[Recruitment for general practice - relationship between practice-based curriculum and career choice]. / Gewinnung hausärztlichen Nachwuchses - Zusammenhang zwischen praxisorientierter Lehre und Karriereentscheidung.

BACKGROUND: Demographic change and recruitment problems in general practice are increasingly threatening an adequate primary care workforce in many countries. Medical schools play an important role in attracting young physicians to this field. The influence of the general practice curriculum on the career choice of graduates has not yet been sufficiently investigated. METHODS: The present study combines continuously collected data of medical students concerning the participation in miscellaneous general practice courses with data of a later graduate survey. RESULTS: Response rate was 64.2%. Although only 4.7% of the participants preferred a career in general practice at study entry, this specialty was, at 12.3%, the second most frequent career choice. Among the future general practitioners, only 18.5% had initially planned this career. The future general practitioners took part significantly more frequently in all facultative general practice courses. They reported more frequently to have met role models in general practice and to have gained experience in rural areas. Future general practitioners would more often prefer to work in rural areas in the future. CONCLUSIONS: Overall, the present results indicate that a broad and practice-oriented general practice curriculum has the potential to attract medical students to the specialty.

Primary care guidelines for geriatric assessment. A structured, comparative analysis.

A structured geriatric assessment (GA) improves the quality of health care; however, the quality of GA guidelines has hardly been investigated. Eight guidelines were identified by systematically searching guideline databases, web sites of guideline developers, and PubMed. The methodological quality was assessed by two appraisers using the German Guideline Evaluation Instrument (DELBI). Guideline content was extracted; organizational and medical recommendations were compared. The methodological appraisal revealed a broad range of quality. The domains "Scope and purpose" and "Clarity and presentation" showed good results. The domains "Applicability" and "Editorial independence" had results that were not as good. Medical recommendations agreed to a great extent. GA should be delivered continuously for all older people in their homes by one responsible assessor. In cooperation with relatives, patient-centered therapy goals should be defined. Differences were identified in profession, instruments, aims, and "tailoring." The quality of primary care guidelines for GA may be improved. Details of organization of a GA require further research.

Do general practitioners recognize mild cognitive impairment in their patients?

OBJECTIVES: The need for recognition of mild cognitive impairment (MCI) in primary care is increasingly discussed because MCI is a risk factor for dementia. General Practitioners (GPs) could play an important role in the detection of MCI since they have regular and long-term contact with the majority of the elderly population. Thus the objective of this study is to find out how well GPs recognize persons with MCI in their practice population. DESIGN: Cross-sectional study. SETTING: Primary care chart registry sample. PARTICIPANTS: 3,242 non-demented GP patients aged 75-89 years. MEASUREMENTS: GPs assessed the cognitive status of their patients on the Global Deterioration Scale (GDS). Thereafter, trained interviewers collected psychometric data by interviewing the patients at home. The interview data constitute the basis for the definition of MCI cases (gold standard). RESULTS: The sensitivity of GPs to detect MCI was very low (11-12%) whereas their specificity amounts to 93-94%. Patients with MCI with a middle or high level of education more often got a false negative assignment than patients with a low educational level. The risk of a false positive assignment rose with the patients' degree of comorbidity. GPs were better at detecting MCI when memory or two and more MCI-domains were impaired. CONCLUSION: The results show that GPs recognise MCI in a very limited number of cases when based on clinical impression only. A further development of the MCI concept and its operationalisation is necessary. Emphasis should be placed on validated, reliable and standardised tests for routine use in primary care encompassing other than only cognitive domains and on case finding approaches rather than on screening. Then a better attention and qualification of GPs with regard to the recognition of MCI might be achievable.

Epidemiology of diabetes mellitus in German general practitioners' consultation--results of the SESAM 2-study.

