Prevalence of cardiovascular disorders among the elderly in primary care in Estonia

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objectiv e &#114 - &#114 To assess the prevalence of diagnoses of cardiovascular disorders among the elderly in family practice. Design &#114 - &#114 Cross-sectional study. Setting &#114 - &#114 Estonia, population aged 65 years or older (206 &#116 915 persons). Subjects &#114 - &#114 811 elderly persons selected randomly from the lists of family practitioners. Main outcome measures &#114 - &#114 Prevalence of hypertension, hypotension, coronary heart disease (CHD), myocardial infarction (MI), heart failure (HF) and cardiac arrhythmias; differences between the genders and age groups. Results &#114 - &#114 The prevalence of cardiovascular disorders was as follows: hypertension 63.2%, hypotension 11.1%, CHD 56.5%, MI 9.8%, HF 41.4% and arrhythmias 37.5%. Women had a significantly higher prevalence of hypertension and men of MI. The prevalence of CHD and hypotension was significantly higher in the oldest elderly persons. Conclusion &#114 - &#114 Among the older population in Estonia, cardiovascular disorders that have broader diagnostic criteria and need expensive methods for verifying (CHD, HF) have a high prevalence and are most likely over-diagnosed. The need for strict and simple diagnostic methods for these disorders in primary care practice continues to be serious.     

Medical doctors' perception of the "number needed to treat" (NNT)

The "number needed to treat" is assumed to be readily understood, but empirical evidence to support this assumption is sparse. 72% of medical doctors recommended a preventive drug therapy when NNT was 50 compared to 52% when NNT was 200. 77% of doctors recommending against a preventive drug therapy thought that only one out of NNT patients benefits from therapy. Since this assumption may be misleading, we suggest that the NNT should be used with caution in clinical practice. Objective &#114 - &#114 While the number needed to treat (NNT) is in widespread use, empirical evidence that doctors or patients interpret the NNT adequately is sparse. The aim of our study was to explore the influence of the NNT on medical doctors' recommendation for or against a life-long preventive drug therapy. Design &#114 - &#114 Cross-sectional study with randomisation to different scenarios. Setting &#114 - &#114 Postal questionnaire presenting a clinical scenario about a hypothetical drug as a strategy towards preventing premature death among healthy people with a known risk factor. Benefit after 5 years of treatment was presented in terms of NNT, which was set at 50 for half of the respondents and 200 for the other half. Subjects &#114 - &#114 Representative sample (n=1616) of Norwegian medical doctors. Main outcome measures &#114 - &#114 Proportion of doctors that would prescribe the drug. Reasons for recommending against the therapy. Results &#114 - &#114 With NNT set at 50, 71.6% (99% CI 66.8-76.4) of the doctors would prescribe the drug, while the proportion was 52.3% (99% CI 47.5-57.1) with an NNT of 200 ( &#104 2 =50.7, p<0.001). Multivariate logistic regression analysis indicated that the effect of NNT on the likelihood for recommending the therapy was age-dependent; young doctors (<36 of age) were more sensitive to the difference in NNTs than older doctors. Thirty-six percent (n=464) of the doctors would not prescribe the drug, and 77.4% (99% CI 68.5-86.2) of those agreed with an argument stating that only one out of NNT patients would benefit from the treatment. Conclusion &#114 - &#114 Medical doctors appear to be sensitive to the magnitude of the NNT in their clinical recommendations. However, many doctors believe that only one out of NNT patients benefits from therapy. Clinical recommendations based on this assumption may be misleading.     

