Dermatoscopic screening in family practice.

BACKGROUND: Screening for dermatologic lesions is important in primary care medicine and may be enhanced by magnified illuminated video images. Viewing skin lesions with a dermatoscopic instrument is very helpful in judging and evaluating their characteristics. Both patients and physicians benefit from the improved diagnostic yield, possible medical-legal protection, enhanced development of the patient-physician relationship, medical practice economic boost, and more efficient dermatologic screening. The higher magnification and illuminated view theoretically enables the physician to make better decisions and helps convince the patient to comply with recommended treatment. METHODS: 57 patients in a single private family practice were interviewed before receiving a visual dermatology screening examination. The physician then recorded his findings and suggested plan. Next, the physician performed a magnified video dermatologic examination and once again recorded his findings, plan, and impression of the patient's reaction to the recommendations and treatment. RESULTS: 57 patients with 79 examination sites demonstrated an increased confidence by both the physician and patient with the video examination over the traditional dermatologic examination. In addition, several changes in proposed treatment were noted following the video examination. CONCLUSIONS: Both the patients and physician believed the magnified video dermatologic examination improved diagnostic accuracy and increased patient motivation to act on physician recommendations.

Esophagogastroduodenoscopy for the family physician.

Esophagogastroduodenoscopy is most commonly performed for evaluation of epigastric pain, severe heartburn, chronic nausea and other dyspepsia syndromes that are not relieved by medical therapy. It should not be performed as an in-office procedure in patients with unstable angina, respiratory failure, active upper gastrointestinal bleeding or hemodynamic instability. Although office esophagogastroduodenoscopy is safe for low-risk patients, the risks associated with anesthesia and the need for postprocedure observation may require other patients to undergo the procedure in a hospital setting. Use of a local anesthetic throat spray reduces the gag response that occurs when the endoscope is swallowed. Sedation is commonly achieved with intravenous administration of a benzodiazepine plus a narcotic, and the effects of these drugs can be rapidly reversed. Complications are rare and most frequently result from medications rather than from the procedure itself.

Skin cryosurgery for the family physician.

Cryosurgery is a valuable addition to the clinical services offered by family physicians. In the office setting, a cryoprobe cooled with nitrous oxide gas or liquid nitrogen spray can be used to initiate gradual controlled destruction of many common skin lesions. Cryosurgery is often an excellent alternative to cold-knife surgery for actinic and seborrheic keratoses, verrucae, benign nevi, skin tags and polyps. Cryosurgically treated lesions usually heal with little or no scar formation. The benefits of various cryosurgical techniques justify the minimal effort and expense required to incorporate them into clinical practice.

Esophagogastroduodenoscopy by family physicians phase II: a national multisite study of 2,500 procedures.

We have prospectively studied 1,783 upper gastrointestinal tract endoscopy procedures as performed by family physicians from thirteen separate office practices. Phase I of the study previously reported on 717 procedures in which patient management was enhanced, diagnostic yields were high, and biopsies were performed where appropriate. In Phase II, the data totaled 2,500 procedures representing 51.1 years of cumulative practice experience by the entire group. All cases were gathered prospectively and biopsies were confirmed by a pathologist's independent tissue analysis. In this series, family physicians were asked to record all complications, and to specify the exact manner in which performance of the procedure enhanced patient management. There have been biopsies in 1,230 (69% biopsy rate) Phase II cases with biopsy reports available in 1,194 (97% reporting rate) cases. There is pathological confirmation of the family physicians' visual diagnosis in 1,104 of 1,194 (93%) available biopsy reports for a 92% accuracy rate. There have been no complications, and the complication rate for the total series (1/2, 500) is now 0.0004.

Nasolaryngoscopy for family physicians.

Nasolaryngoscopy is easy to learn and safe and convenient to perform. It is readily accepted by patients and is a rich source of clinical information. The flexible nasolaryngoscope allows the physician to directly observe the anatomy of the nasal passages, pharynx and larynx. The procedure is helpful for identifying the etiology of chronic nasal complaints and hoarseness. Other possible indications for nasolaryngoscopy include suspected nasal foreign body, recurrent nasal or pharyngeal bleeding, and epiglottitis. With the use of this instrument, treatment of otolaryngologic conditions may be more specific, thereby reducing unnecessary referral or delay in treatment.

Rhinolaryngoscopy by family physicians.

A case series is presented consisting of 210 symptomatic patients evaluated by family physicians using fiberoptic rhinolaryngoscopy. The case series is analyzed to evaluate patient tolerance of the procedure, to measure the time required for the procedure, and to explore the clustering of diagnostic findings as they relate to presenting symptoms. Family physicians performed the examinations in an average of 4.4 minutes, with a median discomfort score of 2 on a scale of 0 to 10. A change in the diagnostic assessment or management plan following examination occurred in 90% of cases. Laryngeal pathology was identified in 73% of patients with chronic hoarseness, 60% of patients with both chronic hoarseness and nasal symptoms, and 3% of patients complaining of chronic nasal symptoms only. Nasal polyps or purulent drainage from the sinus ostia were found in 28% of patients with chronic nasal symptoms, 30% of patients with both chronic hoarseness and nasal symptoms, and 2% of patients with chronic hoarseness only. Incomplete examination (because of gagging) occurred in only 1 of 210 cases. This study demonstrated high diagnostic yield, rapid acquisition of technical skill, minimal patient discomfort, significant impact on diagnosis and management, and minimal time required for examination.

