Evaluation of the use of ultrasonography in primary care

Ultrasonography is proposed as a useful diagnostic aid for primary care physicians. This prospective study describes the demand for ultrasound examinations, excluding heart, vessels and pregnancy monitoring, in primary care in Switzerland. Eleven independent physicians requested an average of 2.7 ultrasound examinations per month and 18 residents 1.9 per month, which was similar to the figure of 2.2 obtained in a population-based study of 82 primary care physicians serving a region of 80, 000 inhabitants. Current demand for ultrasound scanning is low and does not indicate systematic training of primary care physicians until the efficacy of ultrasonography in this setting has been show

Predictive ability of an early diagnostic guess in patients presenting with chest pain; a longitudinal descriptive study

The intuitive early diagnostic guess could play an important role in reaching a final diagnosis. However, no study to date has attempted to quantify the importance of general practitioners' (GPs) ability to correctly appraise the origin of chest pain within the first minutes of an encounter. The validation study was nested in a multicentre cohort study with a one year follow-up and included 626 successive patients who presented with chest pain and were attended by 58 GPs in Western Switzerland. The early diagnostic guess was assessed prior to a patient's history being taken by a GP and was then compared to a diagnosis of chest pain observed over the next year. Using summary measures clustered at the GP's level, the early diagnostic guess was confirmed by further investigation in 51.0% (CI 95%; 49.4% to 52.5%) of patients presenting with chest pain. The early diagnostic guess was more accurate in patients with a life threatening illness (65.4%; CI 95% 64.5% to 66.3%) and in patients who did not feel anxious (62.9%; CI 95% 62.5% to 63.3%). The predictive abilities of an early diagnostic guess were consistent among GPs. The GPs early diagnostic guess was correct in one out of two patients presenting with chest pain. The probability of a correct guess was higher in patients with a life-threatening illness and in patients not feeling anxious about their pain

Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score

Chest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care. Data were collected from a multicenter Swiss clinical cohort study including 672 consecutive patients with chest pain, who had visited one of 59 family practitioners' offices. Using delayed diagnosis we derived a prediction rule to rule out coronary heart disease by means of a logistic regression model. Known cardiovascular risk factors, pain characteristics, and physical signs associated with coronary heart disease were explored to develop a clinical score. Patients diagnosed with angina or acute myocardial infarction within the year following their initial visit comprised the coronary heart disease group. The coronary heart disease score was derived from eight variables: age, gender, duration of chest pain from 1 to 60 minutes, substernal chest pain location, pain increasing with exertion, absence of tenderness point at palpation, cardiovascular risks factors, and personal history of cardiovascular disease. Area under the receiver operating characteristics curve was of 0.95 with a 95% confidence interval of 0.92; 0.97. From this score, 413 patients were considered as low risk for values of percentile 5 of the coronary heart disease patients. Internal validity was confirmed by bootstrapping. External validation using data from a German cohort (Marburg, n = 774) revealed a receiver operating characteristics curve of 0.75 (95% confidence interval, 0.72; 0.81) with a sensitivity of 85.6% and a specificity of 47.2%. This score, based only on history and physical examination, is a complementary tool for ruling out coronary heart disease in primary care patients complaining of chest pain

Chest wall syndrome among primary care patients: a cohort study

BACKGROUND: The epidemiology of chest pain differs strongly between outpatient and emergency settings. In general practice, the most frequent cause is the chest wall pain. However, there is a lack of information about the characteristics of this syndrome. The aims of the study are to describe the clinical aspects of chest wall syndrome (CWS). METHODS: Prospective, observational, cohort study of patients attending 58 private practices over a five-week period from March to May 2001 with undifferentiated chest pain. During a one-year follow-up, questionnaires including detailed history and physical exam, were filled out at initial consultation, 3 and 12 months. The outcomes were: clinical characteristics associated with the CWS diagnosis and clinical evolution of the syndrome. RESULTS: Among 24 620 consultations, we observed 672 cases of chest pain and 300 (44.6%) patients had a diagnosis of chest wall syndrome. It affected all ages with a sex ratio of 1:1. History and sensibility to palpation were the keys for diagnosis. Pain was generally moderate, well localised, continuous or intermittent over a number of hours to days or weeks, and amplified by position or movement. The pain however, may be acute. Eighty-eight patients were affected at several painful sites, and 210 patients at a single site, most frequently in the midline or a left-sided site. Pain was a cause of anxiety and cardiac concern, especially when acute. CWS coexisted with coronary disease in 19 and neoplasm in 6. Outcome at one year was favourable even though CWS recurred in half of patients. CONCLUSION: CWS is common and benign, but leads to anxiety and recurred frequently. Because the majority of chest wall pain is left-sided, the possibility of coexistence with coronary disease needs careful consideration

