[A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]. / Randomiseret, kontrolleret undersøgelse af anvendelsen af CRP-hurtigtest som vejledning ved behandlingen af luftvejsinfektioner i almen praksis.

INTRODUCTION: The aim was to assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a CRP rapid test to support their clinical assessment, and to examine whether the use of the test would have any effect on the course of disease. MATERIAL AND METHOD: A randomised controlled trial was carried out by 35 general practices in the County of Funen, Denmark, with 812 patients with respiratory infection. The main outcome measures were frequency of antibiotic prescriptions and morbidity one week after the consultation, as stated by the patients. RESULTS: The frequency of antibiotic prescriptions was 43% (179/414) in the CRP group and 46% (184/398) in the control group (NS, OR = 0.9). At one week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patient's general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase [mg/l], p < 0.0001). CONCLUSION: From on the present study, the use of a single CRP rapid test to support possible antibiotic treatment of respiratory infections in general practice cannot be recommended.

ICD-10 criteria for depression in general practice.

BACKGROUND: The rate of recognition of depressive disorder in general practice is reported to be low. Current classification systems, i.e. ICD-10 and DSM-III-R, and DSM-IV with operational diagnostic criteria, have led to greater agreement concerning the diagnosis of depressive disorder. The aim of this study was to assess the applicability and validity of the ICD-10 criteria for depression in general practice in Denmark. METHODS: After a 1-day training course in the ICD-10 criteria for depression, ten general practitioners, during an 8-week period assessed all patients aged 18 or older for depressive symptoms in accordance with the ICD-10 criteria. RESULTS: Among a total of 3505 consultations, 116 patients (3.3%) met the criteria for a depressive episode. Of these, 80 (68.8%) accepted to be reinterviewed by a psychiatrist, who confirmed the diagnosis of depressive disorder in 57 of the 80 patients (71.3%). LIMITATIONS: The number of 'false negative' cases are unknown in the study. CONCLUSION: The ICD-10 criteria for depression seem to be appropriate and valid in general practice.

[Penicillin treatment of acute maxillary sinusitis in adults. A randomized, double-blind, placebo-controlled trial from general practice]. / Penicillinbehandling af akut kaebehulebetaendelse hos voksne. En randomiseret, dobbeltblind, placebokontrolleret undersøgelse fra almen praksis.

INTRODUCTION: The aim of the study was to compare the effectiveness of penicillin V with placebo in the treatment of adult patients with acute maxillary sinusitis (in general practice). MATERIAL AND METHODS: The study was designed as a randomised, double-blind, placebo-controlled trial in 26 Danish general practices. The participants were 133 adult patients with acute maxillary sinusitis clinically diagnosed on maxillary pain and raised values of either C-reactive protein (CRP) or the erythrocyte sedimentation (ESR) rate. Main outcome measures were pain score and illness score, and CRP and ESR values after initiation of treatment. RESULTS: Penicillin V led to a better recovery than placebo. The difference in pain reduction was statistically significant three days after initiation of treatment, whereas no significant difference was found in the reduction in the sense of illness. At the end of the study, significantly more patients in the penicillin group were completely free of pain than in the placebo group. This difference was found only in patients with an initial pain score of more than three. The cure rate was 71% in the penicillin group and 37% in the placebo group. Significantly more patients treated with penicillin achieved normal CRP values than those receiving placebo, respectively 88% and 75%. CONCLUSION: Penicillin V is more effective than placebo in the treatment of acute maxillary sinusitis in adults in general practice, but only in patients with pronounced pain.

[Resistance testing in general practice--is it valid?]. / Resistensbestemmelse i almen praksis--duer det til noget?

Resistance of uropathogenic bacteria to antibiotics is an increasing problem in primary health care. The aim of this study was to evaluate antibacterial susceptibility testing of uropathogenic when performed in general practice. Urine specimens with a known quantity of typically uropathogenic bacteria were sent to 25 general practices. The predictive values of testing a bacterial strain as susceptible ranged from 0.89 (nitrofurantoin) to 1.00 (sulphamethizole), and the predictive value of testing a bacterial strain as resistant ranged from 0.55 (trimethoprim) to 0.90 (nitrofurantoin). If susceptibility testing is to be widely implemented in general practice it would be necessary to improve the validity.