Esophagogastroduodenoscopy by family physicians: a national multisite study of 717 procedures.

This is the first multisite report of esophagogastroduodenoscopies (EGDs) performed by family physicians. The first 717 EGDs performed by family physicians from 8 separate office practices provide a practical and safe rationale for selected cognitive and psychomotor aspects of continuing medical education after residency training. Although primarily in private practice, these physicians were affiliated with 6 academic institutions. This group of family physicians received training in short courses. The average amount of hands-on training before independent EGD was 8 supervised cases. Cumulatively, these data represent 227 months (18.9 years) of office practice. All cases were collected sequentially from the beginning of each physician's experience, and 454 cases were collected prospectively. Physicians reported excellent patient tolerance. Diagnostic yields were high, and biopsies were performed where appropriate. Pathologists reviewed biopsy specimens from 213 sites. The family physician endoscopic diagnosis agreed with the tissue diagnosis in 188 cases (88 percent). Physicians believed that EGD enhanced management or changed the diagnosis in more than 89 percent of cases. One bleeding complication requiring overnight hospitalization was noted. This complication rate 0.0014 (1/717) compares favorably with published subspecialty complication rates 0.0013 (1.3/1000). These data confirm the ability of some family physicians to perform EGD and suggest that continuation is safe. Biopsy analysis indicates diagnostic accuracy is high. Further study on the cognitive aspects and the defragmentation of care is needed.

Preliminary study of rhinolaryngoscopy by family physicians.

Flexible fiberoptic rhinolaryngoscopy is an examination technique which has been widely accepted by otolaryngologists. Usefulness and acceptability of the technique was assessed in symptomatic patients in a family practice population. Collaborating family physicians performed 66 examinations, which required 4.6 +/- 0.60 minutes (mean +/- SD) to complete. The median patient discomfort score was 2 on a 0-10 scale ranging from "no discomfort" to "severe discomfort." Change in diagnosis by the primary physician was made in 13 of 18 patients, and change in management plan in 10 of 12 patients, after the examination. Important findings included primary diagnosis of a laryngeal carcinoma, unsuspected nasal polyps, and normal examinations of high quality. These preliminary findings suggest that flexible fiberoptic rhinolaryngoscopy by family physicians is a useful examination, requires little time, and is acceptable to patients. Further study is suggested before general use is advocated.

Flexible fiberoptic sigmoidoscopy: its use in family medicine.

Flexible fiberoptic sigmoidoscopy (FFS) can be both learned and taught by family physicians. The patient benefits because unnecessary referral is reduced. The physician benefits by offering more comprehensive services to the patient and by demonstrating expertise in the procedure. In a collaborative study involving family physicians performing more than 1,500 FFS examinations, both the 35-cm scope and the 65-cm scope were effective instruments, but most physicians who had experience with both scopes preferred the longer one. In addition, the results of this study support a significant advantage in pathology detection for the 65-cm scope compared with the 35-cm scope.

Flexible fiberoptic sigmoidoscopy in family medicine.

Flexible fiberoptic sigmoidoscopy is easily mastered by family physicians. Self-study, along with a minimal amount of supervision, seems to provide adequate training. Patient preparation is essential and is best accomplished with enemas "until clear" rather than with the standard two enemas. Patients prefer the flexible sigmoidoscope to the rigid instrument, and the greater depth of penetration achieved with the former--even with the 35-cm sigmoidoscope--enables the physician to detect significantly more pathologic lesions.

Flexible fiberoptic sigmoidoscopy.

The 35-cm flexible fiberoptic proctosigmoidoscope is a cost-effective instrument for the family physician. Nonendoscopists have mastered its use with no reported complications. Patient tolerance is high compared to tolerance for the rigid scope. The pathology yield per procedure is two to four times greater than that reported with the rigid sigmoidoscope. Yields with the 35-cm instrument have matched those documented with the 65-cm fiberoptic instrument.

Cryotherapy in ankle sprains.

This study assesses recovery from ankle sprains. Thirty-seven final participants were categorized according to the severity of their injury and the use of cryotherapy (15 minutes, one to three times per day) versus heat therapy (15 minutes, one to three times per day) for a minimum of three days. Therapy commenced either less than one hour, from one to 36 hours, or greater than 36 hours after traumatic event. Sprains were graded into five categories based on severity of the injury, but only two categories, subject to conservative treatment, are considered in this study. The study showed that cryotherapy started within 36 hours after the injury was statistically more effective than heat therapy for complete and rapid recovery. Patients in a group with Grade four sprains (unable to bear weight because of pain) reached full activity in 13.2 days compared to 30.4 days in a group using cryotherapy initiated 36 hours after injury or to 33.3 days in a group using heat therapy. Therefore, early use of cryotherapy, continued with adhesive compression, is an effective treatment of ankle sprains yielding earlier complete recovery than late cryotherapy or heat therapy.

Cryotherapy.

Cryotherapy diminishes the inflammatory reaction to trauma and reduces edema, hematoma formation and pain. During the rehabilitation period, cold application enables the patient to develop strength and mobility in an injured area, with minimal inflammation and discomfort. Heat potentiates the body's inflammatory reaction to trauma and results in increased discomfort. Cryotherapy should be used initially and heat should be reserved for improving mobility and absorbing hematomas after all inflammation has subsided.