Is it possible to reduce endoscopy workload using age, alarm symptoms and H. pylori as predictors of peptic ulcer and oesophagogastric cancers?

OBJECTIVES: We examined referrals to oesophagogastroduodenoscopy and the impact of demographic and clinical variables to predict major findings (peptic ulcer, cancer) on oesophagogastroduodenoscopy. METHODS: We collected data on 3669 consecutive patients referred for oesophagogastroduodenoscopy. RESULTS: Dyspeptic and reflux symptoms constituted 80% of oesophagogastroduodenoscopy referrals. A major finding was observed in 419 patients (11.4%). The mean age of cancer patients was 72.7 years (95% confidence interval (CI) 70.0-76.5 years) and that of peptic ulcer patients 62.0 years (95% CI 60.5-63.5 years). Independent risk factors for a major finding were age >50 years (odds ratio (OR) 1.62, 95% CI 1.24-2.10), male sex (OR 1.38, 95% CI 1.11-1.72), ulcer-type pain (OR 2.33, 95% CI 1.80-3.02), weight loss (OR 1.70, 95% CI 1.14-2.53), anaemia (OR 1.82, 95% CI 1.38-2.40), bleeding symptoms (OR 3.27, 95% CI 2.26-4.75) and Helicobacter pylori (OR 2.49, 95% CI 2.00-3.11), whereas reflux symptoms were protective (OR 0.73, 95% CI 0.53-1.00). The area under receiver operating characteristic curve of age over 50 years with alarm symptoms to predict major finding was 0.68 (95% CI 0.65-0.71), which positive H. pylori status increased to 0.71 (95% CI 0.69-0.74). Of the major findings, 87.2% were detected in patients with risk factors. Major findings were detected in 15.1% patients with and 8.1% (p < 0.001) without alarm symptoms. CONCLUSIONS: Dyspeptic and reflux symptoms constitute the majority of oesophagogastroduodenoscopy workload. Discriminative power of alarm symptoms even with positive H. pylori status to detect peptic ulcer or cancer was low. Because of their low cancer risk, reflux and dyspeptic patients younger than 50 years can be treated without oesophagogastroduodenoscopy.

A survey of open-access endoscopy in primary health care centres: outcome of gastric carcinoma patients diagnosed by general practitioners compared with hospital-referred endoscopy.

BACKGROUND: We examined open-access endoscopy service based on general practitioner endoscopists. METHODS: We compared the survival of the gastric carcinoma patients originally diagnosed in health care centres by general practitioner endoscopists and hospital outpatient clinic by specialists. RESULTS: A total of 159 gastric carcinoma cases diagnosed during 1996-2000 were included in to the present study. Of them, 58% (N = 92) and 42% (N = 67) were detected by general practitioners and specialists, respectively. We observed no difference in the mean age of patients (71.3 years versus 71.4 years, p = 0.97) and stage of tumours [15% (N = 14) versus 21% localised tumours (N = 14, p = 0.30)] between cases diagnosed by general practitioners and specialists. The number of patients who underwent radical extirpation were 14% (N = 13) and 19% (N = 13, p = 0.38), respectively. After a minimum follow-up of 3.5 years, 29 patients (18%) were alive. The mean survival time of hospital-diagnosed carcinoma patients was longer (23.6 months versus 18.7 months, p = 0.23). Eight patients had undergone hospital-referred gastroscopy less than 3 years before cancer diagnosis. In multivariate analysis, radical extirpation of carcinoma (odds ratio 0.11, 95% confidence interval 0.04-0.28) predicted survival; whereas age (odds ratio 1.03 per year, 95% confidence interval 0.99-1.07 per year), female sex (odds ratio 1.785, 95% confidence interval 0.71-4.81) and the open-access endoscopy based on general practitioner endoscopists (odds ratio 1.48, 95% confidence interval 0.60-3.65) predicted neither survival nor carcinoma-related death. CONCLUSION: No significant difference was detected in the outcome of gastric cancer patients diagnosed in primary care centres by general practitioner endoscopists and in hospital outpatient clinic by specialists.

Open-access gastroscopy in primary health-care offices to prevent peptic ulcer-related hospitalization and mortality.

