Background/objective: Chest pain is a common complaint and reason for consultation. We aimed to study the epidemiology of chest pain with respect to underlying aetiologies and to establish pre-work-up probabilities for the primary care setting. Methods: We included 1212 consecutive patients with chest pain, aged 35 years and older, attending 74 general practitioners (GPs). GPs recorded symptoms and fi ndings of each patient and provided follow-up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided on the aetiology of chest pain at the time of patient recruitment. Results: The prevalence of chest pain among all attending patients was 0.7%. The majority (55.9%) of patients were women. Mean age was 59 (35-93) years. Of these patients, 53.2% had chest pains at the time of consultation and 29.6% presented with acute (Ͻ 48 hours' duration) chest pain. Pain originating from the chest wall was diagnosed in 46.6% of all patients, stable ischaemic heart disease (IHD) in 11.1%, and psychogenic disorders in 9.5%; 3.6% had acute coronary syndrome (ACS). Conclusion:The study adds important information about the epidemiology of chest pain as a frequent reason for consulting primary care practitioners. We provide updated pre-work-up probabilities for IHD for each age and sex category.

Background: Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. Methods:We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort). Results:The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result ≤ 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%). Interpretation:The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care. AbstractPreviously published at www.cmaj.ca @@

There is a high prevalence of patients consulting GPs for abdominal pain. The review identified a comparably high rate of acute underlying diseases in need of further investigation or therapy. At the same time, the underlying cause of the complaints often remains unexplained. Further symptom-evaluating studies are necessary, ideally using standardized methodology in order to gain sufficient evidence for developing much-needed guidelines and decision support tools.

A proper representation of the uncertainty involved in a prediction is an important prerequisite for the acceptance of machine learning and decision support technology in safety-critical application domains such as medical diagnosis. Despite the existence of various probabilistic approaches in these fields, there is arguably no method that is able to distinguish between two very different sources of uncertainty: aleatoric uncertainty, which is due to statistical variability and effects that are inherently random, and epistemic uncertainty which is caused by a lack of knowledge. In this paper, we propose a method for binary classification that does not only produce a prediction of the class of a query instance but also a quantification of the two aforementioned sources of uncertainty. Despite being grounded in probability and statistics, the method is formalized within the framework of fuzzy preference relations. The usefulness and reasonableness of our approach is confirmed on a suitable data set with information about patients suffering from chest pain.

BackgroundDizziness is a common reason for consulting a general practitioner and there is a broad range of possible underlying aetiologies. There are few evidence-based data about prevalence, aetiology and prognosis in primary care. We aimed to conduct a systematic review of symptom-evaluating studies on prevalence, aetiology or prognosis of dizziness in primary care.MethodsWe systematically searched MEDLINE and EMBASE. Two independent researchers screened titles and abstracts according to predefined criteria. We included all studies evaluating the symptoms ‘dizziness’ or ‘vertigo’ as a reason for consultation in primary care. We extracted data about study population and methodology and prevalence, aetiology and prognosis. Two raters independently judged study quality and risk of bias. We investigated the variation across studies using forest plots, I2 and prediction intervals. Since we anticipated a great amount of clinical and unexplained statistical heterogeneity, we provided qualitative syntheses instead of pooled estimates.ResultsWe identified 31 studies (22 on prevalence, 14 on aetiology and 8 on prognosis). Consultation prevalence differs between 1,0 and 15,5%. The most common aetiologies are vestibular/peripheral (5,4-42,1%), benign peripheral positional vertigo (4,3-39,5%), vestibular neuritis (0,6-24,0%), Menière’s disease (1,4-2,7%), cardiovascular disease (3,8-56,8%), neurological disease (1,4-11,4%), psychogenic (1,8-21,6%), no clear diagnosis (0,0-80,2%). While studies based on subjective patient assessment reported improvement rates from 37 to 77%, these findings could not be confirmed when applying instruments that measure symptom severity or quality of life.ConclusionThere is a broad variety of possible underlying diseases for the symptom dizziness. There exist only few methodologically sound studies concerning aetiology and prognosis of dizziness.Electronic supplementary materialThe online version of this article (10.1186/s12875-017-0695-0) contains supplementary material, which is available to authorized users.

