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PubMed2003

Radiographic equipment and techniques used in general dental practice: a survey of general dental practitioners in England and Wales.

OBJECTIVES: The aims of this study were to determine the self-reported use of panoramic radiography, D- and E-speed film, rectangular collimation, film holders, equipment fitted with a long spacer cone (>200 mm) and the bisecting angle and paralleling techniques by general dental practitioners and to see if use was related to the dentists' age and postgraduate qualifications. METHODS: Three mailings of a self-completion questionnaire were circulated to 800 general dental practitioners working in the National Health General Dental Service in England and Wales. RESULTS: A response rate of 74% was achieved. Sixty-one percent of general dental practitioners reported use of panoramic equipment. Fifty percent of dentists always used E-speed film and 18% always used rectangular collimation. Sixty-eight percent of dentists always used bitewing film holders though fewer (37%) used periapical film holders. Sixty-three percent of dentists always used a long cone. The bisecting angle technique was used by 70% of dentists with 22% always using this technique for periapical radiographs. Thirty-one percent always used the paralleling technique. Use of panoramic equipment, periapical film holders, bisecting angle and paralleling techniques were associated with the dentists' age. Use of periapical film holders, bisecting angle and paralleling techniques and rectangular collimation were associated with dentists' postgraduate qualifications. CONCLUSIONS: There are several features of radiographic equipment and techniques that can aid high quality imaging and reduce patient dose. Although a number of these are being used in general dental practice in England and Wales they have yet to achieve universal adoption.

Adult↗

PubMed1991

Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery.

The goal of this randomized study of high-risk surgical patients was to determine whether intraoperative thoracic epidural anesthesia in combination with light general anesthesia alters postoperative morbidity when compared to a standard technique of "balanced" general anesthesia. A total of 173 patients scheduled for abdominal aortic reconstruction were admitted to the study; 86 were to receive "balanced" general anesthesia (group 1) and 87 thoracic epidural anesthesia in combination with light general anesthesia (group 2). Preoperative evaluation included standard clinical tools, dipyridamole thallium gammatomography, and radionuclide angiography. In these patients, all of whom had peripheral artery disease, there were no significant differences in associated coronary artery disease, hypertension, and cardiovascular treatment. The distribution of left ventricular ejection fraction and the number of patients with thallium redistribution were not statistically different between the two groups. During the postoperative period, group 1 received analgesia of subcutaneous morphine (n = 35), epidural fentanyl (n = 30), or epidural bupivacaine (n = 21). In group 2, 6 patients with a nonfunctioning epidural catheter due to technical failure received a balanced general anesthesia and were eliminated from the study. During the postoperative period, group 2 received analgesia of subcutaneous morphine (n = 26), epidural fentanyl (n = 25), or epidural bupivacaine (n = 30). Cardiovascular morbidity did not differ between the two groups: 22 patients in group 1 and 19 patients in group 2 had a major postoperative cardiac event.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

PubMed1992

Specialism and generalism in the future of general surgery.

The progressive specialism that has characterized the practice of medicine over the last 100 years has occurred almost entirely in a scientific context. Societal needs and social changes have had little influence. As we near the end of the 20th century the benefits of scientific specialism are being questioned. New historical studies of specialism have shown that factors other than new knowledge are the driving force for the creation of some subspecialties. The process by which a new subspecialty is established requires both a national institute and a certification examination. Certification is intended to identify those with specific knowledge and skill by inclusion, but is being perceived increasingly as a process that works by exclusion. General surgery, one of the few "generalist" disciplines, finds itself at a crossroads. Further subspecialization with certification will fragment and destroy the discipline. There are cogent arguments, based on economics and care-delivery issues, to preserve general surgery. Making this choice will commit general surgeons to accept the concept of scientific generalism and to the development of the specialty of general surgery in a social context.

Canada↗

PubMed2005

An analysis of the pattern of detection of leprosy patients by institutions in the general health services in Sri Lanka after the integration of leprosy services into general health services.