Structure and duration of consultations in Estonian family practice

Duration of the consultation is dependent on patient-related factors as well as on factors related to the health care system. Video-recording allows direct evaluation of the consultation and is acceptable to patients. Length of time of consultation is dependent on the patient's age and on the number and nature of the problems, but is not influenced by gender. Objective - &#114 To study the influence of age, gender and the nature of the patient's problems on length of time of consultation in the practices of newly trained family doctors in a recently reconstructed health care system. Design &#114 - &#114 Video-recordings of consultations with consecutive patients in family practice were studied for duration of consultation in relation to age, gender and nature of the problem(s). Setting &#114 - &#114 Primary health care. Subjects &#114 - &#114 405 consecutive consultations were video-taped in the practices of 27 family doctors. Main outcome measures &#114 - &#114 Length of time of consultation and its segments was analysed using the Statistical Package for the Social Sciences. The problems were classified according to the ICPC. Results &#114 - &#114 The average consultation lasted 9.0 min ( &#45 4.9). Physical examination was 2.0 min ( &#45 1.9) and was performed in 79% of all consultations. Respiratory and circulatory problems were the most common. More than one reason for the encounter was given in one-fourth of cases. Consultation time was longer for older age groups and for patients with psychological problems. Conclusion &#114 - &#114 Video-recording allows consultations to be evaluated directly and is acceptable to patients. The high participation rate of patients in our study can be explained by the individual approach and by the family doctor system. The period of consultation was dependent on patient age and on the number and nature of the problems, but was not influenced by gender.     

Treatment of acute rhinosinusitis diagnosed by clinical criteria or ultrasound in primary care

Scand J Prim Health Care 2003;21:00-00. ISSN 0281-34323 Objectives &#114 - &#114 To compare antibiotics and placebo in patients with clinically diagnosed acute maxillary sinusitis (AMS). To study whether sinus ultrasound examination would help to detect those patients who benefit from antibiotic therapy. Design &#114 - &#114 A double-blind, randomised, placebo-controlled multicentre trial. Setting &#114 - &#114 Nine primary care sites in Finland. Subjects &#114 - &#114 150 adult patients (mean age 39.7 years) with a clinical diagnosis of sinusitis. Intervention &#114 - &#114 Antibiotics (amoxicillin 750 mg &#50 2, doxycycline 100 mg &#50 2 or penicillin V 1500 mg &#50 2) or placebo twice daily for 7 days; all patients were examined with sinus ultrasound after randomisation. Main outcome measure &#114 - &#114 Clinical success (patients' report of recovery) in telephone interview at 2 weeks. Results &#114 - &#114 A total of 146 patients completed the 2-week follow-up. Patients receiving antibiotics achieved a slightly higher rate of clinical success than patients receiving placebo (80% vs 66%; p=0.068). Conclusions &#114 - &#114 Antibiotics hasten symptom relief in AMS. Yet many patients recover in 2 weeks without antimicrobial treatment. Only half of patients with a clinical diagnosis of AMS have sinusitis in ultrasound examination.     

Encouraging structured personalised diabetes care in general practice

Scand J Prim Health Care 2003;21:000-000. ISSN 0281-3432 Objective &#114 - &#114 To evaluate the quality of diabetes care achieved on the process and outcomes of care in the context of a multifaceted intervention directed at general practitioners (GPs) encouraging regular follow-up and individualised goal-setting. Design &#114 - &#114 A 6-year follow-up study. Setting &#114 - &#114 A total of 243 Danish GPs and a population-based sample of 729 newly diagnosed, predominantly type 2 diabetic patients participated. Main outcome measures &#114 - &#114 Questionnaires and laboratory assessments were used to determine the proportion of patients reviewed regularly, and their pharmacological treatment and risk factors. Results &#114 - &#114 During the study, the proportion of patients who had an annual clinical examination decreased from 100% to 77%. The proportion given oral anti-diabetic agents or insulin increased from 43% to 71%. Median glycated haemoglobin (HbA 1c ) dropped in the 2nd year to 7.7% (normal range 5.4-7.4%), after which it increased gradually, but remained on average at 1.3% above the upper limit of the normal range. Median blood pressure (systolic/diastolic), total cholesterols and fasting triglycerides were maintained at 145-150/81-85 mmHg, 6.0-6.2 mmol/l and 1.66-1.96 mmol/l, respectively. Initial weight loss was partly regained over 6 years. Conclusion &#114 - &#114 Among centrally supported GPs, most patients were regularly reviewed and obtained acceptable levels of risk factors for at least 6 years, although glycaemic control progressively deteriorated after an initial drop to near-normal average level.     