BackgroundDifferential diagnosis is a crucial skill for primary care physicians. General practice plays an increasing important role in undergraduate medical education. Via general practice, students may be presented with an overview of the whole spectrum of differential diagnosis in regard to common symptoms encountered in primary care. This project evaluated the impact of a blended learning program (using the inverted classroom approach) on student satisfaction and development of skills and knowledge.MethodsAn elective seminar in differential diagnosis in primary care, which utilized an inverted classroom design, was offered to students. Evaluation followed a mixed methods design: participants completed a pre- and post-test, a questionnaire, and a focus group discussion. Interviews were transcribed verbatim and answers were grouped according to different themes. Test results were analysed using the Wilcoxon matched-pairs signed-ranks test.ResultsParticipants (n = 17) rated the course concept very positively. Especially the inverted classroom approach was appreciated by all students, as it allowed for more time during the seminar to concentrate on interactive and practice based learning. Students (n = 16) showed a post-test significant overall gain in skills and knowledge of 33%.ConclusionsThis study showed a positive effect of the inverted classroom approach on students’ satisfaction and skills and knowledge. Further research is necessary in order to explore the potentials of this approach, especially the impact on development of clinical skills.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-015-0346-x) contains supplementary material, which is available to authorized users.

BackgroundTiredness is one of the most frequent complaints in primary care. Although often self-limiting and frequently associated with psychosocial stress, patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up. We conducted a systematic review and meta-analysis of studies reporting on differential diagnosis of fatigue in primary care.MethodsMEDLINE, EMBASE and conference abstracts were searched for primary care based studies of patients presenting with tiredness. Twenty-six studies were included. We report on anaemia, malignancy, serious organic disease, depression and the chronic fatigue syndrome (CFS) as causes of tiredness as presenting complaint.ResultsWe found considerable heterogeneity of estimates which was reduced by limiting our analysis to high quality studies. Prevalences were as follows-anaemia: 2.8 % (CI (confidence interval) 1.6–4.8 %); malignancy: 0.6 % (CI 0.3–1.3 %); serious somatic disease: 4.3 % (CI 2.7–6.7 %); depression 18.5 % (CI 16.2–21.0 %). Pooling was not appropriate for CFS.In studies with control groups of patients without the symptom of tiredness, prevalence of somatic disease was identical to those complaining of tiredness. Depression, however, was more frequent among those with tiredness.ConclusionsSerious somatic disease is rare in patients complaining of tiredness. Since prevalence is similar in patients without tiredness, the association may not be causal. Extensive investigations are only warranted in case of specific findings from the history or clinical examination. Instead, attention should focus on depression and psychosocial problems.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0545-5) contains supplementary material, which is available to authorized users.

BackgroundThe increasing impact of globalisation on healthcare demands new knowledge, skills and attitudes from healthcare professionals. One consequence of this is the rise of Global Health (GH) programs in health education all over the world. In Germany no consensus exists on what GH is and how it should be taught. This study used a grounded theory approach. We conducted eleven in-depth interviews with GH teachers in German medical education to ask them about their views on Global Health and the approaches they took in teaching these topics. Data collection and Analysis informed each other and followed an inductive approach.ResultsOur research identified three major questions: (1) What is GH? (2) What belongs to GH? (3) How can GH be taught? A central finding of our study is the understanding of GH as an umbrella term. We show how this understanding helps clarify the relation between GH and Public Health, International Health and Tropical medicine. At the core of GH we see the supraterritorial determinants of health. Surrounding the core, we describe a wide variety of topics that are a facultative, but not necessarily a compulsory part GH. One of the key characteristics of GH within all its aspects is its multidisciplinary nature. Based on this understanding we present models about the content of GH, how it can be taught and how GH teaching improves and strengthens overall medical education.ConclusionsThis is to our knowledge the first study that conducts in-depth interviews with GH teachers to explore the practical understanding of GH in medical education. While the generalisability of our results needs to be subject of further research, the models presented can help shape the future discourse around GH and its integration into medical education.Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0352-y) contains supplementary material, which is available to authorized users.