Overweight and eating disorders in primary care: a sentinella reporting in 2-20 years old patients

Aims: To describe overweight or eating disorders in primary care consultations of Swiss children or adolescents and analyze responses by physicians. Methods: 150 to 200 primary care physicians participating in the Swiss Sentinel Surveillance Network in collaboration with the Swiss Federal Office of Public Health register their consultations over one year for selected health conditions. We describe reports of consultations where overweight or eating disorders were identified in subjects aged 2-20 years by physicians, patients or their relatives, or referring professionals, between 29.12.2007 and 15.2.2008. Results: 189 consultations were registered in the first 7 weeks of declaration. A short majority concerned female (58%) and 12-20 years old (53%) patients. Half were reported by pediatricians, one third by general practitioners and the remaining minority by internists. The sample included two thirds of Swiss-German and one third of Swiss-French cases. In the male subgroup aged 2-20 and in female children aged 2-11, almost all reported consultations were characterized by overweight. Among female teenagers, underweight was reported in 29% whilst overweight was recorded in 60%. Anorexia was noted in 68% of reported consultations of underweight female teenagers. In underweight patients, advice given by physicians frequently covered both nutrition and physical activity (38%) or nutrition only (29%), while no specific recommendations were recorded for the remaining third. In case of overweight, for one half of consultations patients received both nutritional and physical activity recommendations, for 12% nutritional only, and for one quarter patients were not advised in these domains. No specific treatment was usually proposed to overweight patients (65%), except when bulimia was diagnosed; in such case, one third of patients were proposed a psychological/psychiatric treatment, whereas both psychological and pharmacological treatments were frequently offered for underweight teenagers. Therapy was most often motivated by physicians (50%) or by relatives (44%), more rarely by patients themselves (7%). Conclusions: These preliminary data indicate that in some primary care consultations of young patients with overweight or eating disorders, advice was not given on nutrition and physical activity. This observation needs to be later confirmed with the totality of the consultations registered in 2008 and reasons will be further investigated.

Piercing among adolescents: body art as risk marker.

PURPOSE: To ascertain the prevalence of piercing among a nationally representative sample of adolescents; to assess whether having a piercing is a marker for risk behaviors; and to determine whether having more than one piercing is a cumulative marker for risk behaviors. METHODS: Data were drawn from a cross-sectional survey of a nationally representative sample of adolescents aged 16 to 20 years (N=7548). Controlling for background variables, pierced and non-pierced youth were compared on risk behaviors related to drug use, sexual behavior, and suicide. In a second step, adolescents having one piercing were compared with those having more than one. In both cases, statistically significant variables in the bivariate analysis were included in a logistic regression. Analyses were conducted separately by gender. RESULTS: Overall, 20.2% of our sample had a piercing (excluding earlobes), and it was significantly more prevalent among females than among males (33.8% vs. 7.4%; P<.001). In the bivariate analysis, all risk behaviors were significantly associated with having a piercing, and most of them remained significant in the multivariate analysis. One third of pierced subjects had more than one piercing, with no gender difference in prevalence. In the multivariate analysis, females with more than one piercing were more likely to have had multiple partners and to use cannabis, while no differences were noted for males. CONCLUSIONS: Body piercing is becoming popular among Swiss adolescents, especially females. Having a body piercing seems to be a risk marker for risk behaviors. Moreover, having multiple piercings is a cumulative risk marker for females.

How critical is timing for the diagnosis of influenza in general practice?

