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1.  Localised necrosis of scrotum (Fournier's gangrene) in a spinal cord injury patient – a case report 
BMC Family Practice  2002;3:20.
Background
Men with spinal cord injury (SCI) appear to have a greater incidence of bacterial colonisation of genital skin as compared to neurologically normal controls. We report a male patient with paraplegia who developed rapidly progressive infection of scrotal skin, which resulted in localised necrosis of scrotum (Fournier's gangrene).
Case presentation
This male patient developed paraplegia at T-8 level 21 years ago at the age of fifteen years. He has been managing his bladder by wearing a penile sheath. He noticed redness and swelling on the right side of the scrotum, which rapidly progressed to become a black patch. A wound swab yielded growth of methicillin-resistant Staphylococcus aureus (MRSA). Necrotic tissue was excised. Culture of excised tissue grew MRSA. A follow-up wound swab yielded growth of MRSA and mixed anaerobes. The wound was treated with regular application of povidone-iodine spray. He made good progress, with the wound healing gradually.
Conclusion
It is likely that the presence of a condom catheter, increased skin moisture in the scrotum due to urine leakage, compromised personal hygiene, a neurogenic bowel and subtle dysfunction of the immune system contributed to colonisation, and then rapidly progressive infection in this patient. We believe that spinal cord injury patients and their carers should be made aware of possible increased susceptibility of SCI patients to opportunistic infections of the skin. Increased awareness will facilitate prompt recourse to medical advice, when early signs of infection are present.
doi:10.1186/1471-2296-3-20
PMCID: PMC138815  PMID: 12466026
2.  Prostate-specific antigen testing accuracy in community practice 
BMC Family Practice  2002;3:19.
Background
Most data on prostate-specific antigen (PSA) testing come from urologic cohorts comprised of volunteers for screening programs. We evaluated the diagnostic accuracy of PSA testing for detecting prostate cancer in community practice.
Methods
PSA testing results were compared with a reference standard of prostate biopsy. Subjects were 2,620 men 40 years and older undergoing (PSA) testing and biopsy from 1/1/95 through 12/31/98 in the Albuquerque, New Mexico metropolitan area. Diagnostic measures included the area under the receiver-operating characteristic curve, sensitivity, specificity, and likelihood ratios.
Results
Cancer was detected in 930 subjects (35%). The area under the ROC curve was 0.67 and the PSA cutpoint of 4 ng/ml had a sensitivity of 86% and a specificity of 33%. The likelihood ratio for a positive test (LR+) was 1.28 and 0.42 for a negative test (LR-). PSA testing was most sensitive (90%) but least specific (27%) in older men. Age-specific reference ranges improved specificity in older men (49%) but decreased sensitivity (70%), with an LR+ of 1.38. Lowering the PSA cutpoint to 2 ng/ml resulted in a sensitivity of 95%, a specificity of 20%, and an LR+ of 1.19.
Conclusions
PSA testing had fair discriminating power for detecting prostate cancer in community practice. The PSA cutpoint of 4 ng/ml was sensitive but relatively non-specific and associated likelihood ratios only moderately revised probabilities for cancer. Using age-specific reference ranges and a PSA cutpoint below 4 ng/ml improved test specificity and sensitivity, respectively, but did not improve the overall accuracy of PSA testing.
doi:10.1186/1471-2296-3-19
PMCID: PMC137591  PMID: 12398793
Prostatic neoplasms; prostate-specific antigen; sensitivity and specificity; ROC curve; likelihood functions
3.  Impact of obesity on glucose and lipid profiles in adolescents at different age groups in relation to adulthood 
BMC Family Practice  2002;3:18.
Background
As obesity is rapidly becoming a major medical and public health problem, the aim of our study was to determine: 1) if obesity in Caucasian adolescents at 5 different Tanner stages are associated with obesity in adulthood and its obesity-associated abnormal glucose and lipid profiles, 2) the type of fat distribution is associated with glucose and lipid profile abnormalities, and 3) the risk level and the age of appearance of these abnormalities.
