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1.
Chris Salisbury Sunita Procter Kate Stewart Leah Bowen Sarah Purdy Matthew Ridd Jose Valderas Tom Blakeman David Reeves 《The British journal of general practice》2013,63(616):e751-e759
Background
Demographic and policy changes appear to be increasing the complexity of consultations in general practice.Aim
To describe the number and types of problems discussed in general practice consultations, differences between problems raised by patients or doctors, and between problems discussed and recorded in medical records.Design and setting
Cross-sectional study based on video recordings of consultations in 22 general practices in Bristol and North Somerset.Method
Consultations were examined between 30 representative GPs and adults making a pre-booked day-time appointment. The main outcome measures were number and types of problems and issues discussed; who raised each problem/issue; consultation duration; whether problems were recorded and coded.Results
Of 318 eligible patients, 229 (72.0%) participated. On average, 2.5 (95% CI = 2.3 to 2.6) problems were discussed in each consultation, with 41% of consultations involving at least three problems. Seventy-two per cent (165/229) of consultations included problems in multiple disease areas. Mean consultation duration was 11.9 minutes (95% CI = 11.2 to 12.6). Most problems discussed were raised by patients, but 43% (99/229) of consultations included problems raised by doctors. Consultation duration increased by 2 minutes per additional problem. Of 562 problems discussed, 81% (n = 455) were recorded in notes, but only 37% (n = 206) were Read Coded.Conclusion
Consultations in general practice are complex encounters, dealing with multiple problems across a wide range of disease areas in a short time. Additional problems are dealt with very briefly. GPs, like patients, bring an agenda to consultations. There is systematic bias in the types of problems coded in electronic medical records databases. 相似文献2.
Paul Little Peter White Joanne Kelly Hazel Everitt Shkelzen Gashi Annemieke Bikker Stewart Mercer 《The British journal of general practice》2015,65(635):e357-e365
Background
Few studies have assessed the importance of a broad range of verbal and non-verbal consultation behaviours.Aim
To explore the relationship of observer ratings of behaviours of videotaped consultations with patients’ perceptions.Design and setting
Observational study in general practices close to Southampton, Southern England.Method
Verbal and non-verbal behaviour was rated by independent observers blind to outcome. Patients competed the Medical Interview Satisfaction Scale (MISS; primary outcome) and questionnaires addressing other communication domains.Results
In total, 275/360 consultations from 25 GPs had useable videotapes. Higher MISS scores were associated with slight forward lean (an 0.02 increase for each degree of lean, 95% confidence interval [CI] = 0.002 to 0.03), the number of gestures (0.08, 95% CI = 0.01 to 0.15), ‘back-channelling’ (for example, saying ‘mmm’) (0.11, 95% CI = 0.02 to 0.2), and social talk (0.29, 95% CI = 0.4 to 0.54). Starting the consultation with professional coolness (‘aloof’) was helpful and optimism unhelpful. Finishing with non-verbal ‘cut-offs’ (for example, looking away), being professionally cool (‘aloof’), or patronising, (‘infantilising’) resulted in poorer ratings. Physical contact was also important, but not traditional verbal communication.Conclusion
These exploratory results require confirmation, but suggest that patients may be responding to several non-verbal behaviours and non-specific verbal behaviours, such as social talk and back-channelling, more than traditional verbal behaviours. A changing consultation dynamic may also help, from professional ‘coolness’ at the beginning of the consultation to becoming warmer and avoiding non-verbal cut-offs at the end. 相似文献3.
BACKGROUND: There is a paucity of research evidence concerning communication in paediatric consultations between GPs, adults, and child patients. AIM: This study was carried out to identify features of the interaction between a doctor, a child patient aged 6-12 years, and their carer in the consultation associated with the child's participation. DESIGN OF STUDY: A qualitative analysis of video recordings of 31 primary care paediatric consultations was undertaken, using strategies from the methodology of conversation analysis. SETTING: Primary care, Suffolk, UK. METHOD: NHS GPs from three primary care trusts (PCTs), were invited to participate in this study. Sixteen volunteers from this sample took part. RESULTS: Analysis of the interaction in the consultations revealed that the children had little involvement. Children participated when invited to do so, and took more time than adults to answer a doctor's question. An adult carer was less likely to answer on behalf of a child, when they were in a position to see that the doctor's gaze was directed at the child, and the doctor addressed the child by name. Adult carers, who had not voiced their own concerns first, were seen to interrupt doctor-child talk. In consultations where the participants sat in a triangular arrangement, all parties being an equal distance apart, triadic talk was noted. CONCLUSION: Child involvement in the primary care consultation is associated with adult carers being able to voice their own concerns early in the consultation, and children being invited to speak with the appropriate recipient design. 相似文献
4.