QUESTIONS UNDER STUDY: The diagnostic significance of clinical symptoms/signs of influenza has mainly been assessed in the context of controlled studies with stringent inclusion criteria. There was a need to extend the evaluation of these predictors not only in the context of general practice but also according to the duration of symptoms and to the dynamics of the epidemic. PRINCIPLES: A prospective study conducted in the Medical Outpatient Clinic in the winter season 1999-2000. Patients with influenza-like syndrome were included, as long as the primary care physician envisaged the diagnosis of influenza. The physician administered a questionnaire, a throat swab was performed and a culture acquired to document the diagnosis of influenza. RESULTS: 201 patients were included in the study. 52% were culture positive for influenza. By univariate analysis, temperature >37.8 degrees C (OR 4.2; 95% CI 2.3-7.7), duration of symptoms <48 hours (OR 3.2; 1.8-5.7), cough (OR 3.2; 1-10.4) and myalgia (OR 2.8; 1.0-7.5) were associated with a diagnosis of influenza. In a multivariable logistic analysis, the best model predicting influenza was the association of a duration of symptom <48 hours, medical attendance at the beginning of the epidemic (weeks 49-50), fever >37.8 and cough, with a sensitivity of 79%, specificity of 69%, positive predictive value of 67%, negative predictive value of 73% and an area under the ROC curve of 0.74. CONCLUSIONS: Besides relevant symptoms and signs, the physician should also consider the duration of symptoms and the epidemiological context (start, peak or end of the epidemic) in his appraisal, since both parameters considerably modify the value of the clinical predictors when assessing the probability of a patient having influenza.

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.

Self-reported smoking cessation activities among Swiss primary care physicians.

ABSTRACT: BACKGROUND: Individual counselling, pharmacotherapy, and group therapy are evidence-based interventions that help patients stop smoking. Acupuncture, hypnosis, and relaxation have no demonstrated efficacy on smoking cessation, whereas self-help material may only have a small benefit. The purpose of this study is to assess physicians' current clinical practice regarding smokers motivated to stop smoking. METHODS: The survey included 3385 Swiss primary care physicians. Self-reported use of nine smoking cessation interventions was scored. One point was given for each positive answer about practicing interventions with demonstrated efficacy, i.e. nicotine replacement therapy, bupropion, counselling, group therapy, and smoking cessation specialist. No points were given for the recommendation of acupuncture, hypnosis, relaxation, and self-help material. Multivariable logistic analysis was performed to identify factors associated with a good practice score, defined as >1. RESULTS: The response rate was 55%. Respondents were predominately over the age of 40 years (88%), male (79%), and resided in urban areas (74%). Seventeen percent reported being smokers. Most of the physicians prescribed nicotine replacement therapy (84%), bupropion (65%), or provided counselling (70%). A minority of physicians recommended acupuncture (26%), hypnosis (8%), relaxation (7%), or self-help material (24%). A good practice score was obtained by 85% of respondents. Having attended a smoking cessation training program was the only significant predictor of a good practice score (odds ratio: 6.24 , 95% CI 1.95-20.04). CONCLUSION: The majority of respondents practice recommended smoking cessation interventions. However, there is room for improvement and implementing an evidence-based smoking cessation-training program could provide additional benefit.

Development and validation of a clinical prediction rule for chest wall syndrome in primary care.

ABSTRACT: BACKGROUND: Chest wall syndrome (CWS), the main cause of chest pain in primary care practice, is most often an exclusion diagnosis. We developed and evaluated a clinical prediction rule for CWS. METHODS: Data from a multicenter clinical cohort of consecutive primary care patients with chest pain were used (59 general practitioners, 672 patients). A final diagnosis was determined after 12 months of follow-up. We used the literature and bivariate analyses to identify candidate predictors, and multivariate logistic regression was used to develop a clinical prediction rule for CWS. We used data from a German cohort (n = 1212) for external validation. RESULTS: From bivariate analyses, we identified six variables characterizing CWS: thoracic pain (neither retrosternal nor oppressive), stabbing, well localized pain, no history of coronary heart disease, absence of general practitioner's concern, and pain reproducible by palpation. This last variable accounted for 2 points in the clinical prediction rule, the others for 1 point each; the total score ranged from 0 to 7 points. The area under the receiver operating characteristic (ROC) curve was 0.80 (95% confidence interval 0.76-0.83) in the derivation cohort (specificity: 89%; sensitivity: 45%; cut-off set at 6 points). Among all patients presenting CWS (n = 284), 71% (n = 201) had a pain reproducible by palpation and 45% (n = 127) were correctly diagnosed. For a subset (n = 43) of these correctly classified CWS patients, 65 additional investigations (30 electrocardiograms, 16 thoracic radiographies, 10 laboratory tests, eight specialist referrals, one thoracic computed tomography) had been performed to achieve diagnosis. False positives (n = 41) included three patients with stable angina (1.8% of all positives). External validation revealed the ROC curve to be 0.76 (95% confidence interval 0.73-0.79) with a sensitivity of 22% and a specificity of 93%. CONCLUSIONS: This CWS score offers a useful complement to the usual CWS exclusion diagnosing process. Indeed, for the 127 patients presenting CWS and correctly classified by our clinical prediction rule, 65 additional tests and exams could have been avoided. However, the reproduction of chest pain by palpation, the most important characteristic to diagnose CWS, is not pathognomonic.

