Chronic constipation in children.
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Cathartics↗
Biomedical subjects
Greg Rubin
Publications and source records attributed to Greg Rubin.
The diagnosis of IBS in primary care: consensus development using nominal group technique.
BACKGROUND: The criteria used to identify and diagnose irritable bowel syndrome (IBS) in primary care are unclear, even though most patients are managed entirely in this setting. OBJECTIVE: To use a validated method of consensus development [Nominal Group Technique (Rand version)] (NGT-R) in order to construct a diagnostic framework for IBS appropriate to primary care. METHODS: NGT-R is a formal method of consensus development, which uses structured interaction within a group combined with statistical derivation of group judgements. The group comprised 10 GPs with a special interest in gastroenterology and two gastroenterologists, from 10 European countries. Mailed questionnaires elicited judgements on 242 scenarios for the diagnosis of IBS, within four domains of symptoms, social and lifestyle features, psychological features and investigations. Feedback of group decisions was followed by structured face-to-face interaction and private rescoring of the questionnaire. Consensus was defined as 10/12 ratings within one of three bands, 1-3 (disagreement), 4-6 (equivocal) or 7-9 (agreement). RESULTS: The defining features of IBS in primary care are alteration in bowel habit, bloating and abdominal pain, or discomfort or annoyance (the last reflecting important cultural differences in symptom description). These symptoms need to be present for at least 4 weeks. Supportive characteristics include female sex, family history of IBS, frequent clinic attendances, a recent major life event and a history of somatization behaviours. Abdominal examination was considered necessary in all patients and rectal examination, haemoglobin estimation and colonoscopy in those aged > 55 years. The subtypes of IBS are recognized, but the diagnostic process differs only in minor ways. Final consensus was reached on 46% of statements. CONCLUSION: The basis of IBS diagnosis in primary care differs from, and is less exclusive than, existing criteria. Few features are deemed essential for diagnosis, while psychosocial features, patient characteristics and contextual factors are important in increasing diagnostic probability. There are important cultural differences in the description of key symptoms. These results provide information on the defining characteristics of IBS and the diagnostic process, as it occurs in primary care, and can guide clinical practice.
Age Factors↗
Investigation of infertility management in primary care with open access hysterosalpingography (HSG): a pilot study.
Infertility affects one in seven couples in the United Kingdom. The National Institute for Clinical Excellence (NICE) issued guidance on the management of the infertile couple in February 2004, which included the statement "for the assessment of tubal damage, women not known to have co-morbidities (pelvic inflammatory disease, endometriosis or previous ectopic pregnancy) should be offered hysterosalpingography (HSG)". We made HSG available to six general practices in Newcastle upon Tyne as an open access investigation. Our aim was to evaluate the uptake of open access HSG, speed of access to specialist services and the quality of the information recorded in the referral letter. Using hospital clinical records we tracked the outcome of all infertile couples from the six pilot practices over a nine-month period. Of the 39 referrals identified, 10 women were eligible for open access HSG, of which six HSGs were organized by GPs. Couples who had open access HSG reached a diagnosis and management plan four weeks earlier than those who were referred directly (mean difference 4.0 weeks, 95% confidence interval (CI) -8.8 to 0.4 weeks). The information recorded in the referral letter was generally poor. However, all referrals made via the open access HSG service had the prerequisite tests done. Open access HSG allowed prompter access to specialist services with more complete information passed on in the referral letter. Open access HSG was used in 15% of all infertile couples and 60% of those who fitted the criteria for its use. Open access HSG together with semen analysis and endocrine blood tests may allow GPs to manage the initial stages of the infertile couple and make a diagnosis.
Adult↗
Preferences for access to the GP: a discrete choice experiment.
BACKGROUND: Access to primary care services is one of the key components of the NHS Plan which states that patients should be able to see a health professional within 24 hours and a GP within 48 hours. However, it is not clear how patients value speed of access in comparison with other aspects of primary care. AIM: To investigate patient preferences when making an routine appointment for a GP, and to describe the trade-offs and relationships between speed of access, choice of time and choice of doctor in different patient groups. DESIGN OF STUDY: Discrete choice experiment. SETTING: Adults consulting a GP in six general practices in Sunderland. METHOD: Choice sets based on three attributes (time to appointment, choice of time, choice of doctor) were presented in a self-completion questionnaire. RESULTS: We obtained 6985 observations from 1153 patients. We found that the waiting time to make an appointment was only important if the appointment is for a child or when attending for a new health problem. Other responders would trade-off a shorter waiting time and be willing to wait in order to either see their own choice of doctor or attend an appointment at their own choice of time. For responders who work, choice of time is six times more important than a shorter waiting time and they are willing to wait up to 1 day extra for this. Those with a long-standing illness value seeing their own GP more than seven times as much as having a shorter waiting time for an appointment and will wait an extra 1 day for an appointment with the GP of their choice, women will wait an extra 2 days, and older patients an extra 2.5 days. CONCLUSION: Speed of access is of limited importance to patients accessing their GP, and for many is outweighed by choice of GP or convenience of appointment.