Patients presenting with somatic complaints in general practice: depression, anxiety and somatoform disorders are frequent and associated with psychosocial stressors

Mental disorders in primary care patients are frequently associated with physical complaints that can mask the disorder. There is insufficient knowledge concerning the role of anxiety, depression, and somatoform disorders in patients presenting with physical symptoms. Our primary objective was to determine the prevalence of depression, anxiety, and somatoform disorders among primary care patients with a physical complaint. We also investigated the relationship between cumulated psychosocial stressors and mental disorders. We conducted a multicentre cross-sectional study in twenty-one private practices and in one academic primary care centre in Western Switzerland. Randomly selected patients presenting with a spontaneous physical complaint were asked to complete the self-administered Patient Health Questionnaire (PHQ) between November 2004 and July 2005. The validated French version of the PHQ allowed the diagnosis of mental disorders (DSM-IV criteria) and the analyses of exposure to psychosocial stressors. There were 917 patients exhibiting at least one physical symptom included. The rate of depression, anxiety, and somatoform disorders was 20.0% (95% confidence interval [CI] = 17.4% to 22.7%), 15.5% (95% CI = 13.2% to 18.0%), and 15.1% (95% CI = 12.8% to 17.5%), respectively. Psychosocial stressors were significantly associated with mental disorders. Patients with an accumulation of psychosocial stressors were more likely to present anxiety, depression, or somatoform disorders, with an increase of 2.2 fold (95% CI = 2.0 to 2.5) for each additional stressor. The investigation of mental disorders and psychosocial stressors among patients with physical complaints is relevant in primary care. Psychosocial stressors should be explored as potential epidemiological causes of mental disorders

The 'help' question doesn't help when screening for major depression: external validation of the three-question screening test for primary care patients managed for physical complaints

Major depression, although frequent in primary care, is commonly hidden behind multiple physical complaints that are often the first and only reason for patient consultation. Major depression can be screened by two validated questions that are easier to use in primary care than the full Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria. A third question, called the 'help' question, improves the specificity without apparently decreasing the sensitivity of this screening procedure. We validated the abbreviated screening procedure for major depression with and without the 'help' question in primary care patients managed for a physical complaint. This diagnostic accuracy study used data from the SODA (for 'SOmatisation Depression Anxiety') cohort study conducted by 24 general practitioners (GPs) in western Switzerland that included patients over 18 years of age with at least a single physical complaint at index consultation. Major depression was identified with the full Patient Health Questionnaire. GPs were asked to screen patients for major depression with the three screening questions 1 year after inclusion. Of 937 patients with at least a single physical complaint, 751 were eligible 1 year after index consultation. Major depression was diagnosed in 69/724 (9.5%) patients. The sensitivity and specificity of the two-question method alone were 91.3% (95% CI 81.4 to 96.4) and 65.0% (95% CI 61.2 to 68.6), respectively. Adding the 'help' question decreased the sensitivity (59.4%; 95% CI 47.0 to 70.9) but improved the specificity (88.2%; 95% CI 85.4 to 90.5) of the three-question method. The use of two screening questions for major depression was associated with high sensitivity and low specificity in primary care patients presenting a physical complaint. Adding the 'help' question improved the specificity but clearly decreased the sensitivity; when using the 'help' question, four out of ten patients with depression will be missed, compared to only one out of ten with the two-question method. Therefore, the 'help' question is not useful as a screening question, but may help discussing management strategies

Oral vitamin B12 for patients suspected of subtle cobalamin deficiency: a multicentre pragmatic randomised controlled trial

BACKGROUND: Evidence regarding the effectiveness of oral vitamin B12 in patients with serum vitamin B12 levels between 125-200 pM/l is lacking. We compared the effectiveness of one-month oral vitamin B12 supplementation in patients with a subtle vitamin B12 deficiency to that of a placebo. METHODS: This multicentre (13 general practices, two nursing homes, and one primary care center in western Switzerland), parallel, randomised, controlled, closed-label, observer-blind trial included 50 patients with serum vitamin B12 levels between 125-200 pM/l who were randomized to receive either oral vitamin B12 (1000 μg daily, N = 26) or placebo (N = 24) for four weeks. The institution's pharmacist used simple randomisation to generate a table and allocate treatments. The primary outcome was the change in serum methylmalonic acid (MMA) levels after one month of treatment. Secondary outcomes were changes in total homocysteine and serum vitamin B12 levels. Blood samples were centralised for analysis and adherence to treatment was verified by an electronic device (MEMS; Aardex Europe, Switzerland). Trial registration: ISRCTN 22063938. RESULTS: Baseline characteristics and adherence to treatment were similar in both groups. After one month, one patient in the placebo group was lost to follow-up. Data were evaluated by intention-to-treat analysis. One month of vitamin B12 treatment (N = 26) lowered serum MMA levels by 0.13 μmol/l (95%CI 0.06-0.19) more than the change observed in the placebo group (N = 23). The number of patients needed to treat to detect a metabolic response in MMA after one month was 2.6 (95% CI 1.7-6.4). A significant change was observed for the B12 serum level, but not for the homocysteine level, hematocrit, or mean corpuscular volume. After three months without active treatment (at four months), significant differences in MMA levels were no longer detected. CONCLUSIONS: Oral vitamin B12 treatment normalised the metabolic markers of vitamin B12 deficiency. However, a one-month daily treatment with 1000 μg oral vitamin B12 was not sufficient to normalise the deficiency markers for four months, and treatment had no effect on haematological signs of B12 deficiency