Patient expectations at a multicultural out-patient clinic in Switzerland.

BACKGROUND: Recognizing patient expectation is considered as an important objective for primary care physicians. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. It has been suggested that identifying patient expectations in multicultural contexts can be especially challenging. OBJECTIVES: The aim of the study was to compare health care expectations of Swiss and immigrant patients attending the out-patient clinic of a Swiss university hospital and to assess physicians' ability to identify their patients' expectations. METHODS: Over a 3-month period, all patients attending the out-patient clinic at a Swiss university hospital were requested to complete pre-consultation surveys. Their physicians were requested to complete post-consultation surveys. Outcome measures were patients' self-rated health, resort to prior home treatment, patients' expectations of the consultation, physicians' perception of their patients' expectations and agreement between patients and physicians. RESULTS: We analysed 343 questionnaires completed by patients prior to their consultation (> 50% immigrants) and 333 questionnaires completed by their physicians after the consultation. Most expectations were shared by all patients. Physicians had inaccurate perceptions of their patients' expectations, regardless of patients' origin. CONCLUSIONS: Our study found no evidence that immigrant patients' expectations differed from those of Swiss patients, nor that physicians had more difficulty identifying expectations of immigrant patients. However, physicians in our study were generally poor at identifying patients' expectations, and therefore inter-group differences may be difficult to detect. Our results point to the need to strengthen physicians' general communication skills which should then serve as a foundation for more specific, cross-cultural communication training.

Current cardiovascular risk management patterns with special focus on lipid lowering in daily practice in Switzerland.

Background: There may be a considerable gap between LDL cholesterol (LDL-C) and blood pressure (BP) goal values recommended by the guidelines and results achieved in daily practice. Design Prospective cross-sectional survey of cardiovascular disease risk profiles and management with focus on lipid lowering and BP lowering in clinical practice. Methods: In phase 1, the cardiovascular risk of patients with known lipid profile visiting their general practitioner was anonymously assessed in accordance to the PROCAM-score. In phase 2, high-risk patients who did not achieve LDL-C goal less than 2.6 mmol/l in phase 1 could be further documented. Results: Six hundred thirty-five general practitioners collected the data of 23 892 patients with known lipid profile. Forty percent were high-risk patients (diabetes mellitus or coronary heart disease or PROCAM-score >20%), compared with 27% estimated by the physicians. Goal attainment rate was almost double for BP than for LDL-C in high-risk patients (62 vs. 37%). Both goals were attained by 25%. LDL-C values in phase 1 and 2 were available for 3097 high-risk patients not at LDL-C goal in phase 1; 32% of patients achieved LDL-C goal of less than 2.6 mmol/l after a mean of 17 weeks. The most successful strategies for LDL-C reduction were implemented in only 22% of the high-risk patients. Conclusion: Although patients at high cardiovascular risk were treated more intensively than low or medium risk patients, the majority remained insufficiently controlled, which is an incentive for intensified medical education. Adequate implementation of Swiss and International guidelines would expectedly contribute to improved achievement of LDL-C and BP goal values in daily practice.