Rod Sampson Jeremiah O’Rourke Ross Hendry David Heaney Samantha Holden Alex Thain Ronald MacVicar 《The British journal of general practice》2013,63(608):e185-e191
Background
There is little published research into the impact, on both doctor and patient, of handing over responsibility for choosing appointment length to the patient.Aim
To investigate what impact giving patients control of their appointment length has on the patient and doctor experience.Design and setting
A qualitative study in a single medical practice in Inverness, Scotland.Method
Eligible patients making a ‘routine’ appointment were given a choice of appointment length (5, 10, 15, or 20 minutes). After the consultation, patients were invited to take part in a focused interview. Doctors were asked to keep an audio diary and their experience was explored further in a facilitated focus group. Data were analysed using a thematic analysis approach.Results
Key themes that emerged for patients included the impact of the shift in power and the impact of introducing the issue of time. For doctors, important themes that emerged were impacts on the provider, on the doctor–patient relationship, and on the consultation.Conclusion
Giving patients greater responsibility for choosing appointment length may improve the experience for both doctors and patients. 相似文献5.
Meredith Y. Smith Katherine N. DuHamel Gary Winkel 《Patient education and counseling》2010,81(1):79-86
Objective
This study examined the impact of a brief pain communication/education intervention on patient outcomes in breast cancer. We hypothesized that our intervention would improve patient communication and reduce misconceptions (“Barriers”) concerning pain management, and that patients with lower Barriers, or who perceived their physician as being more facilitative and receptive, would report better outcomes.Methods
Female breast cancer patients with persistent pain (n = 89) were randomly assigned to either a 30-min in-person pain education/communication intervention or control condition and followed for 12 weeks.Results
Intervention group patients reported a significant decrease in pain Barriers but not in other outcomes. Overall, patients with lower barrier scores reported less distress and better emotional well-being. Patients who scored higher in active communication (e.g., asking questions, giving information) reported fewer Barriers and better pain relief. Individuals who perceived their physicians as being more receptive reported better pain management while those who perceived their physicians as being both more receptive and facilitative were more satisfied with their health care.Conclusion
A brief education/communication intervention reduced patients’ Barriers to pain management but did not impact other patient outcomes.Practical Implications
Pain outcomes may be improved by addressing patients’ pain misconceptions and emphasizing a receptive and responsive communication style. 相似文献6.
Karen Falloon C Raina Elley Antonio Fernando III Arier C Lee Bruce Arroll 《The British journal of general practice》2015,65(637):e508-e515
Background
Insomnia is common in primary care. Cognitive behavioural therapy for insomnia (CBT-I) is effective but requires more time than is available in the general practice consultation. Sleep restriction is one behavioural component of CBT-I.Aim
To assess whether simplified sleep restriction (SSR) can be effective in improving sleep in primary insomnia.Design and setting
Randomised controlled trial of patients in urban general practice settings in Auckland, New Zealand.Method
Adults with persistent primary insomnia and no mental health or significant comorbidity were eligible. Intervention patients received SSR instructions and sleep hygiene advice. Control patients received sleep hygiene advice alone. Primary outcomes included change in sleep quality at 6 months measured by the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and sleep efficiency (SE%). The proportion of participants reaching a predefined ‘insomnia remission’ treatment response was calculated.Results
Ninety-seven patients were randomised and 94 (97%) completed the study. At 6-month follow-up, SSR participants had improved PSQI scores (6.2 versus 8.4, P<0.001), ISI scores (8.6 versus 11.1, P = 0.001), actigraphy-assessed SE% (difference 2.2%, P = 0.006), and reduced fatigue (difference −2.3 units, P = 0.04), compared with controls. SSR produced higher rates of treatment response (67% [28 out of 42] versus 41% [20 out of 49]); number needed to treat = 4 (95% CI = 2.0 to 19.0). Controlling for age, sex, and severity of insomnia, the adjusted odds ratio for insomnia remission was 2.7 (95% CI = 1.1 to 6.5). There were no significant differences in other outcomes or adverse effects.Conclusion
SSR is an effective brief intervention in adults with primary insomnia and no comorbidities, suitable for use in general practice. 相似文献7.