Integration of leprosy services into the General Health Services was initiated in 2001 in Sri Lanka, and by the end of 2003 all services related to leprosy care were fully integrated. Against this background, routinely collected data available at the Anti-Leprosy Campaign for a 3-year period from 2000-2003 were analyzed to identify the pattern of the detection of cases by hierarchical institutions in the General Health Services. The analysis showed that more than 75% of leprosy patients had been detected at base, general and teaching hospitals and this trend was increasing proportionally during the period of concern (P < 0.001). Teaching hospitals had detected more than 50% of patients and this trend was also proportionally increasing. Nearly one-third of patients detected at teaching hospitals had been detected at the Central Leprosy Clinic (CLC) at the National Hospital. The trend for case detection at the CLC was decreasing proportionally and in absolute terms during the 3-year period after integration. More than 60% of leprosy patients had been detected at institutions where consultant dermatologists were available. The analysis concluded that centralized leprosy diagnostic and treatment services have been taken over by the institutions in the General Health Services but within districts these activities are predominantly concentrated on higher level institutions with consultant dermatological services. This suggests that similar to the existing general trend of by passing of lower level institutions by patients to seek treatment at higher-level institutions, which are perceived to provide a service of better quality, leprosy patients too prefer to seek treatment at these institutions.

Consultants↗

PubMed2006

General surgery in crisis--factors that impact on a career in general surgery.

INTRODUCTION: The Association of Surgeons of South Africa (ASSA), because of a concern about the decline in the number of applicants for registrar posts, undertook this study into the various factors that may influence the choice of surgery as career option. METHODS: The study involved a combination of desk research and structured interviews with heads of departments, specialists, and registrars in general surgery. RESULTS: The reasons for choosing general surgery as a career included the immediately visible results of a surgeon's efforts and the practical and intellectual challenge of the specialty. General surgery continued to enjoy a high status in society. The greater focus on primary health care has affected facilities at tertiary and secondary institutions. General surgeons worked excessively long hours, which was associated with increased levels of stress and placed severe strains on family life. All respondents felt that their levels of remuneration were 'poor' in relation to other disciplines and professions. CONCLUSION: In this study we identified various factors that impacted either positively or negatively on the choice of general surgery as a career option.

Career Choice↗

PubMed1992

On the use of the generalized t and generalized rank-sum statistics in medical research.

We have used Monte Carlo methods to compare the type I error properties of the conditional and unconditional versions of the generalized t and the generalized rank-sum tests to those of the independent samples t and Wilcoxon rank-sum tests. Results showed inflated type I errors for the conditional generalized tests but not for the unconditional tests. We also compared the power of the unconditional generalized tests to that of the t and Wilcoxon tests under a variety of conditions. Results showed the generalized tests to be much more efficient than their traditional counterparts in some circumstances, but substantially less powerful in others. Based on these and other considerations, we conclude that the application of these newer statistics in medical research needs further consideration.

Data Interpretation, Statistical↗

PubMed1983

Patient education in general practice: opinions of general practitioners.

Fifty-two general practitioners were interviewed regarding their task in patient education and various aspects of it. The view general practitioners have on patient education is complex. Although they consider it a central task, the range of methods they are willing to use is limited. Many general practitioners tend to overlook the fact that they are not the only source of information and explanation for patients. They would prefer to keep control over information given patients, fearing that patients might be confused. It is notable that many general practitioners have no clear standards of what patients need to know. Much depends on the questions the individual patient asks. There are several kinds of information that general practitioners are disinclined to give, particularly relating to uncertainties or information that might alarm the patient. The outlook for improvement must not be overestimated. Some directions are given for supporting the development of patient education.

Attitude of Health Personnel↗

PubMed2002

A brief screening tool for suicidal symptoms in adolescents and young adults in general health settings: reliability and validity data from the Australian National General Practice Youth Suicide Prevention Project.