Ultra-rapid opiate detoxification using deep sedation and prior oral buprenorphine preparation: long-term results.

BACKGROUND: New methods of ultra-rapid opiate detoxification (URD) under intravenous sedation have been criticized because of limited data on safety and long-term follow-up. Premedication with buprenorphine has been advocated to improve safety by decreasing vomiting. Prior research has not explored URD in socially impaired patients. METHOD: Sixteen patients were detoxified with URD and prospectively evaluated over at least 30 months. Data of this procedure were compared with those of our previous study without buprenorphine preparation (Drug Alcohol Depend. 52(3) (1998) 243). The 16 patients were followed up by a general practitioner (GP) before and after URD. The GPs also supervised the 7-day course of buprenorphine treatment prescribed for the 16 patients prior to URD. RESULTS: During the procedure, only one episode of vomiting occurred instead of 13 out of 20 in our previous study. Post-procedure, only two patients experienced moderate withdrawal symptoms, such as persistent nausea, abdominal cramps and vomiting lasting from 24 to 48 h, in comparison with most patients in the previous study without buprenorphine. After a period of at least 30 months (36.0+/-6.38), the 16 patients were still alive and were regularly monitored by their GP. Only two of the 16 never relapsed after URD and reported total opiate abstinence. Fourteen patients relapsed; 12 of these were prescribed a licensed methadone substitution program and two were still using heroin. CONCLUSION: In this small sample, the data indicated that URD with buprenorphine preparation was safe and that it markedly decreased post-procedure morbidity. No patient died over a minimum 30-month follow-up period. Furthermore, the procedure was employed with socially impaired patients. In the long term, a few patients were still free of opiates, while the majority opted for a methadone maintenance program, showing that URD can serve as one possible step in a long-term treatment program.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Violence in primary care: prevalence and follow-up of victims.

BACKGROUND: Primary care physicians underestimate the prevalence of domestic violence and community violence. Victims are therefore at risk of further episodes of violence, with psychological and physical consequences. We used an interview to assess the prevalence of domestic and community violence among Swiss natives and foreigners. In a follow-up study, we evaluated the consequences of the interview for the positive patients. METHODS: We evaluated the prevalence of violence by use of a questionnaire in an interview, in an academic general internal medicine clinic in Switzerland. In a follow-up, we evaluated the consequences of the interview for positive patients. The participants were 38 residents and 446 consecutive patients. Questionnaires were presented in the principal language spoken by our patients. They addressed sociodemographics, present and past violence, the security or lack of security felt by victims of violence, and the patients' own violence. Between 3 and 6 months after the first interview, we did a follow-up of all patients who had reported domestic violence in the last year. RESULTS: Of the 366 patients included in the study, 36 (9.8%) reported being victims of physical violence during the last year (physicians identified only 4 patients out of the 36), and 34/366 (9.3%) reported being victims of psychological violence. Domestic violence was responsible for 67.3% of the cases, and community violence for 21.8%. In 10.9% of the cases, both forms of violence were found. Of 29 patients who reported being victims of domestic violence, 22 were found in the follow-up. The frequency of violence had diminished (4/22) or the violence had ceased (17/22). CONCLUSION: The prevalence of violence is high; domestic violence is more frequent than community violence. There was no statistically significant difference between the Swiss and foreign patients' responses related to the rates of violence. Patients in a currently violent relationship stated that participating in the study helped them and that the violence decreased or ceased a few months later.

