The aim of the study is to determine the diagnostic value of (combinations of) signs, symptoms and simple laboratory test results for colorectal cancer in patients with rectal bleeding presenting in general practice. Initial complaints and findings were compared with the final diagnoses based on clinical follow-up after at least 1 year. Patients studied were those presenting overt rectal bleeding to the general practitioner (83 GPs in the South of the Netherlands). Outcome measures are sensitivity, specificity, predictive values, odds ratios and a prediction model derived from multiple logistic regression analysis. Age, change in bowel habit and blood mixed with or on stool show a statistically significant independent value in the discrimination between patients with a low and those with a high probability of colorectal cancer. Many other variables did not show predictive value. The prediction model has a sensitivitiy of 100% and a specificity of 90%. Although the number of patients with colorectal cancer is small (n = 9) it was possible to identify three characteristics which can be helpful in the prediction of presence or absence of colorectal cancer in general practice. Application of the model presented might prevent 90% of 'unnecessary' invasive diagnostic procedures for patients with rectal bleeding who do not have colorectal cancer (true negative). Testing the performance of the model in other general practice populations is recommended.
Scoring models based on history and physical examination have been developed to discriminate patients with non-organic gastrointestinal disease from those who have organic disease. The application of these models may lead to more efficient diagnosis and prevent somatization. Although the models have high diagnostic accuracy in the population in which they have been developed, their value in other populations has not been established. In this study previously developed models were tested in validation populations defined by the original selection criteria from the studies in which the models were developed and in unselected general practice and outpatient populations. The diagnostic performance of the models are expressed in terms of odds ratio and sensitivity and specificity for the classification of patients as having organic and non-organic disease. The diagnostic performance of all the models were rather low in the validation populations. Relatively few elements of the models had independent diagnostic value. In addition, the correlation between the scoring models, expressed in Cohen's kappa, was extremely low. The diagnostic values of the scoring models were not reproduced in comparable and unselected populations. Therefore, it is concluded that the diagnostic value of such a model has little external validity.
The objective of the studies reported in this paper was to determine the incidence as well as the final diagnostic outcome of rectal bleeding presenting in general practice. Because of the wide variety observed in incidence rates among 83 general practitioners (GPs) in the first study (A) an additional study (B) was undertaken. In study B with 10 GPs special efforts were made to maximize the catchment rate. The mean 'consultation incidence rate' was 7 per 1000 people per year. A follow-up period of at least 1 year was applied to establish the final diagnostic conclusion. Occurrence of colorectal cancer was found in 3% of patients with rectal bleeding. This may represent an overestimation of the prior probability since there was a selection in favour of patients with clinically relevant rectal bleeding. In about 90% of patients rectal bleeding was related to minor ailments or self-limiting disorders. Further study on predictive values of (combinations of) other signs and symptoms is necessary to develop clinical recommendations.
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This study reported here was undertaken to determine the probability of malignancy in patients presenting with unexplained lymphadenopathy in primary care practice and to estimate the effectiveness of current referral patterns by family physicians in relation to malignant disease. Clinical characteristics that may be discriminatory for malignant causes were also investigated. A retrospective analysis was performed of 82 patients who underwent biopsy for unexplained lymphadenopathy from 1982 to 1984; data regarding the incidence of unexplained lymphadenopathy and the referral rate for this problem were obtained from registration projects. A total of 29 malignant lymphadenopathies were identified for a prior probability of 1.1 percent and a posterior (after referral) probability of 11 percent. The ability of the family physician to refer malignant cases within four weeks after initial consultation (sensitivity of referral) was 80 to 90 percent; 91 to 98 percent of benign cases were not referred (specificity of referral). An increased likelihood of malignancy was associated with age over 40 years (4 percent) and supraclavicular lymphadenopathy (50 percent). The incidence of malignancy in patients presenting with unexplained lymphadenopathy to the family physicians is very low (1 to 2 percent). Nevertheless, despite the paucity of validated discriminatory factors, the family physicians perform a reasonably effective selection process toward referral and biopsy.
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