BACKGROUND: Open-access gastroscopy performed by general practitioners is available at some primary care health centres in our Central Finland hospital referral area. The aim of the present study was to examine whether this practice influences peptic ulcer-related hospitalization and mortality. METHODS: Data on peptic ulcer-related hospitalization were obtained from discharge registries of the hospitals. Cause of death statistics were obtained from Statistics Finland Bureau. RESULTS: In 1996--2001, 896 inhabitants living in our hospital referral area were hospitalized owing to peptic ulcer. Of these, 265 (29.6%) had an ulcer related to the use of aspirin (ASA) or non-steroidal anti-inflammatory drugs (NSAIDs). Among the hospitalized patients, mortality was 11.6% (n = 104). In municipalities with or without an open-access gastroscopy service, the rates of hospitalization were 49.1 cases/100,000/year (95% CI 44.8-53.4) versus 77.5 cases/100,000/year (95% CI 72.0-83.0), and ulcer-related mortality 5.6 cases/100,000/year (95% CI 4.1-7.1) versus 9.4/100,000/year (95% CI 7.5-11.3). In municipalities without the service, inhabitants were older and their overall morbidity and mortality higher than in municipalities offering open-access gastroscopy. Of patients under 75 years of age (n = 582), 48 (8.2%) died, compared with 56 (17.8%, P < 0.001) of patients aged 75 years or older (n = 314). Age was the only independent risk factor for death (odds ratio (OR) 1.03 per year (95% CI 1.02-1.05)). Among patients with ASA-NSAID-related ulcer, open-access endoscopy was protective against ulcer-related death (OR 0.17 (95% CI 0.03-0.85)). CONCLUSIONS: Open-access gastroscopy in primary health-care offices significantly reduces ASA-NSAID-related ulcer mortality and may also reduce overall ulcer-related hospitalizations. The present results may, however, be biased by demographic factors. Age is a risk factor for death during ulcer-related hospitalization.

Impact of clinical symptoms and referral volume on endoscopy for detecting peptic ulcer and gastric neoplasms.

BACKGROUND: We investigated the volume of dyspeptic patients referred by general practitioners (GPs) to upper gastrointestinal endoscopy and the impact on endoscopic findings. We also examined the correlation between clinical symptoms and endoscopic findings. METHODS: We collected data on patients sent for upper gastrointestinal endoscopy by GPs of 30 healthcare centres in 1996 in our hospital referral area of 260,000 inhabitants. In addition, national and local cancer registries were used to enumerate the gastric cancer cases detected in 1996. RESULTS: The study population consisted of 3378 patients, mean age 58 years (interquartile range 25 years, male:female 1:1.3). Among the 30 healthcare centres, referral volumes for upper gastrointestinal endoscopy varied from 0.6 to 9.2 per 1000 inhabitants per year (median 3.3/1000/year). In healthcare units with 'high' (> or = 3.3/1000/year, 15 healthcare units, 1297 patients) and 'low' (<3.3/1000/year, 15 healthcare units, 2065 patients) referral volumes, the detection rates were as follows: duodenal ulcer (DU) 3.5% (n = 46) versus 4.0% (n = 83, P = 0.5), gastric ulcer (GU) 4.9% (n = 64) versus 5.3% (n = 110, P = 0.6), gastropathy 43.8% (n = 568) versus 35.6% (n = 736, P < 0.001), gastric cancer 0.5% (n = 6) versus 0.5% (n = 11, P = 0.8), gastric polyps 2.4% (n = 31) versus 1.5% (n = 30, P < 0.05). Independent risk factors for gastric cancer were age (OR 6.5 per decade, 95% CI 2.4-17.9), male sex (OR 5.5, 95% CI 1.8-17.1) and alarming symptoms and/or signs (OR 3.6, 95% CI 1.2-10.7); for GU, Helicobacter pylori (OR 2.6, 95% CI 1.9-3.5) and alarming symptoms (OR 2.0, 95% CI 1.4-2.7); for DU, male sex (OR 1.6, 95% CI 1.1-2.2) and H. pylori (OR 3.9, 95% CI 2.7-5.5); and for gastric polyp(s), age (OR 2.0 per decade, 95% CI 1.1-3.5) and high referral volume (OR 1.7, 95% CI 1.0-2.0). A high referral volume did not associate positively either with the number of peptic ulcers or gastric cancer. CONCLUSIONS: Alarm symptoms associate strongly with significant gastric lesions such as GU and cancer. Increased referral volume results in an increased number of gastropathy and gastric polyp(s), but not of peptic ulcer or cancer.

Physicians' database searches as a tool for early detection of epidemics.

We analyzed retrospectively the use of Physician Desk Reference Database searches to identify epidemics of tularemia, nephropathy, Pogosta disease, and Lyme disease and compared the searches with mandatory laboratory reports to the National Infectious Diseases Register in Finland during 1995. Continuous recording of such searches may be a tool for early detection of epidemics.

Specialized columnar epithelium of the esophagogastric junction: prevalence and associations. The Central Finland Endoscopy Study Group.