Randomised controlled trial of CRP rapid test as a guide to treatment of respiratory infections in general practice.

OBJECTIVE: To assess whether the frequency of antibiotic prescriptions to patients with respiratory infections is reduced when general practitioners (GPs) use a C-reactive protein (CRP) rapid test in support of their clinical assessment, and to study whether using the test will have any effect on the course of disease DESIGN: Randomised controlled trial. SETTING: 35 general practices, County of Funen, Denmark. PATIENTS: 812 patients with respiratory infection. MAIN OUTCOME MEASURES: Frequency of antibiotic prescriptions and morbidity 1 week after the consultation, as stated by the patients. RESULTS: In the CRP group the frequency of antibiotic prescriptions was 43% (179/414) compared with 46% (184/398) in the control group (odds ratio (OR) = 0.9, NS). After 1 week, increased or unchanged morbidity was stated more frequently in the CRP group (12%) than in the control group (8%) (OR = 1.6, p = 0.05). In the control group, the variable having the greatest influence on whether the GP prescribed antibiotics was the patients' general well-being (OR = 2.9, p < 0.0001), whereas in the CRP group the CRP value had the greatest influence (OR = 1.1 per unit increase (mg/l), p < 0.0001). CONCLUSION: Based on the present study, the use of the CRP rapid test in support of a possible antibiotic treatment for respiratory infections in general practice cannot be recommended.

Randomised, double blind, placebo controlled trial of penicillin V in the treatment of acute maxillary sinusitis in adults in general practice.

OBJECTIVE: To compare the effectiveness of penicillin V with placebo in the treatment of adult patients with acute maxillary sinusitis in general practice. DESIGN: Randomised, double blind, placebo controlled trial. SETTING: 26 Danish general practices. PATIENTS: 133 adult patients with a clinical diagnosis of acute maxillary sinusitis based on maxillary pain and raised values of either C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR). MAIN OUTCOME MEASURES: Pain score and illness score as well as measurement of CRP and ESR values after initiation of treatment. RESULTS: Penicillin V led to a better recovery than did placebo. The difference was statistically significant 3 days after the initiation of treatment with regard to pain reduction, whereas no significant difference was found with regard to the reduction in the sense of illness. At the end of the study, significantly more patients in the penicillin group were completely free of pain compared to the placebo group. This difference was only found in patients with an initial pain score of more than three. The cure rate was 71% in the penicillin group and 37% in the placebo group. Significantly more patients achieved normal CRP values when treated with penicillin (88%) as opposed to placebo (75%). CONCLUSION: Penicillin V is more effective than placebo in the treatment of acute maxillary sinusitis in adults in general practice, but only in patients with pronounced pain.

Standardised procedures can improve the validity of susceptibility testing of uropathogenic bacteria in general practice.

OBJECTIVE: To investigate whether the validity of susceptibility testing in general practice would improve when preceded by an intervention. INTERVENTION: Instruction in standardised susceptibility testing procedures given by laboratory instructors. METHOD: Urine specimens containing monocultures of typical uropathogenic bacteria were sent to 23 general practices before and after the intervention. Practices performed susceptibility testing by the Sensicult and the Iso-Res agar methods and the validity of the results before and after the intervention was compared. Results from susceptibility testing at the bacteriological laboratory, Odense University Hospital, were used as gold standard. RESULTS: The median frequency of correct results increased from 82% to 98% for susceptibility testing based on Sensicult (p = 0.001) and from 90% to 96% based on Iso-Res agar (p = 0.05). CONCLUSION: The validity of susceptibility testing in general practice improves when preceded by instruction in standardised procedures.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part I.