Methods
For the first study, data analyses were from a case-control study of adolescents classified according to their BMI; a BMI ≥ 85th percentile for age and sex as overweight, and those with a BMI ≥ 95th percentile as obese. Subjects with a BMI < 85th percentile were classified as controls. WC:AC ratio of waist circumference to arm circumference was used as an indicator of a central pattern of adiposity. Two other indices of central adiposity were calculated from skinfolds: Central-peripheral (CPR) as subscapular skinfold + suprailliac skinfold)/ (triceps skinfold + thigh skinfold) and ratio of subscapular to triceps skinfold (STR). The sum of the four skinfolds (SUM) was calculated from triceps, subscapular, suprailliac and thigh skinfolds. SUM provides a single measure of subcutaneous adiposity. Representative adult subjects were used for comparison. Glucose and lipid profiles were also determined in these subjects. Abnormal glucose and lipid profiles were determined as being those with fasting glucose ≥ 6.1 mmol/l and lipid values ≥ 85th percentile adjusted for age and sex, respectively. Prevalence and odds ratio analysis were used to determine the impact of obesity on glucose and lipid profiles at each Tanner stages for both sexes. Correlation coefficient analyses were used to determine the association between glucose and lipid profiles and anthropometric measurements for both sexes. The second study evaluated in a retrospective-prospective longitudinal way if: 1) obesity in adolescence is associated with obesity in adulthood and 2) the nature of obesity-associated risk factors. Incidence and odds ratio analysis were used to determine the impact of obesity on glucose and lipid profiles at 7 different age groups from 9 to 38 years old in both sexes between 1974 to 2000.
Results
Overall, glucose and lipid profiles were significantly (P < 0.01) associated with all anthropometric measurements either in male and female adolescents. WC:AC, CPR, STR and SUM are stronger predictors of both glucose and lipid profiles than BMI. Obese and overweight adolescents of Tanner stages III and higher are at increased risk of having an impaired glucose and lipid profiles than normal subjects with odds ratios of 5.9 and higher. Obesity in adolescents of 13–15 years old group is significantly (P < 0.01) associated with obesity in adulthood (with odds ratios of at least 12 for both men and women) and abnormal glucose (odds ratio of ≥ 8.6) and lipid profiles (odds ratio of ≥ 11.4).
Conclusions
This study confirmed that adolescents aged between 13 and 15 years old of both sexes with a BMI ≥ 85th percentile are at increased risk of becoming overweight or obese adults and presenting abnormal glucose and lipid profiles as adults. This emphasizes the importance of early detection and intervention directed at treatment of obesity to avert the long-term consequences of obesity on the development of cardiovascular diseases.
doi:10.1186/1471-2296-3-18
PMCID: PMC134463  PMID: 12379160
4.  Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study 
BMC Family Practice  2002;3:17.
Background
Self-medication and non-doctor prescribing of drugs is common in developing countries. Complementary and alternative medications, especially herbs, are also commonly used. There are few studies on the use of these medications in Pokhara Valley, Western Nepal.
Methods
Previously briefed seventh semester medical students, using a semi-structured questionnaire, carried out the study on 142 respondents. Demographic information and information on drugs used for self-medication or prescribed by a non-allopathic doctor were collected.
Results
Seventy-six respondents (54%) were aged between 20 to 39 years. The majority of the respondents (72 %) stayed within 30 minutes walking distance of a health post/medical store. 59% of these respondents had taken some form of self-medication in the 6-month period preceding the study. The common reasons given for self-medication were mild illness, previous experience of treating a similar illness, and non-availability of health personnel. 70% of respondents were prescribed allopathic drugs by a non-allopathic doctor. The compounder and health assistant were common sources of medicines. Paracetamol and antimicrobials were the drugs most commonly prescribed. A significantly higher proportion of young (<40 years) male respondents had used self-medication than other groups.
Conclusions
Self-medication and non-doctor prescribing are common in the Pokhara valley. In addition to allopathic drugs, herbal remedies were also commonly used for self-medication. Drugs, especially antimicrobials, were not taken for the proper duration. Education to help patients decide on the appropriateness of self-medication is required.
doi:10.1186/1471-2296-3-17
PMCID: PMC130019  PMID: 12236905
5.  Antibiotics for coughing in general practice: a questionnaire study to quantify and condense the reasons for prescribing 
BMC Family Practice  2002;3:16.
