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1.  Stool submission by general practitioners in SW England - when, why and how? A qualitative study 
BMC Family Practice  2012;13:77.
Background
We know little about when and why general practitioners (GPs) submit stool specimens in patients with diarrhoea. The recent UK-wide intestinal infectious disease (IID2) study found ten GP consultations for every case reported to national surveillance. We aimed to explore what factors influence GP’s decisions to send stool specimens for laboratory investigation, and what guidance, if any, informs them.
Methods
We used qualitative methods that enabled us to explore opinions and ask open questions through 20 telephone interviews with GPs with a range of stool submission rates in England, and a discussion group with 24 GPs. Interviews were transcribed and subjected to content analysis.
Results
Interviews: GPs only sent stool specimens to microbiology if diarrhoea persisted for over one week, after recent travel, or the patient was very unwell. Very few had a systematic approach to determine the clinical or public health need for a stool specimen. Only two GPs specifically asked patients about blood in their stool; only half asked about recent antibiotics, or potential food poisoning, and few asked about patients’ occupations. Few GPs gave patients advice on how to collect specimens.
Results from interviews and discussion group in relation to guidance: All reported that the HPA stool guidance and patient collection instructions would be useful in their clinical work, but only one GP (an interviewee) had previously accessed them. The majority of GPs would value links to guidance on electronic requests. Most GPs were surprised that a negative stool report did not exclude all the common causes of IID.
Conclusions
GPs value stool culture and laboratories should continue to provide it. Patient instructions on how to collect stool specimens should be within stool collection kits. Through readily accessible guidance and education, GPs need to be encouraged to develop a more systematic approach to eliciting and recording details in the patient’s history that indicate greater risk of severe infection or public health consequences. Mild or short duration IID (under one week) due to any cause is less likely to be picked up in national surveillance as GPs do not routinely submit specimens in these cases.
doi:10.1186/1471-2296-13-77
PMCID: PMC3481435  PMID: 22870944
Stool specimens; Microbiology; Laboratory submission; Diarrhoea; Primary care; Qualitative; National guidance
2.  "...they should be offering it": a qualitative study to investigate young peoples' attitudes towards chlamydia screening in GP surgeries 
BMC Public Health  2010;10:616.
Background
Despite the known health and healthcare costs of untreated chlamydia infection and the efforts of the National Chlamydia Screening Programme (NCSP) to control chlamydia through early detection and treatment of asymptomatic infection, the rates of screening are well below the 2010-2011 target rate of 35%. General Practitioner (GP) surgeries are a key venue within the NCSP however; previous studies indicate that GP surgery staff are concerned that they may offend their patients by offering a screen. This study aimed to identify the attitudes to, and preferences for, chlamydia screening in 15-24 year old men and women attending GP surgeries (the target group).
Methods
We undertook 36 interviews in six surgeries of differing screening rates. Our participants were 15-24 year olds attending a consultation with a staff member. Data were analysed thematically.
Results
GP surgeries are acceptable to young people as a venue for opportunistic chlamydia screening and furthermore they think it is the duty of GP surgery staff to offer it. They felt strongly that it is important for surgery staff to have a non-judgemental attitude and they did not want to be singled out as 'needing' a chlamydia screen. Furthermore, our sample reported a strong preference for being offered a screen by staff and providing the sample immediately at the surgery rather than taking home a testing kit. The positive attitude and subjective norms demonstrated by interviewees suggest that young peoples' behaviour would be to accept a screen if it was offered to them.
Conclusion
Young people attending GP surgeries have a positive attitude towards chlamydia screening and given the right environment are likely to take up the offer in this setting. The right environment involves normalising screening by offering a chlamydia screen to all 15-24 year olds at every interaction with staff, offering screening with a non-judgemental attitude and minimising barriers to screening such as embarrassment. The GP surgery is the ideal place to screen young people for chlamydia as it is not a threatening place for them and our study has shown that they think it is the normal place to go to discuss health matters.
doi:10.1186/1471-2458-10-616
PMCID: PMC2965724  PMID: 20955570
3.  Limited impact on endoscopy demand from a primary care based ‘test and treat’ dyspepsia management strategy: the results of a randomised controlled trial 
Background
Helicobacter pylori testing has been suggested as an alternative to endoscopy for young patients with dyspepsia. Secondary care studies have suggested that demand for endoscopy among this group could be reduced by up to 74%. However, the effect of H. pylori testing in the primary care setting, where the majority of dyspepsia is managed, is unclear.
Aim
To determine the effects of providing a H. pylori serology service for GPs upon demand for open access endoscopy.
Design of study
A prospective randomised controlled trial.
Setting
Forty-seven general practices in Gloucestershire.
Method
General practices were stratified by endoscopy referral rate and randomised into two groups. The intervention group was provided with access to H. pylori serology testing and encouraged to use it in place of endoscopy for patients aged under 55 years with dyspepsia. Endpoints were referral for endoscopy and serology use.
Results
There was a significant reduction in referrals for endoscopy in the intervention group compared to the control group: 18.8% (95% confidence interval = 5.0 to 30.6%; P = 0.009).
Conclusions
Providing GPs with H. pylori serology testing reduced demand for open access endoscopy, but by less than previous studies had predicted.
PMCID: PMC1837846  PMID: 16638253
dyspepsia; endoscopy; Helicobacter pylori; serology
4.  Incidence and clinical variables associated with streptococcal throat infections: a prospective diagnostic cohort study 
The British Journal of General Practice  2012;62(604):e787-e794.
Background
Management of pharyngitis is commonly based on features which are thought to be associated with Lancefield group A beta-haemolytic streptococci (GABHS) but it is debatable which features best predict GABHS. Non-group A strains share major virulence factors with group A, but it is unclear how commonly they present and whether their presentation differs.
Aim
To assess the incidence and clinical variables associated with streptococcal infections.
Design and setting
Prospective diagnostic cohort study in UK primary care.
Method
The presence of pathogenic streptococci from throat swabs was assessed among patients aged ≥5 years presenting with acute sore throat.
Results
Pathogenic streptococci were found in 204/597 patients (34%, 95% CI = 31 to 38%): 33% (68/204) were non-group A streptococci, mostly C (n = 29), G (n = 18) and B (n = 17); rarely D (n = 3) and Streptococcus pneumoniae (n = 1). Patients presented with similar features whether the streptococci were group A or non-group A. The features best predicting A, C or G beta-haemolytic streptococci were patient’s assessment of severity (odds ratio [OR] for a bad sore throat 3.31, 95% CI = 1.24 to 8.83); doctors’ assessment of severity (severely inflamed tonsils OR 2.28, 95% CI = 1.39 to 3.74); absence of a bad cough (OR 2.73, 95% CI = 1.56 to 4.76), absence of a coryza (OR 1.54, 95% CI = 0.99 to 2.41); and moderately bad or worse muscle aches (OR 2.20, 95% CI = 1.41 to 3.42).
Conclusion
Non-group A strains commonly cause streptococcal sore throats, and present with similar symptomatic clinical features to group A streptococci. The best features to predict streptococcal sore throat presenting in primary care deserve revisiting.
doi:10.3399/bjgp12X658322
PMCID: PMC3481520  PMID: 23211183
pharyngitis; primary care; tonsillitis; streptococcus

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