Les données à caractère personnel, carburant du capitalisme de surveillance

International audienceThe financing of digital services through indirect monetization leads to a global and massive collection of personal data, aiming at better targeting their users to better serve them and retain their customers. Solutionist thinking encourages organizations, both private and public, to aggregate data, including sensitive data such as health data, into information systems that are intended to produce knowledge that would be used to solve crises or social problems. However, these data are also likely to be used to influence the individual behavior of people and, on a larger scale, the overall functioning of human societies.The European Union has undertaken to regulate the use of personal data through a succession of texts, including the GDPR, which has rapidly become a worldwide standard. However, private operators are in charge of entire sections of the effective regulation of content, which can lead to more or less detectable censorship. A possible way forward would be to consider social networks as infrastructures, regulated as commons.Le financement des services numériques par la monétisation indirecte conduit à une collecte globale et massive de données à caractère personnel, visant à mieux cibler les personnes pour mieux les servir et conserver leur clientèle. La pensée solutionniste encourage les organisations, tant privées que publiques, à agréger des données, y compris des données sensibles telles que les données de santé, dans des systèmes d'information censés produire des connaissances utiles à la résolution de crises ou de problèmes sociaux. Cependant, ces données sont aussi susceptibles d'être utilisées pour influencer le comportement individuel des personnes et, à plus grande échelle, le fonctionnement global des sociétés humaines.L'Union européenne a entrepris de réguler l'usage des données à caractère personnel par une succession de textes, dont le RGPD, rapidement devenu un standard mondial. Les opérateurs privés sont cependant en charge de pans entiers de la régulation effective des contenus, pouvant conduire à des censures plus ou moins détectables. Une voie possible serait de considérer les réseaux sociaux comme des infrastructures, administrées comme des communs

La confiance du patient en son médicament (poids du médecin traitant et influence des médias dans cette relation)

la confiance du patient en son médicament : poids du médecin traitant et influence des médias dans cette relation. De nos jours, les récentes affaires autour des médicaments, largement diffusées dans les médias comme celle du Médiator, ou plus récemment du Furosemide Teva, mettent la confiance des patients dans leurs médicaments à rude épreuve. Le médecin traitant a un rôle prépondérant à jouer dans l'établissement et le maintien de cette relation de confiance entre le patient et son traitement. L'objectif de cette thèse a été d'étudier l'image qu'a le médicament chez les patients, la confiance qu'ils y accordent, les éventuelles recherches d'informations réalisées par les patients sur celui-ci, et le poids respectif que peuvent avoir le médecin généraliste et les médias dans cette relation au médicament. En mars et avril 2013, un questionnaire anonyme a été distribué en fin de consultation aux patients de trois cabinets de médecine générale en milieu rural en nord-Vendée, à La Gaubretière et aux Herbiers. Les critères d'inclusion étaient le fait d'être patients du cabinet et l'âge supérieur à 18 ans. Au total, 250 questionnaires ont été analysés, et il est apparu que 92,8% des patients avaient tout à fait ou plutôt confiance dans le médicament en général, et ils étaient 97,2% à avoir tout à fait ou plutôt confiance en un médicament prescrit. Il n'existait donc pas de différence selon que le médicament était obtenu sur ordonnance ou non. Le médecin généraliste, de par l'excellente image dont il jouit auprès de ses patients, joue un rôle primordial dans cette confiance, malgré l'influence certaine que peuvent avoir les médias qui pointent largement du doigt actuellement les effets négatifs des médicaments, à grand renfort de sujets télévisuels, et d'ouvrages littéraires à succès. Les patients sont sensibles aux messages véhiculés via la télévision, internet, la presse, mais leur premier interlocuteur et personne de confiance reste leur médecin traitant, dont ils écoutent les conseils et explications et qui garde le dernier mot malgré tout. La confiance envers le médicament est fragile, devant être sans cesse entretenue, et le développement grandissant des médias mérite une attention de tous les instants de la part du soignant, afin que le médicament garde cette image positive auprès de sa patientèle, et qu'il puisse continuer à s'y appuyer dans sa pratique quotidienne.NANTES-BU Médecine pharmacie (441092101) / SudocSudocFranceF