Background
Antibiotics are being overprescribed in ambulant care, especially for respiratory tract infections (RTIs). Gaining insight into the actual reasons for prescribing remains important for the design of effective strategies to optimise antibiotic prescribing. We aimed to determine items of importance for the antibiotic prescribing decision and to make them operational for an intervention trial.
Methods
A postal questionnaire based upon focus group findings was sent to 316 Flemish general practitioners (GPs). On a verbal rating scale the GPs scored to what extent they consider the questionnaire items in decision making in case of suspected RTI in a coughing patient and how strongly the items support or counter antibiotic treatment. Factor analysis was used to condense the data. The relative importance of the yielded operational factors was assessed using Wilcoxon Matched Pairs test.
Results
59.5% completed the study. Response group characteristics (mean age: 42.8 years; 65.9% men) approximated that of all Flemish GPs. Participants considered all the items included in the questionnaire: always the operational factor 'lung auscultation', often 'whether or not there is something unusual happening' – both medical reasons – and to a lesser extent 'non-medical reasons' (P < 0.001). Non-medical as well as medical reasons support antibiotic treatment, but non-medical reasons to a lesser extent (P < 0.001).
Conclusion
This study quantified, condensed and confirmed the findings of previous focus group research. Practice guidelines and interventions to optimise antibiotic prescribing have to take non-medical reasons into account.
doi:10.1186/1471-2296-3-16
PMCID: PMC126270  PMID: 12217080
6.  Increasing the satisfaction of general practitioners with continuing medical education programs: A method for quality improvement through increasing teacher-learner interaction 
BMC Family Practice  2002;3:15.
Background
Continuing medical education (CME) for general practitioners relies on specialist-based teaching methods in many settings. Formal lectures by specialists may not meet the learning needs of practitioners and may cause dissatisfaction with traditional CME. Increasing learner involvement in teaching programs may improve learner satisfaction.
Methods
A quality improvement program for CME for 18 general practitioners in the Tel Aviv region was designed as a result of dissatisfaction with traditional CME activities. A two-step strategy for change was developed. The CME participants first selected the study topics relevant to them from a needs assessment and prepared background material on the topics. In the second step, specialist teachers were invited to answer questions arising from the preparation of selected topics. Satisfaction with the traditional lecture program and the new participatory program were assessed by a questionnaire. The quality criteria included the relevance, importance and applicability of the CME topic chosen to the participant's practice, the clarity of the presentation and the effective use of teaching aids by the lecturer and the potential of the lecturer to serve as a consultant to the participant.
Results
The participatory model of CME significantly increased satisfaction with relevance, applicability and interest in CME topics compared to the traditional lecture format.
Conclusions
Increased learner participation in the selection and preparation of CME topics, and increased interaction between CME teachers and learners results in increased satisfaction with teaching programs. Future study of the effect of this model on physician performance is required.
doi:10.1186/1471-2296-3-15
PMCID: PMC122091  PMID: 12186658
continuing medical education; family medicine; general practitioners; lectures; quality improvement
7.  24-hour efficacy of once-daily desloratadine therapy in patients with seasonal allergic rhinitis [ISRCTN32042139] 
BMC Family Practice  2002;3:14.
Background
Early studies with desloratadine demonstrated efficacy in treating seasonal allergic rhinitis (SAR). A dose-ranging study was conducted to characterize its 24-hour efficacy in patients with SAR.
Methods
Patients (N = 1,026) were randomly assigned once-daily (QD) desloratadine (2.5, 5, 7.5, 10, or 20 mg) for 2 weeks in a placebo-controlled, double-blind study. The end point of 24-hour efficacy was assessed by the mean change from baseline in the average AM instantaneous total symptom score (TSS) over the treatment period. Day 2 data were assessed for efficacy of desloratadine following the first dose. Other efficacy variables included AM/PM previous total nasal and nonnasal symptom scores and individual symptom scores.
Results
Desloratadine 5–20 mg was significantly (P < .01) more effective than placebo in improving total AM instantaneous TSS and AM/PM previous total nasal and nonnasal symptom scores. This dosing range also was significantly (P < .01) more effective than placebo for reducing AM instantaneous TSS beginning with the first dose; thus, demonstrating the full 24-hour efficacy of desloratadine. AM/PM previous scores for all individual symptoms, including nasal congestion, were also significantly improved versus placebo (P < .05) with desloratadine at 5, 7.5, and 20 mg. All treatments were well tolerated. There were no clinically meaningful changes in electrocardiogram parameters.
