Pivmecillinam versus sulfamethizole for short-term treatment of uncomplicated acute cystitis in general practice: a randomized controlled trial

OBJECTIVE

To investigate whether short-term treatment with pivmecillinam was more effective than sulfamethizole in patients with acute uncomplicated urinary tract infection (UTI).

DESIGN

Randomized controlled trial.

SETTING

General practice, Denmark.

SUBJECTS

Patients (n = 167) with uncomplicated UTI confirmed by positive urine phase-contrast microscopy.

MAIN OUTCOME MEASURES

Drug efficacy based on clinical and bacteriological cure.

RESULTS

Urinary symptoms disappeared first in patients treated with pivmecillinam, but after five days there was no significant difference in clinical cure rate between the two antibiotics. At the follow-up visit 7-10 days after initiation of treatment, 95.4% of patients treated with pivmecillinam and 92.6% of patients treated with sulfamethizole had no persistent cystitis symptoms (difference 2.8%, CI -4.5%; 10.0%). Bacteriological cure was observed in 68.8% of patients randomized to pivmecillinam and in 77.9% randomized to sulfamethizole (difference -9.2%, CI -24.7%; 6.3%). Some 26.8% of patients randomized to pivmecillinam experienced a new UTI within 6 months after treatment compared with 18.4% of patients randomized to sulfamethizole (difference 8.4%, CI -4.5%;21.4%). No patients developed septicaemia with urinary pathogens within one year after initial treatment.

CONCLUSION

Patients treated with a three-day regime of pivmecillinam experienced faster relief of symptoms compared with patients treated with a three-day regime of sulfamethizole. Five days after initiation of treatment there was no significant difference in clinical and bacteriological cure between the two antibiotic regimes.

[Fewer readmissions of schizophrenic patients who have contact with their own GP]

INTRODUCTION

The object of the study was to investigate to which extent the GP is part of the follow-up treatment of schizophrenic patients after their discharge from a psychiatric department.

MATERIAL AND METHODS

During a period of one year, 96 schizophrenic patients were discharged and the patients' GP subsequently answered a questionnaire at six and 12 months after the discharge. The questionnaire, which was completed by 37 practices, contained information as to whether the GP had had any contact with the patients concerned and which services the patient had received. Furthermore, register information concerning the admission pattern during the first 12 months after discharge were obtained.

RESULTS

The majority (73,9%) of the patients had contact with their own GP after discharge, and they had the same number of visits as the background population. The visits primarily concerned somatic problems; however, approximately 25% of the patients had psychiatric problems as the major subject of their visit. Significantly fewer of the patients who had contact with their GP were re-admitted to hospital compared with patients who had no contact with their GP, and patients with contact had needed significantly fewer bed-days at 12 months after discharge than the patients without contact to their GP. After adjustment for prognostic factors the differences remained significant.

CONCLUSION

An increased shared care between the GP and the psychiatric system in connection with the treatment of patients with chronic mental disorders may reduce re-admittance and relapse and thus improve the prognosis for this group of patients.

[Infection Control in primary health care]

Infection control in primary health care Infection control in primary health care is underreported and often underestimated. Cross contamination can happen by indirect contact, and general hygienic precautions should be established in all procedures where HCWs are at risk of contact with organic material. This article suggests infection control measures that can be established in primary health care regarding hand hygiene, cleaning and reprocessing of utensils.

[Symptoms and diagnostic work-up in breast cancer]

Symptoms from the breast leading to suspicion of breast cancer are very common. The present review gives guidelines for a rational diagnostic strategy for women with breast symptoms. The triple assessment based on clinical examination, imaging by mammography and ultra sonography, and biopsy is central to the diagnostic work-up. The triple assessment should be performed in the integrated diagnostic system to ensure fast diagnosis and a low rate of inconclusive results. The principles of the triple-test can be deviated from in women under 25 years since breast cancer is extremely rare in this age group. Imaging is not mandatory among older women with clinically obvious cancer verified with biopsy. Breast lumps in men is rarely cancer, and imaging does not contribute to diagnostics.

[Allergology in Denmark 2006]

Allergic diseases are prominent, possibly life threatening, and a cause of worldwide concern. Evidence-based education of doctors in the specialty of allergology is a prerequisite for correct diagnosis and treatment of patients with allergic diseases. Recently, the specialty of allergology has been abolished in Denmark, without any upgrading of the education of doctors in related specialties. As a consequence, one could fear that allergy expertise will be disappearing. We propose collaboration among experts from related specialties with joint mediation of knowledge through a centre of allergology, common educational programs for doctors in training and physician specialists, and collaboration in regional centres of allergology.