The treatment of chronic diseases is of eminent importance in primary care, and type 2-diabetes mellitus is one of the most common dysfunctions. Its world-wide prevalence has been increasing from year to year. Thus, to estimate the prevalence and incidence of diabetes mellitus, we performed the SESAM (Sächsiche epidemiologische Studie in der Allgemeinmedizin) 2-study in cooperation with general practitioners (GPs) from the German state of Saxony; 270 of the 2510 (10.8%) solicited physicians participated. Cross-sectional data were collected from 1 October 1999 until 30 September 2000, from randomly selected patients previously known to the practitioner. From a total of 8877 consultations with 270 GPs, diabetes was prevalent in 14% (n = 1241) of the patients and the incidence was 0.3% (27 of 8877 cases). The consultation prevalence was estimated at 14.3% (n = 1268; CI 13.6-15%). Of the diabetic patients, 3.5% (n = 44) suffered from type 1-diabetes, while type 2-diabetes was found in 66.9% (n = 848) of the cases. "Other diabetes" was determined in 19.2% (n = 244), and "not further specified diabetes", in 10.4% (n = 132) of the cases. Related to the German population in general, the prevalence ranged from 7.9 to 9.2%. The estimated consultation prevalence is about four times higher than that in other European countries. These data are of importance in illustrating the epidemiology of diabetes in the population and the direct repercussions for GPs. They also point out the significance of diabetes as a major challenge to the German health care system.

[Respiratory symptoms in the general practice. An analysis of the Leipzig SESAM Study]. / Atemwegsbeschwerden in der allgemeinärztlichen Sprechstunde. Eine Auswertung der Leipziger SESAM-Studie.

The Saxon Study of General Medicine (SESAM) investigated the reasons why patients consulted the general practitioner, which diagnoses were established and how the patients were subsequently treated. In the majority of cases, the respiratory symptoms were simple infections of the upper and lower respiratory tract. Pneumonia must always be considered, while severe pulmonary diseases are of no significance in the differential diagnosis of respiratory complaints in the general practice.

[Patient care in nursing homes by the family physician]. / Hausärztliche Betreuung des Heimpatienten. Vermeiden Sie Uberdiagnostik und Polypragmasie.

When treating the acute and chronic diseases of nursing home residents, the family physician must consider the patient's decreased ability to make decisions and shortened life expectancy in each case. Nurses tend the elderly people, help them wherever it is necessary, have time to listen to the hardships and worries of their charges and are an irreplaceable help to the family physician for observing patients and assessing the measures taken based on these observations.

[Beta-adrenoceptor antagonists and ACE-inhibitors. Carvedilol compared with metoprolol as combination partner in cases of diabetes and hypertension]. / Beta-Rezeptorenblocker und ACE-Hemmer. Vergleich von Carvedilol und Metoprolol als Kombinationspartner bei Diabetes und arterieller Hypertonie.

Nearly all type 2 diabetic patients are suffering from arterial hypertension. The latter usually becomes manifest earlier than the diabetic metabolic disturbances. Adequate treatment often requires a combination of angiotensin converting enzyme(ACE)-inhibitors and beta-adrenoceptor antagonists. Metoprolol is still the most frequently used beta-adrenoceptor antagonist in this setting. Some clinical trials have shown carvedilol to be superior in improving the metabolic situation and prevention of secondary disorders caused by diabetes. Therefore carvedilol may be the beta-adrenoceptor antagonist of choice for treatment of patients at high cardiovascular risk and especially for diabetes type 2. As comparisons to metoprolol succinate as well as to optimally dosed metoprolol tartrate are missing, a definite superiority of carvedilol cannot be assumed.

[Basic pain management care by the family physician]. / Stufenschema und Kotherapeutika. Schmerztherapeutisches Rüstzeug für den Hausarzt.

After a cleardiagnosis has been made, many acute as well as chronic pain symptoms can be treated by the family physician on an outpatient basis. For the step therapy of chronic pain, particular attention must be given to the side effects. In some cases, side effects necessitate the use of comedication, such as for nausea, constipation or depression. Particularly complex pain treatments should still be treated by the specialist.

[Presenting problem: abdominal pain]. / Vergessen Sie die Kolibris, denken Sie an das Wahrscheinlichste!

The Saxon Study for General Medicine (SESAM) investigated the reasons why patients consulted the general physician, what diagnoses were established, and how the patients were subsequently treated. In the majority of cases, the reason for the abdominal complaints was located in the gastrointestinal or urogenital tract, in the presence of infections or psychosomatic problems. Gynecological problems must also be considered, while diseases other than gastrointestinal are of no significance for the differential diagnosis of abdominal complaints in the general physician's office.