Conclusion
Desloratadine 5–20 mg provided significant 24-hour relief of SAR signs and symptoms. There were no statistically significant differences between the 4 largest doses suggesting that desloratadine 5 mg QD offers the best therapeutic profile for patients with SAR.
doi:10.1186/1471-2296-3-14
PMCID: PMC122063  PMID: 12162793
8.  A note on clinical presentations of amebic liver abscess: an overview from 62 Thai patients 
BMC Family Practice  2002;3:13.
Background
Amebic liver abscess is a tropical disease with a wide spectrum of clinical presentations. Given the often nonspecific nature of the complaints related to amebic abscess, a retrospective review of patients with confirmed disease to recognize the most common patterns of presentation is useful. Here, we study the clinical presentations of 62 Thai patients with amebic liver abscess. We also compare the clinical presentations of Anti HIV seronegative and Anti HIV seropositive patients.
Methods
A retrospective case review was carried out for 62 Thai patients who had been diagnosed with amebic liver abscess. Clinical information was collected, including symptoms and signs, location and number of abscesses. The Anti HIV serology laboratory investigation was also reviewed.
Results
According to our study, the common clinical symptoms and signs are abdominal pain (85.5 %), fever and chills (74.2 %), and abdominal tenderness (69.4 %). The location of the abscess was predominantly in the right lobe (74.2 %), and most of patients had a single abscess (77.4 %). Similar trends in clinical presentations were observed in both Anti HIV seropositive and Anti HIV seronegative subjects.
Conclusions
In conclusion, the clinical presentations of our amebic liver abscess patients were similar to those in previous reports. A similarity to those in the pyogenic liver abscess patients can be observed. Nevertheless, we could not detect important significant differences in the clinical presentations between Anti HIV seropositive and Anti HIV seronegative groups of patients.
doi:10.1186/1471-2296-3-13
PMCID: PMC122079  PMID: 12149132
9.  House dust mite barrier bedding for childhood asthma: randomised placebo controlled trial in primary care [ISRCTN63308372] 
BMC Family Practice  2002;3:12.
Background
The house dust mite is the most important environmental allergen implicated in the aetiology of childhood asthma in the UK. Dust mite barrier bedding is relatively inexpensive, convenient to use, and of proven effectiveness in reducing mattress house dust mite load, but no studies have evaluated its clinical effectiveness in the control of childhood asthma when dispensed in primary care. We therefore aimed to evaluate the effectiveness of house dust mite barrier bedding in children with asthma treated in primary care.
Methods
Pragmatic, randomised, double-blind, placebo controlled trial conducted in eight family practices in England. Forty-seven children aged 5 to 14 years with confirmed house dust mite sensitive asthma were randomised to receive six months treatment with either house dust mite barrier or placebo bedding. Peak expiratory flow was the main outcome measure of interest; secondary outcome measures included asthma symptom scores and asthma medication usage.
Results
No difference was noted in mean monthly peak expiratory flow, asthma symptom score, medication usage or asthma consultations, between children who received active bedding and those who received placebo bedding.
Conclusions
Treating house dust mite sensitive asthmatic children in primary care with house dust mite barrier bedding for six months failed to improve peak expiratory flow. Results strongly suggest that the intervention made no impact upon other clinical features of asthma.
doi:10.1186/1471-2296-3-12
PMCID: PMC116603  PMID: 12079502
10.  Atrial fibrillation in a primary care practice: prevalence and management 
BMC Family Practice  2002;3:11.
Background
Atrial fibrillation is a common serious cardiac arrhythmia. Knowing the prevalence of atrial fibrillation and documentation of medical management are important in the provision of primary care. This study sought to determine the prevalence of atrial fibrillation in a primary care population and to identify and quantify the treatments being used for stroke prevention in this group of patients.
Methods
A prevalence study through chart audit was conducted in the family medicine practice at the Sunnybrook campus of the Sunnybrook and Women's College Health Sciences Centre. The main outcome measures were the prevalence of atrial fibrillation in our primary care practice and the use of warfarin for stroke prevention in this population.