8.
Helen Atherton Yannis Pappas Carl Heneghan Elizabeth Murray 《The British journal of general practice》2013,63(616):e760-e767
Background
Reports suggest approximately 21–23% of GPs in the UK have consulted with patients using email, but little is known about the nature of this use and what it means for clinicians and patients in general practice.Aim
To understand the use of email consultation in general practice by investigating the experiences of existing users and views of experts.Design and setting
A qualitative study conducted in 2010 using purposive sampling and semi-structured interviews in general practice and community settings in some London boroughs.Method
A maximum variation sample of GPs and patients who had used email for consultation in general practice were recruited, as were policy and/or implementation experts. Interviews continued until saturation was achieved.Results
In total 10 GPs, 14 patients, and six experts were interviewed. Consultation by email was often triggered by logistic or practical issues; motivators for ongoing use were the benefits, such as convenience, for GPs and patients. Both GPs and patients reported concerns about safety and lack of guidance about the ‘rules of engagement’ in email consultations, with GPs also concerned about workload. In response, both groups attempted to introduce their own rules, although this only went some way to addressing uncertainty. Long term, participants felt there was a need for regulation and guidance.Conclusion
Consultations by email in general practice occur in an unregulated and unstructured way. Current UK policy is to promote consultations by email, making it crucial to consider the responsibility and workload faced by clinicians, and the changes required to ensure safe use; not doing so may risk safety breaches and result in suboptimal care for patients. 相似文献9.
Caroline O Laurence Angela Gialamas Tanya Bubner Lisa Yelland Kristyn Willson Phil Ryan Justin Beilby the Point of Care Testing in General Practice Trial Management Group 《The British journal of general practice》2010,60(572):e98-e104
Background
Point-of-care testing is increasingly being used in general practice to assist GPs in their management of patients with chronic disease. However, patient satisfaction and acceptability of point-of-care testing in general practice has not been widely studied.Aim
To determine if patients are more satisfied with point-of-care testing than with pathology laboratory testing for three chronic conditions.Design of study
As part of a large multicentre, randomised, controlled trial assessing the use of point-of-care testing in Australian general practice, satisfaction was measured for patients having pathology testing performed by point-of-care testing devices or pathology laboratories. Patients in the trial were managed by GPs for diabetes, hyperlipidaemia, and/or anticoagulant therapy.Method
Patient satisfaction was measured using level of agreement with a variety of statements at the end of the study with a patient satisfaction questionnaire for both the intervention and control groups. Analysis was performed using a mixed model analysis of variance (ANOVA) with allowance for clustering at the practice level following Box–Cox transformations of the data to achieve normality.Results
Overall, intervention patients reported that they were satisfied with point-of-care testing. In comparison with the control group, the intervention group had a higher level of agreement than control patients with statements relating to their satisfaction with the collection process (P<0.001) and confidence in the process (P<0.001). They also viewed point-of-care testing as strengthening their relationship with their GP (P = 0.010) and motivational in terms of better managing their condition (P<0.001).Conclusion
The results from this trial support patient satisfaction and acceptability of point-of-care testing in a general practice setting. 相似文献10.
11.
Caroline J Huxley Helen Atherton Jocelyn Anstey Watkins Frances Griffiths 《The British journal of general practice》2015,65(641):e813-e821
Background
Increasingly, the NHS is embracing the use of digital communication technology for communication between clinicians and patients. Policymakers deem digital clinical communication as presenting a solution to the capacity issues currently faced by general practice. There is some concern that these technologies may exacerbate existing inequalities in accessing health care. It is not known what impact they may have on groups who are already marginalised in their ability to access general practice.Aim
To assess the potential impact of the availability of digital clinician–patient communication on marginalised groups’ access to general practice in the UK.Design and setting
Realist review in general practice.Method
A four-step realist review process was used: to define the scope of the review; to search for and scrutinise evidence; to extract and synthesise evidence; and to develop a narrative, including hypotheses.Results
Digital communication has the potential to overcome the following barriers for marginalised groups: practical access issues, previous negative experiences with healthcare service/staff, and stigmatising reactions from staff and other patients. It may reduce patient-related barriers by offering anonymity and offers advantages to patients who require an interpreter. It does not impact on inability to communicate with healthcare professionals or on a lack of candidacy. It is likely to work best in the context of a pre-existing clinician–patient relationship.Conclusion
Digital communication technology offers increased opportunities for marginalised groups to access health care. However, it cannot remove all barriers to care for these groups. It is likely that they will remain disadvantaged relative to other population groups after their introduction. 相似文献12.
