Do published guidelines for evaluation of irritable bowel syndrome reflect practice?

BACKGROUND: The only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis. METHODS: This is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis. RESULTS: Of the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort. CONCLUSIONS: Primary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes.

Diagnosis and care of irritable bowel syndrome in a community-based population.

OBJECTIVE: To identify the healthcare utilization and evaluation in a community-based population with an incident diagnosis of irritable bowel syndrome (IBS). STUDY DESIGN: Retrospective cohort. PATIENTS: A randomly selected cohort of 149 Olmsted County, MN, adults with an incident diagnosis of IBS between June 1, 1992, and December 31, 1994. METHODS: Retrospective medical record review of each medical encounter for the 10 years before and the 3 years after the incident IBS diagnosis. Specific attention was given to healthcare visits, tests, and treatment associated with documented gastrointestinal (GI) tract symptoms and diagnosis of IBS. RESULTS: Of 149 patients, 98 (66%) were women, and the mean patient age was 46.6 years. Patients averaged 4.7 healthcare visits annually, including 0.5 related to GI tract symptoms. Two thirds of patients had GI tract symptom-related visits at least 2 years before IBS diagnosis. Only 5% of IBS diagnoses were made by a gastroenterologist. Colon examinations (colonoscopy or barium enema) were performed on 47% of patients and were more common in those aged > or = 55 years (58% vs 36%; P = .02). One third of patients had no GI tract testing proximal to the IBS diagnosis. Following the IBS diagnosis, only about half the patients made any IBS or GI tract symptom-related visits per year. CONCLUSION: The path to diagnosis of IBS is through the primary care physician and includes minimal testing and limited follow-up care.

Comparison of health status, socioeconomic characteristics, and knowledge and use of HIV-related resources between HIV-infected women and men.

OBJECTIVES: The authors compared socioeconomic characteristics, and knowledge and use of human immunodeficiency virus (HIV)-related resources and health status measures between HIV-infected women and men registered within the Denver Health and Hospitals health care system. METHODS: Data collected through two Centers for Disease Control-funded surveillance initiatives (Adult Spectrum of Disease and Supplement to HIV/AIDS Surveillance) were linked. Health status measures were obtained using the Medical Outcomes Study (MOS-20) questionnaire. To compare health status measures between genders, men were matched to women based on disease stage, intravenous drug use, race, years of education, employment status, and age. RESULTS: Among all patients interviewed (n = 419), women (n = 52) were more likely to be minority, uneducated, intravenous drug users, and at earlier stages of HIV-disease than men (n = 367). Employment status was not significantly different. Knowledge of available services was generally good among both genders. Women received public assistance and had health insurance (Medicaid) more often than men. Women used support services, social work, and shelter assistance less often than men. The matched pairs analysis (n = 46 pairs) showed no significant differences between genders in physical and social function, mental health, pain, or general health perceptions; however, role function was better in women than in men (P<0.02). CONCLUSIONS: When controlling for factors that may influence health and access to health care, HIV disease generally impacts the health status of both genders similarly. Women scored higher in role function which may reflect family caretakers' responsibilities. Although knowledge of HIV-related resources was similar by gender, men made contact more often suggesting areas for enhanced outreach toward women.

Response ofDendroctonus brevicomis Le Conte (Coleoptera: Scolytidae) to different release rates and ratios of aggregation semiochemicals and the inhibitors verbenone and ipsdienol.

The response of western pine beetle,Dendroctonus brevicomis Le Conte, to different release rates of the aggregation semiochemicals (attractants)exo-brevicomin, frontalin, and myrcene and the inhibitors verbenone and ipsdienol was investigated. Release rates of verbenone ranging from 0.18 mg/ 24 hr to 1.2 mg/24 hr did not result in significant reductions in mean trap catch ofD. brevicomis. In contrast, very low release rates of ipsdienol (0.02-0.4 mg/24 hr) significantly reduced trap catch compared to controls. The combination of verbenone and ipsdienol, released at rates above 0.09 and 0.02 mg/24 hr, respectively, resulted in significantly lower trap catches ofD. brevicomis in attractant-baited traps. Results of an experiment testing a factorial combination of different release rates of verbenone and attractants suggest that response is not ratio-specific. The response curve ofD. brevicomis to the levels of verbenone was similar across all levels of attractants, while the response to equivalent ratios of attractants to verbenone was not similar, suggesting that the behavior of the beetles is primarily influenced by the absolute release rate of verbenone.

Influence of aggregation inhibitors (verbenone and ipsidenol) on landing and attack behavior ofDendroctonus brevicomis (Coleoptera: Scolytidae).

The influence of the aggregation inhibitors verbenone and ipsdienol on the response of western pine beetle,Dendroctonus brevicomis, to attractive host trees was investigated. Paired ponderosa pine trees (Pinus ponderosa) were baited with aggregation semiochemicals to stimulate mass attack. One tree in each pair received an inhibitor treatment consisting of five sets of two verbenone and two ipsdienol dispensers spaced 1 m apart vertically along the tree bole. Beetle landing was monitored with sticky traps on the tree bole, and attack density was assessed from bark samples removed four or seven days after baiting. The inhibitor treatment resulted in a significant reduction of both the numbers of beetles landing on trees and the density of attacking beetles compared to control trees (without inhibitors). The ratios of beetle landing density to attacking density were not different between inhibitor-treated and control trees, nor were the vertical distributions of beetles landing or attacking, suggesting that beetle behavior was primarily influenced at a longer range, prior to landing on the tree. Although the application of verbenone and ipsdienol did not preventD. brevicomis from attacking baited trees, our results suggest that when applied to unattacked (and unbaited) trees, their effectiveness at reducing the attack pressure might allow trees having a certain amount of resistance to survive attack by pioneer beetles.