Surfactant protein A gene locus and respiratory distress syndrome in Finnish premature twin pairs

BACKGROUND. Surfactant protein A (SP-A) polymorphisms are associated with susceptibility to respiratory distress syndrome (RDS). According to present hypothesis the association between SP-A polymorphisms and RDS may not be applicable to the entire population of premature infants. AIM. The present study was designed to evaluate the associations between SP-A allelic variants and RDS in a population consisting of 198 premature twin pairs. METHOD. Genotype analysis of the SP-A1 and SP-A2 genes and twin zygosity definition were carried out. RESULTS. The main SP-A1 allele 6A 2 ( P &#114 = &#114 0.030), genotype 6A 2 /6A 2 ( P &#114 = &#114 0.0042) and haplotype 6A 2 -1A 0 ( P &#114 = &#114 0.016) were over-represented in healthy premature twin infants compared to RDS twins. The homozygous genotype 6A 2 /6A 2 was over-represented in twin pairs of whom both were healthy compared to twins concordant for RDS (odds ratio 0.18, confidence intervals 0.06-0.6, P &#114 = &#114 0.0016) and born between 32 and 36 weeks. 6A 2 /6A 2 was also overrepresented in healthy twin pairs with birth weight sum higher than the median (OR 0.15, CI 0.04-0.6, P &#114 = &#114 0.0025). CONCLUSIONS. In twins, the association between SP-A polymorphism and RDS is different from that seen in premature singleton infants. The factor associated with SP-A genotype-specific susceptibility to RDS appears to be related to the size of uterus and the length of gestation at birth.     

General practitioner assessment of structured oncological information accompanying newly referred cancer patients

Scand J Prim Health Care 2003;21:00-00. ISSN 0281-3432 Objective &#114 - &#114 To investigate general practitioner (GP) assessment of a structured oncology information pack sent to GPs when newly referred patients had visited a department of oncology for the first time, and to compare their assessment of this material with their assessment of traditional information provided by the department. Design &#114 - &#114 Randomised, unblinded clinical trial. Setting &#114 - &#114 Patients and GPs in the catchment area of a regional oncology department. Subjects / patients &#114 - &#114 248 cancer patients and their 199 GPs. Main outcome measures &#114 - &#114 GP assessment of the quality of the information material received for each patient. Results &#114 - &#114 88.3% of the 248 questionnaires were returned. The structured information pack improved GP knowledge of oncology; GPs found themselves better equipped to support and counsel patients during the course of their illness, and practitioner satisfaction with the department rose. Conclusion &#114 - &#114 Intervention, though reasonably simple, inexpensive and not particularly time-consuming, improved cooperation between the specialist department and the GP. While this is a small step in the right direction, the need remains for new initiatives and further studies into how to improve cooperation and communication between the primary and secondary healthcare sectors.     

Markers of inflammation in women on different hormone replacement therapies

BACKGROUND AND AIM. To measure inflammatory markers in postmenopausal women on different forms of hormone replacement therapy (HRT). METHOD. C-reactive protein (CRP), fibrinogen, plasma viscosity (PV), albumin and white blood cell (WBC) count were determined in 749 postmenopausal women. RESULTS. CRP concentration was significantly higher in women on estrogen monotherapy (difference of the median (d) 0.96 &#114 mg/l, P &#114 = &#114 0.013), compared to those without HRT, but there was no difference in women on combined HRT. Fibrinogen concentration was significantly lower in women on estrogen monotherapy (d 0.25 &#114 g/l, P &#114 = &#114 0.004) and combined HRT (d 0.4 &#114 g/l, P &#114 < &#114 0.001), compared to women without HRT. Similarly, PV was significantly lower in women on estrogen monotherapy (d 0.017 &#114 mPa·s, P &#114 = &#114 0.007) and women on combined HRT (d 0.039 &#114 mPa·s, P &#114 < &#114 0.001), compared to those without HRT. No differences were found for WBC count and the negative acute phase marker albumin in the various treatment groups. In contrast to oral estrogen administration, levels of CRP, fibrinogen and PV in women on transdermal estrogen therapy did not differ from the no-HRT group. There was no association between these markers of inflammation and plasma estrogen levels. CONCLUSION. Oral estrogen monotherapy was associated with highest concentrations of CRP. In contrast, other markers of inflammation were either similar or lower in the oral HRT group, compared to the group of women without HRT, suggesting that higher CRP concentrations reflect estrogen effects on CRP expression rather than a systemic pro-inflammatory effect.     