OBJECTIVE: To determine whether a supplement of folic acid given preconceptionally or early in pregnancy had any influence on, birth weight, incidence of preterm labour, low birth weight and small for gestational age. Furthermore, the aim was to elucidate, whether the outcome differed following the administration of two different dosages of folic acid, namely 2.5 and 1.0 mg. MATERIAL: All women in the childbearing age living on the island of Funen, Denmark (population 500,000) were offered a supplement of folic acid over a period of 3 years and 3 months. 14,021 women, who gave birth to 13,860 single-born and 325 multiborn children, were registered. A total of 8184 women took part in the double-blind randomized trial: 2310 had a supplement of folic acid without being randomized and 2721 women received no folic acid supplement. No information regarding the use of folic acid was available in 806 pregnancies. Abortions (512) were excluded. RESULTS AND CONCLUSIONS: A supplement 1.0 mg folic acid had the same effect as 2.5 mg. The effects of supplementing the diet with folic acid given preconceptionally or in the first half of pregnancy in an affluent Northern country were a slight increase of birth weight and a decrease in the incidence of preterm labour, infants with low birth weight and small for gestational age. The greatest effect was seen in the groups receiving folic acid preconceptionally.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part III. Congenital anomalies. An observational study.

OBJECTIVE: The effect of folic acid supplement on the prevalence of congenital anomalies was studied in a Danish population. MATERIAL AND METHODS: From 1983 to 1986 all Danish women resident in the county of Funen were offered free folic acid when pregnant or planning a pregnancy. Data concerning the starting time of folic acid supplement and congenital anomalies were recorded on close to all pregnancies. Children of folic acid supplemented mothers were subdivided as to start of supplement with dividing lines at week 7 and week 11 calculated from the last menstrual period. Structural malformations were subdivided into an early group with malformation development in the first 7 weeks from the last menstrual period and a late group where malformations develop in weeks 8 to 11. RESULTS: In a total of 14,021 pregnancies 10,494 pregnant women (74.8%) had folic acid supplement. No folic acid was taken by 2721 women (19.4%) and in 806 cases (5.8%) information was lacking. The prevalence of congenital anomalies was 380 in 14,185 children (26.7/1000). Children whose mothers started folic acid supplement before the 7th week of pregnancy showed a significantly lower prevalence of the malformations which develop in the first 7 weeks, when compared to pregnancies with a later start of supplement. The result was interpreted as a clearcut trend.

The influence of folic acid supplement on the outcome of pregnancies in the county of Funen in Denmark. Part II. Congenital anomalies. A randomised study.

OBJECTIVE: The effect of folic acid supplement on the prevalence of congenital anomalies was studied in a Danish population. MATERIAL AND METHODS: From 1983 to 1986 all Danish women resident in the county of Funen were offered free folic acid when pregnant or planning a pregnancy. Folic acid dose was randomised to 2.5 or 1.0 mg. A randomised control group was not feasible for ethical reasons. Hospitals, midwives and most general practitioners cooperated to procure information on close to all pregnancies and congenital anomalies were recorded. RESULTS AND CONCLUSIONS: In a total of 14,021 pregnancies resulting in child birth 8184 women (58.4%) had folic acid with randomisation. Supplement was started in the randomised group before the last menstrual period in 1359/8184 (16.6%) and in the first 19 weeks of pregnancy in 6825/8184 (83.4%). The prevalence of congenital anomalies was 224 in 8293 children (27.0/1000). No dose-dependent differences were found in either total anomalies or in those specific malformations which have been reported to occur with reduced prevalence with periconceptional folic acid. The result was probably influenced by a start of supplement too late to affect malformation development in many cases and by the high level of both folic acid doses given compared to usual recommendations. Pregnancies without folic acid supplement showed prevalences similar to the supplemented groups.

Validity of susceptibility testing of uropathogenic bacteria in general practice.

Resistance of uropathogenic bacteria to antibiotics is an increasing problem in primary health care. The aim of this study was to evaluate antibacterial susceptibility testing of uropathogenic bacteria when performed in general practice. Urine specimens with a known quantity of typically uropathogenic bacteria were sent to 25 general practices. The predictive values of testing a bacterial strain as susceptible ranged from 0.89 (nitrofurantoin) to 1.00 (sulphamethizole), and the predictive value of testing a bacterial strain as resistant ranged from 0.55 (trimethoprim) to 0.90 (nitrofurantoin). Interventions to improve the validity of susceptibility testing are desirable if the test should be incorporated in the diagnostic armamentarium in general practice.