Using data from a nationwide project on young people in Australia aimed at assessing suicidality in general health settings, we present a brief screening tool for suicidality (the depressive symptom index suicidality subscale). Two thousand eight hundred and fifty-one (15-24 year old) patients presenting to 247 Australian general practitioners between 1996 and 1998 were assessed. In addition to the suicide screen, patients completed the general health questionnaire-12 and the Center for Epidemiological Studies depression scale. Patients' chief complaints were taken from the summary sheets completed by their general practitioners. Using inter-item correlational and factor-analytic techniques, as well as a general approach to construct validity, we show that the measure has favorable reliability and validity characteristics. We also provide results on cut-points that may facilitate its use in clinical and research settings. Because the screen is brief, easy to use, reliable, and valid, we encourage its use to combat the vexing international health problem of suicide.

Adolescent↗

PubMed1975

Severity of symptoms of psychiatric outpatients: use of the General Health Questionnaire in hospital ang general practice patients.

A sample of 91 new referrals to a community based psychiatric outpatient service was compared with a cross-matched control sample of 107 patients attending the general practitioner's surgery. The subjects in both groups completed the General Health Questionnaire and there was a very marked difference between the scores of the two groups. Seventy-five of the psychiatric group had a high score on the questionnaire, and a large number of these were extremely high, while 74 of the general practice group had a low score. The 'false' positives and negatives are discussed. It is considered that the validity of this questionnaire as a screening device for demonstrating psychiatric morbidity and severity in general practice is further established in this study by showing that in matched samples the expected psychiatric morbidity in general practice can be compared with the much greater morbidity in psychiatric outpatient referrals. For the psychiatric sample more patients showed high scores and these tended to be much higher.

Adjustment Disorders↗

PubMed1993

Auditory frequency generalization and a failure to find octave generalization in a songbird, the European starling (Sturnus vulgaris).

Many species of songbirds have absolute pitch perception. They memorize tones when discriminating between sequences and fail to generalize to novel frequency ranges. I examined frequency generalization in starlings (Sturnus vulgaris) that were trained to discriminate between individual frequencies. Starlings were tested for frequency generalization after training on 2- and 3-tone discriminations. There was no evidence for octave generalization, which is a hallmark of human absolute pitch perception. This suggests that avian absolute pitch perception must not be interpreted as identical with that in humans. A control experiment with 1-tone discriminations indicated that the presence of lit response keys affects the shape of the generalization gradients. Lit response keys are a common feature in avian auditory perception experiments, and this control experiment cautions that results may be affected by this seemingly minor procedural change.

Acoustic Stimulation↗

PubMedDate not supplied

The estimation of body density in men: are general equations general?

Regression equations for estimating body density and fatness from anthropometric measurements are usually specific to the populations from which they are derived, owing to methodological and biological factors. Some equations are, however, regarded as having general validity for subjects of different ages, levels of fatness and fitness. In this study, five such general equations were tested by comparing estimated body density (Dest) with measured body density (Dmeas) in 138 European men employed in an Italian shipyard. Body density was measured by underwater weighing with the simultaneous determination of lung residual volume. Measurements were also made of height, weight, eight skinfolds, four circumferences and seven diameters by standard techniques. Dest from the five general equations were significantly different from Dmeas (P less than 0.001). New prediction equations for estimating D were drawn up by simple and multiple regression of various combinations of skinfolds expressed as individual skinfolds, sums, log sums and the quadratic form. Equations were drawn up on a validation sample (N = 92) and tested on a cross-validation sample (N = 46). The form of skinfolds and the combination selected made little difference to the SEEs and R2 but the inclusion of age resulted in lower SEEs. Stepwise multiple regression produced an equation incorporating thorax and triceps skinfolds and age with an SEE of 6 kg/m3 and R2 of 79%. The derived equations were successfully cross-validated, Dmeas and Dest were not significantly different, ryy' and SEE were similar to those of the validation sample. When the cross-validation sample was divided into two according to age, density or VO2 max, the derived equations were applicable to the upper and lower groups for age or physical fitness but not to the groups differing in fatness. These equations should be validated further on other samples by studies performed with due regard to the methodological factors, both technical and statistical, that may result in specificity. However, the poor performance of the general equations tested and the specificity for fatness of the derived equations suggest that biological factors may preclude the development of general prediction equations for body density.