Results
261 patients in our practice have atrial fibrillation. The overall prevalence in our family practice unit is 3.9%. When considering patients aged 60 and over, the prevalence rises to 12.2%. 204 of our patients with atrial fibrillation (78.2%) are currently being treated with warfarin. Another 21 patients were previously treated and discontinued for a number of reasons. Of the 57 patients not currently treated with warfarin, 44 are treated with ASA, 2 with ticlopidine, and 11 are receiving no preventative treatment.
Conclusions
The prevalence of atrial fibrillation in our practice is higher than the range of prevalence reported in the general literature. However, our coverage with warfarin treatment exceeds previous reports in the literature.
doi:10.1186/1471-2296-3-11
PMCID: PMC116583  PMID: 12031095
11.  A multinational randomized, controlled, clinical trial of etoricoxib in the treatment of rheumatoid arthritis [ISRCTN25142273] 
BMC Family Practice  2002;3:10.
Background
Etoricoxib is a highly selective COX-2 inhibitor which was evaluated for the treatment of rheumatoid arthritis (RA).
Methods
Double-blind, randomized, placebo and active comparator-controlled, 12-week study conducted at 67 sites in 28 countries. Eligible patients were chronic NSAID users who demonstrated a clinical worsening of arthritis upon withdrawal of prestudy NSAIDs. Patients received either placebo, etoricoxib 90 mg once daily, or naproxen 500 mg twice daily (2:2:1 allocation ratio). Primary efficacy measures included direct assessment of arthritis by counts of tender and swollen joints, and patient and investigator global assessments of disease activity. Key secondary measures included the Stanford Health Assessment Questionnaire, patient global assessment of pain, and the percentage of patients who achieved ACR20 responder criteria response (a composite of pain, inflammation, function, and global assessments). Tolerability was assessed by adverse events and routine laboratory evaluations.
Results
1171 patients were screened, 891 patients were randomized (N = 357 for placebo, N = 353 for etoricoxib, and N = 181 for naproxen), and 687 completed 12 weeks of treatment (N = 242 for placebo, N = 294 for etoricoxib, and N = 151 for naproxen). Compared with patients receiving placebo, patients receiving etoricoxib and naproxen showed significant improvements in all efficacy endpoints (p<0.05). Treatment responses were similar between the etoricoxib and naproxen groups for all endpoints. The percentage of patients who achieved ACR20 responder criteria response was 41% in the placebo group, 59% in the etoricoxib group, and 58% in the naproxen group. Etoricoxib and naproxen were both generally well tolerated.
Conclusions
In this study, etoricoxib 90 mg once daily was more effective than placebo and similar in efficacy to naproxen 500 mg twice daily for treating patients with RA over 12 weeks. Etoricoxib 90 mg was generally well tolerated in RA patients.
doi:10.1186/1471-2296-3-10
PMCID: PMC115849  PMID: 12033987
12.  Long term benzodiazepine use for insomnia in patients over the age of 60: discordance of patient and physician perceptions 
Background
The aim of this study was to determine and compare patients' and physicians' perceptions of benefits and risks of long term benzodiazepine use for insomnia in the elderly.
Methods
A cross-sectional study (written survey) was conducted in an academic primary care group practice in Toronto, Canada. The participants were 93 patients over 60 years of age using a benzodiazepine for insomnia and 25 physicians comprising sleep specialists, family physicians, and family medicine residents. The main outcome measure was perception of benefit and risk scores calculated from the mean of responses (on a Likert scale of 1 to 5) to various items on the survey.
Results
The mean perception of benefit score was significantly higher in patients than physicians (3.85 vs. 2.84, p < 0.001, 95% CI 0.69, 1.32). The mean perception of risk score was significantly lower in patients than physicians (2.21 vs. 3.63, p < 0.001, 95% CI 1.07, 1.77).
Conclusions
There is a significant discordance between older patients and their physicians regarding the perceptions of benefits and risks of using benzodiazepines for insomnia on a long term basis. The challenge is to openly discuss these perceptions in the context of the available evidence to make collaborative and informed decisions.
doi:10.1186/1471-2296-3-9
PMCID: PMC113266  PMID: 12019038
13.  Is there a clinically significant gender bias in post-myocardial infarction pharmacological management in the older (>60) population of a primary care practice? 