Natasha J Verbakel Maaike Langelaan Theo JM Verheij Cordula Wagner Dorien LM Zwart 《The British journal of general practice》2015,65(634):e319-e329
Background
A constructive safety culture is essential for the successful implementation of patient safety improvements.Aim
To assess the effect of two patient safety culture interventions on incident reporting as a proxy of safety culture.Design and setting
A three-arm cluster randomised trial was conducted in a mixed method study, studying the effect of administering a patient safety culture questionnaire (intervention I), the questionnaire complemented with a practice-based workshop (intervention II) and no intervention (control) in 30 general practices in the Netherlands.Method
The primary outcome, the number of reported incidents, was measured with a questionnaire at baseline and a year after. Analysis was performed using a negative binomial model. Secondary outcomes were quality and safety indicators and safety culture. Mixed effects linear regression was used to analyse the culture questionnaires.Results
The number of incidents increased in both intervention groups, to 82 and 224 in intervention I and II respectively. Adjusted for baseline number of incidents, practice size and accreditation status, the study showed that practices that additionally participated in the workshop reported 42 (95% confidence interval [CI] = 9.81 to 177.50) times more incidents compared to the control group. Practices that only completed the questionnaire reported 5 (95% CI = 1.17 to 25.49) times more incidents. There were no statistically significant differences in staff perception of patient safety culture at follow-up between the three study groups.Conclusion
Educating staff and facilitating discussion about patient safety culture in their own practice leads to increased reporting of incidents. It is beneficial to invest in a team-wise effort to improve patient safety. 相似文献13.
Trevor Murrells Jane Ball Jill Maben Mark Ashworth Peter Griffiths 《The British journal of general practice》2015,65(639):e642-e648
Background
Diabetes affects around 3.6 million people in the UK. Previous research found that general practices employing more nurses delivered better diabetes care, but did not include data on individual patient characteristics or consultations received.Aim
To examine whether the proportion of consultations with patients with diabetes provided by nurses in GP practices is associated with control of diabetes measured by levels of glycated haemoglobin (HbA1c).Design and setting
A retrospective observational study using consultation records from 319 649 patients with diabetes from 471 UK general practices from 2002 to 2011.Method
Hierarchical multilevel models to examine associations between proportion of consultations undertaken by nurses and attaining HbA1c targets over time, controlling for case-mix and practice level factors.Results
The proportion of consultations with nurses has increased by 20% since 2002 but patients with diabetes made fewer consultations per year in 2011 compared with 2002 (11.6 versus 16.0). Glycaemic control has improved and was more uniformly achieved in 2011 than 2002. Practices in which nurses provide a higher proportion of consultations perform no differently to those where nurse input is lower (lowest versus highest nurse contact tertile odds ratio [OR] [confidence interval {95% CI}]: HbA1c ≤53 mmol/mol (7%) 2002, 1.04 [95% CI = 0.87 to 1.25] and 2011, 0.95 [95% CI = 0.87 to 1.03]; HbA1c ≤86 mmol/mol (10%) 2002, 0.97 [95% CI = 0.73 to 1.29] and 2011, 0.95 [95% CI = 0.86 to 1.04]).Conclusion
Practices that primarily use GPs to deliver diabetes care could release significant resources with no adverse effect by switching their services towards nurse-led care. 相似文献14.
