Schizophrenia in general practice: a national survey of general practitioners in Ireland

Background  

Chronic schizophrenia is challenging to manage in primary care.     

The effects of depression awareness seminars on general practitioners knowledge of depressive illness.

The Royal Colleges of Psychiatry and General Practice wish to increase knowledge of depressive illness among patients and professionals. This study reports the results of a series of depression education seminars in a Health Board in Northern Ireland. Seminars lasted 2 1/2 hours and included didactic teaching and interactive case management vignettes. 88 general practitioners took part (39% of those eligible). Seminars increased knowledge as measured by questionnaire immediately, but this did not appear to be sustained at one year, when compared to a group of general practitioners with no access to such seminars. Educational programmes as described do not appear to have a sustained effect on general practitioners' knowledge of depressive illness.     

Electronic fetal monitoring: a Canadian survey.

OBJECTIVES: To determine the current status of electronic fetal monitoring (EFM) in Canadian teaching and nonteaching hospitals, to review the medical and nursing standards of practice for EFM and to determine the availability of EFM educational programs. DESIGN: National survey in 1989. PARTICIPANTS: The directors of nursing at the 737 hospitals providing obstetric care were sent a questionnaire and asked to have it completed by the most appropriate staff member. The response rate was 80.5% (593/737); 44 hospitals did not have deliveries in 1988 and were excluded. The remaining hospitals varied in size from 8 to 1800 (mean 162.1) beds and had 1 to 7500 (mean 617.1) births in 1988; 18.8% were teaching hospitals. RESULTS: Of the 549 hospitals 419 (76.3%) reported having at least 1 monitor (range 1 to 30; mean 2.6); the mean number of monitors per hospital was higher in the teaching hospitals than in the nonteaching hospitals (6.2 v. 1.7). Manitoba had the lowest mean number of monitors per hospital (1.1) and Ontario the highest (3.7). In 71.8% of the hospitals with monitors almost all of the obstetric patients were monitored at some point during labour. However, 21.6% of the hospitals with monitors had no policy on EFM practice. The availability of EFM educational programs for physicians and nurses varied according to hospital size, type and region. CONCLUSIONS: Most Canadian hospitals providing obstetric services have electronic fetal monitors and use them frequently. Although substantial research has questioned the benefits of EFM, further definitive research is required. In the meantime, a national committee should be established to develop multidisciplinary guidelines for intrapartum fetal assessment.     

Contemporary approaches to managing atrial fibrillation: A survey of Australian general practitioners

Background

Recent attention to the management of atrial fibrillation (AF) and stroke prevention has emphasised the need to support the use of existing pharmacotherapy through available services and resources, in preference to using the new, more expensive, novel oral anticoagulants. In this regard, general practitioners (GPs) are at the core of care.

Aims

To survey Australian GPs regarding their approach to managing AF, particularly in relation to stroke prevention therapy, and to identify the range of services to support patient care.

Methods

A structured questionnaire, comprising quantitative and qualitative responses, was administered to participating GPs within four geographical regions of NSW (metropolitan, regional, rural areas).

Results

Fifty GPs (mean age 53.74±9.94 years) participated. Most (98 per cent) GPs regarded themselves as primarily responsible for the management of AF, only referring patients to specialists when needed. However, only 10 per cent of GPs specialised in “heart/vascular health”. Most (76 per cent) GPs offered point-of-care international normalised ratio (INR) testing, with 90 per cent also offering patient support via practice nurses and home visits. Overall, key determinants influencing GPs’ initiation of antithrombotic therapy were: “stroke risk”/”CHADS₂ score”, followed by “patients’ adherence/compliance”. GPs focused more on medication safety considerations and the day-to-day management of therapy than on the risk of bleeding.

Conclusion

Australian GPs are actively engaged in managing AF, and appear to be well resourced. Importantly, there is a greater focus on the benefits of therapy during decision-making, rather than on the risks. However, medication safety considerations affecting routine management of therapy remain key concerns, with patients’ adherence to therapy a major determinant in decision-making.     