Background
Differences in the management of coronary artery disease between men and women have been reported in the literature. There are few studies of potential inequalities of treatment that arise from a primary care context. This study investigated the existence of such inequalities in the medical management of post myocardial infarction in older patients.
Methods
A comprehensive chart audit was conducted of 142 men and 81 women in an academic primary care practice. Variables were extracted on demographic variables, cardiovascular risk factors, medical and non-medical management of myocardial infarction.
Results
Women were older than men. The groups were comparable in terms of cardiac risk factors. A statistically significant difference (14.6%: 95% CI 0.048–28.7 p = 0.047) was found between men and women for the prescription of lipid lowering medications. 25.3% (p = 0.0005, CI 11.45, 39.65) more men than women had undergone angiography, and 14.4 % (p = 0.029, CI 2.2, 26.6) more men than women had undergone coronary artery bypass graft surgery.
Conclusion
Women are less likely than men to receive lipid-lowering medication which may indicate less aggressive secondary prevention in the primary care setting.
doi:10.1186/1471-2296-3-8
PMCID: PMC111196  PMID: 12015819
14.  Is primary care ready to take on Attention Deficit Hyperactivity Disorder? 
Background
Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood psychiatric disorder. The management of ADHD has recently been highlighted. The National Institute of Clinical Excellence (NICE) and Scottish Intercollegiate Guidelines network (SIGN) have both produced management guidelines. Doctors working within Primary Care in countries such as the United States play an important role in the management of ADHD. In the United Kingdom however the role of doctors in primary care in the management of ADHD, both individually and within shared care protocols, is only now being identified and defined. Is this role for Primary Care likely to be acceptable and effective?
Discussion
There is some evidence that doctors working within Primary Care in the United Kingdom are willing to follow up children on medication for ADHD and carry out monitoring of physical status. However many feel unconfident in the management of ADHD and most have received little or no training in child psychiatry. There are also concerns that adverse media reports will have an undue influence on the attitudes of doctors within primary care to families with children suffering from ADHD.
Summary
There are important barriers to be tackled before shared care protocols for ADHD can be successfully implemented in the United Kingdom. Tailored information about ADHD needs to be provided to doctors in primary care. Clear dialogue between planners and healthcare professionals from both primary and secondary care is essential to ensure that service delivery is acceptable to healthcare providers, tailored to their skills and is adequately resourced.
doi:10.1186/1471-2296-3-7
PMCID: PMC103661  PMID: 11955289
15.  Klippel-Feil syndrome – the risk of cervical spinal cord injury: A case report 
Background
Klippel-Feil syndrome is defined as congenital fusion of two or more cervical vertebrae and is believed to result from faulty segmentation along the embryo's developing axis during weeks 3–8 of gestation. Persons with Klippel-Feil syndrome and cervical stenosis may be at increased risk for spinal cord injury after minor trauma as a result of hypermobility of the various cervical segments. Persons with Klippel-Feil Syndrome often have congenital anomalies of the urinary tract as well.
Case presentation
A 51-year male developed incomplete tetraplegia in 1997 when he slipped and fell backwards hitting his head on the floor. X-rays of cervical spine showed fusion at two levels: C2 and C3 vertebrae, and C4 and C5 vertebrae. Intravenous urography (IVU) revealed no kidneys in the renal fossa on both sides, but the presence of crossed, fused renal ectopia in the left ilio-lumbar region. This patient had a similar cervical spinal cord injury about 15 years ago, when he developed transient numbness and paresis of the lower limbs following a fall.
Discussion and Conclusion
1) Persons with Klippel-Feil syndrome should be made aware of the increased risk of sustaining transient neurologic deterioration after minor trauma if there is associated radiographic evidence of spinal stenosis.
2) Patients with Klippel-Feil syndrome often have congenital anomalies of the urinary tract. Our patient had crossed, fused, ectopia of kidney.
3) When patients with Klippel-Feil syndrome sustain tetraplegia they have increased chances of developing urinary tract calculi. Treatment of kidney stones may pose a challenge because of associated renal anomalies.