Factors associated with enablement in general practice: cross-sectional study using routinely-collected data. 总被引:1,自引:0,他引:1
BACKGROUND: Quality-improvement activities are most often focused on clinical quality indicators. However, patient evaluations are important additional indicators of the quality of general practice consultations, including measures of satisfaction or enablement (that is, the extent to which the consultation enhances the patient's feelings of confidence and ability to cope). There is limited evidence concerning factors associated with enablement in UK general practice. AIM: To identify patient and practice characteristics associated with enablement scores following general practice consultations. DESIGN OF STUDY: Cross-sectional survey using a large routinely-collected dataset of patient evaluations of general practice (190,038 individual patient responses). SETTING: A total of 1031 UK general practices. METHOD: Relationships between health, demographic factors, evaluations of general practice care, and patient self-reported enablement were estimated using multiple regression. RESULTS: The primary predictor of enablement was positive patient evaluation of the GPs' communication. Reported continuity of care accounted for a lower proportion of the variance. Of the included patient demographic variables, ethnicity was a key predictor, with patients from minority ethnic groups reporting greater enablement once other factors were controlled. CONCLUSION: The current results provide support for the construct validity of the enablement measure. However, if enablement is to become a valid and useful measure of quality, it is necessary to understand the mechanisms by which enablement is increased in certain patients and practices. Detailed qualitative research may also be required to explain the relatively high scores of ethnic minority responders, despite lower overall satisfaction scores, and to understand why some items included in the enablement measure are regarded as 'not applicable' by a substantial minority of patients. 相似文献
15.
Triadic communication in the primary care paediatric consultation: a review of the literature. 下载免费PDF全文
BACKGROUND: Children aged 6-12 years are usually seen in primary care with an adult carer. It is a government and professional priority for doctors to try and involve these children in their medical consultations. AIM: To ascertain the evidence available on the amount and type of involvement that children in the 6-12 year age group have in their primary care consultations when the consultation was held with a child, a GP, and an adult. DESIGN OF THE STUDY: Literature review. METHOD: Data sources included MEDLINE, CINAHL, EMBASE, and ERIC, The Cochrane library, PsychINFO, Web of Science and Wilson's Social Science abstracts, hand searching for references, and contact with authors. RESULTS: Twenty-one studies were selected for inclusion in the study. Children were found to have little quantitative involvement in their own consultations. They may take part during information gathering but are unlikely to participate in the treatment planning and discussion parts of the consultation. CONCLUSION: Children in the 6-12 year age group have little meaningful involvement in their consultations. 相似文献
16.
Geoffrey K Mitchell Afaf Girgis Moyez Jiwa David Sibbritt Letitia H Burridge Hugh E Senior 《The British journal of general practice》2013,63(615):e683-e690
Background
Carers of patients with advanced cancer often have health and psychosocial needs, which are frequently overlooked.Aim
To meet the needs of carers through a GP consultation directed by a self-completed carer needs checklist.Design and setting
Randomised controlled trial in general practice with recruitment through specialist oncology clinics, in Brisbane, Australia.Method
Intervention was (a) carer–GP consultations directed by a self-completed checklist of needs at baseline and 3 months; and (b) a GP-Toolkit to assist GPs to address carer-identified needs. Control group received usual care. Outcome measures were intensity of needs, anxiety and depression, and quality of life.Results
Total recruitment 392. Overall, no significant differences were detected in the number or intensity of need between groups. Compared to controls, intervention participants with baseline clinical anxiety showed improvements in mental wellbeing (P = 0.027), and those with baseline clinical depression had slower development of anxiety (P = 0.044) at 6 months. For those not anxious, physical wellbeing improved at 1 month (P = 0.040). Carers looking after patients with poor functional status had more physical needs (P = 0.037) at 1 month and more psychological and emotional needs at 3 months (P = 0.034). Those caring for less unwell patients showed improved mental wellbeing at 3 months (P = 0.022).Conclusion
The intervention did not influence the number or intensity of needs reported by carers of people with advanced cancer. There was limited impact in people with pre-existing clinical anxiety and depression. For the carer of those most severely affected by advanced cancer, it drew attention to the needs arising from the caregiving role. 相似文献17.