Adult↗

PubMedDate not supplied

The general transcription machinery and general cofactors.

In eukaryotes, the core promoter serves as a platform for the assembly of transcription preinitiation complex (PIC) that includes TFIIA, TFIIB, TFIID, TFIIE, TFIIF, TFIIH, and RNA polymerase II (pol II), which function collectively to specify the transcription start site. PIC formation usually begins with TFIID binding to the TATA box, initiator, and/or downstream promoter element (DPE) found in most core promoters, followed by the entry of other general transcription factors (GTFs) and pol II through either a sequential assembly or a preassembled pol II holoenzyme pathway. Formation of this promoter-bound complex is sufficient for a basal level of transcription. However, for activator-dependent (or regulated) transcription, general cofactors are often required to transmit regulatory signals between gene-specific activators and the general transcription machinery. Three classes of general cofactors, including TBP-associated factors (TAFs), Mediator, and upstream stimulatory activity (USA)-derived positive cofactors (PC1/PARP-1, PC2, PC3/DNA topoisomerase I, and PC4) and negative cofactor 1 (NC1/HMGB1), normally function independently or in combination to fine-tune the promoter activity in a gene-specific or cell-type-specific manner. In addition, other cofactors, such as TAF1, BTAF1, and negative cofactor 2 (NC2), can also modulate TBP or TFIID binding to the core promoter. In general, these cofactors are capable of repressing basal transcription when activators are absent and stimulating transcription in the presence of activators. Here we review the roles of these cofactors and GTFs, as well as TBP-related factors (TRFs), TAF-containing complexes (TFTC, SAGA, SLIK/SALSA, STAGA, and PRC1) and TAF variants, in pol II-mediated transcription, with emphasis on the events occurring after the chromatin has been remodeled but prior to the formation of the first phosphodiester bond.

Animals↗

PubMed2004

Isolation, flexibility and change in vocational training for general practice: personal and educational problems experienced by general practice registrars in Australia.

BACKGROUND: GP registrars, in common with other doctors, frequently experience high levels of stress; however, little is known about the nature and outcomes of personal and educational problems experienced during vocational training for general practice. OBJECTIVES: The purpose of our study was to elicit the nature, causes and effects of more severe problems experienced during vocational training for general practice from the registrar's viewpoint and put these into the context of their personal circumstances and background. METHODS: This qualitative study used detailed semi-structured telephone interviews with a selected subgroup of 33 of the 1999 entry cohort of general practice registrars in Australia who had reported serious self-defined problems during an earlier longitudinal questionnaire study. Registrars were asked about the nature, antecedents and outcomes of problems experienced during GP training, actions taken to resolve the problem, and their perceptions of what might have helped prevent or minimize the problem. RESULTS: Problems reported by registrars fell into five major themes: isolation (structural isolation, social isolation and professional isolation); flexibility and choice (administrative issues and balancing work with personal life); change and uncertainty (within general practice and training, intergenerational changes); teaching problems; and work conditions. Actions taken and effects of problems are also discussed in the light of workforce imperatives. Results have been used to develop a list of suggestions for the providers of general practice training. CONCLUSIONS: Registrars commonly experience problems during vocational training. These may be related to structural, social and professional isolation, or a lack of flexibility in training arrangements and balancing work and other commitments. Some of these problems may be amenable to relatively simple solutions involving term placements, selection of training practices and administrative adjustments.

Attitude of Health Personnel↗

PubMed1991

Hormone replacement therapy in general practice: a survey of doctors in the MRC's general practice research framework.