OBJECTIVES: In Barrett's esophagus (BE) normal squamous esophageal epithelium is replaced by specialized columnar epithelium (SCE). BE is related to gastroesophageal reflux disease (GERD) and is a risk factor for esophageal adenocarcinoma. SCE is detected also at normal-appearing esophagogastric junction without BE (junctional SCE). The relationships between junctional SCE, GERD, and cardia adenocarcinoma are obscure and controversial. The aims of the present study were to investigate the prevalence and demographics of junctional SCE and to compare these figures with those reported for BE, and esophageal and cardia adenocarcinoma. A further aim was to examine the association between junctional SCE and GERD, Helicobacter pylori infection, and gastritis. METHODS: One thousand one hundred-nineteen consecutive dyspeptic patients underwent gastroscopy and were enrolled into the study. RESULTS: Junctional SCE was detected in 110 patients (10%). The age-specific prevalence of junctional SCE increased with age. The male:female ratio was 1:1.1. In multivariate analysis, junctional SCE was independently and positively related to endoscopic erosive esophagitis (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.1), cardia inflammation (carditis) (OR, 3.1; 95% CI, 1.4-6.8), and age (OR, 1.4 per decade; 95% CI, 1.2-1.6), but not to corpus H. pylori infection (OR, 1.4; 95% CI, 0.7-2.8), antral (OR, 1.0; 95% CI, 0.5-2.1) or corpus (OR, 0.8; 95% CI, 0.4-1.8) gastritis, or intestinal metaplasia of the antral mucosa in stomach (OR, 1.2; 95% CI, 0.7-2.1). In univariate analysis, junctional SCE was, however, significantly more common in patients with antral-predominant atrophic gastritis (20%), compared with those with normal gastric histology (8%, p < 0.001). CONCLUSIONS: Junctional SCE is age related and may therefore be an acquired lesion. It is associated with cardia inflammation and endoscopic erosive esophagitis, but not with H. pylori infection or gastric intestinal metaplasia. Unlike BE and cardia cancer, junctional SCE occurs with similar frequency in men and women.

An implementation study of the PDRD primary care computerized guidelines.

OBJECTIVE: To study the implementation of electronic guidelines designed for general practitioners (GPs). DESIGN: A descriptive 3-year follow-up study. SUBJECTS: All new subscribers to Physician's Desk Reference and Database (PDRD) in 1992. SETTING: Locations of computers, where PDRD software was installed for the first time in 1992. MAIN OUTCOME MEASURES: Expectations of the program and changes in attitudes towards it, getting started with the system, frequency and continuity of use and estimated usefulness of the program. RESULTS: The guidelines were expected to enhance diagnostic accuracy (60% of subscribers), save time (45%), and reduce costs (11%). After 1 year's use, the opinions of the users on these topics had become slightly more positive. Technical problems delayed starting to use the program in 27%. After 1 year 72% were using the program at least weekly. Using frequency was associated with having the computer in the office. The subscribers who renewed their subscription after one year often became regular users. CONCLUSIONS: The study provides insight into the implementation phase of computer-based guidelines in a population of early adopters. Technical support was essential to overcome the barriers associated with computer technology. The perceived need for information was independent of the age and experience of the physicians.

Physicians' patterns of using a computerized collection of guidelines for primary care.

Physician's Desk Reference and Database is a Finnish collection of computerized primary care guidelines. The program has been in clinical use since 1989. For this study, a function producing a log file of all searches was added to the program. Two hundred twenty-seven users returned log files that contained 15,267 searches. The users made 3.12 (range 1-10.4) searches per day. The average time needed to find and read an article was 4.9 minutes. Sufficient facts were found in 71% of the searches. Dermatology was the most popular field of interest, followed by infectious diseases and cardiology.

PDRD--a computer-based primary care decision support system.

This article identifies the current stage of development and assessment of computer-assisted decision support systems in the domain of general practice. Physician's Desk Reference and Database (PDRD), an electronic medical database, is presented, and a plan for assessment of PDRD is briefly discussed.

Are smokers a risk group for delayed healing of tibial shaft fractures?

A total of 135 patients with a fresh tibial shaft fracture and with no other significant injuries underwent primary conservative treatment. Data on their smoking habits were obtained from hospital records and by questionnaire. Although the smokers had better prospects for healing of the fracture at the outset than non-smokers (lower mean age and less fractures caused by high-energy injuries), the smokers were found to have a significantly longer mean time to clinical union and a higher incidence of delayed union. According to a crude calculation, smokers had a 4.1-fold risk of tibial shaft fracture caused by low-energy injury, compared with non-smokers. An accelerated failure time model showed that the more comminuted or open the fracture, the higher the number of cigarettes smoked and the older the patient, the longer was the time to clinical union of the tibial shaft fracture. Female sex appeared to be a further risk factor for delayed healing. A logit model indicated that comminution of the fracture, smoking and female sex were associated with delayed union and non-union. If a patient has a markedly raised probability of delayed union of tibial shaft fracture because of many risk factors as reported in the previous literature or in this study, operative treatment should be considered as the primary alternative instead of conservative treatment. Stopping smoking during healing of tibial shaft fracture could also promote the union of the fracture.