[Follow-up of non-negative cervical cytological smears in the county of Funen]. / Opfølgning af ikkenegative cervixcytologiske prøver i Fyns Amt.

The outcome of screening for cervical cancer in the county of Funen was evaluated in two sequential periods (1.7.-31.12.1989 and 1.7.-31.12.1992), comprising 17,493 and 18,135 respectively. About 10.5% of the screened women had a define non-negative smear. From the first and the second period 80% and 85.1% of the non-negative smears respectively were followed up within six months. The follow-up of positive smears was 96% in both periods. Four point nine percent and 3.3% respectively of the non-negative smears were not followed up within 18 months. No women were actually lost in the screening system, unless they renounced further follow-up themselves. The follow-up was improved from the first to the second period, presumably as a result of a better general acquaintance with the screening procedures. The study indicates that reorganization of a screening programme requires both time and adjustment. Moreover, it is important that a successful screening programme frequently adjusts its procedures.

[Waiting time for epicrises in Funen County. Analysis of the effect of the practitioners' routine]. / Ventetid på epikriser i Fyns Amt. En analyse af praksiskonsulentordningens effekt.

The hospital discharge report plays an important role in the communication between hospital and general practice. However, the discharge report is often sent several days after discharge, and may not be received when the patient first visits his general practitioner after discharge. An intervention to reduce this delay was carried out between November 1993 and July 1994 at all hospital departments (n = 35) in the County of Funen, Denmark. The intervention consisted of a detailed evaluation of all routines concerning discharge reports followed by initiatives to reduce the waiting time. Criteria and standards for waiting time and quality of discharge reports were stated and evaluated before and after the intervention. As standard for waiting time, at least three-quarters of all discharge reports should be received by the general practitioner within ten days after discharge. Before the intervention half of all departments met this standard. After the intervention two-thirds met the standard. The quality of discharge reports was acceptable both before and after the intervention. This study shows that it was possible to reduce the delay of discharge reports by an intervention made in collaboration between hospital and general practice.

[Rectoscopy and Hemoccult II in irritable colon. A prospective study]. / Rektoskopi og Hemoccult-II ved colon irritabile. En prospektiv undersøgelse.

It was investigated whether Hemoccult-II test (H-II) could reduce the number of colonic examinations in patients with the irritable bowel syndrome, with normal rigid proctoscopic findings. A negative H-II was obtained in 299 patients from general practice and a positive test in nine. Colonoscopy was done in 157 and double contrast barium enema in 142 after random allocation. The nine patients with positive H-II all had colonoscopy. Among the 299 with negative H-II, colonic adenomas were detected in ten and an early cancer in an adenoma in the sigmoid colon; overlooked rectal adenomas were found in three, rectal cancer in one, rectal carcinoid in another and a coecal cancer, which could be palpated, in a third patient. Two patients with colonic cancer and one with adenoma were detected among those with positive H-II. All patients were followed by clinical examination after one year. In conclusion, colonic examination should carry a low priority in patients with symptoms of irritable bowel, negative Hemoccult-II and normal rigid proctoscopic findings performed by an experienced examiner. The investigation confirmed the recommendation of total colonoscopy in patients with a positive H-II and added support for increasing number of endoscopy services in contrast to those of diagnostic radiology, which should be reduced.

Efficacy of the cytobrush versus the cotton swab in the collection of endocervical cells.

Cervical smears should contain endocervical cells to be accepted as adequate for a cytologic diagnosis. Before this study was undertaken, one-third of the smears received in the Cytology Laboratory of Odense University Hospital were inadequate. In an attempt to increase the rate of adequate smears, a randomized study was undertaken to compare the efficacy of the combined spatula-Cytobrush method to that of the spatula-cotton swab method traditionally used by doctors in Denmark. The incidence of smears containing cylindrical and/or metaplastic cells was 89% by the spatula-Cytobrush method as compared to 62% by the spatula-cotton swab method (P less than .001). There were large differences between the rates of adequate smears from the various doctors when using the spatula-cotton swab method (range, 14% to 82%); these differences were far less when using the spatula-Cytobrush method (range, 75% to 100%). A large-scale application of the spatula-Cytobrush method should result in fewer repeat smears required and fewer false-negative smears.