OBJECTIVES: To survey current prescribing practice for hormone replacement therapy among general practitioners and to elicit their views on the role of hormone replacement therapy in the prevention of osteoporosis and cardiovascular disease; to determine whether they would participate in randomised controlled trials to evaluate the long term beneficial and adverse effects of hormone replacement therapy. DESIGN: Postal questionnaires to general practitioners throughout the United Kingdom. PARTICIPANTS: 1268 general practitioners in the Medical Research Council's general practice research framework. RESULTS: 1081 (85%) doctors in 220 (95%) practices responded. The doctors were currently prescribing hormone replacement therapy to an estimated 9% of their female patients aged 40 to 64, and 55% of doctors were prescribing opposed hormone replacement therapy (oestrogen plus progestogen) to more patients than a year previously. Over half the doctors would consider prescribing hormone replacement therapy for prevention of osteoporosis (670, 62%) and cardiovascular disease (611, 57%) to asymptomatic women. Overall, 79% of the doctors (851) would definitely or probably consider entering women who have had a hysterectomy into a randomised controlled trial comparing unopposed (oestrogen only) hormone replacement therapy with opposed hormone replacement therapy; 49% (524) would enter patients with a uterus into such a trial. Among a subsample, 85% (180/210) would consider entering patients without menopausal symptoms into a trial comparing hormone replacement therapy with no treatment (unopposed in patients who have had a hysterectomy, opposed in those with a uterus). CONCLUSION: There is considerable uncertainty among general practitioners as to the balance of beneficial and harmful effects of hormone replacement therapy in the long term, particularly relating to its use for prevention of osteoporosis and cardiovascular disease. Most of these doctors would be prepared to participate in randomised controlled trials to determine the long term effects of this increasingly widely used treatment.

Adult↗

PubMed1996

Socioeconomic determinants of rates of consultation in general practice based on fourth national morbidity survey of general practices.

OBJECTIVE: To identify the socioeconomic determinants of consultation rates in general practice. DESIGN: Analysis of data from the fourth national morbidity survey of general practices (MSGP4) including sociodemographic details of individual patients and small area statistics from the 1991 census. Multilevel modelling techniques were used to take account of both individual patient data and small area statistics to relate socioeconomic and health status factors directly to a measure of general practitioner workload. RESULTS: Higher rates of consultations were found in patients who were classified as permanently sick, unemployed (especially those who became unemployed during the study year), living in rented accommodation, from the Indian subcontinent, living with a spouse or partner (women only), children living with two parents (girls only), and living in urban areas, especially those living relatively near the practice. When characteristics of individual patients are known and controlled for the role of "indices of deprivation" is considerably reduced. The effect of individual sociodemographic characteristics were shown to vary between different areas. CONCLUSIONS: Demographic and socioeconomic factors can act as powerful predictors of consultation patterns. Though it will always be necessary to retain some local planning discretion, the sets of coefficients estimated for individual level factors, area level characteristics, and for practice groupings may be sufficient to provide an indicative level of demand for general medical services. Although the problems in using socioeconomic data from individual patients would be substantial, these results are relevant to the development of a resource allocation formula for general practice.

Adolescent↗

PubMed2001

Access to the evidence base from general practice: a survey of general practice staff in Northern and Yorkshire Region.

AIM: To identify and describe current methods of making health related research evidence accessible to general practice staff in the Northern and Yorkshire Region. METHOD: A postal survey questionnaire of general practice staff in the Northern and Yorkshire Region. RESULTS: At least one completed questionnaire was obtained from 70% of the general practices surveyed, and the individual response rate to the survey was 45%. Just under 60% of all respondents reported having no access to the NHS internet and just under 50% also reported having no access to the internet. All respondents in this survey reported greater access to paper based information than to electronic databases. However, this research provides evidence of differential access to information resources between different professions in general practice with GPs clearly having easier access than other professions to both paper based resources and electronic databases. 70% of all respondents said that they would need to be trained to use either a computer, the internet, or to search databases if the opportunity for easy access to any of these information services was available. CONCLUSIONS: At the time of this survey, general practices seemed to be struggling to set up the infrastructure and develop the skills that are necessary to make best use of available research evidence. In addition, there is a need for further investigation into the reasons why different professions working in the same practice setting have differential access to information resources available in primary care.