Adolescent↗
Taking simvastatin in the morning compared with in the evening: randomised controlled trial.
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Adult↗
Non-attendance in general practice: a systematic review and its implications for access to primary health care.
BACKGROUND: Non-attendance in general practice has received increasing attention over the past few years. Its relationship with access to health care has been recognized and is of particular relevance in light of the access targets set out in the NHS Plan. METHODS: The literature was searched for articles relating to non-attendance. Titles and abstracts were examined, and relevant articles obtained. Bibliographies were examined for further references. Articles that described interventions for reducing non-attendance that were comparative studies and that examined general appointments, as opposed to appointments for screening purposes for example, were of particular interest. RESULTS AND CONCLUSIONS: The epidemiology of non-attendance has been well described, but there is little work on the reasons for non-attendance. Evidence for effective interventions to improve attendance in primary care is lacking, and this may prove to be an area of research interest in the future. As well as specific interventions to reduce non-attendance, new approaches to health care access are required in order to tackle this issue.
Appointments and Schedules↗
A systematic review and meta-analysis of treatments for impetigo.
BACKGROUND: Impetigo is a common clinical problem seen in general practice. Uncertainty exists as to the most effective treatment, or indeed if treatment is necessary. AIM: To determine the most effective treatment for impetigo in a systemically well patient. DESIGN OF STUDY: Systematic review and meta-analysis. METHOD: Databases were searched for relevant studies. The Cochrane highly sensitive randomised controlled trial (RCT) search string was employed and combined with the word 'impetigo' as the MeSH term and keyword. The bibliographies of relevant articles were searched for additional references. RCTs that were either double- or observer-blind, and involved systemically well patients of any age in either primary or secondary care settings, were included. Studies that selected patients on the basis of skin swab results were excluded, as were studies that were not in English. Cure or improvement of impetigo reported at seven to 14 days from start of treatment was the primary outcome measure. Meta-analysis was performed on homogeneous studies. RESULTS: Three hundred and fifty-nine studies were identified, of which 16 met the inclusion criteria. Meta-analysis demonstrated that topical antibiotics are more effective than placebo (odds ratio [OR] = 2.69, 95% confidence interval [CI] = 1.49 to 4.86). There is weak evidence for the superiority of topical antibiotics over some oral antibiotics, such as erythromycin (OR = 0.48, 95% CI = 0.23 to 1.00). There is no significant difference between the effects of mupirocin and fusidic acid (OR = 1.76, 95% CI = 0.77 to 4.03). CONCLUSION: This review found limited high-quality evidence to inform the treatment of impetigo. From that which is available, we would recommend the use of a topical antibiotic for a period of seven days in a systemically well patient with limited disease. Further research is needed on the role of flucloxacillin and non-antibiotic treatments for impetigo.
Administration, Topical↗
A history of diabetes: from antiquity to discovering insulin.
This article, the first of a three-part series, gives a historical account of events for diabetes, dating from antiquity and its first recording in the Ebers Papyrus--an Egyptian document circa 1500 BC. This article describes initial thoughts that diabetes was linked to an alimentary complaint, and concludes with the discovery of it being a chronic systemic disease. It highlights the discoveries and also includes details of the failed attempts to locate the cause and identify a solution to the ancient mysterious disease which became known to all as diabetes mellitus. Early remedies and treatments are included. The article tells how for many centuries individuals suffered from the debilitating complaint with very little offered in terms of treatment or relief. Eventually the pancreas was identified as the causative organ and, some time later, animal experimentation resulted in the abstraction of the substance insulin. The article concludes with Frederick Banting and John Macleod being awarded the Nobel Prize in 1923 for their revolutionary discovery of insulin.
Diabetes Mellitus↗