Malaria prophylaxis: postal questionnaire survey of general practitioners in south east Wales

Postal questionnaires were sent to 494 general practitioners in south east Wales asking about their experience and understanding of antimalarial prophylaxis; 293 were returned, giving a response rate of 59%. Forty eight (16%) of the respondents reported being consulted by immigrants returning home for advice about malaria prophylaxis, of whom 13 (27%) overestimated the time for which their protective immunity might last after leaving the malarious area. Two hundred and eighty respondents (96%) considered that they were responsible for advising travellers and 195 (67%) would always consult a publication before giving chemoprophylactic advice (magazines were particularly popular), but only 18 (6%) would always consult a specialist centre--the Ross Institute in eight cases (3%), a local centre in 39 (13%). Only about half of the doctors were aware of chloroquine resistance in Kenya and Thailand. Over half would withhold chloroquine in pregnancy, and many chose pyrimethamine alone or sulfadoxine-pyrimethamine as suitable chemoprophylactic drugs, though neither is still recommended by the World Health Organisation. One hundred and ninety two respondents (66%) would give advice about protective measures other than chemoprophylaxis. More must be done to encourage general practitioners to contact specialist centres and to educate them in the use of antimalarial chemoprophylactic drugs.     

When to intervene for male and female patients' alcohol consumption: what general practitioners say

Results of a telephone survey of 103 Sydney general medical practitioners are reported. General practitioners were asked to indicate how much alcohol male and female patients would need to be consuming to warrant their intervention. The mean levels at which general practitioners stated they would intervene were 5.1 drinks per day for male patients and 3.8 drinks per day for female patients. These mean scores fall within the consumption ranges identified by the National Health and Medical Research Council (NHMRC) as being hazardous and are below the levels specified as harmful. While the results of the present study indicate some consistency between general practitioners' views and NHMRC recommended levels for low-risk alcohol consumption, there were important discrepancies. For instance, using NHMRC categories of risk, general practitioners would intervene for female patients at significantly higher levels (P less than 0.05) of associated risk than they would for male patients. In addition, many general practitioners did not differentiate between the quantities of alcohol consumed for which they would intervene for male and female patients; this is an area needing attention. While the results indicate that some general practitioners have the basic knowledge required for involvement in detection and early intervention activities for alcohol-related problems, future training programmes should address the fact that two-thirds of general practitioners either overestimate or underestimate the level of patient alcohol consumption at which it is appropriate to intervene.     

Recognition, diagnosis and treatment of fetal alcohol syndrome

Fetal Alcohol spectrum disorders are extremely common. The clinical impact and societal effects are tremendous. Prevention and treatment of these disorders begins with an accurate diagnosis. All health care providers who work with children (and adults) with special health care needs should be alert to these findings. The key to early diagnosis is to always keep the diagnostic possibility in the broad differential diagnoses of growth and developmental disorders. As with most conditions, early recognition and intervention is associated with better outcomes. Once an FASD is identified in a specific patient, prompt referrals and enrollment in indicated services are necessary to get the best outcomes. In this article we review the diagnostic criteria and clues to prompt early identification of FASDs. We also discuss the therapeutic options shown to be most effective for this group of individuals.     

Physician assistants and nurse practitioners: the United States experience

Physician assistants (PAs) and nurse practitioners (NPs) were introduced in the United States in 1967. As of 2006, there are 110 000 clinically active PAs and NPs (comprising approximately one sixth of the US medical workforce). Approximately 11 200 new PAs and NPs graduate each year. PAs and NPs are well distributed throughout primary care and specialty care and are more likely than physicians to practise in rural areas and where vulnerable populations exist. The productivity of NPs and PAs, based on traditional doctor services, is comparable, and the range of services approaches 90% of what primary care physicians provide. The education time is approximately half that of a medical doctor and entry into the workforce is less restrictive. The interprofessional skill mix provided by PAs and NPs may enhance medical care in comparison with that provided by a doctor alone.