Computer User Training↗

PubMed2002

Comparison of patients' and general practitioners' evaluations of general practice care.

OBJECTIVES: To compare patients' and general practitioners' (GPs') evaluations of the quality of general practice care. DESIGN: Written surveys among patients and GPs. SETTING: General practice in the Netherlands. SUBJECTS: 1772 patients (from 45 GPs) and a random sample of 315 GPs. MAIN OUTCOME MEASURES: Patients' and GPs' evaluations of 23 aspects of general practice care and GPs' perceptions of patients' evaluations using a 5 point scale. RESULTS: The response rate was 88% in the patient sample and 63% in the GP sample. The patients' ratings of care were significantly more positive (mean 4.0) than those of the GPs (mean 3.7) as well as GPs' perceptions of patients' evaluations (mean 3.5) (p<0.001). The overall rank order correlations between the patients' evaluations, GPs' evaluations, and GPs' perceptions of the patients' evaluations were 0.75 or higher (p<0.001). Patients and practitioners gave the most positive evaluations of specific aspects of the doctor-patient relationship ("keeping patients' records and data confidential", "listening to patients", and "making patients feel they had enough time during consultations") and aspects of the organisation of care ("provide quick service for urgent health problems" and "helpfulness of the staff (other than the doctor)"). The aspects of care evaluated least positively by patients as well as by GPs were other organisational aspects ("preparing patients for what to expect from specialist or hospital care" and "getting through to practice on the telephone"). CONCLUSIONS: GPs and patients have to some extent a shared perspective on general practice care. However, GPs were more critical about the quality of care than patients and they underestimated how positive patients were about the care they provide. Furthermore, specific aspects of care were evaluated differently, so surveys and other consultations with patients are necessary to integrate their perspective into quality improvement activities.

Adolescent↗

PubMed1996

Comparison of appropriateness of cholesterol testing in general practice with the recommendations of national guidelines: an audit of patient records in 20 general practices.

OBJECTIVE: To compare the profiles of those patients selected by general practitioners for measurement of serum cholesterol with the recommended profiles for opportunistic cholesterol testing described in the national practice guidelines published by the Dutch College of General Practitioners. DESIGN: Retrospective audit of general practitioners' records. MATERIALS: Practice records of 3577 adult patients systematically sampled from 20 general practices. MAIN MEASURES: With criteria set by the national guidelines, the proportion of patients per practice (a) for whom cholesterol testing would be considered justified, and (b) for whom cholesterol testing would be considered unjustified, and the proportion of patients within each of these groups who had had a cholesterol measurement recorded. RESULTS: Cholesterol tests were performed on 415 (11.7%) of the 3577 patients. National guidelines on the management of hypercholesterolaemia state that a positive cardiovascular risk profile is an indication for cholesterol measurement. Just under one fifth (668) of the patients in this study were recorded as having a positive cardiovascular risk profile, but only 31% of these had had their cholesterol measured. Of the patients without recorded evidence of a positive cardiovascular risk profile cholesterol had been measured in 8%. Restricting the analyses to the age group 18-65 (n = 3060) of whom 12.5% had a positive risk profile, did not improve the results. In practices with a computerised information system 37% of patients with recorded evidence of a positive cardiovascular risk profile had had their cholesterol measured. CONCLUSIONS: Cholesterol testing was not targeted as selectively as recommended by the national guidelines. The major problem was failure to test those likely to benefit. Improving the targeting of cholesterol measurements would undoubtedly increase the workload of general practitioners. If the national guidelines are to have an effect on health promotion the first step must be to increase the proportion of patients with positive cardiovascular risk profiles who get their cholesterol tested. A major factor in successfully selecting cases seems to be that practices are equipped with a computerised medical information system.

Adolescent↗