4) Health professionals caring for cervical spinal cord injury patients with Klippel-Feil syndrome and renal anomalies should place emphasis on prevention of kidney stones. A large fluid intake is recommended for these patients, as a high intake of fluids is still the most powerful and certainly the most economical means of prevention of nephrolithiasis.
doi:10.1186/1471-2296-3-6
PMCID: PMC107839  PMID: 11985781
16.  A cross-sectional study of early identification of postpartum depression: Implications for primary care providers from The Ontario Mother & Infant Survey 
Background
This survey's objective was to provide planning information by examining utilization patterns, health outcomes and costs associated with existing practices in the management of postpartum women and their infants. In particular, this paper looks at a subgroup of women who score ≥ 12 on the Edinburgh Postnatal Depression Survey (EPDS).
Methods
The design is cross-sectional with follow-up at four weeks after postpartum hospital discharge. Five Ontario hospitals, chosen for their varied size, practice characteristics, and geographic location, provided the setting for the study. The subjects were 875 women who had uncomplicated vaginal deliveries of live singleton infants. The main outcome measures were the EPDS, the Duke UNC Functional Social Support Questionnaire and the Health and Social Services Utilization Questionnaire.
Results
EPDS scores of ≥ 12 were found in 4.3 to 15.2% of otherwise healthy women. None of these women were being treated for postpartum depression. Best predictors of an EPDS score of ≥ 12 were lack: of confident support, lack of affective support, household income of <$20,000, wanting to stay in hospital longer, identification of learning needs while in hospital, self-identified care needs for an emotional/mental health problem that have not been met and mother's rating of own and baby's health as fair or poor.
Conclusions
Primary care physicians, midwives, and public health nurses need to screen for depression at every opportunity early in the postpartum period. A mother's expression of undue concern about her own or her baby's health may be predictive of postpartum depression. Flexible, mother-focused support from community providers may decrease the prevalence of postpartum depression.
doi:10.1186/1471-2296-3-5
PMCID: PMC107838  PMID: 11950393
17.  Can Australian general practitioners effectively screen for diabetic retinopathy? A pilot study 
Background
Diabetes has been identified as one of the national health priority areas in Australia. After 20 years of diabetes most patients can be expected to develop diabetic retinopathy which, if undetected, is likely to cause significant visual loss or blindness. This paper reports on a pilot study aimed to test the ability of Australian GPs to clinically recognise diabetic retinopathy following a brief training intervention.
Method
17 GPs from a Brisbane Division of General Practice were recruited to participate in a clinical upskilling intervention pilot. Participant scores on clinical assessments were used to analyse GP sensitivity and specificity in screening for diabetic retinopathy. Results were compared with the NHMRC guidelines for acceptable screening accuracy.
Results
Ten of the 17 GPs (59%) achieved a screening sensitivity of 25% or less in the pre test, three (18%) a sensitivity of 50%, and four (23%) achieved a sensitivity of ≥ 75%. In the post-test, all seventeen GPs achieved between 50 and 100% sensitivity. In the pre-test, thirteen (76%) GPs achieved a screening specificity of less than or equal to 50%, and four (23%) a specificity of 75 %. In the post test, four GPs (23%) rated a screening specificity of less than 50%, six (35%) achieved a specificity of 66%, and seven (41%) 100% specificity.
Conclusion
24% of GPs met the NHMRC diabetic retinopathy screening criterion prior to the workshop, and 94% following this brief training intervention. Australian GPs are capable of a much more significant role in community screening for diabetic retinopathy.
doi:10.1186/1471-2296-3-4
PMCID: PMC101373  PMID: 11884247
18.  Longitudinal impact of a youth tobacco education program 
Background
Information on the effectiveness of elementary school level, tobacco-use prevention programs is generally limited. This study assessed the impact of a structured, one-time intervention that was designed to modify attitudes and knowledge about tobacco. Participants were fifth-grade students from schools in western New York State.
Methods
Twenty-eight schools, which were in relatively close geographic proximity, were randomized into three groups; Group 1 was used to assess whether attitudes/knowledge were changed in the hypothesized direction by the intervention, and if those changes were retained four months later. Groups 2 and 3, were used as comparison groups to assess possible test-retest bias and historical effects. Groups 1 and 3 were pooled to assess whether attitudes/knowledge were changed by the intervention as measured by an immediate post-test. The non-parametric analytical techniques of Wilcoxon-Matched Pairs/Sign Ranks and the Mann-Whitney-Wilcoxon Rank Sums Tests were used to compare proportions of correct responses at each of the schools.