[Skin prick tests of patients with hay fever carried out in general practices compared with those carried out in a specialist outpatient clinic]

INTRODUCTION

The aim of our study was to assess whether general practitioners and their staff (practices) who had attended a short CME course with technical instruction in the skin prick test could diagnose and treat unselected patients with allergic rhinoconjunctivitis at the same quality level as the allergy outpatient clinic.

MATERIAL AND METHODS

We performed a multicentre study with the participation of 38 general practices and the Allergy Centre at Odense University Hospital (OUH). After a two-day course for the general practitioner and his practice staff, every practice performed a skin prick test on 10 consecutive adult patients with symptoms of allergic rhinoconjunctivitis during the spring and summer. A standardised questionnaire was also filled in and sent to the Allergy Centre, where the patient subsequently had another skin prick test carried out. The results of the tests were determined in duplicate and then compared.

RESULTS

No significant differences in the quality of the skin prick test for 10 allergens or histamine control were found between the general practice and the Allergy Centre. Discordant results were found in 9%, i.e., a positive result either at the practice or the Allergy Centre, but not at both.

CONCLUSION

After a training course, general practitioners and their staff are fully able to perform and validate skin prick tests for inhalation allergens.

[Screening for cervical cancer in the county of Funen. Status of 25 years of development and experiences]

INTRODUCTION

Since 1979 screening against cervical cancer has been conducted in the County of Funen. In the period 1979-1988 the screening against cervical cancer was opportunistic, where women aged 25-55 years had a PAP-smear taken once a year by their GP or gynaecologists at the hospitals. In this period the coverage was only about 50% and the number of cervical cancer was not decreasing as seen in Counties with organised screening programmes. Since 1989 the screening has been organised in the County of Funen, which will be described in the following, including updating and quality improvements such as implementation of liquid based cytology and semiautomated screening (ThinPrep Imaging System, Cytyc).

MATERIAL AND METHOD

The programme is based on an automated call-recall system designed to invite women aged 23-59 years. The offer is free of charge and the PAP-smears are taken by the general practitioners. All cervical cytological samples from the County are processed and screened at the Department of Pathology Odense University Hospital. Since 2001 the liquid based technique, ThinPrep-Paptest, has been used, and from 2004 an assisted screening (ThinPrep Imaging System) has been implemented in the routine screening.

RESULTS

Switching from opportunistic to organised screening and implementation of liquid based cytology has resulted in a reduction in the number of samples, about 6,500 per year. The diagnostic quality has increased; the number of incidences of cervical cancer was reduced from 62 in 1988 to 18 in 2004 and the mortality from 29 in 1988 to 12 in 2001.

CONCLUSION

Since implementation of the organized screening programme and later of the liquid based cytology the coverage and diagnostic quality have increased. The incidence and mortality of cervical cancer have decreased.

[Quality improvement of referrals from practising physicians. An example of a practicable strategy]

INTRODUCTION

Referrals from practising physicians to hospital departments are of varying quality. This increases the risk of inappropriate or even incorrect patient treatment courses. We examined the quality of referrals to a large department of nuclear medicine before and after initiatives aimed at improving the information and feedback to the practising physicians.

MATERIALS AND METHODS

An evaluation of the quality of referrals (n = 579) from praticising physicians to the Department of Nuclear Medicine, Odense University Hospital, Denmark, recorded during two periods of three months each before and after (1) publication of a referral guideline and (2) a feedback response to those physicians whose referrals were insufficient. A general practitioner (GP) and a specialist in nuclear medicine (NM) judged independently whether the referrals were good, acceptable or unacceptable.

RESULTS

During the two periods, 281 and 298 referrals were received, respectively. Of these, 37% and 27%, respectively, were from practising specialists (PSs). After intervention, 23% more referrals were received from GPs, and the share of "good" referrals also increased (before/after: 48%/72% (GP), 61%/84% (NM)). In contrast, there was a 23% decrease in referrals from PSs, whereas the share of "good" referrals remained unchanged or increased (before/after: 64%/66 % (GP), 64%/96% (NM)). In addition, there was a change in the referral pattern from both GPs and PSs.

CONCLUSION

Relatively simple and inexpensive intervention caused an increase in the number and quality of referrals from GPs and a fall in referrals from PSs without an obvious improvement in quality.

[Quality control of whole-body bone scintigraphy. Patient surveys]

INTRODUCTION

The quality of health care is but sparsely elucidated; surveys of complete patient courses hardly exist. We established and used benchmarks for a major nuclear medicine examination: whole-body bone scintigraphy.