Phenomenological approaches: challenges and choices

Phenomenology is a recognised approach for investigating experiences in health research. Difficulties regarding the approach, however, have been documented with even the definitions and terminology sometimes being unclear. In addition to this, there have been claims that many nurse researchers have failed to report how the gap between philosophically related theory and research practice is managed. While legitimacy can be increased by claims regarding theoretical location, there have also been suggestions that engaging too intensely in methodological awareness can hinder the practice and progress of a research project. A balance is therefore required. This article concentrates on the dilemmas and challenges facing a researcher looking for an appropriate method and approach for a study investigating the experiences of stroke survivors. The challenges of using phenomenology as a research method and the approach of interpretative phenomenological analysis are further considered.     

Folate status and homocysteine level in Italian patients aged under 60 on oral anticoagulant therapy

BACKGROUND. Folate deficiency occurs frequently and the related hyper-homocysteinaemia is considered a risk factor for thrombosis. We investigated folate status and homocysteine (Hcy) concentration in patients under 60 years on oral anticoagulant therapy (OAT) for previous venous or arterial thrombosis and in healthy blood donors. PATIENTS AND METHOD. Thirty-nine patients (mean age 35.2 years) on OAT for longer than 6 months and forty 44 healthy blood donors (mean age 36.0 years) were evaluated. Diet, serum folate (SF), red blood cell folate (RCF), homocysteinaemia, vitamin B12 levels and the mutation C677T of methylenetetrahydrofolate-reductase (MTHFR) gene were determined. RESULTS. The mean SF and Hcy concentrations were significantly higher in patients compared with blood donors (SF &#114 = &#114 17.7 versus 10.5 &#114 nmol/L, P &#114 < &#114 0.0001; Hcy &#114 = &#114 11.7 versus 8.9 &#114 &#55 mol/L, P &#114 = &#114 0.009). Twelve out of 39 patients and 7 out of 44 blood donors were homozygous for the mutation C677T of MTHFR gene. Among the remaining subjects, non-homozygous for the mutation, the patients (27) had mean SF and Hcy levels significantly higher than the (37) blood donors (SF &#114 = &#114 18.1 versus 10.8 &#114 nmol/L, P &#114 < &#114 0.0001; Hcy &#114 = &#114 10.3 versus 7.9 &#114 &#55 mol/L, P &#114 < &#114 0.0006). CONCLUSION. Italian patients aged under 60 years on OAT and non-homozygous for the mutation C677T of MTHFR gene, had SF and Hcy concentrations significantly higher than the control group.     

International Student Mobility in Radiography: Agency and Experience

PurposeThe purpose of the study was to evaluate student exchange experiences to gain insight into what students perceived as benefits, challenges, and overall areas for improvement that might inform and enhance future exchange projects.MethodsA general program evaluation survey, adapted to address the project objectives, was conducted. Eight students from Norway, Canada, and South Africa participating in an international exchange project completed an online survey. The responses were coded and organized in themes such as pre-exchange preparation, home/host country support, challenges, and new learning.Results & ConclusionsDespite the challenges the students experienced, students indicated advantages such as new learning, personal development, and expanded professional knowledge. Students gained an international perspective and deeper understanding of their profession and insight into the similarities and differences in clinical practice emphasizing the importance of creating global citizens through internationalization in radiography education. These student experiences confirmed their agency in disposition, motivation, self-efficacy, and position.     

Nurses' ways of talking about their experiences of (in)justice in healthcare organizations: Locating the use of language as a means of analysis

Nurses have their own ways of talking about their experiences of injustice in healthcare organizations. The aim of this article is to describe how nurses talk about their work-life experiences and discuss the discursive effects that arise from nurses' use of language regarding their political agency. To this end, we present the findings garnered from a study focused on exploring how nurses deploy their political agency to project their idea of social and political justice in public healthcare organizations and how they face the challenges and uncertainties of (re)thinking their institutional order when it does not resonate with their professional ethos. We then discuss the implications that nurses' use of language has in relation to their ability to deploy their political agency to oppose the forms of injustice they face in their daily practice. We conclude by stating that careful attention should be placed on understanding the discursive implications of nurses' use of language on their individual and collective emancipation in healthcare organizations.     