[Diagnostic work-up of abdominal pain by the family doctor: an avertable potentially threatening situation must be excluded]. / Bauchschmerzen beim Hausarzt: Wie viel Diagnostik ist notwendig und sinnvoll?

When patients attend the physician's office with acute abdominal pain, the doctor must first exclude a potentially dangerous condition (acute abdomen) before initiating symptomatic treatment (e. g. painkilling drugs). The need for this is based in the first instance on the presence of severe complaints in combination with the absence of a plausible explanation for the patient's distress, as well as, secondarily, the anxiety of the patient or the person accompanying him, or even the doctor's own anxiety about possibly overlooking a serious pathology.

[Red, yellow, green: management of gastrointestinal complaints]. / Management von Magen-/Darmbeschwerden: Therapie nach der Ampelmethode.

In a patient presenting with acute abdominal pain, initiation of symptomatic treatment must be preceded by the reliable exclusion of a potentially serious situation (acute abdomen = red light). Rapidly progressive or severe abdominal pain mandates an urgent diagnostic investigation on the part of the physician. No less important is the positive diagnosis of psychosomatic disorders (yellow light). If the family doctor fails to properly counsel the patient, too much diagnostic effort can lead to an iatrogenic somatic fixation. In the absence of all the above, the light shows green for causal therapy, an open mind on the diagnosis, symptomatic treatment and follow-up.

[Sports and leisure injuries in summer]. / Sportverletzungen, Beinaheertrinken, Hundebisse. Erste Hilfe bei Sommerunfällen.

In the first days of summer, there is an increase in the number of summer-related accidents and injuries. Typical for the types of sports practiced in summer, such as ball games, cycling or skating are injuries to the wrist and ankle, knee, head and shoulder. The most frequent victims of swimming accidents are children under four years of age, and adolescents aged between 15 and 19 years. During grilling, burns often occur, most of which, however, are superficial and can be treated in the doctor's office. The incidence of dog bites also increases in summer. In such cases consideration must be given not only to tetanus boosters, but also to the possibility of an infection with rabies.

[Insect stings and their sequelae]. / Bienen, Wespen, Hornissen. Kleiner Stich--grosse Wirkung.

In the summer months, insect stings are a common reason for seeking help from the general physician. In the majority of cases a local reaction is seen, but, far less often, an anaphylactic reaction may also occur. Such an acute situation requires calm but decisive action, and the initiation of an evaluation by an allergy specialist. The family doctor should regularly review the facilities for treating an anaphylactic reaction in his office, and, where necessary, optimize them.

[STEP--standardized assessment of elderly people in primary care]. / STEP--Europäische Leitlinie für das standardisierte evidenzbasierte präventive Assessment älterer Menschen in der medizinischen Primärversorgung.

BACKGROUND: There is a need for a standard preventive assessment scheme, which is effective, feasible and acceptable throughout European primary care. METHODS: A consensus based guideline including systematic reviews of the evidence was done by an expert panel of general practitioners (core group) and epidemiologists / geriatricians from seven European countries. RESULTS: The Step group identified 8 health domains to be considered in a preventive assessment; client's perspective and attitudes. physical state, functional state, significant symptoms, mental function, social circumstances, medication and primary preventive issues. To select the health areas with a proven preventive potential the strength of scientific evidence and the relevance to primary preventive care was assessed. The final recommendations graded as the preventive primary care impact factor as follows: A1=strongly recommended were hypertension, symptomatic heart failure, urinary incontinence, hearing impairment, vision impairment, falls, breathlessness, depression, dementia, medication review, functional status, activity and physical exercise. A2=recommended: Hypertension over the age of 80, history of myocardial infarction, symptomatic coronary heart disease, atrial fibrillation, history of TIA or stroke, peripheral vascular disease, diabetes, thyroid dysfunction, osteoporosis, lipids, faecal incontinence, weight status, foot problems, oral heath, osteoarthritis, sleeplessness, pain, social circumstances, tobacco and alcohol use, psychological support for patients with chronic disease and (national) immunization & cancer programs. CONCLUSIONS: The rising population of elderly people in Europe gives cause for health care professionals and policy makers to consider optimal ways to preserve health and function in old age. An Evidence based, proactive preventive geriatric assessment can help to promote heath and function in older people.