Paul Bowie Julie Ferguson Marion MacLeod Susan Kennedy Carl de Wet Duncan McNab Moya Kelly John McKay Sarah Atkinson 《The British journal of general practice》2015,65(634):e330-e343
Background
The use of checklists to minimise errors is well established in high reliability, safety-critical industries. In health care there is growing interest in checklists to standardise checking processes and ensure task completion, and so provide further systemic defences against error and patient harm. However, in UK general practice there is limited experience of safety checklist use.Aim
To identify workplace hazards that impact on safety, health and wellbeing, and performance, and codesign a standardised checklist process.Design and setting
Application of mixed methods to identify system hazards in Scottish general practices and develop a safety checklist based on human factors design principles.Method
A multiprofessional ‘expert’ group (n = 7) and experienced front-line GPs, nurses, and practice managers (n = 18) identified system hazards and developed and validated a preliminary checklist using a combination of literature review, documentation review, consensus building workshops using a mini-Delphi process, and completion of content validity index exercise.Results
A prototype safety checklist was developed and validated consisting of six safety domains (for example, medicines management), 22 sub-categories (for example, emergency drug supplies) and 78 related items (for example, stock balancing, secure drug storage, and cold chain temperature recording).Conclusion
Hazards in the general practice work system were prioritised that can potentially impact on the safety, health and wellbeing of patients, GP team members, and practice performance, and a necessary safety checklist prototype was designed. However, checklist efficacy in improving safety processes and outcomes is dependent on user commitment, and support from leaders and promotional champions. Although further usability development and testing is necessary, the concept should be of interest in the UK and internationally. 相似文献18.
Steve Iliffe Denise Kendrick Richard Morris Mark Griffin Deborah Haworth Hannah Carpenter Tahir Masud Dawn A Skelton Susie Dinan-Young Ann Bowling Heather Gage 《The British journal of general practice》2015,65(640):e731-e738
Background
Regular physical activity reduces falls, hip fractures, and all-cause mortality, but physical activity levels are low in older age groups.Aim
To evaluate two exercise programmes promoting physical activity among older people.Design and setting
Pragmatic three-arm, parallel-design cluster randomised controlled trial involving 1256 people aged ≥65 years (of 20 507 invited) recruited from 43 general practices in London, Nottingham, and Derby.Method
Practices were randomised to the class-based Falls Management Exercise programme (FaME), the home-based Otago Exercise Program (OEP), or usual care. The primary outcome was the proportion reaching the recommended physical activity target 12 months post-intervention. Secondary outcomes included falls, quality of life, balance confidence, and costs.Results
In total, 49% of FaME participants reached the physical activity target compared with 38% for usual care (adjusted odds ratio 1.78, 95% confidence interval [CI] =1.11 to 2.87, P = 0.02). Differences between FaME and usual care persisted 24 months after intervention. There was no significant difference comparing those in the OEP (43% reaching target at 12 months) and usual-care arms. Participants in the FaME arm added around 15 minutes of moderate-to-vigorous physical activity per day to their baseline level; this group also had a significantly lower rate of falls (incident rate ratio 0.74, 95% CI = 0.55 to 0.99, P = 0.042). Balance confidence was significantly improved in both intervention arms. The mean cost per extra person achieving the physical activity target was £1740. Attrition and rates of adverse reactions were similar.Conclusion
The FaME programme increases self-reported physical activity for at least 12 months post-intervention and reduces falls in people aged ≥65 years, but uptake is low. There was no statistically significant difference in reaching the target, or in falls, between the OEP and usual-care arms. 相似文献19.
Ludmila Marcinowicz Jerzy Konstantynowicz Cezary Godlewski 《The British journal of general practice》2010,60(571):83-87
Background
During doctor–patient interactions, many messages are transmitted without words, through non-verbal communication.Aim
To elucidate the types of non-verbal behaviours perceived by patients interacting with family GPs and to determine which cues are perceived most frequently.Design of study
In-depth interviews with patients of family GPs.Setting
Nine family practices in different regions of Poland.Method
At each practice site, interviews were performed with four patients who were scheduled consecutively to see their family doctor.Results
Twenty-four of 36 studied patients spontaneously perceived non-verbal behaviours of the family GP during patient–doctor encounters. They reported a total of 48 non-verbal cues. The most frequent features were tone of voice, eye contact, and facial expressions. Less frequent were examination room characteristics, touch, interpersonal distance, GP clothing, gestures, and posture.Conclusion
Non-verbal communication is an important factor by which patients spontaneously describe and evaluate their interactions with a GP. Family GPs should be trained to better understand and monitor their own non-verbal behaviours towards patients. 相似文献20.
Frans Derksen Jozien Bensing Antoine Lagro-Janssen 《The British journal of general practice》2013,63(606):e76-e84