Living as a chameleon: girls, anger, and mental health.

One's practice as a school nurse affords numerous privileges. One that stands out in my mind is the privilege of bearing witness to the lives of countless girls as they navigated their own aspirations and the expectations of the culture. The stories they iterated to me in my school nurse office form the basis for this discussion regarding the relationship between anger and mental health. I've come to realize that as a school nurse, I was an anger-story listener. In so being, I was given the opportunity and responsibility to influence positive mental health for numerous girls and young women. This feminist qualitative research project explored girls' lived experiences of anger. The findings suggest that experiences of disrespect, dismissal, denied agency, and a denial of the right to verbalize anger eventually led to self-silencing and an eventual disconnect from this important emotion. The girls described strategies associated with the societal response to their anger that are likened here to the ultra-adaptive strategies that chameleons show to survive.     

Qualitative observation in a clinical setting: Challenges at end of life

This paper explores the methodological challenges associated with undertaking qualitative observation in the clinical setting at end of life. The authors reflect on their experiences of using non‐participant observation to explore the nursing care delivered to dying patients in acute hospital wards. The challenges of observation as a method, clearly defining the participant group and involving vulnerable populations, such as the dying patients and their families, will be discussed. Consideration is also given to defining and working within the observational field, the researchers' dual roles, cost versus benefit, impact of culture, religion and ethnicity, and the determination of research limits/boundaries, with reflections from the authors' own experiences used to exemplify the issues.     

Rituals,ghosts and glorified babysitters: A narrative analysis of stories nurses shared about working the night shift

Working the night shift can be fraught and experienced as demanding and, yet, is often dismissed as babysitting. Few researchers have explored the social and cultural meanings of night nursing, including storytelling rituals. In 2019, a narrative study was undertaken. The aim was to explore the stories recalled by nurses about working night shifts. Thirteen Australian nurses participated. Data were gathered using the Biographical Narrative Interview Method, and narrative analysis produced forty stories and three themes: strange and challenging experiences; colleagues can be mentors (or not); and textbook knowledge is only part of what is needed on night shift. Nursing students who engage with these stories may come to understand the challenges of the night shift, and the valuable work that nurses engage in throughout a 24‐hr period, work that involves adept psychosocial and interpersonal skills alongside technical and physical competence.     

Powerlessness,marginalized identity,and silencing of health concerns: Voiced realities of women living with a mental health diagnosis

Using a feminist qualitative approach, this study substantiated many earlier research findings that document how women with a mental health diagnosis experience unequal access to comprehensive health care compared to the general population. Accounts of this disparity are documented in the literature, yet the literature has failed to record or attend to the voices of those living with mental health challenges. In this paper, women living with a mental health diagnosis describe their experiences as they interface with the health‐care system. The participating women's stories clearly relate the organizational and interpersonal challenges commonly faced when they seek health‐care services. The stories include experiences of marginalized identity, powerlessness, and silencing of voiced health concerns. The women tell of encountered gaps in access to health care and incomplete health assessment, screening, and treatment. It becomes clear that personal and societal stigmatization related to the mental health diagnosis plays a significant role in these isolating and unsatisfactory experiences. Lastly, the women offer beginning ideas for change by suggesting starting points to eliminate the institutional and interpersonal obstacles or barriers to their wellness. The concerns raised demand attention, reconsideration, and change by those in the health‐care system responsible for policy and practice.     

Nurse #65X89: the emerging story from an emancipatory study of nursing practice

This article provides a creative account of contemporary nursing practice challenges by using a unitary appreciative inquiry process to create a metastory. A brief review of the Nurse Manifest Project is followed by the story "Nurse #65X89." Nurses are encouraged to explore their own emerging stories and to define avenues for action, emancipation, and change for the profession.