shortens the amount of time required to read a set of films and simplifies the scoring of films, since a number of areas that are difficult to read are eliminated from radiographic assessment.

Psychological status in primary fibrositis and fibrositis associated with rheumatoid arthritis.

Psychological status was investigated in 46 primary fibrositis (PF) patients, 32 with fibrositis occurring in association with rheumatoid arthritis (RAFIB) and in 76 control patients with rheumatoid arthritis. Groups were similar in tests of life stresses: Family Inventory of Life Events, Multidimensional Health Locus of Control, and self-motivation. Only 28% of PF and 25% of RAFIB had Minnesota Multiphasic Personality Inventory profiles classified as "normal" compared with 51-60% of controls. Both PF and RAFIB had elevated "neurotic" scales (hypochondriasis, depression, hysteria), but only PF patients had statistically significant elevations in the pychopathic deviancy, psychasthenia and paranoia scales. When the Arthritis Impact Measurement Scales were used, PF but not RAFIB patients demonstrated statistically significant elevations on the anxiety and depression scales.

Rheumatoid arthritis and antecedent tonsillectomy.

The association of antecedent tonsillectomy (T) and subsequent development of rheumatoid arthritis (RA) was investigated in a population of 405 patients with RA and 223 controls with low back syndrome (LBS) or osteoarthritis (OA). A similar matched pair analysis of 113 RA patients and 113 community controls was also conducted. All patients were matched for age and sex. All groups were similar in demographic characteristics. T(+) and T(-) RA patients were similar in severity and disease characteristic parameters. No differences were found in the frequency of tonsillectomy in either of the RA or control groups. These data suggest that antecedent tonsillectomy is not causally related to the development of RA.

Treatment of xerostomia: a double-blind trial in 108 patients with Sjögren's syndrome.

The first-ever controlled study of a therapeutic modality for xerostomia is reported. A recently described formulation for saliva substitute (SS) has been tested against a glycerine mouthwash as a control saliva substitute (placebo) in a double-blind clinical trial in 108 patients with varying grades of xerostomia of Sjögren's syndrome. The results indicate that SS offered significant relief of nocturnal oral discomfort (p less than 0.02) and more patients reported "excellent" improvement (p less than 0.01) on a five-point graded response. In all other respects, the SS was not significantly better than the placebo. Significant adverse effects were not reported. It is suggested that any such current and future therapeutic modalities for Sjögren's syndrome be subjected to similar critical appraisal of their worth.