MATERIALS AND METHODS

The study material included 458 out of 512 consecutive examinations. Patients were referred by general practitioners (12%), practising specialists (16%) and hospital departments (72%). The survey dealt with waiting times and information provided, as judged by the patient, the referring physician and the Department of Nuclear Medicine (DNM) in relation to referrals, reporting and the passing on of the results to the patient. The DNM judged the quality of the examinations, and the referring physician assessed the implications for diagnosis and treatment.

RESULTS

In 10% of the cases, the patient felt that the waiting time was unsatisfactory, as the referring physician might take up to 150 days to send the referral and because 11% had, after two months, still not been informed of the examination result. Supplementary tomography was used in 38 examinations (8%); of these, only one (3%) provided new evidence. Based on the examination results, the referring physician could make a diagnosis and/or wanted to change management for 61% of patients.

CONCLUSION

Referrals were delayed mainly by the referring physicians, who often forgot to inform their patients of the examination results. Special admissions seldom yielded extra information. The examination result had important clinical implications in almost two thirds of patients.

[Can we rely on the results of urine microscopy and culture when tests are performed in general practice?]

INTRODUCTION

Urinary tract infections (UTI) account for 2-5% of consultations in general practice, but only about half the patients with dysuria have significant bacteriuria (> 100,000 bacteria per ml). A microbiological diagnosis can be made by examination of a urine sample, and in Danish family practice the diagnosis of UTI is often reached by a microscopic analysis or a dip-slide culture test. These methods have a high validity when performed in hospital, but we need knowledge about the validity of microbiological urine examinations when performed in general practice. The aim of this study was to validate detection of bacteriuria by urine microscopy and dip-slide culture in general practice.

MATERIAL AND METHODS

Urine specimens artificially produced by adding a known quantity of bacteria (Escherichia coli, Proteus mirabilis, Enterobacter cloacae, Staphylococcus epidermidis and Enterococcus faecalis) to sterile urine were sent to 25 general practices for microscopic examination and dip-slide culture. No prior instruction in testing procedure was given. As the gold standard, the results of a standardised culture method performed by skilled laboratory technicians at the Department of Microbiology, University of Southern Denmark, were used.

RESULTS

Significant bacteriuria was identified by microscopy with a sensitivity of 95% and a specificity of 83%. The corresponding figures for urine culture were 95% and 96%. The morphology of bacteria was interpreted correctly in 80% of microscopic examinations, and 60% of the bacteria strains were classified correctly in terms of their motility.

DISCUSSION

The results of urine microscopy and culture performed in general practice are to be relied on.

[Resistance tests in general practice. Validity can be improved by standardized procedures]

INTRODUCTION

Susceptibility testing of bacteria in urine is one of the commonest laboratory tests in general practice in Denmark. It is quick and easy to perform, but recent studies have shown low validity when the test is performed in general practice. If it is to continue as a diagnostic tool in general practice, its quality should be improved. The aim of this study was to investigate the effect of an intervention to improve the quality of susceptibility testing in general practice.

MATERIAL AND METHODS

Twenty-three randomly selected general practices took part in the study. The intervention consisted of visits by laboratory technicians who instructed the practitioners in standardised procedures for susceptibility testing. Before and after the intervention, urine specimens containing monocultures of typical uropathogenic bacteria were sent to the practices. The practitioners performed susceptibility testing by the Sensicult and the Iso-Resagar 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 the gold standard.

RESULTS

The median frequency of correct results increased from 82% to 98% for susceptibility testing by the Sensicult method (p = 0.001) and from 90% to 96% by the Iso-Resagar method (p = 0.05).

DISCUSSION

The validity of susceptibility testing in general practice improves when preceded by instruction in standardised procedures.

[A randomized controlled trial of the use of CRP rapid test as a guide to treatment of respiratory infections in general practice]

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.

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.

[Penicillin treatment of acute maxillary sinusitis in adults. A randomized, double-blind, placebo-controlled trial from general practice]

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?]

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.

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.

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.

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]

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]

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]

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.

Can hairspray be used as a smear fixative? A comparison between two types of coating fixatives

Pairs of smears from 25 consecutive women undergoing routine screening and 30 consecutive colposcopy patients suspected of having cervical intraepithelial neoplasia were randomized and fixed with either Merckofix or a hairspray to compare their use as coating fixatives. Vacuolated cells from the cervical transformation zone were present in 9 of 25 and 24 of 30 smears fixed with hairspray against 2 of 25 and 2 of 30 of smears fixed with Merckofix in the two series, respectively. These findings indicate that the fixative effect of commercial hairsprays always should be tested before such hairsprays are introduced into routine procedures.