Results
Pooled analyses showed that short-term retention on most items was achieved. It was also found that retention on two knowledge items 'recognition that smokers have yellow teeth and fingers' and 'smoking one pack of cigarettes a day costs several hundred dollars per year' was maintained for four months.
Conclusions
The findings suggest that inexpensive, one-time interventions for tobacco-use prevention can be of value. Changes in attitudes and knowledge conducive to the goal of tobacco-use prevention can be achieved for short-term retention and some relevant knowledge items can be retained for several months.
doi:10.1186/1471-2296-3-3
PMCID: PMC88884  PMID: 11897014
19.  A survey of physicians knowledge regarding awareness of maternal alcohol use and the diagnosis of FAS. 
Background
Alcohol is the most widely used drug in the world that is a human teratogen whose use among women of childbearing age has been steadily increasing. It is also probable that Fetal Alcohol Syndrome is under diagnosed by physicians. The objectives of this study were twofold: 1) to evaluate the experience, knowledge and confidence of family physicians with respect to the diagnosis of FAS and 2) to evaluate physicians awareness of maternal drinking patterns.
Methods and Participants
A multiple choice anonymous questionnaire was sent to a randomly selected group of family physicians in the Metropolitan Toronto area.
Results
There was a 73% (75/103) total response rate; Overall, 6/75 (8%) of family physicians reported that they had actually diagnosed a child with FAS. 17.9% had suspicions but did not make a diagnosis and 12.7% reported making a referral to confirm the diagnosis. Physician rated confidence in the ability to diagnosis FAS was low, with 49% feeling they had very little confidence. 75% reported counselling pregnant women and 60.8% reported counselling childbearing women in general on the use of alcohol. When asked what screening test they used to detect the use of alcohol, 75% described frequency/quantity. Not a single respondent identified using the current accepted screening method for alcohol use (TWEAK) which is recommended by The Centre for Addiction and Mental Health.
Conclusions
Family physicians do not feel confident about diagnosing FAS. None of the physicians were aware of the current screening methods to accurately gage alcohol use in pregnant and childbearing women
doi:10.1186/1471-2296-3-2
PMCID: PMC65679  PMID: 11860607
20.  Design and performance of a multi-centre randomised controlled trial and economic evaluation of joint tele-consultations [ISRCTN54264250] 
Background
Appropriate information flow is crucial to the care of patients, particularly at the interface between primary and secondary care. Communication problems can result from inadequate organisation and training, There is a major expectation that information and communication technologies may offer solutions, but little reliable evidence. This paper reports the design and performance of a multi-centre randomised controlled trial (RCT), unparalleled in telemedicine research in either scale or range of outcomes. The study investigated the effectiveness and cost implications in rural and inner-city settings of using videoconferencing to perform joint tele-consultations as an alternative to general practitioner referral to the hospital specialist in the outpatient clinic.
Methods
Joint tele-consultation services were established in both the Royal Free Hampstead NHS Trust in inner London, and the Royal Shrewsbury Hospitals Trust, in Shropshire. All the patients who gave consent to participate were randomised either to joint tele-consultation or to a routine outpatients appointment. The principal outcome measures included the frequency of decision by the specialist to offer a follow-up outpatient appointment, patient satisfaction (Ware Specific Questionnaire), wellbeing (SF12) and enablement (PEI), numbers of tests, investigations, procedures and treatments.
Results
A total of 134 general practitioners operating from 29 practices participated in the trial, referring a total of 3170 patients to 20 specialists in ENT medicine, general medicine (including endocrinology, and rheumatology), gastroenterology, orthopaedics, neurology and urology. Of these, 2094 patients consented to participate in the study and were correctly randomised. There was a 91% response rate to the initial assessment questionnaires, and analysis showed equivalence for all key characteristics between the treatment and control groups.
Conclusion
We have designed and performed a major multi-centre trial of teleconsultations in two contrasting centres. Many problems were overcome to enable the trial to be carried out, with a considerable development and learning phase. A lengthier development phase might have enabled us to improve the patient selection criteria, but there is a window of opportunity for these developments, and we believe that our approach was appropriate, allowing the evaluation of the technology before its widespread implementation.
doi:10.1186/1471-2296-3-1
PMCID: PMC65515  PMID: 11835692

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