Ischemic heart disease and primary care: identifying gender-related differences. An observational study

Background: Gender-related differences are seen in multiple aspects of both health and illness. Ischemic heart disease (IHD) is a pathology in which diagnostic, treatment and prognostic differences are seen between sexes, especially in the acute phase and in the hospital setting. The objective of the present study is to analyze whether there are differences between men and women when examining associated cardiovascular risk factors and secondary pharmacological prevention in the primary care setting. Methods: Retrospective descriptive observational study from January to December of 2006, including 1907 patients diagnosed with ischemic heart disease in the city of Lleida, Spain. The clinical data were obtained from computerized medical records and pharmaceutical records of medications dispensed in pharmacies with official prescriptions. Data was analyzed using bivariate descriptive statistical analysis as well as logistic regression. Results: There were no gender-related differences in screening percentages for arterial hypertension, diabetes, obesity, dyslipemia, and smoking. A greater percentage of women were hypertensive, obese and diabetic compared to men. However, men showed a tendency to achieve control targets more easily than women, with no statistically significant differences. In both sexes cardiovascular risk factors control was inadequate, between 10 and 50%. For secondary pharmaceutical prevention, the percentages of prescriptions were greater in men for anticoagulants, beta-blockers, lipid-lowering agents and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, with age group variations up to 10%. When adjusting by age and specific diagnoses, differences were maintained for anticoagulants and lipid-lowering agents. Conclusion: Screening of cardiovascular risk factors was similar in men and women with IHD. Although a greater percentage of women were hypertensive, diabetic or obese, their management of risk factors tended to be worse than men. Overall, a poor control of cardiovascular risk factors was noted. Taken as a whole, more men were prescribed secondary prevention drugs, with differences varying by age group and IHD diagnosis.

Primary care in Switzerland: evolution of physicians' profile and activities in twenty years (1993-2012).

BACKGROUND: According to the Organization for Economic Cooperation and Development, the Swiss healthcare system is one of the most effective in the world. Yet, as other occidental countries, it has to face the increase of chronic diseases frequency and its resulting cost, particularly for primary care (PC). However very few consistent data are available to describe PC features and its evolution over time. The aim of this study is to describe the evolution of the Swiss PC physicians' (PCPs) profile and activities between 1993 and 2012. METHODS: The date come from two independent European surveys carried out in Switzerland respectively in 1993 and 2012. Both surveys were cross-sectional ones and based on representative samples of 200 PCPs, interviewed by questionnaire. RESULTS: In 20 years, PCPs became older (median age 46 vs 56, p < 0.001) and more feminized (7 % vs 22 %, p < 0.001). Nowadays, they more often work in group practices (28 % vs 52 % in 2012, p < 0.001) and are more involved in other paid activities (28 % vs 66 % in 2012, p < 0.001). All the PCPs have a computer in 2012 (78 % in 1993, p < 0.001) and it is mostly used for keeping records of consultations (47 %). The number of daily face-to-face contacts with patients decreased from 31 to 24 but the average length rose from 15 to 20 min (p < 0.001). PCPs provide fewer pediatric and gynecological services but their activity remains globally unchanged in other domains. The frequency of meetings with other disciplines decreased significantly (e.g. once/month face-to-face meets with ambulatory specialists: 78 % vs 23 % in 2012, p < 0.001). The involvement of PCPs in follow-up and treatment of chronic disease globally little differed. In 2012, 8.5 % of the PCPs never performed any chirurgical acts (vs 0 % in 1993, p < 0.001). CONCLUSION: This study showed a substantial evolution of Swiss PC over the last twenty years in terms of socio-demographic, organizational and service provided. The main changes include: feminization and ageing, lower diversity in services provided, fewer but longer consultations. These changes may have important implications for patients' management and will need to be considered for health planning purposes.

Soins palliatifs en établissements médico-sociaux: Caractéristiques et spécificités [Palliative Care in Nursing Homes: Characteristics and Specificities].

Elderly patients in palliative situations residing in a nursing home present characteristics and specificities that clearly distinguish them from patients with advanced cancer. Besides the difficulty to define a precise prognosis, their many comorbidities, their communication difficulties because of cognitive disorders, their high sensitivity to primary and secondary effects of drugs render their management a real challenge for physician and caregivers. Accompanying these patients at the end of their life also raises many ethical problems, especially when they are no longer able to express their wishes and have not previously expressed advance directives.